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Medicine - Finals > General Surgery > Flashcards

General Surgery Flashcards

1
Q

How can an anastomotic leak present?

A

New onset atrial fibrillation, fever and feculent material present in the abdominal wound drain

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2
Q

IVDU groin swellings

A 
May be pseudoaneurysms  (CT to exclude)
Psoas abscess (triad of fever, back pain, limp)
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3
Q

Presentation of Psoas abscess

A

Fever, back pain, limp

usually in immunocompromised individuals

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4
Q

Positions of femoral and inguinal hernias

A

Femoral - below and lateral to pubic tubercle

Inguinal - above and lateral to pubic tubercle

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5
Q

Structures in femoral triangle (medial to lateral)

A

Lymphatics
Femoral Vein
Femoral Artery
Femoral Nerve

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6
Q

Lateral border of femoral triangle

A

Sartorius muscle

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7
Q

Medial border of femoral triangle

A

Adductor longus muscle

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8
Q

Superior border of femoral triangle

A

Inguinal ligament

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9
Q

Difference between mid-inguinal and midpoint of inguinal canal

A

Mid inguinal is midpoint between pubic SYMPHYSIS and ASIS

Midpoint of the inginal canal (is more lateral as it) lies between the pubic TUBERCLE and ASIS

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10
Q

Anterior border of inguinal canal

A

Aponeurosis of external oblique

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11
Q

Posterior wall of inguinal canal

A

Transversalis fascia

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12
Q

Roof of inguinal canal

A

transversalis fascia, internal oblique and transversus abdominis

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13
Q

Floor of inguinal canal

A

inguinal ligament

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14
Q

Which two horizontal anatomical planes are used to divide the abdomen into 9 regions

A

Transpyloric

Transtubular

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15
Q

Pain worse on eating

A

Peptic ulcer

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16
Q

Food relives pain

A

Duodenal ulcer

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17
Q

Abdominal pain that is relieved by leaning forward

A

Think pancreatitis

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18
Q

Patients with abdominal pain that refuses to be examined and move

A

Think peritonism

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19
Q

Indications of abdominal X-ray

A

complicated constipation, foreign body, complicated colitis

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20
Q

Air under which hemidiaphragm is more worrying

A

Right-sided air is more sensitive for free abdominal gas

Left-sided is normal due to stomach gas

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21
Q

Diagnosing hernia

A

Clinical
If needed USS is first line
If there are features of obstruction or strangulation then CT

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22
Q

Coffee-ground vomiting

A

Non-active (bleeding has stopped) haematemesis

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23
Q

Malaena vs iron-tablet stools

A

Malaenia - black foul smelling stool

Iron-tablets cause black stool with lack of distinctive smell

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24
Q

UGI bleed with recent history of aortic graft or AAA repair

A

Aortoenteric fistula

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25
Q

Difference between MW tear and Boerhaave’s syndrome

A

MW tear - superficial mucosal tear

Boerhaave’s syndrome - full thickness tear

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26
Q

Management of complicated/ruptured gastric ulcers

A

Repair, biopsy, OGD in 6-8 weeks

Non-healing risk of malignancy

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27
Q

Which artery is involved in major haemorrhages following peptic ulcer disease?

A

gastroduodenal artery

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28
Q

Anatomy relevant to an indirect inguinal hernia

A

Protrudes through the inguinal ring

Passes lateral to the inferior epigastric artery

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29
Q

Anatomy relevant to femoral hernias

A

Protrudes below the inguinal ligament, lateral to the pubic tubercle

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30
Q

Cause of direct inguinal hernia

A

weakness of transversalis fascia in Hesselbach triangle

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31
Q

Cause of direct inguinal hernia

A

failure of processus vaginalis to close

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32
Q

Which type of hernia is an emergency due to its high risk of strangulation?

A

Femoral

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33
Q

Classification of direct and indirect inguinal hernias wrt Hesselbach triangle

A

Hernias occurring within the triangle tend to be direct and those outside - indirect.

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34
Q

Boundaries of Hesselbach Triangle

A

Medial - rectus abdominis
Lateral - inferior epigastric vessels
Inferior - inguinal ligament

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35
Q

When is laparoscopic repair favoured in inguinal hernia repair?

A

Recurrent hernias and those which are bilateral

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36
Q

What type of inguinal hernia is common in children?

A

Indirect - through inguinal canal due to patent processus vaginalis

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37
Q

What type of inguinal hernia is common in adults?

A

Direct - through Hesselbach’s triangle

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38
Q

Return to work following hernia repair

A

open repair - non-manual work after 2-3 weeks

laparoscopic repair - 1-2 weeks

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39
Q

Hernias that cannot be reduced

A

Incarcerated

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40
Q

Should strangulated hernias be reduced when awaiting surgery

A

No - may precipitate generalised peritonitis

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41
Q

Associations of umbilical hernia in children

A

Associations
Afro-Caribbean infants
Down’s syndrome
mucopolysaccharide storage diseases

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42
Q

Inguinal hernia in children

A

<1 year very high risk of strangulation so emergency procedure required

> 1 year lower risk so elective fix

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43
Q

Sign. colicky pain after eating a fatty meal

A

Biliary colic - gallstone lodged in bile duct

Differentiated from acute cholecystitis by lack of fever and inflammatory markers

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44
Q

Sign. Murphy’s positive

A

Acute cholecystitis

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45
Q

Sign. Rovsings

A

appendicitis

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46
Q

Sign. Boas

A

cholecystitis

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47
Q

Cullens sign

A

Pancreatitis or intra-abdominal haemorrhage

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48
Q

Grey-Turners sign

A

Pancreatitis or retroperitoneal haemorrhage

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49
Q

Features of ascending cholangitis

A

RUQ pain
Fever
Jaundice

This is known as Charcot’s triad

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50
Q

Which is more common; gastric ulcer or duodenal ulcer?

A

Duodenal Ulcer

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51
Q

What is Rovsing’s sign in appendicitis?

A

Rovsing’s sign: more pain in RIF than LIF when palpating LIF

52
Q

Presentation of acute diverticulitis

A

Colicky pain typically in the LLQ

Diarrhoea, sometimes bloody.

Fever, raised inflammatory markers and white cells

53
Q

Buzzword. ‘Tinkling’ bowel sounds

A

Intestinal obstruction

54
Q

Features of renal colic

A

loin pain radiating to groin
restlessness
haematuria

55
Q

Features of pylonephritis

A

fever
rigors
vomiting
loin pain

56
Q

Features of ruptured AAA

A

Acute - sudden collapse

Sub-acute - central abdominal pain radiating to back with developing shock

57
Q

Features of acute mesenteric ischaemia

A

Pain out of proportion to symptoms

History of atrial fibrillation or other cardiovascular disease

Diarrhoea, rectal bleeding may be seen

A metabolic acidosis is often seen (due to ‘dying’ tissue)

58
Q

Features of oesophagitis

A

Haematemesis - small volume of blood often streaking vomit

Malaena rare

History of GORD

59
Q

Features of oesophageal cancer

A

Dysphagia an earlier sign , followed by haematemesis of small amounts of blood

Associated with weight loss and history of GORD

60
Q

Features of Mallory-Weis tear

A

Small transient bleeding following repeated vomiting

usually self-resolving

Malaena rare

61
Q

Features of oesophageal varices

A

Haematemesis with large volume of blood

Possible malaena

Associated with haemodynamic compromise

62
Q

Dieulafoy Lesion

A

Often no prodromal features prior to haematemesis and malaena, but this arteriovenous malformation may produce quite considerable haemorrhage and may be difficult to detect endoscopically

63
Q

Management of bleeding oesophageal varices prior to endoscopy

A

terlipressin prior to endoscopy

64
Q

Management of stable UGI bleeding

A

OGD within 24 hours

If unstable, perform immediate OGD in theatre with anaesthetist present

65
Q

Management of bleeding oesophageal varices

A 
Terlipressing 
Endoscopy 
Banding or Sclerotherapy 
Sengaksten-Blakemore Tube 
Gastric ballooning followed by oesophageal ballooning (deflate within 12 hours to avoid necrosis)
TIPS procedure
66
Q

UGI bleeding

  • Scoring for determining who needs to be admitted
  • Scoring to determine rebleeding risk
A

Blatchford score ≥1 admit

Rockall score ≤4 is low risk

67
Q

Which artery is involved in major haemorrhages following peptic ulcer disease?

A

gastroduodenal artery

68
Q

When should platelets, FPP and prothrombin complex be given in cases of acute bleeding?

A

platelet transfusion if actively bleeding platelet count of less than 50 x 10*9/litre

fresh frozen plasma to patients who have either a fibrinogen level of less than 1 g/litre, or a prothrombin time (international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal

prothrombin complex concentrate to patients who are taking warfarin and actively bleeding

69
Q

Antibiotic prophylaxis for ascites with <15g/L protein

A

Oral Ciprofloxacin

70
Q

Symptoms of osmotic demyelination syndrome

A

speech disturbances, swallowing dysfunction, limb paralysis, movement disorders, and behavioural and psychiatric disturbances

71
Q

Risk factors of breast cancer

A

HRT, Combined Hormonal Contraceptives

Higher exposure to oestrogen

  • Early menarche
  • Late menopause
  • No children/breastfeeding

Positive FHx ?BRCA1/2
Obesity
SHx - alcohol intake
Previous breast or ovarian cancer

72
Q

Breast biopsy gold standard

A

Core needle biopsy - US guided by interventional radiologist

73
Q

Breast examination - Hands above head

A
  • flatten pec major to assess for tethering to chest wall –> Skin dimpling
74
Q

Fibroadenoma differentials

A

Phyllodes tumour - rapidly growing and occurs in slightly older group (30-40)
Breast cyst
Lipomas

75
Q

Difference between wide-local excision and excisional biopsy?

A

Excision biopsy -> benign lesions e.g. lumpectomy

Wide-Local Excision -> lesions with metastatic potential (in breast at least 1cm)

76
Q

Spread of Phyllodes breast tumour

A

Haematogenous - no need for sentinel node examinations

77
Q

Breast Cancer Treatments and Hormone Receptors

A 
ER+ = Tamoxifen (SERM - used for pre-menopausal as oestrogen mostly from ovaries) or Letrozole (Aromatase Inhibitors - blocks peripheral aromatisation of oestrogens in fat)
PR+ = manage as ER+ with SERMs (pre-menopausal) and AI (post-menopausal)
HER2+ = Herceptin (Trastuzumab)
78
Q

Where does breast cancer spreads to?

A

Bone esp. spine
Liver
Lungs

79
Q

Why are aromatase inhibitors first line in ER+ breast cancers in post-menopausal women?

A

Letrozole - blocks peripheral aromatisation of oestrogens in fat

In pre-menopausal women ostrogens are made in ovaries mostly (give tamoxifen to block this)

80
Q

Triple Negative Hormonal Breast Cancer

A

Very aggressive

Needs urgent chemotherapy prior to surgery - refer to oncology

81
Q

Presentation of haemorrhoids

A

Painless bright red rectal bleeding

82
Q

Features of a chronic anal fissure

A

> 6week fissure

Triad of ulcer, sentinel pile, enlarged anal papillae

83
Q

Most common anal cancer

A

Squamous cell carcinoma

84
Q

Normal position of anal fissures

A

posterior midline 90%

if elsewhere suspect other pathology e.g. Crohn’s

85
Q

First-line and Second-line for chronic anal fissure

A

Topical GTN for 8 weeks

If not resolved then Sphincterotomy or BOTOX

86
Q

Management of acute anal fissure

A 
Stool softening with diet and laxatives 
- bulk-forming laxatives are first line 
- lactulose is second line 
Topical lubricants e.g. petroleum jelly 
Topical anaesthetic 
Analgesia
87
Q

Food and drink prior to surgery

A

Clear fluids up to 2 hours before surgery

Non-clear fluids and food for a minimum 6 hours before surgery

88
Q

Which patients should be at the beginning of the elective surgical list?

A

Diabetics

89
Q

Which marker is used to identify parathyroid gland?

A

Methylene blue

90
Q

Prep for phaeochromocytoma surgery

A

alpha and beta blockade

91
Q

Carcinoid tumour removal prep

A

Octreotide

92
Q

Risk factors for AAA

A 
FHx
Smoking 
Male 
Age >65
Hypertension
Syphilis
CTDs - Ehlers Danlos and Marfans
93
Q

Breast Screening

A

50-70 every 3 years (will be expanded to 47-73)

94
Q

Increased risk of Familial Breast Cancer

A

First or Second degree relative

  • diagnosis <40yo
  • bilateral breast cancer
  • male breast cancer
  • Jewish ancestry
  • sarcoma in <45yo
  • glioma or childhood adrenal cortical carcinomas
  • childhood with multiple cancers
  • ≥2 paternal family members with breast cancer
95
Q

Breast cancer and lymph node management

A

Palpable lymphadenopathy -> axillary node clearance at primary surgery

No palpable lymphadenopathy -> pre-operative axillary lymph node

If Axillary US positive -> Sentinel node biopsy to assess nodal burden

96
Q

Management of breast cancer

A

Neoadjuvant Chemotherapy - used in some tumours to downstage lesion allowing more conservative excision e.g. FEC-D for axillar node disease

Surgery - mastectomy or wide-local excision
+ reconstruction

Radiotherapy - following wide-local excision (reduces recurrence by 2/3), mastectomy of T3 or 4 tumour and those with ≥4 positive lymph nodes

Hormone Therapy ER+/PR+ - Tamoxifen (pre or peri - menopausal women) and Anastrozole (AI in post-menopausal women)

Hormone Therapy HER+ - Herceptin (Trastuzumab) - contraindicated in heart disorders

97
Q

Risks of Tamoxifen

A

Endometrial Cancer
VTE
Menopausal symptoms

98
Q

Most common breast cancer

A

Invasive Ductal Carcinoma

99
Q

Mastectomy vs Wide-Local Excision for DCIS

A

<4cm - WLE

>4cm - Mastectomy

100
Q

Index for indication of survival at 5 years with Breast cancer

A

Nottingham Prognostic Index

101
Q

Calculating Nottingham Prognostic Index for breast cancer

A

Tumour Size x 0.2 + Lymph node score + Grade Score

Lymph Node Score: 0 nodes = 1; 1-3 nodes = 2; >3 nodes = 3

102
Q

Nottingham Prognostic Index for Breast Cancer and Survival Rates

A

2.0-2.4 = 93%
2.5-3.4 = 85%
3.5-5.4 = 70%
>5.5 = 50%

103
Q

Suspicion of breast cancer referral

A

2 weeks for triple assessment

  • aged ≥30 with unexplained breast lump
  • aged ≥50 with nipple discharge, skin retraction or other changes

non-urgent referral in <30 with unexplained breast lump

104
Q

Features of breast fibroadenosis

A

Middle-aged
“Lumpy” breasts
Worse symptoms before menstruation

105
Q

Features of duct ectasia

A

Peri-menopausal
Tender lump around areola
If infected - known as plasma cell mastitis
- Green nipple discharge

106
Q

Breast cancer. blood-stained discharge

A

Duct papilloma

107
Q

Ascites SBP prophylaxis after having 1 episode

A

Long term Ciprofloxacin

108
Q

Pre-operative staging for rectal cancer

A

Rectal MRI and CT Chest/Abdo/Pelvis

109
Q

Pre-operative staging for colon cancer

A

CT Chest/Abdo/Pelvis

110
Q

Rectal Cancer showing invasion of mesorectal fascia on MRI

A

Neoadjuvant - chemoradiotherapy

Then Surgical resection

111
Q

Difference between Sigmoid colorectal cancer surgical options?

A

Sigmoid colectomy - descending colon and rectum anastamoses

Hartman’s procedure - L-sided colostomy + rectum kept in - used in emergency e.g. perforation - can be reversed in future once stable

112
Q

Which colorectal cancers benefit from radiotherapy?

A

Rectal cancers only

113
Q

Surgical excision of rectal cancers

A

Total Mesorectal Excision

114
Q

What is the most common gene affected in colorectal cancer?

A

APC

115
Q

Where do HNPCC individuals get CRC?

A

Proximal Colon

116
Q

Features of Gardner’s Syndrome

A 
FAP Colorectal Cancer 
Osteomas of the skull and mandible 
Retinal Pigmentation
Thyroid Carcinomas 
Epidermoid Cysts
117
Q

Colorectal Cancer Screening

A

England: 60-74
Scotland: 50-74

FIT every 2 years

If abnormal invited for colonoscopy

118
Q

Flexible Sigmoidoscopy Screening

A

New - being rolled out
Once-off between 55-60
Allow the detection and treatment of polyps, reducing the future risk of colorectal cancer

119
Q

Turcots Syndrome

A

Polyposis and colonic tumours and CNS tumours

120
Q

Peutz-Jeghers syndrome

A

Hamartomatous polyps in GI tract and increased risk of GI malignancy

121
Q

Cowden Disease

A

Rare autosomal dominant condition
Multiple hamartoma syndrome
Associated with breast carcinoma, colon cancer, thyroid cancer, oral papillomas and acral keratosis.

122
Q

Triad of Plummer-Vinson Syndrome + Treatment

A

dysphagia (secondary to oesophageal webs)
glossitis
iron-deficiency anaemia

iron supplementation and dilation of the webs

123
Q

Management of acute pancreatitis

A
  1. Fluid resuscitation with crystalloids
  2. Enteral nutrition offered to moderately severe or severe cases that present within 72 hours
  3. If cause is stones then cholecystectomy, if necrosis then debridement
124
Q

Safe area for insertion of a chest drain

A

The triangle of safety for chest drain insertion involves the base of the axilla, lateral edge pectoralis major, 5th intercostal space and the anterior border of latissimus dorsi

125
Q

Management of Alcoholic Liver Disease in patients with first presentation of Ascites

A
  1. Avoid Alcohol
  2. Good Nutrition (correct vitamin deficiencies)
  3. Restrict Dietary Salt
  4. If hyponatraemic then fluid restrict

Medicine - Finals (21 decks)

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