Gen surg Flashcards
1
Q
laparotomy:
A
opening up of abdo
2
Q
laparoscopy:
A
keyhole surgery on the abdo
3
Q
adhesions:
A
scar tissue in the abdo that attach contents together
4
Q
volvulus:
A
twisting of colon
5
Q
tenesmus:
A
symptom of full rectum/needing to open bowels after emptying bowels
6
Q
hemicolectomy:
A
removal of a portion of the bowel
7
Q
hartmann’s procedure:
A
removing rectum and or sigmoid colon and forming a colostomy
8
Q
three main causes of intestinal adhesions:
A
previous surgery
peritonitis
intra-abdominal infection
9
Q
kocher incision:
A
open cholecystectomy
10
Q
mercedes benz incision?
A
liver transplant
11
Q
young female with generalised abdo pain which becomes RIF pain over a few days - important ddx:
A
sounds like apendicitis
in this demographic - preg ix
gynae causes
12
Q
set of acute abdominal investigations:
A
FBC, U&E, LFTs, cultures, amylase, VBG, CRP, clotting, 2xG&S, b-hCG
preg ix
urine dip
13
Q
what does air under the diaphragm on an erect CXR indicate?
A
perforation
14
Q
“tinkling bowel sounds” on auscultation =?
A
obstruction buzzword
15
Q
what needs ruling out in elderly male with epigastric pain?
A
MI - do an ECG
16
Q
on abdominal X-ray - thresholds for obstruction on each region of bowel?
A
small bowel - >3cm. central regions
large bowel - >6cm. peripheral region
cecum - >9cm.
17
Q
elderly male man with AF, smoker, generalised abdo pain 10/10 pain minus guarding disproporationate to exam findings with a raised lactate.
pain can be in umbilical region - dx?
A
mesenteric ischemia
18
Q
pathology of mesenteric ischemia?
A
clot in vessels supplying bowel -> ischemia
19
Q
set management plan for acute abdomen (5+1):
A
analgesia (can still give opioids if ?obstr) anti-emetic IVI monitor urine output + cath NBM pending snr rv (Abx)
20
Q
key cx of pancreatitis?
A
necrosis, ARDS, DIC, pseudocysts
21
Q
which condition requires aggressive IV fluid resus?
A
pancreatitis - due to massive 3rd space losses
22
Q
1st line (and sequential ix) for billiary pathology:
A
USS abdo
IF shows CBD dilatation => MRCP
IF shows gallstones => ERCP (to remove)
23
Q
2 commonest causes of pancreatitis?
A
gallstones
ethanol
24
Q
increased amylase and deranged LFTs: dx:
A
gallstone pancreatitis
25
when to CT in ?billiary pathology?
if ?perforation
| or very septic
26
causes of small bowel obstruction:
```
adhesions (post-sx)
hernias
tumours
IBD
intussusception
```
27
causes of large bowel obstruction:
tumours
volvulus
diverticular disease
28
mx obstruction:
IVI, NG - drip and suck
29
what is pseudo-obstruction?
"ileus"
| adynamic bowel minus mechanical obstruction
30
causes of ileus:
hypocalcaemia, other electrolyte imbalances
hypothyroid
MS
post-surgical
31
differentiating between types of shock by temperature of peripheries?
neurogenic, septic and anaphylactic (together called distributive) -> warm peripheries
rest cause cool peripheries
32
28-m BIBA to ED. RTA. wearing his seatbelt during the accident, and did not exit the vehicle as a result of the collision. Appears confused, has bruising and pulsatile swelling over the right side of his neck and eventually becomes unresponsive. He also appears to have a fractured nose and has multiple lacerations across his face including his lips. dx?
carotid artery laceration
33
pulsatile mass and swelling would suggest ?
carotid artery laceration
34
discoloured purple non-demarcated area to the left of the umbilicus. Palpation of the abdomen demonstrates tenderness localised to a firm non-pulsatile mass just to the left of the midline at the level of the umbilicus. There is no guarding or rigidity. Bowel sounds are present.
What is the most likely cause of this mans symptoms?
abdo wall haematoma
35
In those diagnosed with anal fistula, what is best ix to characterise the course of the fistula?
MRI pelvis
36
A 74-year-old male is in recovery following carotid endarterectomy for an 80% stenosis of the carotid artery. Following an uneventful period in recovery the registrar assessed this gentleman's cranial nerves. When asked to poke his tongue out there is deviation to the right toward the right side of the patient. What nerve has been affected?
right hypoglossal
37
26-f ED sudden onset lower abdominal pain past 2 hours. sexually active and not having used condoms. She has not had a sexual health screen but has a long-term partner. On examination, she is tender in the right iliac fossa with a heart rate of 100 bpm, blood pressure 120/75mmHg and temperature 37.8ºC. Which investigation should be performed first?
urine pregnancy test
38
congenital inguinal hernia - mx?
surgical repair immediately
39
congenital umbilical hernia - mx?
conservative mx
| resolves 4-5yo
40
A 22-year-old man suffers 20% partial and full thickness burns in a house fire. There is an associated inhalational injury. It is decided to administer intravenous fluids to replace fluid losses. Which of the intravenous fluids listed below should be used for initial resuscitation?
hartmanns or NS
41
A 19-year-old student falls from a 2nd-floor window. He is persistently hypotensive. A chest x-ray shows a widened mediastinum with depression of the left main bronchus and deviation of the trachea to the right. What is the most likely injury?
aortic rupture
42
Valvulae conniventes (haustra) extend all the way across in?
small bowel obstruction
43
Haustra extend about a third of the way across in?
large bowel obstruction
44
A 19-year-old female presents with severe anal pain and bleeding which typically occurs post defecation. On examination she has a large posteriorly sited fissure in ano.
tx?
topical diltiazem
45
A 43-year-old male has been troubled with symptoms of post defecation bleeding for many years. On examination he has large prolapsed haemorroids, colonoscopy shows no other disease.
tx?
haemorrhoidectomy
46
A 20-year-old man presents with a 24 hour history of anal pain. On examination he has a peri anal abscess.
tx?
incision and drainage
| would have fevers
47
A 42-year-old lady has suffered from hepatitis C for many years and has also developed cirrhosis. On routine follow up, an ultrasound has demonstrated a 2.5cm lesion in the right lobe of the liver.
dx?
HCC
48
A 25-year-old man from the far east presents with a fever and right upper quadrant pain. As part of his investigations a CT scan shows an ill defined lesion in the right lobe of the liver.
dx?
amoebic abscess
49
tx amoebic abscess?
metronidazole
50
A 42-year-old lady presents with right upper quadrant pain and a sensation of abdominal fullness. An ultrasound scan demonstrates a 6.5 cm hyperechoic lesion in the right lobe of the liver. Serum AFP is normal.
dx?
haemangioma
51
A 17-year-old male is admitted with lower abdominal discomfort. He has been suffering from intermittent right iliac fossa pain for the past few months. His past medical history includes a negative colonoscopy and gastroscopy for iron deficiency anaemia. The pain is worse after meals. Inflammatory markers are normal.
dx?
meckels diverticulum
52
A 14-year-old female is admitted with sudden onset right iliac fossa pain. She is otherwise well and on examination has some right iliac fossa tenderness but no guarding. She is afebrile. Urinary dipstick is normal. Her previous menstrual period two weeks ago was normal and pregnancy test is negative.
dx?
mittelschmerz
53
A 21-year-old male is admitted with a 3 month history of intermittent right iliac fossa pain. He suffers from episodic diarrhoea and has lost 2 kilos in weight. On examination he has some right iliac fossa tenderness and is febrile.
dx?
crohns disease
54
A 72-year-old woman who takes regular laxatives comes to surgery. Over the past two days she has developed progressively worse pain in the left lower quadrant. On examination she has a low-grade pyrexia and is tender on the left side of the abdomen
dx?
diverticulitis
sigmoid colon
55
A 37-year-old attends surgery due to a one day history of severe central abdominal pain radiating through to the back. He has vomited several times and is guarding on examination. Parotitis and spider naevi are also noted.
dx?
acute pancreatitis
early IVI
56
A 49-year-old woman presents with pain in the right upper quadrant. This has been occurring for the past 3 months and is often precipitated by a heavy meal. When the pain comes it is typically lasts around 1-2 hours. Clinical examination is unremarkable other than mild tenderness in the right upper quadrant.
biliary colic
57
class III shock is?
tachycardia, hypotension and confusion
58
class I shock is?
fully compensated for
59
Class II shock is?
tachy
60
class IV shock is?
LOC , severe hypotension
61
18-f ED 2 days lower abdominal pain, nausea and vomiting, and has not opened her bowels for 24 hours. She has mild dysuria and her last menstrual period (LMP) was 21 days ago. Smokes 20/day and drinks 15 alcohol/wk. On examination she is haemodynamically stable, with pain in the right iliac fossa. Urinary pregnancy and dipstick are both negative. Which one of the following is the most likely diagnosis?
appendicitis
ddx mittleschmertz (if mid-cucle and normal inflammatory markers)
62
A patient undergoes a right total hip arthroplasty (THA) via a posterior approach. Post operatively she complains of inability to dorsiflex her right foot.
What nerve may have been injured during the procedure?
sciatic nerve
63
A 40-year-old women is being investigated for haematuria. She was living with her sister who has just died from a sub arachnoid haemorrhage. The haematuria is painless and she has mild renal impairment.
dx?
PKD
64
A 75-year-old lady is investigated for episodes of painless haematuria. Apart from COPD from long term smoking she is otherwise well. She has no other urinary symptoms.
dx?
transitional cell carcinoma of the bladder
| 90%
65
A 78-year-old man has a long history of nocturia, urinary frequency and terminal dribbling. He was admitted with urinary retention and was catheterised. On removal of the catheter he has noticed some haematuria.
dx?
BPH
66
where does the duodenum become the jejenum?
ligament of treitz
67
which branch of the aorta supplies the oesophagus-duodenum (including liver and gallbladder):
coeliac trunk
68
which branch of the aorta supplies the duodenum- first 2/3 of the transverse colon?
superior mesenteric artery (SMA)
69
which branch of the aorta supplies the final 1/3 of the transverse colon - rectum?
inferior mesenteric artery (IMA)
70
what is murphy's sign and what does it indicate?
tender on inspiration in RUQ
| inflammation of the gallbladder
71
what is Rosvig's sign and what does it indicate?
tender RIF when press on LIF
| appendicitis
72
what is the psoas strech a sign of and how is it illicited?
appendicitis
| RIF pain when straight leg raise
73
what is rebound tenderness and what does it indicate?
pain when take hand away -
| peritonitis / abdo wall pathology
74
what are tinkling bowel sounds and what do they indicate?
high pitch bowel sounds
| obstruction
75
gallstones + deranged LFTs =
```
ascending cholangitis
(doesn't necessarily present as jaundiced skin/eyes)
```
76
what is biliary colic?
pain due to gallstones WITHIN the gallbladder minus infection minus LFT derangement
77
what is cholecystitis?
infection of the gallbladder - due to gallstones
78
what abx is usually added to coamox when suspected ascending cholangitis?
gentamycin
79
what is the minimum EGFR for a CT-AP? (contrast obvs come on lad)
30
80
mx faecal impaction?
PR then phosphate enema if stool felt in rectum on PR
81
mx volvulus?
flatus tube
| poonami
82
coffee bean sign on x-ray?
sigmoid volvulus
83
red flags for hernias:
red, pain, irreduceable, obstruction, peritonism, if the hernia contains bowel
84
why should you avoid metaclopramide in obstruction?
it is a pro-kinetic - will make things worse la
85
16M severe groin pain after kicking a football. Imaging confirms a pelvic fracture. A previous pelvic x-ray performed 2 weeks ago shows a lytic lesion with 'onion type' periosteal reaction. dx?
Ewing's sarcoma
86
52F Pakistani ethnicity has a lumbar vertebral crush fracture. She has hypocalcaemia and a low urinary calcium. dx?
osteomalacia
87
30F pain and swelling of the left shoulder. There is a large radiolucent lesion in the head of the humerus extending to the subchondral plate. dx?
giant cell tumour
| soap bubble' appearance - mets to lungs
88
should be considered in patients with portal hypertension and lower gastrointestinal bleeding on hx of alcohol misuse and high ALP (405), high ALT (95) and low albumin (31):
rectal varices
89
X has typical features of portal hypertension including ascites, splenomegaly and caput medusae.
portal hypertension
90
73F brisk rectal bleed. She is otherwise well and the bleed settles. On examination her abdomen is soft and non tender. Elective colonoscopy shows a small erythematous lesion in the right colon, but no other abnormality.
dx?
angiodysplasia
91
A 23-year-old man complains of passing bright red blood rectally. It has been occurring over the past week and tends to occur post defecation. He also suffers from pruritus ani. dx?
haemorrhoids
92
A 63-year-old man presents with episodic rectal bleeding the blood tends to be dark in colour and may be mixed with stool. His bowel habit has been erratic since an abdominal aortic aneurysm repair 6 weeks previously. dx?
ischemic colitis
93
A 35-year-old man is admitted with an episode of collapse and passage of malaena. He has been suffering from post prandial abdominal pain for 5 weeks and this is most marked several hours after eating.
dx?
duodenal ulcer
94
72M episode of brisk haematemesis. Following resuscitation an upper GI endoscopy is performed and a prominent blood vessel is identified in the mucosa approximately 6 cm from the O-G junction on the lesser curve of the stomach. dx?
Dieulafoy lesion
95
A 56-year-old man is admitted with a profuse upper gastro intestinal haemorrhage. He is relatively malnourished and has evidence of gynaecomastia.
dx?
oesophageal varices
96
6-wk boy ->clinic by his mother. Right testis is absent. She reports that it is sometimes palpable when she bathes the child. Right testis is palpable at the level of the superficial inguinal ring. What is the most appropriate management?
reassess in 6/12
97
HCC tumour marker?
AFP
98
The Parkland formula for fluid resuscitation in burns is:
| Volume of fluid =
total body surface area of the burn % x weight (Kg) x 4ml
| amount to be given in first 24h with half being given in first 8h
99
what exam confirms indirect inguinal hernia?
After reducing the hernia, indirect hernia can be controlled by applying pressure over the deep inguinal ring
-> no reappearance with cough after inguinal ring covered
100
Reappearance of the lump during coughing when covering the deep inguinal ring would indicate the hernia is?
direct
| herniated bowel does not pass through the deep inguinal ring in direct hernias.
101
Inguinal herniae occur due to a hole in the?
internal oblique and transverse muscles
102
inguinal hernia. What is the most appropriate management?
routine referral for surgery
103
The definition of an Upper GI Bleed is a haemorrhage with an origin proximal to the???
ligament of treitz
104
A 56-year-old lady presents with a 6 month history of dysphagia to solids. She has a long history of retrosternal chest pain that is worse on lying flat and bending forwards. She undergoes an upper GI endoscopy where a smooth stricture is identified.
dx?
peptic stricture
105
76M 5/52 hx progressive dysphagia. Upper GI endoscopy: changes that are compatible with Barretts oesophagus. The oesophagus is filled with food debris that cannot be cleared and the endoscope encounters a resistance that cannot be passed.
dx?
adenocarcinoma of oesophagus
106
A 22-year-old man presents with a 5 month history of episodic retrosternal chest pain together with episodes of dysphagia to liquids. An upper GI endoscopy is performed and no mucosal abnormality is seen. dx?
motility disorder
107
strangulation without symptoms of obstruction:
| firm mass over the abdominal wall. The overlying skin is dusky with signs of ischaemia and necrosis. dx?
richter's hernia
108
50F right-sided medial thigh pain for the past week. There has been no change in her bowels. On examination you noticed a grape sized lump below and lateral to the right pubic tubercle which is difficult to reduce. dx?
femoral hernia
| high risk strangulation - repair urgently
109
Pfannenstiel's incision which op?
c-section
110
Kocher's incision which op?
cholecystecomy
111
Rooftop or Midline incision - which op?
whipple's
112
An 18-year-old student is involved in a car crash, with another car crashing into the side of the car. A chest x-ray shows an indistinct left hemidiaphragm. dx?
diaphragm rupture
113
A 19-year-old motorcyclist is involved in a road traffic accident. His chest movements are irregular. He is found to have multiple rib fractures, with 2 fractures in the 3rd rib and 3 fractures in the 4th rib.
flail chest
114
A 19-year-old student falls from a 2nd floor window. He is persistently hypotensive despite fluid resuscitation. A chest x-ray shows depression of the left main bronchus and deviation of the trachea to the right. Lung markers can be seen in the peripheries of both thoraces. dx?
aortic rupture
115
A syndrome consisting of a PTEN mutation and intestinal hamartomas. dx?
cowden disease
116
A syndrome which may be present in a patient with multiple intestinal hamartomas and pigmentation spots around the mouth dx?
peutz-jegher's syndrome
117
A syndrome likely to be present in a 28-year-old man who presents with a locally advanced mucinous carcinoma of the caecum. There are scanty polyps in the remaining colon. His father died from colorectal cancer aged 34. dx?
lynch syndrome
118
23Freferred to the surgical assessment unit. She complains severe, slow onset, left iliac fossa pain. On examination left iliac fossa pain is confirmed. She denies being sexually active. There is some clinical evidence of peritonitis. Investigations should you ask for next?
pregnancy test - still have to in woman of child bearing age with acute abdomen
119
A 72-year-old man is recovering from an inguinal hernia repair when he suffers from an extensive ischaemic stroke. He is managed on the rehabilitation unit. However, he is still not able to feed safely and repeated swallowing assessments have shown that he tends to aspirate. Which of the following is the best option for long term feeding?
PEG tube
120
67F ED severe abdominal pain which has been worsening 2/7. It began in the lower left side of her abdomen and she has had diarrhoea with it. She has a past medical history of hypertension, chronic kidney disease and diverticular disease.
ix: CXR erect - perforated diverticulitis
121
A 72-year-old woman presents with a 2 day history of colicky abdominal pain and a 24 hour history of vomiting. Her past medical history includes: hypertension, glaucoma, hysterectomy (1992). On examination her abdomen is distended with tinkling bowel sounds. dx?
small bowel obstruction
| secondary to adhesions
122
definitive diagnostic investigation for small bowel obstruction??
CT abdomen
| also for large bowel obstruction
123
67M recurrent episodes of haematuria, typically at the end of the urinary stream, he has been suffering from occasional fevers and has noticed pus on the urethral meatus on occasion. On examination the prostate has no discernable masses but is tender. dx>
prostatitis
124
A 23-year-old female is admitted with loin pain and a fever, she has noticed haematuria for the past week accompanied by dysuria, this was treated empirically with trimethoprim. dx?
pyelonephritis
125
A 56-year-old man is admitted with severe loin to groin pain associated with haematuria. He was well until 1 week ago when he was unwell with diarrhoea and vomiting.
dx?
ureteric calculus
126
Severe acute peri-umbilical bruising in the setting of acute pancreatitis.
whos sign?
cullens sign
127
In acute cholecystitis there is hyperaesthesia beneath the right scapula.
whos sign?
boas sign
128
In appendicitis palpation of the left iliac fossa causes pain in the right iliac fossa. whos sign?
rosving's sign
129
43M long term history of alcohol misuse is admitted with a history of an attack of vomiting after an episode of binge drinking. After vomiting he developed sudden onset left sided chest pain, which is pleuritic in nature. Profoundly septic and drowsy with severe epigastric tenderness and left sided chest pain. dx?
boerhaave's syndrome
left sided rupture of oesophagus
CT contrast -> thoracotomy
130
22M severe retrosternal chest pain and recurrent episodes of dysphagia. These occur sporadically and often resolve spontaneously. No physical abnormalities and the patient seems well. dx?
achalasia
tx Cardiomyotomy
131
An obese 53-year-old man presents with symptoms of recurrent retrosternal discomfort and dyspepsia. This is typically worse at night after eating a large meal. On examination there is no physical abnormality to find. dx?
gord
132
23M medical student ->ED severe right upper quadrant abdominal pain. Sharp, worse on inspiration. He has been feeling tired and short of breath in the last few days and has a cough productive of purulent, bloody sputum. He has a fever, tachycardia and tachypnoea. Recently returned from a week-long holiday drinking 15 units of alcohol a day.
dx?
lower lobe pneumonia
133
A 65-year-old man with a history of ischaemic heart disease presents with sudden onset central abdominal pain radiating to his back. He is clammy and short of breath. dx?
ruptured AAA
134
A 34-year-old man who drinks 21 units of alcohol per week presents with episodic epigastric pain that is relieved by eating. dx?
duodenal ulcer
| relieved by eating
135
A 40-year-old woman with a history of Crohn's disease presents with abdominal pain and distension. She describes constipation for the past 4 days. dx?
intestinal obstruction
136
A 56-year-old man who drinks heavily is found collapsed by friends at his house. He was out drinking the previous night and following this was noted to have vomited repeatedly so his friends brought him home.
dx?
oesophageal rupture
137
45M polytrauma and requires a massive transfusion of packed red cells and fresh frozen plasma. Three hours later he develops marked hypoxia and his CVP is noted to be 5 mmHg. A chest x-ray shows bilateral diffuse pulmonary infiltrates. dx?
TRALI
138
40F assaulted with brick. ?spleen injury. CT abdo - Minimal intra-abdominal bleeding without haemodynamic compromise. mx?
conservative - analgesia + frequent obs
| not warrant a laparotomy
139
6/12 boy is brought to the clinic by his mother. She is concerned that his testes are not located into the scrotum. She has noticed them only when he is in the bath, but not at any other time. dx?
retractile testes
140
In acute pancreatitis there is bruising in the flanks.
| sign?
grey-turner's sign
141
which investigation should you order to offer the most definitive result to assess whether the bladder suture line has healed following bladder wall repair surgery?
cystogram
142
22F 24/40 presents with frank haematuria. She is sexually active. She has had a previous pregnancy resulting in caesarean section. dx?
placenta percreta
143
45F haematuria and loin pain. Temperature of 37C, Hb 180 and creatinine 156. Urine dipstick shows 3+ blood. Blood and urine cultures are negative. dx?
renal vein thrombosis
144
33-M -> GP abdo pain - lower left abdomen, become more severe across the day. Feverish, nauseous, and has vomited x2 past hour. He cannot remember the last time he passed urine or stool, and has had a small painless lump on his lower left abdomen for past month. Clammy, looks unwell. He is tachycardic and normotensive. His abdomen appears mildly distended and is very tender to touch. Localised tenderness in the left iliac fossa. Lump in the left inguinal area that is 2cm x 2cm, erythematous and extremely painful to touch. dx, mx?
strangulated inguinal hernia
| arrange for him to get to ED - do not attempt to reduce
145
if ?ruptured AAA pt comes in extremely hypotensive, what do you do first?
IV access and fluid resus BEFORE vascular review
| shock can kill him
146
TPN is known to result in ???
derangement of LFTs
147
What is the single most appropriate initial investigation(s) to assess for the presence of free fluid in the abdomen and chest?
FAST scan
148
A 32-year-old lady is diagnosed with Medullary carcinoma of the thyroid and has undergone resection of the tumour.
which ix led to the dx?
serum calcitonin high in medullary
149
A 20F undergone a total thyroidectomy for a well differentiated papillary carcinoma. She attends clinic and is well and the surgeon wishes to screen for disease recurrence. what marker can be used?
anti-thyroglobulin abs
150
A 33-year-old lady presents with a recently diagnosed goitre and a diagnosis of Hashimotos thyroiditis is suspected. ix?
thyroid peroxidase abs
151
56M long standing UC and a DALM lesion in the rectum is admitted with jaundice. On CT scanning the liver has 3 nodules in the right lobe and 1 nodule in the left lobe. Carcinoembryonic antigen levels are elevated.
explain liver ca?
metastatic mets from colonic primary (CEA)
152
A 48-year-old lady with chronic hepatitis B infection is noted to have worsening liver function tests and progressive jaundice. Her alpha feto protein levels are grossly elevated. dx?
HCC
153
A 55-year-old man with long standing ulcerative colitis is admitted with cholangitis and weight loss. Blood tests reveal a markedly elevated CA 19-9. dx?
cholangiocarcinoma
| PSC is RF
154
42F burning pain of her anterior thigh which worsens on walking. There is a positive tinel sign over the inguinal ligament.
which nerve affected?
lateral cutaneous nerve of the thigh
155
29F had Pfannenstiel incision. She has pain over the inguinal ligament which radiates to the lower abdomen. There is tenderness when the inguinal canal is compressed.
nerve affected?
ilioinguinal nerve
156
22M shot in the groin. On examination he has weak hip flexion, weak knee extension, and impaired quadriceps tendon reflex, as well as sensory deficit in the anteromedial aspect of the thigh. nerve affected?
femoral nerve
157
analgesics to avoid in renal transplant pts?
NSAIDS - nephrotoxic
158
24M road traffic accident in which he collides with the wall of a tunnel in a head on car crash, speed 85mph. He is wearing a seatbelt and the airbags have deployed. When rescuers arrive he is lucid and conscious and then dies suddenly. dx?
aortic transection
159
30F road traffic accident. She is a passenger in a car involved in a head on collision with another vehicle. Her car is travelling at 60mph. She has been haemodynamically stable throughout with only minimal tachycardia. Marked abdominal tenderness and a large amount of intra abdominal fluid on CT scan dx?
duodeno-jejunal flexure disruption
160
17M motorcycle accident in which he is thrown from his motorcycle. On admission he has distended neck veins and a weak pulse. The trachea is central. dx?
haemopericardium
161
19F lower abdominal pain. OE diffusely tender. Laparoscopy is performed and at operation multiple fine adhesions are noted between the liver and abdominal wall. Her appendix is normal. dx?
PID
162
78M bus stop when he suddenly develops severe back pain and collapses. OE BP 90/40 and HR 110. His abdomen is distended and he is obese. Though tender his abdomen itself is soft. dx?
ruptured aaa
163
```
reduced SVR
increased HR
normal/increased cardiac output
decreased blood pressure
which shock?
```
septic shock
164
```
increased SVR
increased HR
decreased cardiac output
decreased blood pressure
which shock?
```
hypovolaemic
165
```
increased SVR (vasoconstriction in response to low BP)
increased HR (sympathetic response)
decreased cardiac output
decreased blood pressure
which shock?
```
cardiogenic
166
19F involved in an athletics event. She has just completed the high jump when she suddenly develops severe back pain and weakness affecting both her legs. on examination she has a prominent sacrum and her lower back is painful.
dx?
spondylolisthesis
| young female athletes with a bg of spondylolysis
167
15M clinic by his mother who is concerned that he has a mark overlying his lower spine. A patch of hair overlying his lower lumbar spine and a birth mark at the same location. Lower limb neurological examination is normal. dx?
spina bifida occulta
168
38F undergoes a gastric bypass procedure. Post-op she attends the clinic and complains that following a meal she develops vertigo and develops crampy abdominal pain. explanation?
```
dumping syndrome
(osmotic changes and insulin release causes it)
```
169
A 38-year-old lady donates her kidney to her identical twin sibling. type of transplant?
isograft
170
A 53-year-old man with severe angina undergoes a coronary artery bypass procedure and his long saphenous vein is used as a bypass conduit.
type of transplant?
autograft
171
A 38-year-old lady donates her kidney to her niece.
| type of transplant?
allograft
172
eg of Xenograft ?
porcine heart valve
173
20M stabbed outside a nightclub, he has a brisk haemoptysis and in the ED has a drain inserted into the left chest. This drained 750ml frank blood. He fails to improve with this intervention. He has received 4 units of blood. His CVP is now 13. What is the best definitive course of action?
thoracotomy in theatre
| not in ED as he still has a cardiac output
174
patients with ongoing acute bleeding despite repeated endoscopic therapy????
laparotomy and surgical exploration
175
28M RTA sustains a flail chest injury. ED he is hypotensive. OE: elevated jugular venous pulse and quiet heart sounds. Dx?
```
cardiac tamponade
(becks triad: hypotension, muffled heart sounds, raised jvp)
```
176
40M long standing inguinal hernia. Small, direct inguinal hernia. He inquires as to the risk of strangulation over the next year if he decided not to undergo surgery. Risk of strangulation over the next 12 months?
3-5%
177
21F -> ED lower abdominal pain. The pain started centrally and is now localised on the right side. 8/10 pain. She is sexually active and uses condoms. Pain in the RIF with rebound tenderness. Initial investigation should be completed during admission to rule out a potential diagnosis?
urine hcg
| not serum
178
best investigation for hydatid cysts?
CT scan
| percutaneous aspiration CI
179
who gets hydatid cysts?
middle eastern
farmer
raised eosinophils
obstructive lfts
180
Post splenectomy blood film features:
Howell- Jolly bodies
Pappenheimer bodies
Target cells
Irregular contracted erythrocytes
181
Indications for thoracotomy in haemothorax include?
>1.5L initial loss
| >200ml/h for 2h
182
A 28-year-old man presents with hypertension and haematuria. Haematological investigations show polycythaemia but otherwise no abnormality. CT scanning shows a left renal mass. dx?
renal adenocarcinoma
183
A 68 year of man presents with recurrent episodes of left sided ureteric colic and haematuria. Investigations show some dilatation of the renal pelvis but the outline is irregular. dx?
transitional cell carcinoma
184
differentiating lynch syndrome from FAP?
lynch - normal reaining mucosa in bowel - in FAP there are polyps
185
what may cause bubbly urine?
enterovesical fistula
186
A 48-year-old male with a long standing history of dyspepsia and pain several hours after eating is found to have a peptic ulcer. He presents with a brisk haematemesis with fresh red blood. Which blood vessel is most likely responsible?
gastroduodenal
187
A 70-year-old lady presents with a number of skin lesions that she describes as unsightly. On examination she has a number of raised lesions with a greasy surface located over her trunk. Apart from having a greasy surface the the lesions also seem to have scattered keratin plugs located within them. dx?
seborrhoeic keratosis
| scaly, thick, greasy surface with scattered keratin plugs
188
A 28-year-old female presents with a small nodule located on the back of her neck. It is excised for cosmetic reasons and the histology report states that the lesion consists of a sebum filled lesion surrounded by the outer root sheath of a hair follicle. dx?
pilar cyst
| foul smelling cheesy material and are surrounded by the outer part of a hair follicle.
189
A 21-year-old lady presents with a nodule on the posterior aspect of her right calf. It has been present at the site for the past 6 months and occurred at the site of a previous insect bite. Although the nodule appears small, on palpation it appears to be nearly twice the size it appears on examination. The overlying skin is faintly pigmented. dx?
dermatofibroma
pigmented and are often larger than they appear. sites of previous trauma
190
A 3-year-old boy is referred to the clinic with a scrotal swelling. On examination the mass does not transilluminate and it is impossible to palpate normal cord above it. dx?
indirect inguinal hernia
191
A 52-year-old obese lady reports a painless mass in the groin area. A mass is noted on coughing. It is below and lateral to the pubic tubercle. dx?
femoral hernia
192
A 21-year-old man is admitted with a tender mass in the right groin, fevers and sweats. He is on multiple medical therapy for HIV infection. On examination he has a swelling in his right groin, hip extension exacerbates the pain. dx?
psoas abscess
193
A 22-year-old man presents with a discharging area on his lower back. On examination there is an epithelial defect located 6cm proximal to the tip of his coccyx and located in the midline. There are two further defects located about 2cm superiorly in the same position. He is extremely hirsute. What is the most likely diagnosis?
pinodial sinus
194
A 32-year-old lady has previously undergone a wide local excision and axillary node clearance (5 nodes positive) for an invasive ductal carcinoma. It is oestrogen receptor negative, HER 2 positive, vascular invasion is present. She has a lesion suspicious for metastatic disease in the left lobe of her liver.
mab?
trastuzumab - herceptin !!!!!
195
A 22-year-old lady has severe peri anal crohns disease with multiple anal fistulae, the acute sepsis has been drained and setons are in place. She is already receiving standard non biological therapy.
mab?
infliximab
196
A 63-year-old man presents with a locally unresectable gastrointestinal stromal tumour. Biopsies confirm that it is KIT positive. mab?
imatinib
197
20F mobile lump in the upper outer aspect of her right breast. On examination she has a firm mobile mass in the upper outer quadrant of her right breast. dx?
fibroadenoma
60% lesions 18-25yos
mobile. biopsy if>4cm
198
55F nipple discharge. On examination she has a slit like retraction of the nipple in the centre of this area is a small amount of cheese like material. No discrete mass lesion is palpable in the underlying breast. dx?
duct ectasia
199
48F discomfort in the right breast. Discrete soft fluctuant area in the upper outer quadrant of her right breast. A mammogram is performed and a 'halo sign' is seen by the radiologist. dx?
breast cyst
200
Females < 30 years with a non-tender, discrete and mobile lump =
fibroadenoma
201
older women. painless lump or with nipple change, nipple discharge and skin contour changes.
ductal ca
202
older women. painful lumpy, often worse around menstruation. dx?
fibroadenosis
203
intraductal carcinoma associated with a reddening and thickening (may resemble eczematous changes) of the nipple/areola
paget's disease of the breast
204
Dilatation of the large breast ducts
Most common around the menopause
May present with a tender lump around the areola +/- a green nipple discharge
If ruptures may cause local inflammation, sometimes referred to as 'plasma cell mastitis' dx?
mammary duct ectasia
multiple ducts discharging
can be nipple inverted
205
More common in obese women with large breasts
May follow trivial or unnoticed trauma
Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
Rare and may mimic breast cancer so further investigation is always warranted dx?
fat necrosis
206
More common in lactating women
| Red, hot tender swelling of breast. dx?
breast abscess
| 'tender, fluctuant'
207
Local areas of epithelial proliferation in large mammary ducts
Hyperplastic lesions rather than malignant or premalignant
May present with blood stained discharge dx?
duct papilloma
208
First-line management of mastitis is
to continue breastfeeding normally
209
A key reason for considering neo-adjuvant chemotherapy in breast cancer is ?
try to downsize the tumour before surgery and allow breast conserving surgery rather than mastectomy
210
Pathology results show that the tumour is oestrogen receptor positive, HER2 negative. Which one of the following adjuvant treatments is she most likely to be offered?
tamoxifen
| pre-menopausal
211
She is HER2 -ve and ER -ve, however her TNM stage is T2N2M0. tx?
FEC-D chemotherapy
| she is node positive
212
br ca women who are ER +ve, post-menopausal - tx?
aromatase inhibitors
sfx - Osteoporosis
213
UK breast ca screening?
mamogram 3yrly
| 47-73
214
BRCA gene mutations transmission?
Autosomal dominant
| heterozygous
215
The 'snowstorm' sign on ultrasound of axillary lymph nodes indicates?
extracapsular breast implant rupture
216
ectasia mx?
if not bothering woman leave it
| if bothering total duct excision
217
Breast fibroadenoma mx:
surgical excision biopsy if >3cm
218
Axillary node clearance is associated with
arm lymphoedema and functional arm impairment
| if pt opts not for this -> RT
219
A 74-year-old woman presents with a breast lump. On examination, it has a soft consistency. The lump is removed and sliced apart. Macroscopically there is a grey, gelatinous surface. dx?
mucinous carcinoma
220
A 74-year-old woman presents with an erythematous rash originating in the nipple. It is spreading to the surrounding areolar area and the associated normal tissue. dx?
pagets disease of nipple
| -> urgent breast referral
221
A 53-year-old woman presents with a bloody nipple discharge. On mammography there is calcification behind the nipple areolar complex. A core biopsy shows background benign change, but cells that show comedo necrosis which have not breached the basement membrane. dx?
ductal carcinoma in situ
| Comedo necrosis is a feature of high nuclear grade ductal carcinoma in situ.
222
What is the most common type of breast cancer?
Invasive Ductal Carcinoma (no special type)
223
29-year-old man presents to his GP with several days of pain on defecation. There is sometimes a small amount of fresh, bright-red blood on the toilet paper - dx, tx?
```
anal fissure
1st - bulk-forming laxatives
2nd - GTN topical (chronic)
3rd - sphinchterectomy
can also try lube
```
224
ddx fissure from haemorrhoids?
haemorrhoids - painless
| fissure - painful
225
Patient >= 60 years old with new iron-deficiency anaemia →
urgent 2ww CRC
226
toxic megacolon vs caecal volvulus - IBS diseases:
toxic megacolon - UC
| caecal volvulus - crohn's
227
63M descending colonic tumour and undergoes surgery to remove it. The surgeon is able to remove the tumour entirely and form an anastomosis of the large bowel but wants to protect it by defunctioning the bowel. what will he do?
loop ileostomy
| used to defunction the colon and protect the large bowel
228
65F recently had a colonoscopy and been found to have a malignant tumour in the most distal portion of the rectum, involving the anal sphincter. Which of the following surgical procedures would be the best option for her?
```
Abdominoperineal resection (AP resection)
up to 8cm distal rectum
```
229
A 38-year-old lady presents with symptoms of obstructed defecation that date back to the birth of her second child by use of ventouse. She passes mucous and suffers from pelvic pain. Digital rectal examination and barium enema are normal. dx?
rectal intussusception
| obstructs defecation
230
A 19-year-old male presents with bright red rectal bleeding that occurs post defecation onto the paper and into the pan. Apart from constipation his bowel habit is normal. Digital rectal examination is normal. dx?
haemorrhoids
| -analgesia, ice packs, stool softners
231
tumour that is in the mid-rectum, and doesn't extend past the mid-rectum. What is the most appropriate surgical management for a mid-rectal tumour?
anterior resection
| upper 2/3 rectum
232
Unruptured sigmoid volvulus is primarily managed by?
decompression by rigid sigmoidoscopy and flatus tube insertion
233
which stoma is flush to the skin?
colonoscopy
| enzymes in the colon are less alkaline than those in the small intestine and so are less damaging to the skin.
234
Carcinoma of the splenic flexure requires a?
left hemicolectomy
235
A 65-year-old man with carcinoma of the caecum - op?
right hemicolectomy
236
A 45-year-old man presents with a carcinoma 10cm from the anal verge, he has completed a long course of chemoradiotherapy and has achieved downstaging with no evidence of threatened circumferential margin on MRI scanning. mx?
anterior resection with covering loop ileostomy
237
73M emergency Hartmann's procedure performed for an obstructing sigmoid cancer. path: moderately differentiated adenocarcinoma that invades the muscularis propria, with 3 of 15 lymph nodes showing evidence of disease. What is the correct stage for this?
Duke's = C
| as has node involvement
238
triad of vomiting, pain and failed attempts to pass an NG tube???
gastric volvulus
| Borchardt's triad
239
Patients with diverticulitis flares can be managed with?
oral abx at home
| if condition worsens/does not improve within 72h then go to ED for IV metro+ceftriaxone
240
defunctioning loop ileostomy. Pt ready for d/c needs o/p f/u with surgeon in 3/52. consultant asks you to do an ix 2/52 from now - what is it?
gastrografin enema to check anastamosis healed prior to reversal
241
One-off flexible sigmoidoscopy at age for bowel screening?
55yo
242
24F long history of obstructed defecation and chronic constipation. She often strains to open her bowels for long periods and occasionally notices that she has passed a small amount of blood. On examination she has an indurated area located anteriorly approximately 3cm proximal to the anal verge. dx?
solitary rectal ulcer syndrome
flexible sigmoidoscopy a lesion is biopsied and reported as showing 'fibromuscular obliteration'.
243
A 37-year-old man with a history of internal haemorrhoids presents as his symptoms have recently flared. He now describes piles which he has to manually reduce following defecation. What grade of haemorrhoids does he have?
3 - can be reduced
1- do not protrude
2-reduce spontaneously
4- cannot be reduced
244
A 54 year old man is referred to clinic with change in bowel habit, blood in his stools, lethargy and weight-loss. A colonoscopy is ordered which shows a high rectosigmoid mass. Which operation would be most appropriate?
anterior resection
245
22M first presentation of ulcerative colitis. Despite aggressive medical management with steroids, azathioprine and infliximab his symptoms remain unchanged and he has developed a megacolon. surgery?
sub total colectomy
fulminant UC
leave rectum in situ
246
22F long history of severe perianal Crohns disease with multiple fistulae. Keen to avoid a stoma. However, she has progressive disease and multiple episodes of rectal bleeding. A colonoscopy shows rectal disease only and a small bowel study shows no involvement with Crohns. surgery?
proctectomy
| stoma won't reduce the bleeding
247
22M long history of ulcerative colitis. Well controlled with steroids. However, attempts at steroid weaning and use of steroid sparing drugs have repeatedly failed. He wishes to avoid a permanent stoma. surgery?
panproctocolectomy with ileoanal pouch
| cure
248
40M known diverticular disease dx 1 year previously is admitted with acute abdominal pain. His abdomen is maximally tender in the left iliac fossa and he describes pneumaturia. His GP has been giving him metronidazole for 2 days. ix?
abdo CT
249
83F known diverticular disease is admitted with a brisk PR bleed. On assessment the bleeding is settling and her abdomen is soft. Hb 10.2, other blood tests are normal - mx?
active observation
250
A 72-year-old man is admitted with large bowel obstruction and CT scan suggests diverticular stricture in the sigmoid colon. mx?
laparotomy
if ruptured/peritonism straight to this
251
18M PMH constipation presents with bright red rectal bleeding and diarrhoea. He has suffered episodes of faecal incontinence, which have occurred randomly throughout the day and night. dx?
proctitis
| nocturnal diarrhoea, incontinence = IBD
252
56M episodes of pruritus ani and bright red rectal bleeding. Mass in the ano rectal region and biopsies confirm squamous cell cancer. dx?
anal ca
| HPV strongest RF
253
why use epidural analgesia post-colorectal surgery?
reduced time taken to return to normal bowel function
254
21F 24 hour hx increasingly severe ano-rectal pain. Febrile and the skin surrounding the anus looks normal. She did not tolerate an attempted digital rectal examination. dx?
intersphinchteric abscess
255
21F 6/12 hx offensive discharge from the anus. Increasingly annoyed at the need to wear pads. Small epithelial defect in the 5 o'clock position, approximately 3cm from the anal verge. dx?
anal fistula
256
GP: 15-year-old female presenting with nipple discharge. Her 84-year-old grandmother died 8 months previously from breast cancer. The discharge is bilateral and pale in colour. The volume is small and on examination, there are no masses palpable. She is concerned she has breast cancer. dx?
hormonal changes
257
55F wide local excision and sentinel lymph node biopsy for breast cancer. The histology report shows a completely excised 1.3cm grade 1 invasive ductal carcinoma. The sentinel node contained no evidence of metastatic disease. The tumour is oestrogen receptor negative. mx?
RT - everyone who has breast conserving surgery gets RT as reduces recurrence
258
An 88-year-old lady presents with a large mass in the upper inner quadrant of her right breast. Investigations confirm an oestrogen receptor positive, invasive ductal carcinoma. She has declined operative treatment. mx?
letrozole (aromatase-i)
259
The combination of a grade 3 tumour and axillary nodal metastasis in a young female would attract a recommendation for ??
cytotoxic chemo
260
anorectal pain and a tender lump on the anal margin?
| blue-black
thrombosed haemorrhoids
261
brought out on the left side of the abdomen, and sewn flush with the skin.??
colostomy
262
commonest crc?
adenocarcinoma
263
A 69-year-old woman undergoes a radical mastectomy for a T3 triple-negative carcinoma in her left breast. The pathology report shows cancerous cells at the margins of the resected specimen. mx?
ipsilateral chest wall and regional LN RT
264
first line management for breast cancer. If the tumour is less than 4cm a??
surgery
| wide local incision
265
(progressive, erythema and oedema of the breast in the absence signs of infection such as fever, discharge or elevated WCC and CRP) and an elevated CA 15-3. dx?
inflammatory breast cancer
266
A 38-year-old lady who smokes heavily presents with recurrent episodes of infection in the right breast. On examination, she has an indurated area at the lateral aspect of the nipple areolar complex. Imaging shows no mass lesions.dx?
periductal mastitis
| co-amox
267
may be used in patients with stress incontinence who don't respond to pelvic floor muscle exercises and decline surgical intervention?
duloxetine
268
1st-line treatment for urge incontinence and are all antimuscarinic agents?
oxybutinin, tolterodine, solifenacin
| 2nd line - mirabegron (B3 ag)
269
what indicates pancreatitis severity?
hypocalcaemia
270
Gastrectomy may result in ?
B12 deficiency - SCDC
On examination, vibration and pinprick sensation are reduced symmetrically and he has a wide-based ataxic gait. His ankle reflexes are absent however his knee reflexes are brisk.
271
Porcelain gallbladder (intramural gallbladder wall calcification) is a strong risk factor
cholangiocarcinoma
| also PSC
272
Acute cholecystitis treatment:
IV ABx + early laparoscopic cholecystectomy within 1 week of diagnosis
273
common causative agent for ascending cholangitis?
e coli
274
score is more specific to acute pancreatitis?
glasgow > apache
275
glasgow score (PANCREAS):
```
Pa02 <8kPa
Age >55 years
Neutrophilia WBC >15x10^9
Calcium <2mmol/L
Renal function Urea >16mmol/L
Enzymes LDH >600 ; AST >200
Albumin <32g/L
Sugar Blood glucose >10mmol/L
```
276
Charcot's cholangitis triad:
fever, jaundice, RUQ
277
temp cause of pancreatitis?
hypothermia
278
cholecystectomy. Two weeks following this procedure, she presents to the GP with ongoing jaundice. Murphy's sign is negative, and she is in pain.
What is the most likely cause for her jaundice?
gallstones in CBD can cause ongoing pain and jaundice post-cholecystectomy
279
preferred diagnostic test for chronic pancreatitis - looking for pancreatic calcification???
CT abdomen
| first-line USS - r/o gallstone/obstruction
280
useful for determining whether the cause of the isolated hyperbilirubinaemia is due to haemolysis or Gilbert's syndrome.?
FBC
281
Gastric MALT lymphoma - mx?
eradicate h pylori - PPI + amox + clari - triple therapy
282
investigating suspected acute pancreatitis and may be useful for late presentations > 24 hours??
lipase>amylase
283
best ways for differentiating between acute cholecystitis and biliary colic is that people with cholecystitis?
systemically unwell
284
mx acute pancreatitis?
fluids and analgesia - not abx routinely
285
47F -ED 1/7 acute epigastric abdominal pain along with nausea and vomiting. Her pain is worse on eating and when she lies down but improves on leaning forward.
She claims this has never happened before but, in the past, has experienced colicky upper abdominal pain.
Very sweaty, and appears to have a large body habitus. Mild scleral icterus is also noted in examination.
dx?
pancreatitis
286
A 65-year-old man has a long series of medical problems. He has severe abdominal pain following meals, has developed diabetes, has to take digestive enzymes, and describes that his faeces floats. All of these symptoms have started in the last 20 years.
dx?
chronic alcohol -> chronic pancreatitis
287
Reynold's pentad =?
charcot's triad + hypotension + confusion
ascending cholangitis
288
common mx of ascending cholangitis (definitive)?
ERCP <48h
289
mx pancreatic pseudocysts?
conservative mx
| if infection, mass effect on abdominal organs or a persisting pseudocyst beyond 12 weeks - fine needle aspiration
290
AXR: Multiple small calcific foci can be seen in the pancreas - dx?
chronic pancreatitis
291
differentiating between cholecystitis and cholangitis?
LFTs normal cholecystitis
292
A 45-year-old man presents with an episode of alcoholic pancreatitis. He makes slow but steady progress. He is reviewed clinically at 6 weeks following admission. He has a diffuse fullness of his upper abdomen and on imaging a collection of fluid is found to be located behind the stomach. His serum amylase is mildly elevated. Which of the following is the most likely explanation?
pseudocysts
293
DM monitoring in chronic pancreatitis patients?
Annual HbA1c
294
(azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate) cause???
pancreatitis
295
Pigmented gallstones are associated with?
sickle cell
296
A 51-year-old woman presents with recurrent episodes of epigastric pain radiating through to her back, typically brought on by eating a heavy meal. She drinks around 20 units of alcohol per week. During the current episode she noticed that her sclera were yellow. dx?
common bile duct stones
297
surgical emphysema (subcutaneous emphysema) on XR:
if can see striations of the pec major muscle lateral to the lung field
common post lap chole
298
blockage of which duct does not cause jaundice?
cystic duct or gallbladder
299
A 52-year-old woman presents with sepsis secondary to ascending cholangitis. Blood cultures grew Escherichia coli sensitive to gentamicin. She has received 2 days of treatment with gentamicin. The gentamicin levels have been in normal range. She remains febrile with rigors, a rising white cell count and tenderness in the right upper quadrant.
why?
abscess or deep seated infection
