General surgery (passmed) Flashcards
What are the two ‘signs’ of appendicitis to do with discolouration?
Periumbilical discolouration
- Cullen’s sign
Flank discolouration
- Grey-Turner’s sign is described but rare
What is the sign for Cholecystitis, pain in the RUQ when pressed?
Murphy’s
What is Rovsing’s sign for?
Appendicitis
Classic differentials for abdo swelling?
Pregnancy
Intestinal obstruction
Ascites
Urinary Retention
Ovarian Ca.
Location and aetiology of inguinal hernias and femoral hernias?
What type has the highest risk of strangulation?
Direct Inguinal
- Above and medial to pubic tubercle
- Medial to epigastric vessels
- Weakness in transversalis fascia
Indirect Inguinal
- Above and medial to pubic tubercle
- Lateral to epigastric vessels
- Failure of the processus vaginalis to close
Femoral
- Below and lateral to the pubic tubercle
Femoral has the highest risk of strangulation
Difference in an umbilical and paraumbilical hernia?
Paraumbilical is an asymmetric bulge - half is covered by skin
What are the three biological therapies used in Rheumatoid arthritis and Crohns disease?
Adalimumab
Infliximab
Etanercept
What is cryptorchidism?
A congenital undescended testis
What is Scheuermann’s disease?
- Presentation (symptoms and signs)
- What is it
Epiphysitis of the vertebral joints is the main pathological process
Presentation:
- Predominantly affects adolescents
- Symptoms include back pain and stiffness
- X-ray changes include epiphyseal plate disturbance and anterior wedging
- Clinical features include progressive kyphosis (at least 3 vertebrae must be involved)
Types of scoliosis?
Structural and non-structural
Non structural typically disappears upon movement
What are the three categories of spina bifida?
Myelomeningocele
- The worst, may have neurological defects
Meningocele
- ?just needs to be closed
Occulta
- Fine, about 10% of babies
What is Spondylolysis?
Congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/ L5.
May be asymptomatic and affects up to 5% of the population.
Spondylolysis is the commonest cause of spondylolisthesis in children.
What is Spondylolisthesis?
One vertebra is displaced relative to its immediate inferior vertebral body
May occur as a result of stress fracture or spondylolysis
Treatment for spondylolisthesis?
Treatment depends upon the extent of deformity and associated neurological symptoms, minor cases may be actively monitored. Individuals with radicular symptoms or signs will usually require spinal decompression and stabilisation.
What determines whether you should gastric feed/feed elsewhere?
Upper GI function
If dysfunction then jejunal/duodenal
What are the four types of fistulae, and their features?
Enterocutaneous
- Intestines to skin
- High or low output (>500ml is high)
Enteroenteric/enterocolic
- Small bowel or large bowel
Enterovaginal
- Bowel to vagina
Enterovesicular
- Bowel to bladder
- Pneumouria
Management of fistulas?
Most will heal by themselves if not associated with underlying inflammatory condition
If enterocutaneous then need to protect skin, e.g. use stoma bag.
Can use octreotide if high volume (less pancreatic secretions)
What is the Parkland formula for fluid resus in burns?
4 x (total burn surface are x weight (kg))
Half given in first 8 hours
At what percentage body surface cover should you fluid resus in kids and adults?
> 15% in adults
> 10% in kids
Summary of low acute GI management?
Consider admission if:
* Over 60 years
* Haemodynamically unstable/profuse PR bleeding
* On aspirin or NSAID
* Significant co-morbidity
Management:
- All patients should have a history and examination, PR and proctoscopy
- Colonoscopic haemostasis aimed for in post polypectomy or diverticular bleeding
Groin lumps key questions
Is there a cough impulse
Is it pulsatile AND is it expansile (to distinguish between false and true aneurysm)
Are both testes intra scrotal
Any lesions in the legs such as malignancy or infections (?lymph nodes)
Examine the ano rectum as anal cancer may metastasise to the groin
Is the lump soft, small and very superficial (?lipoma)
Scrotal lumps key questions
Is the lump entirely intra scrotal
Does it transilluminate (?hydrocele)
Is there a cough impulse (?hernia)
What are hydatid cysts?
Investigations and management?
Caused by the tapeworm parasite Echinococcus granulosus
Need CT and surgery
Boundaries of hesselbachs triangle?
Medial: Rectus abdominis
Lateral: Inferior epigastric vessels
Inferior: Inguinal ligament
Management of inguinal hernias?
If at risk, or if patient is well then surgical repair (usually mesh)
Open if first time
Laparoscopic if recurrence or bilateral
Common types of liver tumours?
95 % are mets from another primary
Primaries
HCC
- Normally secondary to chronic Hep B infection
Cholangiocarcinoma
- PSC biggest risk factor
Management of pancreatitis?
Enteral nutrition
Abx
- Imipenem
- May not be worth it if mild disease
Surgery
- If due to gallstones, then early cholecystectomy
- If obstructed biliary system due to stones then ERCP
- Maybe debridement or aspiration if necrosis
- If infected necrosis then radiological drainage or necrosectomy
Definitions of massive haemorrhage?
Loss of blood volume in 24 hours (7% of weight)
Loss of 50% blood volume in 3 hours
Loss of blood volume >150ml a minute
What are the three main types of antigen that may give rise to rejection in organ transplant?
ABO
HLA
MHC
Most common type of pancreatic cancer?
Adenocarcinoma of the head of the pancreas
Presentation of pancreatic cancer?
Classically painless jaundice
Patients typically present in a non-specific way with anorexia, weight loss, epigastric pain
Loss of exocrine function (e.g. steatorrhoea)
Atypical back pain is often seen
Investigation choices for pancreatic cancer?
Ultrasound has a sensitivity of around 60-90%
High resolution CT scanning is the investigation of choice if the diagnosis is suspected
Primary malignant bone tumours?
Chondrosarcoma
Osteosarcoma
Ewing’s tumour
Where are pilonidal cysts normally located?
Midline of natal cleft
What is Meckel’s diverticulum
A Meckel’s diverticulum is a congenital abnormality that is present in about 2% of the population
Typically 2 feet proximal to the ileocaecal valve
May be lined by ectopic gastric mucosal tissue and produce bleeding, and RIF pain
Types of shock?
There are five
Septic
Haemorrhagic
Neurogenic
Cardiogenic
Anaphylactic
What is the aetiology in neurogenic shock?
Spinal cord transection, usually at a high level.
There is a resultant interruption of the autonomic nervous system.
The result is either decreased sympathetic tone or increased parasympathetic tone
What is the aetiology in cardiogenic shock?
The main cause is ischaemic heart disease
Presentation of small bowel obstruction?
Central abdominal pain
Nausea and vomiting
‘constipation’ with complete obstruction
abdominal distension may be apparent, particularly with lower levels of obstruction
What does TPN include, where should it ideally be given?
Bags contain combinations of glucose, lipids and essential electrolytes, the exact composition is determined by the patients nutritional requirements.
Ideally given centrally (PICC line)
What are the types of transplant?
Allograft
Transplant of tissue from genetically non identical donor from the same species.
Isograft
Graft of tissue between two individuals who are genetically identical
Autograft
Transplantation of organs or tissues from one part of the body to another in the same individual e.g. Skin graft
Xenograft
Tissue transplanted from another species e.g. Porcine heart valve
When would you perform a diagnostic peritoneal lavage?
Document bleeding if hypotensive
UGIB presentation?
Haematemesis and/ or malaena
Epigastric discomfort
Sudden collapse
After UGIB endoscopy what score do you need to do?
Rockwall score to determine risk of re-bleeding
Polycythaemia occurs in which renal ca.?
Adenocarcinoma of the kidney
In a pt with haemothorax at what point do you want to do a thoracotomy?
> 1.5L of blood loss initially or >220/hour for the next two hours.
How can you tell apart FAP and HNPCC (lynch)?
HNPCC does not have loads of polyps
Most common scoring system in pancreatitis?
Glasgow
Small bowel obstruction management?
Drip (Iv fluids) and suck (NG tube)
