General Surgery Flashcards
1
Q
Dysphagia + regurgitation of stale food + halitosis
Dx
Investigation
A
Zenker’s diverticulum - pharyngeal pouch
Barium swallow - endoscopy is contraindicated
2
Q
Old age patient with worsening dysphagia - for solids and then for soft foods and liquids
Long-standing gastric reflux
Suspect?
A
Oesophageal carcinoma
- barium swallow = irregular narrowing + proximal shouldering
3
Q
Most common type of oesophageal ca
A
Adenocarcinoma
4
Q
How is dx of oesophageal ca made
A
Upper GI endoscopy + biopsy
5
Q
RFs for oesophageal ca (2)
A
GERD
Barrett’s oesophagus
6
Q
Features of gastric carcinoma
A
Virchows node
Wt loss old age tiredness vomiting dyspepsia anemia
May have associated hepatomegaly and ascites
Late stage metastasises to liver
7
Q
RFs gastric carcinoma (6)
A
Old age Blood group A H pylori Smoking Spicy food Pernicious anemia
8
Q
Haemoglobin levels before surgery
- elective
- emergency
A
Elective :
<10 - delay , investigate anemia
<8 -transfuse and defer surgery
Emergency
<10 - proceed with surgery
<8 - transfuse blood + proceed with surgery
9
Q
Causes of hypercalcemia
A
Multiple myeloma
Sarcoidosis
SCC of lung
Breast and prostate ca
10
Q
Diverticulosis mainly occurs on
A
Sigmoid colon - left lower abdomen
11
Q
Analgesia after open surgery
A
Patient controlled analgesia with morphine
12
Q
Operating on patients with history of MI
A
No elective surgery fro at least 6 months after MI
13
Q
Features of obstructive jaundice
A
Jaundice, dark urine, pale stools
Raised ALP
14
Q
Most appropriate investigation obstructive jaundice
A
US abdomen
15
Q
Causes of obstructive jaundice
A
Choledolithiasis
Cancer head of pancreas - painless jaundice
Periampullary tumour
16
Q
Feared complication of hemicolectomy
A
Anastomotic leak
- 5-10 days after surgery
17
Q
RFs for anastomotic leak
A
DM Smoking Immunocompromised - RA, asthma, COPD, steroid use Rectal anastomoses Peritoneal contamination
18
Q
Complications of an anastomotic leak
A
Intra-abdominal abscess
Peritonitis
- start BSA and do CT abdo pelvis with contrast
19
Q
Investigation done for suspected colorectal ca
A
Colonoscopy
20
Q
Presentations of colorectal ca
Left
Right
A
Left -
obstructive sx, changes in bowel habits, dark blood per rectum
+anemia + wt loss
Right - caecal
Microscopic bleeding, obstructive sx less common as diameter is wider
21
Q
Abscess at site of skin suture
Treatment
A
Local exploration
ABx and drainage
22
Q
Chariots triad seen in
A
FRJ
Fever + right upper abdominal pain + jaundice
Ascending cholangitis
23
Q
Reynolds Pentad
A
Charcot’s + confusion + hypotension
24
Q
Management of ascending cholangitis
A
Broad spectrum antibiotic - ampicillin-sulbactam
Biliary drainage
25
Complications of thyroidectomy (4)
Hypocalcemia - parathyroid damage/removal
Acute airway obstruction - hematoma
= evacuate hematoma
Nerve injury
- unilateral to RLN - hoarseness
- bilateral to RLN- aphonia, airway obstruction
- ext branch sup laryngeal - dysphonia = loss of high pitched sounds = monotone
Wound infection
26
Rare and serious complication of hypocalcemia
Impetigo herpetiform
27
ECG findings hypocalcemia
Prolonged QT
28
Treatment of hypocalcemia
10 ml 10% calcium gluconate
29
Thyroid storm
Cause
Features
Manipulation of thyroid during surgery in hyperthyroid pt
Tachycardia, palpitation, high body temperature, diarrhoea, vomiting, reduced consciousness, tremors
30
Treatment of thyroid storm
Beta blockers - propanolol
- control tachy and tremors
High dose steroids - inhibits T4 to T3 conversion
31
Features of acute mesenteric ischemia
| Causes
Sudden onset severe abd pain + tenderness - exceed physical signs
Abd distension + absent bowel sounds
VBG lactate is HIGH
Gangrene irreversible
AF - emboli occlude blood supply of large segment of mesentery
MI pt develops hypotension>low blood reaching mesentery
32
Treatment of acute mesenteric ischemia
O2
| IV fluids, analgesia, antibiotics and then urgent surgery
33
Ischemic colitis
Features
Cause
Transient interruption of blood supply to colon
Gradual onset - over hours
Pain and tenderness = mod -severe, usually starts at LIF
+- bloody diarrhoea
Cause= multi factorial - HF, MI, shock etc
34
Treatment of ischemic colitis
Conservative or surgical management
35
Respiatory alkalosis while on oxygen face mask
| Next step
= hyperoxemia
Reduce O2
36
Post op oliguria
Investigation
Management
Usually happens after epidural analgesia
Post void residual volume on bladder scan
If > 500 - re insert catheter
37
Post op - hypotensive and oliguric
Iv fluid challenge
| Might be internal bleeding or acute renal injury
38
RFs for anorectal abscess (3)
DM
Immunocompromised
Chromes disease
39
Perianal fistula management
Superficial (simple/low fistula)
= lay open (fistulotomy)
Deep (complex/high)
- crosses internal and external sphincters
= seton suture, ligation on inter-sphincteric fistula tract
40
Diabetic pre-op management
(T2DM)
Major surgery
Minor surgery
Major
- stop oral hypoglycemic before surgery
Minor
- continue same routine
41
Diabetic pre-op management
(T1DM)
Major surgery
Minor surgery
Major
= sliding scale IV insulin before surgery , continue until diet per mouth restored
Or start IV insulin, dextrose and saline pre-op
Minor
= omit insulin on day of surgery
42
No gastric bubbles seen
Oesophageal atresia
43
Single bubble sign
Gastric/pyloric atresia
44
Double bubble sign
Duodenal atresia
45
Triple bubble sign
Jejunal atresia
46
Post natal Xray shows NGT coiled in oesophagus
Oesophageal atresia
47
RFs of rectal ca
```
FHx
Smoking
Polyposis syndromes
Low fibre diet
IBD
```
48
Common precipitating factors of diverticulosis
Low fibre diet
| Age > 50 Y
49
Management of bleeding diverticulitis
Urgent surgical ward admission
FBC, CRP
Colonoscopy to correct/stop bleeding
50
Haemorrhoid grading (4)
1- bleeding no prolapse
2- prolapse with delectation ; spontaneous reduction
3- prolapse with delectation - needs manual reduction
4- prolapsed, incarcerated - can’t be manually reduced
51
Acute gastric distension/dilatation
Cause
Management
Blood supply of stomach affected in certain abdominal surgeries
Accumulation of air inside stomach
NGT insertion - deflate stomach
52
How can acute gastric distension cause hypotension
Dilated stomach can compress surrounding vessels incl aorta so blood pressure drops
53
Treatment of carpal tunnel
Cute transverse carpal ligament
| Aka flexor retinaculum/anterior annular ligament
54
Management of acute anal fissure (<6 wks)
```
Huber high fluid diet
Bulk forming laxative s- Lactulose
Petroleum jelly before defecating
Topical anaesthetics
Analgesia
```
55
Chronic canal fissure management
Same as acute
GTN - 1st line for chronic anal fissure
If not effective after 8 weeks - 2ry referral for sphincterotomy or Botox
56
Inguinal vs femoral hernia
Inguinal - above + medial to pubic tubercle , cough impulse, reducible
More in males
Femoral - below and lateral, rarely has cough impulse, irreducible (femoral canal is narrow)
- more in female , strangulate easily, below inguinal ligament
57
RFs for inguinal hernias
```
Male
Lifting heavy objects
Old age
Chronic cough
Prev abd surgery
```
58
Types of inguinal hernia
Indirect - Passes through Deep and superficial inguinal ring , lies lateral to inf epigastric a.
Direct - passes through posterior wall of inguinal canal
Lies medial to inferior epigastric a.
59
Cause of paralytic ileus (7)
```
Post op complication
Electrolyte imbalance - hypokalemia, hypERcalcemia
Anticholinergics
Post trauma
Opiates
Peritonitis
Immobilisation
```
60
Features of paralytic ileus
Abd distension - bloated no passing of flatus
Absent bowel sound s
Nausea, vomiting
61
Treatment of paralytic ileus
NGT and IV fluids
62
When should WBCs and CRP be repeated post op
After 24 hrs
63
Prophylactic ABx given before surgery of colon/rectum
Cefuroxime + metronidazole
| Given within 30 mins of first incision or at anaesthesia induction
64
Tumour marker for hepatocellular ca
AFP
- is also a tumour marker for teratoma
65
Perianal hematoma
| Treatment
Analgesics
| Self resolving
66
Post thyroidectomy +SOB + stridor
| Treatment
Cut subcutaneous sutures to relieve pressure
| Consider intubation
67
Dunphy sign
Increased pain with any coughing or movement.
| Appendicitis
68
Greatest risk factors for colorectal ca
Old age
| Family history
69
Greatest risk of urinary bladder ca
Smoking
70
Sigmoid ca vs caecal ca
Sigmoid - left lower abdominal pain/mass + bleeding PR
Caecal - rt lower abdominal pain/mass
No bleeding PR
Both have old age, weight loss and anemia in common
71
Commonest site of ischemic colitis
Splenic flexure and rectosigmoid
- this area has fewer collaterals (weak spots / watersheds)
72
Fluid filled mass in midline of the neck , moves upwards on tongue protrusion on swallowing
Likely dx?
Most appropriate investigation
Thyroglossal cyst
| US
73
Features of oropharyngeal ca
Lump/ulcer in mouth or throat
Referred otalgia
Persistent sore throat and painful swallowing
Typically old and a smoker
74
Features of nasopharyngeal ca
Swollen cervical LNs
Eustachian tube obstruction - Otitis media, epistaxis, nasal obstruction
CHL, tinnitus
75
RFs nasopharyngeal ca
EBV
Smoking
Alcohol
76
Features of tonsil ca
Persistent sore throat
Progressive hoarseness
Dysphagia + painful swallowing
Palpable lump on ant lateral neck
77
Tonsil ca spreads to
Mandible
| Trismus + throat pain
78
Features of Quinsy
```
Trismus
Saliva dribbling
Otalgia
Hot potato voice
Uvular deviation
Red and inflamed bulge above and lateral to tonsil
```
79
Plummer Vinson is common in
Postmenopausal women
It’s a RF for oropharyngeal ca
80
Pt not breathing after being exposed to burn
Intubation has failed
What is the next step
Cricothyroidotomy
| - cricothyroid membrane pierced
81
Noisy hyperactive bowel sounds + constipation
Abd pain and distension
Likely dx
Next best step
Intestinal obstruction
IV fluids, analgesics order XR - multiple air fluid levels
Urgent referral to surgical ward
82
Head of pancreas ca
| Features
```
Back pain
Wt loss, hx of smoking, alcohol
Obstructive jaundice
= raised total and conjugated bilirubin
Pale stool, dark urine, pruritus , raised ALP
Abnormal LFTs
High blood glucose
```
83
Head of pancreas ca vs cholangiocarcinoma
CC - pain in RUQ
P - pain in back
Blood glucose elevation only seen in pancreatic ca
CC = jaundice weight loss and RUQ pain
84
Head of pancreas ca
Initial investigation
Investigation of choice
US
| HRCT-IOC
85
What used to assess prognosis of head of pancreas ca
CA 19-9
86
Management of head of pancreas ca
W/o. Mets - whipples resection
= panceaticoduodenectomy
W/ mets - palliative ERCP with stent
87
Colorectal screening
Fecal immunochemicaltest
60-74 = every 2 years = England
50-75 - in Scotland
88
Cervical ca screening
Pap smear - cytology HPV
25-49 YO - every 3 years
50-64 Y - every 5 years
89
Which hernia can descend into scrotum
Indirect inguinal hernia
90
Common causative organism of breast abscess
S.aureus
91
Courvoisiers sign
Non tender palpable distended gallbladder
| Seen in pancreatic ca
92
Testis ca
| Request ____
Lactate dehydrogenase
93
What increases risk of testicular ca* by x10
Hx of undescended testis
*seminoma esp , request LDH
94
Treatment of bowel obst caused by advance malignancy or chemo
Palliative colostomy
95
Most common site of fistula in Crohn’s disease
Rectovaginal - female
| Male - bladder + rectum
96
Surgical management of inguinal hernia
1st time - open repair with prosthetic mesh , placed posterior to the cord structures
Recurrent - laparoscopic approach , mesh
97
Femoral hernia vs inguinal hernia management
Inguinal -
Surgery not required unless symptomatic or irreducible
Femoral - surgical repair even if asymptomatic
98
Splenectomy vaccines
Pneumococcal + meningococcal. Vaccine
= pre splenectomy
*also given every 5 years after splenectomy
Influenza vaccine
= post splenectomy
* all hyposplenic or asplenic plts should receive this vaccine annually , best time is autumn Oct-Nov
99
IDA is common presentation of what ca
Colon ca - right sided
Left sided too + blood in stool
100
Newly formed ulcer on top of SCC
| Think
SCC
101
Suspected appendicitis
- hemodynamically stable male/female
- unstable
Unstable- theatre, exploaratory laparotomy y
Stable
- young fit male - threatre - laparoscopic
- young fit female - US, then take to theatre
= r/o gyne cause
Anyone >50 Y - CT to r/o cancer
102
Most common type of colorectal ca
Adenocarcinoma
