Miscellaneous 2 Flashcards
What is gynaecomastia and what causes it? What is the difference between this and galactorrhoea?
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
Key questions in gynaecomastia history?
Duration, progression Systemic symptoms - visual disturbance? Any new medications PMH - liver disease, testicular issues Family history Drug/alcohol use
Which testicular issues are associated with gynaecomastia?
Previous orchidopexy for cryptorchidism could predispose to hormone-secreting testicular tumours
Investigation of gynaecomastia?
Clinical exam - breast and testicular Testicular US if indicated Bloods - inlc BHcG and prolactin
9 causes of gynaecomastia?
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
Management options for idiopathic gynaecomastia?
Conservative Medical - tamoxifen
Surgical - liposuction (better than subareolar incision and excision of tissue)
What is acute pancreatitis? Underlying mechanism of damage?
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
Investigating/diagnosing pancreatitis?
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
How to identify severity of pancreatitis?
Clinical factors including obesity, hypoxia, haemodynamic compromise and signs of haemorrhage Biochemical factors including age, liver enzymes, urea, glucose, LDH, albumin, O2 sats, WCC
What scoring systems are there for acute pancreatitis? What is the difference? What constitutes a severe attack?
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
What is the mortality of a severe attack of pancreatitis?
20-50%
Complications of acute severe pancreatitis?
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
When and why would you CT an acute severe pancreatitis routinely?
Around 1 week - to look for necrosis
Management of pancreatic necrosis?
Conservative - enteral nutrition, monitoring If infected - radiologically aspirate for MC+S and start antibiotics, usually minimal invasive
Surgical necrosectomy as rescue procedure
Management of pancreatitis associated with gallstones?
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
Management of fluid collections in pancreatitis?
Generally percutaneous - drain if exerting significant pressure or if infected
Manage of haemorrhagic pancreatitis? Where does the blood come from?
May be managed with IR if bleeding from retroperitoneal vessels
What clot complication may occur in severe pancreatitis?
Portal or splenic vein thrombosis, which may cause portal hypertension
Managing pancreatitic pseudocyst?
If over 6cm, persists over 12 weeks and symptomatic can either do cystogastrostomy or minimally invasive alternative
What is the most common extra-intestinal complication of Crohn’s in GI tract? Why?
Gallstones - because of impaired bile salt resorption in terminal ileum
4 reasons why diarrhoea may occur in Crohn’s disease?
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
What is this?
Erythema nodusm
What is this and where may it be found in IBD patients?
Pyoderma gangrenosum - around stoma sites
What is this? What is it made of and how is it managed?
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
From what do dorsal ganglia arise? What about volar?
Scapholunate articulation
Volar more from radiocarpal joint and adhere to radial artery
What is a Maisonneueve injury?
spiral fracture of fibula extending inferiorly to inveolve syndesmosis with injury to malleolus
2 mechanisms of traumatic pneumothorax?
Penetrating trauma - flap of lung issue creating one-way valve
Blunt injury cauing rib fracture which may pierce pleura
What should you do for lung penetrating trauma with even very small pneumothorax? Why?
Chest drain
May progress to tension
How are flat feet typically managed?
Conservatively, with insoles/shoe inserts
How is ankle arthritis managed?
Symptomatically, can consider arthoplasty or arthrodesis
What are the 3 main ankle ligaments that you can assess clinically? How?
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
What is pes planus and what causes it in adults?
Flattening of arches - in adults degenerative, obesity
What is plantar fasciitis?
Tearing of calcaneal attachment of plantar fascia - thick and tender on examination
What is hallux valgus?
Lateral deviation of great toe where first metatarsal head moves off sesamoids to increase intermetatarsal angle, causing corns and calluses
What is Charcot foot?
Markedly deformed foot with lack of sensation and hyperaemia, stigmata of arterial insufficiency. Secondary to diabetes, neuropathy
What is a Morton’s neuroma?
Plantar digital neuroma of plantar nerve between 3rd and 4th metatarsal heads, causing burning pain and paraesthesia of affected toes.
Examinatino findings for Morton’s neuroma?
Palptaing between and just distal to metatarsal heads is painful
Metatarsal comperssion may cause Mulder click
What deformities and exam findings may be seen in CMT?
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
What is anterior metatarsalgia and what is on exam?
pain under metatarsal heads with associated widening of foot, flattened medial arch, claw toes and calloses
Describe this? How would you manage?
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
What would make you surgically manage a fracture?
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
Why are cardiac myocytes able to generate own action potentials?
Electrochemically unstable membrane - in SA node gradually depolasrises from -70 to -50mV and then fully depolarises generating electrical impulse
Why do transplants with denervated hearts have high resting HR? What is it?
100 - no vagal tone so spontaneous discharge of 100/min
Why do cardiac cells have refractory period? What can happen in pathological instances?
To allow for adequate ventricular filling
In prolonged pathological tachycardia, inadequate ventricular filling can lead to fall in CO
What are the sympathetic and parasympathetic innervations to the heart?
PNS - Vagus nerve, ACh
Symp - cardiac plexus - NA (beta1 in SA node), adrenaline
How much of the cardiac cycle is normally made up of diastole?
2/3
Why can air embolus occur e.g. if neck veins exposed to air?
Atrial pressures can be negative, so can entrain air - make sure good positioning
What is the usual cardiac output in L/min?
5-6L/min
What is cardiac output affected by?
Anything which affects HR and SV - preload, EF, drugs, nervous system
Afterload - aortic resting pressure - particularly important as determines perfusion pressure of myocardium
What is Starling’s Law of the heart?
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
What is Laplace’s law? What heart things does it explain?
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
Where are peripheral baroreceptors located and what do they do? How do they work?
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
Where are atrial stretch receptors found? What is the Bainbridge reflex?
In atria between pulmonary veins and vena cava
Bainbridge reflexes results in increase of heart rate due to stretch of atria
What is the rate of HIV transmission following needlestick injury from an infected person?
Hep B/ Hep C?
0.3% for HIV (0.2-0.5)
30% for unvaccinated Hep B, 1.8% for Hep C
Blood testing regime post needlestick?
At time from donor and recipient
6 weeks and 3 months
Differentials/management of catheter not draining?
Anuric - renal failure
Catheter blocked/malfunctioned/malpositioned
Examine abdomen, bladder scan / US renal tract, bladder washout/irrigation + urine dip
What is the usual size of urinary catheter?
14 or 16 Fr
Discuss diathermy and pacemakers?
Contraindicated in ICDs
If not, need to ensure electrode placement so that electricity doesn’t pass through pacemaker
Management of pacemakers in elective surgery?
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
Safe bipolar plate placement?
Large contact area, dry shaved area, away from bony prominences
In which settings is bipolar better than monopolar?
Patients with pacemakers
Extremities with end arteries
Structures with narrow pedicle
Difference between antiseptic and disinfectant?
Antiseptic = on living tissue
Disinfectant = on inanimate object
Discuss differences between chlorhexidine, betadine and isopropyl alcohol?
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
Important characteristics of surgical drapes?
Strong and withstand wet/dry stresses
Non-irritant
Flame retardant
Barrier for microorganisms or fluids
Breathable
Electrostatic properties
Differences between cleaning, disinfection and sterilization?
Clearning = removing visible debris
Disinfection = reducing number of organisms
Sterilization = removing all microorganisms including spores
How are surgical trays sterilized? What about heat-sensitve things e.g. endoscopes?
Usually steam autoclaved using moist heat
Heat senstive things can be either irradiated or ethylene oxided
Management of warfarin for elective surgery?
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
What is C Diff?
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
4 antibiotics at particularly high risk for C Diff?
Co-amoxiclav
Cephalosporins
Clindamycin
Ciprofloxacin
Also vanc
What is betadine better than chlorhex against? Other advantage?
Fungi, mycobacterium, viruses
Less flamable
Does any sterilization destroy prions?
No
4 different methods for sterilisation?
Steam/heat - autoclave for surgical equipment
Cold/chemical - plastics/endoscopes
Gas sterilisation - sutures and electrical equipment
Ionising radiation - catheters, syringes
4 chemicals used in sterilisation?
Ethylene oxide
Formalderhyde
Gluteraldehyde
Hydrogen peroxide
What is actinic keratosis?
Premalignant (for SCC) condition brought about by UV light
What histological features suggest skin SCC?
Atypical keratinocyte proliferation
Invasion of dermis
Keratin pearls
How long would you keep a clean dressing on for generally?
1 week, clean and dry
Times for suture removal depending on site?
Face - 5 days
Scalp - 7 days
Trunk or limbs - 10-14 days
Signs and symptoms of LA toxicity?
Peroral tingling/numbness
Drowsiness,
Seizures
Coma
Apnoea, paralysis
Arrhythmias
Shock (negative inotropes and vasodilators)
Risks of surgery-related MI in terms of time post MI? How long would you wait?
Within 30 days = 30%
1-3 months = 8-19%
3-6 months = 6%
Less after 6 months so wait til then if poss
Why are metallic heart valves highest risk for thrombosis?
Low-flow vs aortic
Duration of onset of oral vs IV vit K?
Oral = 12-24 hours
IV = 6 hours
When would you hold the COCP surrounding surgery?
4 weeks before if major, involving limbs or significant reduction in mobilisation
Restart 2 weeks after full mobilisation
What FEV1/FVC ratio is associated with higher risk of surgery?
Less than 50%
Describe Glasgow score for pancreatitis?
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
Alternative scoring systems for pancreatits?
APACHE 2
Ranson
Balthazar - CT ststem
How would you manage stridor?
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
Inidications for surgical airway?
Failed intubation
Laryngeal trauma/fracture
Upper airway obstruction due to laryngeal oedema, burns, facial trauma, haemorrhage, bilat vocal cord palsy etc.
Tracheostomy vs cricothyroidotomy?
Tracheostomy is between 2nd-5th tracheal rings
vs cricothyroidotomy in cricothyroid membrane between cricoid and thyroid cartilages
Layers when doing tracheostomy?
Skin
Subcutaneous fat
Superficial fascia incl platysma
Investing layer deep cervical fascia
Strap muscles (usually retracted)
Pretracheal fascia
Thyroid isthmus
Trachea
Define a fistula?
Abnormal communication between two epithelial or endothelial lined surfaces, lined with granulation tissue
What is a sinus?
Blind-end tract lined by granulation tissue
What is an abscess?
Pus filled cavity surrounded by granulation tissue
5 risk factors for enterocutaneous fistula?
Surgery
Cancer
Irradiation
Infection
Inflammation e.g Crohns
Classification of fistula by output?
Low = less than 200ml per day
Moderate = 200-500ml per day
High = over 500ml per day
SNAP of managing fistulas?
Sepsis control
Nutritional support
Adequate fluid/electyolte and anatomical assessment
Plan and protect skin
What kind of nutrition is recommended for high output fistula and why?
TPN - because reduces output and can manage electrolyte disturbance/prevent further high output due to oral intake
Complications of TPN?
Metabolic - high or low BM, hypoK, hypoPho, hypoMg
Related to venous access- throbmoembolism if peripheral, infection, complications of central lien insertion
Complications of central line insertion?
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
Indications for central line insertion?
Monitoring - CVP, Swan Ganz - cardiac output
Interventional - TPN, inortopes/pressors, haemodialysis, transcutaneous pacign wires (Swann sheath)
Preferred sites for central lines?
Right IJV
Then left IJV
Subclavian veins
Femoral veins
What is the obturator sign?
Flexion and internal rotation of right hip causes pain due to irritation of obturator internus - due to appendicitis
Initial pain of appendicitis travels through which general visceral afferent nerev?
Lesser splanchnic
Scoring systems for appendicitis?
Alvarado
Appendicits Infallamtory Response (AIR)
Advantages of lap approach over open for e.g. appendix, chole?
Better cosmesis
Quicker recovery
Less post op pain
Lower rate of post op wound infection
Easier visualisation of other intra-abdominal structures
