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Surgery MD2 > Learning Objectives > Flashcards

Learning Objectives Flashcards

1
Q

What are hypertrophic and keloid scars and what is the difference?

A

Hypertrophic - exaggerated normal remodelling response, within wound margins, improves over time and responds to steroids and pressure

Keloid - extends beyong wound margins and progresses over time, more common with darker skin, less responsive to steroids and pressure

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2
Q

What are the management options for dupuytrens contracture?

A

Nothing

Limited Fasciectomy

Radical Fasciectomy

Fasciotomy

Amputation

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3
Q

What are some causes of dupuytrens contracture?

A

Alcohol

Congenital

Work

Epileptic drugs

Diabetes

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4
Q

What are the main differential diagnoses for dysphagia?

A

Oesophageal cancer

Achalasia

Oesophageal Stricture

Stroke

Parkinsons

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5
Q

What are the investigations for dysphagia?

A

Video swallow

Gastroscopy

Barium swallow

CT

Manometry

Endoscopic US

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6
Q

What is the management for some differentials for dysphagia (pharyngeal pouch, oesopahgeal cancer, stricture, hiatus hernia, achalasia)?

A

Pharyngela Pouch - surgical repair

Cancer - surgery, adjuvant therapy

Stricture - surgical dilation, PPI, fundoplication

Hiatus Hernia - laporascopic repair

Achalasia - divide LOS, dilation

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7
Q

What is the pathophysiology of aortic dissection?

A

Tear in the aortic intima - more commonly ascending aorta - leads to blood tracking between the intima and the media

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8
Q

What are 5 risk factors associated with aortic dissection?

A

Hypertension

Aortic Aneurysm

Atherosclerosis

Male/increasing age

Collagen disorder - marfans, ehlers danlos

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9
Q

What is the presentation of an aortic dissection?

A

Tearing pain radiating to the back +/- syncope

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10
Q

What are the investigations and management for aortic dissection?

A

Investigations - BP different in each arm, D-dimer, CT

Management - analgesia, antihypertensives, beta blockers, surgery

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11
Q

What is the pathophysiology and presentation of Marfan syndrome?

A

Pathophys - defect in fibrillin 1 gene, autosomal dominant, trouble producing elastin

Presentation - long bone excess growth, mitral valve prolapse, aortic regurg, joints lax, pectus carinatum (pigeon chest), scoliosis

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12
Q

What is the investigation and management for Marfan syndrome?

A

Investigation - genetic testing, echo

Management - surgery, observation

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13
Q

What are the common sites of berry aneurysm?

A

Posterior communicating and anteroir communicating arteires - branch points where vessels are weakest and are anastomosing

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14
Q

What is a complication of berry aneurysm rupture and what is the treatment?

A

SAH - vasospasm few days later due to breakdown of blood products - treat with papaverine (vasodilation)

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15
Q

What is thrombophilia and what may cause it?

A

Increased tendency of the blood to clot

Causes

  • Factor V leiden
  • Prothrombin mutation
  • Protein C, S, antithrombin deficiency
  • Antiphospholipid syndrome
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16
Q

What are the most common presentations of thrombophilia?

A

DVT

PE

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17
Q

What is the pathophysiology of vasculitis?

A

Inflammatory leucocytes in vein walls causing reactive damage and loss of vessel integrity - bleeding and downstream tissue ischaemia and necrosis

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18
Q

What are the risk factors for vasculitis?

A

Smoking

HTN

Hypercholesterolaemia

Infection

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19
Q

What is the pharmacological management for vasculitis?

A

Methotrexate

Prednisolone

Cyclophosphamide

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20
Q

What are the classifications of vasculitis?

A

Large vessel

  • Giant cell
  • Takayasu

Medium vessel

  • Polyarteritis
  • Kawasaki

Small vessel

  • ANCA
  • Immune complex
    • Good pastures
    • IgA vasculitis
  • Autoimmune - SLE
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21
Q

What are the normal ranges of ABGs?

A

pH= 7.35-7.45

PaCO2= 35-45mmHg

PaO2=100 (>85)mmHg

HCO3= 22-30

SaO2 95-100%

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22
Q

What is the acute management for raised ICP?

A

Maintain ICP at less than 20-25mmHg (dexamethasone, mannitol)

Avoid aggravating factors: obstruction of venous return (head position, agitation), respiratory problems (airway obstruction, hypoxia, hypercapnia), fever, sever hypertension, hyponatremia, anaemia, seizures

Sedation

Drainage of CSF

Osmotherapy with mannitol or hypertonic saline

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23
Q

What are the risk factors for dementia?

A

Age

ApoE4 mutation

Head trauma

Smoking

Education

Vascular disease

Diabetes

Lewy body disease

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24
Q

What are the featrues of Alzheimers?

A

Memory loss

Loss of social and occupational functioning

Diminished executive function

Speech and motor deficits

Personality change

Behaviour and psychological disturbance

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25
Q

What is the treatment for an ischaemic stroke?

A

Thrombolysis (tPA - ateplase) within 4 hours of symptom onset

Aspirin

Fibrinolytic therapy

Antiplatelet

Mechanical thrombectomy - clot retrieval

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26
Q

What are the causative agents of meningitis and their CSF features?

A
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27
Q

What are the signs and symptoms of meningitis?

A

Headache

Rash

Neck stiffness

Photophobia

Nausea and vomiting

Fever

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28
Q

What is required for diagnosis of MS?

A

More than one episode of demyelination or evidence of more than one lesion on MRI

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29
Q

What may be the first presentation of MS?

A

White middle aged woman - temporary visual or sensory loss (optic neuritis)

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30
Q

What are the common causes of abdominal distension?

A

Flatus

Faeces

Foetus

Fluid

Fat

Fing big tumour

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31
Q

What is the investigation for bowel obstruction?

A

CXR - free fluid under the diaphragm

Supine AXR - dilated loops of bowel

Erect AXR - air fluid levels (>3 is abnormal)

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32
Q

What antigen is raised in colorectal cancer?

A

CEA - only of use if it is high on diagnosis to look at after treatment to see value dropping (may also be elevated normally in smokers)

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33
Q

What are the major risks of scope procedures and what anaesthetic method is used?

A

Perforation and haemorrhage

Sedation - propofol

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34
Q

What is a Hartmanns procedure?

A

Sigmoidectomy without anastomoses (colostomy bag) –> can come back after ~3 months and assess for rejoining (can bring out a temporary ileostomy to reduce stress on recently joined anastomoses)

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35
Q

Patient presents with eye pain worse with movement and colour vision is dulled and there may be loss of vision. What is the likely pathology and how can this be tested?

A

Optic neuritis

Swinging light test - afferent pupillary defect

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36
Q

What are the causes of a hydrocoele?

A

Primary - idiopathic (bilateral)

Secondary - cancer, mumps, epidiymal orchitis, trauma

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37
Q

What are the tumour markers for testicular cancer?

A

LDH

Beta-hcg

alpha-fetoprotein

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38
Q

Where do the testicular lymph nodes drain?

A

Paraaortic nodes

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39
Q

What are some signs and symptoms for SBO?

A

Nausea and vomiting (fecalant material)

No flatus

Absolute constipation

Abdominal distension

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40
Q

What are the management steps for a SBO?

A

Fluid resuscitation

NGT

Surveillance - most resolve within 48 hours

Nutritional support

Surgery - division of adhesions

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41
Q

What are some causes of spinal cord compression?

A

Tumour

Abscess

Degeneration - disc prolapse, OP, spondylosis, canal stenosis

Infection

Haematoma

Developmental - syrinx (fluid filled cavity in spinal cord), cyst

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42
Q

What are the red flags of back pain?

A

Hx of cancer

Sciatica

Pain at rest

Pain not relieved by analgesia

Fatigue, night sweats, loss of weight/appetite

Age < 20 or > 50

Glucocorticoid use

IVDU

Rapid progression

> 1 month duration

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43
Q

What is the cause of cervical myelopathy and how does a patient present?

A

Cause is usually cervical vertebrae degeneration and canal stenosis in the elderly

LMN signs in upper limbs and UMN signs in lower limbs with neck pain

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44
Q

What may be the presenting complaints of a patient experiencing cauda equina compression?

A

Urinary retention/trouble initiating urination or incontinence

Constipation and faecal incontinence

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45
Q

Where is a spinal malignancy most commonly found?

A

Thoracolumbar region - dual blood supply

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46
Q

Where is a spinal abscess usually found and how does one present?

A

Thoracolumbar region - dual blood supply

Pain, neurological deficit, fever, diaphoresis, fatigue

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47
Q

What are the presenting symptoms of perianal disease?

A

PR bleeding

Pain

Anal lumps/swellings

Itch

Discharge

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48
Q

What are some PAINFUL perianal conditions?

A

Anal fissure

Haemorrhoids (strangulated)

Haematoma

Abscess

Anal cancer

Proctalgia fugax

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49
Q

What are some PAINLESS perianal conditions?

A

Fistula

Skin tags

Haemorrhoids (1st, 2nd, 3rd degree)

Low rectal cancer

Rectal prolapse

Polyps

Warts

Pruritis ani

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50
Q

What are the investigations for perianal pathology?

A

DRE (contraindicated with pain)

Sigmoidioscopu

Proctoscopy

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51
Q

What are the management options for an anal fissure?

A

Topical analgesia

Stool softener (Coloxyl + Senna)

Sitz bath

Rectogesic ointment - GTN (vasodilation to promote healing)

Nifedipine

Botox injection to intersphincteric space

Lateral sphincterotomty

  • More indicated in males
  • May lead to flatus incontinence, especially in females

Fissurectomy

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52
Q

What are the management options for perianal abscess?

A

Drainage

Antibiotics

(Surgery)

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53
Q

What are the management options for haemorrhoids?

A

1st (internal) - High fibre diet (reduce constipation), injection sclerotherapy, phenol in almond oil

2nd (protrude on defecation) - Diet modification, rubber band ligation

3rd (usually protruding) - Haemorrhoidectomy

4th (strangulated, painful) - Analgesia and surgery

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54
Q

What are the management options for anal warts?

A

Improve hygeine

HPV vaccine

Local excision

(Chemoirradiation therapy)

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55
Q

What are the management options for pruritis ani?

A

Topical steroid

Antifungal

Oral antihistamine

Avoid excessive wiping

Excise skin tags

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56
Q

What are the management options for low rectal cancer?

A

Radiotherapy

Chemotherapy

Surgical removal

  • Low anterior resection (high risk of faecal incontinence)
  • Abdomino-perineal excision - removal of rectum and anus, permanent stoma
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57
Q

What are the management options for anal cancer?

A

Radiotherapy

Chemotherapy

Abdominoperineal resection - permanent stoma

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58
Q

What is this pathology, the presentation and management?

A

Orbital Cellulitis

Painful red eye, fever, malaise

Surgical drainage and IV antibiotics

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59
Q

What is this pathology and what is the presentation and management?

A

Pterygium

Impaired ocular appearance, vision loss

Treat with topical lubricants and surgery

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60
Q

What is this pathology and what is the management?

A

Subconjunctival haemorrhage

Self resolving

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61
Q

What is this pathology, the presentation and management?

A

Scleritis

Aching pain, impaird vision

Urgent referral to opthalmologist

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62
Q

What is this pathology and the management?

A

Foreign body

Removal via surgery

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63
Q

What is this pathology and the management?

A

Hyphaema

Usually occurs due to blunt trauma

Treat with topical steroids and cycloplegics

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64
Q

What is this pathology, the presentation and management?

A

Acute angle closure glaucoma

Painful unilateral red eye, worsening vision, sudden onset

Acetaxolamide, beta blocker, steroids, laser

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65
Q

Patient presents with flashes of light and blurred vision, what is the pathology?

A

Retinal detachment

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66
Q

What is this pathology and the management?

A

Keratoconus

Need hard contact lenses or corneal transplant

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67
Q

Patient presents with dull colour vision, blurred vision and glare, what is the likely pathology?

A

Cataract

Need lens transplant

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68
Q

Patient presents with sudden painless unilateral vision loss and this fundoscopy view, what is the pathology?

A

Central retinal artery occlusion

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69
Q

Patient presents with sudden painless unilateral vision loss and this fundoscopy view, what is the pathology?

A

Central retinal vein occlusion

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70
Q

Patient presents with rapid decrease in central vision, metamorphosphia and central scotoma, what is the pathology and treatment?

A

Wet macular degeneration - anti-VEGF injections every 4-6 weeks for life

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71
Q

Patient presents with a gradual decrease in central vision and central scotoma, what is the pathology and treatment?

A

Dry macular degeneration - vitamin supplementation

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72
Q

What are the common benign breast conditions and their presentations?

A

Fibrocystic - scar tissue, rubbery and firm

Fibroadenoma - small lumps

Mastitis - breast enlarged due to infection (more common when breastfeeding) - staph aureus - manage with flucloxacillin

Fat Necrosis - lumps when areas of fatty breast tissue are damaged

Calcification - non painful, non palpable

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73
Q

What are the pros and cons of investigations for breast disease (mammogram, US, FNA, core biopsy)

A

Mammogram: early screening to pick up small cancers, lots of lesions picked up that may have never been a problem, radiation exposure

US: doesn’t pick up all calcification, non-invasive

FNA: can work out nature of lesion, quick and simple, brusing bleeding and infection, seeding risk (displace tumour cells)

Core Needle Biopsy - tissue type lesion, haematoma, not always feasible for lesion in tricky spot

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74
Q

What is key for home breast examinations?

A

Better to examine breasts after a period - hormone levels are low and breasts should be at their ‘normal’

Look for even shaping and colour

Nipple changes, redness, rash, swelling, dimpling of skin –> consult doctor

Roll over breast while lying down to feel for lumps

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75
Q

What are the most common type of renal stones and what are the risk factors?

A

Calcium Oxalate

Risks: dehydration, high sodium diet, fam hx, climate, anatomical abnormalities

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76
Q

What are the causes of kidney stone formation?

A

Hypercalcaemia - primary HPT, immobile, cancer, sarcoidosis

Uric Acid Lithiasis - gout, idiopathic, low urine output

Metabolic - cystinuria

Secondary Urolithiasis - infection, obstruction

77
Q

What is the typical presentation with renal calculi?

A

Pain

Haematuria

Infection (fever)

78
Q

What is the typical presentation with ureteric calculi?

A

Sudden onset of severe flank pain which may radiate to groin

79
Q

What is the investigation for acute stone episodes?

A

FBE, U&E, creatinine

Serum calcium and uric acid

CMP

MSU

CT-KUB

80
Q

What are the management options for kidney stones?

A

Pain relief

Hydration

Expulsive therapy - alpha blockers (relax ureter wall)

Lithotripsy - shock waves to break down stones

Nephrolithotomy - remove stone through kidney cortex

Endoscopic surgery

81
Q

What is the presentation for obstructive pyonephrosis and what is the management?

A

Presentation - flank pain, unwell, febrile, urinary symptoms, sepsis

Management - IVABx, decompression, fluids

82
Q

What are some strategies to prevent renal strone recurrence?

A

Hydration

Reduce dietary salt

Urinary alkalinisation

Thiazide diuretics/allopurinol

83
Q

What are some causes of haematuria?

A

Renal - glomerulonephritis, cancer, trauma, calculus, infection

Ureter - TCC (transitional cell carcinoma), calculus

Bladder - TCC, cystitis (MOST COMMON CAUSE), calculus, trauma

Prostate - BPH, carcinoma, prostatitis

Urethra - structure, urethritis, trauma, carcinoma

84
Q

What are some investigations for haematuria?

A

Urine

  • Micro
    • RBC
    • Morphology
    • Glomerular (upper tract bleeding - red cells look misshapen)/non-glomerular (red cells look untouched)
    • Protein/casts (suggestive of renal parenchymal problem)
  • Cytology
  • Culture

Imaging

  • US urinary tract
  • CT urogram (not in people who can’t tolerate contrast)

Endoscopy

  • Cystoscopy (retrograde pyelogram)
  • Ureteropyeloscopy (+/- biopsy)
85
Q

What are some differentials for headache and their features?

A

Tension - late in day, occipitalis and frontalis muscle spasm

Migraine - photophobia, scintillating scotoma, aura

Meningitis - fever, neck stiffness

Encephalitis

Subdural Hematoma - elderly, alcoholics, anticoagulants

Tumour - morning headaches, seizures, neurological deficits

Trauma

Temporal Arteritis - unilateral, usually > 50, visual disturbance, jaw claudication, scalp tenderness

Aneurysm (strong association b/w berry aneurysms and adult polycystic kidney disease - autosomal dominant - bicuspid aortic valve with aortic coarctation)

Sinusitis

Cluster headache

Glaucoma - unilateral, visual disturbance

86
Q

What are common investigations used to diagnose SAH?

A

CT - within 12-24 hours, may be normal

LP - looking for bloodstained CSF that doesn’t clear on 3 consecutive samples

Cerebral angiography

87
Q

What is the early management for SAH?

A

Observation - BP, RR, HR (watching for coning and cushings triad - bradycardia, hypertenson and irregular resp rate)

Analgesia (avoid opioids)

Surgica Clipping

Endovascular coil embolization

88
Q

What are some complications of SAH?

A

Vasospasm

Acute hydrocephalus

Rebleeding

89
Q

What is normal ICP?

A

7-15mmHg (supine)

90
Q

What are the signs of malignancy on mammogram and US for breast disease?

A

Mammogram - spiculated mass, irregular borders, microcalcification

US - hypoechoic, poster acoustic shadowing, taller than wide

91
Q

What arethe prognostic and predictive features of breast carcinoma?

A

Prognostic

  • Size
  • Histology (ductal, lobular)
  • Grade
  • Margins
  • Lymph invasion

Predictive

  • PR and ER status (positive in low grade)
  • HER2 status (positive in high grade)
92
Q

What are the common causes of upper GI bleeding?

A

Peptic ulcer disease

Gastristis

Oesophageal varices

Mallory weiss tear

93
Q

What are haematemesis and melena?

A

Hematemesis - bleeding in upper GIT, leading to vomiting of fresh blood

Melena - black stool due to processing of blood from upper GIT - proximal to ileocaecal valve

94
Q

When is bleeding haemodynamically significant?

A

Blood loss > 500mL

Resting tachycardia, HR > 100bpm

Systolic BP < 100mmHg

Orthostatic Hypotension - pulse increase of > 20 bpm OR systolic pressure decrease of > 20 mmHg

95
Q

What are the risk factors, pathogenesis and clinical features, investigation and principles of management of adenocarcinoma?

A

Risks - older adult smokers, women, non-smokers

Pathogenesis - outer lung, EGFR/ALK mutations, most common non-small cell

Clinical - chest pain, haemoptysis, cough, B symptoms, SOB

Investigations - Hb, LFT, CXR, PET, sputum, bronchoscopy, FNA, tissue biopsy

96
Q

What are the risk factors, pathogenesis and clinical features, investigation and principles of management of large cell carcinoma?

A

Risks - smoking

Pathogenesis - rapid growth, not common, any part of lung

Clinical - chest pain, SOB, cough, haemoptysis, B symptoms

Investigations - Hb, LFT, CXR, PET, sputum, bronchoscopy, FNA, tissue biopsy

Management - chemo, radiation, surgery

97
Q

What are the risk factors, pathogenesis and clinical features, investigation and principles of management of small cell carcinoma?

A

Risks - adult smokers

Pathogenesis - most aggressive lung cancer, near bronchi, obstruction or distant mets on presentation

Clinical - cough, SOB, chest pain, haemoptysis, ADH syndrome, cyshingoid (hormone secretion), B symptoms

Investigations - Hb, LFT, CXR, PET, sputum, bronchoscopy, FNA, tissue biopsy

Management - chemotherapy (rapid response)

98
Q

What are the risk factors, pathogenesis and clinical features, investigation and principles of management of squamous cell carcinoma?

A

Risks - men, smokers

Pathogenesis - cells lining airways, central

Clinical - chest pain, SOB, haemoptysis, B symptoms, cough

Investigations - Hb, LFT, CXR, PET, sputum, bronchoscopy, FNA, tissue biopsy

Management - surgery, chemotherapy, radiation

99
Q

What are the patterns of injury following FOOSH and the best imaging for these?

A

Colles Fracture - distal radius, dinner fork deformity, AP and lateral wrist X-rays, extraarticular fracture, risk of median nerve damage

Smith Fracture - distal radius, palmar angulation (reverse colles), oblique wrist x-ray

Scaphoid fracture - risk of avascular necrosis of proximal scaphoid, image scaphoid (fat pad sign, terry thomas sign - scapholunate ligament disruption), CT may be better

100
Q

What is the appropriate management for septic arthritis?

A

Joint washout

GP - vancomycin, clindamycin, cephalosporin, joint aspiration

GN - 3rd gen cephalosporin, joint aspiration, IV ciprofloxacin, gentamicin

MSSA - IV flucloxacillin then oral flucloxacillin (4 weeks)

MRSA - IV vancomycin, joint aspiration then oral clindamycin

101
Q

What are the risk factors, presentation, investigations and treatment for epididymitis?

A

Risks - STI (chlamydia), e.coli, mumps, elderly, diabetic, immunosupressed

Presentation - pain, urethritis (discharge), dysuria, haematuria, unilateral swollen scrotum

Investigation - MSU, US

Treatment - analgesia, empiric Abx (trimethoprim, cephalexin, augmentin), epididimectomy

102
Q

What are the risk factors, presentation, investigations and treatment for hydrocele?

A

Risks - idiopathic (bilateral), cancer, mumps, epididymal orchitis, trauma

Presentation - swollen scrotum

Investigations - US, tumour markers

Management - radical orchidectomy, PET, jabalay (evert tunica vaginalis)

103
Q

What are the risk factors, presentation, investigations and treatment for varicocele?

A

Presentation - ‘worms’ left side when standing, pain

Management - surgical tie off of cremaster veins

104
Q

What are the risk factors, presentation, investigations and treatment for fourniers gangrene?

A

Risks - infection of scrotum - necrotising fasciitis

Presentation - unilateral black scrotum

Management - debridement, graft, reimplant testes

(fatal if left alone)

105
Q

What are the risk factors, presentation, investigations and treatment for testicular cancer?

A

Risk - 20-34, caucasion, trauma, hormones, atrophy, undescended testes

Presentation - painless lump, hydrocele, scrotal swelling (seminoma most common)

Investigation - US, tumour markers, CT, PET

Treatment - radical orchidectomy, BEP chemo (bleomycin, etoposide, cisplatin), radiotherapy (best for seminoma), lymph node dissection

106
Q

What are the risk factors, presentation, investigations and treatment for lymphoma?

A

Presntation - unilateral testicular swelling, B symptoms

Investigations - US (hypoechoic lesion)

Management - orchiectomy, chemotherapy

107
Q

What is the cause, drainaing site and treatment for penile cancer?

A

Squamous cell carcinoma

Drains to inguinal nodes

Penectomy (amputation) or radiotherapy

108
Q

What are the risk factors, presentation, investigations and treatment for testicular torsion?

A

Risk - < 25, neonate, trauma, undescended testi, cold weather

Presentation - acute severe pain, swelling, trauma, nausea and vomiting

Investigations - tender firm testicle, absent cremasteric reflex, urinalysis, US, doppler

Treatment - fixation, dartos pouch

109
Q

What is myocarditis, how does a patient present and what is the treatment?

A

Myocardial inflammation due to viral infection - influenza, coxsackie, parvovirus, CMV, adenovirus, rubella, enterovirus, HCV

Presentation - chest pain, fatigue, arthralgia, peripheral oedema

Treatment - abx, steroids, diuretics, low salt diet, pacemaker

110
Q

What is shock, why does it occur, how does it present and what is the management?

A

Inadequate organ perfusion nd oxygenation due to imbalance between supply and demand

Causes

  • Cardiogenic (MI, arrhythmia, aortic stenosis, mitral regurg)
  • Hypovolemic (haemorrhage, vomiting, diarrhoea, burns, dehydration)
  • Obstructive (PE, tension pneumothorax, tamponade)
  • Distributive (septic, anaphylactic, neurogenic)

Presentation - tachycardia, tachypnoea, hypotension, cold clammy skin, confusion, anxiety, low urine output, cyanosis, LOC

Management - DRSABCD, volume resus, vasopressors, rectify cause

111
Q

What are some causes of sudden cardiac death?

A

Coronary heart disease

Congenital heart conditions

Cardiomyopathy

Valve disease

Arrhythmia - VF, VT, asystole, PEA

Previous MI

Trauma

Drugs

Long QT (greater than half the RR interval) - thiazide, macrolides, methadone, haloperidol, antihistamines

Cocaine

Aortic dissection

112
Q

What are the types of cardiomyopathy and what is the most common?

A

Dilated

Hypertrophic

Restrictive

Arrhythmogenic

113
Q

What are some of the signs of chronic liver disease?

A

Spider naevi: central arteriole with radiating small vessels, blanches, >2 is abnormal, normally in SVC distribution

Splenomegaly

Jaundice: high bilirubin, sign of decompensation, can have isolated jaundice and high bilirubin (Gilberts, haemolytic disease (haemolysis))

Ascites: abdominal free fluid due to reduced oncotic pressure (low albumin production) and increased portal pressure

Caput Medusa: portal hypertension leading to umbilical anastomoses dilating

Clubbing: increased soft tissue of distal fingers and toes - maybe due to arterial hypoxaemia due to pulmonary AV shunt

Leuconychia: white flecks in the nail bed - due to low albumin or compression of capillary flow

Palmar Erythema: excessive oestrogens altering microvasculature

Dupuytrens Contracture: chronic liver disease (alcohol), manual labour, anti-epileptics, diabetes

Parotidomegaly: associated with alcoholism (fatty infiltrate due to alcohol toxicity and malnutrition)

Gynaecomastia: excessive oestrogen, spironolactone medication (K sparing diuretic)

Bruising: reduced production of clotting factors and platelets (thrombocytopenia)

Coagulopathy: reduced clotting factors, thrombocytopenia

114
Q

What are some of the investigation findings associated with chronic liver disease?

A

LFT

  • Low albumin
  • Raised bilirubin
  • AST > ALT (cirrhosis)

Coagulopathy

  • Prolonged INR (1.2-1.3)
  • Low platelets (<200) - possible portal HTN, folate or B12 deficiency, IPT

Ultrasound

  • Cirrhotic shrunken liver

Fibro-scan

  • Assess liver stiffness (> 13kPa)
115
Q

What is decompensated liver disease?

A

Decompensated alcohol related liver disease occurs when there is a deterioration in liverfunction in a patient with cirrhosis, which presents with jaundice, coagulopathy, ascites, and hepatic encephalopathy.

116
Q

What are some causes of liver failure?

A

Autoimmune hepatitis

Primary biliary cirrhosis (autoimmune, women)

Primary sclerosing cholangitis (associated with IBD)

Haemochromatosis

Wilsons Disease - excess copper deposition in liver

NASH

Budd-chiari - hepatic venous outflow obstruction

HCC (hep B)

117
Q

What are the key functions of the liver?

A

Synthesis of clotting factors (not factor 8 - produced in liver sinusoidal cells and endothelial cells outside of liver and circulates bound to Von Willebrand factor until an injury occurs)

Glucose homeostasis - gluconeogenesis, glycogen storage

Albumin synthesis

Conjugation and clearance of bilirubin

Ammonia metabolism and urea cycle

Drug metabolism and clearance

Immune - dealing with gut bacteria and products

118
Q

What things increase the risk of breast cancer?

A

Early menarche

Late menopause

Nulliparus

No breastfeeding

Obesity

Genetics

119
Q

What are the fertility issues with breast cancer treatment?

A

Premature ovarian failure or amenorrhoea with chemotherapy - need to consider fertility preservation

120
Q

What endocrine therapy is available for breast cancer?

A

Tamoxifen (PR, ER)

Herceptin (HER2+ve)

121
Q

What are the issues with surgical management of breast cancer?

A

Breast conservation surgery - risk of incomplete clearance

Consider double mastectomy and prophylactic oopherectomy

Lymph node clearance leading to lymphedema - chronic pain and loss of function

122
Q

What are the types of anaemia and their causes?

A

Microcytic (<80 MCV)

  • Thalassemia
  • Anaemia of chronic disease
  • Iron deficiency (NSAIDs, stomach ulcer, colitis, piles, bowel cancer, menorrhagia, veganism, pregnancy, low iron diet)
  • Lead poisoning
  • Sideroblastic

Normocytic (80-100 MCV)

  • Acute blood loss
  • Bone marrow failure
  • Chronic disease (malignancy, rheumatological, coeliac)
  • Destruction - haemolysis
  • EPO low (chronic renal failure)

Macrocytic (>100 MCV)

  • B12/Folate low
  • Alcoholism
  • Liver failure
  • Drugs (phenytoin)
  • Hypothyroid
  • Aplastic (radiation, benzenes)
  • Increased
  • Reticulocytes
123
Q

What is the pathology of pagets disease?

A

Disease that causes bones to grow too large and weak – usually in spine, pelvis, skull or leg - abnormal osteoclast activation

124
Q

What is the pathology of avascular necrosis?

A

Cellular death of components of bone due to impaired blood supply – usually occurs at epiphysis of long bones, femoral head, femoral condyles, humeral head, scaphoid, talus

125
Q

What is the pathology of osteomyelitis?

A

Infection of the bone/bone marrow usually via bacterial access to blood - Pyogenic bacteria most common

Can be isolated bacteraemia or associated with systemic sepsis

126
Q

What is the pathology of septic arthritis?

A

Infection of a joint

  • Staph aureus
  • Strep pyogenes
  • Haemophilus influenzae
  • Knee most common site
127
Q

What is the pathology of a lipoma?

A

Benign tumour composed of adipose tissue – most commonly occurring on trunk or proximal limbs

128
Q

What is the pathology of an osteosarcoma?

A

Malignant mesenchymal tumour in which the tumour cells produce bone

129
Q

What are some non-infective causes of fever?

A

Tumour - lymphoma, RCC, hepatoma, metastatic malignancy

Drugs (beta lactams, sulfonamides, quinidine, hydralazine, allopurinol, bleomycin, phenytoin, barbiturates)

Vasculitis (temporal arteritis)

SLE

Rheumatic fever

Sarcoidosis

IBS

Thromboembolic disease

Hyperthyroidism

Gout

Febrile neutropenia - chemotherapy, immunosuppression

130
Q

What are the causes of post op fever?

A

Wind

  • Pneumonia
  • PE (day 5 post op)
  • Atelectasis (early)
    • More common in upper abdo surgery where breathing is more difficult due to pain
    • Treatment - chest physio, antibiotics, CXR

Water

  • UTI
  • Catheter
  • Alcohol withdrawal

Walking

  • DVT
  • Acute gout

Wonder Drugs

  • Antimicrobials
  • Heparin

Wound

  • Sutures
  • Cannula
  • Injection sites
  • Pressure ulcers
131
Q

What are the main causes of lower urinary tract symptoms in men?

A

E.coli, klebsiella, proteus, providencia

IDC

Retention

Vesicouterine reflux

Renal tract obstruction - BPH, stones, stricture

Previous UTI

>50

Instrumentation of renal tract

132
Q

What are the main causes of lower urinary tract symptoms in women?

A

E.coli, staph saphrophyticus

Intercourse

Poor hygiene

Vesicouterine reflux

Recurrent UTI

Catheter

Retention

Spermicide use

Family history

Foreign body - stone, stitch

Post menopausal urogenital atrophy

133
Q

What is the pathophysiology of BPH?

A

Hyperplasia of epithelial and stromal prostatic components, increased stromal : epithelial ratio. Over time can get bladder outlet obstruction. Increased epithelial tissue mostly in transition zone

134
Q

What are the risk factors for BPH and what is the typical presentation?

A

Risks - age, family history

Symptoms - urinary retention, hesitancy, dribbling, weak stream, straining, intermittency

135
Q

What is the treatment available for BPH?

A

5-alpha reductase inhibitor (reduce prostate growth)

Alpha blockers (reduce smooth muscle tone)

TURP

136
Q

What is the difference between painful and painless urinary retention?

A

Acute urinary retention is usually painful and chronic urinary retention is often painless

Acute urinary retention generally presents as inability to pass urine and is typically associated with lower abdominal and or suprapubic discomfort

Chronic retention - bilateral hydronephrosis, bloating, overflow incontinence (first notice bed wetting)

137
Q

What conditions can lead to osteoporosis?

A

Thyrotoxicosis

Primary hyperparathyroidism

Chronic liver or kidney disease

Hypercalciuria

Rheumatoid arthritis

Diabetes

Multiple myeloma

HIV

Mastocytosis

Immunosuppression

Osteogenesis imperfecta

138
Q

What are some risk factors for osteoporosis?

A

Low exercise

Smoking

Poor nutrition - calcium/vitamin D deficiency

Prolonged amenorrhea

Post menopausal <50

Excessive alcohol use (> 2 units daily)

BMI <20 or obesity

139
Q

How is vitamin D deficiency related to osteoporosis?

A

Low vitamin D means there is no aid to absorb calcium, reduced calcium means that bone must be resorbed (osteoclasts) to maintain the extracellular calcium level

140
Q

How are osteopaenia and osteoporosis diagnosed via bone density scanning?

A

Osteopenia - low bone density, DXA T-score 1-2.5

Osteoporosis - DXA T-score < 2.5 due to reduced number of normally mineralised bone trabeculae

141
Q

What is osteomalacia?

A

Defective bone mineralisation and fragility due to insufficient dietary calcium, vitamin D deficiency or resistance or due to increased renal loss of phosphate, DXA score can be in osteopenia or osteoporosis range (rickets in kids - wide ankles and wrists, short stature and bowed legs)

142
Q

What are some preventative strategies for osteoporosis?

A

Weight bearing exercise

Diet rich in calcium and vitamin D

Weight loss

Smoking cessation

143
Q

What are the therapeutic options for osteoporosis?

A

HRT: block osteoclast activation

Raloxifene (women only): agonist at oestrogen receptors in bone and CVS

Bisphosphonates - alendronate, risedronate, zoledronate: inhibit osteoclast formation and initiate osteoclast apoptosis, may cause jaw necrosis

Teriparatide: stimulates osteoblasts (PTH)

Denosumab: bind RANKL to prevent osteoclast action

Strontium: inhibit osteoclast formation and boost osteoblast activity, increase

144
Q

What are some differentials for a patient presenting with haemoptysis, cough and SOB?

A

Lung cancer

PE

Pneumonia

TB

Bronchiectasis

Trauma

145
Q

What are the respiratory causes of clubbing?

A

Idiopathic pulmonary fibrosis

Lung cancer

Bronchiectasis

Empyema

Cystic fibrosis

146
Q

What is the prevalence of lung cancers (most to least common)?

A

Adenocarcinoma

Squamous cell

Large cell

Small cell

147
Q

What is the typical presentation of lung cancer?

A

Cough

Change in voice

SOB

Haemoptysis

Chest Pain

Metastatic symptoms - bone pain, headaches

Lethargy

Weakness

Low weight and appetite

148
Q

Why would there be a normal lactate in testicular tosion?

A

Strangulation or incarceration would cause lactate to be released - indicative of ischaemia - but due to blood supply being cut off, this is not released into the general circulation and is not picked up on routine testing

149
Q

Where does a spigellian hernia occur?

A

Occurs at the lateral edge of rectus abdominus at arcuate line

150
Q

What is the management for diverticulosis?

A

If recurrent episodes of diverticulitis and repeated administration of antibiotics, need to consider bowel resection or hartmanns to prevent recurrence of infection and irritation

151
Q

What is COPD?

A

Irreversible airway inflammation and disruption of airflow

152
Q

What are the risk factors for COPD?

A

Male

Indigenous

Smoking (active and passive)

Air pollution

Alpha-1 antitrypsin deficiency

Bronchial hyperresponsivness

Recurrent RTIs

153
Q

What is the pathogenesis of COPD?

A

Noxious agents lead to airway inflammation, loss of elasticity and remodelling

Neutrophils, macrophages and CD8T cells cause an imbalance of proteinases - causing further lung damage

154
Q

What is the pharmacologic management for COPD?

A

Smoking cessation: nicotine replacement, bupropion (antidepressant), varenicline (nicotinic receptor partial agonist)

Beta-2 agonists (SABA - salbutamol, LABA - salmeterol), SE: tremor, tachycardia

Anticholinergics: tiotropium, ipratropium (LAMA), SE: dry mouth

Inhaled corticosteroids: fluticasone

Influenza (annually) and pneumococcal (5 yearly) vaccines

155
Q

What is the non-pharmacologic management for COPD?

A

Stop smoking: advice, willpower, counselling, courses

Pulmonary rehabilitation

Home oxygen therapy - 2-4L/min for 16hrs/day

Portable oxygen

156
Q

What are the types of refractive error and what are they?

A

Myopia - short sighted, light focuses before the retina, cannot see things distant

Hyperopia - long sighted, light focuses behind the retina, cannot see things close up

Astigmatism - visual acuity lessened, football shaped cornea

Presbyopia - age 40, focal point of light starts to move behind the retina, need to hold things further away to focus on them, age related due to lack of flexibility of the lens

157
Q

What is primary open angle glaucoma?

A

Progressive creeping peripheral visual field loss (central loss comes late), elevated intraocular pressure and extreme pain when acute.

Caused by neurodegenerative damage due to blochage of aqueous humour in the anterior chamber

158
Q

What are the types of diabetic retinopathy?

A

Non-proliferative: aren’t new vessels, mild, moderate and severe types, intra retinal and superficial bleeds (microaneurysms), exudative serous material leaking into macular region, can have intraocular injections to settle

Proliferative: new vessels forming, haemorrhage, treat with pan retinal photocoagulation - demand on the blood vessels is reduced to protect the retina

159
Q

What is the likely pathology if a patient complains of fence posts bending in their vision?

A

Macular degeneration (process is metamorphopsia)

160
Q

What are the types of macular degeneration?

A

Dry

Slowly progressing, little yellow spots in the retina (drusen) - waste material that collect under the retina (pigment epithelium not getting rid of waste material - early and intermediate MD) - drusen cause a bump in the retina causing a disruption in images, NO treatment (diet high in antioxidants is only recommendation for waste clearance)

Wet

Bleeding into the retinal tissue due to breakdown of barrier and blood vessels growing into the retina, treatable via injections of anti VEGF drugs (repetitive - every 4,6 or 8 weeks - intraocular injection for life), rapidly progressive

161
Q

What is this pathology?

A

3rd cranial nerve palsy

Diplopia

Eyes turned down and out with ptosis

162
Q

What is this pathology?

A

4th cranial nerve palsy

Eye raised and head tilt to try to overcome palsy

163
Q

What is this pathology?

A

6th cranial nerve palsy

Cannot turn eye out when trying to look in that direction

Lateral rectus impaired

164
Q

What are the features of a glioma?

A

Tumour arising from brain parenchyma

50% malignant astrocytomas

Signs - headache, visual loss, pain, weakness, numbness

165
Q

What are the features of a meningioma?

A

Most common benign brain tumour

May cause no symptoms as there is no infiltration of brain tissue

Presentation - raised ICP, seizures, diplopoa

Radiation only known risk factor

166
Q

What are the features of a pituitary adenoma?

A

Pituitary gland tumour causing bitemporal hemianopia (loss of vision on lateral sides of each eye)

May secrete hormones

Treat with hypophysectomy

167
Q

What is parkinsons?

A

Loss of dopaminergic neurons in the substantia niagra in the basal ganglia and lewy bodies throughout the cortex causing a progressive decline in motor function

168
Q

What is the presentation of parkinsons?

A

(usually asymmetrical to start with)

Resting tremor (4-6Hz)

Rigidity

Slow onset of anosmia

Bradykinesia

Postural instability

Hypophonia

Dysphagia

Stooped posture

Pedestal turning

Depression

Expressionless face

Dementia

Constipation

Fatigue

Shuffling gait

Micrographia

169
Q

What is the treatment for parkinsons?

A

Levodopa/ carbidopa (prevents levodopa conversion outside brain - reduce emesis)

Bromocriptine (dopamine agonist)

Cabergoline (dopamine agonist)

Selegilline (MAO-B inhibitor, prevent dopamine reuptake)

Deep brain stimulation

170
Q

What is primary angiitis and what is the presentation and differentials?

A

Vasculitis confined to the CNS

Presentation - prodrom, headache, cognitive impairment, stroke, seizures, TIA

Differentials - stroke, SLE, SAH, infection, systemic vasculitis

171
Q

What are the red flags for headache?

A

Systemic illness

Neurologic signs

Onset sudden

Over 40-50

Prior headaches different

172
Q

What movement is not possible with a median nerve dysfunction?

A

Thumb abduction

173
Q

Why will a collateral ulnar ligament injury not heal without surgery?

A

Won’t heal with splintage due to adductor aponeurosis overlying - which in injury ends up being under the ligament, so the ligament cannot heal back to normal position

174
Q

What is a lung abscess and what are the risk factors?

A

Circumscribed collection of pus in the lung leading to cavity formation and air filled level of CXR

Risks -

Aspiration of gastric contents

Elderly

Reflux

Immunosuppression

Bronchial obstruction

Alcoholism

Malnourished

Klebsiella, pseudomonas

Most common in right lower lobe

Pre-existing lung damage - at risk of aspergillus

175
Q

What is the presentation for lung abscess and how should it be investigated?

A

Fever, productive cough (putrid)

CXR - see cavitation with air fluid level

176
Q

What is the treatment for a lung abscess?

A

Antimicrobials

Drainage

177
Q

What are the common causes of community acquired pneumonia?

A

Strep pneumonia

Mycoplasma pneumoniae

Chlamydia

Legionella

Influenza

Adenovirus

Rhinovirus

178
Q

What is the presentation of pneumonia?

A

Fever

Chills

Cough

Sputum

Dyspnoea

Myalgia

Arthralgia

Pleuritic pain

179
Q

What is the treatment for community acquired penumonia?

A

Empirical Antibiotics

Macrolide – azithromycin/clarithromycin

Fluoroquinolone

Amoxicillin

Doxycycline

Oxygen

180
Q

What are the main causes of hospital acquired pneumonia?

A

Gram negative bacilli – pseudomonas aeruginosa, E.coli, klebsiella, acinetobacter

181
Q

What is the treatment for hospital acquired penumonia?

A

Penicillin

Macrolide

Doxycycline

182
Q

What causes a pleural effusion and how does a patient present?

A

Causes

  • Congestive heart failure
  • Infection – pneumonia (gram positive most common)
  • Malignancy
  • Post surgery

Symptoms

  • SOB
  • Cough
  • Pleuritic chest pain
  • Fever and chills
  • Tachypnoea
183
Q

What is the treatment for a pleural effusion?

A

Chest physio

Fluid drainage (chest catheter)

Antibiotics

Diuretics

Cancer treatment

184
Q

What is idiopathic fibrosis, causes, symptoms, investigations and management?

A

Fibrotic lung disease with no known cause that progresses over years - characterised by scar tissue formation within the lungs

Causes

  • Cigarette smoking
  • Environmental exposure

Presentation - SOB, cough

Investigations

  • X-ray
  • Spirometry (restrictive - low FVC, normal FEV1)

Management

  • Lifestyle - smoking cessation
  • Supplemental oxygen
  • Antifibrotics (pirfenidone, nintedanib)
  • Pulmonary rehab
  • Lung transplant
185
Q

What is bronchiectasis, causes, symptoms, investigations and management?

A

Chronic infection in small airways resulting in the lungs becoming damaged, scarred and dilated

Causes: Chronic airway infection (usually bacterial) – immune response results in chronic inflammation, pneumonia, COPD, smoking

Symptoms

  • Productive cough
  • Mucopurluent sputum
  • Recurrent infections
  • Fatigue
  • Nasal inflammation

Investigations - sputum sample, CXR, CT (widening of airways)

Management - chest physio, inhaled bronchodilator, inhaled hyperosmolar agent, long term oral macrolide, inhaled antibiotic, lung transplant, ventilation (oxygen)

186
Q

What is ARDS, causes, symptoms, investigations and management?

A

Acute respiratory distress syndrome – widespread inflammation in the lungs

Causes: pneumonia, sepsis, aspiration, trauma, smoke inhalation

Symptoms - SOB, hypoxia

Diagnosis: acute onset, bilateral CXR opacity, hypoxaemia, widespread consolidation

Management - low tidal volume plateau pressure limited mechanical ventilation

187
Q

How do you get a malignant mesothelioma?

A

Asbestos - recurrent effusions, shrinking lung, 100% mortality

188
Q

How does an appendectomy cause a hernia?

A

Damage to the iliohypogastric nerve at McBurnies point- damaging inguinal muscles resulting in lack of nerve supply to internal oblique and transversus abdominus muscles - resulting in weakness of anterior abdominal wall and risk of direct inguinal hernia

Surgery MD2 (2 decks)

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