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Plab Hla Myint Aung > General Surgery > Flashcards

General Surgery Flashcards

1
Q 
Inguinal Hernia (medial or lateral to the Epigastric artery )
medial
A

*indirect hernia (congenital not closing of deep ring ). > pass deep ring lat. to inf. epigastric
then protude from sup. ing. ring ,
above&medial to pubic tubercle

  • femoral» below&lat. to pubic tubercle
  • direct(weakness of the ant abd wall esp Conjoint tendon = internal oblique + transverse abdomenalis )»medial to inf. epigastric vs
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2
Q

Anal fissures or Hemorrhoid

A

Hemorrhoid (internal and external via DENTATE line )
Splashing of blood / prolapse when straining / bright red blood / Covering the stool
Painless
a streak of blood on TOILET PAPER
Internal haemorrhoids can be missed with a DRE,
we need a proctoscope or a rigid sigmoidoscope to diagnose them.

Tx
1) Conservative - digital replacement /

Anal fissures (3,7,11)
Painful
Streaks of Blood on the STOOL

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3
Q 
Anorectal Abscess  consist of 
Perianal, 60%
Ischiorectal,  20%
Intersphinteric,  5%
Supralevator, 4%
Postanal abscesses are types of Anorectal abscess.

Perianal abscess will be in the submucosal or subcutaneous area of the anus.

A

Ddx
Inflammatory Bowel Disease
Anal Cancer
Colon Cancer

Abscess Management = Incision and Drainage (Antibiotics if certain condition)

Give ANTIBIOTICS only in case of DIABETES/ Immunosuppression / Valvular Ht disease/ Sepsis

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4
Q

Anal Fissure:

A

Acute (<6wks) & Chronic (>6wks)

C/F: Severe pain during defecation +
blood streaked stools +
long H/O constipation & straining +
pt refuses rectal examination due to fear of pain

  • Rx :
    Medical Mx (1st line)
    Keep stools soft (adequate fluids + vegetables + laxatives for constipation :
    Isapgul for adults, lactulose for children) +
    Topical GTN cream (0.4%) (reduces anal tone)
    If severe pain during defecation -> 1-2ml of lidocaine before toilet for max 2wks

Refer to 2ndary care if not resolves within 2wks for children & 6-8wks for adults, or asymptomatic adults with anal fissure over 12-16wks

2ndary Care : Topical CCB (2% Diltiazem or Nifedipine) cream PR or Botulinum toxin (expensive)
if fails –> go for surgery : LATERAL INTERNAL SPHINCTEROTOMY (best) or Fissurectomy

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5
Q 
Mesenteric ischaemia(Infarct / irreversible gangrene / AF and embolus ) vs 
Ischaemic colitis (angina comes and go)
A

Mesenteric ischaemia
Sudden onset
pain is unproportionate to clinical findings / Absent Bowel sounds
elderly patient with AF and embolus
Urgent surgery to restore blood flow and remove necrotic ts

Ischaemic colitis
Multifunctional - transient interruption of blood supply
Moderate Colicky abdominal Pain start at Left iliac fossa
Bloody Diarrhoea
Conservative or Surgery

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6
Q

Bleeding per rectum Investigation
AGE > 55 (can be CA) - colonoscopy
Age < 55 (if you think Hemorrhoids )- proctoscopy or rigid sigmoidoscopy

A

painless bleeding per rectum +
no finding on examination
if more than 55 years = colonoscopy (likely cancer )

if less than 55 years = proctoscopy (likely haemorrhoids)

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7
Q 
Paralytic ileus (absent BS) (X ray abdomen ) (IV and NG suction )
Anastomosis Ileus (CT abdomen )Vs 
IO  ( increased BS)
A

Paralytic ileus.
common after major surgeries and extensive bowel handeling.
excessive opiate analgesia.
Tx - NG tube suction and give IV fluids. reduce opiates.
maintain electrolytes and encourage mobilisation.

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8
Q

> 60 IDA with no occult blood in the stool

IF Cancer where? Right Sided or Left Sided

A

IDA without obvious rectal bleeding= Cecum tumor (Right Sided ) (Polypoidal or cauliflower cancer )

With obvious occult blood in stool (Old age ) = Most common Sigmoid Colon(Left sided ) Ulcerative

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9
Q

Recto Vaginal fistula
1st - Tissue damage / Injury
2nd - Crohn’s Disease

A

Crohn’s Disease
most common site of inflammation is the ileum
Least common site is the rectum

Enterovaginal fistula is highly unlikely due to two reasons.

  1. Illeum rarely forms a fistula with vagina.
  2. In the stem it is clearly said fouls smelly feculant dischage.

Right sided stomas are less feculent than Left sided ones. due to anatomical proximity

Recto vaginal fistulas are common

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10
Q

35 yr Post OP CS cant pass urine
Most commonly dt effect of Epidural

Single Most Appropriate Investigation&raquo_space;»> Bladder scan (a type of USG to Measure urine volume before and after voiding and also residual vol )
not IVU or USG

A

New inserted catheter removed within 48 hr
In CS removed same day or the next day

If Post Void Residual Volume 300-500mm and unable to void or uncomfortable and
If PVRV>500 mm &raquo_space;» reinsert catheter

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11
Q

P or R or S hemorrhage

A

Primary Hemorrhage: immediately after Sx

Reactionary Hemorrhage: within first 24 hours of Sx

Secondary Hemorrhage: occurs 24 hours or more post Sx.

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12
Q

Corhn ‘s Disease

A

Crohn’s Disease: -
site: mouth to anus - skip lesions - cobblestone appearance -
affects ALL layers of intestine -
****increased goblet cells -
transmural granulomas + - skin tags, perianal fistula + -
Kantour’s string sign, Rose thorn ulcer +

Ulcerative Colitis: - COLON -
affects INNERmost lining of colon -
loss of haustrations - crypt abscesses + -
****decreased goblet cellls -
toxic megacolon -
bloody diarrhea

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13
Q

Ddx of colo-rectal Carcinoma SITE and Presentation

A

Rectal - Change in Bowel habit / Red bleeding / incomplete and painful deification
Sigmoid colon - Change in Bowel habit / Dark red bleeding
Right sided location - IDA / Mass / wt loss
40% emergency - Large bowel O / Peritonitis / Perforation
Colicky pain / Bloating

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14
Q

Carpel tunnel syndrome

Tingling and numbness on not relieved with steroids

A

Flexor Retinaculum= Transverse Carpal Ligament = Anterior Annular Ligament

Tests: TINLE’S test, Nerve conduction study, Electromyogram

Mx: braces/splint, NSAID, Steroid injection&raquo_space; Temporary

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15
Q

CHOLECYSITITS = inflammation = Fever + Pain + J

Cholelithiasis = Galls stones in the GB (pain only when GB contracts after meals ) NOFEVER (5-F Syndrome—fair, fat, female, fertile and over forty).

Acute Pancreatitis = Alcohol + Fatty stool

A

RECURRENT attacks of RUQ following FATTY meals are characteristic for GALLSTONES

during the attack&raquo_space; N ,V,Abd.pain& fatty diarrhea while in

CHOLECYSTITIS (INFLMATION) the Fever+ Acute severe RUQ pain with +ve murphy sign

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16
Q

Post Splenectomy / Remembrance Day (Nov 11) Vaccination

A

Another clue here, is that the pt. came on the Remembrance Day which is (November 11th).
So it would be better to give the Influenza vaccine prior to the “Peak flu season”

Other post-splenectomy vaccines:

  1. Pneumococcal vaccine —> Given 2-3 weeks after surgery and every 5 years.
  2. Influenza —> Annually
  3. Meningococcal —> Every 5 years

Hi B Inflenzae vaccination is no longer recommended due to excellent current control of Hib

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17
Q

Upper Right Quardrant Pain Radiating to the left Shoulder

Stable/ Dx Gall stones / Mgx

A

Gall Stones without symptoms - Reassure
Gall Stones with Symptoms (Stable ) - Elective surgery

Emergency lapratomy
Gangrenous gall bladder
Perforated gall bladder and
Detoriating patient with sepsis

18
Q 
Pharyngeal Pouch (Zenker's Diverticulum )
Stale food / Bad Breath 
Old age /  Men 5 times > female
Endoscopy Contraindicated (perforation )
Barium meal dx
A
19
Q

Indications to Post phone the surgery

MI have to wait 6 months

A

Indications to postpone an elective surgery
1.Cardiac disease less than 6 months ago (M.I etc)
2.Uncontrolled D.M
3.Chest infection
4.Uncontrolled HTN
5. For Hb == If hb<10 postpone and investigate first
If hb<8 with symptoms then postpone and do blood transfusion

20
Q

Generalized Guarding and Rigidity and increased PR after Sudden onset of abdominal pain / NV / Fever 38.7

A

Think of Acute Abdomen (Perforation of Diverticulum or appendix )

21
Q

Thyroglossal Cyst (not thyroid nodule )

A

most common neck mass in children (10 year kid)

Cystic, painless and non tender,
MOVES WITH TONGUE PROTRUSION AND SWALLOWING

When infected: tender red hot, fever +/- dysphagia and dysphonia.

*****USG is the standard/best confirmatory inv ++++++++++++++++++

Thyroid scan when ectopic thyroid tissue diagnosis is needed. (most common site)

Rx: Sistrunk

D/D - Brachial cyst Cystic hygroma

22
Q

CS 3130
35 year old 10 day post of Laparoscopic Cholecystectomy (BMI <21 )
With RUQ pain and Fever / increased HR BP RR
Most appropriate investigation

A

If Patient is OBEASE and COMPLICATED L. Cholecystectomy
then SUSPECT BILE LEAK

Healthy and BMI 21 within normal (Uncomplicated )- -SUSPECT ABSCESS

ERCP&raquo_space;> High suspicion of Bile leak
MRCP&raquo_space;> Moderate suspicion of Bile leak
CT abdomen&raquo_space;» High suspicion of ABSCESS

23
Q

Haemorrhoid Grade with no symptoms&raquo_space;» what to do

A

Gall stone+ no symptop= Reassurance
Gallstone in CBD+ no symptom= Laparoscopic cholecystectomy or ERCP

Haemorrhoid+No symptom=no action required (How terrible the Haemorrhoid looks)

Inguinal Hernia in an elderly person+ No symptom=No action required

24
Q

Old and WT LOSS over MONTHS
/ incomplete defication / Change in Bowel habits /
BUT PR examination - Found no mass

A

Colo-Rectal Carcinoma
Tenesmus
Secretion of Mucus and blood in the stool

Ddx
Diverticulitis 
Pain left iliac fossa after some DAYS 
FEVER / TACHYCARDIA 
Left iliac fossa tenderness
25
Q

Hyper Oxyaemia / Hyperoxia

A

PaO2 >16 mmHg
Lead to oxygen Toxicity / Breathing oxygen at High Partial Pressure
Become breathless and dyspneic

26
Q

Appendicitis and Tx and Investigation
Uncomplicated
Complicated (perforation )

A
27
Q

most important risk factor for CA colon / ovary / bladder

A

colon CA: AGE / Family

ovarian cancer: FAMILY HISTORY

urinary bladder CA: SMOKING

Gastric : Age / H pylori / Blood Gp A (Virchow LN enlargement )

28
Q

When to give Antibiotics before Elective anterior restoration

A

For an elective lower bowel surgery,
it would be expected that bowel preparation was done.
This will reduce the bacterial load,

so IV antibiotics at induction of anesthesia would be adequate.

29
Q

Thyroidectomy complication

2 nerves 3 complications

A

Thyroidectomy Complications—-

RECURRENT LARYNGEAL NERVE:
U/L— Hoarseness
B/L— Aphonia and Airway obstruction (with stridor seen)

SUPERIOR LARYNGEAL NERVE -
External Branch: – Dysphonia (inability to create High-pitch sound) – Singers harmed! (Monotone voice)

29
Q

Thyroidectomy complication

2 nerves 3 complications

A

Thyroidectomy Complications—-

RECURRENT LARYNGEAL NERVE:
U/L— Hoarseness
B/L— Aphonia and Airway obstruction (with stridor seen)

SUPERIOR LARYNGEAL NERVE -
External Branch: – Dysphonia (inability to create High-pitch sound) – Singers harmed! (Monotone voice)

30
Q

Insulin Regime

A
31
Q

Perianal Fistula Management

A 
Superficial / Simple / Low fistula (sphincters and muscles not Involved )
Lay open (fistulotomy - open wound healing )

Deep / Complex / High fistula
Ligation of the intersphincteric fistula tract

32
Q

Diverticulitis (Pouching of Large colon dt unknown causes )
Age>40
Constipation and low fibre diet

A

acute onset of LEFT sided abdominal pain +
massive per rectal bleeding = Haematochezia
nausea & vomitting +
fever & tachycardia +
constipation & bloating + LEFT ILIAC FOSSA tenderness +

low fibre diet/eats lots of canned meat**

Ix - CT Scan of abdomen

Rx :if haemodynamically unstable due to massive bleeding = urgent admission & resuscitate + IV antibiotics (cefuroxime + metro)

33
Q

Child with Oral burn not breathing well
Intubation has failed
what to do next

A

In case of emergency,
if intubation fails :
2nd line –> Cricothyrodotomy (easier) - short term solution Provide Oxygenation and not Ventilation
2cm transverse inscision through the skin and cricothyroid membrane .

Tracheostomy takes more skill & has more risk of injury but overall better in long term care

34
Q

Car accident / Hemi arthroplasty(head of femur replacement )
Most common post-operation complication

A

Post op infection

Not avascular necrosis
Not fat embolus

35
Q

Radical inguinal orchiectomy(with external oblique fascia closure after surgery if not hernia )
Inguinal or Incisional hernia
after Post op Testicular tumor removal via Inguinal approach

A

Timing is key.

Incisional hernia occurs after 3-6months post op

Inguinal hernia if < 3 months

36
Q

USG or CT best initial investigation ????? in Different Jaundice pt

A

Red flag signs for Pancreatic Cancer - CT&raquo_space;>USG&raquo_space;» Ca 19-9 (80% sensitive)
(Wt loss / Painless Jaundice / Back pain and Epigastric pain / alcohol drinking / new T1 DM )

J with Epigastric or RUQ pain (Gall stones )- USG

37
Q

Free Screening test IN UK - BBC

A

Breast
Bowel Colon
Cervical

38
Q

SU 0369
Stoma closed
then stoma

A
39
Q

Murphy’s Triad ( Appendicitis vs Ectopic preg Vs Splangitis VS ovarian torsion )

A

Murphy’s triad is seen in appendicitis.
It consists of,

1) right iliac fossa pain
2) nausea and vomiting
3) fever

Shifting pain from the abdomen to the Right iliac fossa /Rebound tenderness

40
Q

To Do Ct abdomen GI 1471

A

Suspected Abscess,
Suspected Pancreatic Cancer,
Anastomotic Leakage,

pt >50y with suspected cancer —-> CT Abdomen

Corhns Disease
pt with CD + recent oncet increase in diarrhea +
Fever+ high TLC + very high CRP&raquo_space;» ilial Abscess

CT ABDOMEN to decide whether to perform :
1) percutaneous drainage OR 2) surgical drainage

41
Q

Crohn’s Disease
Entero - Vaginal fistula choose in the following order

1) Reto Vg fistula
2) ileum Vg fistula (If rectal is not in the options )
3) Sigmoido Vg fistula (least least common sit )

A

Plab Hla Myint Aung (29 decks)

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