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MRCS Part B - Paul Edit > Miscellaneous 3 > Flashcards

Miscellaneous 3 Flashcards

1
Q

Differentials for leukoplakia?

A 
Candidiasis
SCC
Lichen planus
Mouth ulcers
Frictional keratosis
Geographic tongue
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2
Q

Describe leukoplakia?

A

White patch/plaque on oral mucosa that is a little riased, not painful but can’t be scraped off

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3
Q

What is the significance of leukoplakia?

A

Pre-malignant for SCC

Stop smoking and alcohol

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4
Q

Commenest head and neck cancer in UK?

A

SCC

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5
Q

RFs for SCC of the oral cavity?

A 
Smoking, alcohol
HIV, EBV, HPV
Poor dental hygiene
Radiation
Betel nut chewing
Wood/nickel dust
Preserved food intake
Being Asian
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6
Q

Common sites of SCC?

A 
Oral cavity
Anus
Penis/vulva
Lung
Oesophagus
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7
Q

Lymph drainage of tongue?

A

Tip = submental nodes
Anterior 2/3 = submandibular nodes
Posterior 1/3 = superior/inferior deep cervical lymph nodes

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8
Q

What are the 4 extrinsic muscles of the tongue? Innervation?

A

Genio, hyo, stylo and palatoglossus

All hypoglossal except pglossus which is pharyngeal branch of vagus

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9
Q

4 kinds of intrinsic muscles of tongue? Innervation?

A

Superior and inferior longitudinal
Transverse
Vertical muscles
Hypoglossal

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10
Q

What constitutes a radical neck dissection?

A

Removal of level 1-5 LNs as well as SCM, IJV and CN11

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11
Q

Nerve supply to anterior and posterior belly of digastric?

A 
Anterior = CN5 - mandibular, inferior alveolar nerve
Posterior = CN7 digastric branch
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12
Q

What does the marginal mandibular nerve innervate?

A

Ipsilateral depressor anguli oris

Ipsilateral labii inferioris

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13
Q

Nerve supply to tongue?

A

Ant 2/3 - general = lingual nerve from CNV3 mandibular, special = chorda tympani of CN7
Post 1/3 all = glossopharyngeal

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14
Q

Is chemo or radio better for head/neck SCC?

A

Radio

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15
Q

Define a flap?

A

Unit of tissue moved from donor to recipient site with its own blood supply intact

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16
Q

What are the 4 muscles of mastication?

A

Medial and lateral pterygoids
Masseter
Temporalis

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17
Q

Define an ulcer?

A

Abnormal discontinuatino of a mucous membrane

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18
Q

What do parietal cells of stomach secrete?

A

HCl

Intrinsic factor

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19
Q

What cells secrete pepsinogen?

A

Chief cells

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20
Q

What cells secrete gastrin?

A

G Cells

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21
Q

What cells secret mucous in stomach?

A

Mucous cells

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22
Q

What stimualtes release of gastric acid?

A

Vagus activity - PNS
Gastrin from G cells
Histamine from mast cells

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23
Q

What inhibits the release of gastric acid?

A

Somatostatin, cholecystokinin and secretin

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24
Q

How does H Pylori survive in the stomach? What is it and how is it pathogenic?

A

Uses flagella to keep away from lumen (and flow), buries through mucosa and into epithelial lining
Produces urease which alkalinizes its microenvironment (ammonia binds H+ to ammonium)
Gram negative bacilus
By infecting the gastric mucosa it creates inflammation and causes hypersecretion of gastric acid via G-cell and gastrin overactivity, also ammonium is toxic

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25
Q

3 tests for H Pylori?

A

CLO - campylobacter like organisms - at biopsy (organisms converts urea to ammonia and CO2)
C13 breath test - similar principle
Stool antigen

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26
Q

Treatment for H Pylori?

A

Tripel therapy - PPI, 2 abx e.g. amox and met/met and clari depending on local senstivities

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27
Q

Why might someone with hyperparathyroidism get peptic ulceration?

A

‘Groans’ - causes acid stimulation

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28
Q

How do PPIs work?

A

Blockc action of H/K ATPase in parietal cells

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29
Q

Treatment for low grade MALT lymphoma?

A

H Pylori edrication

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30
Q

RFs for gastric cancer?

A

H Pylori
Chronic atrophic gastritis with intestinal metaplasia
Prev gastric adenomatous polyps or prev gastrectomy, nitrosamines

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31
Q

Spread of gastric cancer?

A

Lymph - local then supraclavic incl virchow
Directly to omenta, pancreas, diaphragm, duodenum, transverse colon
Blood - lung/liver

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32
Q

For what lesions is a subtotal gastrectomy useful?

A

Distal gastric lesion

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33
Q

3 red flag criteria for 2ww endoscopy ?gastric/oesophageal cancer?

A

New dysphagia
Upper abdominal mass
Over 55 with weight loss and at least 1 of upper abdominal pain, dyspepsia or reflux

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34
Q

Is H Pylori more commonly associated with gastric or duodenal ulcers?

A

Duodenal

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35
Q

Where does gastroduodenal artery come from and what are its terminal branches?

A

Common hepatic artery

Right gastroepiploic artery, and superior pancreaticoduodenal artery

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36
Q

What are Bilroth 1 and 2 operations?

A

Reconstructive surgery post antrectomy/partial gastrectomy
1 - gastroduodenostomy
2 - gastrojejunostomy

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37
Q

What effect does vagotomy have on gastric emptying?

A

Increases it

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38
Q

What epithelium lines biliary ducts?

A

Columnar

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39
Q

What is the most common cancer of biliary tree? What is it histologically?

A

CholangioCa

Adenocarcinoma (from columnar ep)

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40
Q

Most common causes of cholangioCa in UK?

A

PSC
Chronic liver diease
HIV

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41
Q

Most common causes of cholangioCa in developing world?

A

Liver fluke

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42
Q

What is a Klatskin tumour?

A

Cholangiocarcinoma originating at junction of left and right hepatic ducts

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43
Q

Difference between PBC and PSC?

A 
PBC = associated with AMA, affects interlobular bile ducts. chronic granulomatous inflammation.
PSC = inflammation and strictures of intra and extrahepatic biliary tree. associated with IBD (UC) and HIV
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44
Q

5 functions of the spleen?

A 
Immune response - white pulp
Circulatory filtration - red pulp
Storage of platelets 
Haematopoeisis in fetus
Iron reutilisation
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45
Q

How big is a normal spleen?

A

10cm, 150g

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46
Q

Grading system for splenic injury?

A

AAST
1 - less than 1cm or haemtoma less than 10% SA
2 - 1-3cm or 10-50%
3 - over 3cm, over 50% or involving trabecular vessels
4 - involving hilar/segmental vessels
5 - shattered spleen, intraperitoneal haemorrhage or devasculrisation

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47
Q

Complications of splenectomy?

A

Immediate - haemorrhage
Early - gastric necrosis or ileus, subphrenic abscess, pancreatitis
Late - pancreatic fistula, immunosuppression, thrombocytosis and clot risk

48
Q

Antibiotics prophylaxis post splenectomy?

A

For at least 2 years or until age 16; lifelong if imunosupressed
Give pen V or amox, or clari if pen allergic
+ ‘rescue’ broad spec abx

49
Q

Vaccines for post splenectomy patients? Timing?

A 
Pneumococcal
HiB vasccine
Meningococcal
Annaul flu
At least 2 weeks before if elective, or at least 2 weeks after if emergency
50
Q

4 blood film features post splenectomy?

A

Increased platelets count
Howell Jolly - red cell remantns w platelets
Pappenheimer bodies - granules of siderocytes containing iron
Target cells

51
Q

4 areas of differentials for splenomegaly?

A

Infective - EBV, CMV, HIV, malaria, TB
Increased portal pressure - cirrhosis, portal vein thrombosis
Haem disease - haemolytic anaemias, myeloprolifertive disorders, sickle cell, thalassaemia, leukaemia/lymphoma
Systemic disease - Gaucher, amyloid, sarcoid, RA (Feltys)

52
Q

Lifetime risk of ulcer disease if you have H Pylori? Lifetime risk of cancer with H Pylori?

A

10-20%

1-2%

53
Q

Tumour markers for seminoma?

A

Placental ALP

sometimes BhcG

54
Q

5 uses of tumour markers?

A

Screening - e.g. AFP in cirrhotics
Diagnosis - e.g. Ca125
Monitoring response to treatment e.g. thyroglobulin post thyroidectomy
Measuring for recurrence e.g. PSA
Severity of underlying disease e.g. CA15-3 rarely elevated in localised breast Ca but often high ni metastatic Ca

55
Q

3 point immobilsation for C spine?

A

Sandbags/blocks
Tape
Hard collar

56
Q

What are the 5 areas of haemrroahge as per ATLS?

A 
Chest
Abdomen
Pelvis
Long bones
Floor
57
Q

Define shock?

A

Inadequate tissue perfusion to meet metabolic requirements

58
Q

Discuss classes of haemorrhagic shock?

A

Class 1 = 0-15% circulation loss, normal obs
Class 2 = 15-30%, tachypnoae and tachycardia but normal BP
Class 3 = 30-40%, hypotensive with pulse less than 140
Class 4 = over 40%, hypotensive, tachy over 140, confused/lethargic and anuric

59
Q

Normal circulating volume of e.g. 70kg man?

A

5L

60
Q

What causes TURP syndrome? Why does it happen?

A

Dilutional hyponatraemia from large volume hypotonic glycine-rich irrigation system
Because can’t use saline as it limits diathermy use

61
Q

Pathophysiology of TURP syndrome?

A

Dilutional hyponatraemia occurs due to large volume hypotonic irrigation
Hyponatraemia causes cerebral oedema
Also as glycine is broken down it is turned into ammonia and can cause encephalopathy

62
Q

How to prevent and manage TURP syndrome?

A

Reduce glycine time to 1 hour max
If op going longer than this, change irrigation fluid to 0.9% NACl and insert 3 way catheter
Also minimise exposure to open venous sinuses during surgery
Consider fluid restrcition and ICU support

63
Q

How and where does furosemide work?

A

Loop diuretic acting on thick ascending loop of Henle, blocking Na/K/2Cl pump and preventing Na resorption (therefore preventing concentration of urine)

64
Q

2nd line management of significant GI bleed secondary to varices if endoscopic first line fails?

A

Sengstaken Blakemore tube

Terlipressin/ocrtreotide - vasoconstric mesenteric vessels - not in severe hypovollaemia or cardiovascular disease

65
Q

How long does a Sengstaken Blakemore tube stay in?

A

Deflate and assess after 24 hours - if bleeding stops remove 48 hours after insertion
Leave inflated for another 24 hours if not controlled

66
Q

3 complications of Sengstaken Blakemore tube?

A

Oesophageal perforation
Ischaemic necrosis of oesophageal mucosa
Aaspiration pneumona

67
Q

Normal portal system pressure?

A

Less than 10mmHg

68
Q

Rule of 2/3 in portal hypertension?

A

2/3 of cirrhotics get portal hypertension
2/3 of portal hypertensives get oesophageal varices
2/3 of oesophageal varices present with acute bleeding

69
Q

6 areas of portosystemic anastomosis?

A 
Lower oesophageus
Umbilicus
Bare area of liver
Retroperitoneum
Patent ductus venosus
Upper anal canal
70
Q

Rectal blood supply?

A 
SRA = from IMA
MRA = from internal iliac
IRA = from internal pudendal
71
Q

Venous drainage of rectum?

A

SRV to IMV then splenic vein then portal vein
Middle/distal to iliac vein then IVC
Hence is a site of portocaval anastomosis

72
Q

4 options for uncontrolled variceal bleeding?

A

Repeat sclerotherapy, conservative management
TIPS - transjugular intrahepatic portosystemic shunt
Surgical shunt
Liver transplant

73
Q

Describe TIPS procedure?

A

Transjugular intrahepatic portosystemic shunt
IJV cannulated using US and hepatic vein accessed
Stent inserted between hepatic vein and branch of portal vein to reduce portal pressure

74
Q

Problems associated with TIPS procedure?

A

Encephalopathy - due to diversion of portal contents away from liver
Stent blockage - 50% after 1 year

75
Q

Role of terlipressin in variceal bleed?

A

Can be started at presentation as long as not in severe hypovolaemic shock or severe heart failure
Continue until definitive haemostasis or after 5 days

76
Q

Role of prophylactic antibiotics in variceal bleed?

A

Give - reduces mortality

77
Q

Define sepsis?

A

Life-threatending organ dysfunction due to dysregulated host response to infection

78
Q

Define septic shock?

A

Sepsis plus MAP less than 65mmHg and lactate over 2, despite adequate fluid resuscitation

79
Q

Pathophysiology of DIC?

A

Pathological activation of coagulation cascade and consumption of clotting factors, causing diffuse thrombosis and end vessel occlusion alongside increased bleeding tendency e.g. from mucosa

80
Q

How does aspirin work?

A

Cyclo-oxygenase inhibitor, reducing thromboxane A2 and subsequent platelet aggregation

81
Q

How does clopidogrel work?

A

Inhibits ADP receptor on platelet membranes to reduce platelet aggregation

82
Q

Differentials for abdo pain in elderly?

A 
Cancer
Diverticulitis, abscess, stricture etc.
Obstruction due to above or volvulus
Perforation
Inflammatory bowel disease
83
Q

When are diverticular abscesses managed conservatively vs surgically?

A

3cm or less = conservative with abx

Larger than 3cm = drainage - radiologically/percutaneously or open/lap

84
Q

Triad of fat embolism?

A

Respiratory distress, cerebral features and petechial rash

85
Q

Non-traumatic causes of fat embolism syndrome?

A 
Bone marrow transplant
Liposuctionn
Acute pancreatitis
Bypass
Fat necrosis of omentum
Sickle cell crisis
Bone tumour lysis
Parenteral lipid infusion
Surgery - IM nailing
86
Q

When does fat embolism syndrome present?

A

Within 12-72 hours post injury

87
Q

Brain imaging of choice for fat embolism syndrome?

A

MRI - normal MRI essentially rules out

88
Q

What fluid is useful in fat embolism syndrome?

A

Albumin solution

Sometimes IV ethanol, dextran 40, heparin

89
Q

What measures may present development of fat embolism syndrome?

A

EArly fixation/immobilisation of long bone fractures within 24 hours of onset
Early steroids and CPAP
Specific orthopaedic surgical measures

90
Q

Equation governing acid base balance? What mediates it?

A

Henderson Hasselbach, mediated by carbonic anhydrase

91
Q

3 ways CO2 is transported in blood?

A

Dissolved in solution
Buffered with water as carbonic acid (Henderson Hasselbach)
Bound to proteins - Hb

92
Q

What is the chloride shift?

A

Shift occuring in cells whereby Cl is slighly higher in arterial blood than venous, as it is substituted for bicarb to facilitate CO2 excretion

93
Q

What is a buffer and what are the 2 most common blood buffers?

A

Mixture of weak acid and weak base, which can resist changes in pH
In blood these are bicarbonate and haemoblobin

94
Q

6 causes of normal AG acidosis?

A 
Renal tubular acidosis
Tubular damage
Diarrhoea
Ileostomy high output
HyperPTH
Hypoaldosterone
95
Q

Causes of metabolic alkalosis?

A 
Vomiting
Use of diuretics
Low chloride states
Renal loss of H
Excess antacids
96
Q

What is ARDS?

A

Clinical syndrome of acute respiratory failure and non-cardiogenic pulmonary oedema, leading to hypoxaemia and reduced lung compliance refractory to oxygen therapy

97
Q

Criteria for ARDS?

A

Diffuse bilateral pulmonary infiltrates on CXR
Normal pulm art wedge pressure
Reduced Pa/FiO2 ratio

98
Q

Causes of ARDS?

A

Lung vs non-lung
Lung = pneumonia, aspiration, pulmonary contusions, fat embolism, smoke inhalation, near drowning
Non-lung = acute pancreatitis, polytrauma, sepsis, massive transfusion, DIC, bypass

99
Q

Management of ARDS?

A

Treat underlying cause
ICU - high PEEP if I+V
Proning - reduces atelectasis and improves V/Q
Query drugs e.g. steroids

100
Q

Biochemical findings suggestive of gastric outlet obstruction?

A

Hyponatraemia, hypokalaemia, hypochloraemic metabolic alkalosis
AKI

101
Q

Causes of gastric outlet obstruction?

A

Benign vs malignant
Benign e.g. pyloric stenosis, ulcer disease, foreign body
Malignant - gastric or duodenal cancer, pancreatic cancer

102
Q

ECG changes in hypokalaemia?

A

Flat/inverted T waves
U waves
ST depression
Prolonged PR interval

103
Q

Indications for renal replacement therapy?

A 
Persistent hyperkalaemia
Anuria
Severe acidosis
Refractory fluid overload
Uraemic complications e.g. pericarditis, encephalopathy
Drug overdose
(rarely) temperature control
104
Q

HLA matching minimses the risk of what type of tranplant reaction?

A

Acute

105
Q

Types of transplant reaction and mechanisms?

A

Hyperacute - preformed antibodies against tissue
Acute - T cell mediated
Chronic - mechanism unclear

106
Q

What equivalent dose of steroids mandates cover for surgery?

A

5mg per day prednisolone

107
Q

5 things screened for in blood transfusion?

A

HIV, Hep C/B, syphilis, HTLV (first time)

108
Q

What does FFP contain?

A 
albumin
complement
all clotting factors
fibrinogen 
vWF
109
Q

What does cryyoprcipitate contain?

A

Factor 8, 13
Fibrinogen
vWF

110
Q

Red flags when assessing tracheostomy airway?

A

If cuff up - gurgling, bubbling or vocalisation from mouth
Visibly displaced tube
Respiratory distress

111
Q

Key components of tracheostomy box?

A 
Trache tube of same size
Trache tube 1 size smaller
Spare inner tubes
Resus bag and mask
Suction and suction catheters
0.9% NaCl and syringe to moiisten plug
Scissors and tape
112
Q

How do you manage a trache with no air coming out of it?

A

2222, airway emergency
High flow O2 over mask and face
Remove speaking valve/cap and inner tube if present
Try to pass suction catheter and suction if able
Deflate cuff if catheter doesn’t pass
If still obstructed - take out

113
Q

How would you ventilate a trache patient with intact larynx if trache malfunctinos and unable to clear? How would this differ if trache with laaryngectomy?

A

Take it out, cover with gauze/tape and ventilate via mouth and nose
If laryngectomy, use LMA/paeds face mask over stoma

114
Q

5 early complications of tracheostomy paitnets post insertion?

A 
Bleeding
Pneumothroax
Dislodged tube or false passage
Subcutaneous/mediastinal emphysema
Tracheooesophageal fistula
115
Q

Variations of tracheostomy tubes?

A

Single or double lumen
Fenestrated or unfenestrated
Cuffed or uncuffed

MRCS Part B - Paul Edit (29 decks)

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