Misc Flashcards
Causes of Cushing’s syndrome
High ACTH = Pituitary adenoma (Cushing’s disease) OR Ectopic ACTH
Low ACTH = adenoma of adrenal cortex; carcinoma of adrenal cortex; iatrogenic
Cushing’s syndrome Ix
- Preliminary: overnight dexamethosone suppression test OR 24 hour urinary free cortisol
- Confirmation: 48 hour dexamethasone suppression test
- Localise lesion: Plasma ACTH + high dose dexamethasone (Cushing’s disease shows response) + imaging (CT chest and adrenals or MRI pituitary)
Claudication with normal pulses
- Neurogenic
- Anaemia
- B-blockers
Critical limb ischaemia O/E
6 Ps Pain Pallor Pulseless Perishingly cold Paraesthesia Paralysis (best indicator of danger to limb)
ABPI measurements
> 1 normal
0.5-1 intermittent claudication
0.3-0.5 rest pain/critical limb ischaemia
<0.3 gangrene + ulceration
Leriche’s syndrome
bilateral buttock pain and erectile impotence due to common iliac disease
A red foot!
May have chronic arterial disease with pooling, feel temperature and raise leg to see if fast exsanguination (means it is chronic)
Venous ulcer features
Site = Medial gaiter region of leg Sloped edges Lots of exudate Usually associated with limb oedema Extra features of venous insufficiency
Extra features of venous insufficiency
Varicose veins
DVT
Venous eczema
Haemosiderosis (cayenne pepper petechiae)
Lipodermatosclerosis (scarring of subcutaneous fat)
Atrophie blanche (angular scarring after injury)
Inverted champagne bottle leg
Arterial ulcer feature
Site = Feet/toes/ankle
Punched out edges
Painful
with trophic changes and gangrene
Venous ulcer Rx
Graduated compression dressing
Antibiotics for any infection
Arterial ulcer Rx
Conservative Endovascular revascularisation (angioplasty) Surgical revascularisation eg fem-pop bypass, fem-distal bypass etc
Trendelenburg Tourniquet test
Raise leg vertical (if no pain) and empty varicose veins; once empty place tourniquet on upper thigh, ask to stand and see whether veins refill:
If doesn’t fill then sapheno-femoral incompetence
If fills slowly then mix of sapheno-femoral incompetence and perforating veins (that bridge deep and superficial) incompetence
NB can also have sapheno-popliteal incompetence which typically affect short saphenous vein
Sapheno-femoral incompetence test
Place finger at SFJ (2cm infero-lateral to pubic tubercle) and get patient to cough, if can feel then positive
Varicose veins warm and tender
= superificial phlebitis
Varicose veins Rx
Conservative = elastic support hose; weight loss; regular exercise
Injection sclerotherapy = suitable for small varices from perforating veins (not for SFJ incompetence)
Surgery = SFJ ligated or Long saphenous vein stripped; for sapheno-popliteal can ligate the junction (do not strip short saphenous vein as can damage sural nerve)
Post-thrombotic syndrome
Chronic venous insufficiency secondary to DVT
Intradermal lump (impossible to slide skin over)
Sebaceous cyst (punctum)
Abscess
Dermoid cyst
Granuloma
Subcutaneous lumps (skin can slide over)
Lipoma (smooth and fluctuant)
Ganglion (moves with tendon)
Neurofibroma
Lymph node
Neurofibromatosis Type 1 (AD)
aka von Recklinghausen's disease: CATCHES Cafe au lait (>6) Axillary freckling Tumours of nervous system Cutaneous neurofibromata HTN Eye features (lisch nodules) Scoliosis
Neurofibromatosis Type 2 (AD)
Bilateral acoustic neuromas (key)
Other tumours of nervous system
Fewer cutaneous features
Sloping edge
Venous ulcer
Punched out edge
Arterial ulcer
Undetermined edge
TB, pressure necrosis
Rolling edge
BCC
Everted edge
SCC
Erythema nodosum DDx
Painful, purple raised lesion on shins Idiopathic Sarcoidosis Infection (strep, TB) IBD Drugs (Sulphonamides) Malignancy (lymphoma, leukaemia) Pregnancy
Melanoma
ABCDE Asymmetry of shape Border irregular Colour variation Diameter >6mm or increasing Elevation
Hernia
Protusion of whole or part of viscus through an opening in the wall of its containing cavity into a place where it is not normally found
Direct inguinal hernia
Through weak point in posterior wall of inguinal canal (Hesselbach’s triangle)
Indirect inguinal hernia
Through internal inguinal ring down inguinal canal and out of external inguinal ring
Femoral vs inguinal
Femoral inferior to pubic tubercle and usually not reducible as usually incarcerated with high likelihood to strangulate; direct moderate risk of incarceration and indirect = low risk
Femoral needs urgent surgery
Borders of Hesselbach’s triangle
Inferior epigastric artery
Inguinal ligament
Linea semilunaris (lateral border of rectus muscle)
Within = direct hernia (so inferior to inferior epigastric artery)
Hernia Repair
Open mesh repair Open suture repair Laparoscopic: 1. Total extraperitoneal procedure (TEP) 2. Trans-abdominal procedure (TAP)
Richter’s hernia
Only part of bowel herniates meaning strangulation can occur without obstruction. More common in femoral hernia
Deep ring
Opens at midpoint of inguinal ligament into transversalis fascia
Superficial ring
In aponeurosis of external oblique superior to pubic tubercle
Inguinal canal
Roof = internal oblique
Floor = inguinal ligament
Back wall = transversalis fascia
Front wall = external oblique
Mid-inguinal point
Midpoint of ASIS and pubic symphysis
Where femoral artery crosses
Midpoint of inguinal ligament
MIdpoint of ASIS and pubic tubercle
Pulsation in neck lump
Carotid body tumour
Neck cysts (transilluminate)
Thyroglossal, branchial, cystic hygroma
Pembreton’s test
Raise hands slowly and watch for facial plethora (venous compression, SVCO) and ask to take a deep breath in to see if stridor (tracheal compression)
Classic Grave’s features
Goitre Specific to Graves: Exopthalmos Ophthalmaplegia Pretibial myxoedema Thyroid acropathy
Signs of active disease
AF
Tremor
Lid lag
Thyroid bruit
End colostomy
Usually left with 1 lumen, doesn’t spout and hard stool
Can be from Abdomino-peroneal (AP) resection for low rectal tumour (no back passage) or Hartmann’s procedure for higher tumour (have back passage)
End ileostomy
Usually right, 1 lumen, spouting and soft/liquid stool
For UC or FAP, panproctocolectomy
Loop ileostomy (temporary stoma)
Usually right, 2 lumens, spout and soft/liquid stool
To defunction obstruction or anus is bad Crohn’s
Loop colostomy (temporary stoma)
Upper abdomen, 2 lumens, not spouting and hard stool
Stoma complications
Haemorrhage Necrosis Prolapse Retraction Obstruction Parastoma hernia High output
Spigelian hernia
Through semilunaris at upper border of rectus sheath
High risk of incarceration so always repaired
Epigastric hernia
Through linea alba at epigastric region
True umbilical herna (congenital)
In neonates
Through umbilicus and usually resolves in early life
Paraumbilical hernia (acquired)
Through linea alba usually above umbilicus, often irreducible and always repaired as high chance of incarceration
Surgical emphysema on X-Ray of anterior chest wall
If the anterior chest wall is affected air can outline the pectoralis major muscle, giving rise to the ‘ginkgo leaf’ sign
Goodsall’s rule
States that if the perianal skin opening is posterior to the transverse anal line, the fistulous tract will open into the anal canal in the midline posteriorly, sometimes taking a curvilinear course.
A perianal skin opening anterior to the transverse anal line is usually associated with a radial fistulous tract
Rule not applicable to fistulas >2.5cm from anal verge
Haemorrhoids seen at
3, 7 and 11 o’clock
Proctitis causes
Crohn’s, UC and C. diff
Anal fissure seen at
Location: midline 6 (posterior midline 90%) & 12 o’clock position. Distal to the dentate line
Chronic fissure > 6/52: triad: Ulcer, sentinel pile, enlarged anal papillae
Dentate (pectinate) line significance
Divides upper 2/3 (columnar) and lower 1/3 (squamous) of anus which distinguishes:
[] iliac and superficial inguinal lymph drainage
[] superior and middle + inferior rectal arteries
[] internal and external haemorrhoids (makes sense if you think about arteries)
Medication for PAD
naftidrofuryl oxalate OR cilostazol
Remember to prescribe clopidogrel (1st line now) and statin
Cavernous sinus syndrome
Most commonly caused by cavernous sinus tumours (like nasopharyngeal).
Diagnosis is based on signs of pain, opthalmoplegia, proptosis, trigeminal nerve lesion (opthalmic branch) and Horner’s syndrome.
Co-presciption with goserelin for prostate cancer
Cyproterone acetate as this avoids the flare up of prostate symptoms
Homonymous quadrantanopias
PITS:
Parietal=Inferior
Temporal=Superior
Left pathology ==> right sided lesion and vice versa
In practice though most homonymous quadrantanopias are caused by occipital lesions
Bitemporal hemianopia
upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
Tumour markers: S-100
Melanoma
Schwannoma
Tumour markers: bombesin
Small Cell lung cancer
gastric cancer
neuroblastoma
Gingival hyperplasia causes
phenytoin, ciclosporin, calcium channel blockers and AML
