Revision Flashcards
1
Q
What is the commonest salivary gland malignancy?
A
Adenocarcinoma (remember that 80% of all salivary tumours are Pleomorphic adenoma)
2
Q
In a patient with a ? salivary gland cancer, which nerve must you test?
A
Facial
Ask if any change in hearing or taste?
Look for symmetry
Check facial movement - raise eyebrows, smile, puff out cheeks
Consider doing corneal reflex (affererent = trigeminal, efferent = facial)
3
Q
What is Frey’s syndrome?
A
A complication of surgery to remove parotid tumour. Patient sweats while eating due to abnormal connection between autonomic and facial nerve fibres)
4
Q
Most likely diagnosis in a patient with chest pain, shock and surgical emphysema?
A
Oesophageal perforation - a surgical emergency
5
Q
What is the most common type of hiatus hernia?
A
Sliding accounts for 80%
Part of the gastro-oesophageal junction enters the thorax
Rolling accounts for 5% (with the rest mixed) and describes the proximal part of the stomach, moving into the thorax (higher risk of strangulation)
6
Q
Upper 2/3 oesophagus = squamous
A
Lower 1/3 = adenocarcinoma (barrets)
7
Q
Why are beta blockers used in the prophylaxis of oesophageal varices?
A
Reduce portal pressure
(this is important as each time oesophageal varices bleed, the mortality is 20%
8
Q
What is Heller’s operation used for?
A
Management of achalasia (muscles of stomach and LOS is divided down to the muscosa)
9
Q
Where is the anatomical cut-off for an upper GI bleed?
A
The ligament of Treitz (found at the duodojejunal flexures)
10
Q
Which condition is treated with a Ramstedt pyloromyotomy?
A
Pyloric stenosis
Non-bilious vomit and olive in RUQ
11
Q
What is Meckels diverticulum?
A
Persistence of the vitello-intestinal duct
Problems are mainly ulceration and haemorrhage as many contain gastric mucosa
12
Q
Most common site of diverticulosis?
A
Sigmoid colon
(remember diverticulosis is simply the presence of diverticula)
Itis = inflamed
Diseases = causing pain and change in bowel habit
(gastrograffin enema can be good for detecting diverticulosis)
13
Q
What are the complications of diverticular disease?
A
Perforation Bowel obstruction Haemorrhage Fistula Abscess
14
Q
A Hartmann’s procedure is primarily used for emergency surgery of colorectal tumour/ inflammation. Describe it?
A
Resection of rectosigmoid colon with closure of anorectal stump and formation of an end colostomy
(there is potential for reversal)
15
Q
Which 2 tumour markers are used for bowel cancer?
A
CEA
CA 19-9
16
Q
Duke’s criteria for colorectal cancer
A
A = confined to bowel wall (90% survival) B = through bowel wall (60% survival) C = regional lymph nodes (30% survival) D = distant mets (5% survival)
17
Q
Which gene is faulty in FAP?
A
Autosomal dominant disruption of APC gene
Which is an important tumour suppressor
18
Q
Management of anal fissure?
A
- Examine if possible
- increase fibre and stool softeners
- medical e.g. GTN cream, Botox (helps to relax sphincter)
- surgical for failed medical management
19
Q
What conditions do you have to rule out in a patient with a perianal abscess?
A
1) Cancer
2) TB/ immunosupression
3) Crohns’
The main complication of an abscess is fistula formation
20
Q
What condition needs excluded in a child with a rectal prolapse?
A
CF
21
Q
What are the 2 different types of rectal prolapse?
A
1) Full thickness - prolapse of all layers of the rectum through anus
2) Mucosal - prolapse of rectal mucosa through anus
22
Q
Anal cancer is rare and associated with HPV and receptive intercourse. Histologically what is the most common type?
A
Adenocarcinoma
23
Q
Remember valvulae conniventes are found only in SMALL bowel and cross the entire bowel
A
Haustra are found in LARGE bowel and do NOT cross the entire bowel
24
Q
Red currant jelly stool in a baby?
A
Intussusception
Abdo pain, sausage shaped mass
Surgery only if reduction with an air enema fails
25
How could you differentiate between a mechanical bowel obstruction and an ileus?
History e.g. if just had bowel surgery and no other risk factors —> ileus from touching bowel is most likely
NO bowel sounds - often tinkling in mechanical obstruction
26
What are the 2 main complications of a hernia?
Obstruction
| Strangulation
27
Briefly describe the anatomy of the inguinal canal
Floor = inguinal ligament Roof = internal oblique/ transversus abdominus
Anterior wall = external/ internal oblique
Poster = transversalis fascia
28
What are the contents of the inguinal canal?
Spermatic cord/ round ligament
Genital branch of genitofemoral nerve
Ilioinguinal nerve
29
What is the difference between a direct and indirect inguinal hernia?
Indirect = enters and passes through inguinal canal and can therefore descend into scrotum (LATERAL to inferior epigastic vessels)
Direct = bulge though weakened posterior wall —> cannot descend into scrotum (Medial to the inferior epigastric vessels)
30
Hernia superior and medial to the pubic tubercle = inguinal hernia
Hernia inferior and lateral to pubic tubercle = femoral hernia
(more common in older women)
These require surgery due to the higher risk of strangulation/ obstruction
31
Patient has positive Murphy sign. What is this? How is it performed?
Palpate the gall bladder with 2 fingers
Ask the patient to take a deep breath in - this will push the liver + gall bladder causing pain and sharp stop of breathing in a patient with CHOLECYSTITIS
32
What is the difference between ascending cholangitis and cholecystitis?
Cholangitis = gall stone impacted in CBD —> infection and jaundice (classically jaundice, RUQ and fever)
Cholecystitis = stone impacts and blocks gall bladder outlet
33
Thrombophlebitis migrants = tender nodules in affect blood vessels. What are they associated with?
Pancreatic and lung cancer
34
What is Courvoisiers Law?
In jaundice, if the gall bladder is palpable then it is unlikely to be due to stones
35
Dercums disease?
Typical patient is an obese middle aged female with multiple, tender lipomas
36
What is Fournier’s Gangrene?
Necrotizing fasciitis of the penis/ scrotum
| (more common in alcoholics/ immunosupressed etc)W
37
What is Marjolin’s ulcer?
An SCC which develops in a chronic ulcer
38
Breslow thickness <1mm —> 5 year survival is 95-100%
>4mm —> 5 year survival is <50%
39
1st line treatment for heart failure = ACEI + Beta blocker
2nd line = spironolactone, ARB or hydralazine + nitrate
Digoxin + cardiac re-synchronisation therapy is 3rd line
40
Which additional heart sound is most likely in left sided heart failure?
Third heart sound
41
How is malnutrition diagnosed clinically with regard weight loss?
Unintentional weight loss of >10% within 3-6 months
42
A Whipples resection is used for pancreatic cancers which are operable. The cancer is removed and the remaining pancreas and duodenum is joined. What is the major complication?
A leak of the anastomoses- monitor drain fluid for amylase. If present then discuss with senior and arrange imaging
This can be potentially fatal
43
Parkland formula for fluid resuscitation in burn victims
Surface area % x weight in kg x 4ml
44
What is the cut off for orthostatic hypotension?
Fall in SBP of >20 or DBP of >10
OR systolic BP < 90 on standing
45
What is hepatorenal syndrome?
A type of progressive kidney failure seen in patients with severe liver damage often cirrhosis
Type 1 = occurs in <2 weeks, doubling of creatinine OR halving of creatinine clearance. Need liver transplant but VERY poor prognosis
Type 2 = slowly progressive, often due to ascites
46
Nitrates are contraindicated in patients with aortic stenosis due to the risk of profound hypotension
Furesomide is the best option as it will provide symptomatic relief
47
How should a patient with suspected heart failure be investigated?
Previous MI = echo within 2 weeks
No previous MI = measure BNP, if high then echo within 2 weeks
If raised but not high then echo within 6 weeks
48
In patients with NAFLD, the enhanced liver fibrosis blood test should be offered to assess advanced fibroisis
It combines hyaluronic acid + procollagen + tissue inhibitor of metalloproteinase 1
49
Which drug could be used in an old lady who suffers from orthostatic hypotension which has not improved with conservative measures?
Fludrocortisone (it increases Na and H20 reabsorption)
50
Peugeot Jeghers syndrome
Autosomal dominant
Numerous polyps in the GI tract —> GI bleeding, malignancy and intussusception
Pigmented freckles
51
Best surgical option for a patient with UC and toxic mega-colon?
Sub-total colectomy
Remove everything apart from the rectum (touching the rectum has a high risk of complications)
(panproctocolectomy with ileoanal pouch is only offered electively)
52
How do you calculate ABPI?
Highest ankle pressure / highest brachial pressure
<0.9 = PAD
< 0.5 = critical limb ischameia
>1.3 = probably atherosclerosis
(remember that leg pressure should normally be slightly higher)
53
Why is rest pain worse at night in intermittent claudication?
BP falls at night
| Feet are elevated
54
What is leriche syndrome?
Combination of buttock claudication and impotence
55
Most likely diagnosis in a 30 year old male with claudication in lower limbs. He is a heavy smoker.
Buerger’s disease - inflammation and occlusion of medium sized vessels
MUST stop smoking
56
What is the difference between Raynaud’s disease and Raynaud’s phenomenon?
Disease = idiopathic, usually occurs in females
Phenomenon = occurs secondary to other causes e.g. SLE or other CTD
(Remember spasm of arteries in the hands and toes causes —> white (ischameia) —> blue (hypoxia) —>hyperaemia
57
Remember that venous ulcers are classically...
```
Shallow
Irregular and shallow edge
On the gaiter area
Associated with little pain
Granulation tissue
```
58
Give some examples of the different types of aneurysms?
True aneurysm = abnormal dilatation of ALL layers of this vessel
```
Congenital : berry aneurysm
Degenerative : AAA
Inflammatory : Kawasaki
Infection
Trauma
```
59
When does the AAA screening programme start?
Men aged 65
| remember that 95% of AAA are infra-renal
60
Remember that 10% of men with a AAA will also have a popliteal aneurysm
If you find a popliteal aneurysm then have a feel of the tummy
61
What is the main risk factor for aortic dissection?
Chronic hypertension
It causes a shearing of the tunica intima (innermost layer) and allows the accumulation of blood between the tunica intima and media —> false lumen
Other RF include Marfan’s and Ehlers-danlos
62
Complications of aortic dissection?
Aneurysm
Bleed into pericardium > tamponade
Bleed into mediastinum (very bad)
Compress other vessels e.g. cubclavian
63
What is the difference between type A and B aortic dissection?
A = involves ascending aorta —> very bad and is a surgical emergency
B = starts at the subclavian artery —> medical management of BP
Obviously B has a MUCH better prognosis
Suspect a dissection in everyone with unequal pulses (and a widened mediastinum on CXR)
64
Fibroadenomas are usually harmless. In what circumstances should you consider excision?
1) age >40
2) >4cm
3) increasing in size
4) patient choice??
65
Most likely cause in a youngish women with a small lump in the sub-areloar area. There is blood stained nipple discharge
Duct papilloma
| A benign neoplasm of the duct requiring surgical exicision
66
Likely diagnosis in lady with a nipple lump (including secretions) and retractions as well as nipple discharge
The
Duct ectasia
Dilatation of mammary ducts
May need surgery if excessive discharge
It is a benign condition
67
How would you describe cyclical breast pain?
Breast pain/ heaviness worse in mid-cycle
Obvious cyclical nature
Not harmful so mainstay is reassurance and consideration of analgesia as required (if sure there is no cancer)
68
Advice for mastitis
1) use hot compress
2) limit wearing a bra
3) keep feeding - express as much milk as possible
4) come back if not settled in 12-24 hours for antibiotics
5) if there is an abscess it will need drained
69
Give a differential for gynaecomastia?
1) Drugs e.g. spironolactone, digoxin
2) obesity/ FH
3) Oestrogen secreting tumour
4) renal failure
Consider treatment options such as tamoxifen or damazol
Surgery rarely required
70
RF for breast cancer
1) Personal/ FH
2) HRT
3) Obesity
4) OCP
5) Alcohol
6) Female
7) Age
8) early menarche, late menopause
9) nulliparous
71
Remember that grading is done under the microscope e.g. what the cells look like
Staging is TNM - it uses lots of information and puts it all together
72
Wide local excision is ALWAYS followed by radiotherapy in breast cancer
Mastectomy if tumour too large, breast to small or patient choice
Radiotherapy is offered after mastectomy if tumour stage is T3 or above
73
What is the main complication of axillary node biopsy and radiotherapy for breast cancer?
Lymphoedema of the arm
74
Level 2 clearance = nodes lateral and deep to pec minor
Level 3 clearance = also includes apical nodes
75
Drug used in oestrogen receptor +ve breast cancer?
Tamoxifen (oestrogen receptor blocker)
76
Side effects of tamoxifen
- hot flushes
- vaginal dryness
- reduced libido
- cataract
- taste change
- skin rashes
- low mood/ poor concentration
- VTE
- Tumour flare (if spread to bones)
- Endometrial hyperplasia
77
Who receives gosereline for breast cancer?
ER+VE breast cancer in pre-menopausal ladies
78
Letrozole/ anastrazole is used for ER +ve breast cancer in post-menopausal women
Letrozole is an aromatase inhibitor which reduces peripheral oestrogen synthesis
79
Which adjuvant treatment should be considered in a HER2 +ve breast cancer?
Tratuzumab (Herceptin)
Remember it is only useful in the 20% of tumours that are HER2 positive
80
Chemoprevention is offered to women at high risk of developing breast cancer. What agent should be used?
Pre-menopausal = tamoxifen for 5 years (if no increased risk of VTE)
Post-menopausal = letrozole for 5 years
81
How is BRCA1 inherited?
It is autosomal dominant —> 50% of children will be affected
It causes a 40% lifetime risk of breast/ ovarian cancer
82
Lady presents with progressive breast swelling and redness. No pain, discharge or lumps. Systemically well. WBC normal. CA 15-3 elevated?
Most likely an inflammatory breast cancer
83
How do you calculate the Nottingham prognostic index?
Tumour size x 0.2 + lymph node score + grade score
Score <2.4 = 95% 5 year survival
Score >5.4 = 50% 5 year survival
84
Remember that fat necrosis can cause a hard irregular lump
Which may also be tethered to the skin —> must do a mammogram to exclude cancer
85
In breast lumps, 4cm is the magic number
```
<4cm = WLE
>4cm = mastectomy
```
For a fibroadenoma, refer for removal if >3cm and causing discomfort
86
Multiple ducts with ‘creamy/ green’ discharge = duct ectasia
| nipple inversion too
Singular duct with blood stained discharge = introduction papilloma (may need a microdocechtomy - removal of the affected duct)
87
Breast lump with halo sign?
The halo sign is highly suggestive of a benign process e.g. a cyst which is usually a soft, fluctuations swelling
88
Andrew is going to have a thryoidectomy. What are the risks?
1) Normal bleeding, infection and anaesthetic risk
2) Recurrent laryngeal nerve damage —> voice change
3) hypothyroid —> thyroxine
4) Parathyroid —> calcium problem
89
Differential of a goitre?
```
Graves
Hashimoto
Toxic multinodular goitre
Iodine deficiency
Thyroid cancer
De Quervains (hyper and then hypo thyroid)
```
90
Patient with goitre, hypothyroidism and biopsy showing fibrosis and infiltration by IgG 4 plasma cells?
Riedel’s thyroiditis
91
Papillary thyroid cancer is commonest and does NOT usually spread
Follicular cancer usually spreads via blood
| papillary is private, follicular floats in blood
92
Which type of thyroid cancer in a patient with MEN II?
Medullary (it secretes calcitonin which is a very useful marker for recurrence)
93
Which thyroid cancer affects elderly people, is rapidly progressive and spreads to lymph nodes and local tissue early?
Anaplastic
94
Diagnosis of carcinoid tumour?
24 hour urine collection for 5-HIAA
Imaging e.g. CT/ USS
MIBG = nuclear medicine scan to detect primary
Treatment is with resection BUT somatostatin analogues e.g. octreotide
95
Men 1 P’s (parathyroid, pancreas and pituitary)
Men 2a TAPs (thyroid medullary, adrenal phaeochromocytoma and parathyroid) and Men2b is a MAN (Marfinoid, medullary, adrenal phaeochromocytoma and neuromas)
96
How is the area of a burn worked out??
Wallace rule of 9’s
```
Head and neck = 9%
Each arm = 9%
Anterior trunk = 18%
Posterior trunk = 18%
Each leg = 18 %
Perineum = 1%
```
97
Remember that body fluid composition is 2/3 intracellular and 1/3 extracellular e.g. plasma, interstitial fluid
The traditional maintenance fluids = 1 salty (saline) and 2 sweet (5% dextrose) with 20 mmol K in each bag
98
What is coup and centre-coup with regard to head injuries?
Coup = injury at the site of impact e.g. where you hit your head
Contrecoup = injury at the opposite side (where the head has struck on the rebound)
Contrecoup is usually more severe
99
Secondary brain injury can occur after hypoxia. How do you calculate cerebral perfusion pressure?
Cerebral perfusion pressure = BP - ICP
| this explains why head injury reduces cerebral perfusion pressure as it increases ICP
100
Management of patient with SAH?
1) ABCDE
2) prompt imaging and referral to appropriate neurosurgeon
3) nimidopine (CCB to prevent vasospsam)
4) BP control (pressure high enough to allow perfusion but not risk bleeding)
5) Rebleeding is a major complication and cause of death - hope the coil/ embolisation works well
101
Sub-dural = bridging veins which are damaged and bleed
| Alcoholics and old people
Extra-Dural = extra-dural vessels bleed due to trauma
Lucent period
Immediate surgical decompression
102
Talk about the anatomy of nerve roots being affected by prolapsed discs?
C-spine:
- there is a mis-match e.g. the C6 nerve root travels under C5 pedicel
- both central and lateral prolapses affect the same nerve root
Lumbar spine:
- match: L5 nerve root travels under L5 pedicle
- Central prolapse affects the nerve root below e.g. central L4/5 prolapse affects L5 nerve root
- Lateral prolapse affects the nerve root above e.g. lateral L4/5 prolapse affects L4 nerve root
- As most symptomatic prolapses are CENTRAL - it follows that most will affect the nerve root below
103
Communicating hydrocephalus = the pathways are working but there is impaired CSF absorption
E.g. meningitis or SAH
Non-communication = a lesion is obstructing the flow of CSF e.g. tumour or congenital
104
Give 5 causes of carpal tunnel syndrome?
1) pregnancy
2) obesity
3) RA
4) Hypothyroid
5) acromegaly
105
Erb’s palsy = upper (C5/6)
Remember U&E’s in waiters position
Klumpke palsy = T1 (lower)
Claw hand and wasting of hand muscles
106
In which area should you check for sensory loss in a patient with a wrist drop?
Check for sensation in the anatomical snuff box
| Can they extend their wrist?
107
What is the most likely cause of rectal bleeding following a Hartmann’s procedure?
Hartmann’s removes the affected bowel and leaves the rectum and anus unattached —> no passage of faeces etc
The most likely cause of painless bleeding is therefore diversion proctitis
108
Sudden onset painless profuse rectangle bleeding =
Diverticular disease
109
Differential diagnosis for milky white ascitic fluid?
1) infection
2) Chylous ascites - due to intra-operative damage of the thoracic duct
Diagnosis of chylous ascites is by confirming there is a dry high lipid level
110
What is balanitis xerotica obliterans?
The male equivalent of lichen sclerosis
Painful, itchy white spots which are associated with a number of complications including increased risk of infection, increased risk of SCC and scarring which leads to phimosis (inability to retract foreksin) and urethral strictures
111
What is the cause of neurogenic or spinal shock?
Typically transaction of the spinal cord which disrupts the autonomic system
Usually deceased sympathetic tone
—> vasodilatation = skin is warm and flushed and CO is reduced due to low preload
112
Rest pain and claudication is ABPI <0.5
Ulceration and gangrene if ABPI <0.3
113
Cause of epididymo-orchitis
- young, sexually active = chlamydia or gonorrhoea
| - older, no sex, urinary infections etc = E.COLI
114
Testicular lump which cannot be separated from the testes and transluminates?
Hydrocoele (collection of fluid in the tunica vaginalis)
Although hydrocoeles are benign, they are associated with testicular cancer which has to be excluded on USS
In CHILDREN it is associated with a patent processes vaginalis
115
What is an ASA grade?
The classification used to determine patients physical status prior to anaesthetic
ASA 1 = healthy patient, non-smoker
ASA 2 = mild disease e.g. smoker, well controlled DM/ HTN
ASA 3 = severe systemic disease e.g. COPD, poorly controlled HT/DM, previous MI
ASA 4 = severe systemic disease that is a constant threat to life e.g. recent MI, stroke
ASA 5 = moribund - not expected to survive operation e.g. massive trauma or ruptured AAA
116
Congenital umbilical hernias usually resolve by age 4-5 so no treatment is required
More common in premature babies
Congenital inguinal hernia have a high risk of strangulation —> need surgical correction ASAP
117
Pancreatic pseudocyst is a very common complication of pancreatitis. How should it be managed?
If systemically well = conservatively e.g. close monitoring
If unwell = radiological FNA (the use of a drain or endoscopy would introduce infection)
118
How does duodenal atresia typically present?
With non-projectile vomiting in the first few hours after birth in a baby with Down’s syndrome
An AXR will show the double bubble sign
119
How to remember Cullen’s and Grey Turner’s?
Cullen = central (periumbilical bruising)
| Grey Tunrners = 2 words for 2 flanks affected
120
How do you test for brainstem death?
- pupils - fixed, no response
- no corneal reflex
- no oculus-vestibular reflex (eye movement after injection of ice water into ears)
- no response to pain
- no cough reflex
- no respiratory effort
121
What is suxamethonium apnoea?
Some patients have an autosomal dominant mutation meaning they lack a specific acetylcholinesterase which breaks down suxamethonium
As a result, the muscle relaxant takes longer to wear off so patients need intubated for a while
122
Remember a ileostomy is spouted - this means the end is raised above the skin so the surrounding skin is not irritated by alkaline fluid from the gut
Colostomies are flush to the skin
123
Management of ALL patients with intermittent claudication?
1) Stop smoking
2) graded exercise
3) statin (atorvostatin 80mg)
4) antiplatlet e.g. clopidogrel
5) manage existing hypertension
6) amputation is required
124
Management options for an uncomplicated anal fissure
1) relieve constipation with high fibre diet, lots of fluid and bulk forming laxative
2) analgesia such as paracetemol
3) topical anaesthetics
4) lubricants to be used prior to defaecation
5) GTN spray for chronic fissure (>6 weeks)
125
All Ca and phosphate containing stones are radio-opaque so easily seen on AXR
Urate and xanthine stones are radio-lucent
Cystine stones are semi-opaque
126
Remember that renal cell carcinoma is also called renal adenocarcinoma
It is the commonest type of kidney cancer and is associated with paraneoplastic syndromes such as polycythameia, hypercalcamia and thrombocytopenia
127
Management of renal colic in patients with a fever and evidence of hydronephrosis on imaging.
(Non-contrast CT is imaging of choice)
Surgical decompression is required as she is obstructed and there is a evidence of infection —> at risk of urosepsis.
128
What advice should a man be given after having a vasectomy?
1) not effective immediately - will need to use barrier contraception for a few weeks afterwards
2) return after 12 weeks for a semen analysis —> if clear can have unprotected sex
3) risk of infection and bruising
4) 5% of men have chronic testicular pain
129
Popcorn calcification or cotton wool spots?
Chondrosarcoma
Typically affects the pelvis of middle aged people
130
Codman’s triangle
A triangular area of new sub-peritoneal bone that is creased when the periosteum is raised away from the bone
Associated with osteosarcoma - the commonest malignant bone tumour
131
Sunray spiculation
Associated with osteosarcoma which is also linked with codman’s triangle
132
Onion skin periosteal reaction
Ewing’s sarcma
| Onion and wings is super tasty
133
Asymptomatic AAA <5.5cm in diameter are treated with US surveillance
Symptomatic, aortic diameter >5.5.cm or rapidly enlarging = surgery (EVAR or open)
