OSCE surgical Flashcards
Differentials for neck lumps?
Midline: Thyroglossal cyst Goitre Anterior triangle: Enlarged lymph node Enlargment of the parotid gland Branchial cyst Carotid tumour Lipoma Posterior triangle: Lipoma Lymph node Sebaceous cyst
Differentials for goitre (enlarged thyroid)?
Grave’s disease
Multinodular goitre
Neoplastic - adenocarcinoma
Inflammation of thyroid - Hashimoto’s thryoiditis, subacute thyroiditis
Differentials for hypothyroidism?
Iodine deficiency
Subacute thyroiditis
Surgery/carbimazole/radioiodine
Differentials for hyperthyroidism?
Toxic multinodular goitre
Grave’s disease
Thyroid adenoma
Differentials for parotid swelling?
Bilateral: Infection - bacterial/viral TB Alcohol Sjogren's syndrome Unilateral: Duct blockage Neoplastic growth.
How do you differentiate Grave’s from toxic MNG?
• Goitre is smooth in grave’s
• Graves has exophthalmos and pretibial myxedema
TSH receptor antibodies!!!
What is the treatment of hyperthyroidism?
• Medical - carbimazole, beta blockers
• Radioiodine - but not in pregnant women, those that live with children, or people who are incontinent since it is excreted in urine
Partial thyroidectomy or total thyroidectomy - if medication fails, cannot take medication, breathing trouble, cosmetic reasons, dysphagia
How would you investigate a DVT?
Order a d-dimer test!!(d-dimers are derivatives of fibrin so will be high on those with a DVT)
Order USS of leg
DDx for pain or swelling of lower limb:
cellulitis, chronic venous insufficiency, venous obstruction, fracture, hematoma, lympoedema
What are some clinical features that are suggestive that this is a DVT?
Swollen leg more than 3cm radius than the non affected leg. History of active cancer Recent long haul flight Recent paresis, paralysis or immobilization of the leg Recently bedridden for more than 3 days Recent surgery within 4 weeks Entire leg swollen Pitting edema
Treatment of DVT and PE?
IV heparin
Symptoms of PE?
Sudden onset chest pain Worse with exercise Dyspnoea Coughing up blood/white foam Can have fever
How would you investigate a PE?
Order a d-dimer
Chest xray to exclude other causes of chest pain
MRI/CT (MRI if pregnant)
Pulmonary angiogram is gold standard but has risks as dye can cause anaphylactic reaction or kidney damage in those with renal failure
What is the difference between transudate and exudate?
Transudate is when there is less than 30g/L of protein in the fluid, which is usually due to chronic liver disease, hypoalbuminemia, volume overload.
Exudate is when there is more than 30g/L in the fluid and is usually due to an inflammatory process or infection such as pancreatitis, TB, malignancy or lymphoedema.
What causes ascites in CLD?
- Hypoalbuminemia
- Portal HTN
Upregulation of RAAS system causing salt and water retention (which is why we give spironolactone which is an aldosterone antagonist)
- Portal HTN
What are some drugs that can cause gynecomastia?
DISCO MTV
Digoxin Isoniazid Spirinolactone Calcium channal blockers Oestrogens
Methyldopa
Tricyclic antidepressants
Verapimil
What are the causes of hepatomegaly?
INCHIB
Infection - TB, malaria, Hepatitis,
Neoplastic - primary cancer/mets
Congestion (venous) - RHF, occlusion of the hepatic veins (Budd-Chiari syndrome)
Heamatological - sickle cell and hemolytic anemia, lymphoma/leukeamia
Infiltrative - NAFLD, heamachromotosis
Biliary - PBC/PSC
What are the causes of splenomegaly?
MMM
Massive - Myloproliferative disease such as chronic myleoid leukeamia, malaria
Moderate - (up to umbilicus) portal HTN, hemolytic anemia
Mild - Hard to GRIP - Glandular fever, rheumatoid arthritis, infective endocarditis, pernicious anemia
What are some extraintestinal manifestations of IBD?
Clubbing Mouth ulcers (crohn's) Eyes - episcleritis, conjuctivitis Skin - erythema nodosum, pyogenic gangrenosum Joint pain PSC (UC) Amyloidosis
What are some causes of claudication if the pulses are normal?
- Spinal stenosis
- Beta blockers - causes peripheral vasoconstriction
Anemia
- Beta blockers - causes peripheral vasoconstriction
What are the 6 Ps of the critically ischaemic limb?
• Pulseless • Pain • Pallor • Paralysis • Paraesthesia Perishingly cold
What is an ABPi measurement mean and how do you do it?
You divide the ankle blood pressure against the brachial blood pressure and if the result is 1 there is no PVD. If it is between 0.8 - 1 it suggests there will be mild PVD. If between 0.5-0.8 moderate PVD. If less than 0.5 it suggests severe disease.
What is leriche’s syndrome?
Bilateral buttock pain and erectile dysfunction due to common illiac disease.
What is the differences between venous ulcer and arterial ulcer?
• With arterial ulcers the hx is likely to mention rest pain and claudication. With venous it is likely to mention previous DVT’s/PE’s/varicose veins.
• Arterial ulcers are more likely to be on the feet, toes and ankle, while venous is likely to be medial calf.
• Arterial ulcers are punched out, while venous are sloped.
• Arterial usually have little exudate while venous lots due to blood stasis and therefore edema.
• Arterial are usually more painful.
Venous ulcer usually associated with edema
What is the treatment for venous ulcers?
Compression stockings, antibiotics for infection
What is the treatment for arterial ulcers?
Conservative, surgical revascularization
What are diabetic foot features?
• Peripheral neuropathy
• Large and small arterial disease
Autonomic function - reduced sweating, infection, dry cracked skin
List differentials for a breast lump:
• Malignant - invasive ductal carcinoma is most common or
Benign - fibroadenoma, breast cyst (may be painful), abcess (painful, hot and wollen breast)
What is the triple assessment of a breast lump?
- Examination
- Fine needle aspiration
Imaging -USS/Mammogram
- Fine needle aspiration
What does breast dimpling mean?
It does not necessarily mean that it is a sign of invasion of a cancer into underlying musculature.
However, an intramammary tumour can pull on a ligament which could show as tethering.
What are some breast cancer treatments available out there?
• Surgery - lumpectomy, total/partial mastectomy, wide local excision, axillary clearance if clinical node positive, radical mastectomy if underlying musculature is involved
• Chemotherapy - greatest benefit in young, node +ve pts
• Radiotherapy
Tamoxifen - given for all pts especially those with estrogen/progestrone +ve tumours
What is the definition of a hernia?
The protrusion of whole or part of a viscous through an opening in the wall of its containing cavity into a place in which it is normally not found.
What are the groin hernias?
• Indirect inguinal hernia - through the internal inguinal ring, through the inguinal canal and out the deep inguinal ring. Usually low risk of strangulation.
• Direct inguinal hernia - through a weakening in the posterior wall of the inguinal canal (Hesselbach’s triangle). Moderate risks.
Femoral hernia - through the femoral canal which is underneath the inguinal ligament. Highest risk of strangulation.
What are the borders of Hessle Bach’s triangle?
- Inferior epigastric artery
- Inguinal ligament
Lateral border of rectus muscle
- Inguinal ligament
Risk factors for developing a hernia?
• Family history
• Weak abdomnial muscles due to previous surgery, age
Anything that increases intra abdominal pressure: heavy lifting, pregnancy, obesity, ascites, COPD/chronic cough,
What are some complications of a hernia?
- Bowel obstruction - vomiting, constipation, colicky pain, distention
Strangulation - ischemia - necrosis - peritonitis
