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MRCS Part B > Misc 7 > Flashcards

Misc 7 Flashcards

1
Q

What is the mechanism behind dilutional hyponatraemia e.g. in heart failure?

A

Activation of RAAS and also ADH release from posterior pituitary
Both lead to fluid retention but only one of these leads to Na retention so relative hyponatraemia (TBS actually high)

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2
Q

3 ways in which patients lose heat intraoperatively?

A

Radiation - from skin (there is also vasolidation which worsens this)
Evaporation - body surfaces and open cavities
Conduction into air and theatre table
Also cold fluids/anaesthetic agents, and shivering prevented due to paralysis

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3
Q

Normal response to hypothermia?

A

Symp response - shivering, piloerection, periph vasoconstriction

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4
Q

RFs for intra/post op hypothermia?

A

Pre op hypothermia
Worsening ASA grade
Major/exposed or prolonged surgery
Combined GA and regional

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5
Q

What is the classic ECG finding in hypothermia and what is it? When is it seen?

A

J - Osborn wave
Usually seen at less than 32 degrees
Upward deflection between QRS and ST

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6
Q

Complications of hypothermia in relation to surgery?

A

Coagulopathy
Decreased metabolism and CO
Decreased drug metabolism - prolonged mechanism of action

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7
Q

Discuss division of total body water e.g. for 70kg male?

A 
TBW = 42L
28L = intracellular
14L = extracellular
11.5L = interstitial
3.5L = intravascular
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8
Q

Hartmanns composition?

A 
Na 131
Cl 111
K 5
Ca 2
Bicarb (as lactate) 29
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9
Q

0.9% NaCl composition?

A

154 Na

154 Cl

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10
Q

What is the classification system for traumatic pelvic fractures? What are the 3 types?

A

Young and Burgess
AP compression - open book fracture
Lateral compression
Vertical shear - fall from height, superior displacement of one hemipelvis on the other

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11
Q

What level do you apply a pelvic binder at?

A

Greater trochanters

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12
Q

Discuss management of major bleeding due to pelvic fracture?

A

Any hypotenisve major trauma should have pelvic binder
Then discuss with IR if active bleeding and pelvic fracture
If no target - preperitnoeal packing
If large vessel injury not amenable to IR - vascular opinion

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13
Q

Where do the majority of bleeds come from in pelvic fractures with blunt trauma?

A

Pelvic venous plexus

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14
Q

Lethal triad of trauma?

A

Hypothermia, acidosis and coagulopathy

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15
Q

What is the difference between Early Total Care and Damage Control Surgery?

A 
DCS = haemorrhage control, compression of major cavities and decontamination
ETC = early definitive treatment of injuries after period of initial resus
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16
Q

Pathophysiology of Type 1 hypersensitivity reactions?

A

Antigens bind to IgE antibodies on mast cells and basophils/eosinophils
Then degranulate to produce histamine, heparin, platelet activating factor
Increase in leukotrienes, prostaglandins
Above cause vasodilation, smooth muscle spasm, capillary leak due to increased vascular permeability and excessive epithelial glandular secreteion

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17
Q

Treatment of type 1 hyypersensisitvty reaction?

A

IM adrenaline 500 micrograms (0.5ml 1/1000) - can repeat after 5 mins if doesnt help
Chlorphenamine 10mg IV/IM
Hydrocortisone 200mg IV
IV fluid challenge 500ml

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18
Q

How to size guedels and nasopharyngael airways?

A

Guedel = incisor to angle of mandible

NP airway = external nare to tragus

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19
Q

What effect may jaundice have on pulse oximetry?

A

Bilirubin can falsely lower reading

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20
Q

Complications of colloids?

A

Anaphylaxis

Coagulopathy

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21
Q

3 causes of increased CVP?

A

Fluid overload/ventricular failure
Cardiac tamponade
Chronic respiratory disease

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22
Q

Level 0 - 3 care?

A 
0 = normal ward patient
1 = ward with critical care input
2 = HDU = single organ failure, 2:1 nursing
3 = ICU = multi organ failure, 1:1 nursing
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23
Q

Caring for post op trache patient?

A

Humidified oxygen
Regular tube care and suction
Emergency kit availability

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24
Q

Under what circumstance would you be fully immune to tetanus?

A

When you’ve had 5 doses - 3 in early months then 2 boosters

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25
Q

What causes tetanus?

A

Clostridium tetani

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26
Q

What is the neurotoxin produced by c tetani?

A

Tetanospasmin

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27
Q

Differences between exotoxin and endotoxin?

A 
Exo= gram pos or neg, immunogenic
Endo = gram neg only, non-immunogenic
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28
Q

Alpha 1 activation causes?

A

Vasoconstriction and increased duration of contraction

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29
Q

Beta 1 activation causes?

A

Positive inotropy and chronotropy with minimal vasoconstriction

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30
Q

Beta 2 activation causes?

A

Vasodilation

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31
Q

Dopamine1/2 activation causes what?

A

Kidneys - induces diuresis

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32
Q

What is dobutamine most useful for and why?

A

Beta 1/2 activation to cause improved cardiac contractility and reduce afterload

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33
Q

Why is norad preferred in e.g. septic shock?

A

Acts primarily on alpha 1 to cause vasoconstriction with relatively little tachycardia

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34
Q

2 ways of calculating MAP?

A

(SBP + (2xDBP))/3

(COxSVR) + CPP

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35
Q

What is CVP monitoring useful for?

A

Gives indication of volume status (cardiac filling)

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36
Q

What is preload?

A

Ventricular filing - how fmuch its stretched pre systole (end of diastole)

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37
Q

Why would you consider ET intubation for mechanical ventilation?

A

Airway reasons - low GCS, facial/upper airway trauma etc., obstruction from inhalation smoke etc
Breathing - respiratory failure due to lung pathology, due to neuromuscular failure or to manage head injuries

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38
Q

Just intubated somoene and they are still hypoxic? What do you do?

A

call for help, apply 100% O2
Check tube position, if in doubt take it out
Check tube blockage
Check for kinking/disconnection
Manually bag to assess compliance - ?bronchospasm
Rule out pneumothorax
Check ventilator working properly

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39
Q

Define ventilation?

A

Tidal volume x respiratory rate

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40
Q

3 basic types of mechanical ventilation?

A

Prsesure controlled
Volume controlled
Pressure suport - supports patients own work of breathing

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41
Q

Normal tidal vlume by weight?

A

7ml/kg

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42
Q

Immediate, early and late complications of mechanical ventilation?

A

Immediate - airway trauma, failure, dental damage
Early - baro/volume trauma - pneumothorax/pneumoed/emphysema, raised intrathoracic pressure and reduced preload leading to CV collapse
Late - VAP, respiratory muscle atrophy, tracheal stenosis, tracheal fistula

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43
Q

3 rerquirements for weaning ventilation?

A

Resolution of intiial reason for ventilation
Adequate gas exchange - reducing O2 req
Adquate resp drive and power - spontaneous breathing trials

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44
Q

Managing new AF (acute) that doesnt resolve with correction of cause?

A

If stable - oral cardioversion e.g. amiodarne, digoxin

If unstable - DC or chemical cacrdiovert

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45
Q

Give 4 specific post op complications of open AAA repair?

A

Abdo copmartment syndrome
Bleeding
Lower limb ischaemia
Post op ileus

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46
Q

What postiion for remove central line? Why?

A

Head down or supine

To reduce risk of air embolus

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47
Q

How might teunnelled lines need to be removed?

A

In theatre - larger incision needed to dissect to plastic retaining cuff

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48
Q

5 causes of ischaemia?

A 
Obstruction of arterial supply
Obstruction of venous outflow e.g. compartment syndrome
Anaemia
CO poisoning
Pulmonary disease and poor oxygenation
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49
Q

Likelihood of reinfarction if major surgery within 1 month post MI? Vs over 6 months?

A

30%

vs 5%

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50
Q

Clopidogrel lasts for how long?

A

8 days - lifespan of platelets

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51
Q

Mechanisms of actino of aspirin?

A

COX 1 (blocks thromboxane A2 formation, platelet aggregation) and COX 2 (analgesia ,antiinflammatory/pyriexa) inhibition

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52
Q

Mechanism of action of clopidogrel?

A

Prevents platelet aggregation oby irreversibly inhibitring plaetelet ADP receptor

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53
Q

What are the 2 phases of metabolic response to injury?

A

Ebb - decreased CO, metabolic rate, energy expenditure and temperature
Flow - catabolic then anabolic phase

54
Q

Risks/beenfits of NJ tubes?

A

Good - thinner, less uncomfortable, less risk of aspiration

Bad - more prone to kinking/blockign, may need radiological insertion

55
Q

What kind of enteral feeding is preferred in pancreatitis and why?

A

NJ

Because bypasses DJ flexure, reducing secretion of cholecystokinin (which worsens pancreatic inflammatory process)

56
Q

How is respiratory quotient calculated?

A

CO2 excreted / O2 consumed

57
Q

WWhat is usually in an epidural?

A

Local anaesthetic and opiate

ee.g. bupivocaine and fentanyl

58
Q

What are the 4 stages of pain sensation transmission? Which drugs act at each?

A

1 - transduction - e.g. NSAIDs
2 - transmission - LA
3 - modulation - TENS
4 - perception - opioids

59
Q

Where are pancreatic pseudocysts usually found?

A

In leser sac, obstructing epiploi foraemn of winslow withi inflammatory adhesions

60
Q

4 methods of drainage of pancreatci psueodcysts?

A

Percutaneous/IR
Endoscopic - via posterior wlal of stomach
Open pseudocystogastrostomy
Open psuedocystojejunostomy if inferior

61
Q

Complicatinos of chronic pancreatitis?

A 
Psueodcyst
Peripancreatic fluid collections
DM
Malnutrtition
Biliary obstruction
Fistula formation - pancreatic ascites
62
Q

RFs for breast cancer?

A 
Early menarche, late menopause
Increasing age
FH/genetics
Nulliparous or late 1st baby
Smoking
Obesity
Use of HRT
Prev breast Ca
63
Q

What is BRCA 1 associated with?

A

Breast, ovarian and fallopian Ca

64
Q

What is BRCA 2 associated with?

A

Breast, pancreatic Ca, melanoma

65
Q

What is the breast sceening programme?

A

Mammogram ervery 3 years from 50 to 71 routinely

66
Q

How is sentinel node biopsy performed?

A

Radio isotope/blue dye injected to subdermal layer around areola pre-op - at surgery sentinel lymph node identified with dye/geiger counter and excised, frozen section - if positive all LNs removed

67
Q

What is DCIS?

A

Most common non invasive breast Ca, microcalcifications, histologically looks like abnormal cells within BM

68
Q

What is the difference between simple and skin sparing mastectomy?

A

In simple, whole breast taken. In skin sparing, nipple-aerolar complex is preserved

69
Q

What layer is dissected down to in WLE breast Ca? What is placed on this layer?

A

Down to pectoral fascia

Titanium clips placed on fascia to facilitate accurate radiotherapy

70
Q

What are the levels of axillarry LNs?

A 
1 = inferolateral to pect minor
2 = posterior to pect minor
3 = superomedial to pect minor
71
Q

Complications of masteectomy?

A 
Primary haemorrhage or haematoma
Wound infection
Skin flap necrosis
Wound dehiscence
Numb scar
Cosmetically poor scar
Seroma formation
Long thoracic or thoracodorsal nerve damage
Tumour recurrence
72
Q

What 2 parts of the breast are rebuilt post mastectomy?

A

Breast mound

Nipple areolar complex

73
Q

Options for rebuilding breast mound?

A

Implant alone
Implant and flap e.g. lat dorsi myocutaneous flap
Autologous flap alone

74
Q

Options for rebuilding nipple areolar complex?

A

Nipple reconstruction - usually done 6 months after treatment finished
Tattooing for areolar reconstruction

75
Q

What are 3 kinds of flaps for breast reconstructino?

A

TRAM
DIEP
SGAP/IGAP (super/inf gluteal artery perforators)

76
Q

Role of radiotherpay in breast cancer?

A

Offered to everyone who has had WLE to reduce recurrence

Recommended if tumour over 5cm, positive resection margins, 4 or more pathological nodes in axilla, node positive

77
Q

Local complications of radiotherapy in breast cancer?

A

Skin erythema or permanent discolouration
Lymphoedema
Swelling of remaining breast tissue

78
Q

Discuss oestrogen receptors in breast cancer?

A

ER = 70% of breast cancers
Pre-menopausal - block production with tamoxifen for 5 years
Post-menopausal - block peripheral conversion with letrozole/anastrazole

79
Q

What is herceptin used for?

A

Monoclonal Ab Trastuzumab used for HER-2 positive cancers

80
Q

Is ER positivity a good thing in breast Ca? What about HER-2?

A

ER is good
HER-2 is bad
with respect to recurrence

81
Q

First differential to rule out in acute flank/loin pain?

A

Rupture AAA

82
Q

Potential outcomes of a mid ureteric stone?

A 
Resolution
Ongoing colic
Obstruction
Obstruction and infection
Haematuria
SCC (if longstanding)
83
Q

3 sites of stone obstruction in kidney stones?

A

Pelvi-ureteric junction
Pelvic brim, where ilaics cross
Vesico-ureteric junction

84
Q

Causes of renal stones?

A 
MEtabolic states
Abnormal anatomy eg horseshoe
Infections e.g proteus
Gastric e.g. IBD
Dehydration
High BMI, diet
85
Q

Why does proteus cause renal stones?

A

Proteus cleaves urea to alkalaize urine

This reduces solubility of PO4, prompting formation of struvite (magnesium ammonium phosphate stone)

86
Q

5 kinds of renal stones?

A 
Calcium oxalate
Calcium pyrophosphate
Struvite
Cystine
Uric acid
87
Q

Differences between smooth and skeletal muscle?

A 
Smooth = circumferential, autonomic (voluntary) and lines walls of viscera
Smooth = calmodulin, skeletal = troponin (calcium binding protein)
88
Q

How is micturition controlled neurologically?

A

Storage phase - SNS - L1-3 relaxes detrusor and contracts internal sphincter
Micturition - PNS - S2-4 contracts detrusor and relaxes internal sphincter
External sphincter is under somatic control

89
Q

3 ways of defining AKI?

A

UO under .5ml/kg for 6 hours
Creat rise over 26 in 48 hours
Creat rise in over 1.5x baseline in 1 week

90
Q

Give 6 indicitions for renal replacement therapy?

A 
Refractory hyperkalaemia
Fluid overload
Severe acidosis
Complications of uraemia e.g. pericarditis
Acute poisonoing
CKD 5
91
Q

Divisions of types of renal replacement therapy?

A

Intermittent - haemodialysis, peritoneal dialysis

Continuous - haemofiltration, haemodiafiltration, renal transplant

92
Q

What is dialysis disequilibrium syndrome?

A

Acute onset of neurological symptoms in patients undergoing dialysis, due to rapid change in serum osmolality causing cerebral oedema

93
Q

What is a naevus?

A

Benign proliferation of normal constituent cells of skin

94
Q

Give 4 kinds of naevi?

A

Melanocytic
Vascular e.g. strawberry, port wine
Epidermal - warty
Connective tissue - Shagreen patch in TS

95
Q

Act governing tissue donation in UK?

A

Human tissue act 2004

96
Q

Indication for renal transplant?

A

End stage renal disease regardless of cause

97
Q

Contraindications for renal transplant?

A

Malignancy that is not curative or not been in remission for 5 years
Untreated HIV/AIDS
IHD with 5 year predicted death of 50% or more
Chronic or persistent infection
Unlikely to comply w medications, regular class A drug taker etc

98
Q

Where are transplanted kidneys normally put? Where does tranpslanted ureter go?

A

RIF

Anastamosed to kidney

99
Q

Blood supply/venous drainage of transplanted kidneys?

A

External iliac arery and vein

100
Q

What are the main stages of organ recovery e.g. kidney?

A

Warm ischaemic - from when donor circulation stops to when perfusion solution flowing
Cold ischaemic - from when perfusion solution flowing to when kidney transplanted into recipient (kidney is on ice for transplant and shold be tx within 24 hours)

101
Q

What is perfusion solution and what is it used for?

A

Ice cold solution of solutes, pH buffers, adenosine, membrane stabilisers etc to keep kidney viable

102
Q

How is immunosuppression achieved with regards to transplant surgery?

A

At time - pred and an anti-CD drug of some sort
Maintenance triple therapy - pred, calcineurin inhibitor (tacro/serolimus/ciclosporin) and purine synthesis inhibitor (azathioprine)

103
Q

Complications of immunosuppression associated with transplant?

A 
Nephro/hepatotoxicity/neurotoxicity
Leukopenia
Skin changes
HTN, fluid retention
Effects of steroids
Malignancy e.g. skin
Infections esp atypicals
104
Q

What is acute transplant rejection, what are the subdivisions and why does it happen? Treatment?

A

Accellerated if within first week, acute if within 100 days
T cell mediated, diffuse infiltration/arteritis/tubulitis etc
Treat with steroids at high dose

105
Q

Why does chronic transplant rejection occur?

A

Humeral system - graft fibrosis and atrophy

106
Q

Features of renal transplant rejection?

A

Pain, swelling, redness at site
Temperatures
Decreasing urine output and worsening renal function
Fluid retentino

107
Q

How is renal transplant rejection diagnosed?

A

Biopsy

108
Q

Complications of renal transplant other than rejection/complications of immunosuppression?

A

Delayed primary function - may be due to long cold ischaemic time or re-perfusion injury
Vascular - anastamotic leak, thrombosis, stenosis, vessel kinking
Urological - urine leak, ureteric stricture
Lymphocele - may need drainage

109
Q

What is primary donor dysfunction in e.g. renal transplant?

A

Failure of donor organ to function in absence of any other obvious cause

110
Q

1 year graft survival of renal transplants? Better or worse than other kinds?

A

Over 90% This is better than the other kinds

111
Q

Symptoms of BPH?

A

Filling - frequency, urgency, nocturia
Voiding - hesitancy, incomplete voiding, terminal dribbling, poor stream
Other - retention, freq UTIs, haematuria, bladder stones

112
Q

Invstigating BPH?

A 
Exam incl PR
IPSS - prostate symptom score
urine dip
PSA
TRUS (trans rectal US)
IVU - IV urography
voidingi charts
urodynamics
113
Q

Management of BPH?

A

Conservative - bladder training, avoiding drinks before bed, exercise, patient support etc
Medical - alpha blockers/5a reductase inhibitors
Surgery - TURP, open prostatectomy, laser enucleation

114
Q

RFs for prostate Ca?

A

Age, Afrocaribbean/African, Obesity, FHx, diet

115
Q

Scoring/grading system for prostate Ca?

A

Gleason score

116
Q

Management of prostate Ca?

A

Stratify into local, locally advanced and advanced with MDT
Options include serveillance, radio/brachyterhapy, hormonal therapy (gosurelin, flutamide), TURP, chemo or steroids, radical prostatectomy or high intensity focused US/cryotherapy

117
Q

Complications of TURP?

A 
Bleeding
Infection
TURP syndrome
Retention or incontinence
Retrograde ejaculation
Strictures
Erectile dysfunction
118
Q

Where are the urethral sphincter muscles in relation to the prostate?

A 
Internal = above gland, at bladder neck
External = below gland, in deep perineal pouch
119
Q

What is the prostatic utricle?

A

Small blind ended pouch opening in centre of seminal colliculus - openings of ejaculatory ducts are either side of utricle

120
Q

Causes of bilateral parotid swelling?

A

Infection - viral e.g. mumps, bacterial e.g. TB
Inflammation - sarcoid/sjogrens
Metabolic - cirrhosis, cushings, myxoedema, bulimia, diabetes, malnutrition, gout
Local - sialectasis
Drugs - thiouracil, isoprenaline, high oestrogen OCP

121
Q

Causes of unilateral parotid swelling?

A

Any of bilateral plus:
Cancer - benign or malignant
Stones or external ductal compression

122
Q

What is pseudoparitomegaly and what causes it?

A

Mimics parotid swelling

Due to either masseter hypertrophy or periauricular lymphadenopathy

123
Q

Are stones more common in submadibular, sublingual or parotid glands? Why?

A

Submandibular - because saliva here has higher mucous content and increased concentration of calcium/phosphate than saliva of the others
Also submandibular secretion is against gravity, causing stasis

124
Q

How might parotid/submandibular stones differ?

A

Parotid often small and multiple, 50% within gland

Most submandibular are larger, solitary and intraductal

125
Q

Pathology of salivary gland calculus formation?

A

Saliva is rich in calcium and phosphate

Slow flow predisposing

126
Q

Are salivary stones usually radio opaque?

A

Yes - majority of submandibular, and most parotid ones

127
Q

Discuss parotid cancers?

A

Most benign e.g. pleomorphic adenoma or Whartins tumour, small amount malignant e.g. mucoepidermoid carcinoma or adenoid cystic carcinoma

128
Q

Complications of parotidectomy?

A

Immediate - CN7 palsy, greater auricular nerve damage (and earlobe numbness)
Early - haematoma, infection
Late - Freys gustatory sweating, salivary fistula

129
Q

What is Freys syndrome and why does it happen?

A

Gustatory facial sweating in region of auriculotemporal nerve (V3 branch) in response to gustatory stimulus
Due to autonomic nerve rewiring - following injury to auriculotemporal nerve as it reattaches to sweat glands in skin via symp fibres (rather than salivary gland)

130
Q

What does the auriclotemporal nerve come from and what does it normally do?

A

V3 branch

Usually PNS to parotid secretion/salivation, and SNS to face for sweating/flushing

131
Q

What are the innervations of the rotator cuff muscles?

A

Supra and infraspinatus - suprascapular nerve
Subscapularis - subscapular nerve (also teres major)
Teres minor - axilalry nerve

132
Q

Outline how you would test all the myotomes?

A 
C5 - shouulder abduction/elbow flexion
C6 - wrist extension/elbow flexion
C 7- elbow extension
c8 - finger flexion
T1 - finger abduction
L2- hip flexion
L3 - knee flexion
L4 - ankle dorsiflexion
L5 - EHL
S1 - ankle plantarflexion

MRCS Part B (25 decks)

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