General Flashcards
DDx of scrotal masses
Benign:
- hydrocele
- epididymal cyst
- varicocoele
- epididymo-orchitis
- inguinal hernias
- benign epididymal tumours
Malignant:
- testicular cancer
Types of testicular cancers
Germ cell tumours (95%)
Non-germ cell tumours include: leydig cell tumours, sertoli cell tumours, secondary metastasis
What embryonic level does testicular cancer spread via lymphatic drainage?
T11-L4
Tumour markers for testicular cancer?
a-feto protein (AFP)
B-HCG
LDH -> usually elevated in metastatic disease
e.g high B-HCG and no AFP = most likely a choriocarcinoma
What is an orchidectomy?
removal of one or more testes
Testicular cancer staging
Testicular cancer risk factors
- An undescended testicle
- Family history of testicular cancer
- HIV infection
- Carcinoma in situ of the testicle
- Having had testicular cancer before
- Being of a certain race/ethnicity (Black and Asian-American men have higher incidence)
- increased height
- male infertility
Testicular cancer treatment
Orchidectomy followed by chemotherapy (if required) and retroperitoneal lymph node dissection (RPLND) if there is residual mass
If a seminoma then can also use radiation.
What do you expect to find on examination of testicular cancer?
A painless lump that is:
- non-tender
- reduced sensation
- arise from the testicle
- is a hard lump that is irregular
- non-fluctuant
- cannot transluminate the lump
Investigations for testicular cancer?
Scrotal US
Tumour markers - B-HCG, AFP, LDH (not as specific)
Stage tumour using a CT
Histopathological confirmation post orchidectomy (do not biopsy before removal due to risk of tumour seeding)
SEs of testicular cancer treatment
Infertility
Nerve damage around the testes (often cannot ejaculate due to damage to the sympathetic fibres)
Hypogonadism (may need to supplement with testosterone
Increased risk of cancer in the future
which testicular cancer is radioresistant
non-seminoma -> aggressive germ cell cancer arising from mixed cells. More aggressive than seminoma testicular cancer.
Risk factors for breast cancer?
- Fx (oncogenes, BRCA1 or 2 mutation)
- early menarchy and/or late menopause (increased length of oestrogen exposure)
- age at first live birth (later birth age = increased risk)
- nulliparity
- hormone replacement therapy
- atypical hyperplasia (abnormal cells on biopsy but not cancer)
- high alcohol use
- obesity (associated with increased estrogen)
- high radiation exposure
- smoking
- low fibre, high fat diet
Breast cancer mammography screening vs diagnosis
Screening is a two place imaging to assess any abnormal masses within the breast
Diagnostic takes multiple images specific to one area/location of the breast to assess a concerning mass of interest. Usually part of triple testing (examination + history, imaging, biopsy)
What does Ki67 assess in breast cancer prognosis?
Looks at how quickly the tumours are growing. The higher the Ki67, the quicker it is growing.
what is the triple test approach in breast cancer?
- Hx and examination
- imaging (mammogram and/or US
- non-excision biopsy (fine needle aspiration and/or core biopsy)
Invasive vs npn invasive breast cancers
Non-invasive:
- ductal carcinoma in situ (DCIS)
- lobular carcinoma in situ (LCIS)
Both have potential to become invasive breast cancers.
Invasive:
- invasive ductal carcinoma
- invasive lobular carcinoma
Benign DDx of breast lump
breast cyst
fibroadenoma
breast abscess
fat necrosis of the breast
solidary intraductal papilloma
What is Paget’s disease of the nipple?
malignant cells/paget cells involved in DCIS extend within the ductal system -> infiltrate the skin of the nipple without crossing the basement membrane -> causes itching and oozing of the nipple -> usually poorly differentiated.
Lifetime risk of breast cancer and ovarian cancer in women with the BRCA1 gene mutation?
85% breast cancer and 40% ovarian cancer
Prophylactic surgery is a mastectomy and a bilateral salpingo oorophorectomy
What cancer is the BRCA2 gene associated with?
higher risk of breast and ovarian cancer, as well as pancreatic cancer, melanoma, sarcoma and prostate cancer (in males)
Difference between transudate vs exudate?
Transudate is low protein fluid associated with liver cirrhosis, CCF, hypoproteinemia. Does not contain inflammatory cells.
Exudate in a high protein fluid associated with cancer, pancreatitis, abscess/peritonitis, bowel ischemia, BO
Difference between sclerotic vs lytic bone metastasis?
Sclerotic (aka osteoblastic) refers to distant tumour deposits from a primary tumour into the bone. It causes osteogenesis. A
Associated with prostate cancer, and TCC (a rare kidney cancer).
Lytic bone metastasis is when tumour cells dissolve bone and make it less dense. It causes osteolysis. Associated with renal cancer, thyroid cancer, melanoma and lung cancer. Also breast cancer but is can be mixed
Tumours most associated with bone metastasis?
Breast cancer
Prostate cancer
Melanoma
Kidney/renal cancer
Lung cancer
Thyroids
Best imaging modality to assessing bone metastasis?
CT followed by MRI
What is the aim of adjuvant vs neoadjuvant therapy in cancer treatment?
Adjuvant ‘mops’ up any cancer cells after the main treatment (e.g. radiation post mastectomy). This decreases the rate of local recurrence and micro-metastasis
Neoadjuvant is aimed to reduce tumour size prior to main treatment (e.g. chemotherapy to reduce breast cancer size prior to mastectomy).
What is the arterial supply of the breast?
internal thoracic, axillary, and intercostal arteries
what is the venous drainage of the breast?
internal thoracic, axillary and intercostal veins
What is the lymphatic drainage of the breast?
lymph fluid drains into the axillary nodes (75%), parasternal nodes (20%), and posterior intercostal nodes (5%)
Where does breast cancer metastasis main occur?
occurs through haematogenous and lymphatic spread -> into the lymph nodes, bone, liver, lungs, and brain (LBLBL)
S&S of breast cnacer
Signs:
- breast asymmetry
- nipple retraction/inversion
- colour/skin changes e.g. erythema, peau d’orange
- lymphadenopathy - swollen lymph nodes (esp. of the axilla)
- lymphedema of the arm
- signs of metastasis such as bone pain
Symptoms:
- painless lumps (hard, uneven borders)
- bloody discharge from the nipples
Tumour marker for breast cancer?
CA.15-3
Ovarian cancer tumour markers?
CA 125
Why is core needle biopsy preferred of fine needle biopsy for breast cancer diagnosis?
Core needle biopsy allows for moledular typing, fine needle does not
What is a sentinel node biopsy?
Radioactive substance or blue dye is injected into the tumour and will travel to affected lymphnodes. Lymph node with metastatic disease can then be identified and assessed whether lymph node dissection is required.
What chemotherapy agents are typically used in the treatment of breast cancer?
FEC
Fluorouracil, epirubicin, and cyclophosphamide
Add docetaxel if there is lymph node involvement.
Can be given before (neoadjuvant) or after surgery (adjuvant).
What hormonal therapy is used in breast cancer?
If ER positive:
- Premenopausal: use tamoxifen (an estrogen receptor antagonist in the breast, and estrogen receptor agonist in bone and uterus). This means it will prevent osteoporosis but it increases the risk of endometrial cancer (and VTE).
Tamoxifen is effective in reducing local recurrence, mortality and contraletal breast cancer
- Postmenopausal: use aromatase inhibitors to reduce the production of oestrogen which decreases cancer growth, but also causes menopausal symptoms.
May consider ovarian function suppression via radiotherapy, oophorectomy or medical (triptorelin)
Contraindications for hormonal therapy n breast cancer treatment?
Pregnancy
Which target therapy is used in HER2 positive cancers?
Trastuzumab (aka Herceptin) is a monoclonal antibody that targets HER2
Can cause gastrointestinal upset and is cardiotoxic
What are some complications of a full axillary node dissection?
Damage to the long thoracic nerve -> winging of the scapula
Damage to the thoracodorsal nerve
Lymphodema
Shoulder stiffness, pain, numbness
Risk of infection to the surgical area
What does HER2 stand for?
Human epidermal growth factor receptor
Tipple negative breast cancer risk factors?
- age (more common in younger patients)
- race - more common in African-American
- being premenopausal
- young age of first pregnancy
- obesity
- BRCA1 mutation
What age group are mammograms freely offered to in Australia?
Every two years for people aged 50-74yrs
Prevention vs treatment of VTE
Prevention = enoxaparin 40mg subcut
Treatment = enoxaparin 1.5mg/kg subcut daily. Can also start oral anticoagulant such as warfarin.
Use IV heparin is kidney impairment.
Causes of increased ALP?
hyperparathyroidism, Paget disease, osteoblastic bone tumours, osteomalacia, rickets, healfing fractures, liver disease, hyperthyroidism
What is an annular pancreas?
Head and neck of the pancreas wraps around the duodenum -> get gastric distention and vomiting
What is pancreas divisum
Abnormaility in pancreatic duct/drainage -> leads to chronic pancreatitis
Causes of acute pancreatitis?
Alcohol use
Biliary tract disease
Obstruction due to neoplasms
Iatrogenic (ERCP_
Drugs (frusemide)
Trauma
Causes of acute pancreatitis?
Alcohol use
Biliary tract disease
Obstruction due to neoplasms
Iatrogenic (ERCP_
Drugs (frusemide)
Trauma
Pathophysiology of acute pancreatitis?
Acina cell injury via multiple mechanisms (obstruction, inflammation, drugs, ischemia, premature activation of enzymes) -> premature activation of pancreatic enzymes -> autodigestion of the pancreas (proteases, lipases, and elastases).
Cullens vs gray turners sign?
Cullens is around the umbillicus and grey turner is the flanks (bruising in pancreatitis due to internal retroperitoneal haemorrhage)
Acute pancreatitis signs and symptoms:
- severe abdominal pain
- elevated serum lipase
- bloody abdominal fluid (due to small vessel haemorrhage due to elastase)
- ARDS
- electrolyte disturbances and renal failure
- Shock
Acute pancreatitis treatment
Usually pancreatic rest and supportive treatment is all that is required. Very severe cases where infective necrosis is present will require surgery and empiric ABx.
Give pain relief
NBM until pain free and has bowel sounds
Give IV fluids/resusc
Chronic pancreatitis sequale
Recurrent mild pancreatitis leads to chronic injury and scarring of the pancreas. Leads to loss of function and acini. Ressults in pancreatic insufficiency (weight losss, malnutrition, diarrhea/steatorrhea, diabetes mellitis)
What does I GET SMASHED stand for?
I = idiopathic
G = gallstones
E = ethanol
T = trauma
S = steroids
M = mumps or malignancy
A = autoimmune
S = scorpion sting
H = hypertrigliceridemia or hypercalcemia
E = ERCP
D = drugs (diuretics, NSAIDs)
Diagnostic criteria for acute pancreatitis?
Abdominal pain suggestive of acute pancreatitis
Raised serum lipase -> 3 times the upper limit (can also do amylase but not as specific)
characteristic findings of acute pancreatitis on CT
What would be seen on abdominal CT in acute pancreatitis?
- pancreatic enlargement
- oedema
- fat stranding
- free fluid
- complications including necrosis, pseudocyst, abscess
Treatment of acute pancreatitis?
Pancreatic rest
Fluid administration (normal saline)
Pain relief (morphine or fentanyl)
ABs have limited role unless pancreatic necrosis (occurs due to haemmaorhage and damage to the blood vessels) or an abscess is present.
Recommence food when patient is pain free and tolerating food.
Also consider the underlying cause and treat. e.g ERCP if gallstone obstruction
Why can hypocalcemia result from acute pancreatitis?
The pancreatic lipase breask down peripancreatic and mesenteric fat. Get release of fatty acids that bind calcium which results in hypocalcemia.
Causes of chronic pancreatitis?
excessive alcohol consumption
idiopathic pancreatitis
ductal obstruction
other causes include CF, AI, hereditary conditions.
Are serum amylase and lipase usually raised in chronic pancreatitis?
They are usually normal due to fibrosis and atrophy of the pancreas
What is the foecal pancreatic elastase test helpful for?
Identifies pancreatic exocrine insufficiency in chronic pancreatitis.
Faecal elastase will be low in pancreatic insufficiency
Treatment/management of chronic pancreatitis?
Lifestyle:
- reduce risk factors such as excessive alcohol use, smoking
Identify diabetes and manage
Pain management using analgesia
Pancreatic enzyme replacement therapy
Indication for cholecystectomy?
- symptomatic cholelithiasis with or without complications
- asymptomatic cholelithiasis in patients who are at an increased risk of gallbladder cancer or gallstone complications
- cholecystitis
- gallbladder polyps >0.5 cm
- porcelain gallbladder
What is Strasberg’s classification of bile duct damage during surgery?
What is Charcot’s triad?
Presenting feautres of acute cholangitis (NOT CHOLECYSTITIS) including fever, abdominal pain, and jaundice.
What is Reynold’s pentad?
Occurs in suppurative cholangitis where patients have fever, abdominal pain, jaundice, confusion, and hypotension.
Treatment of acute cholangitis?
Monitor for sepsis and treat with empiric ABs (gent, amp, met) before commencing targeted therapy once cultures are returned.
Establish biliary draining (usually via ERCP)
Supportive therapy (e.g pain, nausea, fluids)
Cholecystectomy if gangrenous
What is Ranson’s criteria for acute pancreatitis?
Mild vs moderate vs severe acute pancreatitis?
Mild = no organ damage, no local or systemic complication
Moderate = transient organ failure that resolves within 48hr and/or local or systemic complication without persistent organ failure
Severe = persistent organ failure that may involve one or more organs.
Cholangitis vs cholecystitis
Cholangitis = inflammation of the bile duct
Cholecystitis = inflammation of the gallbladder. Murphy’s sign will be positive
What are gallstones made up of?
Usually cholesterol, calcium, and bilirubin.
Usually radiopaque.
Will create an acoustic shadow behind it.
Cholelithiasis vs choledocholithiasis
Cholelithiasis = gallstone in the gallbladder
Choledocholithiasis = gallstones within the bile duct
Risk factors for gallstones
Six F’s = female, fat, forty, fertile, fair skinned, family hx
Modifiable:
- physical inactivity
- low fibre intake
- hypercholesterolemia
- rapid weight loss (bariatric surgery patients)
Non-modifiable:
- liver cirrhosis
- Crohn’s disease (inflamed terminal ileum impairs bile acid recirculation)
- presence of gallstones
- comorbidities such as T2DM, cirrhosis, jaundice
Empiric ABs used for cholecystitis
Gentamicin + ampicillin
If chronic biliary obstruction then add metronidazole
Treatment for cholecystitis?
Withhold oral feeds if going for surgery (then low fat diet)
Empiric ABs gent + amp +/- met
Cholecystectomy -> laparoscopic vs open
Percutaneous cholecystostomy or ERCP to remove gallstone in bile duct. Cholecystectomy better to prevent recurrence.
Supportive care -> fluids, analgesia (morphine), lifestyle modification post surgery such as low fat diet 1 week following surgery.
What is Mirizzi syndrome?
gallstone located in the Hartmann’s pouch causing compression of the adjacent hepatic structures. Can result in obstructive jaundice.
Diverticulitis risk factors?
advanced age
genetic risk factors
smoking
elevated BMI
cheotherapy
high red meat consumption
connective tissue diseases such as Marfan Syndrome or Ehlers-Danlos syndrome
chronic constipation
low fibre diet
Diverticulitis pathophysiology?
Formation of diverticulosis (most commonly in the sigmoid colon) due to weakening of the diverticular wall (age, vascular penetration) and increase in intraluminal pressure -> bacteria or faecal matter enters the diverticular -> results in inflammation/infection -> can form complications such as abscess or perforation.
Diverticulitis essentials of diagnosis + clinical features?
Essentials of diagnosis:
- fever
- left lower abdominal pain
- leukocytosis
Clinical features:
- low grade fever
- left lower quadrant pain
- altered bowel habits (usually contipation)
- acute abdomen would possibly indicate perforation or peritonitis.
Most common organisms involved in diverticulitis?
E.coli
enterococcus
bacteroides fragilis
Diverticulitis complications?
Perforation
Abscess formation
intestinal obstruction due to inflammatory related narrowing
Fistula formation (usually rectovesical fistula
What is the Hinchey classification?
I - pericolic abscess formation
II - pelvic, intra-abdominal, or retroperitoneal abscess
III- generalised purulent peritonitis
IV - generalised fecal peritonitis
Management of complicated diverticulitis?
Complicated diverticulitis:
- in patient management with broad spectrum IV antibiotic
- gentamicin, metronizadole, ampicillin IV
- CT guided percutaneous drainage for abscesses of more than 4cm (Hirchey 1 or 2)
- emergency colectomy in patients with generalised peritonitis → Hartmann’s procedure where part of the descending or sigmoid colon is removed and a stoma bag is attached (can be connected to the sigmoid colon later on). Performed in Hirchey 3 or 4 (purulent or faecal peritonitis)
- patients should be nil by mouth and receive IV fluids
Definition of diverticulosis?
Herniation of the mucosa and submucosa through the muscular layer of the colon wall
Preferred imaging modality for suspected diverticulitis?
Abdominal and pelvic contrast CT
Use MRI or US if CT is contraindicated
Anterior vs posterior PUD rupture?
Anterior = arteries not impacted, more likely to result in free intra-peritoneal gas under the diaphragm.
Posterior = gastroduodenal artery likely to be perforated. Causes bleeding into the intra-peritoneal cavity.
Pain fibres involved in visceral vs parietal pain?
Visceral pain = c-fibres
Parietal/somatic pain = A and c-fibres (more localised)
Most common causes of acute abdomen?
GIT: appendicitis, large or small bowel obstruction, perforated peptic ulcer, diverticulitis, IBD, mesenteric adenitis
Liver, spleen, biliary:
- acute cholecystitis, acute cholangitis, acute hepatitis, spontaneous rupture of the spleen
Pancreatic:
- acute pancreatitis
Urinary:
- renal or ureteral colic, acute pyelonephritis, acute cystitis
Gynae:
- acute salpingitis, ruptured ovarian cyst, ruptured ectopic pregnancy
Types of colon polyps?
Non-neoplastic polyps include: hyperplastic polyps, inflammatory polyps, haemartomatous polyps. These polyps have a low potential to become malignant.
Neoplastic polyps include adenomas (e.g. tubular, tubulovillous, and villous adenomas) and serrated types. These polyps have moderate to high potential to become malignant if given enough time to grow.
Most CRC arise from dysplastic adenomatous polyps.
CRC staging
Staging:
TNM staging:
T part
- T1 → invaded the submucosa
- T2 → invaded the muscularis propria
- T3 → invaded to the serosa/adventia or perirectal tissues
- T4 → invaded into the peritoneum and surrounding tissues
N part
- 0 → no lymph node involvement
- 1 → invaded 1-3 local lymph nodes
- 2 → invaded 4 or more local lymph nodes
- 3 → distant lymph node metastasis
M part
- 0 → no metastsis
- 1 → metastasis
Lynch Syndrome vs FAP?
Lynch syndrome: accounts for 2-10% of CRC and is caused by a mutation of a MMR genes (esp MLH, MSH, PMS2). This leads to microsatellite instability and an increased risk of CRC. Condition is autosomal dominant.
Familial adenomatous polyposis: accounts for 1% of CRC. Affected patients have multiple precancerous adenomatous polyps with the onset of polyps at a mean age of 16. They have a 95% lifetime risk of developing CRC. Also autosomal dominant. Management includes polyp removal but will eventually require a protocholectomy and ileostomy.
CRC screening recommendations
CRC management:
Colon:
- colectomy (hemi, sigmoid, subtotal, total) with lymph node dissection indicated in all resectable tumours
- chemotherapy including FOLFOX (usually used as an adjuvant therapy)
- radiation is typically not used due to risk of radiation enteritis
- preoperative chemotherapy or immunotherapy considered for stage IV CRC
Rectal:
- surgical resection if possible
- neoadjuvant radiation may be used to decrease tumour size
- adjuvant chemotherapy considered
Mutation pathways involved in CRC
- Chromosomal instability
- Most common pathway
- Abnormality to chromosomal segregation (M phase)
- Mutation to APC, p53, DCC, K-Ras, B-Raf, C-Myc
- Seen in most cases of CRC (FAP)
- Microsatellite instability
- Typically associated with mutations in mismatch repair enzymes including MSH2 and MLH1
- Seen in Lynch Syndrome
- Aberrant methylation
- Abnormal patterns in epigenetic methylation. Usually hypermethylation which causes DNA to wrap tightly, leading to the silencing of genes.
Types of AF
paroxysmal = less than 1 week
persistent = >1week to 12mth
longstanding = 1yr
new onset
permanent = decision for no more control strategies
valvular = mitral stenosis or mechanical HV
Causes of AF
atrial dilatation -> HTN, valve dysfunction
sepsis
electrolytes abnormalities
thyroid - thyroidoxicosis or hyperthyroidism
alcohol
drugs - cocaine
Grave’s disease treatment?
anti-thyroid medications
radioactive iodine therapy -> thyroid takes up the radioactive iodine which progressively kills the thyroid cells to decrease its function
beta blockers - symptom control
surgery (partial or full thyroidectomy)
corticosteroids for poptosis
Prostate cancer vs BPH on
Prostate cancer symptoms
Early prostate cancer is typically asymptomatic and detected by early screening.
Lower urinary tract symptoms include:
- frequency
- urinary retention
- haematuria
- incontinence
- nocturia
- dribbling
Metastatic:
- bone pain, pathological fractures
- lymphadema
BPH complications
Urinary stasis -> recurrent UTIs and bladder calculi
Bladder wall hypertrophy and pseudodiverticula
Renal impairment -> pyelonephritis, hydroureteronephrosis
Prostate cancer risk factors
increasing age
Fx
genetics (BRCA1/2, lynch syndrome)
high BMI
smoking
chemical exposure (firefighters at greater risk)
Prostate cancer on DRE vs BPH?
Prostate cancer:
- hard, enlarged, asymmetrical/bumpy nodular mass, loss of median sulcus
BPH:
- enlarged, non-tender smooth, can still feel median sulcus
Investigations for suspected prostate cancer?
- DRE
- prostate specific antigen (PSA) levels. PSA is a serine protease produced only by the prostate gland. Therefore it is an organ specific marker. It is elevated in benign and malignant conditions.
- multiparametric MRI (mpMR)I of the prostate
- transrectal US of the prostate (also used to guide a prostate biopsy)
- perform prostate biopsy if there is clinical suspicion of prostate cancer. Need to give prophylactic ABx to prevent prostatitis.
True or false…
5-alpha reductase inhibitors can suppress PSA production?
True -> therefore needs to be taken into account if screening patient for prostate cancer in they are on 5-alpha reductase inhibitors for BPH
What is the Gleason system used for?
Grading cell differentiation in prostate cancer.
How is prostate cancer staged?
TNM staging
Prostate cancer treatment?
Watchful waiting - if a slow growing tumour, limited life expectancy. Still check PSA and perform DRE regularly.
Active surveillance - regular monitoring with DRE, PSA, biopsies, mpMRI
Radiotherpay
Radical prostatectomy
Androgen deprivation therapy (aims to decrease testosterone levels via medical or surgical castration.
Chemotherapy - usually an adjunct to androgen deprivation therapy. Docetaxel most commonly used.
Prostate cancer DDx
BPH
UTI/cystitis
overactive detrusor muscle
Prostatitis
What type of cancer is prostate cancer?
usually adenocarcinoma arising from gland cells.
Other types include small cell carcinomas.
Sites of metastatic spread in prostate cancer?
bone
liver
lungs
lymph nodes
Current australian recommendations for prostate screening?
no recommendations. Controversial as to whether PSA screening and DRE are beneficial. Informed patient decision making is encouraged.
BPH management?
non-pharm:
- medication reconcilliation, reduced fluid intake, reduced caffeine intake, reduced alcohol intake, bladder emptying techniques.
Pharm:
- a-blockers relax SM of the neck of bladder and internal urethral sphincter -> this improves urine outflow e.g tamsulosin, doxazosin
- 5a-reductase inhibitors decrease conversion of testosterone to DHT -> this decreases prostate growth. e.g. finasteride
- antimuscarinics to inhibit the PSns muscarinic receptors in the detrusor smooth muscle. Causes a decrease in muscle tone.
Phosphodiesterase type 5 inhibitors reduces tone in the detrusor muscle, prostate, and urethra.
Surgical:
TURP (transurethral resection of the prostate) is gold standard therapy. Indicated when pharmacology is insufficient or contraindicated. It is resection of the hyperplastic tissue around the urethra.
Can causes sexual dysfunction, retention, stricture and the BPH may be recurrent.
What 4 counter-regulatory hormones increase in DKA?
cortisol
glucagon
growth hormone
epinephrine
Remember all of these hormones will oppose insulin
What is pyrexia of unknown origin?
A temperature of > 38.3°C recorded on multiple occasions that lasts for > 3 weeks with no clear etiology despite appropriate diagnostics on 3 outpatient visits, 3 days in the hospital, or 1 week of invasive ambulatory investigation.
inheritance pattern for FAP
autosomal dominant inheritance -> mutation to the APC gene
What is CEA?
carcinoembryonic antigen -> found in increased amounts in blood in people who have colon cancer
Foregut artery and nerve supply
mouth to ampulla
coeliac artery
coeliac plexua
midgut artery and ner supply
ampulla to distal third of the transverse colon
SMA
superior mesenteric plexus
hindgut artery and nerve supply
distal transverse colon to rectum
IMA
inferior mesenteric plexua
visceral pain felt based on foregut, mid gut and hind gut origin
foregut = epigastrium
midgut = periumbilical
hindgut = suprapubic
what does murphys, mcburnerys, rovsing’s and grey turners sign each indicate?
murphy’s = cholecystitis
tender over mcburney’s = appendicitis
roving’s sign (RIF tenderness on palpation of the LIF) = suggests free fluid in pelvis
Grey-turner’s sign = retroperitoneal bleeding (occurs in pancreatitis)
Ranson’s criteria for pancreatitis diagnosis?
raised lipase (3 x upper limit of normal)
epigastric pain
CT proven pancreatic stranding
Need 2/3
mild, moderate and severe acute pancreatitis?
mild = no organ failure and no local or systemic complications
moderate = transient organ failure that last less than 48 hours
severe = persistent organ failure for more than 48hrs
Pancreatic cells that produce lipase?
Acinar cells (also produces other enzymes)
Types of seminoma and non-seminoma germ cell testicular cancers?
Seminoma
Non-seminoma:
- choriocarcinoma
- terotoma
- yolk sac carcinoma
- embyronal carcinoma
- mixed
DAPT loading dose and continuous dose?
Loading:
Aspirin = 300mg
Clopidogrel = 300mg
Therapeutic/prophylactic:
Aspirin = 100mg
Clopidogrel = 75mg
Ruptured abdominal aortic aneurysm classic triad of symptoms?
- hypotension
- sudden onset of severe abdominal and/or back pain
- tender pulsatile abdominal mass
What is micardis?
Telmestartan
what surgery can be offered in AAA?
endovascular aneurysm repair - risk of a persistent endoleak
or
open surgical repair.
Features of a SBO on x-ray
- predominately central dilated bowel loops (peripheral in LBO). Dilation >3cm
- Air-fluid levels noted in erect position (>2.5cm width)
- dilation of small bowel loops present -> small bowel anatomical folds of the small bowel become more apparent
- minimal air distal to site of obstruction
Outline the types of Salter Haris Fractures?
CRC prognosis based on staging
Features of a good screening test?
Screening is intended for a target population where they do not have symptoms of the disease
Garden classification of NOFs?
What is the Pauwels classification used for?
Describe 3 significant findings on this CT image?
What is the diagnosis?
Superficial haematoma on the left side of the head
Biconvex haemorrhage
Midline shift to the right
Diagnosis: extradural haematoma (aka epidural haematoma)
What is the diagnosis? What is a salient feature?
Subdural haematoma (between the dura mater and the arachnoid mater).
Salient feature: crescentric shape of haemorrhage. Some midline shift.
Dose of apixaban for VTE treatment?
renal clearance > 25ml/min
Apixaban dose for atrial fibrillation?
5mg twice daily. If valvular AF, then use warfarin and adjust to INR of 2-3
Name some anticoagulants and the doses required for the prevention of VTE
Which bacteria do gentamicin, metronidazole, cephazolin, and ampicillin cover?
cephazolin = gram +ve and skin flora
ampicillin = gram positive
metronidazole = anaerobes
gentamicin = wide spectrum but gram -ve in particular (does not cover an +ve)
When to stop taking warfarin prior to surgery?
take last dose 6 days prior to surgery so there are 5 days of not taking warfarin prior to the surgery.
What does HAS-BLED stand for? And what is it assessing?
Risk of bleeding in a patient with AF
What is this?
cutaneous lupus
know the gallstone image. This is choledocoliathesis
Cutaneous larva migrans
Cutaneous larva migrans is the correct answer. It is most commonly caused by cat or dog hookworm larvae. The parasite is typically confined to the epidermis as it lacks the collagenase necessary to break through the basement membrane. Most infections are localized in the lower extremity as it is a common site of larval penetration. The eruption appears to migrate as the larvae move up to a few centimeters daily.
Management of compartment syndrome?
