PasTest Surgery Flashcards
1
Q
What is pneumatosis intestinalis?
A
Cystic colllections of gas localised to wall of colon
2
Q
Causes of pneumatosis intestinalis?
A
Bowel necrosis, immunosuppression, severe obstructive pulmonary disease
3
Q
Significance of pneumatosis intestinalis?
A
A radiographic finding and not a diagnosis; aetiology varies from benign to fulminant disease. Considered an ominous finding in bowel ischaemia, particularly if associated with portomesenteric venous gas. Prognosis excellent if primary (15%) and poor if associated with obstructive and necrotic GI disease
4
Q
Management of pneumatosis intestinalis?
A
If primary, usually no treatment needed. If have bowel ischaemia or perforation, may need surgery (especially if not responding to non-operative treatment, or have signs of perforation, peritonitis, abdominal sepsis)
5
Q
Patients with terminal ileal resection at greatest risk of what anaemia?
A
Macrocytic, normochromic anaemia (B12 absorption). See megaloblasts in BM.
6
Q
Where does iron absorption occur in gut?
A
Jejunum and duodenum
7
Q
Where is vitamin D absorbed in the gut?
A
Jejunum, as a free vitamin.
8
Q
Causes of angular stomatitis?
A
Candida infection, staphyloccal infection. Can be iron/B12 deficiency or dermatitis (atopic, contact, seborrhoeic).
9
Q
Centor criteria for tonsillitis?
A
One point for tonsillar exudate, tender anterior cervical lymph nodes, history of fever, absence of cough. Treat with Abx for 3 or 4.
10
Q
Treating tonsillitis?
A
Protect airway, adequate analgesia, antibiotics if indicated. Specific criteria for surgical intervention.
11
Q
DD tonsillitis and infectious mononucleosis?
A
Lower grade fever in mono, minimal exudate, more likely to have palpable spleen and be adolescent.
12
Q
Clinical findings in infantile hydrocephalus?
A
Tense anterior fontanelle, ‘cracked pot’ sound on percussion, transillumination of cranial cavity, ‘setting sun’ appearance of the eyes, thin scalp with dilated veins, abnormally large skull on growth charts
13
Q
Investigation for infantile hydrocephalus?
A
CT or MRI head
14
Q
Common cause of infantile hydrocephalus and two associated CNS malformations?
A
Stenosis of the aqueduct of Sylvius. Associated with spina bifida and meningomyelocoele
15
Q
Definitive treatment for infantile hydrocephalus?
A
CSF shunt with one-way valve between lateral ventricle and right atrium or peritoneum. After shunting can monitor ventricular size by ultrasonography through the open anterior fontanelle.
16
Q
Causes of acute limb ischaemia following femoral arteriogram and balloon angioplasty?
A
Thrombosis, dislodgement of atheromatous plaque, internal dissection during/after angioplasty
17
Q
Management of acute limb ischaemia following femoral artery procedures?
A
Analgesia and anti-coagulation with IV heparin, infusion of tPA (prostaglandin-derived thrombolytic agent), thromboembolectomy, repair or removal of intimal flap (varies according to cause)
18
Q
Cystic artery is usually a branch of what artery?
A
Right hepatic!
19
Q
Cardinal features of bowel obstruction?
A
Absolute constipation, colicky abdominal pain, distension, vomiting. High-pitched or tinkling bowel sounds suggestive of mechanical bowel obstruction; functional obstruction (pseudo-obstruction) has similar clinical picture with absent bowel sounds
20
Q
DD large bowel and small bowel obstruction?
A
In SBO, constipation appears after the onset of vomiting; reverse in LBO
21
Q
How does anal fissure cause constipation?
A
Often follows constipation; hard stool causes tear, anal spasm and further constipation. May not tolerate PR. Get vicious cycle.
22
Q
Treating constipation cause by anal fissures?
A
Stool softeners, local anaesthetic, topical nitrates or diltiazem. Severe cases may require anal stretch or lateral sphincterotomy under anaesthetic. Also increase fibre.
23
Q
Pregnancy and GI symptoms?
A
Causes constipation due to pelvic mass and reduced GI motility; later get indigestion as SM relaxation reduces tone of LOS therefore get reflux
24
Q
Tenesmus?
A
Associated with IBS and rectal tumours (either malignant or polyps); if older and have anorexia, weight loss less likely to be IBS
25
Causes of SBO?
Most common is adhesions (70%), then hernia, then malignancy, then foreign body.
26
Management of SBO?
Fluid resuscitation, diagnosis and correction. Then "drip and suck" (IVT and regular aspiration through large-bore NG tube). Surgery is suspected strangulation.
27
Dividing causes of SBO?
Intraluminal (gallstone ileus, food bolus, bezoars, parasites), intramural (tumour inc. carcinoma, lymphoma, sarcoma, and stricture inc. Crohns, radiation enteritis, post-operative), extramural (hernia inc. inguinal, diaphragmatic, incisional, femoral)
28
Transpyloric plane?
Located at L1. Aka Addison's plane. Halfway between jugular notch and superior border of pubic symphysis. Pylorus of stomach, first part of duodenum, duodenal-jejunal flexure, hepatic and splenic flexures of colon, fundus of GB, neck of pancreas, hila of kidneys and spleen, ninth costal cartilage, spinal cord termination, origin of SMA and confluence of SMV and splenic vein to form portal vein.
29
Management of urinary stones?
Most commonly extracorporeal shock wave lithotripsy (contraindicated in pregnancy and coagulopathy). Surgery for larger stones. Endoscopic retrograde procedures if lithotripsy fails. Can wait for spontaneous passage if ~3mm or so but if has got stuck at the pelvi-ureteric junction it has yet to reach the narrowest point so very unlikely to happen
30
First-line treatment for osteoporosis?
Bisphosphonate (daily or weekly, either risedronate or alendronate) + calcium/vit D)
31
Where do most gastric cancers arise from?
Cardia
32
History of trauma followed by fluctuating confusion and conscious level in elderly patient?
Likely to be subdural haematoma
33
Why are elderly more at risk of subdural?
Thinner cortical bridging veins, increased subdural space, increased probability of falls, use of medications that alter clotting
34
Which cerebral bleeds are more likely in the context of coagulopathy?
Subdural, usually. SAH associated with significant trauma or aneurysm, extradural with significant trauma. Mild trauma + bleed = subdural.
35
Chronic subdural vs acute?
Acute = headache, impaired GCS, focal signs, over-coagulated. Chronic is more insidious.
36
Damage to common peroneal nerve?
Not uncommon during varicose vein surgery. Get inability to dorsiflex (foot drop) and evert. Foot slaps floor. May also occur in fibular fractures or their treatments e.g. pressure from plaster back-slab
37
Triad in normal pressure hydrocephalus?
Gait disturbance, urinary incontinence, fluctuating confusion
38
MRI findings in normal pressure hydrocephalus?
Ventricular enlargement and increased signal intensity around ventricles (suggesting increased CSF production). Sulci well-preserved. Can also diagnose with serial lumbar punctures.
39
Treatment of normal pressure hydrocephalus?
LP and therapeutic drainage of CSF. Can consider CSF catheter or shunt to avoid repeated LPs (ventriculo-peritoneal shunt)
40
Why do trauma patients get hyperkalaemia?
Massive transfusion, acidaemia (buffering of H+ causes K+ efflux). Get tented T waves, then PR and QRS widen and slow and get ventricular arrhythmias. If doing massive transfusion, must do regular blood gases. Regular calcium gluconate/chloride and insulin/50% dextrose should be given.
41
ECG changes in hypocalcaemia?
Prolongation of QTc (due to lengthening of ST)
42
Hypokalaemia ECG changes?
Prominent U waves, ST depression, prolonged PR interval, T wave flattening, long QT, torsades
43
Hyperkalaemia ECG changes?
First get peaked T waves, then get atria paralysis above 6.5 (P wave widens and flattens, PR segment lengthens, P waves eventually disappear), above 7 get prolonged QRS, high-grade AV block, any kind of conduction block e.g BBB, sinus bradycardia or slow AF, development of sine wave (pre-terminal), then asystole/PEA/VF
44
Acute osteomyelitis of radius/ulna in children?
Fever, severe pain, malaise, forearm inflamed and swollen
45
Investigating acute osteomyelitis in children?
Aspirate from area of maximal inflammation, send fluid for gram staining and culture and sensitivity. May see raised WBC, ESR and anti-staphylococcal Ab titres
46
Plain radiographs in acute osteomyelitis?
Limited value during first few days. By the end of the second week get periosteal new bone formation and metaphyseal mottling (classic signs of pyogenic osteomyelitis). Should not delay treatment waiting for these signs.
47
Differentials for acute osteomyelitis (of forearm)?
Cellulitis, acute suppurative arthritis, sickle cell crisis, Gaucher's (pseudo-osteitis), pyomyositis in tropical climates (same organisms)
48
Which investigation is indicated for determining whether a patient is a good candidate for bypass surgery?
Digital subtraction arteriography (compare images before and after IV iodinated contrast; after-image has adjacent bones and soft tissues removed to show clear picture of arteries). Assess patients "run-off" (if good, then distal arteries are well supplied by collaterals and therefore a good candidate for bypass surgery). Can use contrast arteriography if digital not available.
49
Usual cause of mechanical back pain?
Sedentary lifestyle!
50
Pain radiating down leg, paraesthesiae over lateral aspect of left lower leg and foot, SLR limited?
Sciatica caused by compression of L5 nerve root (usually caused by L4/5 prolapse)
51
Spinal stenosis presentation?
Get claudication, relieved within minutes of sitting down. Surgical treatment is by spinal decompression. Must exclude vascular causes as PVD presents very similarly (so must assess peripheral circulation)
52
28-year-old with severe lower back pain, incontinent of urine, loss of perineal sensation and SLR limited bilaterally?
Central disc prolapse; emergency requiring urgent decompression.
53
Managing sudden sensorineural hearing loss (SSNHL)?
ENT emergency. Often no cause found. Causes include trauma, drugs, SoL, acoustic neuroma, Lyme disease, syphilis, sarcoid, multiple sclerosis, AI inner disease, hyperviscosity, rare metabolic and mitochondrial disorders..
Must confirm hearing loss is SN with Hx, Ex, audiometry. Start steroids immediately (14 days oral pred), MR brain or audiometry to exclude retrocochlear pathology. Consider 'salvage therapy' with intratympanic steroids, hyperbaric oxygen therapy. In well patient, with no PMH or other features on examination, most commonly idiopathic
54
Mechanism of Cushing's reflex?
Raised ICP, tonsillar herniation and subsequent compression of brainstem. Get severe hypertension, bradycardia, irregular, decreased respiration
55
Nutrition guidance for surgery?
No food for six hours before, clear fluids up to two hours before
56
Ludwig's angina?
Painful, symmetrical swelling of the floor of the mouth and upper neck due to dental infection; life-threatening and need urgent input from surgical/critical care teams
57
TGN and MS?
More common in MS, and may be bilateral
58
Parotid swelling and symptoms?
Most parotid swellings leave facial nerve intact. Most common is benign pleomorphic adenoma. Involvement of facial nerve associated with malignant tumours so should test this in all patients with parotid swelling
59
Frontal sinusitis vs herpes zoster?
Both can present with forehead pain. Sinusitis worse with leaning forward. Pain may precede rash in shingles.
60
Score for severity of pancreatitis?
```
Modified Glasgow Score. Done on admission. One point for each of the following criteria (spelling PANCREAS).
PaO2 <8,
Age >55
Neutrophilia (WCC>15)
Calcium <2
Renal (urea >16)
Enzymes (AST/ALT>200 or LDH>600)
Albumin <32
Sugar >10
```
61
Interpreting Modified Glasgow Score?
3 or more = severe attack and need ITU
62
AXR for ?gallstones?
Not indicated as many stones are radiolucent (so sensitivity low) and other modalities e.g. USS, MRCP and ERCP are effective
63
Some indications for AXR?
Suspected foreign body, clinical suspicion of obstruction, abdominal foreign body, constipation
64
Recurrent laryngeal nerve innervates?
Sensory innervation to the trachea and larynx below vocal cords, and innervates all muscles of the larynx except the cricothyroid (external laryngeal nerve, a branch of the superior laryngeal, which also gives off the internal laryngeal to provide sensation to larynx above vocal cords
65
Thoracic duct?
Starts at T12 from cysterna chyli, drains all the lymph from below the diaphragm, left thorax and left head and neck; starts at the right of the aorta, ascends to the right of the aorta and oesophagus as it passes through the diaphragm, then crosses midline on the left, posterior to oesophagus, at T5, drains into confluence of left subclavian and IJV. Has valves. Injury can cause chylothorax
66
Role of the cricothyroid muscle?
Innervated by external laryngeal nerve (branch of superior laryngeal); elongates vocal cords; injury means one vocal cord cannot be tensed so cannot produce notes of high frequency
67
Management of acute limb ischaemia caused by embolus?
Urgent embolectomy with a Fogarty catheter. Post-embolectomy, anticoagulate with IV heparin and switch to warfarin.
68
Testicular tumour resembling glomeruli?
Yolk sac tumour (endodermal sinus carcinoma). Mucinous tumour containing Schiller-Duval bodies which resemble primitive glomeruli. AFP secreted. Most common testicular tumour in under 4s.
69
Most common testicular tumour?
Seminoma. Large cells with fluid-filled cytoplasm that stain CD117 positive. AFP usually normal, HCG elevated in minority. LDH often elevated.
70
Clinical picture in MG?
Ptosis, neck weakness, dysphonia and (predominantly) proximal limb weakness in variable pattern over day. Tensilon (edrophonium) can be used to confirm diagnosis.
71
Antibodies positive in MG?
ACh receptor antibodies
72
Management of MG?
Pyridostigmine for symptomatic control, immunosuppression for control of disease. May be associated with benign mediastinal thyroid tumours and in such cases surgery to tumour can improve myasthenia control. Other AID may be associated
73
What are anti-smooth muscle antibodies and anti-mitochondrial antibodes associated with?
AIH and PBC respectively
74
Lateral blow to upper leg causing fractured neck of fibula may damage which structure?
Common peroneal nerve
75
Choosing between IV morphine and SC pethidine?
Morphine favoured in acute, severe pain because acts quicker, dose can be titrated more readily, has safer side effect profile and lower risk of toxicity. Both have depressive effects on CVS so not used if shocked
76
Why are NSAIDs bad in acute trauma?
If have acute trauma and may need surgery etc., NSAIDs create very high risk of stress ulcer.
77
Monitoring AAA?
Done with USS or CT. If 3-4.4cm, done yearly. If 4.5-5.4cm, 3 monthly. >5.5cm = vascular surgery referral. Initial screening done by US. Women not routinely screened. Men may be invited at 65.
78
What size AAA is indicated for surgery?
>5.5cm
79
Managing suspected AAA leak?
Most patients should have CT before theatres to assess extent of leak
80
Repairing AAA?
Most commonly open surgery with insertion of synthetic graft, or endovascular repair. Can do aortic aneurysmorrhaphy (suturing sac)
81
Where is ampulla of Vater?
Where common bile duct and pancreatic duct enter second part (descending) duodenum. Cannulated during ERCP to allow access to biliary tree.
82
GIST?
Gastrointestinal stromal tumour. Can occur anywhere in GI tract, but 50-70% in stomach. Most common tumours of mesenchymal origin in GI tract. Have spindle cells (70%), epitheloid-like cells or mixed types. Tend to occur over 40, equal in men and women. Stain for DOG1. Treat with resection. Can use imatinib and systemic chemotherapy if complete resection not possible.
83
Managing acute pancreatitis?
Resuscitate: oxygen, IV fluids, pain relief, NG aspiration, IV broad spec Abx. Monitor lung function and oxygenation (RR and ABG), BP, HR, CVP, U&E, LFT, urine output, pancreatic function (BG, serum and urinary calcium). Surgery to manage complications of haemorrhage/necrosis in fulminant disease, or pseudocyst/abscess formation in subacute
84
Complications of acute pancreatitis?
Hypovolaemic shock, respiratory failure, renal failure, secondary infection, pseudocyst/abscess formation, hypocalcaemia.
85
Where is ampulla of Vater?
Where common bile duct and pancreatic duct enter second part (descending) duodenum. Cannulated during ERCP to allow access to biliary tree.
86
GIST?
Gastrointestinal stromal tumour. Can occur anywhere in GI tract, but 50-70% in stomach. Most common tumours of mesenchymal origin in GI tract. Have spindle cells (70%), epitheloid-like cells or mixed types. Tend to occur over 40, equal in men and women. Stain for DOG1. Treat with resection. Can use imatinib and systemic chemotherapy if complete resection not possible.
87
Managing acute pancreatitis?
Resuscitate: oxygen, IV fluids, pain relief, NG aspiration, IV broad spec Abx. Monitor lung function and oxygenation (RR and ABG), BP, HR, CVP, U&E, LFT, urine output, pancreatic function (BG, serum and urinary calcium). Surgery to manage complications of haemorrhage/necrosis in fulminant disease, or pseudocyst/abscess formation in subacute
88
Complications of acute pancreatitis?
Hypovolaemic shock, respiratory failure, renal failure, secondary infection, pseudocyst/abscess formation, hypocalcaemia.
89
Lymphatic drainage of breast?
Axillary nodes, supraclavicular nodes, internal mammary chain and inferior epigastric chain
90
Work-up for breast lump?
Clinical exam, then core needle biopsy, FNAC and US/mammogram findings are graded. Do sentinel LN biopsy if malignant to determine axillary nodal status.
91
Three causes of widened mediastinum in trauma?
Cardiac tamponade, aortic dissection/rupture, oesophageal rupture
92
Danger with small, missed pneumothorax?
Exacerbated by mechanical ventilation (get tachycardia, hypotension, rise in ventilation pressure)
93
Causes of pneumomediastinum?
Rupture oesophagus or bronchus; if have pneumothorax and lung collapse too then bronchus is likely culprit
94
Peutz-Jeghers?
AD condition characterised by the development of numerous GI hamartomatous polyps and mucocutaneous hyperpigmentation (macules). Risk of colorectal, breast, liver and lung cancer very high (15-fold gen pop risk for GI cancer). May get abdo pain, GI bleeding, intussusception.
95
Serrated polyposis syndrome?
Aka hyperplastic polyposis syndrome. Characterised by numerous serrated and or hyperplastic polyps in the colon and rectum. Not associated with any one genetic defect and not inherited in simple Mendelian fashion. Increases CRC risk.
96
Direct and indirect inguinal hernias?
Direct inguinal hernias is a protrusion through a weakness in the posterior wall of inguinal canal through transversalis fascia, medial to the epigastric vessels; indirect go straight through the deep inguinal ring and therefore are lateral to the inferior epigastrics
97
Lynch syndrome?
AD inherited. Aka HNPCC. Relatively fewer polyps than other inherited disorders, but have high malignant potential. Most common inherited CRC. Also associated with malignancies of breast, stomach, endometrium and urinary tract.
98
Peutz-Jeghers?
AD condition characterised by the development of numerous GI hamartomatous polyps and mucocutaneous hyperpigmentation. Risk of colorectal, breast, liver and lung cancer.
99
Gardner syndrome?
Subtype of FAP; AD inheritance. Hundreds of colorectal polyps and extra colonic manifestations (intestinal polyps, desmoids, osteomas, epidermoid cysts). Will inevitably develop CRC and therefore prophylactic surgery is the mainstay
100
Where do femoral hernias emerge?
Lateral to pubic tubercle
101
Diverticulitis?
Fever, LLQ tenderness, PR bleeding, vomiting. Associated with increasing age and low fibre diet. Mostly LHS. Management is generally conservative with Abx (cef and met). 15% patients require surgery. Complications include obstruction, perforation, fistula, abscess. Do erect CXR and AXR (perf/ob)
102
Inguinal hernias or femoral more likely to be become strangulated?
Femoral much more likely
103
Should all groin hernias be repaired?
Most should be repaired, especially when become symptomatic. However, if unfit for surgery can be treated conservatively e.g. using a truss
104
Diverticulitis?
Fever, LLQ tenderness, PR bleeding. Associated with increasing age and low fibre diet. Mostly LHS. Management is generally conservative with Abx. 15% patients require surgery. Complications include obstruction, perforation, fistula, abscess.
105
Diameters of small and large bowel?
Small normally maximum of 3cm; large bowel is max 6cm and 9cm at the caecum.
106
Appearance of air-fluid levels in small bowel?
Characteristic of small bowel obstruction
107
Appearance of the three broad categories of burns?
Superficial (red, moist in appearance, very painful); partial thickness (superficial dermal are drier and whiter, painful, slow return of blood with blanching; deep dermal are mottled red (capillary staining) with reduced sensation and do not blanch; may have blisters); full thickness (insensate, with white and waxy/leathery appearance; do not bleed with pinprick)
108
Where do the biceps heads attach?
Short head to coracoid process; long head to supraglenoid tubercle.
109
What does the talus articulate with at the subtalar joint?
The calcaneus. Also they articulate at the talocalcaneonavicular joint
110
Most common surgical diagnosis in children who present to hospital with acute abdominal pain?
Appendicitis (most commonly second decade of life)
111
Most common surgical diagnosis in acute abdomen under the age of two?
Intussusception
112
Antidote for local anaesthetic toxicity?
Intralipid, a 20% lipid emulsion
113
What is a peri-mortem Caesarean delivery and what is the timescale?
Delivery per abdomen in woman dying from maternal collapse or cardiopulmonary arrest; if resuscitation has not improved maternal situation in 4 minutes then do emergency C section (within five minutes) to increase chances of maternal and fetal survival (relieve aortocaval compression, increase venous return)
114
When to suspect that patient may have a breast abscess?
Recent mastitis, a painful, swollen lump in the breast with redness, heat and swelling of the overlying skin; fever and/or general malaise; need urgent referral to general surgeon who can confirm diagnosis with ultrasound and drain abscess
115
Can you have blisters in a first-degree burn?
No!
116
Clinical manifestations of pinealoma?
Slow-growing tumour of pineal gland; might compress midbrain cerebral aqueduct, causing non-communicating hydrocephalus (CSF cannot reach IV ventricle); midbrain tumour can also compress E-W nucleus (in grey matter near aqueduct) and therefore get no parasympathetic input to oculomotor nucleus so get mydriasis.
117
What symptoms will lesions in lateral geniculate nucleus cause?
Visual symptoms!
118
Gold standard test for bladder cancer?
Cystoscopy
119
Failure of proliferation of which pharyngeal arch causes branchial cleft cyst?
Second pharyngeal arch; cyst may have fistulous opening on the lateral neck
120
What is an isograft?
Transplant of tissue or organ from two genetically identical individuals e.g. identical twins; this is the best option as risk of reaction is almost non-existent
121
What is an allograft?
Transplant between two individuals of same species who are not twins
122
Orthotopic graft?
A graft that is transplanted in its normal anatomical position e.g. skin; kidney transplant is non-orthotopic
123
Xenograft?
Graft of tissue from one species to another e.g. porcine heart valves
124
Managing oliguria in patients who are hypovolaemic and vasoplegic?
Give fluid challenge and infusion of vasopressor e.g. noradrenaline
125
What is a Swan-Ganz catheter?
Specialised catheter inserted into the pulmonary artery to measure pressure; useful if have poor cardiac performance
126
Why could abdominal surgery cause vasoplegia?
Faecal soiling of peritoneum can cause release of inflammatory mediators particularly inducible nitric oxide synthetase
127
Injury to thoracodorsal nerve?
Leads to paralysis of the latissimus dorsi
128
Injury to medial pectoral nerve?
Innervates pectoralis major and minor; damage to the nerve paralyses these so shoulder will be abducted, laterally rotated, retracted and elevated
129
Which arteries supply lesser curvature of the stomach?
Left and right gastric; left gastric is one of the three branches of the coeliac trunk
130
Which arteries supply the greater curvature of the stomach?
Left and right gastroepiploic arteries
131
Which arteries supply the fundus of the stomach?
Short gastric arteries, which branch from the splenic artery
132
Management of ABPI 0.6-0.9?
First line is management of risk factors and clopidogrel, second line is enrolment on exercise programme, third line is surgical consideration including arterial duplex USS
133
When is revascularisation indicated in PVD?
Critical limb ischaemia (ABPI<0.4); do arterial duplex USS then possible contrast enhanced MRI
134
What is the management when emergency surgery is required and INR is raised?
Need urgent reversal of anticoagulation; give Beriplex (prothrombinex) IV before theatre. Vit K IV would be appropriate if theatre is the following day. FFP would be second-line to Beriplex
135
Back pain after coughing fit in elderly woman?
Mild trauma such as this can be sufficient to induce osteoporotic wedge fractures
136
Painless, fluctuant swelling in right groin with kyphotic angulation of dorsal spine?
TB of the dorsal spine (Pott's disease of the spine); destruction of adjacent vertebral bodies by caseation leads to collapse, get spinal angulation; paravertebral abscess tracks down to the deep psoas fascia and points in the groin. Long history of poor health, may present with parasthesiae and leg weakness
137
Confirming TB of the dorsal spine?
Mantoux/Heaf skin test (+ve), raised ESR, chest radiograph showing primary lesion, radiograph of entire spine to detect distant occult lesions and assess angulation and number of vertebrae/disc spaces involves, CT or MRI for evidence of impending cord compression, needle aspiration of groin abscess
138
Treating Pott's disease of the spine?
Eradicate TB, correct deformity by draining abscess and evacuating infected material, correction of angulation with strut grafts and spinal fusion, physiotherapy, high protein diet
139
Serious complication of Pott's disease of the spine?
Pott's paraplegia
140
Differentiating between spinal TB and tumour metastases?
Both can cause vertebral body collapse, but disc space usually preserved in metastasis
141
34 year old woman with known UC, intermittent jaundice, itching, right hypochondriac pain, weight loss, raised ALP?
PSC
142
Hyperbilirubinaemia in Gilbert's?
Mild unconjugated
143
Fistula in ano?
Abnormal connection between anal canal and perianal skin, may form after an abscess/IBD/surgery; often visible lesion O/E. Presnet with discharge, pruritus, pain and swelling.
144
Topiramate and bone disease?
Used as anti-epileptic and for migraine prophylaxis. Causes chronic metabolic acidosis by RTA (normal anion gap); causes defective bone mineralisation (osteomalacia-like state) and can get pathological fractures. Diagnosis is topiramate-induced osteopathy
145
Pathophysiology and presentation of anal fissure?
Tear in lower anal canal distal to dentate line; get acute pain on defecation that can last for hours, often 'stinging'; sphincter in spasm on DRE and may have tender, indurated and fibrotic ridge
146
Fistula in ano?
Abnormal connection between anal canal and perianal skin, may form after an abscess; often visible lesion O/E
147
Haemorrhoids and pain?
Vascular cushions in anal canal; usually asymptomatic or painless PR bleeding; may cause discomfort if external and thrombosed. If in significant pain, unlikely to be haemorrhoids
148
Four classical radiological signs for osteoarthritis?
Joint space narrowing, subchondral cysts, subchondral sclerosis and ostephytes
149
What is a Colles' fracture?
Dorsally displaced, dorsally angulated fracture of the distal radius (dinner fork). FOOSH. Get transverse fracture of distal radius, 1 inch proximal to radiocarpal joint, radial shortening. Distal fragment dorsally angulated. Loss of radial inclination, ulnar angulation of wrist. Dorsal displacement of distal fragment. >60% have associated fracture of ulnar styloid
150
Patient with head injury, no symptoms and bruise behind R ear?
Need urgent CT head (as has Battle's sign).
151
Signs of basal skull #?
Battle's sign, panda eyes, rhinorrhoea (CSF from nose), otorrhoea
152
What is a Colles' fracture?
Dorsally displaced, dorsally angulated fracture of the distal radius (dinner fork)
153
Normal management of Colles' fracture and considerations?
Normally can be managed with closed reduction (following haematoma block) and below-elbow backslab. Open reduction and internal fixation provides most anatomical reduction but has risks (e.g. if osteoporotic, anaesthetic risks) then conservative (closed and backslab) better. After swelling has reduced, use full cast
154
Using fixation (e.g. plate and screws) in osteoporotic bone?
Much weaker hold and more likely to loosen
155
Why do you not use full casts immediately in fractures?
Fails to allow for swelling so may get compartment syndrome
156
? infertility, with low sperm count and mobile mass in left scrotum. US shows dilated veins in pampiniform plexus?
Varicocoele. Spermatogenesis inhibited at higher temperatures so get lower sperm count
157
Layers of the testes?
```
Some Doctors Exaggerate Conditions, Increasing Patients V(w)orry Tremendously
Skin
Dartos Layer
External spermatic fascia
Cremaster muscle
Internal spermatic fascia
Parietal tunica vaginalis
Visceral tunica vaginalis
Tunica albuginea
```
158
Varicocoele pathophysiology and treatment?
Pampiniform plexus encircles afferent testicular artery (cool blood to promote spermatogenesis); varicosities in these veins = varicocoele. More common on LHS because left gondal vein drains into left renal vein. Treat with varicocelectomy or embolisation
159
Two causes of cryptorchidism?
Premature infants or XXY
160
What renal calculi are associated with Crohns?
Calcium oxalate stones
161
Calcium oxalate stones?
Increased urinary oxalate can be genetic (primary oxaluria), idiopathic or enteric (severe bowel inflammation and malabsorption or extensive small bowel resection); treat with dietary calcium citrate. Give analgesia during colic and ensure no concomitant infection. May need lithotripsy
162
What causes calcium carcbonate stones?
High amounts of calcium in the body (either dietary or conditions such as hyperparathyroidism)
163
What causes magnesium carbonate stones?
UTIs; also known as struvite stones (made from Mg, ammonia and phosphate)
164
PCL tear?
Most commonly presents as part of damage in other ligaments. Mechanism = hyperextension or hyperflexion. Knee swollen, flexion mildly restricted. Instability when walking down stairs. Positive posterior drawer
165
Meniscal tears?
Most common knee injury; two peaks (young athletes and elderly); acutely are the result of rotational injury to the knee. Get knee locking. Do McMurray's test. MRI most sensitive to diagnose.
166
McMurray's test?
Knee flexed, one hand over side of knee, other on sole of foot. Then externally rotate knee while forced to extension, then IR with forced extension. If former causes pain/pop = medial meniscus; if latter = lateral meniscus
167
PCL tear?
Most commonly presents as part of damage in other ligaments. Mechanism = hyperextension or hyperflexion. Knee swollen, flexion mildly restricted. Positive posterior drawer
168
Collateral ligament tear?
Follows sudden forced twist, or direct blow to the side of the knee; presents with pain on medial or lateral side, swelling and feeling of giving way
169
Patella tendon rupture?
Men aged 30-40, high tensile forces applied during knee extension, on a weakened tendon. RFs include chronic tendonitis, chronic corticosteroid use, CKD, overuse or previous injury, DM. Present with infrapatellar pain or swelling, pain on weight bearing and difficulty straightening the leg. May have pop or feel knee give way. Xray shows displacement of patella.
170
Achilles tendon rupture?
Present with history of audible snap associated with sudden onset of pain. Do Simmond's test.
171
What is Simmonds' test?
Used to diagnose Achilles tendon rupture. Patient kneeling on chair/couch with both feet and ankles free to hang off the edge. Normally, squeezing calf muscles causes plantarflexion of foot; if Achilles is partially or completely ruptured this will not occur.
172
Cancrum oris (noma) presentation, causes and treatment?
Presents as ulcerating lesion in cheeks that exposes buccal cavity and alveolar margin. A necrotising stomatitis or severe ulcerative gingivitis from gums spreading to mandible and cheek. May get
trismus, overwhelming sepsis. Caused by protein-calorie malnutrition, chronic anaemia (e.g. hookworms), measles, poor oral hygiene. Treat with parenteral broad spectrum Abx, NG feeding of high protein-calorie diet, antiseptic mouthwash and wound irrigation, close of defect after healing with cutaneous pedicled flap transfer.
173
When should potassium be added in DKA management?
When K+ falls below 5.5mmol/L
174
What can diagnostic peritoneal lavage show?
Intraperitoneal bleeding or bowel contents
175
Possible intra-abdominal visceral injuries from fall?
Liver, spleen, pancreas, duodenum, diaphragm, kidneys, urinary bladder
176
Clinical/other findings that would require an emergency surgical exploration of the abdomen?
Signs of peritonism and increase in abdominal girth signify intraperitoneal haemorrhage or rupture of a hollow viscus. Imaging or diagnostic peritoneal lavage would detect bleeding and/or visceral injuries before the onset of lethal complications (oligaemia and/or toxic shock)
177
Risk factors for haemorrhoids?
Age, constipation, pregnancy and vaginal delivery, (any cause of increased intraabdominal pressure e.g. protracted vomiting, lifting heavy weights, low-fibre diet, obesity)
178
Clinical features of haemorrhoids?
Itching, painless PR bleeding, may have rectal fullness, discomfort or soiling. May describe fleshy lump protruding from anus.
179
Criteria for admission referral in haemorrhoids?
Acutely thrombosed haemorrhoids, perianal haematoma, associated perianal sepsis, large, permanently prolapsed haemorrhoids (may need haemorrhoidectomy)
180
Managing haemorrhoids?
Fluid and fibre, manage constipation, anal hygeine, analgesia. If does not respond, may need secondary care treatment e.g. rubber band ligation, injection sclerotherapy, photocoagulation, diathermy, haemorrhoidectomy, haemorrhoid artery ligation
181
Sentinel pile?
External lump on anus which is associated with chronic anal fissures
182
Grades of pressure sores?
```
1 = non-blanching erythema with no break in skin
2 = shallow open ulcer with pink wound bed
3 = full thickness tissue loss with exposed subcutaneous fat, but not muscle or tendon. May be shallow or deep, may have undermined wound edges
4 = exposed bone, muscle, tendon
5 = ?
```
183
When is anterior resection used and when is AP resection used?
Anterior resection for non-obstructed tumours of the distal sigmoid, middle or upper rectum; AP (abdomino-perineal) for operable low rectal and anorectal tumours; anus, rectum and sigmoid colon removed and end-colostomy fashioned.
184
Swelling, pain and inflammation of bunions? What causes symptoms? What causes deformity?
Hallux valgus deformity with inflammatory arthritis of first MTP; symptoms caused by pressure/friction on the medial aspect of the first metatarsal head, producing joint deviation, exostosis formation and arthritis; deformity by habitual wearing of narrow, unyielding, raised heel shoes producing progressive lateral deviation of the big toe
185
Treating hallux valgus?
Conserviative measures by changing shoes to wide fronts and low heels are unsatisfactory (poor compliance); surgery indicated instead
186
Best material for mass closure of abdominal wall at laparotomy?
1-0 nylon; non-absorbable, good tensile strength, synthetic, monofilament suture
187
Best material for 2cm lipoma excised from forearm?
3-0 monocryl; dissolvable, non-absorbable, monofilament, synthetic. Can be used to close clean wounds as subcuticular continuous stitch. Good here as little tension on small clean wound
188
Best material for emergency laparotomy for perforated duodenal ulcer?
Skin clips; likely to be contamination, so do thorough washout and drainage, but still high chance of wound infection so do clips. Quick to apply so good when unstable or end of long operation, but are interrupted and can be easily removed to release any purulent fluid if wound infection suspected
189
Best closure for emergency laparotomy for intra-abdominal compartment syndrome?
Laparostomy (leave 'open abdomen') with temporary covering over abdominal contents (transparent to visualise bowel and monitor ischaemia); good for compartment syndrome because intrabdominal pressures rise over perfusion pressure causing multiorgan failure. Close at 72 hours once shown signs of recovery
190
Closure for 36 y/o lady with dog bite on right forearm?
Leave superficial wound open; animal bites should be irrigated to clean and left open to heal by secondary intention ('dirty' wounds) as easily become infected. Patient should have oral Abx (co-amox typically) and ensure tetanus up-to-date; if not then consider IM human tetanus immunoglobulin
191
Closure for 54 y/o man, 7 days post-op with a superficial wound dehiscence throughout the full length of his midline abdominal wound?
Wound infection has caused the skin and SC fat to part or dehisce; this is superficial, because the underlying fascia is intact and the intra-abdominal contents protected. Can either give topical dressing and allow to heal by secondary infection (takes weeks) or do vacuum-assisted closure (VAC) using negative pressure to promote healing. Either done initially in theatre or on ward with advice from tissue viability
192
How does deep dehiscence present?
Pink serous discharge, haematoma or complete bowel protrusion. Likely need re-operation.
193
Clinical features of cribiform plate fracture?
Panda eyes, rhinorrhoea. NG tube or nasopharyngeal airway contraindicated
194
Clinical features of middle cranial fossa fracture or occiput fracture?
Battle sign, haemotympanum, otorrhoea
195
Best initial first aid for minor scald?
Run under cool or tepid water for 10-30 minutes, then apply cling film. Immediate cooling (within 20 minutes) helps, Iced water can cause vasoconstriction so is bad. Elevate burn if oedema present. Cling film protects wound, allows water loss, allows further assessment; do not wrap circumferentially around limb as may impair perfusion. Run under water for longer in chemical burns.
196
When is butter indicated for burns?
Burns caused by hot tar; helps remove it and therefore stop burning
197
What is the Salter Harris classification used for?
Physeal feactures (i.e. involve growth plate); can only occur in children before fusion of the physis
198
Most common finding in patients with Salter-Harris fracture?
Fracture through the metaphysis sparing the epiphysis
199
Salter-Harris classification?
```
S I - slipped
A II - above
L III - lower
T IV - through or traverse or together
4 V - ruined or rammed
```
200
Three main types of post-operative bleeding (in patient undergoing elective splenectomy)?
Primary haemorrhage (during surgery, from uncontrolled bleeding points); reactionary haemorrhage (after return to normal BP); secondary haemorrhage (a few days later as result of infection)
201
Managing immediate post-operative haemorrhage?
Quarter-hourly BP, pulse and RR; examination of wound and abdominal girth measurement; resuscitation if required, blood volume replacement, emergency surgical re-exploration and haemostasis
202
Preventing infections in patients post-splenectomy?
Increased susceptibility to pneumococcal infections (decreased CMI); give vaccine (pneumovaccine) and antibiotic (phenoxymethylpenicillin) for future invasive procedures
203
Preserving immunity in splenectomy?
Re-implant small portion of the spleen during splenectomy for splenic trauma; in children, salvage spleen by repairing if possible
204
Management of SCFE?
In situ screw fixation (usually percutaneously)
205
Management of DDH?
Hip spica casts
206
Normal AAA screening result?
<3cm
207
Features of sebaceous cyst?
Small, smooth lumps closed by hair follicle blocked; have central punctum. Attached to the skin so skin does not move over them. Mobile above deep structures so will not move on swallowing etc. Can become infected, and become tender, erythematous, hot. May be excised if unsightly or infected.
208
Features of lipoma?
Deep to the skin, so skin moves over them. Soft, doughy, mobile on palpation. May need USS to rule out sarcoma/liposarcoma.
209
Sternocleidomastoid tumour?
Congenital lump, appears in first few weeks and may grow or recede; beneath SCM to deep to the skin. Typically restricts contralateral head movement.
210
Blood supply to sigmoid colon?
Sigmoid arteries which branch directly from the IMA
211
What does the ileocolic artery branch from and supply?
Terminal artery of SMA; supplies ileum, caecum and ascending colon
212
How does herpes encephalitis present?
Severe headache, confusion or reduced GCS with no obvious cause
213
Gynaecomastia and cancer?
5-10% of patients with testicular cancer have gynaecomastia as only presenting sign so need full abdominal and genital examination
214
Appropriate management for patient with hypocalcaemia and mild tingling/numbness after having parathyroid surgery earlier in the day?
Observe - transient hypocalcaemia very common after parathyroidectomy
215
Levels of hypocalcaemia management after parathyroidectomy?
Observe usually sufficient; can give oral calcium if symptoms persist; symptoms usually improve within 30 minutes of oral supplementation. Too slow for tetani. Can give infusion of calcium-containing fluids if have 'hungry bones'. IV calcium gluconate if in tetani or calcium below 1.9. Vit D will promote absorption from gut but will not happen quickly.
216
When is IV calcium gluconate used for hypocalcaemia?
Those with frank tetany or serum calcium below 1.9
217
Levels of hypocalcaemia management after parathyroidectomy?
Observe usually sufficient; can give oral calcium if symptoms persist; symptoms usually improve within 30 minutes of oral supplementation. Too slow for tetani. Can give infusion of calcium
218
Most appropriate immediate action in man who cannot pass urine after RTA, in pain, stable haemodynamically. with xray showing displaced fracture of right pubic ramus?
Radiograph means may have urethral or bladder injury prior to catheterisation; cannot catheterise urethrally or suprapubically until know. Best way to exclude is via retrograde urethrography (contrast passed up urethra and do radiograph to check for extravasation)
219
Imaging of choice for suspected bladder/urethra injury?
Retrograde urethrography
220
Investigating persistent symptoms in patients with haemorrhoidal disease after outpatient interventions?
If young and low risk of CRC, can do flexi sig; if older or Fhx of CRC, get colonoscopy. If normal, get full examination under anaesthesia to examine rectum, to diagnose and treat any haemorrhoids, fissures, fistulas or abscesses Sigmoidoscopy may also be better if have fresh bleeding as suggests rectal/anal disorder; if mixed in or dark then colonoscopy better!
221
Characteristics of ACL injury?
Immediate haemarthrosis, positive anterior drawer, unable to weight bear
222
Haemarthrosis after meniscal injury?
It is possible as are vascular peripherally, but less so to inner 2/3
223
What is malignant hyperthermia?
Inherited myopathy, where inhaled anaesthetics such as suxamethonium trigger a sustained influx of calcium into muscle cells from SR, causing hypermetabolic state, cannot control temp/02/Co2 so get circulatory collapse and death. Treatment is recognition, removal of stimuli, continue with propofol or other IV anaesthetics, stopping surgery ASAP, cooling and dantrolene. ICU. Do muscle biopsy after.
224
Prolonged paralysis after suxamethonium administration?
Can occur in patients with abnormal pseudocholinesterase level or function, due to the presence of inherited poorly functioning genetic alleles. FHx should be looked for, diagnosis is by blood test
225
Suxamethonium and pressures?
Intracranial and intraocular pressures transiently rise after suxamethonium administration; only relevant to patients with ocular and intracranial disease
226
Suxamethonium and potassium?
Potassium rises by up to 0.5mmol/L after sux administration; can be much greater if severe muscle damage or recent burns
227
Managing suspected scaphoid fractures?
Suspected with FOOH and pain at base of thumb. Request scaphoid series, AP and lateral. Treatment indicated without findings as often normal; do scaphoid plaster and sling. Remove plaster and repeat after 14 days (risk of AVN). Then new cast if fractured. Alternatively, if immobilisation will be severe to work etc., can do CT/MR
228
Treating otitis externa?
If have significant inflammation, give topical antibiotic +/- a topical steroid (inflam) for 7 days. Oral antibiotic penetration to external ear very poor; good for middle ear. Also give simple analgesia and self-care e.g. not using cotton buds, keeping dry. Could use oral amox if evidence of systemic infections or middle ear infection coexisting!
229
Adminstering inotropes?
E.g. adrenaline; should be given through CVL as can cause local vasoconstriction and tissue ischaemia
230
Uses of CVLs?
Drugs (inotropes), parenteral nutrition, blood products, fluid, measuring CVL
231
Cx of central lines?
Local site and systemic infection, arterial puncture, haemotomas, catheter-related thrombosis, air embolus, dysrhythmias, atrial wall puncture, lost guidewire, anaphylaxis (Abx-impregnated), chylothorax
232
Three main locations of CVLs?
IJV, SCV and femoral veins; site of choice is subclavian (lowest sepsis rate), but higher risk of Cx i.e. iatrogenic pneumothorax. Femoral lines most susceptible to infection
233
What lines can be used for parenteral feeding?
Central or peripheral, but central safer. If peripheral, then must be treated with aseptic technique as prone to infection
234
Chest radiographs and CVLs?
Recommended on insertion of subclavian and IJ lines to confirm correct placement within SVC and exclude pneumothorax. Does not need repeating on removal.
235
What other structure may be damaged in scaphoid fractuer?
Radial artery; this crosses the floor of the anatomical snuffbox
236
How common is PFO?
30%
237
Risk associated with bicuspid aortic valve?
Common cause of premature AS
238
Management of anterior left glenohumeral dislocation?
Immediate manipulation and reduction under sedation in emergency room resus. If this fails, go to theatre for closed reduction under GA. Open reduction only used if closed has failed. Slings are not used in immediate management of shoulder dislocation, but broad arm sling may be used following succesful reduction
239
Ultrasound in acute cholangitis?
Shows gallstones in 80% of cases, and/or dilated intra/extrahepatic ducts
240
What is Buerger's disease?
Arteritis of small and medium-sized arteries that afflicts young male smokers. Rare. Presents with intermittent claudication etc.
241
What is Takayasu's disease?
Rare arteritis causing claudication and neuro signs resulting from arterial occlusion e.g. dizziness. Causes intimal fibrosis of the arteries with vascular narrowing. Much more common in women and commonly presents with pulseless upper limbs
242
Most common causative organisms in acute cholangitis?
Gram negative is E. coli, gram positive is enterococci
243
How does gall bladder empyema present?
Infection of biliary tree, get gall bladder empyema (GB fills with purulent material). Patients present as with cholecystitis e.g. RUQ pain, fevers and rigors, but no jaundice until later on as no actual obstruction
244
Investigation if suspect aortic dissection?
CT aortogram can quickly confirm diagnosis and look at extent. Echo may show pathology but not quantify it.
245
What is a benign oesophageal stricture?
Present with dysphagia (solids, not liquids), history of GORD. Best treated with endoscopic dilatation and aggressive treatment of GORD. DD is cancer.
246
Presentation of diffuse oesophageal spasm?
Dysphagia for solids and liquids, usually accompanied by squeezing chest pain
247
Presentation of lower oesophageal web?
Episodic dysphagia because foods larger in size than diameter of the web will become lodged in the distal oesophagus
248
Most common presenting symptom in testicular cancer?
Painless lump
249
Epididymal cyst?
Painless lump on superior pole of testicle; soft, non tender and regular border. DD seminoma (firm)
250
Managing septic arthritis?
Aspirate knee joint and send for cell count, microscopy and culture; relieves pain and is therapeutic. If there was pus, then do arthroscopy and washout. IV Abx after aspirate. Ultrasound will not confirm any infection.
251
Considerations when examining varicose veins?
Examine CVS and peripheral vasculature, but also examine abdomen as abdominal masses can cause varicose veins. May be tumour, fetus etc.
252
Causes of varicose veins?
Abdominal masses (physiological or pathological), DVT, AV malformations. RFs include FHx, obesity, oral contraceptives and prolonged standing.
253
Managing varicose veins?
If asymptomatic, do not treat. Do full exam inc. abdomen, Doppler to identify area of incompetence, then treat (injection sclerotherapy, surgery)
254
Healing by secondary intention?
Used when significant tissue loss has occurred, wound edges cannot be suitably apposed without excessive tension. Leave wound open, healing occurs from deeper layers by formation of granulation tissue, contraction of tissue and epithelisation from the wound edges
255
What is resolution in wound healing?
Restoring tissue completely to pre-morbid state; not possible in secondary intention.
256
Healing by primary intention?
Healing of uncontaminated wounds with minimal tissue loss where wound edges can easily be apposed without excessive tension. Allows healing by rapid epithelisation and formation of minimal granulation tissue; considerably faster than secondary/tertiary
257
Gauge of urinary catheters?
Decreasing gauge = larger catheter; 16 is bigger than 14
258
Re-inserting permanent indwelling catheters?
Urinary sepsis can be fatal, so give single dose of gentamicin unless good reason e.g. significant renal impairment as prophylaxis
259
How often do long-term catheters need changing?
Every 12 weeks
260
Rockall score?
Identifies patients at risk of adverse outcome after acute UGI bleeds. Clinical (old age, co-morbid, presence of shock) and endoscopic (diagnosis, stigmata of acute bleeding) criteria. >6 = indication for surgery, >8 = higher mortality.
261
Co-morbidities in Rockall score?
One point for heart failure or IHD, two for renal or liver failure, three for metastatic disease
262
Indication for cardiac transplantation?
End-stage heart disease, not remediable by more conservative measures (meet two or more criteria)
263
Visible bleeding in Rockall score?
None for no bleeding or some dark red spots, two points if blood seen in UGI tract or adherent clot or visible vessel bleeding
264
Contraindications for cardiac transplant?
Absolute = active infection; relative includes irreversible renal dysfunction (EGFR <30), clinically severe symptomatic cerebrovascular disease, tobacco and substance misuse, active malignancy, severe irreversible pulmonary HTN
265
Who is offered referral for surgery for osteoarthritis?
People who experience joint symptoms that have a substantial impact on their QOL and are refractory to non-surgical treatment
266
Highest rates of anaphylaxis among anaesthetic agents?
Muscle relaxants e.g. suxamethonium and rocuronium
267
Adult anaphylaxis adrenaline dose?
IM 0.5ml of 1:1,000; can repeat after 5 mins
268
Paediatric anaphylaxis adrenaline doses?
```
<6 = 0.15ml of 1:1,000
6-12 = 0.3ml of 1:1,000
>12 = adult (0.5ml)
```
269
Chlorphenamine and hydrocortisone doses for anaphylaxis by age?
<6 months: chlorphenamine 250mcg/kg, hydro 25mg
6mo-6ye: 2.5mg chlor, 50mg hydro
6-12 years: 5mg chlor, 100mg hydro
>12 = adult = 10mg chlor, 200mg hydro
270
Scrotal swelling examination?
TEST
Is it TENDER
Can you EXCEED the lump i.e. get above it?
Is the lump SEPARATE from the testis i.e. can you identify testis and epididymis?
Does it TRANSILLUMINATE?
271
Scrotal swelling differential diagnosis?
```
TWO TESTES
T - trauma
W - waricocoele
O - orchitis
T - tumour
E - epididymitis
S - spermatocele
T - torsion
E - hErnia (indirect inguinal)
S - serous fluid i.e. hydrocoele
```
272
Contents of the spermatic cord?
```
3 arteries (testicular, ductus deferens, cremasteric)
3 nerves (genital branch of genitofemoral, cremasteric, autonomics)
3 other things (ductus deferens, pampiniform plexus, lymphatics)
3 fascias (external spermatic fascia, cremasteric fascia, internal spermatic fascia)
```
273
What do medullary carcinomas of the thyroid produce?
Calcitonin; opposes PTH action
274
Aortic dissection pathophysiology?
Tear in intima creates false lumen
275
Risk factors for aortic dissection?
Male, age, HTN, CTD e.g. Marfan and EDS
276
Lingual nerve injury during surgery on left SMG symptoms?
Loss of taste and general sensation over anterior 2/3 of left side of tongue
277
Detecting bronchus injury?
Occurs with major blow to chest when glottis closed; may get surgical emphysema. If not detected, will become evidence once air leak persists or gets worse on connecting the chest drain to suction and lung fails to re-expand. Manage air leaks through pleurodesis (obliterate pleural space by adhesion of pleura mechanically or using patches)
278
Presentation of fat embolism?
Multiple trauma patients are at risk. Presentation includes respiratory failure, cerebral dysfunction and petechiae
279
Investigation after USS for work-up of painless jaundice with obstructive bloods and distal CBD obstruction on US?
ERCP - must exclude mass at head of pancreas. ERCP allows visual inspection, cytological brushings and can stent and drain obstructed bile duct (may be able to remove stone if this is present rather than tumour). CT would not allow pathological diagnosis, nor would MRCP
280
How many views in mammography screening?
Two - cranio-caudal and lateral oblique
281
Who is offered standard breast screening?
50-70, 3 yearly.
282
What is triple assessment of breast lump?
Clinical assessment and imaging (mammography +/- USS), histopathology
283
Hemi-section of spinal cord features?
E.g. Brown-Sequard syndrome. Ipsilateral loss of vibration and proprioception and ipsilateral hemiplegia, with contralateral loss of pain and temperature
284
Cauda equina syndrome features?
Compressive lesions at L4/5 or L5/S1; asymmetric weakness, saddle anaesthesia, decreased knee reflexes and radicular pain; eventually bowel and bladder retention
285
Age for lung and heart transplants?
65 is usually upper limit for single or double lung transplant, and 55 for both heart and lung transplants
286
Absolute contraindications for lung transplant?
End-stage liver or renal disease, bone marrow failure (e.g. pancytopenia) active smoking, debilitating psychiatric illness
287
Most common indication for lung transplant?
COPD
288
FEV1 for transplant in COPD?
FEV1 of <25% post bronchodilator is an indicator
289
Extradural haematoma presentation?
Disruption to MMA under pterion; deteriorate over 4-6 hours in adult; get pupillary and limb signs as temporal uncus herniates, compressing CN III with parasympathetic fibres and crus cerebri carrying UMN to contralaterl body. Classically get lucid interval after initial LOC then declining GCS
290
What do the hilar LNs drain?
Lungs
291
What do mediastinal LNs drain?
Trachea and oesophagus
292
Advantage of split-skin graft over full-thickness skin graft?
Split skin graft consists of epidermis and part of dermis from donor side, while full-thickness graft includes full dermis. Split-skin graft has lower metabolic requirements therefore higher chance of survival. Also, donor site in full thickness will need closing which takes longer to heal
293
Ulnar collateral ligament of thumb injury?
Skiers/gamekeepers thumb; abduction force exerted on thumb. UCL of MCP. Get weak pincer grip, reduced ROM of thumb at MCPJ. MCPJ may be swollen with burning pain. Diagnose with lateral stress testing; difficult acutely so can do US/MRI. Treatment for partial tear is immobilisation with thumb spica. If completely ruptured may need surgery as pincer grip important.
294
Ulnar collateral ligament of thumb injury?
Skiers/gatekeepers thumb; abduction force exerted on thumb. UCL of MCP. Get weak pincer grip, reduced ROM of thumb at MCPJ. MCPJ may be swollen with burning pain. Treatment is immobilisation with thumb spica. If completely ruptured may need surgery.
295
Scaphoid fracture Px?
FOOSH, elderly. Pain and swelling in anatomical snuff box, tender over scaphoid tubercle, pain on ulnar deviation of wrist, pain on axial compression of thumb. More likely to be male. Usually little pain and deformity of wrist. Pain worse on wrist and thumb movement. Reduced ROM. Fractures of proximal 1/3 of bone or displaced # are at risk of AVN so need reduction and k-wire insertion
296
Scaphoid fracture Px?
FOOH, elderly. Pain and swelling in anatomical snuff box. Pain worse on wrist and thumb movement. Reduced ROM. Fractures of proximal 1/3 of bone or displaced # are at risk of AVN so need reduction and k-wire insertion
297
EPL strain px?
Usually result of repeated extension of thumb and wrist (bowling, manual labour, gardening). Pain over thumb and dorsal wrist present even without movement, pain worse on palpation and with thumb and wrist extension. Treatment is rest, ice, analgesia.
298
De Quervain's tenosynovitis?
Idiopathic inflammation of EPB and APL, pass through first dorsal compartment. Pain and swelling on lateral aspect of wrist. Finklstein's test (flexion of thumb across palm and then ulnar deviation of the wrist) reproduces this pain
299
Common complication of subdural haematoma?
Recurrent haemorrhage. Get breakdown and organisation of the haematoma, these are attached to the inner surface of the dura and not the arachnoid. This lesion can retract as granulation tissue matures until there is aonly a thin layer of reactive connective tissue (subdural membranes); bleeding occurs from the thin-walled vessels of the granulation tissue
300
What is axonal tearing?
Usually occurs where there is rapid displacement of the head and brain, e.g. high-velocity RTA or significant fall from height
301
Managing BPH?
Initially just monitor, symptom relief with tamsulosin or finasteride, regular PSA monitoring. Can do transurethral resection to relief LUT symptoms in BPH.. Can offer long-term catheter if not fit for surgery, or palliatively in prostate cancer
302
Stercobilin in stool?
In biliary tree obstruction, get reduced bilirubin secretion into duodenum, and therefore urinary excretion of urobilinogen decreased and presence of stercobilin in stools is reduced (clay-coloured stools) (but increased bilirubin in urine giving it dark colour seen in obstructive jaundice)
303
How is urobilinogen produced?
Intestinal bilirubin metabolised by bacterial in distal SI to create urobilinogen, some of which is reabsorbed in EHC and excreted in urine. If obstruction in biliary tree, less intestinal excretion so reduced urinary urobilinogen
304
Pathological features of pulmonary hypertension?
Medial hypertrophy of vasculature, arterial fibrosos and narrowing of arterial lumen leading to arterial thrombosis in lungs. Plexogenic pulmonary arteriopathy (tufts of endothelial proliferation) prominent in primary pulmonary hypertension. All this leads to hypertrophy of RV.
305
What is ARDS?
Rapid onset of resp. insufficiency secondary to diffuse alveolar damage. Alveoli filled with proteinaceous debris and desquamated alveolar lining cells and alveolar septae lined by hyaline membranes
306
Lung findings in Goodpasture's?
Lungs filled with fresh haemorrhage and haemosiderin-laden macrophages
307
Non-erosive arthritis most commonly seen in which patients?
SLE patients.
308
Infective lactational mastitis?
Mainly first 12 weeks of breastfeeding. Get pain, tenderness, worse when breastfeeding, swelling and (wedge-shaped) erythema, fever, malaise, rapid onset, usually unilateral. Occurs because get nipple trauma, then milk stasis and infection. CFs are redness, breast pain, fever and chills. Most are secondary to S. aureus. Give oral fluclox and continue breast-feeding. If allergic, macrolides. Culture breast milk if recurrent and adjust Abx accordingly.
309
Infective lactational mastitis?
Mainly first 12 weeks of breastfeeding. Occurs because get nipple trauma, then milk stasis and infection. CFs are redness, breast pain, fever and chills. Most are secondary to S. aureus. Give oral fluclox and continue breast-feeding. If allergic, macrolides. Culture breast milk if recurrent and adjust Abx accordingly.
310
History and presentation of vocal cord nodules?
Aka singer's nodules; small hard growths on vocal cords caused by voice abuse. Conservative = rest and speech therapy. Surgical excision may be needed
311
Laryngeal carcinoma?
Most commonly SCC; middle aged or older, mostly men. Smoking and alcohol RFs. May have weight loss and dysphagia.
312
MND and voice/speaking?
Presents with dysarthria rather than dysphonia
313
Managing abrupt drop in urine output in catheterised patients with history of haematuria?
Most likely caused by clot causing obstruction in tube and retention; flush catheter with 50ml of saline to dislodge clot. Do not use litres as this will damage bladder and healing in some patients
314
Next step in 13 year old with very likely torsion symptoms and examination?
No investigations; just take to theatre immediately
315
Differentiating torsion from orchitis or epididymitis?
Orchitis is milder pain; epididymitis similar symptoms but improved by raising testicle, unlike in torsion. Epididymo-orchitis mainly third decade and above, torsion more in under 20s.
316
Differentiating torsion from orchitis or epididymitis?
Orchitis is milder pain; epididymitis similar symptoms but improved by raising testicle, unlike in torsion
317
Raised ALP in UC patients?
Likely PSC. 2/3 PSC patients have UC, 5% UC get PSC
318
How does lunate injury occur and present?
Fall on outstretched arm with forced wrist dorsiflexion. Uncommon fracture, common dislocation. Lunate broader anteriorly than posteriorly so vulnerable in FOOH. Present with pain and marked swelling on anterior (volar) aspect of wrist. Compresses median nerve so get numbness and paraesthesiae in thumb/index/middle/radial ring fingers
319
How does lunate injury occur and present?
Fall on outstretched arm with forced wrist dorsiflexion. Uncommon injury. Lunate broader anteriorly than posteriorly so vulnerable in FOOH. Present with pain and marked swelling on anterior (volar) aspect of wrist. Compresses median nerve so get numbness and paraesthesiae in thumb/index/middle/radial ring fingers
320
Causes of aortic stenosis?
Rheumatic fever, elderly (calcification), congestive heart failure
321
Examination features of aortic stenosis?
PALE PETS
Pulse pressure narrow
Apex beat forceful, not displaced
Left ventricular outflow obstruction, LVH and enlarged coronary arteries
Ejection click may be heard from biscupid valve
Pulsus alternans
Ejection systolic murmur radiating to carotids
Thrill palpable in aortic area
Slow rising carotid
322
Cx of aortic stenosis?
Sudden death, LV failure, arrhythmias, MI, Stokes-Adams attacks (collapse without warning with seconds of LOC)
323
Spinal anaesthetic in patients with aortic or mitral stenosis?
These are relative contraindications, because they are fixed cardiac output states which, in the presence of a sympathetic block produced by the spinal anaesthetic may lead to profound hypotension
324
Features of Paget's disease?
Previously asymptomatic, now has bone and joint pain, no worsening joint pain. Calcium and PO4- normal, raised ALP. (Isolated raised ALP). Caused by environmental and genetic factors. Can be asymptomatic for years. Get excessive bone breakdown and disorganised formation, leading to pain, deformity, fracture, arthritis. May affect tibia, femur, pelvis, lumbar spine and skill. If affects skull, may get frontal bossing, hearing loss, headaches. Rx = bisphosphonates and calcitonin.
325
Features of Paget's disease?
Previously asymptomatic, now has bone and joint pain, no worsening joint pain. Calcium and PO4- normal, raised ALP. Caused by environmental and genetic factors. Can be asymptomatic for years. Get excessive bone breakdown and disorganised formation, leading to pain, deformity, fracture, arthritis. May affect tibia, femur, pelvis, lumbar spine and skill. If affects skull, may get frontal bossing, hearing loss, headaches. Rx = bisphosphonates and calcitonin.
326
Biochemistry of primary hyperparathyroidism?
High calcium, low PO4-, normal ALP.
327
Biochemistry in osteomalacia?
Calcium and PO4 low, ALP raised
328
Which structure is related to the submandibular duct and therefore prone to damage during surgery?
Lingual nerve
329
What nerve is at risk when making initial incision for SMG excision/
Mandibular branch of facial nerve; this is why you make the incision two finger-breadths below the inferior border of the mandible (nerve lies just inferior to inferior border)
330
Smith's fracture?
Distal radial fractures with volar displacement of distal fragment (reverse Colles'). FOOSH in flexion.
331
Barton's fracture?
Distal radius intra-articular fractures with radiocarpal dislocations
332
Galeazzi fracture?
Fracture of radial shaft with distal radioulnar dislocation
333
Monteggia fracture?
Proximal ulnar fracture with dislocation of radial head
334
Maintenance fluid calculation?
30ml/kg/day
335
When is urgent AAA repair indicated?
High risk for rupture e.g. symptomatic or evidence of rapid expansion. If big and stable, elective repair
336
Most common cause of acute burns in adults and children?
Hot water spills and scalds (followed by contact burns, then flame and flash burns)
337
Causes of pyrexia post-op?
Atelectasis (1-2 days), wound infection (7-8 days), PE (9-10 days), anastomotic leak (5-6 days), HAP (3-4 days)
338
Presentation of atelectasis?
Commonly 1-2 days post-operatively. SOB and pyrexia. Commonly due to positive pressure ventilation in GA. Treated with salbutamol and saline nebs + chest physiotherapy
339
Name a syndesmosis?
Inferior tibiofibular joint
340
Name a synchondrosis?
First rib and sternum (first sternocostal)
341
Name a secondary cartilaginous joint?
Pubic symphysis
342
Otosclerosis?
Common AD disorder, conductive hearing loss, characteristically worse during pregnancy. Has incomplete penetrance so may be no FHx. Causes fixation of the stapes. Treatment includes hearing aids, sodium fluoride, surgery (stapedectomy or stapedotomy). See "Carhart notch" on bone conduction audiometry.
343
Structure at risk when making lumbar incision below the 12th rib?
Costodiaphragmatic recess
344
Presentation of hip dislocation?
Internally rotated leg. Head of femur most often lies posterior to acetabulum. Rare to dislocate non-prosthetic hip without significant trauma.
345
Managing renal trauma with large haemotoma
May need transfusion. If unstable, do explorative laparotomy and may need nephrectomy
346
Complications of renal trauma?
Perinephric abscess, hypertension, chronic renal failure, urinoma, delayed haemorrhage
347
Presentation of splenic rupture?
LUQ pain, shoulder tip pain, hypotension. Disruption of splenic parenchyma on CT
348
Risk factors for male breast cancer?
Increased age, radiotherapy exposure, family history of breast cancer, high oestrogen levels (liver cirrhosis, obesity), Klinefelters, damage or malfunction of the testes
349
Daily needs of potassium?
1mmol/kg/day
350
Risk factors for post-operative nausea and vomiting used in Apfel score?
Non-smoking, history of PONV or motion sickness, post-operative opiod admission, female sex. Others not used in score include GA, increased duration of anaestheisa, use of volatile anaesthetics and NO and surgery type (cholecystectomy, laparoscopy, gynaecological surgery), younger age
351
Spinal TB on MRI?
Multiple, ring-enhancing lesions
352
What is Trousseau's sign?
Carpopedal spasm caused by inflating blood pressure cuff above systolic pressure for three minutes; indicates hypocalcaemia (along with Chvostek's sign); do ECG if find (may see prolonged QT_ and venous gas urgently
353
What ECG abnormalities can hypocalcaemia cause?
Prolonged QT and potentially torsades
354
What structures may be damaged by fractured surgical neck of humerus?
Posterior and anterior circumflex arteries, axillary nerve
355
Duodenal ulcers and blood supply?
Mostly occur at D1 (first part), where the gastroduodenal artery travels just posterior; can erode and get haematemesis
356
First-line investigation for suspected SAH?
CT without contrast (shows hyperdense area in basal cisterns); if confirmed do angiography to find location and treat as appropriate e.g. clipping. Reduce occurrence of secondary complications too.
357
When would you do LP for suspected SAH?
If suspect SAH and CT head normal (2% cases); if no contraindications do LP after 4-12 hours to diagnose xanthochromia reliably (simple microscopy of blood cells could be from traumatic tap)
358
Hereditary haemorrhagic telaniectasia, with exertional dyspnoea and haemoptysis?
Likely to be pulmonary AV malformation; may get sharply defined lesion on CXR
359
Work-up for male infertility?
First do semen analysis (volume, pH, sperm concentration, total sperm number, total motility, vitality and morphology); then can do testosterone level, genetic testing (e.g. XXY), FSH level, testicular biopsy (e.g. if have azoospermia). Can also collect sperm for IVF in biopsy
360
Train of four testing?
Method used in anaesthesia post-operatively to determine muscle contraction and the presence of NM blockade. Four consecutive electrical stimuli given, should get four equal contractions.
361
Most common locations for renal calculi?
Pelvi-ureteric junction, within ureter at pelvic brim, vesico-ureteric junction (most common site)
362
Where does medial breast drain to and significance?
Enter thorax to drain into internal mammary LNs. Very hard to treat thoracic nodes, so fortunately these cancers (medial) are rarer. Get more drainage away from axilla etc. when blocked by malignancy or damaged by treatment
363
Main blood supply to breast?
Lateral thoracic artery (branch of axillary)
364
Globus pharyngeus?
Subjective sensation of lump or mass in throat; diagnosis of exclusion based on history and exam. sensation may arise from GORD or frequent swallowing associated with anxiety etc. Assoc. with GORD, raised UOS pressure, pharyngitis, tonsillitis, postnasal drip etc. Symptoms not worse during swallowing, food does not stick, eating and drinking provide relief. Treat cause.
365
Red flags for laryngeal cancer?
Dysphonia/aphonia, dysphagia, dyspnoea, otalgia, aspiration, blood-tinged sputum, fatigue, weakness, cachexia, neck mass
366
Typical and atypical GORD symptoms?
Typical is heartburn, regurgitation, dysphagia; atypical = extraoesophageal e.g. coughing, chest pain, wheezing
367
Rheumatoid and anaesthetic death?
Prone to atlanto-axial subluxation which can be induced by intubation, causing death/quadriparesis
368
Which anaesthetic can cause adrenal insufficiency?
Etomidate
369
Managing mastitis in non-lactating patient?
Always secondary to infection so needs antibiotics; if breastfeeding may just be milk stasis so can be treated conservatively in some cases
370
Inflammatory breast cancer presentation?
Swollen, erythematous, hard breast. Develops quickly, often changes to nipple.
371
Parotid duct landmark?
1/3 way down line from tragus of ear to philtrum of lip
372
Where does parotid duct open in mouth?
Opposite second upper molar
373
Tacrolimus side effects?
Nephrotoxicity, diabetes mellitus, neurotoxicity; typically do bloods every 2-3 weeks after transplant then monitor.
374
Which drugs can cause gingival hyperplasia?
Phenytoin, CCBs, ciclosporin
375
Which drugs can cause hirsutism?
Ciclosporin, phenytoin, androgen agonists such as danazol
376
Which drugs can cause osteoporosis?
Corticosteroids, heparin derivatives, thiazide diuretics
377
Which drugs can cause psychosis?
Corticosteroids, cannabis, hallucinogens as phencyclidine
378
Clinical features of PBC?
Xanthelasma, jaundice, pruritus, raised LFTs
379
Endovascular or open surgery?
Endovascular repair has lower mortality rates but higher long-term complications
380
Most common site of acute osteomyelitis in children?
Metaphyses of tibia
381
X-rays in acute osteomyelitis?
May be normal for first 2 weeks; bone scans may show abnormalities in this case
382
Risk factors for acute osteomyelitis?
Older age, debilitation, haemodialysis, sickle-cell disease, IV drug use
383
Most common side of acute osteomyelitis in adults?
Vertebrae, humerus, maxilla, mandibular bones
384
Ways of bacteria causing osteomyelitis?
Haematogenous most common, then local spread (contiguous spread) and following penetrating trauma including dental procedures
385
Organisms causing osteomyelitis?
In adults and children, most common S. aureus, GAS, H. influenze and enterobacter; in sickle-cell Salmonella is most common
386
Features of acute supraspinatus tendon tear?
Pain at rest, pain in anterior and lateral aspects of shoulder, pain referred to neck, pain at night, limited abduction of affected shoulder (painful arc), pain intensified with abduction against resistance, pain on internal rotation (Hawkins Kennedy impingement sign positive)
387
Managing suspected supraspinatus tear?
NSAID, ultrasound. Extensive tears need surgery, partial care conservatively
388
EVAR vs TEVAR?
TEVAR done for thoracic aorta aneurysms
389
Presentation of suprascapular nerve injury?
Difficulty in first thirty degrees of abduction, painless, may be rucksack wearing (neuropraxia). Supplies supra and infraspinatus. Supraspinatus muscle damage would be painful, not just weak.
390
Methods of damaging long thoracic nerve?
Trauma in sports (superficial), radical mastectomy and axillary clearance, prolonged carrying of heavy bag
391
What is Courvoisier's law?
Palpable gall bladder in presence of painless jaundice unlikely to be due to gallstones
392
Complications of gallstones?
Acute pancreatitis, biliary colic, cholecystitis, gallbladder abscess, bowel obstruction
393
ERCP vs cholecystectomy for gallstones?
ERCP can relieve acute obstruction with sphincterotomy but does not remove cause; cholecystectomy is definitive
394
Joints most commonly involved in OA?
Hips, knees, lower lumbar and cervical vertebrae, PIPs and DIPs, first CMC joints, first tarsometatarsal joints
395
What are Heberden's nodes?
Prominent osteophytes at DIPs, characteristically in women not men
396
Presentation of gout?
Mostly only one joint, usually first MTP. Get swelling and deformity with joint destruction
397
Pseudogout?
Calcium pyrophosphate dihydrate deposition, elderly people, previously injured joints, most commonly knee, acute attacks with marked pain, meniscal calcification, joint space narrowing (radiodense deposits in menisci/other cartilage)
398
Investigation for planning AAA repair?
Can diagnose clinically, but do CT do asses dimensions and anatomical relations especially re renal arteries. If these are not affected, may be amenable to EVAR
399
IV arteriogram in AAA rupture?
Completely inappropriate as contrast will flow into cavity and cause peritonitis
400
Managing epistaxis?
First aid measures normally okay; if recurrent/prolonged then do cautery with silver nitrate if anterior bleeding point seen (e.g. Little's area). Bloods etc. likely to be normal if young and otherwise well. If cautery does not work or cannot see origin of significant bleed, insert nasal tampon and refer to ENT
401
Facial nerve palsy and lump at angle of jaw?
Highly suggestive of parotid gland adenocarcinoma. Facial nerve passes through parotid, cancer can invade and get palsy. Poor prognosis if facial nerve involved. Could also be sarcoidosis.
402
Why is PT increased in obstructive jaundice?
Vitamin K absorption impaired; give vit K to correct
403
Bloods in haemolytic anaemia?
Mixed conjugated and unconjugated hyperbilirubinaemia, with no ALP
404
Rule of 9s for burns?
9% head, 18% anterior torso, 18% posterior, 9% each arm, 9% each leg, 1% genitalia/perineum. Palm = 1% as rule
405
Zollinger-Ellison syndrome?
Gastrin-secreting tumour; triad of peptic ulceration, gastric acid hypersecretion and non-beta-cell islet tumour of pancreas. Mostly aged 30-50. 90% gastrinomas are on head of pancreas and proximal duodenal wall (most common). Associated with MEN syndrome.
406
When are CT/MR used in scaphoid #?
If second series of xrays (after 10-14 days) indeterminate but clinical suspicion remains
407
Minimal acceptable urine output?
0.5ml/kg/hour
408
Keloid scar?
Abnormal proliferation of scar tissue at site of cutaneous injury, does not regress, grows beyond original margins. More pigmented skin is main risk factors. Rare at extremes of age. Most frequently upper chest, shoulders, earlobes. If under tension while healing, infected, burns or acne scars = particularly likely
409
Keloid scar vs hypertrophic scar?
Keloid grows beyond original margins, hypertrophic does not, and may reduce over time
410
Nerve affected in hamate #?
Ulnar nerve
411
Most frequently fractured carpal?
Scaphoid
412
When is total hip replacement done?
Electively for severe OA, can be done as emergency for fracture in patient with good baseline
413
When do hemiarthroplasty of hip?
(Austin Moore hemiarthroplasty); head of femur replaced but acetabulum intact. Done in emergency if have poor baseline i.e. unlikely to outlive ten year arthroplasty span
414
Fibroadenomas?
Small, discrete, benign; most common between 16-24 years; grow under influence of oestrogen, can grow during menstrual cycle and pregnancy. Can be multiple. Smooth, lobulated, usually 2-3cm. Triple assessment.
415
Management of fibroadenomas?
If under 25, usually just observe, if 25-35, conservative, if over 35, excise. Excise at any age on patient request.
416
Breast cysts?
Mostly perimenopausal (35-50); rare after menopause unless on HRT. Discrete, tender lumps, cannot be distinguished from tumours. Most regress spontaneously, others after aspiration. If persists after aspiration or aspiration blood-stained, refer for triple assessment
417
Fibrocystic disease?
Usually women 20-50; get nodularity ('lumpiness'), pain and tenderness. Symptoms variable and greatest about a week before menstruation, decrease when it starts. Rx is analgesia and good bra!
418
Achalasia?
Motility disorder of the oesophagus, causing failure of LOS to relax. Dysphagia and regurgitation. Liquids and solids. Can be primary or secondary to oesophageal cancer, chagas. Treatment of primary achalasia if fit is pneumatic dilatation of LOS. Only done if good surgical candidates as risks perforation. If not a good candidate, then can give sublingual ISDN, nifedipine as bridge to definitive treatment, botulinum A also. Gastrostomy can be done if failed initial management and poor surgical candidates with severe achalasia.
419
Placing emergency surgical airway?
Cricothyroid membrane. Mostly avascular. (Cricothyroidotomy).
420
Land-mark for emergency tracheostomy?
Anterior midline between second and third tracheal cartilages
421
First-line therapy for TM perforation?
Watch and wait, most heal in 6-8 weeks
422
Pes planovalgus?
"Flat foot"; decrease in medial longitudinal arch. Mostly resolves spontaneously, usually bilateral. May get arch or pre-tibial pain. If asymptomatic, usually resolves spontaneously and arch develops with age. If symptomatic, use athletic heels, or may need orthotics e.g. heel cups. Rarely need surgery.
423
Definitive treatment of PSC?
Liver transplant. Get sclerosis of intra and extra hepatic ducts at multiple sites ("beading") so stenting is pointless. May get recurrence in transplanted liver.
424
Vitamin supplementation in PSC?
Get fat-soluble vitamin deficiency so supplement these
425
Which recurrent laryngeal nerve is most likely to be damaged?
Left, as loops down over arch of aorta so can be affected by mediastinal tumours
426
Presentation of anterior shoulder dislocation?
Hold arms externally rotated and slightly abducted (posterior = internally rotated or adducted; less common. Seizures or ECT). Can injury axillary nerve so get deltoid weakness and numbness on sergeants patch. Acromion becomes prominent with gap beneath.
427
Supraspinatus tendonitis?
Get painful arc (70-120)
428
Africa patient with gallstones that are greenish-black, multifaceted, 0.5-1cm?
Likely to be sickle cell anaemia. Get haemolysis, hyperbilirubinaemia, and pigment stone formation.
429
CT appearance of extradural?
Convex collection respecting suture boundaries; Rx is craniotomy and evacuation
430
Red flags for back pain?
Thoracic pain, age <20 or >55 with new pain, fever/weight loss, any history of cancer, progressive neuro deficit, bladder or bowel, recent serious infection or illness, recent serious infection or illness, night pain, history of IVDU, long standing steroid use
431
What does positive straight leg raise indicate?
Lumbosacral nerve root irritation e.g. due to disc prolapse
432
Anterior inferior cerebellar artery stroke?
Vertigo and ipsilateral hearing loss
433
Posterior inferior cerebellar artery stroke?
Lateral medullary syndrome aka PICA syndrome; get contralateral pain and temperature loss on body, and ipsilateral on face. May have ataxia, vertigo.
434
Site of AAA and repair?
If involves renal arteries, cannot do EVAR
435
Who needs insulin sliding scale?
Any surgical patient on insulin who will miss more than one meal or who is having abdominal surgery (likely to result in ileus). Stop sliding scale once eating, drinking and taking usual insulin.
436
Cervical spondylosis and electric-current-like symptoms?
Get osteophytes, compression of cervical cord, and Lhermitte phenomenon
437
Three causes of Lhermitte?
MS, osteophytes compressing cervical cord, midline disc herniation
438
Sialothiasis presentation?
Most common in SMG. Pain and swelling after eating. Mostly men over the age of 40. Predispose to infection.
439
Most appropriate investigation for acutely ischaemic limb?
Angiography; shows site of occlusion so can formulate treatment strategy. ABPI not good acutely. Doppler good but not as good.
440
Where does dissection of descending aorta propagate to?
Distally along left lateral side of aorta to left renal artery. Proximally to aortic root (get haemopericardium, aortic regurgitation, cardiac tamponade). Can also rupture into left pleural cavity (close to descending aorta) and left hemithorax
441
Time frame of swelling in joint after injury?
0-2 hours = rapid = haemarthrosis due to cruciate ligament rupture; 6-24 hours = gradual = effusion due to meniscal injury
442
Presentation of cardiac tamponade?
Beck's triad (hypotension, distended neck veins, muffled heart sounds), tachycardia, raised JVP, hypotension. May get pulsus paradoxus (abnormally large decrease in stroke volume and systolic BP during inspiration, electrical alternans, decreased GCS, Kussmaul's sign. Do ECG, CXR, echo.
443
Risk factors for oesophageal carcinoma?
Smoking, alcohol, Barret's oesophagus, obesity, nitrosamine exposure, Plummer-Vinson syndrome
444
Causes of SAH?
Intracranial aneurysm (most common), AV malformation, traumatic, anticoagulation, idiopathic
445
What type of intracranial bleed does hypertension cause?
Intraparenchymal
446
Structures most likely to be damaged by supracondylar humeral fracture?
Brachial artery, ulnar nerve
447
AFP and seminomas?
Seminomas do not produce elevated AFP. If it is raised, treat as non-seminamatous tumour, or teratoma.
448
DD acute cholecystitis and biliary colic?
Raised inflammatory markers and HR in cholecystitis
449
Who needs hospital admission and IV Abx for tonsillitis?
Breathing difficulty, clinical dehydration, pertonsillar abscess/cellulitis/parapharyngeal abscess/retropharyngeal abscess, Lemierre's syndrome, marked systemic illness
450
Ameobic abscess?
RUQ pain, swinging fever, tenderness. May occur after amoebic dysentery (not always) which presents with slowly increasing diarrhoea which can be profuse and bloody. Get anchovy sauce pus in liver. Differential is streptococcal species (green/yellow pus). Single well-defined lesion. Treat with metronidazole.
451
Hydatid disease?
Echinosis. Progressive liver symptoms over years. Rapid worsening with cyst rupture or infection. Chronic tapeworm infection (Echinococcus granulosus). Sheep is host so sheep-farming is risk. Calcified, multiple cysts in liver. Treat with excision and albendazole.
452
Spleen dimensions, weight and surface anatomy?
Odd numbers 1,3,5,7,9,11
| (dimensions are 1 inch x 3 x 5), weight is 7 ounces, underlies ribs 9-11
453
Assessing perforation with radiograph?
Do erect CXR, sat up for 10-15 minutes before. If cannot sit up, can do lateral decubitus abdominal film, but most likely just do CT CAP
454
Subscapularis tear?
Weak internal rotation, increased passive external rotation, positive belly press and lift-off test
455
Features of multiple myeloma?
Bone pain (lytic lesions), confusion (calcium), pancytopenia with macrocytosis, renal impairment, hypercalcaemia (raised ALP), ESR >100. Differential is myelofibrosis (rarer)
456
Ix for myeloma?
Plain radiographs of all painful bony areas, urinary Bence-Jones, serum electrophoresis
457
Fat necrosis of breast?
Usually a consequence of breast surgery or direct trauma to breast
458
Differentiating between infected sebaceous cyst and breast abscess?
Cyst is skin lesion, may have punctum, attached to skin. Abscess is in breast parenchyma.
459
Tietze syndrome?
Costochondritis; inflammation of costochondral junctions at the edge of the sternum following a viral illness.
460
Testicular cancer presentation and ultrasound?
Dull, painless testicular mass which cannot be separated from the testicle on physical examination. Get well-defined hypoechoic lesions without cystic areas. Spreads haematogenously from testicular veins to renal veins/IVC
461
Parkland formula for burns patients?
4ml/kg * % burn. = fluid requirements for first 24 hours. Give half over first 8 hours and half over 16. Warm fluids first.
462
Indications for x-ray of ankle injuries in ED?
Ottawa ankle rules.
If unable to weight-bear both immediately after injury and at the time of assessment, or tender over posterior aspect of medial or lateral malleoli, navicular bone or 5th metatarsal, get xray.
463
What does French gauge mean for catheters?
Size in french unit is roughly the external circumference in millimetres
464
Pancreatic divisum?
Congenital abnormality of the pancreas; ducts of dorsal and ventral buds fail to fuse, get problematic pancreatic duct drainage and get recurrent pancreatitis in young people
465
Pancreatic pseudocyst?
Collection of fluid usually in lesser sac. Can occur after episode of pancreatitis. Get necrotic debris collecting in lesser sac. Can cause symptoms by local pressure effects e.g. vomiting, gastric outlet obstruction. If symptomatic, can drain cyst with endoscopy. Can become infected and get sepsis/haemorrhage.
466
Pseudocysts and necrotic pancreatic collections?
Both occur after acute pancreatitis. Pseudocyst is liquid only, necrotic collection is solid so need different treatment.
467
Chronic pancreatitis?
Does not result in rise in serum amylase. Get calcification on CT/xray.
468
Why give warfarin with LMWH for PE?
LMWH takes 48-72 hours to take effect, so give warfarin at the same time.
469
Rivaroxaban and LMWH?
Must not be prescribed concurrently
470
Who gets heparin not LMWH for PE?
Patients with renal impairment
471
Causes of acute urinary retention?
Infection, constipation, acute on chronic retention, recent surgery (anaesthesia and pain)
472
Investigating colo-vesical fistula?
Present with pneumaturia and faeces in urine. Often diverticular, can be tumour. Contrast enema may help.
473
Testing radial nerve?
Sensory at first dorsal webspace of hand, motor by extending wrist against resistance
474
Controlling indirect inguinal hernia?
Ask patient to reduce, place two fingers over deep ring (half inch above midpoint of inguinal ligament [ASIS to pubic tubercle]), ask to cough. If protrudes, more likely to be direct.
475
Characteristics of venous ulcer?
Indolent, shallow, moist granulating floor with associated varicosities and surrounding pigmentation. Get poor skin nutrition because of induration and pitting oedema.
476
Treating and preventing recurrence of venous ulcers?
Limb elevation, wound toilet, non-stick dressing, four layer bandaging (+/- split-skin grafting). Treat varicose veins surgically.
477
Pathophysiology of all four types of chronic leg ulcers?
1. Ischaemic (poor tissue perfusion as result of pressure)
2. Neuropathic (anaesthetic, caused by peripheral nerve degeneration seen in leprosy and diabetes)
3. Tropical ulcers (infections by bacteria or fungi)
4. Venous (chronic venous stasis)
478
Malignant complication of chronic venous ulcers?
Marjolin's ulcer can arise (SCC)
479
Causes of direct and indirect inguinal hernias?
Direct most commonly seen i elderly, associated with straining, higher risk if builder etc. Less common. Presents as lump in groin. Can extend into scrotum if enlarged or chronic.
Indirect more common. Pain, dragging. FHx, prematurity, abdominal wall defects, patent processus vaginalis.
480
Spigelian hernia?
Rare, at lateral edge of RA at semilunar line. Occurs through defect in Spigelain fascia. Seen in over 50s.
481
Treatment of choice for 92 year old with displaced subcapital #NOF?
Intracapsular, blood supply impaired so must replace head. Just do hemiarthroplasty if elderly.
482
Treatment of choice for 24 y/o motorcyclist with closed fracture of femoral shaft?
Intramedullary nailing (stabilises fracture, promotes union, allows early mobilisation and rehab)
483
Nine month old with spiral fracture of femoral shaft?
Gallows traction very effective under one
484
Treating 57 year old with undisplaced, intertrochanteric fracture?
Extracapsular, undisplaced so do DHS or cephalomedullary nail
485
First investigation in any prostate condition?
Serum PSA. If elevated, urology referral. Can be elevated in infection, post-DRE, urinary retention.
486
False aneurysm?
Blood collects around vessel wall; not surrounded by arterial wall so is false. Can be iatrogenic after angiograms etc.
487
Adductor canal boundaries and contents?
Bound posteriorly by adductor longus and magnus, anterolaterally by vastus medialis and anteriomedially by sartorius. Contains femoral artery and vein, branch of femoral nerve supplying vastus medialis, and saphenous nerve
488
Unconjugated jaundice and urine?
Will be no bilirubin in urine as is insoluble
489
Dubin-Johnson syndrome?
Congenital failure of excretion of conjugated bilirubin into bile canaliculi so caused conjugated jaundice
490
Intrahepatic cholestasis?
Get raised serum bilirubin, bilirubin in urine, mildly elevated ALP and high AST (reverse in extrahepatic). Causes are drugs, alcohol, infective hepatitis or liver lesions
491
Haemolytic anaemia and bilirubin picture?
Classically get raised serum bilirubin, anaemia, no urinary bilirubin. However, if slow, and can keep up, may get very mild conjugated hyperbilirubinaemia wiht bilirubinuria
492
Mesenteric ischaemia?
Patients who are arteriopaths. Risk factors include AF, age, smoking, DM. Get post-prandial pain, weight loss. May get "thumbprinting" on AXR if progresses to mesenteric ischaemia. Gases show met. acidosis with profound base deficit. Diagnosis of exclusion.
493
SMG infection?
Get stone in submandibular duct (pain, worse around mealtimes, swelling that comes and goes) then obstruction (fixed, tender swelling), unpleasant taste in mouth. Pus behind lower incisors, swelling in anterior triangle. SMG stones most common because of length and tortuosity of duct. Management is antibiotics and ENT referral for removal
494
Where is cystic hygroma found?
Posterior triangle of neck (SCM, trapezius, clavicle). Transilluminates, soft, poorly-compressible, infants.
495
Mechanism for peau d'orange?
Lymphatic obstruction by malignancy causing lymphatic oedema
496
Duct ectasia?
Age-related, ducts shorten and dilate so nipple inverts (slit-like). In malignancy, nipple appears retracted and pulled in.
497
Branchial cyst?
Usually get cystic lesions in upper anterior triangle, third decade. Aspirate shows cholesterol crystals.
498
Pulsatile neck mass?
Either carotid aneurysm or carotid body tumour. Aneurysm is fluctuant, may get dysphagia, associated with bruit. Can present with TIA/CVA, Anterior triangle lump.
499
Two settings for end ileostomy?
Panproctocolectomy for UC or FAP, or emergency where unsuitable to form distal anastomosis e.g. severe sepsis
500
Loop colostomy?
Proximal opening drains faeces, and distal mucus. Usually a temporary stoma to protect distal anastomosis, or relieve distal obstruction from CRC (palliative and not temporary). LUQ or RUQ.
501
End colostomy?
Usually LHS, usually sigmoid. Usually permanent. Distal end of colon is blind loop.
502
Loop ileostomy?
Usually done to protect distal anastomosis and is temporary.
503
Mucous fistula?
Can be anywhere on abdomen, usually LIF, involves single lumen of bowel brought to surface to collect mucus in the distal part of the bowel. Is accompanied by colostomy or ileostomy to collect fluid/faeces.
504
Gastric vs duodenal ulcer?
Duodenal worse when hungry, better when eating. Upper GI flatulence i.e. burping associated with duodenal. Also C14 breath test more likely to be positive in duodenal.
505
Meckel's diverticulum?
Asymptomatic (usually) lesion in ileum, classically 60cm from ileocaecal valve. In adults is diagnosis of exclusion. Demonstrate radiologically using technetium-99 (concentrates in gastric mucosa)
506
What predisposes to SCC and adenoncarcinoma of oesophagus?
Achalasia and alcohol. Most commonly affects upper and middle oesophagus. Barrets and GORD predispose to adenocarcinoma (lower).
507
Management/surveillance of Barretts?
Pre-malignant for adenocarcinoma. Should be on acid-lowering therapy and 2-5 yearly surveillance (depending on length of segment affected). Treat with ablation and excision if needed. Get metaplasia of squamous epithelium to glandular
508
Manifestations of haemochromatosis?
ED, diabetes, cirrhosis, arthritis
509
Weber's lateralising to one ear?
That ear may have conductive loss (so bone conduction preferred) or other ear has SN loss
510
Triangle of Calot boundaries and use?
Hepatic duct medially, cystic duct laterally, inferior edge of liver superiorly; dissect into in cholecystectomy to identify cystic artery and cystic duct for ligation
511
Conservative measures in PVD?
Stop smoking, close monitoring of DM/HTN, exercise to develop collaterals, diet (low chol), weight loss, foot care (podiatry/chiropody, protective footwear)
512
Treating subdural?
Burr hole drainage if symptomatic. Give mannitol if signs of raised ICP (reduced GCS, low pulse rate, high BP, papilloedema)
513
Treating SAH?
Endovascular coiling, nimodipine infusion (reduce vasospasm which is a Cx which can cause cerebral ischaemia)
514
Reynold's pentad?
Charcot's triad, shock, altered mental state = severe ascending cholangitis
515
Murphy's sign?
Palpating RUQ; inspiration stopped as inflamed GB descends and contacts palpating hand. Negative on LUQ. Suggests acute cholecystitis. Pain more constant in this than in biliary colic.
516
Signs in appendicitis?
Rovsing = palpation of LLQ produces pain in RLQ.
Psoas = RLQ pain with extension of R hip/flexion against resistance)
Obturator (RLQ pain with internal/external rotation of flexed right hip.
More common = rebound tenderness, guarding and rigidity
517
Costovertebral angle tenderness?
Positive in pyelonephritis aka Murphy's punch sign
518
Kehr's sign?
Positive Kehr's sign seen in splenic rupture. Acute shoulder tip pain due to irritation of peritoneum
519
Causes of CES?
Disc herniation/prolapse, malignancy, epidural abscess/haematoma
520
What is compressed in CES?
Multiple lumbosacral nerve roots distal to conus medullaris (termination)
521
Managing CES?
Treat nerve root ischaemia with vasodilators e.g. lipoprostaglandin E1. Treat with antibiotics if infectious, chemo/radio if neoplasm.
However, urgent surgical decompression within 24 hours of initial medical management
522
Clinical features of CES?
Leg weakness, sphincter disturbance (urinary retention, post-void residual incontinence), decreased rectal tone, sexual dysfunction, saddle anaesthesia, bilateral absence of ankle reflexes. May not have leg pain. Diagnose by MRI/CT.
523
Investigations for presence of distal metastases in breast cancer?
LFTs, CXR, US/isotope liver scan, radionuclide bone scan, BM biopsy, brain scan if indicated
524
Principle of breast cancer treatment?
Mastectomy or breast conserving surgery with sentinel needle biopsy +/- axillary clearance, radiotherapy after wide local excision to breast and to axilla, adjuvant chemotherapy based on tumour grade and nodal status
525
Managing acute sinusitis?
If <10 days symptoms, likely associated with cold. If >10 days, may be viral or bacterial, but oral antibiotics not usually indicated as bacterial self limiting. Cna give high dose intranasal steroid if more than 10 days, for 2 weeks. Reserve IV Abx for Cx (severe sepsis, periorbital/intraorbital/intracranial Cx).
526
Complications of acute sinusitis?
Severe systemic illness, intra/periorbital (periorbital oedema/cellulitis, displaced eyeball, double vision, opthalmoplegia, new reduced VA), intracranial (swelling over frontal bone, meningitis symptoms and signs, severe frontal headache, focal neurology. Give IV Abx
527
HIV patient with recurrent paranasal sinusitis, febrile episodes, CN III palsy, unstable gait, headaches?
Cerebral abscess; chronic infections from paranasal sinuses produce thrombophlebitis that extends through cribriform plate and infect subdural space. Aspirate, antibiotics accordingly (IV). May need craniotomy if large or multi-loculated.
528
Three ways intracranial abscess can arise?
Extradurally, subdurally or within brain. Scalp infection or open skull fracture causes extradural infection, thrombophlebitis from middle ear or sinus infection can affect subdural (more likely in IC)
529
Managing variceal bleed?
Resuscitate, correct clotting, IV terlipressin, endoscopic band ligation, balloon tamponade using Sengstaken-Blakemore if uncontrolled
530
Chronic bacterial prostatitis?
Considered in men with history of recurrent bacteriuria. The prostate can be source of recurrent UTIs. Middle aged men with relapsing UTIs. E coli typically involved. PSA slightly elevated.
