SPECIALTY SURGERY Flashcards
30 year old male smoker with painful blue fingertips
Buergers disease
aka thromboangiitis obliterans
What features of a AAA means there should be should there be surgical repair
above 5.5cm
symptomatic ie pain
rapidly growing
features of an acutely ischaemic limb
6 Ps
PAIN
PULSELESS
PARASTHESIA
PARALYSIS
PALE
PERISHINGLY COLD
What emergency treatments are there for acute limb ischaemia?
surgical embolectomy
Intra-venous heparin
Intra-arterial thrombolysis
ABSOLUTE contraindications for intra-arterial thrombolysis?
Non-viable limb (irreversible ischaemic change – insensate/fixed skin mottling)
Internal bleeding
Suspected aortic dissection
Prolonged or traumatic CPR
Previous allergic reaction
Heavy vaginal bleeding
Pregnancy or < 18 wks postnatal
Acute pancreatitis
Severe liver disease
Active lung disease with cavitation
Oesophageal varices
Recent trauma or surgery (< 2 wks)
Recent head trauma
Cerebral neoplasm
Recent haemorrhagic stroke
Severe hypertension (>200/120 mmHg)
RELATIVE contraindications for intra-arterial thrombolysis?
History of severe hypertension
Peptic ulcer
History of CVA
Bleeding diathesis
Anticoagulants
Complications of aortic dissection
o Cardiac complications include aortic rupture, aortic regurgitation, myocardial
ischaemia and congestive heart failure.
o Stroke and ischaemic neuropathy → Neurological deficit can occur in up to
40% of patients, and can dominate the clinical picture
o Mesenteric ischaemia
o Renal failure
o Death
Complications of surgery
Bleeding
Infection
Damage to surrounding structures
Return to theatre
VTE
difference in the managament of type A and type B aortic dissection
type A:
Medical emergency
A-E
surgical repair
type B:
A-E
If stable, best managed medically with BP and pain control
Lifestyle: smoking cessation
long term patients may be considered for thoracic endovascular repair
(TEVAR).
risk factors for AAA
o Increasing age
o Male gender 9:1 M:F
o Atherosclerotic disease
o Smoking
o Hypertension
Screening for AAA
o Screening in the UK offers an abdominal USS for all men at 65.
o Patients with a AAA >5.5cm should be seen by a vascular service within 2
weeks and considered for surgical intervention.
o Patients with AAA 4.5 – 5.4cm should be followed up by a vascular service
with 3-monthly USS.
o Patients with AAA 3.0 – 4.4cm should be followed up by a vascular service
with yearly USS.
o Patients <3cm can be discharged from the surveillance service.
common cause of acute limb ischaemia
o Embolism
o Trauma
o Aortic dissection
o Peripheral artery disease (PAD) progression
o Iatrogenic damage during surgery
common cause of chronic limb ischaemia
atherosclerotic disease
clinical features of chronic limb ischaemia
o Symptoms are usually bilateral.
o Claudication – patients initially have intermittent claudication, a cramping
pain brought on by exercise and relieved by rest.
o As the disease progresses patients begin to experience pain at rest.
o Finally, the blood supply becomes poor enough to result in gangrene and
tissue loss.
examination findings of chronic limb ischaemia
▪ Inspection may reveal marbled skin, hair loss, muscle wasting, arterial
ulcers and tissue loss.
▪ On palpation the limb will be cold, with weak or absent pulses and
delayed capillary refill time.
Classification system used for acute limb ischaemia
Rutherford classification:
I- viable
IIa- threatened: salvagable if promptly treated
IIb- threatened: salvagable with immediate revascularisation
III- major tissue loss or permanent nerve damage inevitable
Investigations for acute limb ischaemia
Bedside:
Doppler USS of the legs
ABPI
ECG
Bloods:
FBC
VBG- esp lactate
G&S
clotting profile
Imaging:
CT angiography
Management of acute limb ischaemia
A-E
15% O2 NRB
IV access and fluids
NBM
unfractionated heparin
analgaesia
surgical revascularisation
complications of revascularisation surgery
▪ Reperfusion injury:
* Revascularisation leads to increased blood flow and venous
return to flush out the toxic metabolites from the ischaemic
tissue. This results in a systemic inflammatory response.
▪ Compartment syndrome:
* Revascularisation can also lead to tissue swelling due to
oedema and the inflammatory response of reperfusion injury.
* Patients with long ischaemic time often have prophylactic
fasciotomies to prevent this.
▪ Rhabdomyolysis:
* The release of toxic muscle cell components from damaged
ischaemic muscle into the circulation.
* This can lead to AKI due to myoglobin release, and metabolic
disturbances such as hyperkalaemia and metabolic acidosis.
cholecystitis Mx
Medical:
IV fluids
analgaesia
IV antibiotics
surgical:
laparoscopic cholesystectomy within a week
causes of cholecystitis
gall stones causing statis of bile in gall bladder causing infection
gives breeding ground for infection so give prophylactic Abx
esp. Klebsiella
what are gall stones made of
pigment stones
cholesterol stones
RF for gall stones
Asian hispanic ethnicitis
Pregnancy
what is biliary colic
movement of bile stones in the gall bladder with contraction
Features of biliary colic
RUQ pain radiating to shoulder tip
no signs of inflammation ie fever
features of cholecystitis
Constant RUQ
murphys +ve
fever
murphys sign
palpate RUQ get pt to take deep breath in- arrest in breathing
what is Caltot’s triangle in laparoscopic cholecystectomy
triangle surgeons want to visualise as it contains R hepatic artery
what are the benefits cholecystostomy and when would it be done
regional anaesthetic
USS guidance
used in ppl who are bad candidates for GA and cholecystectomy
what is acute/ascending cholangitis
blockage of common bile duct by a stone causing stasis and infection
charcots triad
jaundice
RUP
fever
reynolds pentad
jaundice
RUP
fever
sepsis/ hypotension
Altered mental state
most common causative organisms for acute cholangitis
Klebsiella
E.coli
streptococcus
pseudomonas
Management of acute cholangitis
medical management
USS abdomen- dilated common bile duct
MRCP- contrast
ERCP
complications of ERCP
Pancreatitis
bleeding
damage to surrounding structures
Infection
risk of aspiration
death
What is mirizzi syndrome
gallstone at the neck of the gallbladder which impinges and compresses hepatic duct
cholecystitis that presents as cholangitis
Features of acute pancreatitis
acute burning abdo pain radiating to back
guarding
low grade fever
reduced bowel sounds
How do gall stones cause pancreatitis
blockage of pancreatic duct so retrograde flow of pancreatic enzymes which damages pancreas
how does alcohol cause pancreatitis
causes dysfunction of duodenal sphincter so back flow in biliary tract
causes of pancreatitis - classify
obstruction
-gallstones
-alcohol
toxic/metabolic
- hypercalcaemia
- hypertriglyceridaemia
Iatrogenic
- steroids
-ERCP
infection
- mumps
What is grey turners sign
haemorrgae of retroperitoneal vessels
what is cullens sign
blood translocating along umbilical embryological remnant
Scoring systems of pancreatitis
Glasgow imrie score
(spells pancreas)
Investigations for pancreatitis
bedside:
examine
A-E
bloods:
ABG
FBC- WCC
U&Es
LFTs
albumin
amylase
lipase - most sensitive and specific but more expensive
Bone profile- Ca
lipid profile- triglycerides
why might someone have low PaO2 in pancreatitis
ARDS
fluid in lungs not caused by HF
Cause of shock in pancreatitis
3rd spacing
inflammation causing leakage of fluids into 3rd spaces leading to distributive shock
Complications of acute pancreatitis
Local
abscess
pseudocyst- fibrous scar tissue causing a cyst (not epithelial tissue)
chronic pancreatitis
ARDS
hypocalcaemia
glucose hommeostasis derangement
hypovolaemic shock
DIC
additional medications to give in alcoholic pancreatitis
pabrinex
chlorodiazepoxid- prevent delerium tremens
appendicitis mimics
mittelschmerz (ovulation pains)
ovarian torsion
testicular torsion
ovarian cyst rupture
ectopic pregnancy
Mesenteric adenitis- lymphadenopathy in abdomen
PID
What is Mcbernies point
why do you typically get change in location of pain from general to focussed in appendicitis
visceral peritonium is poorly innervated so pain is more general
as inflammation gets worse it irritated the parietal peritonium which has better innervation causing more localised pain
what is Rovsvigs sign
palpation of LIF will cause pain in RIF
dragging peritoneum over appendix
what is psoas sign
hyperextension of hip
dragging psoas muscle over appendix causing pain
complications of appendicitis
perforation
appendiceal mass- omentum policiling affect
appendiceal abscess
signs of chronic venous insufficiency
haemosiderin deposition and pigmentation
venous eczema
oedema
venous ulcers and atrophy blanche
lipodermosclerosis
varicose veins
telangectasia
Investigations for vascular disease
Bedside:
Hand held doppler of vessels
ankle- brachial pressure index (assess for arterial disease. the lower the index the worse the arterial supply peripherally)
Bloods:
RFs for peripheral vascular disease:
HbA1c
lipid profile
clotting
G&S if requiring surgery
Imaging:
Duplex USS- visualises deep and superficial vessels, shows flow direction and characteristics
CT angiogram
MRI
RFs for AAA
Proven:
smoking
age >60
male
genetics
Possible:
HPTN
hyperlipidaemia
>BMI
classical triad of a ruptured AAA
pain- abdo/ back
hypotension
pulsatile abdominal mass
Investigations for AAA
bedside:
examination
abdo USS (100% sensitive)
BP
bloods
pre surgery: G&S and clotting
FBC, U&Es, lipid
Imaging
CT- important for planning surgery
what arteries do the visceral arteries branch from?
coeliac axis
superior mesenteric artery
inferior mesenteric artery
common causes of acute mesenteric ischaemia
atherosclerotic disease
cardiac emboli eg. from AF
aortic anerysm
aortic dissection
arteritis
hypercoaguability
malignancy causing venous compression
hypotension/ shock
clinical presentation of acute mesenteric ischaemia
abdo pain disproportionate to abdominal findings
vomiting and diarrhoea
abdo distension
rectal bleeding and sepsis as the bowel becomes gangrenous
first line investigation for acute mesenteric ischaemia
bloods not useful dont waste time
CT angiography gold standard
clinical features of chronic mesenteric ischaemia
mesenteric angina- post prandial pain due to digestion not getting metabolic demands
epigastric, gradual worsening, plateau of pain then slow resolution
-initially after large meals
weight loss and food aversion
diarrhoea, vomiting and bloating
mat have bruits
standard things to think about when managing a vascular patient
Conservative:
- diet and exercise
- blood sugar control
Medical:
Mx of CVD RFs
- antihypertensives
- statin
- anticoag
Surgical
- consideration for surgery:
–> surgical bloods (G&S, clotting), fluids, NBM
complications of ischaemia-reperfusion
compartment syndrome- acute inflammation of muscle after restoring perfusion
systemic complications of ROS and neutrophil activatios:
- renal failure (metabolic acidosis, hyperkalaemia, ATN)
- ARDS
- arrhythmias, cardiogenic shock
- hepatic failure
- gastrointestinal endothelial oedema leading to endotoxic shock
risk factors for VTE
Pregnancy and 6weeks post partum
malignancy
Immobility
obestity
hyperlipidaemia
OCP
dehydration
antiphospholipid syndrome
myeloproliferative (CML, PCRV)
Inherited
- factor V leiden
- protein C def
- protein S def
- antithrombin def
scoring system for the likelihood of a DVT
wells score
pathophysiology of varicose veins
superficial venous reflux or incompetence, usually due to failure of valve mechanism
pathophysiology of skin changes with varicose veins
abnormal pressures within the venous system induced by reflux causes subsequent extravasation of blood into tissues
- deposition of haemosiderin, eczema, atrophie blanche, lipodermatosclerosis, ulceration
what is an aneurysm
stretching of all the lumen of the artery and loss of ability to recoil
above what size is deamed an AAA
> 3cm
causes of lower limb ulceration
vascular:
- arterial disease
- venous disease
- vasculitis
Infection/ inflammation:
- osteomyeltitis
- staph abscess / cellulitis
- syphilis
- Yaws
- cutaneous anthrax
- cutaneous TB
- leprosy
- cutaneous leishmaniasis
Trauma
Metabolic
- diabetes- neuropathy
Iatrogenic
- steroids
Neoplastic
- BCC
- SCC
- melanoma
- lymphoma
- sarcoma eg. kaposi
Congenital
- sickle cell disease
- thalassaemia
Nutritional
- vitamin C def
- zinc def
dermatology
- pyoderma gangrenosum
what condition is associated with aortic aneurysm common in females
Takayasus aortitis
3-4.4cm
4.5-5.5
> 5.5
refer USS every year
USS every 3 months
seen by vascular in 2 wekks
management of AAA
conservative
- lifestyle changes
medical
- anti hypertensives
surgical
- open repair
- endovascular aortic repair (EVAR)
What is intermittent claudication vs critical limb ischaemia
stable angina of the lower limbs
and unstable angina- rest pain
important things to ask in Hx of intermittent claudication
How far until pain
what specifically stops activity- pain, breathless, joints
location of pain
characteristic of pain
does the pain go away after rest?
blood thinner used in plaque disease
anti platelet
eg. clopidogrel
becasue want to stop platelets adhereing to plaque
positive buergers gets
pallor then reactive hyperaemia in affected limb
what does calcification do to the ABPI
becomes unreliable as cant compress artery when taking BP
triad of for Leriche syndrome
bilaterally absent femoral pulses
bilateral intermittent claudicaition
erectile dysfunction
what is leriche syndrome
issue is high up at aorto-iliac junction
both legs affected, both femorals and the pudendal artery which supplies the penis
Mx of intermitent claudication
conservative:
manage CVD RFs
medical
Clopidogrel
Atorvostatin
Naftidrofuryl oxalate (5HT2 receptor antagonist causing peripheral vasodilator. CI with renal calculi)
Surgery
- endovascular angioplasty and stenting
- endarterectomy
- bypass surgery
thrombus vs embolus
thrombus a clot adheres to a vessel wall
embolus dislodged and moved elsewhere
blood thinner used in AF
anti coag
eg. DOAC
due to poor blood flow in heart leading to stasis and increased risk of clotting
acute limb ischaemia Ix
Bedside:
ECG
ABPI
doppler/ duplex USS
bloods:
ABG, FBC, U&Es, CK, clotting, G&S
imaging
digital subtraction angiography
Management of acute limb ischaemia
conservative
- IV fluids,
- analgaesia
- O2
med
- antiplatelet eg. clopidogrel
- anticoag eg unfractionated heparin
surgical revascularisation
- endovascular thrombolysis - directly to the clot
- endovascular thrombo-embolectomy- foggety catheter
- open thrombectomy
- bypass surgery
amputation is non viable limb
Management of chronic venous insufficiency ulcer
compression bandage
elevation
encourage exercise
debridement
clean with saline
dressings
CI for compression stockings
peripheral arterial disease
Marjolin’s ulcer
SCC inside of an ulcer
ulcer with horny growth
aortic dissection RFs
HPTN
smoking
cocaine
connective tissue disease
what is an aortic dissection
intimal wall tear in aorta causing a false lumen
pseudoaneurysm
Ix for aortic dissection
bedside
- BP in both arms
- ECG
bloods:
-G&S, clotting
-ABG
Imaging
- CXR: widened mediastinum
- CT
Mx of type B aortic dissection
HPTN control
IV beta blockers eg. labetelol
Mx of type A
immediate surger
call cardiothoracics and ITU
TEVAR
Breast examination findings:
- Rubbery firm mobile mass.
- Well circumscribed and smooth.
- Usually non-tender.
Fibroadenoma
Changes with menstrural cycles and pregnancy
fibroadenoma
breast cyst
NICE recommendations for referring to breast clinic on the 2 week referral wait
-Age >30 with an unexplained breast lump or axillary lump
- Age > 50 with unilateral nipple discharge or retraction
- Any patient with skin changes suggestive of malignancy
clinical presentation of breast cysts
o Cysts can be solitary or multiple
o Often fluctuate with menstruation, increasing in size or becoming tender just
prior to menstruation.
o Exam:
§ Smooth and mobile lump
- non tender
Management of breast cyst
o Asymptomatic breast cysts require no management, and usually self-resolve
o Symptomatic breast cysts can be aspirated, which is usually definitive
treatment.
o After aspiration cysts can recur and may need repeat aspiration.
Mastalgia causes
True mastalgia:
- most commonly pre menstruation tenderness
§ Symptoms usually worsen 2 weeks prior to menstruation, relieved
with the onset of menstruation.
§ Bilateral
§ Breast tenderness
§ Lumpiness
§ Fullness and heaviness of the breast
Extra-mammary:
- pulled muscle
- costrochondritis
What is an intraductal papilloma
A benign growth of ductal epithelial cells
clinical features of an intraductal papilloma
o Bloody or clear nipple discharge
o The patient may or may not have a palpable mass
Investigations and management for pt presenting with nipple discharge
Referred to one stop breast clinic under 2ww for mammogram and USS
Core biopsy
excision of growth as biopsy cant distinguish well between benign and malignant papillomas
Excision can either be surgical (open diagnostic biopsy) or by vacuum excision
(performed by the radiologists under image guidance)
What are scleritic lesions of the breast
Characterised by a fibroelastotic core with radiating ducts and lobules in a stellate
arrangement.
types:
sclerosing adenosis, radial scars and
complex sclerosing lesions (CSLs)
Clinical features of a phyllodes tumor
Both benign and malignant phyllodes tumors will rapidly grow
May feel very similar to a fibroadenoma i.e. well-circumscribed and
smooth
Mastitis RFs
o Milk stasis:
- Poor infant attachment
-Reduced number or duration of feeds
o Nipple trauma
o Immunosuppression
o Smoking
Clinical features of mastitis
o Painful breast
o Overlying erythema
o Generally unwell – fever and malaise
o Examination:
-Tender breast
-Hot to touch with erythema
-May be systemically unwell with tachycardia, tachypnoea and fever
Management of acute mastitis
o Conservative:
- Reassurance that the breast should return to normal shape and
function following treatment
- Patients should be encouraged to continue breast feeding
-If breastfeeding is too painful or the child refuses, women should
express milk via hand/pump instead.
o Medical:
-Regular analgesia –> Paracetamol (generally avoid ibuprofen whilst
breastfeeding)
- oral Abx: fluclox or erythromycin if pen allergy
If signs of sepsis pt should be referred immediately to the ED
If abscess- USS drainage
Green/brown/white nipple discharge and sub areolar pain
peri/post menopausal
duct ectasia
Features of fat necrosis
o Hard painless lump
o Skin may have overlying bruising
o Examination:
-Firm lump
-May see overlying skin changes
often follows trauma/ surgery/ radiotherapy
Most common type of breast cancer
ADENOCARCINOMA
Invasive ductal carcinoma
(70% of malignancies)
Invasive lobular carcinoma (20%)
Breast cancer RFs
Oestrogen exposure:
- COCP
- HRT
- early menarche
- late menopause
- nulliparity
- obesity
Genetics
- FHx
- BRCA
- previous breast cancer
Clinical features of breast cancer
- painless lump usually found in the upper outer quadrant
skin changes:
- peau d’orange (Damage or obstruction of lymphatics leads to oedema of the
breast and an orange peel like appearance)
-skin teathering (Malignant spread to the suspensory ligaments (of Astley
Cooper) from the dermis to posterior breast capsule, causing
tethering of the skin.)
Nipple changes:
- bloody discharge
- nipple inversion
-pagets disease of the breast (rare form of breast cancer originating from specific paget cells in the nipple)
Describe the TNM staging of breast cancer
o T1 = <2cm, no skin fixation
o T2 = 2-5cm, skin fixation
o T3 = 5-10cm, ulceration and pectoral fixation
o T4 >10cm, chest wall expansion, skin involved
o N1 = Axillary LN’s mobile
o N2 = Axillary LN’s fixed
o N3 = extra-axillary.
o M0 = no metastasis
o M1 = metastasis
Investigations for suspected breast cancer
referred under the 2ww cancer pathway
one-stop clinic for triple assessment
- clinical examination
- imaging: <35 USS, >35 USS+ mammography
- Biopsy
solid lump –> core biopsy
cystic lump –> FNA for cytology
biopsies undergo immunohistochemistry to test for OR, PR and Her2 receptors
what is the single most important prognostic factor of breast cancer
nodal involvement
MOA of tamoxifen and when is it used
a selective oestrogen receptor modulator
in pre menopausal women who have ER+ breast cancer
MOA of letrozole and anastrozole
aromatase inhibitor
used in ER+ve post menopausal women as Aromatisation accounts for the majority of oestrogen production in this group
examples of chemotherapy agents used in breast cancer
Docetaxel
Doxorubicin
MOA of Trastuzumab
mAb against HER2 receptor
progressive, erythema and oedema of the breast in the absence signs of infection such as fever, discharge or elevated WCC and CRP) and an elevated CA 15-3.
inflammatory breast cancer
types of kidney stones and which is the most common?
Calcium oxalate (most common)
calcium phosphate
uric acid stones
struvite stones (produced by bacteria)
cystine stones (AR cystinuria)
RFs for kidney stones
hyper
pathophysiology of struvite stones
in people with recurrent upper UTI, the bacteria can metabolise urea into ammonia which then crystalises into struvite
can for a staghorn calculin in the renal pelvis and this can be seen on plain Xray
Loin to groin pain differentials
renal colic
testicular torsion
ruptured AAA
investigations for suspected renal calculi
bedside:
- urine dipstick (haematuria), urine MS&C
- pregnancy test
- obs (signs of sepsis)
bloods:
- FBC, CRP (infection)
- U&Es, bone profile (biochemical assessment)
- renal profile (AKI)
Imaging
- CT KUB- imaging of choice
- plain Xray but 1/3 of stones are radiolucent
- ultrasound KUB (less radiation but harder to get a clear picture if larger body habitus)
management of acute renal stones
conservative:
- analgaesia - NSAIDS (PR / IM diclofenac)
- antiemetics if N&V
- watch and wait- for stones <5mm, let the stones pass
- tamsulosin (a blocker- SM relaxant) can help stone pass
- lifestyle advice: low oxalate diet (spinach, beetroot, black tea), low purine diet (kidney, anchovies, spinach) hydration
medical intervention if:
- signs of infection/ sepsis
- servere pain
- not able to pass
- occupation (eg. pilots)
options:
- extracorporeal shockwave lithotripsy
-flexible ureterorenoscopy
- percutaneous nephrolithotomy
- Abx- IV co-amoxiclav/ cefotaxime/ ciprofloxacin
where is the collection of fluid in congenital hydrocele
within a panant processus vaginalis
secondary causes of hydrocele
fluic in tunica vaginalis secondary to trauma, tumor
diffuse lumpy swelling in scrotum associated with infertility
varicocele
managemet of epidydimal cyst
supportive- NSAIDs
aspiration
swelling in scrotum, non tender, cant palpate above
inguinal hernia
anatomy of inguinal hernia
most common causes of epidydimal orchitis in young men
chlamydia and gonorrhoes
Abx for epidydimo orchitis in young sexually active man
IM cef, 14days doxy
most common cause of epidydimo orchitis in older men
E coli
management of scrotal haematoma
USS
emergency referral to hospital
cover with Abx
if particularly large- aspirate
RFs for testicular cancer
undescended testes
hernia in infancy
common types of testicular cancers
Germ cell tumor- seminoma, teratoma
where do testicular cancers fisrt metastasise to
parailiac lymphnodes
Ix for testicular cancer
USS
tumor markers- AFP, bHCG, LDH
CT/ MRI
clinical features of torsion
sudden onset pain
loin to groin
N+V
pain and swelling of testes
surgical management of torsion
bilateral orchidopexy
also consent for orchidectomy
bedside investigations mneumonic
PUBES
Peakflow
uranalysis
BCG
ECG
Swabs
common sites for stones to get stuck
pelvicuteric junction
crossing iliac vessels at pelvic brim
vesicoureteric junction
RFs for stones
hypercalcaemia
dehydration
congenital anatomical defects eg. horseshoe kidney
hydronephrosis
CI for ESWL
severe athereosclerosis or calcifide vessels
urgent treatment of stones
- sepsis
- obstruction
- congenital renal abnormalitis
- nephrostomy tube placement
- uteric stent placement
- open sugery
what is pyonephrosis
obstruction and build up of pus in kidney
ECG changes in hyperkalamia
tall tented T waves
PR prolongation
arrythmia
loss of P waves
medication that can help K+ excretion in the kidneys in chronic hyperkalaemia
calcium resonium
causes of acute urinaary retention
prostatic obstruction
urethral strictures
anticholinergics
alcoohol
cauda equina syndrome
clot retention
causes of chronic urinary retention
pelvic malignancy
diabetes
MS
prostate enlargement
Investigations for BPH/ prostate cancer
bedside
DRE- smooth in BPH, hard and craggy in cancer
urine analysis
IPSS
bloods
PSA
U&Es
FBC, CRP
renal profile
imaging
transrectal USS
MRI
special
biopsy
Mx of BPH
conservative
- avoid caffiene/ alcohol
bladder training
medical
- a blockers eg. tamsulosin
5a reductase (eg. finasteride)
surg
transurethral resection of the prostate (TURP)
Complications of TURP
the glycine used in the surgery can cause hyponatraemia so must do post op U&Es
RFs for transitional cell carcinoma
smoking
exposure to aromatic amines (pains, rubber, dye)
chronic cystitis
pelvic irradiation
most common renal cell carcinoma
clear cell carcinoma
medical condition associated with renal cell carcinoma
von hippel lindau syndrome
CXR finding in metastatic renal cell carcinoma
cannon ball mets in the lung
key family history cancers in breast hx
breast
bowel
ovarian
breast exam on inspection
skin changes - peau d’orange, erythema, puckering
nipple changes
symmetry
discharge
visible masses
what is peau d’orange
inflammation of cupus suspensory ligamnets causing dimpling
nipple changes
nipple inversion, discharge, eczema, scaling/ dryness
what are you assessing for when assessing a breast mass
size
border
temperature
tenderness
fixed/ tethering
consistency
3 questions for discharge
quantity, quality, colour
breast lump ddx
physiologically normal breast lump
benign cystic changes
fibroadenoma
abscess (esp smokers)
carcinoma
breast screening
between 50-70
every 3 years
mammography
paternal breast cancer FHx
refer to breast clinic even if no lump as paternal very strong
fibrocystic changes
lumpt breast
pain
changes with menstrual cycle
Important before giving steroids esp dexamethasone
check glucose
perscribe PPIs
difference between DCIS and invasive carcinoma
in situ hasnt invaded basement membrane yet
both are malignant cells
what is sentinal node biopsy
inject blue radioactive dye into lump area
see first node it drains to by sensor to radioactivity
take node and send to histology
will let you know if its hot or cold -ie has the cancer spread to that node?
invasive breast cancers
ductal carcinoma (best prognosis)
lobular carcinoma
inflammatory breast cancer (poorest prog)
prosnostic indicator after breast cancer diagnosis
Nottinham prosnostic indicator
chemotherapy used in breast cancer
taxane based
duration of hormonal therapy in breast cancer
5 years
side effect of anastrazole
osteoporosis
side effect of tamoxifen
VTE
vaginal bleeding
endometrial Ca
amenorrhoea
symptoms under anticipatory prescribing
pain - paracetamol, NSAIDS, opiods
secretions - hyoscine
agitation - midazolam
N+V - metaclopromide, cyclizine
breathlessness - opiods, fan
bowel obstruction management
drip and suck
conservative
NG tube and aspirate
IV fluids maintenance
NBM
admit to surgery
let reg know
medical
analgaesia
gastrograffin- form of contrast. lessens oedema in bowel wall and improves obstruction
AXR at this point
surgery
might not go to surgery for a couple of days
bowel ileus
common post bowel surgery
paralytic
tinkling bowel sounds
obstruction like conditions
bowel ileus/ parylitic ileus
pseudo obstruction- adynamic bowel. lots of trapped wind due to disruption of nervous system of bowel
small bowel obstruction causes of
intraluminal
- bezoars
gallstone ileus
intramural
- malignancy(neuroendocrine, melanoma)
IBD complications
extrinsic
- adhesions
hernias
large bowel obstruction casues
intraluminal
faecal impaction
foreign bodies
intramural
colorectal cancer
diverticularstrictures
IBD comp
extrinsic
adjacent cancers
volvulus
hernias
what is closed loop obstruction
obstruction in large bowel if there is an airtight iliocaecal valve
ticking time bomb for perforation
get a CT and call on call reg for immediate surgery
triad of features in right sided colorectal cancers
Fe def anaemia
change in bowel habits
weight loss
common presentation of left sided cancer
bowel obstruction
what are complications of haemerrhoids?
- PR bleeding
- Thrombosis
- soiling
what are haemerrhoids
sweeling of venous plexus in rectum/ anus
Mx of haemerhhoids
conservative:
- analgaeis
- cooling packs
-increase fibre in diet
medical
- stool softeners
Invasive
- rubber band ligation
- injection sclerotherapy
- haemorroidectomy
- haemorrhoidal artery ligation
best investigation for suspected bowel obstruction
CT abdo pelvis with contrast
can differentiate between pseudo and true obstruction
best visualisation before surgery
cause of frank haematuria
Bladder/ renal cancer
prostate cancer
glomerulonephritis
renal colic
severe UTI
what is murphys sign?
what is it a sign of?
inspiratory arrest on palpation of the RUQ
Acute cholesystitis
what is charcots triad and what is it a sign of?
RUQ pain, fever and jaundice
ascending cholangitis
what is reynolds pentad
RUQ pain
fever
jaundice
hypotension
altered GCS
what is riglers sign and what is it indicative of?
gas both within the lumen and free within the peritoneal cavity.
perforation
Managament of BPH
conservative:
- watch and wait
- safety netting on urinary retention symptoms (abdo pain, reduced urination)
Medical:
- alpha 1 antagonists (Tamsulosin) to relax SM
surgical
- transurethral resection of the prostate (TURP)
side effects of tamsulosin
dizziness
postural hypotension
dry mouth
depression
