Gen surg Flashcards
laparotomy:
opening up of abdo
laparoscopy:
keyhole surgery on the abdo
adhesions:
scar tissue in the abdo that attach contents together
volvulus:
twisting of colon
tenesmus:
symptom of full rectum/needing to open bowels after emptying bowels
hemicolectomy:
removal of a portion of the bowel
hartmann’s procedure:
removing rectum and or sigmoid colon and forming a colostomy
three main causes of intestinal adhesions:
previous surgery
peritonitis
intra-abdominal infection
kocher incision:
open cholecystectomy
mercedes benz incision?
liver transplant
young female with generalised abdo pain which becomes RIF pain over a few days - important ddx:
sounds like apendicitis
in this demographic - preg ix
gynae causes
set of acute abdominal investigations:
FBC, U&E, LFTs, cultures, amylase, VBG, CRP, clotting, 2xG&S, b-hCG
preg ix
urine dip
what does air under the diaphragm on an erect CXR indicate?
perforation
“tinkling bowel sounds” on auscultation =?
obstruction buzzword
what needs ruling out in elderly male with epigastric pain?
MI - do an ECG
on abdominal X-ray - thresholds for obstruction on each region of bowel?
small bowel - >3cm. central regions
large bowel - >6cm. peripheral region
cecum - >9cm.
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?
mesenteric ischemia
pathology of mesenteric ischemia?
clot in vessels supplying bowel -> ischemia
set management plan for acute abdomen (5+1):
analgesia (can still give opioids if ?obstr) anti-emetic IVI monitor urine output + cath NBM pending snr rv (Abx)
key cx of pancreatitis?
necrosis, ARDS, DIC, pseudocysts
which condition requires aggressive IV fluid resus?
pancreatitis - due to massive 3rd space losses
1st line (and sequential ix) for billiary pathology:
USS abdo
IF shows CBD dilatation => MRCP
IF shows gallstones => ERCP (to remove)
2 commonest causes of pancreatitis?
gallstones
ethanol
increased amylase and deranged LFTs: dx:
gallstone pancreatitis
when to CT in ?billiary pathology?
if ?perforation
or very septic
causes of small bowel obstruction:
adhesions (post-sx) hernias tumours IBD intussusception
causes of large bowel obstruction:
tumours
volvulus
diverticular disease
mx obstruction:
IVI, NG - drip and suck
what is pseudo-obstruction?
“ileus”
adynamic bowel minus mechanical obstruction
causes of ileus:
hypocalcaemia, other electrolyte imbalances
hypothyroid
MS
post-surgical
differentiating between types of shock by temperature of peripheries?
neurogenic, septic and anaphylactic (together called distributive) -> warm peripheries
rest cause cool peripheries
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
pulsatile mass and swelling would suggest ?
carotid artery laceration
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
In those diagnosed with anal fistula, what is best ix to characterise the course of the fistula?
MRI pelvis
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
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
congenital inguinal hernia - mx?
surgical repair immediately
congenital umbilical hernia - mx?
conservative mx
resolves 4-5yo
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
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
Valvulae conniventes (haustra) extend all the way across in?
small bowel obstruction
Haustra extend about a third of the way across in?
large bowel obstruction
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
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
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
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
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
tx amoebic abscess?
metronidazole
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
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
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
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
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
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
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
class III shock is?
tachycardia, hypotension and confusion
class I shock is?
fully compensated for
Class II shock is?
tachy
class IV shock is?
LOC , severe hypotension
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)
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
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
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%
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
where does the duodenum become the jejenum?
ligament of treitz
which branch of the aorta supplies the oesophagus-duodenum (including liver and gallbladder):
coeliac trunk
which branch of the aorta supplies the duodenum- first 2/3 of the transverse colon?
superior mesenteric artery (SMA)
which branch of the aorta supplies the final 1/3 of the transverse colon - rectum?
inferior mesenteric artery (IMA)
what is murphy’s sign and what does it indicate?
tender on inspiration in RUQ
inflammation of the gallbladder
what is Rosvig’s sign and what does it indicate?
tender RIF when press on LIF
appendicitis
what is the psoas strech a sign of and how is it illicited?
appendicitis
RIF pain when straight leg raise
what is rebound tenderness and what does it indicate?
pain when take hand away -
peritonitis / abdo wall pathology
what are tinkling bowel sounds and what do they indicate?
high pitch bowel sounds
obstruction
gallstones + deranged LFTs =
ascending cholangitis (doesn't necessarily present as jaundiced skin/eyes)
what is biliary colic?
pain due to gallstones WITHIN the gallbladder minus infection minus LFT derangement
what is cholecystitis?
infection of the gallbladder - due to gallstones
what abx is usually added to coamox when suspected ascending cholangitis?
gentamycin
what is the minimum EGFR for a CT-AP? (contrast obvs come on lad)
30
mx faecal impaction?
PR then phosphate enema if stool felt in rectum on PR
mx volvulus?
flatus tube
poonami
coffee bean sign on x-ray?
sigmoid volvulus
red flags for hernias:
red, pain, irreduceable, obstruction, peritonism, if the hernia contains bowel
why should you avoid metaclopramide in obstruction?
it is a pro-kinetic - will make things worse la
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
52F Pakistani ethnicity has a lumbar vertebral crush fracture. She has hypocalcaemia and a low urinary calcium. dx?
osteomalacia
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
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
X has typical features of portal hypertension including ascites, splenomegaly and caput medusae.
portal hypertension
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
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
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
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
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
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
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
HCC tumour marker?
AFP
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
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
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.
Inguinal herniae occur due to a hole in the?
internal oblique and transverse muscles
inguinal hernia. What is the most appropriate management?
routine referral for surgery
The definition of an Upper GI Bleed is a haemorrhage with an origin proximal to the???
ligament of treitz
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
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
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
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
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
Pfannenstiel’s incision which op?
c-section
Kocher’s incision which op?
cholecystecomy
Rooftop or Midline incision - which op?
whipple’s
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
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
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
A syndrome consisting of a PTEN mutation and intestinal hamartomas. dx?
cowden disease
A syndrome which may be present in a patient with multiple intestinal hamartomas and pigmentation spots around the mouth dx?
peutz-jegher’s syndrome
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
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
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
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
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
definitive diagnostic investigation for small bowel obstruction??
CT abdomen
also for large bowel obstruction
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
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
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
Severe acute peri-umbilical bruising in the setting of acute pancreatitis.
whos sign?
cullens sign
In acute cholecystitis there is hyperaesthesia beneath the right scapula.
whos sign?
boas sign
In appendicitis palpation of the left iliac fossa causes pain in the right iliac fossa. whos sign?
rosving’s sign
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
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
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
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
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
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
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
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
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
40F assaulted with brick. ?spleen injury. CT abdo - Minimal intra-abdominal bleeding without haemodynamic compromise. mx?
conservative - analgesia + frequent obs
not warrant a laparotomy
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
In acute pancreatitis there is bruising in the flanks.
sign?
grey-turner’s sign
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
22F 24/40 presents with frank haematuria. She is sexually active. She has had a previous pregnancy resulting in caesarean section. dx?
placenta percreta
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
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
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
TPN is known to result in ???
derangement of LFTs
What is the single most appropriate initial investigation(s) to assess for the presence of free fluid in the abdomen and chest?
FAST scan
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
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
A 33-year-old lady presents with a recently diagnosed goitre and a diagnosis of Hashimotos thyroiditis is suspected. ix?
thyroid peroxidase abs
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)
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
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
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
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
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
analgesics to avoid in renal transplant pts?
NSAIDS - nephrotoxic
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
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
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
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
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
reduced SVR increased HR normal/increased cardiac output decreased blood pressure which shock?
septic shock
increased SVR increased HR decreased cardiac output decreased blood pressure which shock?
hypovolaemic
increased SVR (vasoconstriction in response to low BP) increased HR (sympathetic response) decreased cardiac output decreased blood pressure which shock?
cardiogenic
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
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
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)
A 38-year-old lady donates her kidney to her identical twin sibling. type of transplant?
isograft
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
A 38-year-old lady donates her kidney to her niece.
type of transplant?
allograft
eg of Xenograft ?
porcine heart valve
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
patients with ongoing acute bleeding despite repeated endoscopic therapy????
laparotomy and surgical exploration
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)
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%
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
best investigation for hydatid cysts?
CT scan
percutaneous aspiration CI
who gets hydatid cysts?
middle eastern
farmer
raised eosinophils
obstructive lfts
Post splenectomy blood film features:
Howell- Jolly bodies
Pappenheimer bodies
Target cells
Irregular contracted erythrocytes
Indications for thoracotomy in haemothorax include?
> 1.5L initial loss
>200ml/h for 2h
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
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
differentiating lynch syndrome from FAP?
lynch - normal reaining mucosa in bowel - in FAP there are polyps
what may cause bubbly urine?
enterovesical fistula
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
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
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.
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
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
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
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
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
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 !!!!!
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
A 63-year-old man presents with a locally unresectable gastrointestinal stromal tumour. Biopsies confirm that it is KIT positive. mab?
imatinib
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
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
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
Females < 30 years with a non-tender, discrete and mobile lump =
fibroadenoma
older women. painless lump or with nipple change, nipple discharge and skin contour changes.
ductal ca
older women. painful lumpy, often worse around menstruation. dx?
fibroadenosis
intraductal carcinoma associated with a reddening and thickening (may resemble eczematous changes) of the nipple/areola
paget’s disease of the breast
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
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
More common in lactating women
Red, hot tender swelling of breast. dx?
breast abscess
‘tender, fluctuant’
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
First-line management of mastitis is
to continue breastfeeding normally
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
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
She is HER2 -ve and ER -ve, however her TNM stage is T2N2M0. tx?
FEC-D chemotherapy
she is node positive
br ca women who are ER +ve, post-menopausal - tx?
aromatase inhibitors
sfx - Osteoporosis
UK breast ca screening?
mamogram 3yrly
47-73
BRCA gene mutations transmission?
Autosomal dominant
heterozygous
The ‘snowstorm’ sign on ultrasound of axillary lymph nodes indicates?
extracapsular breast implant rupture
ectasia mx?
if not bothering woman leave it
if bothering total duct excision
Breast fibroadenoma mx:
surgical excision biopsy if >3cm
Axillary node clearance is associated with
arm lymphoedema and functional arm impairment
if pt opts not for this -> RT
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
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
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.
What is the most common type of breast cancer?
Invasive Ductal Carcinoma (no special type)
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
ddx fissure from haemorrhoids?
haemorrhoids - painless
fissure - painful
Patient >= 60 years old with new iron-deficiency anaemia →
urgent 2ww CRC
toxic megacolon vs caecal volvulus - IBS diseases:
toxic megacolon - UC
caecal volvulus - crohn’s
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
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
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
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
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
Unruptured sigmoid volvulus is primarily managed by?
decompression by rigid sigmoidoscopy and flatus tube insertion
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.
Carcinoma of the splenic flexure requires a?
left hemicolectomy
A 65-year-old man with carcinoma of the caecum - op?
right hemicolectomy
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
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
triad of vomiting, pain and failed attempts to pass an NG tube???
gastric volvulus
Borchardt’s triad
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
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
One-off flexible sigmoidoscopy at age for bowel screening?
55yo
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’.
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
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
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
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
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
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
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
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
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
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
why use epidural analgesia post-colorectal surgery?
reduced time taken to return to normal bowel function
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
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
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
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
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)
The combination of a grade 3 tumour and axillary nodal metastasis in a young female would attract a recommendation for ??
cytotoxic chemo
anorectal pain and a tender lump on the anal margin?
blue-black
thrombosed haemorrhoids
brought out on the left side of the abdomen, and sewn flush with the skin.??
colostomy
commonest crc?
adenocarcinoma
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
first line management for breast cancer. If the tumour is less than 4cm a??
surgery
wide local incision
(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
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
may be used in patients with stress incontinence who don’t respond to pelvic floor muscle exercises and decline surgical intervention?
duloxetine
1st-line treatment for urge incontinence and are all antimuscarinic agents?
oxybutinin, tolterodine, solifenacin
2nd line - mirabegron (B3 ag)
what indicates pancreatitis severity?
hypocalcaemia
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.
Porcelain gallbladder (intramural gallbladder wall calcification) is a strong risk factor
cholangiocarcinoma
also PSC
Acute cholecystitis treatment:
IV ABx + early laparoscopic cholecystectomy within 1 week of diagnosis
common causative agent for ascending cholangitis?
e coli
score is more specific to acute pancreatitis?
glasgow > apache
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
Charcot’s cholangitis triad:
fever, jaundice, RUQ
temp cause of pancreatitis?
hypothermia
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
preferred diagnostic test for chronic pancreatitis - looking for pancreatic calcification???
CT abdomen
first-line USS - r/o gallstone/obstruction
useful for determining whether the cause of the isolated hyperbilirubinaemia is due to haemolysis or Gilbert’s syndrome.?
FBC
Gastric MALT lymphoma - mx?
eradicate h pylori - PPI + amox + clari - triple therapy
investigating suspected acute pancreatitis and may be useful for late presentations > 24 hours??
lipase>amylase
best ways for differentiating between acute cholecystitis and biliary colic is that people with cholecystitis?
systemically unwell
mx acute pancreatitis?
fluids and analgesia - not abx routinely
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
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
Reynold’s pentad =?
charcot’s triad + hypotension + confusion
ascending cholangitis
common mx of ascending cholangitis (definitive)?
ERCP <48h
mx pancreatic pseudocysts?
conservative mx
if infection, mass effect on abdominal organs or a persisting pseudocyst beyond 12 weeks - fine needle aspiration
AXR: Multiple small calcific foci can be seen in the pancreas - dx?
chronic pancreatitis
differentiating between cholecystitis and cholangitis?
LFTs normal cholecystitis
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
DM monitoring in chronic pancreatitis patients?
Annual HbA1c
(azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate) cause???
pancreatitis
Pigmented gallstones are associated with?
sickle cell
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
surgical emphysema (subcutaneous emphysema) on XR:
if can see striations of the pec major muscle lateral to the lung field
common post lap chole
blockage of which duct does not cause jaundice?
cystic duct or gallbladder
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
