Clinica Flashcards
1
Q
What are the differentials for Abdominal pain post op (colectomy)
A
Anastomotic leak Septic shock Haemorrhagic shock Perforation Obstruction Wound infection
2
Q
Differentials for post op shock
A
Haemorrhage Sepsis (depends how long after) PE MI Anaphylaxis
3
Q
Post cholecystectomy Ix
A
Bedside: ECG, BM, Urine dip (+pregnancy)
Bloods: FBC, U/Es, LFTS, CRP, amylase/lipase +/-D-dimer
Imaging: Erect CXR, Abdo USS looking free fluid. If stable, consider CT abdo
If not stable may need Dx Laparotomy
4
Q
Haemorrhagic shock classification
A
5
Q
Ix for drop in urine output
A
Bedside: BM, ECG, Urine dip and Microscopy, bladder scan
Bloods: classic + lactate
Imaging: USS Kidneys (?hydro)
Special: paired urine and serum osmolality
6
Q
Pre-renal causes of AKI
A
Local: renal artery stenosis or renal vein thrombosis
7
Q
Renal causes of AKI
A
ATN
8
Q
Post renal causes of AKI
A
Upper: - Intraluminal: stone - Extraluminal: retroperitoneal fibrosis, malignant compression Lower: - Urethral stricture - prostate - blocked catheter
9
Q
Treatment of hyperkalaemia
A
- calcium gluconate 10%:10ml
- Insulin + Dextrose: 10 units in 50mls of 50% dextrose
- Nebulised salbutamol
- Resonium
Continued cardiac monitoring
10
Q
Indications for dialysis
A
Resistant fluid overload
Resistant high K
High Urea (encephalopathy)
Resistant met acidosis
11
Q
How haemodialysis different from haemofiltration
A
Dialysis: counter flow of blood and dialysate fluid separated by semi-permeable membrane
Filtration: High hydrostatic pressure pushing blood into semi-permeable membrane, forming ultrafiltrate (small molecules and electrolytes pass through the membrane). Ultrafiltrate is then disposed and replaced by normal fluid
12
Q
Scoring system for AKI
A
RIFLE from KDIGO (Kidney disease, improving global outcomes)
13
Q
Management of failed 12Fr catheter
A
Try a larger cath
If not try a tieman
If not consider suprapubic or percutaneous needle aspiration
14
Q
Differentials swollen leg post op
A
DVT
Cellulitis
Lymphoedema
Fracture
15
Q
Well’s DVT score
A
16
Q
Wells DVT score interpretation
A
17
Q
Duration of anticoagulation for DVT
A
3-6 months
3 months for unprovoked
3 months for provoked but the provoking factor no longer present (eg post op)
3-6 months for cancer
18
Q
Complications of DVTs
A
PE
Post-thrombotic syndrome (pain, swelling, haemosiderin, varicose veins)
19
Q
Prevention of DVTs
A
Compression stocking
Elevation
Early mobilisation
Anticoagulation
20
Q
A to E assessment for post op tonsilar bleed
A
Airway C: Patency O: Suction Breathing C: RR, SpO2, expansion, Breath sounds O: 15L non-rebreathe Circulation C: HR, BP, peripheral and central cap refill, HS O: - 2 large bore cannulae, bloods (clotting, G+S, +/- Xmatch, culture, VBG), - IV hartmanns if tachycardic. - Consider catheter for fluid balance Disability C: BM, GCS, Pupils Exposure C:rash, abdo exam, wound site
21
Q
Tonsillar bleed mx before operation
A
Inform senior
Abx
Fluids/blood
Control bleeding:
1. LA spray with adrenaline
2. If obvious bleeding point: Cauterise with silver nitrate stick
3. if no obvious bleeding point: gargle hydrogen peroxide 3% diluted 1:4
22
Q
Manual reduction technique for paraphimosis
A
- apply general pressure
2. thumbs on the glans, index finger behind the prepuce slowly pushing back
23
Q
Pathophysiology of paraphimosis
A
Retracted prepuce proximal to glans forms a constricting ring
Impedes venous and lymphatic return
Causing engorgement of vessels distally
Swelling causes further obstruction ultimately cutting the arterial supply
24
Q
Analgesia for paraphimosis reduction
A
LA without adrenaline
penile block or ring block
25
Other non-operative approach to paraphimosis
Osmotic method: gauze soaked with 50% dextrose
| Dundee method: making multiple needle tracts in the swollen glans to create path for fluid drainage under pressure
26
Mx of intra-abdominal abcess
1. abx
| 2. drainage (percutaneous or surgical)
27
Possum scoring system
Physiological and operative severity score for enUmeration of mortality and morbidity
Developed in 1991 by Copeland et al, revised by Portsmouth in 1998
28
Anticoagulation mx for pt needing urgent operation on warfarin for metalic valve
Consult cardiology and trust guideline
| Might reverse with vit K whilst starting on UFH
29
Sepsis 6
Take: culture, lactate, UO
Give: O2, fluids, Abx
30
SIRS def
Symptoms and signs of infection
| 2 or more of the following: HR:90, RR>20, WCC>12 or<4
31
SIRS vs Sepsis vs Septic shock
SIRS: systemic inflammation
Sepsis: SIRS + confirmed/suspected source of infection
Severe sepsis: Sepsis + organ dysfunction (eg low urine output or high lactate)
Septic shock: severe sepsis and persistent hypotension despite resus
32
Scoring system for UGI bleeding
Rockall or Blatchford
Pre and post endoscopy rockall scores
Predicts the need for endoscopy or risk of re-bleeding (post endoscopy rockall)
33
Mx of UGI bleeding
Depends on the cause
If peptic ulcer: IV omeprazole
If oesophageal varices: IV terlipressin to reduce splanchnic flow, reducing bleeding, and prophylactic abx
Endoscopy
34
Riglers sign
Air present on both sides of bowel wall
| Sign of bowel perforation
35
Common causes of small bowel obstruction
Adhesions
| Hernia
36
Common causes of large bowel obstruction
Malignancy
Volvulus
Diverticulitis
37
Causes of bowel obstruction
Intraluminal
Gallstone ileus, ingested foreign body, faecal impaction
Mural
Cancer, inflammatory strictures*, intussusception**, diverticular strictures, Meckel’s diverticulum, lymphoma
Extramural
Hernias, adhesions, peritoneal metastasis, volvulus
38
Mx of sigmoid volvulus
A-E, bowel decompression using riles tube and IVI + analgesia
1st line: Rigid Sigmoidoscopy and insertion of flatus tube
2nd line: flexi sigmoidoscopy
3rd line: Surgical ?sigmoidectomy
39
Types of necrotising fasciitis
Type 1: polymicrobial:aerobic and anaerobic
Type 2: Haemolytic group A strep: strep pyogenes
Type 3: Gas gangrene: clostridium perfringes
40
Special test for Necrotising fasciitis
Finger Sweep test:
an incision over the suspected area may reveal:
- dishwasher coloured fluid
- pus exudate
- necrotic tissue
If the tissue dissects easily with minimal resistance: positive finger sweep test
41
Risk factors for necrotising fasciitis
Immunocompromised eg DM, HIV, malignancy
Post op
Trauma eg IVDU, burn
42
Prognosis of necrotising fasciitis
Early diagnosis and debridement improves outcome
Mortality between 20-50%
43
Contraindications for skin graft
General: patient fitness for op
Local: vascularity, growth of micro-organisms, necrotic tissue
44
Signs of appendicitis
Rosving
Rebound tenderness
Psoas sign
Obturator sign
45
Rosving sign
LIF palpation causes pain in RIF
| ?appendicitis
46
Psoas sign
Extend hip causes RIF pain
47
Psoas sign
HIP Extension against resistance causes RIF pain
48
Complication of acute appendicitis
Sepsis - septic shock - multi-organ failure
Periappendicular abscess
Perforation of appendix
Death
49
Complication of acute appendicitis
Sepsis - septic shock - multi-organ failure
Periappendicular abscess
Perforation of appendix
Death
50
Why you have to operate on appendicitis but cholecystitis might be treated with ABX
Appendix supplied by appendicular artery (small end artery) which could get thrombosed with sepsis, leading to gangrene and perforation
Cholecystitis: gallbladder supplied by both cystic and right hepatic arteries, even if one thromboses, another likely to be able to supply the appendix
51
6 Ps of acute limb ischaemia
```
Painful
Pallor
Pulseless
Perishingly cold
Paralysis
Paresthesia
```
52
Ix of acute limb ischaemia
Bedside: ECG, BM
Bloods: FBC, UEs, CRP, G+S, lactate, ?thrombophilia screen
Imaging: Areterial duplex or CT angio
53
Rutherford classification of acute limb ischaemia
>6 hours likely to be irreversible
54
Mx of acute limb ischaemia
Heparinise whilst awaiting imaging
Rutherford I and IIa: conservative with
- heparin loading and infusion (monitor APTT)
Rutherford IIb or worse: surgical
55
Surgical mx for acute limb ischaemia
If the cause is embolic, the options are:
- Embolectomy via a Fogarty catheter
- Local intra-arterial thrombolysis*
- Bypass surgery (if there is insufficient flow back)
If the cause is due to thrombotic disease, the options are:
- Local intra-arterial thrombolysis
- Angioplasty (Fig. 3)
- Bypass surgery
If >6hrs: amputation
56
3 components of normal doppler waveform
Multiphasic
Pulsatile
Regular amplitude
57
Causes of acute limb ischaemia
Acute thrombotic in situ (60%): acute occlusion in a vessel with pre-existing atherosclerosis
Embolic (30%): Cardiac (AF, MI, prosthetic/damaged valve), malignancy
Others: trauma , infection, dissecting aneurysm
58
ABPI interpretation
```
>1.3: arterial calcification seen in DM, RA, vasculitis
0.8< -- <1.3 normal
0.5< -- <0.8 moderate PAD: claudication
0.3< -- <0.5 severe PAD: rest pain
<0.3 critical limb ischaemia
```
59
Complications of ischaemic limb if left untreated
Loss of limb (40%)
| Death (20%)
60
Complications of ischaemic limb when treated
Reperfusion syndrome ->compartment syndrome/chronic pain
Complications of thrombolysis: CVE, retroperitoneal bleed
61
Chronic limb ischaemia rutherford vs fontaine classification
62
Mx of critical limb ischaemia
Urgent vascular referral for consideration for surgical intervention :
- stent
- bypass
- amputation
63
ATLS acute assessment
C: triple c-spine immobilisation should be established until spine is declared clear
A: cant do head tilt chin lift or jaw thrust (c-spine). start with airway adjuncts if needed and call anaesthetists
B: Check for haemothorax, pneumothorax, cardiac tamponade, flail chest. Apply 15L non-rebreathe regardless of COPD
C:
IV access*2, Warmed crystalloid 30ml/kg initial bolus (10ml/kg if HF),
- look for bleeding: floor and 4 more
D: GCS, pupils, BM, temp. Analgesia as per WHO
E: expose,log roll, abdo exam, check integrity of pelvis and apply binder
AMPLE Hx
Secondary Survey
64
Ample hx
```
Allergies
Medication
PMHs
Last meal
Events
```
65
Imaging Ix for Trauma
Chest, c-spine, pelvic XR
FAST scan
Full trauma series CT TAP +/- head
66
How to differentiate between haemothorax and pneumothorax
Haem: dull percussion, no distended neck veins, deviated trachea
Pneum: hyper-resonant, distended neck veins, deviated trachea
67
Definition of massive haemothorax
Chest drain empties 1.5L or more than 200ml/hr for 2 hrs
68
Mx of massive haemothorax
Transfusion
Chest drain
Explorative surgery to control bleeding
69
Epigastric pain differentials
```
GI:
- pancreatitis
- Cholecystitis
- peptic ulcer
- GORD
- obstruction
Cardiac:
- MI
- pericarditis
Vascular:
- AAA
Endocrine:
- DKA
```
70
Normal amylase
<100
| if it is 3 times or more is most likely pancreatitis
71
Risk factors for gallstones
Fat
Female
Fertile
Forty
72
Causes of pancreatitis
```
GETSMASHED
Gallstones
Alcohol
Trauma
Steroids
Mumps
Autoimmune eg SLE
Scorpion
High Ca, High Lipid, low temp
ERCP
Drugs: azothioprin, NSAIDs, thiazides
```
73
Severity of pancreatitis scoring
APACHE II
| Glasow score
74
APACHE score
75
Glasgow pancreatic score
76
Criteria for CT scanning in pancreatitis patients
Not until after 48/72hrs: inflammatory changes are not radiographically present
Unless suspecting pancreatic carcinoma
If mild pancreatitis, unlikely to need CT
If severe pancreatitis, will definitely need CT for: assessing complications, provide prognostic info (risk of necrosis/infection)
77
Complications of pancreatitis
```
Necrosis +/- infection
Pseudocyst
ARDS
Chronic pancreatitis
Retroperitoneal haemorrhage: grey-turner/cullens
Death
```
78
Mx of gallstone pancreatitis
MRCP + Cholecystectomy
| If bile duct stones/or unfit for surgery: ERCP and sphincterotomy
79
Acute groin pain differentials
```
Gen Surg:
- Hernia: femoral or inguinal and 2ndary small bowel obstruction
Ortho:
- Psoas abscess
- OA flare
Vascular:
- femoral aneurysm
- saphenous varix
- AAA
Others:
- lipoma
- lymphadenopathy
```
80
Commonest type of hernia
Gen population: Direct inguinal hernia
Paeds: indirect inguinal (patent process)
Elderly female: femoral
81
Femoral triangle anatomy
```
Femoral canal
Femoral sheath (artery and vein)
```
82
Femoral canal boundaries
Medial: Lacunar lig
Ant: pectineal muscle
Post: Inguinal ligament
Lat: femoral vein
Note great saphenous coming in! common source of bleeding post herniotomy
83
Femoral canal content
Fat
| Lymph nodes of cloquet
84
Differentials for testicular swelling
```
General:
- direct inguinal hernia
Uro:
- torsion
- hydrocele
- varicocele
Trauma
- haematocele
Malignancy
- tumour
Infective:
- mumps
- epididymo-orchitis
```
85
Types of non seminoma
Teratoma
Yolk sac tumour
Choriocarcinoma
86
Testicular germ cell tumour types
Seminoma
Non seminoma
87
Seminoma vs non seminoma age group
Seminoma: ~ 40 yo
Non seminoma: 20-30 yo
88
Testicular germ cell tumour types
Seminoma
Non seminoma
89
Blood test for testicular cancer
AFP
bHCG
LDH
90
Risk factors for testicular cancer
FHx
Down syndrome
Klinefelters syndrome
Cryptorchidism
91
Surgical approach for testicular cancer
Inguinal (not testicular) approach as minimised seeding
92
Presentation of testicular torsion
```
Hx:
- Sudden onset severe pain
- N+V +/- abdo pain
O/E:
- Globally tender, high riding/transverse
- absence of cremasteric reflex
```
93
Blood supply to femoral head
94
Weight bearing status following Hemi/total/DHS/Cannulated hip screw
Hemi/total: weight bear as tolerated
| DHS/Cannulated hip screw: minimally weight bearing/non weight bearing for 6 weeks to facilitate fracture healing
95
Hemi vs total for intracapsular NOF
Hemi if:
- immobile
- low AMTS
- Co-morbid/high risk of GA
96
How many hip fractures?
| Mortality
30 day: 10%
| 1 yr: 30%
97
Surgical approach to hip replacement
Anterolateral for hemi
| Posterior for total
98
Mx of pertrochanteric hip fractures
DHS
99
Mx of subtrochanteric fractures
IM nail
100
Assessment of neurovascular status in children with upper limb fracture
Median: 'ok' sign -> flexor policis longus (FPL) and flexor digitorum profundus (FDP) + sensation on the thumb
Ulnar: middle finger over index finger: intrinsic hand muscles + sensation of little finger
Radial: extend wrist + Sensation on the back of the hand
CRT + radial +ulnar pulses
101
Mx of radial fracture in children
Backslab + NBM
Discuss with senior
Consent and mark for TENS wires or plates and screws
102
Mx of spiral femoral fractures in kids
Plating or TENS nailing of femur
103
Signs of non-accidental injury
Multiple fractures at different stages of healing
| Scapula, ribs, lateral clavicle, skull fracture
104
How long does it take for fractures to heal
4 wks for hard callus to appear on xray
4-6 wks start of mobilisation: 3 months completion of callus formation
3-6 wks of healing time in kids
Remodelling up to 6 months
105
BOA guidelines: compartment syndrome Ix and management
In pt with clear signs/sx,
1. any circumferential dressing should be removed and pt reviewed after 30 mins
2. If persists, needs urgent decompression
In pt with Dx uncertainty
1. record intracompartmental pressures
2. If diastolic blood pressure - the compartment pressure < 30 mmHg ; suggests positive
3. Needs to D/w consultant if positive whether needs decompression
4. If absolute compartment pressure >40mmHg, it is definitely compartment syndrome
106
BOA guidelines: compartment syndrome Hx and exam
1. Time: of injury and evaluation
2. Mechanism of injury/RFs
3. Pain: out of proportion? on passive extension
4. Analgesia: ?regional, response to analgesia
5. Neurovascular status
6. GCS
107
Treatment for lower leg compartment syndrome
2 incision 4 compartment fasciotomy
108
BOA guidelines: Spinal clearance principles in trauma
1. Inclusion: unconscious, unable to cooperate or who have distracting injuries
2. Examine the entire spine on arrival: any injury found requires urgent imaging
3. If unlikely to be conscious in 48hr, need radiological imaging
4. Radiological imaging: CT Head (extend to c spine), CT CAP for coronal view, AP and lateral xray of thoracic and lumbar. needs reporting by a radiologist before clearing the spinal immobilisation measures. MRI needed for cord injury
109
BOA Guidelines for open fractures
1. Need orthoplastics
2. Prophylactic abx
3. Neurovascular exam before and after reduction
4. Re-align and splint
5. CT trauma +/- angio
6. Informal debridement to remove gross contamination, take pics, then cover with saline soaked gauze and occlusive dressing
110
BOA guideline: Timing to debride an open fracture
Debridement should be performed using fasciotomy lines for wound extension where possible
— Immediately for highly contaminated wounds (agricultural, aquatic, sewage) or when there is an associated vascular compromise
(compartment syndrome or arterial disruption producing ischaemia).
— within 12 hours of injury for other solitary high energy open fracture
— within 24 hours of injury for all other low energy open fractures.
111
When would you use haemofiltration or haemodyalisis
Dialysis: less expensive, less technical
Filtration: Less effect on BP, lower risk of hyperlipidaemia
112
BOA Guidelines on operating on Fraily trauma pts
1 . TEP
2. Timing:
- orthogeries review within 72 hrs
- operate within 36 hrs, aim for FWB
- PT on day 1 post op
3. Orthogeries assessment includes:
- bone health
- anticoagulation
- Multifactorial fall assessment
- nutrition
- pain mx
113
Causes of hip fractures in elderly
Weakness caused by:
- osteoporosis
- met deposits
- metabolic conditions eg pagets
- rarely osteomyelitis
114
Ix for painless haematuria
Bedside: urine dip, bladder scan
Bloods; routine
Imaging: CT KUB
Special: flexi/rigid cystoscopy
115
Causes of D1 post-operative pyrexia
1. Pulmonary atelectasis
2. Infection prior to operation: catheter, cannula, LURTI/UTI
3. PE
116
How to manage pulmonary atelectasis post op
1. Analgaesia : PCA
2. Oxygen if low sats
3. Chest physio
4. If issues with oxygenation, contact outreach
117
Risk factors for abdo wound dehiscence
Pre-op: wound healing impairment
RF: DM, anaemia, jaundice, malignancy, vit c deficiency
Peri-op:
- Surgical: poor suturing, increased bowel handling
- equipment: poor sutures
Post- op:
- anything that increases intra-abdo pressure: cough, high BMI, constipation
118
Jenkin rule
suture length should be at least four times the wound
sutures placed 1cm apart
1cm bites
119
Surgery for wound dehiscence
1. debride non viable tissue around the wound edges
2. repair with non absorbant sutures eg nylon 1.0 or PDS including peritoneum, rectus sheath, fascia layers but not skin
3. separate skin closure
120
Difference between incisional hernia and wound dehiscence
Skin intact in incisional hernia
121
Complications of any fracture
Early: bleeding, infection, NV compromise
Intermediate: compartment syndrome, bleeding infection
Long term: malunion or non-union
122
Complications of any fracture
Early: bleeding, infection, NV compromise
Intermediate: compartment syndrome, bleeding infection
Long term: malunion or non-union
123
What nerve damaged in supracondylar fractures
Anterior interosseus nerve branches off median in the proximal forearm:
Innervates flexor pollucis longus and digitorum profundus (cant make the ok sign)
124
What nerve damaged in supracondylar fractures
Anterior interosseus nerve branches off median in the proximal forearm
125
How to classify supracondylar fractures
Gartland classification
126
How to prepare someone for theatre
```
NBM + maintenance IVF
Mark and consent
Anaesthetics: ECG and CXR
Bloods: G+S + routine + INR
Covid Swab
TEP form
VTE
Inform: SpR, ITU, Emergency theatre staff
```
127
Differentials for UGI Bleed
```
Oesophageal varices
Duodenal or peptic ulcers
Malignancy
Trauma
Gastritis/Oesophagitis
Mallory-weis tear
Arterio-venous malformation
```
128
Arterial supply of nose bleed
Internal and external carotid artery plexus (Little's area or kiesselbach's plexus)
Mainly sphenopalatine and greater palatine arteries (branches of the maxillary artery)
129
ENT Mx of epistaxis
If anterior: Simple anterior: 1st: silver nitrate cautery 2nd: packing
If posterior: balloon tamponade (if anterior packing has failed)
Abx post nasal packing
130
Immediate mx of epistaxis
Press on the cartilagenous part of the nose for 15 to 20 mins whilst leaning forward to avoid the blood flow posteriorly and risk occluding the airway
131
When to give abx in epistaxis
If no source of bleed found, nose is usually packed for 48hrs.
Abx needed if pack is in place for more than 48 hrs
Toxic shock syndrome is a complication otherwise
132
What does grade 2 shock and abdo pain imply
Should be interpreted as ruptured AAA until proven otherwise
133
Most common site of AAA
Infrarenal 80%
| Suprarenal 20%
134
RFs for AAA
```
Male
Age >55
HTN
Smoking
High Cholesterol
FHx
```
135
Differentials for bowel obstruction
1. large bowel obstruction
2. small bowel obstruction
3. Pseudo-obstruction
4. ileus
136
Pseudo-obstruction vs ileus
Both are acute distention of bowels in absence of any mechanical obstruction
Ileus (Ogilvie's syndrome) includes both small and large bowel
Pseudo includes only large bowel (mainly caecum and ascending colon)
137
Causes of pseudo obstruction or paralytic ileus
Meds: opiates
Electrolyte imbalance
Neurological: MS, parkinsons
Trauma: including recent surgery
138
Mx of pseudo obstruction
NBM IV fluids 24-48hr
If not resolved, flatus tube decompression
Sometimes could give neostigmine to help reduce the secretions
Minority will need resection
139
Difference in history of Small bowel vs large bowel obstruction
Large bowel: constipation proceeds nausea
| Small bowel: (profuse) vomiting proceeds constipation, spasmatic crampy abdo pain
140
Bowel sound in obstruction
Tinkling
141
Indications for AXR
Obstruction
Perforation
Volvulus
Toxic megacolon in acute IBD
142
Complications of small bowel obstruction if managed conservatively
Sepsis
| Intra-abdominal abscess
143
Complications of small bowel obstruction if managed surgically
Early complications such as infection and haemorrhage
Intermediate such as bleeding, anastomatic leak, abdo wound dehiscence
Late: short gut syndrome, chronic pain
144
Different types of skin grafts
Split thickness:
- includes the germinal layer,
- leaves islands of germinal layer in the donor site, allowing it to heal by re-epithelisasation and is able to become a donor site in 6 wks
Full-thickness:
- includes all layers of dermis and epidermis
- needs to be sutured close (or closure by split-thickness skin graft)
Composite graft:
- includes special tissue like cartilage for nasal reconstruction
145
Criteria for Burns referral to a tertiary centre
- Partial thickness > 10%
- hands, feet, face, genitalia , or major joints
- full-thickness burns in any age group
- Electrical, chemical, inhalation burns
- Burns injury in patients with co-morbidities that could affect recovery
• Any patient with burns and concomitant trauma (such as fractures) in which the burn poses the greatest risk of morbidity or mortality.
• Burned children in hospitals without qualified personnel or equipment for the care of children
• Burn injury in patients requiring special social, emotional or long term rehabilitative support.
146
DDx for hip pain in 13 yo
SUFE
Undiagnosed Perthes
Muscular injury
Trauma
147
Examination findings for SUFE
Shortened, externally rotated hip
Reduced internal rotation
Waldling gait with external rotation
148
Mx of SUFE
May require a period of bed rest
| May need fixation with a cannulated hip screw
149
Transpyloric plane landmark for?
```
Hilum of the left kidney
SMA
Fundus of gallbladder
Neck of pancreas
1st part of deuodenum
portal vein
```
150
Calot triangle borders
Cystic duct
Common hepatic duct
Inferior hepatic border
151
Inguinal canal borders:
- superficial ring
- deep ring
- anterior wall
- posterior wall
- roof
- floor
- superficial ring
- deep ring
- anterior wall: ext oblique
- posterior wall: transversalis fascia + conjoint tendon medially
- roof: int oblique, transversus abdominus
- floor: inguinal ligament
152
6 Ps of acute limb ischaemia
```
Pulseless
Parasthaesia
Pain
Perishingly cold
Paralysis
Pallor
```
153
Major haemorrhage definition
Loss of entire blood volume in 24 hrs (eg 5 L in 70kg man)
| Loss of 50% in 3 hours
154
Beck's triad
Muffled heart sounds
Hypotension
Raised JVP
155
Factors increasing risk of hip dislocation post replacement
Patient:
- F >M (*2)
- Age
- obesity
- alcohol
Surgical:
- posterior approach>antero-lateral
- capsular excision
- smaller femoral head size
156
Anterio-lateral vs posterior approach risk vs benefit
A-L: increased risk of
- sciatic n palsy,
- trochanteric bursitis
- post op bleed
Posterior:
- increased risk of dislocation
157
Risk factors for anastamotic leak
Patient:
- age (old)
- gender (male)
- malnutrition
- long term steroids
- Smoking and alcohol
Operative:
- poor operative technique
- increased bowel handling
- level of anastemosis (left sided worse than right sided)
Post op:
- sepsis
- constipation
158
Operative mx of anastemotic leak
1. faecal diversion
Washout + Loop ileostomy or colostomy
2. Hartmanns procedure
Resection of anasetomsis and closing the proximal stump
(difficult to reconstruct later)
159
Alternative to erect CXR if patient cannot sit up
Left lateral decubitus film (lean on the left side)
| Air between liver and abdo wall
160
Operative mx of a perforated ulcer
Omental patch repair if large through a upper midline laparotomy incision
(could sometimes self seal with conservative mx)
161
Intussesseption month of presentation
Winter months (some link with flu like symptoms pre-disposing)
162
Age of presentation for intussusception
6-9months old
163
Intussusception sx
colicky pain
D+V
Sausage shaped mass
Red currant jelly stool
164
Pyloric stenosis age
4-6 wks of life
165
Pyloric stenosis Sx
projectile non bile stained vomit
166
Pyloric stenosis Ix
Test feed
USS: thickened pylorus, target sign
167
Pyloric stenosis mx
Ramstedt pyloromyotomy (open or laparoscopic)
168
Causes of urinary outlet obstruction
Prostate:
- benign or malignant
- prostatitis
Urethral structure
Constipation
Neurological: MS, DMII
169
Gleason scoring for prostate
Given as two numbers
Refers to predominant and second most predominant cell type
6 or more tend to do worse
4 or less tend to do better
170
Gleason scoring for prostate
Given as two numbers
Refers to predominant and second most predominant cell type
6 or more tend to do worse
4 or less tend to do better
171
Cierny Mader staging system
```
Osteomyelitis staging
1 and 2 abx, 3 and 4 surgical rx
1. medulla
2. superficial
3. localised
4. diffuse
```
172
Mx of cardiac tamponade
Pericardiocentesis
| In post op pts: re-do sternotomy and removal of blood in pericardial sac
173
What are the common sites of post op infection
6 Cs:
```
Cannula
Catheter
Calf: dvt
Cut (incision)
Chest
Collection
```
174
Boerhaave syndrome
Maklers triad:
- surgical emphysema
- recurrent vomiting
- oesophageal perf
175
3 types of wound healing
Primary intension: wound closed by sutures
Secondary: closed from base up by granulation formation
Tertiary: delayed closure, first wait for granulation tissue, then close the top
176
Supracondylar fracture classification
Gartlands classification
1: cast immobilisation 4 wks
2: closed reduction and percutaneous pinning (CRPP)
3 and 4: CRPP or open reduction
176
Supracondylar fracture classification
Gartlands classification
1: cast immobilisation 4 wks
2: closed reduction and percutaneous pinning (CRPP)
3 and 4: CRPP or open reduction
177
Different types of haemorrhage
Primary: during operation
Reactive: within 24hrs post-op - clot dislodgement, or rise in BP post op leading to bleeding
Secondary: 7 days post op most likely infection, injury
178
Volkmanns contracture
Forearm fracture could lead to ischaemia and necrosis of forearm muscles
Leads to fibrosis and shortening, especially the flexor component
