General Surgery Flashcards
1
Q
Boundaries of Hesselbach’s Triangle
A
Medial: Rectus abdominis
Lateral: Inferior epigastric vessels
Inferior: Inguinal ligament
MR LI II
2
Q
Contents of the inguinal canal:
A
Spermatic cord (round ligament) + llioinguinal nerve
3
Q
This is medial to the inferior epigastric artery
A
Direct inguinal hernia
4
Q
This is lateral to the inferior epigastric artery
A
Indirect inguinal hernia
5
Q
are ABOVE and medial to the pubic tubercle
A
Inguinal hernias
6
Q
BELOW and lateral
A
femoral hernias
7
Q
has impulse on coughing
A
Inguinal hernias
8
Q
are usually irreducible (due to the narrow femoral canal)
and cough impulses are rarely detectable
A
Femoral hernias
9
Q
Only they can extend into the scrotum
A
Indirect inguinal hernias
10
Q
Incarcerated:
A
fixed to the wall
11
Q
Strangulated:
A
obstructed bl. supply
12
Q
Femoral hernia
A
(NAVY VAN
13
Q
Groin hernias differences
A
14
Q
Breast Anatomy
A
15
Q
Breast cancer
A
Invasive ductal carcinoma.
Other types are
classified as ‘Special Type
Invasive lobular carcinoma
Ductal carcinoma-in-situ (DCIS)
Lobular carcinoma-in-situ (LCIS)
16
Q
This is the most common type of breast
cancer. been renamed ‘No Special Type (NST).
A
Invasive ductal carcinoma.
17
Q
One of the predisposing factors:
40% lifetime risk of breast/ovarian cancer
A
BRCA1, BRCA2 genes
18
Q
Other predisposing factors:
A
1st-degree relative premenopausal relative with breast cancer (e.g. mother)
Nulliparity, 1st pregnancy > 30 years (twice risk of women having 1st child < 25 years)
Early menarche, late menopause (risk increases with more menstrual cycles as the breast undergoes division and apoptosis, which increases the risk of genetic mutation and tumor formation)
Combined hormone replacement therapy (relative risk increase * 1.023/year of use), COCP
Past breast cancer
Not breastfeeding
ionizing radiation
p53 gene mutations
Obesity
Previous surgery for benign disease (more follow-up, scar hides lump)
19
Q
Decreased risk
A
Early pregnancy
Longer time breastfeeding
20
Q
Management of Breast Cancer
A
1) Surgery: Around two-thirds of tumors can be removed with a wide-local excision.
Mastectomy x
® Multifocal tumor e
® Central tumor
® Large lesion in small breast
® DCIS >4cm
Wide Local Excision
®Solitary lesion
® Peripheral tumor
® Small lesion in large breast
® DCIS<4cm
2) Radiotherapy: to reduce recurrence.
3) Hormonal therapy: when tumor cells have hormone receptors, it blocks the effects of the hormones such as estrogen. Tamoxifen in pre-menopausal, in post-menopausal, aromatase inhibitors such as anastrozole (side-effects of tamoxifen include an increased risk of endometrial cancer, venous thromboembolism and menopausal symptoms)
4) Biological therapy: Trastuzumab, useful for HER-2 positive. Noting that it cannot be used in cardiac patients
5) Chemotherapy
21
Q
Invasive ductal carcinoma extending to the epithelium
A
Breast ca
(Invasive Intraductal)
22
Q
In situ carcinoma involving the nipple epidermis
A
Paget’s disease of the breast
23
Q
Well-circumscribed lump with clear margins and separate from the
surrounding fatty tissue, there’s overgrowth of fibrous and glandular
tissue
A
Fibroadenoma
24
Q
Fibrosis + epitheliosis with cystic formation
A
FbroadnoCIS
25
Cystic formation with mild epithelial hyperplasia in ducts
Fibrocystic changes of the breast
26
Breast cancer screening
* Women aged 50-74 years are offered mammogram
every 2 years
27
Breast cancer screening
* In high risk group, mammogram would be offered annually from ages
40-69
28
Core biopsy =
tru-cut biopsy
29
Sentinel LN biopsy is done
staging
30
Triple assessment of the breast
1. Clinical
2. Radiology
- <35-= USG
- >35 = Mammogram
3. FNAC
31
USG
is used in young patients instead of mammograms due to increased tissue density which reduces sensitivity and specificity of a mammography
32
There're four instances in which prophylactic mastectomy is advised:
1. Strong family history of breast cancer
2. Presence of gene mutations (BRCA1 or BRCA2)
3. Previous cancer in one breast
4. Biopsies showing lobular carcinoma in situ and/ or atypical hyperplasia of the skin
33
Remember these are offered in cases in which patients has a strong family history and has genetic markers for the cancer
prophylactic bilateral mastectomies and prophylactic bilateral oophorectomies
34
Axillary lymph node clearance
Indications
+ Positive sentinel lymph node biopsy (SLNB)
* Invasive breast cancer
35
Common complications
Axillary lymph node clearance
Numbness around the scar and upper arm (can be permanent)
Lymphoedema (localized fluid retention and tissue swelling caused by a compromised lymphatic system)
Seroma (fluid collection at the site of operation)
Frozen shoulders
36
<30years
Often described as "breast mice’ as they are firm, discrete, non-
tender, highly mobile lumps
Fibroadenoma
37
Middle-aged women
Lumpy breasts which may be painful
Symptoms may worsen prior to menstruation
FibroadenoCIS (fibrocystic disease)
(Benign mammary dysplasia)
38
Breast cancer
Hard, irregular lump
There may be associated nipple inversion or skin tethering
39
Chronic eczematous changes (itching — erythema — scales — blood stained nipple discharge — inverted nipple)
Usually unilateral
Diagnosed by punch biopsy
Paget's disease of the breast
40
Duct ectasia
Most common around the menopause
May present with a tender lump around the areola
® Green or brown nipple discharge
* Nipple retraction
® Associated with smoking
41
Duct papilloma
Hyperplastic lesions rather than malignant or premalignant
Most common cause of blood-stained nipple discharge
There could be skin changes
42
Breast abscess
More common in lactating women
Unilateral, red, hot tender and fluctuant swelling
May present with purulent nipple discharge
43
Fat necrosis
More common in obese women
May follow trivial or unnoticed trauma
Firm & solitary localized lump and usually painless
Skin around the lump may be red, bruised or dimpled
Rare and may mimic breast cancer so further investigation is always
warranted
44
Ductal fistula
Suggested by para-areolar discharge
May follow abscess drainage or incision, there may be history of a spontaneous rupture of inflammatory mass preceding the fistula
Managed by excision under antibiotic cover
Recurrence is common
45
may also develop around the breast tissue
Lipomas and sebaceous cysts
46
CYStic and CYClical
fibroadenoClS
47
Haemorrhoidal tissue is part of the normal anatomy which contributes to anal continence. These mucosal
vascular cushions are found in the left lateral, right posterior, and right anterior portions of the anal canal (3 o'clock, 7 o'clock, and 11 o'clock respectively). Hemorrhoids are said to exist when they become enlarged, congested and symptomatic
Haemorrhoids
48
Features of Haemorrhoids
+ Painless rectal bleeding = the most common symptom
* Pruritus
« Pain: intermittent and usually not significant unless piles are thrombosed
+ Soiling may occur with third- or fourth-degree piles
49
Types of Haemorrhoids
External
Internal
50
+ Originate below the dentate line (lower 1/3 of the anal canal)
« Prone to thrombosis, may be painful
External
51
« Originate above the dentate line (upper 2/3)
+ Do not generally cause pain
Internal
52
* Severe recurrent rectal shooting pain
in the absence of any rectal disease
® Usually oceurs at night, after bowl
action or following ejaculation
* Anxiety is an associated feature
Proctalgia fugax
53
Grading of internal haemorrhoids:
Cannot be reduced |
Grade IV
54
Grading of internal haemorrhoids:
Do not prolapse out of the anal canal
Grade |
55
Grading of internal haemorrhoids:
Prolapse on defecation but reduce spontaneously
Grade ll
56
Grading of internal haemorrhoids:
Can be manually reduced
Grade lll
57
Management:
Soften stools =
increase dietary fiber and fluid intake
58
Management:
To alleviate symptoms =>
topical local anesthetics and steroids may be used
59
Management:
Outpatient treatments =
Rubber band ligation is superior to injection sclerotherapy
60
Management:
reserved for large symptomatic haemorrhoids which do not respond to outpatient treatments
Surgery
61
Management:
Newer treatments:
Doppler guided hemorrhoidal artery ligation, stapled haemorrhoidopexy
62
« typically present with significant pain
« examination reveals a purplish, edematous, tender subcutaneous perianal mass
« if patient presents within 72 hours = referral should be considered for excision
« Otherwise patients can usually be managed conservatively with stool softeners, ice packs and analgesia
+ Symptoms usually settle within 10 days
Acutely thrombosed external haemorrhoids
63
* Exquisite pain with defecation FRESH blood streaks covering the stools
* The fear of pain is so intense they avoid bowel movements and get constipation
* They refuse PR exam = PR done under anesthesia
s Acute: <6 weeks, chronic > 6 weeks
Anal fissure
64
In Anal fistula:
if low-submucosal or simple =
Lay open (fistulotomy),
65
In Anal fistula:
if complex/high (cross internal and external sphincters) =
Seton suture (ligation of fistula tract)
66
Complex fistulas can NOT be laid open as it could result in
fecal incontinence
67
60% are adenocarcinoma that occurs at the head of the pancreas
Pancreatic cancer
68
Risk factors of Pancreatic cancer
* Smoking
* Alcohol is an indirect RF as it causes chronic pancreatitis and liver cirrhosis
* Diabetes
* Chronic pancreatitis
69
Features of Pancreatic cancer
* Head: - Obstructive jaundice = Dark urine, pale stool, pruritis.
* Maybe painless although 70% are associated with epigastric or LUQ pain radiating to the back.
* Body or Tail: Epigastric or LUQ pain radiating to the back, relieved by sitting forward
* Both: Anorexia, weight loss or atypical weight loss
* Migratory thrombophlebitis (Trousseau sign): felt as small lumps under the skin
Investigations
70
nonspecific investigation of Pancreatic cancer
CA19-9
71
What are the other investigation of Pancreatic cancer?
* Transabdominal US
« CT
72
Management of Pancreatic cancer?
* Whipple's resection (Pancreaticoduodenectomy): considered when no metastasis.
- Side-effects :
dumping syndrome (a group of symptoms, including weakness, abdominal discomfort, and sometimes abnormally rapid bowel evacuation, occurring after meals in some patients who have undergone gastric surgery) and peptic ulcer disease
* ERCP with stenting for palliation
73
Rare cancer of the bile duct
Cholangiocarcinoma
74
Features of Cholangiocarcinoma
* Jaundice
* RUQ pain
* Weight loss
75
Features of
* Jaundice
* RUQ pain
* Weight loss
75
Colorectal cancer:
Asymptomatic people with no personal /family hx of bowel cancer: iFOBT every 2 yearly (50-74)
Low risk
76
Colorectal cancer:
One first-degree relative with CRC dx <55 yrs: iFOBT every 2 yearly (40-49); then
colonoscopy every 5 years (50-74)
Moderate Risk
77
Colorectal cancer:
: At least THREE first-degree or second-degree relatives with CRC, with at least ONE relative
diagnosed > 55 yrs: iFOBT every 2 yearly (35-44); colonoscopy every 5 years (45-74)
High Risk
78
For all patients this should be given for at least 2.5 years commencing at 50 until 70 years of age are
recommended unless contraindicated.
Aspirin
79
more common than gastric ulcers, epigastric pain relieved by eating
Duodenal ulcers
80
epigastric pain worsened by eating
Gastric ulcers
81
Features of upper gastrointestinal hemorrhage may be seen (hematemesis, melena etc.)
Peptic ulcer disease
82
Pain initial in the central abdomen, then right iliac fossa
Anorexia is common
Tachycardia, low-grade pyrexia, tenderness in RIF
McBurney sign = rebound tenderness at McBurney point
Rovsing's sign = mare pain in RIF than LIF when palpating LIF
Appendicitis
83
Usually due to gallstones or alcohol
Severe epigastric pain
Vomiting is common
Examination may reveal tenderness, ileus and low-grade fever
Periumbilical discoloration (Cullen's sign) and flank discoloration (Grey-Turner's sign)
Acute Pancreatitis
84
RUQ radiates to the right shoulder or the back and interscapular region
May be following a fatty meal. Slight misnomer as the pain may persist for hours
Obstructive jaundice may cause pale stools and dark urine
It is sometimes taught that patients are female, forties, fat and fair
Managed as acute cholecystitis
Biliary colic
85
History of gallstones symptoms (see above)
Continuous RUQ pain.
Jaundice is NOT usually present with cholecystitis
Fever, raised inflammatory markers and white cells
Murphy's sign positive (arrest of inspiration on palpation of the RUQ)
US = thick-walled, shrunken gallbladder
TTT = nil by mouth — analgesics (morphine) — IV fluids — antibiotics
Surgery = Laparoscopic cholecystectomy is usually indicated if patient is fit, if
perforated GB <> Open surgery
Acute Cholecystitis
86
Colicky pain typically in the LLQ
Fever, raised inflammatory markers and white cells
Diverticulitis
87
Severe central abdominal pain radiating to the back
Presentation may be catastrophic (e.g. Sudden collapse) or sub-acute (persistent severe central abdominal pain with developing shock)
Patients may have a history of cardiovascular disease
Abdominal Aortic Aneurysm
88
History of malignancy/previous operations
Vomiting
Not opened bowels recently
‘Tinkling' bowel sounds
Intestinal Obstruction
89
Management of biliary colic (when stones occlude the cystic duct):
Analgesia
Nil by mouth
Rehydrate
Elective laparoscopic cholecystectomy is usually indicated
90
Complications of tonsillectomy:
Intraoperative:
-Hemorrhage => replace the loss
-Dental trauma
Postoperative:
- Reactive bleeding (during 24hours post-op) = explore + replace the loss
- 2ry bleeding (up to 7days post-op) = admission + IV antibiotics
- Temporary dysphagia.
91
2ry hemorrhage is caused by necrosis of the blood vessels related to a previous repair, often precipitated by wound infection. The best step is
Admission and IV antibiotics.
92
Asymptomatic fluid-filled midline neck mass below the level of hyoid bone
Most often in children and adolescents
Most common cause of midline masses in children = accounts for 75% of midline masses in children
Thyroglossal cyst
93
How to diagnose Thyroglossal duct?
1. US neck: to distinguish between solid and fluid-filled cyst = It can confirm the diagnosis
2. MRI & CT: when malignancy is suspected\Large cyst
3. Thyroid scan with tc-99m: to determine if there's ectopic thyroid tissue
4. FNAC
94
In elective/planned operations:
+ Hb <10g/l =
investigate and postpone
95
In elective/planned operations:
+ Hb <8g/l =
transfusion
96
97
In emergency operations:
+ Hb<10g/l >
transfusion
98
In emergency operations:
Hb <8 g/l =
transfusion and stabilize before proceeding
99
Post-op hypovolemia and oliguria can be caused by:
Hemorrhage
Adrenal cortex and posterior pituitary response to stress which release aldosterone and ADH respectively
100
- if the patient developed post-op hypotension and subsequent oliguria, it can be corrected by
Fluid challenge
101
Fluid challenge
Rapid (up to 15 mins) administration of 500 ml crystalloid (normal saline/Hartmann’s)
Immediate reassessment, if there's still evidence of hypovolemia — administer a further bolus of 250-500 ml
102
post-op oliguria:
* Normotensive =
recheck the catheter
103
post-op oliguria:
* Hypotensive = intra-abdominal bleeding =
IV fluids
104
This is where celiac trunk stops supplying the gut and the superior mesenteric
artery takes over
Ampulla of Vater
105
are defined as ‘a leak of luminal contents from a surgical join between two hollow viscera’
Anastomotic leaks
106
After any GI surgery, there are 3 main concerns:
1. Anastomotic leaks
Definitive investigation ?
CT with contrast
106
are defined as ‘a leak of luminal contents from a surgical join between two hollow viscera’
Anastomotic leaks
107
Management of Anastomotic leaks?
Bowel rest (NBM), IV antibiotics and IV fluid.
Minor leaks maybe managed through observation and bowl rest alone with drainage if needed while exploratory laparotomy if a major leak
108
Complication of Anastomotic leaks?
Peritonitis where there's severe generalized abdominal pain with generalized guarding and rigidity
109
Clinical Presentation of Anastomotic leaks?
=> abdominal pain and fever, typically 5-7 days post-operatively
110
Risk factors for Anastomotic leaks?
immunosuppressed,
corticosteroids,
smoking,
diabetes,
peritoneal contamination,
rectal anastomosis
111
are defined as ‘a leak of luminal contents from a surgical join between two hollow viscera’
Anastomotic leaks
111
After any GI surgery, there are 3 main concerns: What are the other 2 concerns aside from Anastomotic leaks?
2. Post-op bleeding
* reactive bleeding (during 24hours post-op)
* 2ry bleeding (up to 7days post-op)
3. Surgical site infection and subsequent sepsis
112
Hot tip: if the patient present 10 days after bowel surgery with abdominal pain, it's most likely
Anastomotic leak
113
Most common post-op complication is
INFECTION
114
It's better to remove the catheter post-op in 24-48h using TWOC procedure. Reinsert again if
PVRVs is 300-500ml with discomfort, voiding problems or feeling of fullness 2) PVRVs >500ml
115
are defined as ‘a leak of luminal contents from a surgical join between two hollow viscera’
Anastomotic leaks
115
- PVRV is measure by
‘bladder scan’
116
Acute pain + Bluish/purple in color
tender peri-anal lump near the anal verge
History of straining
TTT:
-Analgesics, stool softeners
-Incision and drainage
Perianal hematoma (external thrombosed hematoma)
117
Red and tender + throbbing pain (worsens when sitting down).
Usually with low immunity / Diabetes / Crohn's
Can be associated with constipation
TTT:
Incision and drainage
Antibiotics
Perianal abscess
118
Antibiotic prophylaxis (IV) in colonic surgery should be given at the time of induction of anesthesia or within the
first 30 mins of the first excision:
+ Cefuroxime: to cover gram -ve and +ve.
* Metronidazole: against anaerobic bacteria.
119
Esophageal atresia:
* Prenatal signs =
Polyhydramnios, small stomach, absent fetal stomach bubble detected on US
120
Esophageal atresia:
* Postnatal signs =
Cough, airway obstruction, secretions, blowing bubbles, distended abdomen, cyanosis, aspiration. Inability to pass a catheter into the stomach = X-ray show it coiled in the esophagus
121
X-ray show double bubble sign (stomach & duodenum).
Duodenal atresia
122
are two rare birth defects that cause a baby to be born with some of their internal
organs extending out of the body through a hole in the belly
Gastroschisis and Exomphalos
123
hole in belly button
intestines covered by protective sac
Exomphalos
124
hole next to the belly button
intestines not covered by a protective sac
Gastroschisis
125
Non-specific as vomiting, tiredness, weight loss, abdominal pain and anemia
Gastric carcinoma
126
Risk factors for Gastric carcinoma
- Aging
- H. pylori infection
- Blood group A
- Gastric adenomatous polyp
- Pernicious anemia
- Smoking
- Diet: salty, spicy, nitrates
127
Enlarged right supraclavicular LNs:
Hodgkin's lymphoma
Lung cancer
Esophageal cancer
128
Signs suggesting incurability:
- Troisier’s sign: enlarged left supraclavicular lymph nodes (Virchow's LN)
- epigastric mass
- hepatomegaly
- jaundice
- ascites
129
- Tumor of the pulmonary apex, on top of the right or left lung
- Spreads to nearby tissues like ribs and vertebrae
- Most are NSCLC
Pancoast tumor
130
Cessation of Gl motility
Paralytic ileus:
131
Absent bowel movements + NO pain =
Paralytic ileus
132
Exaggerated bowl sounds + pain =
Mechanical obstruction
133
Causes of Paralytic ileus
- prolonged surgery, exposure and handling of the bowel
- peritonitis and abdominal trauma
- electrolyte disturbance
- anticholinergics and opiates
- immobilization
134
What is the Clinical Picture of Paralytic ileus?
- nausea, vomiting
- abdominal distension
- absent bowel sounds
135
What is the imaging of the paralytic ileus?
Abdominal x-ray to show air/fluid filled loops of small and/or large bowel
136
What is the management of the Paralytic Ileus?
* Management: (Drip & Suck)
- NG tube to empty the stomach from fluid & gas when the patient is nauseated or vomiting
- IV Aluid
- Maintain electrolyte balance
- Reduce opiates and analgesia
- Encourage the patient to mobilize
- Lactulose or erythromycin can stimulate bowl movement
137
inflammation of the diverticulum, common in >50yrs and low fiber intake
Diverticulitis:
138
All patients with diverticular disease who are symptomatic or hemodynamically unstable require
urgent admission
139
This is contraindicated in acute diverticulitis
Colonoscopy
140
: pain is non-specific and intermittent
Intussusception
141
Clinical Presentation of Diverticulitis
- Rapid onset of LIF pain and tenderness
- Nausea and vomiting.
- Bloating and constipation -. –
- Diarrhea
- Features of infection: fever, tachycardia, raised WBCs and high CRP (>50 mg/L)
- If perforated = guarding and rigidity
142
What are the investigations of Diverticulitis?
CT abdomen and pelvis
143
* Treatment of Diverticulitis?
- IV Antibiotics + IV Fluids
- Increase dietary fiber intake
144
Complications of Diverticultiis
Massive rectal bleeding that requires admission.
145
herniation of the large colon
Diverticulum (plural diverticula
146
the presence of asymptomatic diverticula
Diverticulosis
147
symptomatic diverticula
Diverticular disease
148
inflammation of the diverticula
Diverticulitis
149
Diverticulitis is a left-side appendicitis
True
150
Torsion of the colon around its mesenteric axis resulting in compromised blood flow and closed loop obstruction
Sigmoid volvulus
151
Usually an elderly man with chronic constipation
Sigmoid volvulus
152
What are the clinical presentations of Sigmoid volvulus?
: patient suddenly develops a classic picture of painful intestinal obstruction:
- abdominal distension
- vomiting (classically with no nausea?)
- pain
- absolute constipation
153
What is the investigation of Sigmoid volvulus?
X-ray shows a coffee bean sign (omega sign)
154
What is the Management of Sigmoid Volvulus?
Rectal tube decompression,
Laparotomy and resection
155
Anemia, Lt-sided colon cancer > Obstructive symptoms
Rt-sided colon cancer
156
tend to be exophytic so it rarely causes obstruction of feces
Rt-sided colon cancer
157
Old + changing bowel habits + bleeding PR + single ulcer =
Colorectal cancer until proven otherwise
158
How is the colorectal cancer diagnosed?
Diagnosed by :
colonoscopy with biopsy,
barium enema,
CT scan
159
* PR bleeding. Deep red on the surface of stools.
» Change in bowel habit. Difficulty with defecation, sensation of incomplete evacuation, and painful defecation
Rectal location
160
+ PR bleeding. Typically dark red
+ Change in bowel habit
Descending-sigmoid location
161
Iron deficiency anaemia may be the only elective presentation
Weight loss
Mass in right iliac fossa
Disease more likely to be advanced at presentation
Right-sided location
162
Up to 40% of colorectal carcinomas will present as emergencies.
» Large bowel obstruction (colicky pain, bloating, bowels not open)
« Perforation with peritonitis
= Acute PR bleeding
Emergency presentations
163
is NOT for diagnosis however it’s useful for monitoring
CEA
164
Anemia is not evident with left sided cancer because:
1. Bleeding is noticed as fresh blood with stool, cancer cecum is far away, it won't be presented with fresh blood
2. Right colon is wider than left colon = obstruction is more prominent with the left side, let alone its exophytic
nature
165
bilateral ovarian malignancy due to metastasis from GIT cancer (most commonly gastric
carcinoma)
Krukenberg Tumor:
166
Risk factors for colon cancer
1- Age.
2- Family history.
3- Smoking.
167
most common salivary gland tumor
Parotid > submandibular > sublingual
Painless + slowly growing
Firm, single, nodular mass and usually mobile
Benign and can become malignant
Treated by superficial parotidectomy or enucleation
Pleomorphic adenoma (benign mixed tumor):
168
- mobile, soft, cystic mass and usually painless
Adenolymphoma
(Warthin's tumor)
169
- bilateral swelling of all salivary glands
- swelling of lacrimal glands resulting into narrowing of palpebral fissure
Mikulicz’s disease
170
- pain especially when eating
- fever, redness, swelling
Parotiditis
171
- excessive sweating on cheeks when eating instead of salivation
- due to nerve damage as a parotid surgery complication
Frey’s syndrome
172
CA 125
Ovarian cancer
173
Prostate specific antigen (PSA)
Prostatic carcinoma
174
CA 15-3
Breast cancer
175
CA 19-9
Pancreatic cancer
176
LDH
Seminoma
177
Carcinoembryonic antigen (CEA)
Colorectal cancer
178
Alpha-fetoprotein (AFP)
Hepatocellular carcinoma, teratoma
179
is an alternative to diagnostic ERCP for imaging the biliary tree and investigating biliary obstruction.
MRCP
180
is used when US cannot detect CBD stones while the duct is dilated and/or LFT are abnormal.
MRCP
181
Typical old patient, smoker
Persistent sore throat
A lump in the mouth or throat
Referred otalgia
Difficulty swallowing or moving mouth or jaw
Unexplained weight loss
Oropharyngeal carcinoma:
182
Multifactorial (thrombotic event
or hypoperfusion such as shock,
HF or MI) causing transient
interruption of blood supply
Ischemic colitis
183
* Embolic (in patients with AF) causing total loss of blood supply to one segment of the bowel
* decreased mesenteric arterial blood supply (in patients with hypotension 2ry to myocardial ischemia)
Mesenteric ischemia
184
gradual onset (over hours)
pain starts at the LIF
moderate colicky pain and tenderness with bloody diarrhea
Ischemic colitis
185
* sudden onset of abdominal pain
* severity of the pain exceeds the physical signs
* absent bowel sounds
* abdominal distension and tenderness
* metabolic acidosis with high lactate
Mesenteric ischemia
186
* conservative
* surgical
Ischemic colitis
187
* resuscitate (O;), rehydrate and administer IV
analgesics and IV antibiotics
* Urgent surgery to remove or bypass obstruction
* removal of necrotic bowel maybe required
Mesenteric ischemia
188
is caused by the reactivation of the varicella zoster virus in the
geniculate ganglion of the facial nerve.
Ramsay Hunt syndrome (herpes zoster oticus)
189
Features of Ramsay Hunt syndrome (herpes zoster oticus
- Pain deep within the ear is often the first feature (often radiates to the ear pinna)
- facial nerve palsy
- vesicular rash around the ear
- other features include vertigo and tinnitus
190
Management of Ramsay Hunt syndrome (herpes zoster oticus
- oral acyclovir and corticosteroids are usually given
191
Simple analgesics
aspirin, NSAIDs
192
Weak opioids
codeine, tramadol
193
Strong opioids:
morphine, fentanyl, diamorphine, oxycodone
194
Nerve block
epidural
195
After myocardial infarction, elective surgery should not be performed for the next
6 months
196
Dysphonia (inability to create high-pitched voices), they would have
monotonous voice
Superior laryngeal nerve injury
197
Hoarseness of voice
Unilateral RLN injury
198
Aphonia and airway obstruction
Bilateral RLN injury
199
If the patient presents with a typical lipoma where the mass hasn't been growing at all =
Reassure
200
If there's a possible lipoma of liposarcoma and there's uncertainty =
US
201
If the US shows features of a liposarcoma =
MRI
202
If there's doubt of its diagnosis with imaging or if it's interfering with the patient’s activities (e.g. difficulty sitting back against a chair) =
Removal by excision
