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Interview Preparation > Clinical Station - New Patient > Flashcards

Clinical Station - New Patient Flashcards

1
Q

What are the risk factors for NOF fracture (structure this!)

A
  • Osteoporosis
  • Metabolic = Osteomalacia, Paget’s
  • Malignant = metastatic deposits, primary cancer
  • Infective = osteomyelitis
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2
Q

How would you approach NOF fracture assessment

A
  1. ATLS principles with A-E approach
  2. Treat any life threatening issues and resuscitate with Crystalloid
  3. Take an AMPLES history before starting appropriate analgesia
  4. Once stable, take a focused history to include cause of fall and mobility and calculate AMTS
  5. Perform a focused examination of the limb ensuring documentation of the NV status
  6. Bed side tests - urine dip, ECG, MRSA swabs
  7. Haematological tests - FBC, U&E, Bone Profile, LFT, G+S
  8. Imaging - AP and lateral of hip, CXR, ?full length femur
  9. Consider further investigations e.g. echo
  10. Inform senior of patient
  11. Commence additional treatments as per local protocol such as VTE prophylaxis and MRSA decolonisation
  12. Mark and consent patient for theatre and keep NBM
  13. Discuss at next trauma meeting to be listed and arrange OG review
  14. Update NOK
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3
Q

Outline Garden Classification

A
  1. Stable fracture with Valgus impaction
  2. Non-displaced, complete fracture
  3. Displaced fracture with maintained end-to-end contact
  4. Completely displaced fracture
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4
Q

Who should be offered THR according to NICE following NOF fracture

A

Displaced intracapsular hip fracture who:

  • Able to walk independently out of doors with no more than 1 stick
  • Are not cognitively impaired
  • Are medically fit for anaesthesia
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5
Q

How would NOF fracture be managed in a younger patient

A
  • ORIF (attempt to preserve native femoral head)

- High risk of AVN so follow up closely and consent appropriately

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6
Q

Hip fracture complications (structure this)

A
  • Bone healing = non-union, malunion, osteonecrosis
  • Biomechanical = dislocation
  • Social = loss of independence
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7
Q

Supracondylar fracture associated injuries

A
  • Neurological = AIN neuropraxia
  • Vascular = Brachial artery spasm/injury
  • Bony = Ipsilateral distal radius fracture
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8
Q

How can you detect supracondylar fractures on XR

A
  • Soft tissue signs = posterior fat pad, anterior sail

- Bony measurements = displacement of anterior humeral line, alteration of Baumann angle

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9
Q

How are supracondylar fractures classified

A

Gartland Classification:

  1. Non-displaced
  2. Displaced in 1 plane with posterior periosteal hinge
  3. Complete displacement
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10
Q

How are supracondylar fractures treated

A

T1 - cast immobilisation for 3-4 weeks
T2 - CRPP
T3 - CRPP or ORIF

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11
Q

How would you approach assessing a patient with suspected supracondylar fracture

A
  1. ATLS principles with A to E approach
  2. Ensure legal guardian is present
  3. AMPLES history
  4. Examine limb paying close attention to soft tissues and NV status
  5. Analgesia
  6. Splint in 30-40 degrees of flexion
  7. NBM
  8. Consent form 2
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12
Q

Supracondylar fracture complications (structure this)

A
  • Hardware = pin migration, infection
  • Bony = cubitus varus/valgus
  • Vascular = brachial artery injury, Volkmann ischaemic contracture
  • Neurological = AIN palsy
  • Soft tissue = stiffness
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13
Q

Differential diagnosis for painless haematuria (structure this)

A
  • Bladder = cancer, cystitis
  • Renal = RCC, renal stones
  • Ureter = ureteric stones
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14
Q

Investigations for painless haematuria (structure this)

A
  • Bedside = observations, urine dip, urine MC&S, ECG
  • Haematological = FBC, U&E, LFT, Bone profile, Coag, G+S
  • Imaging = US KUB, CT KUB , IV Urogram
  • Invasive = cystoscopy (Gold standard for bladder cancer)
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15
Q

NICE Guidelines for haematuria

A
  • Patients over 50 with microscopic haematuria

- Any patient with macroscopic haematuria

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16
Q

Outline the treatment for bladder cancer

A
  • Superficial = TURBT, intravesical chemotherapy
  • Invasive = radical cystectomy, radical radiotherapy
  • Metastatic = platinum-based chemotherapy
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17
Q

Grade 1 Shock

A
  • 15% blood loss (750ml)
  • Mild tachycardia <100
  • Normal BP
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18
Q

Grade 2 Shock

A
  • 30% blood loss (1.5L)
  • Tachycardia 100-120
  • BP normal
  • RR >20
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19
Q

Grade 3 Shock

A
  • 40% blood loss (2L)
  • Tachycardia 120-140
  • Hypotension
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20
Q

Grade 4 Shock

A
  • > 40% blood loss
  • Tachycardia >140
  • Marked hypotension
  • Confusion
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21
Q

Loin pain differential diagnosis

A
  • AAA
  • Pyelonephritis
  • Renal colic
  • Diverticulitis
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22
Q

How would you assess a patient with loin pain

A
  1. ATLS principles with an A to E approach
  2. Full history focusing on urinary symptoms, infective symptoms, AAA
  3. Focused abdominal examination feeling or expansile or other masses, renal angle tenderness
  4. Basic bedside tests including urine dip, ECG
  5. Insertion of IV cannula and take bloods including cross-match 10 units
  6. FAST scan to ascertain AP diameter of abdominal aorta
  7. Alert senior
  8. If renal colic then CT KUB, If AAA then CT angiogram
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23
Q

Define an aneurysm

A

Pathological dilatation of an artery >1.5x its normal diameter

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24
Q

Define true aneurysm

A

Dilatation involving all layers of the vessel wall

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25
Q

Define false aneurysm

A

Defect in the vessel wall with blood outside the lumen but contained within fibrous capsule

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26
Q

When is elective AAA repair indicated

A

AA diameter >5.5cm

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27
Q

What are the causes of aneurysms

A
  1. Degenerative
  2. Inflammatory
  3. Congenital
  4. Mycotic
  5. Infective
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28
Q

What are the risk factors for AAA (structure this)

A 
Modifiable:
- HTN
- Smoking 
- Hyperlipidaemia 
Non-Modifiable:
- Age
- Male sex
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29
Q

Outline the management options for ruptured AAA (structure this)

A
  • Conservative = palliation

- Surgical = open or endovascular

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30
Q

Most common site of AAA

A

Infrarenal abdominal aorta

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31
Q

Most common site of AAA rupture and consequence

A

Posterior wall causing retroperitoneal haemorrhage

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32
Q

6 Ps of critical limb ischaemia

A
  • Pain
  • Pulseless
  • Perishing cold
  • Pallor
  • Paraesthesia
  • Paralysis
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33
Q

Outline the principles of management in acute limb ischaemia

A
  1. Resuscitation
  2. Escalation to a vascular centre
  3. Immediate anticoagulation with 5000 units IV heparin
  4. Analgesia
  5. Restore arterial continuity
  6. Identify and correct underlying source of embolus
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34
Q

How does a limb with <6 hours of ischaemic time appear

A

White

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35
Q

How does a limb with 6-12 hours ischaemic time appear

A

Mottled with blanching on pressure

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36
Q

How does a limb with >12 hours ischaemic time appear

A

Fixed mottling

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37
Q

Outline the management for critical limb ischaemia (structure this)

A
  • Conservative = palliation with medication to optimise comfort
  • Medical = heparin infusion, typically on a vascular ware
  • Surgical = embolectomy or amputation
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38
Q

Outline the components of a vascular examination

A
  • Look = signs of PVD e.g. eczema, ulcers, gangrene
  • Feel = temperature, capillary refill time, peripheral pulses, aorta, sensation and power
  • Listen = bruits over major arteries
  • Additional = cardiovascular examination
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39
Q

Buergers angle for critical ischaemia

A

25 degrees

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40
Q

When should fasciotomy be considered in reperfusion surgery

A

If ischaemic time >6 hours

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41
Q

Outline the structure of the skin

A
  • Epidermis - superficial part consisting of 5 layers

- Dermis - split into reticular and papillary layer

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42
Q

What type of collagen is found in skin

A

Mostly Type 1 in a ratio of 4:1 with Type 3

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43
Q

How are burns classified

A
  1. Superficial/Epidermal
  2. Superficial partial thickness
  3. Deep partial thickness
  4. Full thickness
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44
Q

Define a partial thickness burn

A

Burn leaves part of the germinal epithelium in tact (dermis) so complete healing can take place

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45
Q

Define a full thickness burn

A

Destroys the germinal layer (dermis) and therefore can only heal by scarring

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46
Q

How does a superficial burn appear

A

Red, moist, blanching (no blistering)

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47
Q

How does a superficial partial thickness burn appear

A

Moist, blistered, pink, blanching

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48
Q

How does a deep partial thickness burn appear

A

dry, mottled, red, non-blanching

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49
Q

How does a full thickness burn appear

A

dry, leather, hard, non-blanching, painless

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50
Q

Outline the rule of 9s

A
  • Front trunk = 18%
  • Back trunk = 18%
  • Upper limb = 9%
  • Lower limb front = 9%
  • Lower limb back = 9%
  • Head and neck = 9%
  • Perineum = 1%
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51
Q

How can TBSA be estimated

A
  • Rule of 9s

- Palm surface area

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52
Q

When is IV fluid resuscitation required in burns

A
  • Adult = TBSA >15%

- Child = TBSA >10%

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53
Q

How is IV fluid resuscitation calculated in burns patients s

A

Parkland Formula = 2 x weight (KG) x TBSA

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54
Q

List the criteria for Burns Unit transfer

A
  • Need burn fluid resuscitation
  • Face/feet/hands/genitals
  • Deep partial thickness or full thickness burns
  • Significant electrical/chemical burns
  • Inhalation injury
  • Co-morbidities that could affect recovery
  • Burns and concomitant trauma
  • Burnt children
  • Special social requirements
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55
Q

Outline the surgical interventions required in burns

A
  • Full thickness = split thickness graft

- Circumferential = escharotomy

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56
Q

How would you manage a burns patient?

A
  1. Stop the burning process
  2. Establish airway control
  3. Ensure adequate ventilation
  4. Manage circulation with burn shock protocol
  5. AMPLES history
  6. Blood work inc carboxyhaemoglobin
  7. CXR if suspected inhalation injury
  8. Assess for signs of compartment syndrome
  9. Analgesia and sedation
  10. Tetanus prophylaxis
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57
Q

When is tracheal intubation required in a burns patient?

A
  • Signs of airway obstruction
  • TBSA >40%
  • Extensive facial burns
  • Burns in mouth
  • Difficulty swallowing
  • Respiratory compromise
  • Decreased GCS
  • Carboxyhaemoglobin >10%
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58
Q

List three types of skin graft

A
  1. Full thickness = consists of epidermis and whole depth of dermis. Donor site requires closure.
  2. Split thickness = includes epidermis and part of the dermis. Donor site heals by re-epithelialisation.
  3. Composite graft = contains skin, cartilage, or other tissue
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59
Q

Swollen testicle differential diagnosis (structure this)

A
  • Testicular = malignancy, hydrocele, spermatocele, epididymitis, torsion
  • Abdominal = hernia
  • Vascular = varicocele
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60
Q

Most likely causes of epistaxis (structure this)

A
  • Local = digital trauma causing bleeding from Little’s area
  • Systemic = anticoagulation, bone marrow failure, thrombocytopenia, liver failure
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61
Q

How would you manage a patient with epistaxis

A
  1. My priority would be to arrest the haemorrhage
  2. I would assess the patients in an ATLS fashion using an A to E approach
  3. This would involve assessment of his pulse, BP, CR, respiratory rate and an estimation of blood loss
  4. I would secure IV access and take bloods for FBC, clotting, crossmatch
  5. I would commence resuscitation fluids as appropriate
  6. I would ask a member of the nursing staff to apply pressure to the cartilaginous part of the nose with the patient leant forward
  7. I would contact my senior and the ENT registrar on call
  8. If simple measures failed to arrest the bleeding I would want to insert a nasal pack
  9. If a single bleeding point was identified this could be chemically cauterised with silver nitrate
  10. It is likely ENT would perform rhinoscopy
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62
Q

Patient with epistaxis has a raised INR, what would you do?

A
  1. I would consider the reason why the patient requires Warfarin and discuss reversal with my registrar or haematology
  2. I would stop the Warfarin and give oral or IV Vitamin K as per NICE guidelines
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63
Q

List the risk factors for renal stone formation

A
  • High protein intake
  • Family history
  • Warm climate
  • Dehydration
  • Previous stones
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64
Q

Where are stones likely to impact in the renal tract

A
  1. PUJ
  2. SIJ
  3. VUJ
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65
Q

Differential diagnosis for ureteric colic

A
  • AAA
  • Appendicitis
  • Diverticulitis
  • Ectopic pregnancy
  • Salpingitis
  • Ovarian torsion
  • Biliary colic
  • Pyelonephritis
  • PUJ obstruction
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66
Q

What is the Gold Standard investigation for renal stone disease

A

CT-KUB (IV Urogram)

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67
Q

Outline the acute management of ureteric colic

A
  1. Supportive - rectal diclofenac, antiemetics, rehydration, alpha blockers
  2. Drainage - if septic will require nephrostomy or retrograde ureteric stent
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68
Q

Outline the surgical management of ureteric stones in a non-septic patient

A
  1. ESWL - for stones <2cm

2. Ureteroscopy and stone destruction

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69
Q

Outline the surgical management of renal stones in a non-septic patient

A
  1. ESWL
  2. PCNL
  3. Flexible ureterorenoscopy and laser lithotripsy
  4. Open surgery
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70
Q

Describe the structure of the prostate

A
  1. Transitional zone - surrounds the urethra proximal to the ejaculatory ducts (where BPH occurs)
  2. Central zone - surounds ejaculatory ducts
  3. Peripheral zone - where cancer arises
  4. Anterior fibromuscular stroma
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71
Q

What are the most common causes of urinary tract obstruction? (structure this)

A
  • Upper tract = stones, malignancy, PUJ obstruction
  • Lower tract = BPH, prostate cancer, urethral stricture
  • Neurological = MS, diabetes
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72
Q

How does BPH typically present

A

Voiding LUTS - hesitancy, poor stream, straining, terminal dribbling

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73
Q

How can the symptoms of prostate disease be graded

A

International Prostate Symptom Score

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74
Q

How would you investigate a patient with suspected BPH

A
  1. Urinalysis
  2. Post-void bladder scan
  3. Renal function
  4. PSA
  5. Uroflowmetry
  6. Formal urodynamic studies
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75
Q

Outline the management of BPH (structure this)

A
  • Conservative = lifestyle measures e.g. reduce caffeine, reassurance
  • Medical = Adrenergic antagonsists and 5alphja-reductase inhibitors
  • Surgical = TURP, retropubic prostatectomy
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76
Q

What is TURP syndrome

A
  • Caused by absorption of large volumes of irrigation fluid through the prostatic venous plexus
  • Causes hypervolaemia, hyponatraemia, cerebral oedema
  • Symptoms include confusion, bradycardia, visual changes, seizures
  • Treat with diuretics
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77
Q

How would you insert a suprapubic catheter

A
  1. Consent the patient
  2. Prepare the lower half of the abdomen with chlorhexadine and inject LA above the pubic symphysis
  3. As anaesthetic injected more deeply urine should be aspirated
  4. Make a small incision and use a trochar and plastic sheath to introduce a 16Fr catheter
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78
Q

What are the contraindications to suprapubic catheterisation

A
  • Previous abdominal surgery
  • History of bladder TCC
  • Any bleeding tendency
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79
Q

Describe the Gleason Score

A

Grading system used to determine prognosis in patients with prostate cancer:

  • 2-4 = low grade
  • 5-7 = moderate grade
  • 8-10 = high grade
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80
Q

Outline the treatment options for Prostate Cancer (structure this)

A
  1. Conservative - active surveillance for low grade disease
  2. Medical - hormonal therapy in metastatic disease
  3. Radiological - radiotherapy or brachytherapy for localised disease
  4. Surgical - radical prostatectomy for localised disease
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81
Q

What organisms cause urinary tract infections

A
  • E.coli
  • Proteus
  • Klebsiella
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82
Q

How would you investigate a testicular lump

A
  1. Examination
  2. Urine dip
  3. USS scrotum
  4. CXR to exclude chest mets
  5. Renal USS in older men with varicocele
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83
Q

What are the two classes of testicular torsion

A
  1. Extravaginal - seen in neonates, incomplete fixation of the gubernaculum to the scrotal wall allows twisting
  2. Intravaginal - most common, high investment of the tunica vaginalis allows testis to rotate
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84
Q

Signs of testicular torsion

A
  • Acutely painful and tender hemiscrotum
  • Pain radiates to groin/loin
  • Vomiting
  • Testes lie horizontal as opposed to vertical (bell-clapper)
  • Loss of cremasteric reflex
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85
Q

What causes hydroceles

A
  • Children = patent processus vaginalis (primary hydrocele)

- Adults = primary, infection, tumour, trauma

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86
Q

How does a hydrocele present

A
  • Painless scrotal swelling
  • Able to palpate the cord above
  • Transilluminates
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87
Q

Outline the treatment of hydroceles

A
  • Conservative = if not causing discomfort
  • Aspiration = carries risk of infection
  • Open repair (gold standard) = Lord Repair or Jaboulay repair
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88
Q

How is an epididymal cyst differentiated from a hydrocele

A

The testicle can be palpated separately from a cyst

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89
Q

What is a varicocele

A

Dilatation of the pampiniform plexus that runs within the spermatic cord

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90
Q

Describe how testicular cancer presents

A
  • Painless testicular lump
  • Described as a heaviness/ache
  • Testes feel firm with thickened cord
  • Can present with metastatic disease e.g. chest symptoms
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91
Q

Outline the management of testicular cancers

A
  1. Orchidectomy via an inguinal approach
  2. Follow up depends on type and stage
    - Seminoma confined to testes = surveillance CTs
    - Seminoma with lymph node mets = chemoradiotherapy
    - NSGT confined to testes = close surveillance
    - NSGT with mets = combination chemotherapy
92
Q

What are the important sites of blood loss to consider in trauma

A
  • Obvious external exsanguination
  • Thorax
  • Abdomen
  • Pelvis
  • Long bones
93
Q

How would you apply a pelvic binder?

A

I would internally rotate the patient’s legs at the hips and apply the pelvic binder at the level of the greater trochanters. I would then tighten the binder and secure it in position.

94
Q

What is shock?

A

A state where the circulatory system is unable to achieve adequate end organ perfusion

95
Q

What are the types of shock (structure this)

A
  1. Cardiogenic shock which is pump failure
  2. Distributive shock which includes septic, neurogenic and anaphylactic shock
  3. Hypovolaemic shock
96
Q

What are the stages of hypovolaemic shock

A

Can be remembered as a tennis score (0-15-30-40)

  1. <15% loss - mild tachycardia
  2. 15-30% loss - pulse pressure narrows
  3. 30-40% - hypotension
  4. > 40% - profound end organ dysfunction
97
Q

List the causes of haematemesis (structure this)

A
  1. Oesophageal = varices, ulceration, trauma, Mallory-Weiss
  2. Stomach = ulcers, cancer, varices
  3. Duodenal = ulcers, varices, malignancy, angiodysplasia
98
Q

Why does Hb reading not reflect acute blood loss

A

In acute blood loss both red cells and plasma are lost in the same ratio. Serum Hb will only fall after redistribution of interstitial fluid into the plasma occurs 8-12 hours later.

99
Q

Approach to acute assessment of UGIB

A
  1. ATLS principles and adopt A-E approach
  2. If the patient is alert and communicating airway maintenance can be assumed
  3. I would look, feel and listen to the chest and attach a pulse oximeter. I would administer oxygen.
  4. I would assess circulation through CR, pulse, and BP assessment. I would listen to the heart. I would look for other sources of obvious blood loss.
  5. I would insert 2 large bore cannula and take bloods for FBC, U&E, LFT, Coag, Crossmatch, VBG
  6. I would commence a 500ml fluid bolus and assess response
  7. I would examine the patients abdomen looking for epigastric tenderness, peritonitis, or masses and perform a PR examination
  8. I would take an AMPLES style history
  9. I would alert my SpR and ITU
  10. If presumed blood loss was >1.5L I would initiate hte major haemorrhage protocol
  11. I would commence IV PPI +/- Terlipressin
  12. I would contact the on-call scope consultant and keep the patient NBM
100
Q

Outline the definitive treatment for UGIB pathology

A
  1. Varices - endoscopy coagulation or banding, IV vasopressin
  2. Ulcer - endoscopic coagulation or injection, local excision, partial gastrectomy
  3. Cancer - partial or subtotal gastrectomy
101
Q

How do duodenal ulcers present

A
  • Epigastric pain on fasting
  • Pain at night
  • Relieved by food and antacids
  • Relapsing remitting
  • Back pain
102
Q

How do gastric ulcers present

A
  • Pain on eating
  • Weight loss
  • N+V
  • IDA
103
Q

How are ulcers investigated

A
  1. Endoscopy + CLO
  2. Double-contrast barium meal
  3. H. pylori tests
104
Q

Outline the difference between the surgical management of gastric ulcers Vs. duodenal ulcers

A
  • Gastric = removal of the ulcer and antrum with Bilroth 1 or 2
  • Duodenal = reduce acid secretion via vagotomy
105
Q

What is dumping syndrome

A

Group of cardiovascular and GI symptoms resulting from rapid gastric emptying after truncal vagotomy or gastric resection.

  1. Early dumping is due to hypovolaemia
  2. Late dumping is due to hypoglycaemia
106
Q

What postoperative complications are associated with ulcer operations (structure this)

A
  • Anastomotic = obstruction, leak, oesophagitis, bleeding, reflux
  • Nerve related = diarrhoea, gastric atony, gastric outlet obstruction, gallstones
  • Loss of stomach function = dumping, B12 deficiency, IDA, malnutrition
  • Gastric remnant cancer
  • Pancreatitis
107
Q

Why do you get low calcium in pancreatitis

A

Fat necrosis results in the release of triglycerides. These combine with calcium in a process called saponification leading to hypocalcaemia.

108
Q

Eponymous signs associated with pancreatitis

A
  • Grey-Turners sign = bruising on the flanks caused by retroperitoneal haemorrhage
  • Cullen’s sign = peri-umbilical bruising secondary to pancreatic enzyme tracking to the anterior abdominal wall with subsequent tissue digestion
109
Q

Common causes of epigastric pain

A
  • Pancreatitis
  • Gastritis
  • Peptic ulcer
  • MI
110
Q

Common causes of umbilical pain

A
  • SBO
  • Intestinal ischaemia
  • Aortic aneurysm
    Gastroenteritis
  • Crohn’s
111
Q

What are the causes of acute bowel ischaemia

A
  • Acute embolic or thrombotic occlusions of the SMA
  • Non-occlusive mesenteric ischaemia due to low CO
  • Mesenteric vein thrombosis
112
Q

Difference between embolic and thrombotic SMA occlusion

A

Embolic occlusion (from MI or AF) spare the jejunum as they lodge at the branch of the middle colic artery

113
Q

Gold standard investigation for mesenteric ischaemia

A

Mesenteric angiography

114
Q

Outline the management of mesenteric ischaemia

A
  1. Resuscitate
  2. Restore blood flow:
    - SMA embolus = arteriotomy and embolectomy
    - Thrombus = aortmesenteric bypass
  3. Resect necrotic bowel
  4. Assess viability of dubious bowel
115
Q

Scoring systems for pancreatitis

A
  • Glasgow

- Ranson

116
Q

Outline the Glasgow score

A
  • PaO2 <8
  • Age >55
  • Neutrophils >15
  • Calcium <2
  • Renal (urea >16
  • Enzymes (AST >200, LDH >600)
  • Albumin <32
  • Sugar (glucose >10)
117
Q

Define a mechanical bowel obstruction

A

Physical blockage inhibiting the transit of bowel contents

118
Q

Define a closed loop obstruction

A

Colonic obstruction with a competent ileocaecal valve that prevents air escaping proximally into the small bowel, accelerating large bowel distension

119
Q

Outline the management of pseudo-obstruction

A
  1. Rule out mechanical obstruction
  2. Correct electrolytes and nutrition
  3. Rigid sigmoidoscope and flatus tube
  4. Prokinetics such as Erythromycin and Neostigmine
120
Q

Common causes of SBO

A
  1. Adhesions
  2. Hernias
  3. Intra-abdominal neoplasia
121
Q

Common causes of LBO

A
  1. Tumour
  2. Diverticular stricture
  3. Volvulus
122
Q

Describe expected bowel sounds in obstruction Vs. ischaemia

A
  • Obstruction = high pitched and tinkling

- Ischaemia = absent

123
Q

What is Laplace Law

A

As pressure rises, tension in the wall is maximal at the point where the diameter of the tube is greatest

124
Q

Describe how you would manage SBO?

A
  1. Unless there is evidence of strangulation, perforation or closed-loop obstruction then you can initially manage non-operatively
  2. This involves analgesia, antiemetics, and symptoms control
  3. An NG tube would be used to decompress the stomach and IV fluids administered to replace losses
  4. The patient should be kept NBM
  5. I would discuss the patient with my seniors and also explain the diagnosis to the patient
125
Q

What factors suggest strangulation in SBO

A
  • Tachycardia
  • Fever
  • Tenderness and peritonism
  • Leucocytosis
  • High risk hernias/unscarred abdomen
126
Q

Define cholecystitis

A

Cholecystitis occurs when a gallstone becomes impacted in Hartmann’s pouch, blocking the exit of the GB

127
Q

How would you assess a patient with suspected cholecystitis?

A
  1. I would assess the patient according to ALS principles using an A to E approach and treat any life threatening issues as they arose
  2. I would check the patients allergy status and given analgesia
  3. Assuming the patient is stable I would take a focussed history taking note of nature of pain, eliciting features, PMH, alcohol intake
  4. I would then perform a focused examination of the abdomen, looking for signs of jaundice and CBD obstruction
  5. I would take some initial blood tests including FBC, U&E, LFT, Amylase, Clotting, Crossmatch and a VBG
  6. I would then arrange imaging including an USS abdomen and erect CXR
  7. If there were signs of infection or pancreatitis I would start antibiotics according to local guidelines
  8. I would score the patient to gauge severity
  9. I would make the patient NBM, start IV fluids and commence a fluid balance chart
  10. I would alert my senior registrar and ITU if required
128
Q

What are the complications of cholecystitis?

A
  • GB Empyema or abscess
  • Perforation with biliary peritonitis
  • Gallstone ileus
  • Mirizzi syndrome
  • Chronic cholecystitis
129
Q

Differential diagnosis for diffuse goitre

A
  • Physiological
  • Iodine Deficiency
  • Treated Graves disease
130
Q

Differential diagnosis for solitary thyroid nodule

A
  • Adenoma (80%)
  • Papillary Ca
  • Follicular Ca
  • Medullary Ca
  • Cyst
  • Fibrosis
  • Thyroiditis
131
Q

Differential diagnosis for parathyroid mass

A
  • Adenoma
  • Hyperplasia
  • Carcinoma
132
Q

How would you examine a neck lump?

A
  • Size, shape, sounds, skin
  • Tenderness, temperature, tethering, transillumability
  • Colour, contour, compressibility, consistency
  • Provocative movements - tongue protrusion, swallowing
  • Systemic features of thyroid disease
133
Q

How would you investigate a neck lump

A
  1. Bedside observations
  2. Blood tests - TFT, PTH, Bone profile, Calcitonin
  3. Antibody screen - TBG, TPO, TSH-receptor
  4. Triple Assessment - Exam, USS, FNAC
134
Q

Management of papillary carcinoma

A
  1. Total thyroidectomy with neck dissection
  2. T4 for TSH suppression
  3. Annual thyroglobulin
135
Q

Management of thyroid adenoma

A

Thyroid lobectomy for confirmation of diagnosis

136
Q

Management of acute thyroiditis

A

Antibiotics and analgesia

137
Q

Management of De Quervains thyroiditis

A

Aspirin and Prednisolone

138
Q

How do you manage an expanding neck haematoma following thyroidectomy

A
  1. Release the skin sutures
  2. Evacuate the subcutaneous haematoma
  3. If there is swelling beneath the strap muscles then divide the vicryl sutures and evacuate the haematoma from this layer
  4. Urgent senior support
139
Q

Complications of thyroidectomy

A
  • Bleeding
  • Nerve damage - ELN, RLN
  • Thyroid crisis
  • Hypothyroidism
  • Hypocalcaemia
  • Stridor
  • Laryngeal oedema
  • Aspiration of vomit
  • Tracheomalacia
  • Pain
  • Dysphagia
  • Keloid/hypertrophic scars
140
Q

Most common abdominal organs injured in blunt trauma

A
  • Spleen
  • Liver
  • Small bowel
141
Q

What is a contraindication to FAST and DPL studies in the trauma patient

A

Already identified indication for laparotomy

142
Q

Where does the FAST scan examine?

A
  • Pericardial sac
  • Hepatorenal fossa
  • Splenorenal fossa
  • Pelvis (Pouch of Douglas)
143
Q

What are the signs of splenic trauma

A
  • Haemorrhage

- Kehr’s sign - shoulder tip pain

144
Q

How is splenic trauma classified?

A
  1. Capsular tear
  2. Tear and parenchymal injury
  3. Tear up to the hilum
  4. Complete fracture
145
Q

How is splenic trauma managed?

A
  • Haemodynamic instability = laparotomy and splenectomy
  • Stable 1-3= HDU observation
  • Stable 4 = consider laparotomy
146
Q

What long-term prophylaxis is required in splenectomy patients

A
  • Pneumovax
  • Hib vaccin
  • Meningovax
  • Penicillin
147
Q

How is liver trauma graded?

A 
1 = small laceration or subcapsular haematoma 
6 = avulsion incompatible with survival
148
Q

How is pancreatic trauma typically sustained?

A

Blunt trauma arising from compression of the pancreas against the spinal column

149
Q

How is pancreatic trauma graded?

A
  • Major = proximal gland damage with gland disruption
  • Intermediate = distal gland damage with duct disruption
  • Minor = contusion or laceration without duct injury
150
Q

Who is renal trauma more likely to occur in and why?

A

Children - kidneys are relatively larger

151
Q

How is renal trauma classified?

A 
1 = contusion, subcapsular haematoma 
2 = minor laceration of the cortex 
3 = major laceration extending through the cortex and medulla 
4 = major laceration involving the collecting system 
5 = completely shattered kidney or renal pedicle avulsion
152
Q

What are the criteria for renal imaging?

A
  • Any penetrating trauma to flank or abdomen with haematuria
  • Blunt trauma with haematuria
  • Blunt trauma with microscopic haematuria and SBP <90
  • Deceleration injury
  • Associated major intra-abdominal injury and microscopic haematuria
  • Any child with a degree of haematuria
153
Q

How is renal trauma managed?

A
  • 98% blunt trauma is managed conservatively with USS monitoring
  • Indications for renal exploration include:
    a) Persistent hypotension
    b) Expanding haematoma
    c) Disruption of the renal pelvis with leakage of urine
154
Q

What are the signs of bladder trauma?

A
  • Macroscopic haematuria
  • Lower abdominal pain and oliguria/anuria
  • Urinary peritonitis
  • Blood urea rises with extravasation of urine
155
Q

How is bladder trauma investigated?

A

Retrograde cystography

156
Q

What should you do if you suspect urethral trauma?

A

Perform retrograde urethrogram

157
Q

List the indications for laparotomy in abdominal trauma

A
  • Blunt abdominal trauma with hypotension and positive FAST
  • Hypotension with abdominal wound that penetrates the anterior fascia
  • Gunshot wounds that traverse the peritoneal cavity
  • Bleeding from the stomach, rectum, or GU tract following penetrating trauma
  • Evisceration
  • Peritonitis
  • Free air
  • CT scan demonstrating rupture, bladder injury, renal pedicle injury
  • Aspiration of stomach contents or >10cc blood on DPL
158
Q

How can a child’s size and weight be quickly assessed during trauma

A

Broselow paediatric emergency tape

159
Q

What is the most common cause of cardiac arrest in children

A

Hypoxia secondary to airway obstruction

160
Q

Outline the issues of child airway management related to anatomy

A
  1. Large occipitut means c-spine is naturally flexed when supine
  2. Tongue and tonsils are relatively large
  3. Funnel shaped larynx pools secretions
  4. Short trachea
  5. Vocal cords are difficult to visualise
161
Q

Difference on oropharyngeal airway insertion for children

A

Do NOT insert upside down due to risk of damage to soft tissue structures

162
Q

Preferred definitive airway in children

A

Orotracheal intubation using uncuffed ET tube

163
Q

Risks of bag-valve-mask in ventilating children

A

Barotrauma

164
Q

How much blood needs to be lost for a child to become hypotensive?

A

45%

165
Q

Equation for estimating weight in children

A

(2 x age in years) + 10

166
Q

Fluid bolus volume in children

A

20ml/KG

167
Q

What is the most common immediately life threatening chest injury in children?

A

Tension pneumothorax

168
Q

What factors raise suspicion of NAI?

A
  • Discrepancy between history and injury
  • Delayed presentation
  • Repeated trauma
  • Incoherent history between parents
  • History of “doctor shopping”
  • Inappropriate response to medical advice
  • MOI implausible based on the child’s development stage
169
Q

Define primary and secondary head injury

A
  • Primary = occurs at the time of injury and directly damages the brain tissue
  • Secondary = occurs after primary injury and is caused by hypoxia, hypercapnia, hypotension, raised ICP, infection
170
Q

What causes extradural haematoma?

A
  • Trauma to the temporal or parietal bones

- Rupture of the middle meningeal artery

171
Q

How does extradural haematoma present?

A
  • Initial concussion
  • Lucid interval
  • Rapid decompensation
  • Pupillary dilatation
172
Q

Why does pupillary dilatation occur in extradural haematoma?

A

Herniation of the uncus of the temporal lobe across the tentorial edge compresses the 3rd nerve

173
Q

What causes acute subdural haematoma?

A
  • Severe head trauma

- Rupture of bridging veins

174
Q

Describe the Monroe-Kelly Doctrine

A
  • Explains intracranial compensation for an expanding intracranial mass
  • Cranium is a rigid box, therefore the total volume must remain constant if ICP is not to change
  • Increase in volume of one constituent results in compensatory fall in another
175
Q

How is cerebral blood flow calculated

A

MAP - ICP

176
Q

How should raised ICP be managed?

A
  • CTB for diagnosis of cause
  • Non-operative = nurse with head up, maintain normal pCO2, ICP bolt, optimise fluid management, mannitol, hyperventilate, thiopental
  • Operative = burr holes, craniotomy
177
Q

Outline the criteria for neurosurgery unit consultation

A
  • Skull fracture with abnormal neurology
  • Confusion or other neuro disturbance >12 hours
  • Coma continuing after resus
  • Suspect open basal skull fracture
  • Depressed skull fracture
  • Deterioration in GCS
  • Significant abnormality on imaging
178
Q

What are the indications for immediate CTB in head injury?

A
  • Suspicion of NAI
  • Post-traumatic seizure
  • GCS <14 (<15 in paeds)
  • GCS <15 2 hours post-injury
  • Open or depressed fracture
  • Basal skull fracture
  • Focal neurological deficit
  • 5cm laceration in children <1
179
Q

What are the 6 life-threatening chest injuries

A
  • Airway obstruction
  • Tension pneumothorax
  • Open pneumothorax
  • Massive haemothorax
  • Intercostal disruption
  • Cardiac tamponade
180
Q

Define flail chest

A

Two rib fractures in the same rib of two consecutive ribs (or when there is costochondral separation of a single rib from the thorax)

181
Q

What are the signs of flail chest

A
  • Paradoxical chest wall movement
  • Respiratory distress
  • Crepitus of ribs
  • Hypoxia
  • Hypovolaemia if associated with blood loss
182
Q

How does tension pneumothorax cause shock?

A

Obstructive shock - increasing pressure within the thoracic cavity causes marked reduction in venous return

183
Q

How is tension pneumothorax treated?

A
  • Immediate needle decompression

- Definitive chest drain insertion

184
Q

Signs of open pneumothorax

A
  • Respiratory distress
  • Sucking chest wound
  • Reduced air entry and increased percussion note over effected side
185
Q

How is open pneumothorax treated

A
  • Occlude wound with 3-sided dressing
  • Insert chest drain at alternative site
  • Will likely require surgical closure
186
Q

Define massive haemothorax

A

> =1500ml of blood drained from one side of the chest cavity on insertion of a chest drain (usually caused by penetrating thoracic injury)

187
Q

When is thoracotomy indicated in massive haemothorax

A

Immediate blood loss >2000ml or continuing loss of >200ml/hr

188
Q

What are the signs of cardiac tamponade?

A
  • Beck’s triad = raised JVP, muffled heart sounds, low BP
  • Kussmaul sign = raised JVP on inspiration
  • PEA arrest
189
Q

How can cardiac tamponade be distinguished from tension pneumothorax?

A

Tamponade will have breath sounds bilaterally

190
Q

How is cardiac tamponade treated?

A
  • Ideally thoracotomy should be performed ASAP by a trained surgeon
  • If unavailable, a subxiphoid pericardiocentesis can be used as a last resort
191
Q

Describe the 10-second A-E assessment

A

Asking the patient their name and what happened:

  • Talking = airway maintained
  • Speech = breathing not severely compromised
  • Description = alert and conscious with good perfusion to the brain
192
Q

What three XRs are used in the primary survey

A
  • XR C-spine
  • CXR
  • AP Pelvis
193
Q

What is the secondary survey?

A

A head-to-toe evaluation of the trauma patient including a complete history and physical assessment, including reassessment of the vital signs

194
Q

Outline the AMPLE history

A
  • Allergies
  • Medications
  • PMH
  • Last meal
  • Events
195
Q

Outline your approach to the management of an open fracture

A

Make way immediately to the patient as high energy trauma!

  1. ATLS
  2. Treat life-threatening issues
  3. History and top-to-toe examination
  4. Focused limb examination with documentation of neurovascular status (if concern use ABPI -> angiogram)
  5. IV antibiotics, tetanus, analgesia
  6. Re-align and splint limb
  7. Photograph wound
  8. Remove gross contamination and cover with saline soaked gauze and occlusive film
  9. Trauma CT
  10. AP and lateral XRs
  11. Alert senior
  12. Explain to patient, NBM, IV fluids, consent for theatre
196
Q

Outline the urgency of open fracture operating

A
  • Immediate = highly contaminated or vascular compromise
  • Within 12 hours = solitary high energy open fracture
  • Within 24 hours = low energy open fracture
197
Q

Differential for limping child aged 1-3

A
  • DDH
  • Discitis
  • Cerebral palsy
  • Toddler’s fracture
198
Q

Differential for limping child aged 4-10

A
  • Transient synovitis

- Perthes disease

199
Q

Differential for limping adolescent

A
  • SUFE
  • Osgood Schlatters
  • Osteochondritis dissecans
200
Q

Differential for limping child at any age

A
  • Septic arthritis
  • Osteomyelitis
  • JIA
  • Reactive arthritis
  • Malignancy
  • NAI
201
Q

How is Perthes disease managed

A
  • Bed rest
  • Pain relief
  • Physiotherapy
202
Q

Risk factors for DDH

A
  • Breech
  • First born
  • Family history
  • Oligohydramnios
203
Q

How should suspected DDH be imaged?

A
  • Birth - 4 month = USS

- >4 months = XR

204
Q

How is DDH treated?

A
  • Pavlik harness (<6 months and reducible)
  • Closed reduction and Spica (>6 months)
  • Open reduction and Spica (>18 months)
  • Open reduction and femoral osteotomy (>2 years)
205
Q

Define SUFE

A

Displacement of the epiphysis infero-posteriorly through the physis

206
Q

Risk factors for SUFE

A
  • Obesity

- Endocrine disorders

207
Q

What are the consequences of SUFE

A

It is an orthopaedic emergency as further slippage risks AVN

208
Q

Signs of SUFE on examination

A
  • Waddling gait
  • Foot will be in ER and can be short
  • ROM is limited particularly in IR
209
Q

In whom should prophylactic contralateral hip fixation be performed in with SUFE

A
  • Initial slip at young age <10
  • Open triradiate cartilage
  • Obese males
  • Endocrine disorders
210
Q

What are the complications of SUFE

A
  • Osteonecrosis of the femoral head
  • Contralateral SUFE
  • Chondrolysis
  • Residual proximal femoral deformity
  • Slip progression
211
Q

Define a hernia

A

Protrusion of all or part of a viscus through the wall of the cavity in which it is usually contained

212
Q

Cause of indirect inguinal hernias

A

Congenital failure of the processus vaginalis to close

213
Q

Path of an indirect inguinal hernia

A

Extends through deep ring, inguinal canal, and superficial ring to descend into the scrotum

214
Q

Cause of a direct inguinal hernia

A

An acquired weakness in the abdominal wall which tends to develop in adulthood

215
Q

Path of a direct inguinal hernia

A

The hernia passes directly forward through the defect in the posterior wall (transversalis fascia) of the inguinal canal. It does NOT typically end up in the scrotum.

216
Q

Outline how you would examine a hernia

A
  • Site, size, shape, sounds
  • Tethering, tenderness, temperature, transillumability
  • Colour, contour, compressibility, consistency
  • Assess reducibility
217
Q

Investigations for hernia

A
  • Basic blood panel including lactate
  • USS
  • CT abdomen and pelvis
218
Q

What are the indications for emergency surgical intervention in hernias?

A
  • Obstruction
  • Strangulation
  • Perforation
219
Q

What are the principles of hernia repair?

A
  • Reduce hernia contents
  • Remove hernia sac
  • Repair defect
220
Q

Why might an ankle fracture not reduce?

A

Periosteum, deltoid ligament, or soft tissues may be stuck in the joint

221
Q

How would you assess a patient with an ankle fracture?

A
  1. ATLS principles using an A to E approach
  2. If the patient was stable I would take a focused history - MOI, comorbidity, mobility, smoking, meds
  3. Focused examination of the limb with clear documentation of NV status and skin integrity
  4. Clinically deformed ankles should be urgently reduced and splinted
  5. AP and Lateral XR with AP proximal tibia if maisoneuneuve fracture suspected
  6. Re-check NV status following reduction
  7. Check adequacy of reduction with repeat XR
  8. Baseline bloods and ECG to prepare for theatre
  9. VTE prophylaxis as per local protocol
222
Q

How would you assess a patient with suspected spinal trauma?

A
  1. ATLS approach ensuring the C-spine is triple immobilised
  2. Once life threatening injuries are excluded perform a secondary survey using logroll technique
  3. Assess need for c-spine imaging using Canadian c-spine rule or NEXUS
  4. Perform a full neurological assessment and document this using an ASIA chart
  5. Request appropriate imaging - MRI is the investigation of choice for spinal cord injury
223
Q

What is the difference between neurogenic and spinal shock?

A
  • Neurogenic shock = low BP due to loss of vasomotor tone

- Spinal shock = flaccidity and loss of reflexes before spasticity ensues

224
Q

Describe Central Cord Syndrome

A

Characterised by disproportionately greater loss of motor strength in the upper extremities than the lower extremities with varying degrees of sensory loss. Typically occurs after hyperextension injuries in those with cervical canal stenosis.

225
Q

Describe anterior Cord Syndrome

A

Results from injury to the motor and sensory pathways in the anterior part of the cord. Characterised by paraplegia and bilateral loss of pain and temperature sensation. However, sensation from dorsal column is preserved.

226
Q

Brown-Sequard Syndrome

A

Results from hemisection of the cord, usually by penetrating trauma. Consists of ispilateral motor loss (corticospinal) and loss of position sense (dorsal columb) with contralateral loss of pain and temperature sensation (spinothalamic)

Interview Preparation (9 decks)

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