Misc 5 Flashcards
What is a breast fibroadenoma?
Proliferation of epithelium and stromal tissue of duct lobules
Round/oval well defined, rubbery mobile less than 5cm
Where are fibroadenomas commonly found?
Upper outer
Bilateral/multiepl
Outline breast triple assessment?
Physical exam
Imaging - USS for patients under 35-40 or male, mammography for older
Tissue = FNA/core
What imaging is suitable for women of different ages investigating breast Ca?
US for under 35-40 as denser breast tissue
Mammogrphy for older women
What gradings are the components of the triple assessment for breast given?
1-5 where 1 is normal/insufficient, 2 is benign, 3 is uncertain, 4 is suspcious and 5 is malginant
Give 2 examples of biphasic breast lesions? Differences between them?
Phylloides tumour
Fibroadenoma
Phylloides usually larger, present later in life and grow rapidly
Management of phylloides tumour?
Depends on behaviour, from WLE to mastectomy
What are breast cysts?
Fluid filled inverted lobules presenting in peri-menopausal females - smooth discrete painful lumps
Management of breast cysts?
Confirm diagnosis with mammography/USS
Can aspirate if persistent; if aspirate blood stained or lesion persistent then needs triple assessment
Different types of mastalgia?
Cylical - usually both breasts
Non cyclical - may be medications e.g. contraceptives, antidepressants or antipsychotics
Extarmmary - chest wall/shoulder
What is ‘true mastalgia’ and what causes it?
Exaggerated response of breast tissue to hormaonl changes during menstrual cycle causing enlrgement, pain and nodularity
Management f cylclical mastalgia?
Reassurance, pain relief
Soft/support or well fitting bra
Specialists options include danazol
What is an abscess?
Colelction of pus surrounded by granulation/fibrous tissue
How can breast abscesses be divided?
Lactational or non-lactational
Common bacteria in lactational abscesses?
S aureus, epidermidis
Strep species
Management of lactational abscesses?
Refer to gen surgery for US, drainage of abscess and fluid culture
Continue breast feeding if poss or express if not
What is a common type of non-lactational mastitis and what are its features? Who does it occur in?
Peri-ductal mastitis
Painful, red, tender with nipple retration lump and discharge
Can form abscesses
Occurs in young female smokers
What is Mondor’s disease? Management?
Sclerosing thrombophlebitis of superficial veins of breast and chest wall
Conservative management with NSAIDs
Give 7 causes of nipple discharge?
Physiological Cancer Duct ectasia - creamy +/- bloodstained Intra-ductal papilloma Epithelial hyperplasia Galactorrhoea - bilateral milk production Gestational
Features of duct ectasia? Management?
Involutional change in perimenopausal women causing shortening and dilatation of subareolar ducts
Can have discharge, nipple retraction or mass
Discharge can be creamy or bloodstained
Management requires duct excision to exclude malignancy
Features of intraductal papilloma? Is there an increase risk of cancer?
Serous or bloodstained discharge plus or minus palpable lump
Yes if multi-ductal
Features of epithelial hyperplasia? Is there an increased risk of cancer?
Increase in number of epithelial cells lining terminal ducto-lobular units
Bloody nipplie discharge
May be increased risk if widespread
Differentials for haematuria and difficulty passing urine from prox to distal?
Kidneyts - cancer, pyelonephritis
Ureter - calculus, tumour
Bladder - cancer, calculus, cystitis
Urethra - stricture
Why can difficulty passing urine occur in bladder cancer?
2 reasons - clot retention if bleeds heavily
Or cancer itself obstructs passage into urethra - less likely
Describe how to do bladder washout and irrigation?
Pass a 3 way catheter
Instill 50ml boluses to disperse any large clots and suction out, monitoring in/output
Attach irrigation and monitor volume
Most common type of bladder cancer in western world?
Transitional cell
4 RFs for transitional cell bladder cancer?
Smkoing
Males
Dyes e.g. hairdresseers
Ruber.leather
Most common type of bladder cancer in developing world? Why?
Squamous cell - due to schistosoma haematobium causing chronic inflalmmation
2 most common causes of squamous cell bladder cancer in western world?
Bladder calculi
Indewlling catheters
Due to chronic inflammation and metaplsai
Gold standard investigations for visible haematuria? Alternatives?
Flexible cystoscopy with biopsy
Ct urogram or US if poor renal function
MRI / staging CT to look for local invasion or metastasis
Surgical options for bladder cancer?
If early - transurethral resection with resectoscope
Radical cystectyom for muscle invasive cancer
What does a radical cystectomy entail in men?
Removal of bladder, lymph nodes, uretrha, seminal vesicles, prostate and part of vas
What does a radical cystectomy entail in women?
Removal of bladder, lymph nodes, urethra, cervix, uterus, fallopian tubes +/- ovary and vagina
Reconstruction post radical cystectomy?
Urinary diversion - incontinent e.g. ileal conduit into urostomy bag
- continent e.g. kock, indian or mitrofanoff pouch
Treatments to prevent recurrence of bladder cancer?
Intravesical chemo - mitomycin C
BCG immunotherapy
RFs for thyroid cancer?
Female Radiation in early years Family history or cancer syndrome Obseity Goitre or thyroiditis Acromegaly
Discuss utility of US in thyroid nodules?
Numeber, size and location - useful for interval scanning
Sonographic features - solid appearance, absence of halo, microcalcification, vascularity and irregular margins = cancer
Look for lymph nodes
3 indications for removal of nodular goitre?
?cancer
Pressure symptoms e.g. stridor, venous obstruction, dysphagia
Hyperthyroidism refractory to medical treatment
Usual causes of primary hyper PTH?
Usually adenoma
Sometimes hyperplasia or carcinoma
Differentiating from secondary and tertiary hyperPTH?
Secondary = low calcium due to renal disease or malabsoprtion - high PTH due to neg feedback Tertiary = autonomous hyperplastic parathyroids in patients with secondary PTH resulting in profound hyperCa
Causes of hypoPTH?
Post thyroidectomy - iartrogenic Autommune such as Addionsis, percinious anaemai Post radiotherapy Low Mg DiGoerge
What happens to aldosterone and renin in secondary hyperaldosternoism? Causes?
Both high
E.g. renal vascular disease, renin secreting tumours or liver cirrhosis
Which cells secrete PTH?
Chief cells
Mechanism of secondary hyperPTH?
Renal failure - less conversion of 25-1,25 hydroxyvit D in kidneys, so reduced uptake of Ca from GI tract, reduced release from bone and inreased renal excretion
Results in hypocalcaemia and hyper PTH due to neg feedback
2 main uses of frozen section in surgery?
Guide if lesions malignant or benign
Guide if resction margins clear
Which 2 cells are seen in normal parathyroid tissue?
Chief
Oxyphil
Indications cor anaesthetic rv in burns?
Hx of fire in enclosed space Soot around nostrils, in nose or mouth or singeing of nasal hairs Carbonaceous sputum Hoarseness Stridor/wheeze Drooling COHb over 10%
Differentiation of burn thickness?
Superficial = epidermis only
Partial thickness = superficial (epidermis and upper dermis) and deep (epidermis and whole dermis but not underlying tissue) dermal burns
Full thcikness= through epidermis, dermis and into subcutaenous tissue
Features of spuerficial dermal burns?
Pinks skin that blanches with slow cap refill
Painful
Feels normal to touch
Often moist with blisters
3 ways of estimating burns surface area?
Wallace’s rule of 9 - head, arm = 9 each, torso front and back = 18 each, leg = 18 each, genitals 1%
Lund and Browder charts
Patients hand = 1%
Indications for fluid replacement in burns?
Over 15% TBSA in any thickness, or 10% in children give 4xBWxTBSA
ATLS states over 20% in deep partial or full thickness give 2xBWxTBSA (so half)
Doesn’t include maintenance
Indications for referrral to speicalist burns unit?
Over 5% in children or 10% in adults Under 5 or over 60 year old High pressure steam, electricity or chemical Circumferential burns Inhalation injuries Serious comorbidity NAI suspected
Mount Vernon formula?
Used to caclulate burn fluid resus - weight x % divided by 2, given 6 times over 36 hours
Features of epidermal burns?
e.g. sunburn, red, painflu, doesnt blister, dry, blanches and refils
Features of deep derpmal burns?
red, blotchy mottled skin that doesnt blanch. may be blistersed but less painful than superficial dermal
Features of full thickness burns?
leathery charred skin, pale non blanching
Painless
What is sedation?
Alteration in consciousness +/- analgesia +/- decreased anxiety
Difference between light, deep and GA sedation?
Light = conscious - own airway with intact reflex mechanism, response to stimuli, anxiolytic Deep = airway may need support, repeated painful stimuli for response GA = unrousable, airway unprotected
Contraindications to sedation?
Neuromuscular insufficiency Clinically unstable Long lasting procedure Not appropirately starved Lack of approrpirate monitoring Patient refusal
Describe how to sedate e.g. for shoulder relocation?
Move to resus with monitoring - 3 lead ECG, sats, BP, HR
Appropriately trained staff
Good IV access
ACcess to reversal agents
Multidrug approach e.g. morhpine, midaz, NO2
Describe how morphine and midaz might be used for sedation?
Morphine 0.1mg/kg IV for loading
Midaz 1-2mg per dose IV
5 discharge criteria from ED following proceduarl sedation?
Normal obs Normal mental status Managing PO intake Pain controlled Someone at home to supervise
4 SIRS criteria?
pulse over 90 RR over 20 or low PACO2 WCC over 12 or under 4 temp over 38 or udner 36 Need 2 or more
Clinical features of nec fasc?
POOP Possble skin break Swelling, disolouration Blister formation with dark fluid and necrosis Subctaneous oedema and crepituus Systemic symptoms
4 types of nec fasc?
1 - polymicrobial e.g. s aureus, haemophilus, pseudomanos and coliforms
2 - monomicrobial - GAS e.g. pyogenes, MRSA
3 - monomicrobial e.g. clostridium
4 - fungal e.g. candida
Score system for nec fasc?
LRINEC - Laboratory risk indicator for nec fasc
Ratinoale behind second look surgery e.g. for nec fasc?
Returning to theatre after planned period of time to examine affected regions under GA - often to look for need for further debridement
Differentials for nec fasc of groin?
Groin abscess/cellulitis
Pseudoaneurysm of groin
Simple perianal abscess
Immobilising c spine straight away?
Rigid collar on firm surface, supplemented with blocks and tape
Most common level of c spine fracture?
C5
What is a hangmans fraccutre? Typical mechanism?
Fracture through both pedicles of C2
Usually flexion-extension injury
What si a jefferson fracutre? Typical mechanism?
Burst fracture of C1 with double fractures thorugh ant and post arches
Head on injury with axial loading e.g. diving headfirst into pool
Spinal vs neurogenic shock?
Spinal = flaccid paralysis, arreflexia and sensory loss followign spinal cord trauma Neurogenic = actual shock due to loss of symp tone
What is the bulbocavernosus reflex and why is it used?
S2-4 nerve roots, sphincter contraction following tug on cath/glans squeeze/clitoral pressure. suggests spinal shock if absent with supportive sensorimotor signs
Anaesthetic issues with untreated aortic stenosis?
Limited coronary blood supply as cardiac output fixed, can’t ersponse to decreased afterload that may occur in anaesthesia or blood loss
Also with spinal anaehetsics, drop in BP can’t be compensated for
Coronary perfusion pressure is equal to?
Systemic diastolic arterial pressure - left ventricular end diastolic pressure
Normal coronary axis?
-30 to +90 degrees in frontal plane
Leads 1 and 2 normamlly both positive
Voltage criteria for LVH?
S in V1 plus R in V5/6 over 35mm (7 large suwares)
Mechanism of action of mannitol?
Osmotic diuretic - filtered in glomerulsus but not reabsorbed, so increased osmolality of filtrate nd increased water excretion in urine
How and where do thiazides work?
Proximal part of CT, prevents reabsorption of Na via Na/Cl symporter
How and where do potassium sparing diuretics work? work?
Aldosterone antagonists - distal part of DCT
Prevents activation of Na/K exchange which normally swaps Na in urine for K, preventing concentration of urine
Outline equipment required for chest drain insertion?
Sterile gloves and gown, drapes Local anaesthetic, syringe + needles Scalpel and blade Clips, large haemostat Dissecting scissors Chest tube - 30Fr Silk 1/0 suture Gauze/swabs Underwater drainage system Occlusive dressing
5 indications for chest drain insertion?
Tension pneumo Traumatic pneumo Haemothorax Large secondary pneumo Large spont pneumo not resolved by needle decompression
Inidications for cardiothoracics team in pnuemothorax?
Spontaneous haemothorax
Bilateral pneumo
Second ipsilateral pnuemo
Persistent air leak after a week or failure to re-expand
At risk profrsesionals e.g. driver, pilot
Pneumothorax in pregnancy
Excision margins for excsiion of small skin lesion? How would this change if you suspected SCC? How to site lesion?
2mm
4mm if SCC
Elliptical incision 3:1 lenght:width
Time for suture removal at different sites?
Face = 5 days
Scalp = 7 days
Trunk or limb s= 10-14 days
What kind of dressing might you use for a contaiminated open wound?
Alginate packing/dressing
What features of tissue during wound debridement separates non-viable from viable tissue?
Bleeding
What other prophylactics should patients who have contaminated wound washout and debridement receive?
Antibiotis
Tetanus
4 steps of wound debridement?
Removal of obvious contaminants
Irrigation/washout
Excision of dead or devitalised tissue
Wound management
What is NCEPOD and what are the classifications of surgical timing?
National Confidential Inquiry into Patient Outcome and Death
1 - immediate - resus and intervention for life saving
1a - immediate - resus prior to surgery, limb or organ saving
2 - urgent - wwithin hours
3 - expedited - within days
4 - elective - all else
ASA grades and examples?
1 - fit and well
2 - mild sysetmic disease - well controlled asthma
3 - severe systemic disease well controled e.g. angina
4 - severe systemic disease poorly controlled e.g. advanced COPD, unstable angina
5 - life threatening e.g. multi organ failure
Layers passed through in midline laparotomy?
Skin Campers fascia - subcut fat Scarpas fascia Linea alba Transversalis fascia Extraperitoneal fat Peritoneum
What might a left paramedian incision be used to access?
Spleen
How may wounds be classified?
Mechanism - incised, lacerated, abrasion, de-gloving, burns
Contamination - Clean, Clean contaminated, Contaminated, Dirty
Depth - Superficial deep
What are the contaminated wound types?
Clean e.g. skin lesion excision
Clean contaminated e.g. cholecystectomy with no leak
Contaminated e.g. cholecystectomy with bile leak
Dirty e.g. perforated bowel
Give the 5 absorbable sutures and how long they take to resorb?
Vicryl rapide - 42d Vicryl 56-70d Cat gut 70-90d Monocryl 91-119 d PDS 180-210 d
Appropriate suture for facial closure, superficial?
Ethilon, prolene
Appropriate suture for facial closure, deep tissue?
Vicryl
Appropriate suture for abdominal mass closure?
PDS
Appropriate suture for bowel anastomosis?
Vicryl
Staples
Apprpirate suture for vascular anastomoses?
Prolene
Apprporiate suture for forming a stoma?
Vicryl
Define diathermy?
Use of high frequency electrical current to generate heat to cut or coagulate tissue
Minimum plate size for monopolar?
70 square cms
Define cutting, coagulation, blend and spray?
Cutting - continuous, high heat, cells explode. sinus wave form
Coagulation - square wave form, pulsing current, cells dehydrate
Blend - mix of coag and cutting
Spray - coagulation over wide area
What is rheumatic fever? What type of reaction is it?
Systemic post-GAS pharyngeal infection affecting heart, skin, joints and brain
Type 2 hypersensitivity
What heart problems may follow rheumatic fever?
60% of post carditis patients will have chronic rheumatic heart disease - most commonly mitral or aortic, and usually regurge that may preced stenosis over years
General differentials for infections in post op patients?
Wound Lines Chest Urine Relative to site of surgery e.g. intra abdominal
Criteria for diagnosing infective endocarditis?
Dukes criteria - 2 major, 1 major 3 minor, or 5 minor
What are the major Dukes criteria for IE?
Causative organisns in blood cultures - s viridans, strep bovis, HACEK, s aureus, enterococci
Lesions on endocardium on echo - valve vegeitation, asbcess etc
Criteria for diagnosing rheumatic fever?
Modified Jones
Requires evidence of strep infection and associated post-strep features
Why is IE so hard to treat?
Valves do not receive specific blood supply so neither immune mechanisms nor Abx can reach valves
Are prophylactic antibiotics used to prevent endocarditis?
Not routinely
What is a neoplasm? 3 features
Abnormal growth of tissue displaying uncoordinated growth which exceeds that of normal tissue and continue despite removal of original stumulus
Discuss neoplasms division by cell type?
Unicellular - epithelial, mesenchymal or lymphoma
More than one cell type from one germ layer - pleomorphic adenoma, fibroadenoma
More than one cell type from more than one germ layer - teratoma
Types of epithetlial neoplasa?
Papilloma, adenoma, carcinoma
Types of mesenchymal neoplasia?
Fibroma, lipoma, sarcoma
Differences between benign and mlaignant neoplasia?
Benign = non invasive, no mets, well differentiated, slow growing, normal nuclei, well cicrumscribed with pseudocapsule and rarely necrose
Vs malignant which is invasive through BM, can met, may be poorly differentiated, rapidly growing, abnormal nuclear morophology with irregular border and necrosis common
2 physiological and 2 pathological examples of hyperplasia?
Physiological = breast during puberty, thyroid during pregnancy Pathological = BPH, Adrenals in cushings
2 physiological and 2 pathological examples of hypertrophy?
Physiological = muscle enlargment with exercise, uterus in pregnancy Pathological = LVH/cardiomyopathy, thyroid in graves
What is a hamartoma? examples?
Tumour like malforamation composed of disogranised arrangment of different amounts of tissue normally found at that site, which grows under normal growth controls
E.g. peutz jeghers, haemangiomas, lipoma. bronchial hamartoma, CNS hamartoma, melanocytic naevus
What is metaplasia? 2 pathological examples?
Reversible replacement of one fully developed cell type with another differentiated cell type
E.g. barrets oesophagus - squamous to adeno/columnar epithelium
Trasnformation zone of cervix due to HPV - columnar to squamous epithelium
What is dysplasia?
Disordered cellular development charactersied by increased mitosis and pleomorphism without ability to invade basement membrane or metastasis
Hisotological features of dysplasia?
Increased mitosis
Pleomorphism
Aneuploidy
Hyperchromatism
Mechanisms by which tumours spread?
Haematogoenous Local invasion Lymph Transcoelomic CSF for CNS Iatrogenic e.g. seeding during biopsy
What is a polyp?
Abnormal growth of tissue projecting from a mucous membrane or epithleial surface
Classifications/types of polyps?
Non-neoplastic - metaplastic, hamartomatous, inflammatory pesudeopolyps
Neoplastic - tubular, tubulovillous and villous in order of most to least common
Which type of neoplastic polyp has highest malignant potential?
Villous
Then tubulovillous, then tubular
Complcaitions of GI polyps?
Malgiant transformation Ulceration Bleeding Infection Intussusception Protein or potassium loss
Where are the polyps seen in FAP?
Intestinal
Also duodenal periampullary adenomas, gastric polyps
What syndromes are associated with FAP and additional tumour sites?
Gardner - oestoma (mandible), mesenteric fibroma, thyroid, epidermoid cysts
Turcot - CNS e.g. medulloblastoma
Recommended surveillance for FAP?
Colonoscopy from age 12-14, then every 1-3 years depending on phenotype
Gastroscopy and duodenoscopy at 25
At what age are patients usually offered surgery for FAP?
Around 25
Options of surgery for FAP?
Total colectomy and ileorectal anastamosis, with regular stump surveillance via sigmoid/pouchoscopy
Total panproctocolectomy with end ileostomy or ileoanal pouch
What surveillance is required for FAP post surgery?
UGI endoscopy every 6 months to 4 years
Sigmoid/pouchoscopy every 1-3 years if joined up
Medications decreasing number of polyps in FAP?
Celecoxib
Sulindac
Features of Peutz Jehgers?
Multiple hamartomatous polyps (AD inheritance)
Increased risk of breast, lung, uterus and panc cancer
Pigmentation around lips/perioral skin
Any surgery prophylactically needed in Peutz Jehgers?
No - low malignant potential for intestinal hamartomas
How might colorectal polyps progress to adenocarcinoma in someone without a genetic predispoisiotn?
Acculmulation of genetic defects causing progression from normal cells to dysplasia to malignant cells that can invade through BM
Carcinomas typically spread by which route?
Lymph (exvcept follicular thyroid Ca - blood)
Sarcomas typiaclly spread by which route?
Blood
Define diverticulum?
Abnormal outpouching of a hollow viscus into surrounding tissues
