starting of week 1 generla surgery quesmed questions Flashcards
persistent diarrhoea, abdo pain adn weight loss with mouth ulcers
crohns
RIF mass crohns or UC
crohns
gold standard investigation for achalasia
manometry - high resting pressure in lower oesophageal sphincter, incomplete relaxation of oesophageal sphicter upon swallow, absense of peritstalsis( need last two for dx
findings on manometry in achalasia
high resting pressure in lower oesophageal sphincter incomplete relaxation of oesophageal sphincter upon swallow
absence of peristalsis( need last two for dx
pneumobilia
air within the biliary tree
Abdominal X-ray shows distended small bowel loops with pneumobilia.
gallstone ileus - hallmark sign - cx small bowel obstruction
Gallstone ileus is a mechanical intestinal obstruction due to gallstone impaction within the gastrointestinal tract.
wound dehiscence
Refers to separation of the surgical wound which can occur particularly after abdominal surgery.
Wound dehiscence is a serious and potentially life-threatening post-op complication.
Management of wound dehiscence
Cover the wound with wet sterile gauze
Transfer to theatre for resuturing - definitive
dypepsia
lifestyle and ppi
pancreatitis can have gallstones
what is a mallory weiss tear
A Mallory–Weiss tear is a partial thickness tear of the oesophagus that typically presents with haematemesis
what is a mallory weiss tear
A Mallory–Weiss tear is a partial thickness tear of the oesophagus that typically presents with haematemesis
He suddenly develops severe chest pain and difficulty breathing. On examination, there is crepitus on palpation of the chest wall. An urgent chest X-ray is performed, which shows a widening of the mediastinum and free air in the soft tissues of the neck. What is the most likely underlying diagnosis?
subcutaneous emphyema too
booherave syndrome - oesphageal rupture post vomit - rething and chest pain too - creptisu is the emphsema
surgeyr needed
You are asked to perform an abdominal examination on a 55 year old female patient on the ward.
On examination there is a mass arising from the left upper quadrant. You are unable to palpate the superior border of the mass and the mass moves with respiration. The mass is dull to percuss. You also notice the patients hands are defomed, with symmetrical ulnar deviation at the metacarpophylangeal joints and Z-thumb deformity.
Which of the following investigation findings is consistent with the most likely diagnosis?
Neutrophil count 1.5 x 10^9/L
This is the correct answer. The patient presents with clinical features consistent with Felty’s syndrome, an uncommon extra-articular manifestation of rheumatoid arthritis. Felty’s syndrome is characterised by the triad of: rheumatoid arthritis with splenomegaly and neutropenia
A GP is examining the abdomen of a 61-year-old woman. She has an old, well-healed scar: a horizontal line in the right iliac fossa. What is the eponymous name of this incision?
lanz incision - appendicetemony
A GP is examining the abdomen of a 61-year-old woman. She has an old, well-healed scar: a horizontal line in the right iliac fossa. What is the eponymous name of this incision?
lanz incision - appendicetemony
Transverse incision used when
paed laparotomies
Transverse incision used when
paed laparotomies
Kocher incision
This is an oblique incision under the right costal margin used for open cholecystectomy
rutherford morrison incision
oblique flank for colon and pelvis
Pfannenstiel incision
c section
young screaming, bowel prolpase into lumen of bowel - recurrent jelly stool sausage mass unwell 3 day prior most common describing what and most comon where in what age group
intersusseption
ilioceacal region
3-12 months
laparotomy if perforation or penumatic reduction if well
swinging pyrexia and mass in right iliac fossa after previous appendiciitis what thinking
apendicular abscess - occurs after perforation
SIRS repsonse -
out of proportion sx to exmaiantion findings what are we thinking
has a AF to
acute mesenteric ischaemia
AF could mean embolism of cardiac origin lodged in mesenteric arteries precipitating sudden onset ischaemia
out of proportion sx to exmaiantion findings what are we thinking
has a AF to
acute mesenteric ischaemia
AF could mean embolism of cardiac origin lodged in mesenteric arteries precipitating sudden onset ischaemia
Acute mesenteric ischaemia most common site of occlusion
SMA
Acute mesenteric ischaemia most common site of occlusion
SMA
lynch syndrome what cancers
Endometrial
Patients with Lynch syndrome, as well as having a high risk of colorectal cancer, are at a higher risk of developing endometrial cancer. They are also at risk of developing breast, prostate and gastric cancer.
first line ix for looking for rectal cancer
colonoscopy or flexible sigmoidoscopy
You are a medical student on the surgical ward and are asked to examine the abdomen a 50 year old female patient.
On examination there is a well healed large oblique scar over the right iliac fossa. Beneath the scar, you can feel a smooth mass. You are unable to palpate the inferior border of the mass and it is dull to percuss. The patient looks well and vital signs are within normal range.
Which of the following examination findings may also be present?
Gingival hyperplasia
This is the correct answer. The patient presents with a Rutherford Morrison scar secondary to a renal transplant. Following renal transplant patients require long-term immunosuppressive therapy. The immunosuppressive agent cyclosporin can cause gingival hyperplasia
A 32 year old male , painful swollen left leg and nausea. few hours ago the swelling was limited to a small area of his calf, and has rapidly spread. He reports cutting his leg whilst gardening a couple of days ago
left leg is diffusely blistering and erythematous. There are patches of anaesthesia over the affected skin.
Vital signs are: temperature 38.2’C, heart rate 102 bpm, blood pressure 85/65 mmHg, oxygen saturations 97% on room air, respiratory rate 24/min.
Given the most likely diagnosis, which of the following is the most appropriate definitive management?
surgical debridment for nec fasc
staging of upper GI endoscopy cancer
CT CAP after biopsy
where are most anal fissures located
painful and bleeding
posterior midline of anal canal
Sentinel pile visible on retraction of the buttock
These are found in 20% of patients with an anal fissure. They are more likely to occur in patients with chronically recurring anal fissures, so are unlikely in this patient
acute choleysiitis caused by what organism
e.coli
inguinal hernia mx
Most inguinal hernias are repaired even if they are asymptomatic. This patient appears to be fit enough to undergo surgery
acute mesenteric ischameia what test is diagnostic
CT angio
A 70-year-old man is on the ward following a sigmoidectomy for sigmoid cancer. He develops tachypnoea and a fever of 38.7 °C, with severe pain in the abdomen 6 days postoperatively. On examination, the abdomen is rigid with rebound tenderness. The wound site looks clean and has started healing. What is the most likely cause of his symptoms?
Anastomotic leak
This is the most likely diagnosis given the clinical features and time period post-surgery. The most common presentations of an anastomotic leak are abdominal pain (sometimes peritonitis) and fever. Leaks usually present 5–7 days postoperatively. The definitive investigation for a suspected anastomotic leak is a CT scan of abdomen and pelvis with contrast. Leaks can be managed conservatively if small; however, in this case, it is likely the patient will need surgical intervention.
post surgery abdo pain , tachyp and fever - rebound tenderness and rigid abdomen - defintive investigation for anastomic leak
CT scan of abdomen and pelvis with contrast
can you take metfomrin throughout sugery
yes
isloatd rise in amylase - UC drug
sulfasalazine
cx of central line insertion
Post-insertion pneumothorax
true bowel perforation presetns with
peritonic abdomen
what is a marker of severity and poor porgnosis in pancreatitis
Ca 1.95 mmol/L
This is the correct answer. Hypocalcaemia is a marker for the severity of pancreatitis. HypERcalcaemia can cause pancreatitis, whilst hypOcalcaemia is an indicator for severity of pancreatitis. This is because calcium gets trapped in the tissue surrounding the necrosing tissue around the pancreas. This process is called saponification
what is a marker of severity and poor porgnosis in pancreatitis
Ca 1.95 mmol/L
This is the correct answer. Hypocalcaemia is a marker for the severity of pancreatitis. HypERcalcaemia can cause pancreatitis, whilst hypOcalcaemia is an indicator for severity of pancreatitis. This is because calcium gets trapped in the tissue surrounding the necrosing tissue around the pancreas. This process is called saponification
patients with COPD before surgery what 3 tests should you do
Lung function tests
Chest x-ray
Arterial blood gas (if the patient is known to retain carbon dioxide)
does TPn increase the risk of gallstone
yes
enteral feeding
get striaght into digestive tract- exmaple would be through an nG tube
where are bile salts reabsorbed
terminal ileum
if you have an ileal resection what are you at an increased risk of
stone formation
crohns - will icnrease likelyhood of iliel removal
inplantabel device what ASA
4
constant threat tot life
AP resection used when
this will result in what stoma
This is used for lower rectal tumours (<8cm from anal margin) and involves removing the anus, rectum and lower part of the sigmoid colon. This results in the patient having a permanent colostomy stoma, and therefore an anterior resection is preferred when the tumour is high enough to do so.
what and when is an anterior resection used
what would you need temporarily to allow the anastamosis to heal
This patient has a rectal cancer that is high from the anal margin (>8cm).where the upper rectum and lower sigmoid colon are removed and an anastomosis created. An ileostomy might be created temporarily in order to allow the anastomosis to heal.
poorly controlled diabetes what do you need
variable rate insulin infusion
valvulae conniventes
cross that whole small bowel
haustra do not cross teh whole large bowel
what does TPN contain
and what is the compliation other than liver problems
TPN contains a combination of glucose, lipids and essential electrolytes.
It is highly irritant to veins. While it can be given peripherally, it should only be given through central access. For example, a central line or peripherally inserted central catheter (PICC) line.
This patient has had an emergency total colectomy, meaning he is likely to have TPN for more than 14 days, further increasing his risk of thrombophlebitis.
Thrombophlebitis is the most likely complication to develop in this patient, as his TPN is currently being given through a peripheral cannula.
is volvulus less common that bowel tumour as a cause of large bowel obstruction
yes
A 55-year-old woman is triaged to the surgeons following an emergency admission with severe diverticulitis. She is haemodynamically unstable with high inflammatory markers. She is taken to theatre for emergency surgery where her sigmoid colon is removed and a colostomy is created.
What operation has this patient received?
Hartmann’s procedure
This is a Hartmann’s procedure, where the sigmoid colon is removed and a colostomy is formed. The stoma can be reversed at a later date if desired. This operation is used in emergencies, particularly in diverticulitis as the sigmoid colon is the most commonly affected site.
A 65 year old female presents with acute ischaemic bowel and is booked for an emergency laparotomy. She undergoes a central line insertion before the operation but acutely deteriorates with circulatory collapse straight after the line is inserted and flushed. An air embolus from the line insertion is suspected. What method during line insertion helps reduce the risk of air emboli?
Trendelenburg position
An air embolus is a rare but severe complication of central line insertion in which a large air bolus enters the venous circulation. It can present with sudden severe circulatory collapse immediate after central line insertion. The Trendelenburg position is where the patient lies with the head tilted down 15 degrees and the feet elevated in the air. This allows gravity to assist the filling and distension of the upper central veins to reduce the risk of air entering the system. Another method to reduce this risk is to flush the line whilst advancing it to aid distention.
A computed tomography (CT) abdomen and pelvis is performed, which shows thickening of the sigmoid colon wall and pericolonic fat stranding. What is the most likely cause of her symptoms?
diverticulitis
toxic megacolon ix
xr
PBC risk factor for what cancer
hepatocellular carcinoma
A 3 month old baby boy is brought to A&E because today he has been crying inconsolably and he had had strange poos. The stool is red and goopy. He has also vomited milky fluid twice today. He has not had a fever.
On inspection, the child appears unwell and is screaming. It is difficult to properly examine the chest or abdomen because he is inconsolable. An abdominal ultrasound shows concentric rings of hyper- and hypo-echogenicity.
What is the best option to manage this child’s condition?
Rectal air insufflation
This boy with inconsolable crying and currant-jelly stool most likely has intussusception. Intussusception is a condition where one part of bowel telescopes into an adjacent segment. It is managed with rectal air insufflation in theatre
A 58-year-old man on the surgical ward develops fever and shortness of breath. He underwent a laparotomy for a perforated duodenal ulcer 2 days ago and his pain has been poorly controlled post-operatively. He denies any cough or chest pain. Past medical history includes hypertension and type 2 diabetes, and he is currently taking ramipril, metformin, paracetamol, morphine and dalteparin.
On examination, observations are Sp02 93%, heart rate 85 bpm, BP 136/82 mmHg, temperature 38.1 degrees. There is reduced air entry at both lung bases and his abdomen is soft with tenderness around his wound. There is no leg swelling or calf tenderness.
What is the most likely diagnosis?
Atelectasis
post-operative fever around 1-2 days after surgery and can cause shortness of breath. The examination findings of reduced air at the lung bases are typical. It most often occurs due to poor pain control, as this means patients struggle to cough to clear their lungs and have shallow breathing. A chest x-ray would likely show shadowing at the lung bases.
Atelectasis
mx of atelectasis
Management includes adequate pain control, saline nebulisers and chest physiotherapy.
post surgery resection and patietn presnting with signs of peritonic shock first thing to rule out is and what investigation
anastomotic leak
CT AP
what diabetes is caused by chronic pancreatitis
Diabetes mellitus can occur as a result of pancreatic disease and is referred to as type 3c diabetes. It has a higher risk of hypoglycaemia compared to other types of diabetes and is caused by exocrine dysfunction secondary to pancreatic fibrosis.
can also have pseudocyst or cancer
A 73 year old man is recovering from an abdomino-perineal resection on the general surgical ward. On day 6 the patient complains of feeling unwell and of increased pain around the wound. It is noted that he has had several fever spikes over the last 3 days.
On examination there is marked erythema around the wound and copious pus-like discharge from within the wound. Wound swabs are taken and IV fluids and antibiotics are initiated.
What is the definitive management of this patient?
Removal of sutures, washout of the wound and wound left open
This management opens up the infected pocket, cleans the area and allows the wound to heal by second intention
Secondary intention healing means a wound will be left open (rather than being stitched together) and left to heal by itself, filling in and closing up naturally. It will mean you need regular dressings to the area for up to six weeks, but the time to full healing depends on the size, depth and site of the wound.
new sutures create space for pus collection
2 most common causes of small bowel obstruction
adhesions and hernias
dumping syndrome post gastrectomy for gastric cancer
A Billroth I procedure is a partial gastrectomy with a gastroduodenal anastomosis that is performed in gastric cancer or bariatric surgery. It can cause various metabolic complications, one of which is dumping syndrome.
Early dumping syndrome occurs 10–30 minutes after food and is caused by the passage of hypertonic gastric contents into the small bowel, which causes intestinal distension owing to the rapid fluid shift. This can lead to symptoms of vomiting and hypovolaemia (leading to faints), which triggers a sympathetic response, causing sweating and tachycardia. This can be managed by advising the patient to have smaller and more frequent meals.
Late dumping syndrome would present with the same symptoms; however, it usually occurs 1–3 hours after eating. It is caused by a sudden increase in insulin following the passage of food through the bowel and can lead to hypoglycaemia, which would also trigger a sympathetic response to cause tachycardia and diaphoresis.
type 1 diabetics insulin dose
Start a variable rate insulin infusion, continue long-acting insulin at 80% of normal dose and stop short-acting insulin
pneumobilia - air in biliary tree -sign of
gallstone ileus - small bowel obstruction
difference between superifical and full thickness dehiscene
Superficial dehiscence is where the skin wound fails to close but the rectus sheath remains intact.
Full-thickness dehiscence means the rectus sheath fails to heal and can lead to the herniation of abdominal contents through the open wound.
The definitive treatment of full-thickness wound dehiscence is urgent return to theatre for wound closure.
rf for wound dihiscence
Risk factors for developing wound dehiscence include smoking, obesity, poor tissue perfusion postoperatively and increased intra-abdominal pressure postoperatively (for example due to the patient coughing or heavy lifting).
sx of bowel obstruction
Abdominal pain with distension (Initially colicky pain that becomes continuous)
Bloating and vomiting (often bilious)
Failure to pass flatus or stool
History of abdominal/gynaecological surgery or hernia
Tympanic, high-pitched bowel sounds on examination
Empty rectum on examination in complete bowel obstruction
ix in obstruction
Basic blood tests including FBC, U+Es and lactate
FBC (Looking for leukocytosis or anaemia)
U+Es (Organ dysfunction or signs of hypovolaemia)
Lactate (An important examination to establish if there is bowel ischaemia or necrosis) It can be falsely low – the liver can break down lactate quickly so may not increase until late in the presentation
Amylase (Always important in all cases of acute abdomen)
Abdominal and chest X-ray
Assess in upright position to look for pneumoperitoneum
Absence of air in the rectum can indicate complete obstruction
cancer of oesophagus where if laryngeal nerve involved
upper 1/3
spontaneous bacterial peritonitis what drug do you offer
oral ciprofloxacin
mineralcorticoid work on sodium channel and soidum pottasium pumo - lower potassium
glucocortiocids have anti inflammatory effect
orla candida tx
nystatin
paracetamol other fucntion
anti-pyretic
in parkisnons why do you treat with dopamin A first
becuase with L dopa over time substantia nigra gets wrose so dosent work as well
why do you weane people of steriods
reduce risk of adesonain crisis
as HPA axis oversuprrrsed
acid-Schiff (PAS)-positive macrophages,
Tropheryma whipplei
This is the correct answer. This patient presents with symptoms of Whipple’s disease, a rare, systemic condition caused by Tropheryma whipplei. Treatment is with long term administration of co-trimoxazole
57%
co amoxcilav causes
cholestatic jaundice
when do you stop COCP before surgery
4 weeks
does magnesium replacement cause diarrhoea
yes
A serum ascites albumin gradient (SAAG) of <1.1 g/dL is consistent with causes such as
malignancy and infection(TB)
mx of gastroparaeiss
metoclopramide
common cause of post op urinary retention
Spinal anaesthesia is a common cause of post-operative urinary retention. The medications used in a spinal anaesthetic include opioids, of which urinary retention is a common side effect.
A 45 year old man was admitted to the ward with severe nausea, vomiting, abdominal pain, diarrhoea and fever. Past medical history is significant for hypertension (on Enalapril). He has frequently taken over-the-counter ibuprofen for the past few months. He appears weak and tachycardic, with dry mucous membranes and normal blood pressure.
Blood urea nitrogen 56 mmol/L (2.5 - 7.8 mmol/L) Serum creatinine 200 umol/L (60-120 umol/L)
Which of the following investigation would be most helpful for further evaluation of his acute kidney injury?
Fractional excretion of sodium
Hypovolaemia (due to acute gastroenteritis) causes vasoconstriction of renal arterioles leading to decreased blood flow to the kidneys and subsequent decline in GFR. Ibuprofen and enalapril use can worsen renal failure. Fractional excretion of sodium helps to differentiate prerenal acute kidney injury (AKI) and acute tubular necrosis. In prerenal AKI, sodium is reabsorbed to maintain circulating blood volume; therefore, there will be reduced sodium in the urine. In comparison, a raised fractional excretion of sodium usually indicates acute tubular necrosis.
A 65-year-old woman visits her General Practitioner for a check-up. As part of this check-up, blood tests are taken. They show her blood calcium concentration to be low, and blood phosphate concentration to be high. Parathyroid hormone (PTH) is also raised.
Decreased function of which of the following organs would be responsible for the woman’s blood test results?
The kidneys
This is the correct answer. The kidneys control the excretion of calcium and phosphate ions. If 1000mg of calcium a day is consumed orally in the diet, then approximately 150mg is excreted from the kidneys and the rest lost via the faeces. This keeps the body in calcium balance. Similarly, if the daily intake of phosphate is 1200mg then 800mg is excreted from the kidneys, and the rest lost in the faeces. This means there is no net gain or loss of calcium or phosphate ions. In renal failure, this control becomes unbalanced. Calcium levels decrease as the kidneys cannot activate vitamin D. Phosphate is retained, and high levels of Parathyroid hormone (PTH) are released
A 63 year old man is admitted to hospital the day before an elective hernia repair. His medical history includes polymyalgia rheumatic for he takes 15mg prednisolone OD orally.
What is the most appropriate perioperative management of his steroid therapy?
convert to what steriods
Stop prednisolone and give 50-100mg hydrocortisone IV
This is the standard peri-operative management of a patient on prednisolone as it uses IV medication and the dose can be adjusted post-operatively to account for increased steroid demand. Hydrocortisone is also useful because it has both mineralocorticoid and glucocorticoid action
A 75-year-old lady with newly diagnosed end-stage renal failure has her first haemodialysis session. During the dialysis, she rings the nursing bell due to a new headache and vomiting. The nurse checks her observations which show a heart rate of 45 and a blood pressure of 190/92. She rapidly deteriorates and develops irregular breathing. What is the most likely diagnosis?
Dialysis disequilibrium syndrome
Dialysis disequilibrium syndrome is a rare but potentially fatal complication of haemodialysis, particularly in patients who are starting it. Patients may develop cerebral oedema. This is thought to be due to rapid shifts in urea, an osmotically active substance, between different fluid compartments during haemodialysis. In cerebral oedema, there is raised intracranial pressure, which is suggested here by the headache, vomiting and Cushing’s triad - low heart rate, raised blood pressure (with wide pulse pressure) and irregular breathing.
