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MRCS Part B - Paul Edit > Miscellaneous 2 > Flashcards

Miscellaneous 2 Flashcards

1
Q

What is gynaecomastia and what causes it? What is the difference between this and galactorrhoea?

A

Gynaecomastia is abnormal amount of breast tissue in males usually due to increased oestrogen:androgen ratio Galactorrhoea is different and due to actions of prolactin on breast tissue

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2
Q

Key questions in gynaecomastia history?

A

Duration, progression Systemic symptoms - visual disturbance? Any new medications PMH - liver disease, testicular issues Family history Drug/alcohol use

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3
Q

Which testicular issues are associated with gynaecomastia?

A

Previous orchidopexy for cryptorchidism could predispose to hormone-secreting testicular tumours

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4
Q

Investigation of gynaecomastia?

A

Clinical exam - breast and testicular Testicular US if indicated Bloods - inlc BHcG and prolactin

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5
Q

9 causes of gynaecomastia?

A

Physiological e.g. in puberty
Androgen deficiency -
Klinefelters
Testicular failure e.g. mumps
Testicular cancer e.g. HcG secreting seminoma
Liver disease
Ectopic tumour secreting HcG Hyperthyroidism
Haemodialysis
Drugs e.g. spironolactone, digoxin, cannabis, cmietidine, finasteride, steroids and oestrogens

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6
Q

Management options for idiopathic gynaecomastia?

A

Conservative Medical - tamoxifen

Surgical - liposuction (better than subareolar incision and excision of tissue)

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7
Q

What is acute pancreatitis? Underlying mechanism of damage?

A

Acute inflammation of the pancreas gland causing interstitial oedema, cellular destruction and release of pancreatic enzymes Presumed mechanism is premature activation of enzymes within the gland itself

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8
Q

Investigating/diagnosing pancreatitis?

A

Largely clinical Amylase can be acutely raised up to around 48 hours before falling again, if over 3x greater than normal = suggestive. Lipase less prone to false negative as elevated for longer CT not routinely done unless delayed, severe or uncertain diagnosis All patients need CXR and US to look for stones

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9
Q

How to identify severity of pancreatitis?

A

Clinical factors including obesity, hypoxia, haemodynamic compromise and signs of haemorrhage Biochemical factors including age, liver enzymes, urea, glucose, LDH, albumin, O2 sats, WCC

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10
Q

What scoring systems are there for acute pancreatitis? What is the difference? What constitutes a severe attack?

A

Glasgow Ranson Difference is when parameters are measured - on admission or at 48 hours Severe attack = derangement of 3 or more parameters, or CRP over 150 at 48 hours

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11
Q

What is the mortality of a severe attack of pancreatitis?

A

20-50%

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12
Q

Complications of acute severe pancreatitis?

A

Early - ARDS, renal failure, haemodynamic instability and shock Mid (1 week) - local complications e.g. necrosis, fluid collections, peripancreatic abscesses, haemorrhage, effusion, splenic vein thrombosis Later (over 4 weeks) - pseudocyst, chronic pancreatitis

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13
Q

When and why would you CT an acute severe pancreatitis routinely?

A

Around 1 week - to look for necrosis

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14
Q

Management of pancreatic necrosis?

A

Conservative - enteral nutrition, monitoring If infected - radiologically aspirate for MC+S and start antibiotics, usually minimal invasive

Surgical necrosectomy as rescue procedure

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15
Q

Management of pancreatitis associated with gallstones?

A

US - if stones do MRCP
Do ERCP or cholecystectomy when well in same admission or soon after
Alternative would be cholecystectomy an on table cholangiogram +/- transcystic CBD exploration

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16
Q

Management of fluid collections in pancreatitis?

A

Generally percutaneous - drain if exerting significant pressure or if infected

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17
Q

Manage of haemorrhagic pancreatitis? Where does the blood come from?

A

May be managed with IR if bleeding from retroperitoneal vessels

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18
Q

What clot complication may occur in severe pancreatitis?

A

Portal or splenic vein thrombosis, which may cause portal hypertension

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19
Q

Managing pancreatitic pseudocyst?

A

If over 6cm, persists over 12 weeks and symptomatic can either do cystogastrostomy or minimally invasive alternative

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20
Q

What is the most common extra-intestinal complication of Crohn’s in GI tract? Why?

A

Gallstones - because of impaired bile salt resorption in terminal ileum

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21
Q

4 reasons why diarrhoea may occur in Crohn’s disease?

A

Inflammation in acute phase causing wall inflammation and secretion of mucous into bowel lumen Terminal ileal disease and bile acid malabsorption Patients with extensive resection or extensive disease causing short gut syndrome due to decreased absorption Entero-colic fistulas - small bowel contents straight into distal colon

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22
Q

What is this?

A

Erythema nodusm

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23
Q

What is this and where may it be found in IBD patients?

A

Pyoderma gangrenosum - around stoma sites

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24
Q

What is this? What is it made of and how is it managed?

A

Ganglion cyst - soft mobile compressible lesion usually on dorsal aspect of wrist- cyst wall of epithelial cells containing fluid from underlying tendon or joint - may occur due to ligaementous strain or embryological remnant of synovial tissue

Usually conservative - usually resolve spontaneously

If excise, risk of recurrence

Usually excise volar ganglia but consider where radial artery is

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25
Q

From what do dorsal ganglia arise? What about volar?

A

Scapholunate articulation

Volar more from radiocarpal joint and adhere to radial artery

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26
Q

What is a Maisonneueve injury?

A

spiral fracture of fibula extending inferiorly to inveolve syndesmosis with injury to malleolus

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27
Q

2 mechanisms of traumatic pneumothorax?

A

Penetrating trauma - flap of lung issue creating one-way valve

Blunt injury cauing rib fracture which may pierce pleura

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28
Q

What should you do for lung penetrating trauma with even very small pneumothorax? Why?

A

Chest drain

May progress to tension

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29
Q
A
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30
Q

How are flat feet typically managed?

A

Conservatively, with insoles/shoe inserts

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31
Q

How is ankle arthritis managed?

A

Symptomatically, can consider arthoplasty or arthrodesis

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32
Q

What are the 3 main ankle ligaments that you can assess clinically? How?

A

Deltoid - felt at medial malleolus - evert foot

Lateral - felt at lateral malleolus - invert foot

Tibiofibular (inferior) ligament - anteriorly around joint - dorsiflex and move talus laterally, if disrupted talus moves

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33
Q

What is pes planus and what causes it in adults?

A

Flattening of arches - in adults degenerative, obesity

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34
Q

What is plantar fasciitis?

A

Tearing of calcaneal attachment of plantar fascia - thick and tender on examination

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35
Q

What is hallux valgus?

A

Lateral deviation of great toe where first metatarsal head moves off sesamoids to increase intermetatarsal angle, causing corns and calluses

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36
Q

What is Charcot foot?

A

Markedly deformed foot with lack of sensation and hyperaemia, stigmata of arterial insufficiency. Secondary to diabetes, neuropathy

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37
Q

What is a Morton’s neuroma?

A

Plantar digital neuroma of plantar nerve between 3rd and 4th metatarsal heads, causing burning pain and paraesthesia of affected toes.

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38
Q

Examinatino findings for Morton’s neuroma?

A

Palptaing between and just distal to metatarsal heads is painful

Metatarsal comperssion may cause Mulder click

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39
Q

What deformities and exam findings may be seen in CMT?

A

Symmetrical elevation of arches with plantar flexed first ray, hindfoot varus, claw toes and flat foot

Heel-toe walking (Marionette gait) and absent ankle jerks

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40
Q

What is anterior metatarsalgia and what is on exam?

A

pain under metatarsal heads with associated widening of foot, flattened medial arch, claw toes and calloses

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41
Q

Describe this? How would you manage?

A

Distal radial transverse fracture of left wrist with dorsal angulation of fracture fracgment, associated ulnar styloid fracture

Manage with reduction and casting with haematoma block, or consider fixing given styloid fracture

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42
Q

What would make you surgically manage a fracture?

A

Young person, high energy mechanism of injury

Suggestive of instability:

Dorsal tilt of more than 20 degrees

Communited fractures

Ulnar styloid injury, neck of femur injury etc.

Intra-articular disruption

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43
Q

Why are cardiac myocytes able to generate own action potentials?

A

Electrochemically unstable membrane - in SA node gradually depolasrises from -70 to -50mV and then fully depolarises generating electrical impulse

44
Q

Why do transplants with denervated hearts have high resting HR? What is it?

A

100 - no vagal tone so spontaneous discharge of 100/min

45
Q

Why do cardiac cells have refractory period? What can happen in pathological instances?

A

To allow for adequate ventricular filling

In prolonged pathological tachycardia, inadequate ventricular filling can lead to fall in CO

46
Q

What are the sympathetic and parasympathetic innervations to the heart?

A

PNS - Vagus nerve, ACh

Symp - cardiac plexus - NA (beta1 in SA node), adrenaline

47
Q

How much of the cardiac cycle is normally made up of diastole?

A

2/3

48
Q

Why can air embolus occur e.g. if neck veins exposed to air?

A

Atrial pressures can be negative, so can entrain air - make sure good positioning

49
Q

What is the usual cardiac output in L/min?

A

5-6L/min

50
Q

What is cardiac output affected by?

A

Anything which affects HR and SV - preload, EF, drugs, nervous system

Afterload - aortic resting pressure - particularly important as determines perfusion pressure of myocardium

51
Q

What is Starling’s Law of the heart?

A

If all other factors remain constant, increase in EDV (preload) triggers stretching of ventricles and subsequent increase in SV and therefore CO. True up to a point, when EDV exceeds ventricular capacity to contract effectively CO can decline

52
Q

What is Laplace’s law? What heart things does it explain?

A

For hollow organs with a circular cross section, total circumferential wall tension depends upon circumference of wall x thickness of wall and on wall tension

Explains why ventricular pressure rises due to physical change in heart size during ejection phase, and why dilated diseased heart will have impaired function

53
Q

Where are peripheral baroreceptors located and what do they do? How do they work?

A

Aortic arch and carotid sinus

Stimulated by stretch (pressure) and trigger vagus (aortic) and glossopharyngeal (carotid) nerve firing

Increase PNS discharge to SA node

Decrease SNS discharge to ventricular muscle via cardiac plexus

Decrease SNS to venous system causing reduced VR

Decrease PVR

54
Q

Where are atrial stretch receptors found? What is the Bainbridge reflex?

A

In atria between pulmonary veins and vena cava

Bainbridge reflexes results in increase of heart rate due to stretch of atria

55
Q

What is the rate of HIV transmission following needlestick injury from an infected person?

Hep B/ Hep C?

A

0.3% for HIV (0.2-0.5)

30% for unvaccinated Hep B, 1.8% for Hep C

56
Q

Blood testing regime post needlestick?

A

At time from donor and recipient

6 weeks and 3 months

57
Q

Differentials/management of catheter not draining?

A

Anuric - renal failure

Catheter blocked/malfunctioned/malpositioned

Examine abdomen, bladder scan / US renal tract, bladder washout/irrigation + urine dip

58
Q

What is the usual size of urinary catheter?

A

14 or 16 Fr

59
Q

Discuss diathermy and pacemakers?

A

Contraindicated in ICDs

If not, need to ensure electrode placement so that electricity doesn’t pass through pacemaker

60
Q

Management of pacemakers in elective surgery?

A

Ensure patient has passport with them, type known etc. and ideally had recent check up

Ensure theatre has CPR and temporary pacing equipment available

Continuous ECG monitoring

Judicious use of monopolar (with plate far away from pacemaker, in short bursts) and bipolar

61
Q

Safe bipolar plate placement?

A

Large contact area, dry shaved area, away from bony prominences

62
Q

In which settings is bipolar better than monopolar?

A

Patients with pacemakers

Extremities with end arteries

Structures with narrow pedicle

63
Q

Difference between antiseptic and disinfectant?

A

Antiseptic = on living tissue

Disinfectant = on inanimate object

64
Q

Discuss differences between chlorhexidine, betadine and isopropyl alcohol?

A

Chlorhex has broadest spectrum and lasts for >4 hours after application, but is poor against spores and fungi. Bacterostatic at low concentration, bacterocidal at higher concentrations

Betadine can irritate skin and is shorter lasting, but has some activity against spores. Works via oxidization

Isopropyl is fast acting with good broad spectrum, but no activity against spores

65
Q

Important characteristics of surgical drapes?

A

Strong and withstand wet/dry stresses

Non-irritant

Flame retardant

Barrier for microorganisms or fluids

Breathable

Electrostatic properties

66
Q

Differences between cleaning, disinfection and sterilization?

A

Clearning = removing visible debris

Disinfection = reducing number of organisms

Sterilization = removing all microorganisms including spores

67
Q

How are surgical trays sterilized? What about heat-sensitve things e.g. endoscopes?

A

Usually steam autoclaved using moist heat

Heat senstive things can be either irradiated or ethylene oxided

68
Q

Management of warfarin for elective surgery?

A

If low risk - stop 5 days pre op, check day before and ensure INR less than 1.5 before surgery

If high risk - stop 4-5 days pre op, consider treatment dose LMWH which is stopped 12 hours pre op, check INR before surgery and ensure less than 1.5

Restart as soon as happy with haemostasis - keep treatment dose LMWH going until INR in range if high risk

69
Q

What is C Diff?

A

Gram positive anaerobic bacilus often commensal in GI tract but commonly associated with nosocomial infection particularly in instances of broad spec Abx use

Normal gut flora disturbed and allows C Diff to proliferate and start producing toxins

70
Q

4 antibiotics at particularly high risk for C Diff?

A

Co-amoxiclav

Cephalosporins

Clindamycin

Ciprofloxacin

Also vanc

71
Q

What is betadine better than chlorhex against? Other advantage?

A

Fungi, mycobacterium, viruses

Less flamable

72
Q

Does any sterilization destroy prions?

A

No

73
Q

4 different methods for sterilisation?

A

Steam/heat - autoclave for surgical equipment

Cold/chemical - plastics/endoscopes

Gas sterilisation - sutures and electrical equipment

Ionising radiation - catheters, syringes

74
Q

4 chemicals used in sterilisation?

A

Ethylene oxide

Formalderhyde

Gluteraldehyde

Hydrogen peroxide

75
Q

What is actinic keratosis?

A

Premalignant (for SCC) condition brought about by UV light

76
Q

What histological features suggest skin SCC?

A

Atypical keratinocyte proliferation

Invasion of dermis

Keratin pearls

77
Q

How long would you keep a clean dressing on for generally?

A

1 week, clean and dry

78
Q

Times for suture removal depending on site?

A

Face - 5 days

Scalp - 7 days

Trunk or limbs - 10-14 days

79
Q

Signs and symptoms of LA toxicity?

A

Peroral tingling/numbness

Drowsiness,

Seizures

Coma

Apnoea, paralysis

Arrhythmias

Shock (negative inotropes and vasodilators)

80
Q

Risks of surgery-related MI in terms of time post MI? How long would you wait?

A

Within 30 days = 30%

1-3 months = 8-19%

3-6 months = 6%

Less after 6 months so wait til then if poss

81
Q

Why are metallic heart valves highest risk for thrombosis?

A

Low-flow vs aortic

82
Q

Duration of onset of oral vs IV vit K?

A

Oral = 12-24 hours

IV = 6 hours

83
Q

When would you hold the COCP surrounding surgery?

A

4 weeks before if major, involving limbs or significant reduction in mobilisation

Restart 2 weeks after full mobilisation

84
Q

What FEV1/FVC ratio is associated with higher risk of surgery?

A

Less than 50%

85
Q

Describe Glasgow score for pancreatitis?

A

PaO2 less than 8

Age over 55

Neuts over 15

Calcium less than 2

Renal (urea)

Enzymes - LDH/AST

Albumin less than 32

Sugar - glucose over 10

Score of 3 or above = severe

86
Q

Alternative scoring systems for pancreatits?

A

APACHE 2

Ranson

Balthazar - CT ststem

87
Q

How would you manage stridor?

A

Crash trolley, call anaesthetics/ENT

If obtunded - examine airway/suction, use adjuncts, head tilt chin lift/jaw thrust and 15L O2

If ok - sit upright

Consider dex 8mg IV and adrenaline 1mg neb

88
Q

Inidications for surgical airway?

A

Failed intubation

Laryngeal trauma/fracture

Upper airway obstruction due to laryngeal oedema, burns, facial trauma, haemorrhage, bilat vocal cord palsy etc.

89
Q

Tracheostomy vs cricothyroidotomy?

A

Tracheostomy is between 2nd-5th tracheal rings

vs cricothyroidotomy in cricothyroid membrane between cricoid and thyroid cartilages

90
Q

Layers when doing tracheostomy?

A

Skin

Subcutaneous fat

Superficial fascia incl platysma

Investing layer deep cervical fascia

Strap muscles (usually retracted)

Pretracheal fascia

Thyroid isthmus

Trachea

91
Q

Define a fistula?

A

Abnormal communication between two epithelial or endothelial lined surfaces, lined with granulation tissue

92
Q

What is a sinus?

A

Blind-end tract lined by granulation tissue

93
Q

What is an abscess?

A

Pus filled cavity surrounded by granulation tissue

94
Q

5 risk factors for enterocutaneous fistula?

A

Surgery

Cancer

Irradiation

Infection

Inflammation e.g Crohns

95
Q

Classification of fistula by output?

A

Low = less than 200ml per day

Moderate = 200-500ml per day

High = over 500ml per day

96
Q

SNAP of managing fistulas?

A

Sepsis control

Nutritional support

Adequate fluid/electyolte and anatomical assessment

Plan and protect skin

97
Q

What kind of nutrition is recommended for high output fistula and why?

A

TPN - because reduces output and can manage electrolyte disturbance/prevent further high output due to oral intake

98
Q

Complications of TPN?

A

Metabolic - high or low BM, hypoK, hypoPho, hypoMg

Related to venous access- throbmoembolism if peripheral, infection, complications of central lien insertion

99
Q

Complications of central line insertion?

A

Immediate - haematoma, haemorrhage, haemo/pneumo/chylothorax, right atrial perf and tamponade, air embolism, arrhythmia

Early - blocakage, pseudoaneurysm

Late - infection, thrombosis, vascular stenosis or erosion, catheter fracture

100
Q

Indications for central line insertion?

A

Monitoring - CVP, Swan Ganz - cardiac output

Interventional - TPN, inortopes/pressors, haemodialysis, transcutaneous pacign wires (Swann sheath)

101
Q

Preferred sites for central lines?

A

Right IJV

Then left IJV

Subclavian veins

Femoral veins

102
Q

What is the obturator sign?

A

Flexion and internal rotation of right hip causes pain due to irritation of obturator internus - due to appendicitis

103
Q

Initial pain of appendicitis travels through which general visceral afferent nerev?

A

Lesser splanchnic

104
Q

Scoring systems for appendicitis?

A

Alvarado

Appendicits Infallamtory Response (AIR)

105
Q

Advantages of lap approach over open for e.g. appendix, chole?

A

Better cosmesis

Quicker recovery

Less post op pain

Lower rate of post op wound infection

Easier visualisation of other intra-abdominal structures

106
Q
A

MRCS Part B - Paul Edit (29 decks)

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