Miscellaneous Key Flashcards
Key Points on Preoperative Management:
Key Points on Absolute Contraindications to Elective Surgery:
- Recent Myocardial Infarction (MI): Elective surgery should be postponed for at least
6 months following an MI to reduce the risk of perioperative cardiac complications. - Recent Pulmonary Embolism (PE): Surgery should be delayed for at least 3 months
after a pulmonary embolism to allow for adequate anticoagulation and patient
stabilization. - Uncontrolled Heart Failure: Surgery should be delayed until heart failure is
stabilized or controlled for a minimum of 4-6 weeks prior to the elective procedure. - Severe Aortic Stenosis: Surgery should not proceed in patients with severe
symptomatic aortic stenosis until after appropriate aortic valve intervention, which
should occur at least 3 months before elective surgery, unless urgent treatment is
required. - Uncontrolled Hypertension: Surgery should be postponed if the patient has severe
uncontrolled hypertension (e.g., systolic BP > 180 mmHg or diastolic BP > 110
mmHg)
due to the increased risk of perioperative cardiovascular complications,
such as stroke, myocardial infarction, or bleeding.
- Active Infection: Elective surgery should be delayed in the presence of active
infection (e.g., sepsis, cellulitis) until the infection is treated and controlled.
Operating on a patient with an active infection increases the risk of wound
infections, sepsis, and poor postoperative recovery.
Key Points on Preoperative Investigations for a Healthy Patient:
full blood count (FBC) • For healthy patients with no significant medical history, it is still standard practice to
perform a for all patients before major surgery, such as knee
arthroplasty, to check for any undetected anaemia or abnormalities.
• NICE guidelines recommend a full blood count before major surgery to evaluate for
potential blood loss risks.
• ECG is recommended for patients over 65 years old or those with systemic diseases
to check for underlying cardiovascular conditions.
• Chest X-ray is no longer routinely recommended as a preoperative test unless there
are specific indications, such as chronic lung disease or recent respiratory infections.
controlling pain due to vertebral metastasis (e.g. from breast, prostate)
All steps might be consumed (Paracetamol, NSADs, Morphine).
This is because the
lower vertebral pain due to metastasis is usually very severe.
◙ What would be prescribed as adjuvant if there is still moderate to
severe pain?
→ Radiotherapy
If it is inappropriate to use Radiotherapy, or if used but failed to
manage the pain?
→ bisphosphonates
◙ What if the pain is neuropathic in nature? “Shooting, electric shock like,
Burning, Paraesthesia”
→ Gabapentin or Amitriptyline
Analgesics Ladder
Analgesics Ladder
◙ Simple Analgesics → NSAIDs (Diclofenac), Aspirin, Paracetamol.
◙ Weak Opioids → Codeine, Tramadol.
◙ Strong Opioids → Morphine, Fentanyl, Diamorphine, Oxycodone.
◙ Epidural Nerve Block.
♠ Bone pain due to metastasis → Radiotherapy.
♠ Neuropathic pain → Gabapentin, Amitriptyline, Pregabalin.
Brain metastasis → ↑ Intracranial pressure → Nausea, vomiting,
headache…etc.
♦ Give “Dexamethasone” i.e., glucocorticoids (to shrink the peri-lesional oedema
and thus alleviate the increased intracranial pressure symptoms)
√
♦ Give “Cyclizine” for nausea and vomiting. (The best anti-emetic for ↑ ICP).
√ Dexamethasone is the preferred glucocorticoids in intracerebral edema and the
symptoms tend to improve within several hours after administration.
√ The usual dose → 4 mg, 4 times a day (PO or IV).
NOTE:
After an Open surgery, give → Patient controlled analgesia with Morphine (it can be
weaned off later).
NOTE:
After an Open surgery, give → Patient controlled analgesia with Morphine (it can be
weaned off later).
Bone pain due to bone metastasis →
No full response? → add
♠ Neuropathic pain →
♠ Visceral pain →
- ♠ Capsular pain (liver) →
♠ Muscle Spasm → Baclofen
♠ Trigeminal neuralgia → Carbamazepine = Anticonvulsant
7, ♠ Intractable hiccup due to liver metastasis
1.
Radiotherapy.
Bisphosphonate e.g. Zoledronic acid
- Gabapentin, Amitriptyline,
Pregabalin, Duloxetine- neuro pain
3.Antispasmodics (e.g. Mebeverine). -visceral pain
4 NSAIDs (e.g. Ibuprofen/ Naproxen).
- Baclofen
6, Carbamazepine = Anticonvulsant
7 →Metoclopramide
Liver metastasis → peripheral cause of hiccup (gastric stasis and dilatation → irritation of
vagus nerve), (
Diaphragmatic irritation by liver metastasis → irritation of phrenic nerves).
These are peripheral causes of Hiccup → give Metoclopramide.
- ♠ Intractable hiccup due to Central cause (e.g. Cerebral Lesion) →
2 ♠ Constipation secondary to opioids →
3 ♠ Vomiting secondary to opioids →
4 ♠ Vomiting secondary to ↑ ICP →
5 ♠ Itching due to jaundice →
♠ Intractable hiccup due to Central cause (e.g. Cerebral Lesion) →
Chlorpromazine/ Haloperidol/ Midazolam
♠ Constipation secondary to opioids
♠ Vomiting secondary to opioids →
♠ Vomiting secondary to ↑ ICP →
♠ Itching due to jaundice →
- Senna (Stimulant Laxatives).
- Metoclopramide.
4.Cyclizine.
5.Cholestyramine.
Superior Vena Cava Obstruction
Superior vena cava (SVC) obstruction is an oncological emergency caused by
compression of the SVC. It is most commonly associated with lung cancer. Another
cause is Lymphoma.
◙ Features
√ Dyspnoea (SOB) is the most common symptom.
√ Swelling of the face, neck and arms - conjunctival and periorbital oedema may be
seen.
√ Facial plethora.
√ Headache: often worse in the mornings.
√ Visual disturbance.
√ Pulseless jugular venous distension
(distension of the veins of neck and upper chest).
◙ Causes
♦ Common malignancies:
non-small cell lung cancer, lymphoma
♦ Other malignancies:
metastatic seminoma,
Kaposi’s sarcoma,
breast cancer
aortic aneurysm
♦ Mediastinal fibrosis
♦ Goitre
♦ SVC thrombosis
◙ Management
√ General: dexamethasone, endovascular stenting.
√ Treatment of the cause.
Very Important: Anti-emetics for Nausea and Vomiting
◙ Anti-emetic in renal failure/ Hypercalcemia (metabolic cause) or Drug or Toxin
induced vomiting
→ Haloperidol. (1st line)
◙ However, if there is associated Parkinson’s disease, Haloperidol is contraindicated!
Instead of Haloperidol, we use instead:
→ Levomepromazine. (2nd line)
Never use Haloperidol or Metoclopramide in patients with Parkinson’s)!
◙ Anti-emetic due to ↑ ICP (e.g. brain metastasis, intracerebral tumour e.g.
glioblastoma) or vomiting due to bowel obstruction
→ Cyclizine.
◙ Anti-emetic due to Chemotherapy, Radiotherapy
→ Ondansetron.
◙ Post-operative intractable Nausea and Vomiting
→ IV Ondansetron
◙ Anti-emetics in Hyperemesis gravidarum (the first step is IV fluids)
√ 1st line: “zine” family e.g. Cyclizine, Promethazine
√ 2nd line: IV Metoclopramide, Ondansetron
√ 3rd line: Steroids
◙ Vertigo (e.g. Meniere’s/ BPPV/ Vestibular neuritis)
→ Buccal Prochlorperazine.
A patient developed shortness of breath and headache for several weeks.
He has
swellings of his arms and face, and distension of his neck and upper chest veins but
not pulsatile which have been worsening over weeks.
O/E, he has facial plethora,
intermittent headaches, no audible stridor or laryngeal oedema
.
SVC Obstruction.
√ The likely Dx →
- √ The Most appropriate Investigation →
- √ The most appropriate immediate/ next management →
- √ The treatment of choice →
1 CT Chest WITH Contrast.
2 Dexamethasone.
3 Endovascular stenting of the obstructed SVC.
A 44-YO female is referred to the surgical ward with right upper quadrant pain for 2
days. O/E → yellow conjunctiva, tenderness over the right upper quadrant,
tachycardia and fever of 39 C.
The labs are as follows:
HB normal, WBC 21 (high),
bilirubin 94 (high), Alkaline phosphatase 460 (high)
AST 73 (high),
Albumin normal, CRP 277 (high)
- The likely diagnosis → -
The Next Ix →
Ascending Cholangitis.
Abdominal Ultrasound
Remember:
Acute “Ascending” Cholangitis:
• Charcot’s Triad (frj) → Fever, Right upper quadrant pain, Jaundice. HL ±
(HypOtension and Leucocytosis).
• Investigations → Ultrasound and Blood cultures.
Hx of cancer (esp. Breast, Prostate or myeloma)
+
Backpain
+
Neurological Symptoms (e.g. Urinary incontinency, Lower Limb Weakness)
→ Suspect MSCC (Malignant Spinal Cord Compression)
→ Urgent MRI of the whole Spine
A 38 YO man presents with a 2-year history of soft swelling over the right scapula. He
notices it has slowly grown in size over the past 6 months.
O/E: Painless, non-tender,
4 cm lump over the right scapula, it is not fixed to the underlying structures, there is
no erythema nor tenderness.
Lipoma.
◙ The Likely Dx →
◙ The most appropriate Ix → Ultrasound.
39 YO man presents with 2-year history of soft swelling over the right scapula. He
claims that it has not grown in size.
O/E: Painless, non-tender, 4 cm lump over the
right scapula, it is not fixed to the underlying structures, there is no erythema nor
tenderness.
◙ The Likely Dx → ◙ The management → Lipoma.
Reassure
√ Lipomas are benign soft-tissue masses composed of fatty tissues enclosed by a
fibrous capsule.
√ They are soft, rubbery in consistency, mobile, painless, grow very slowly.
√ If a patient presents with typical lipomas that are not growing and not interfering
with life → Reassure.
√ If there are doubts that it is Liposarcoma (e.g. > 5 cm, ↑ in size, painful, deep
anatomical location) → perform Ultrasound.
√ If the result of US is suspicious → refer for MRI ± Surgical removal
An elderly + Multiple fractures + T-score of -2.5 or lower (e.g. -2.7)
→ Osteoporosis.
• First line management → Bisphosphonates
(e.g. Alendronate ‘’Alendronic acid’’ or risedronate or zoledronic acid).
• HRT (Hormonal Replacement Therapy) should not be given as a first line
management as it has serious side effects such
as Venous Thromboembolism (VTE),
Stroke, Breast cancer, coronary diseases.
• T-Score interpretation: assessed by DEXA scan and reflects Bone Mineral Density
(BMD):
-1 or higher → Normal
Between -1 and -2.5 → Osteopenia
-2.5 or lower → Osteoporosis
