Surg Flashcards

Question

Q: What are the predisposing factors for breast cancer?

Answer 1

BRCA1 and BRCA2 genes (40% lifetime risk of breast/ovarian cancer) 1st-degree relative with premenopausal breast cancer (e.g., mother) Nulliparity or first pregnancy >30 years (twice the risk compared to women having first child <25 years) Early menarche and late menopause Combined hormone replacement therapy (relative risk increases by 1.023 per year of use) Combined oral contraceptive use Previous breast cancer Not breastfeeding Ionising radiation p53 gene mutations Obesity Previous surgery for benign breast disease (possible more follow-up needed as scar may hide lumps)

Answer 2

Offered to women aged 50-70 years Mammogram every 3 years Women >70 years can still have mammograms but must arrange their own appointments

Answer 3

Invasive ductal carcinoma (No Special Type - NST) (most common) Invasive lobular carcinoma Ductal carcinoma-in-situ (DCIS) Lobular carcinoma-in-situ (LCIS)

Answer 4

Eczematoid nipple change linked with breast malignancy Present in 1-2% of breast cancer cases 50% associated with an underlying mass lesion, with 90% being invasive carcinoma 30% without a mass still have underlying carcinoma

Answer 5

Cancer cells block lymphatic drainage Causes inflamed breast appearance Rare, around 1 in 10,000 cases

Answer 6

Common in women under 30 years Discrete, non-tender, highly mobile lumps ("breast mice")

Answer 7

Common in middle-aged women "Lumpy" breasts, possibly painful Symptoms may worsen before menstruation

Answer 8

Hard, irregular lump Possible nipple inversion Skin tethering

Answer 9

Intraductal carcinoma Reddening and thickening of the nipple/areola May resemble eczematous changes

Answer 10

Dilatation of large breast ducts Most common around menopause Tender lump around the areola Green nipple discharge If ruptured, may cause local inflammation ("plasma cell mastitis")

Answer 11

Local epithelial proliferation in large mammary ducts Hyperplastic, not malignant or premalignant May present with blood-stained discharge

Answer 12

More common in obese women with large breasts Often follows minor or unnoticed trauma Initial inflammatory response Firm, round lump that may become hard and irregular Can mimic breast cancer, requiring investigation

Answer 13

More common in lactating women Red, hot, tender swelling

Answer 14

Lipomas Sebaceous cysts

Answer 15

Develops from a whole lobule Mobile, firm, smooth breast lump ("breast mouse") Represents 12% of all breast masses

Answer 16

No increase in risk of malignancy

Answer 17

If the fibroadenoma is >3cm

Answer 18

A common cause of breast pain in younger females Varies in intensity with the menstrual cycle

Answer 19

Not usually associated with point tenderness of the chest wall (more likely to be Tietze's syndrome) Pain intensity varies according to the menstrual cycle Examination focuses on identifying focal lesions (e.g., cysts)

Answer 20

Wear a supportive bra Conservative treatments: oral and topical analgesia Flaxseed oil and evening primrose oil are sometimes used but not recommended If no improvement after 3 months and pain affects quality of life, consider referral

Answer 21

Bromocriptine Danazol However, many women discontinue due to adverse effects

Answer 22

Dilatation and shortening of the terminal breast ducts within 3cm of the nipple Common, with incidence increasing with age

Answer 23

Nipple retraction Occasionally creamy nipple discharge

Answer 24

It may be confused with periductal mastitis, which presents in younger women, particularly smokers Periductal mastitis typically involves periareolar or subareolar infections and may be recurrent

Answer 25

Microdochectomy (if young) Total duct excision (if older)

Answer 26

Inflammation of the breast tissue Typically associated with breastfeeding, affecting around 1 in 10 women

Answer 27

Painful, tender, red hot breast Fever and general malaise may be present

Answer 28

Continue breastfeeding Simple measures: analgesia, warm compresses

Answer 29

If the patient is systemically unwell If there is a nipple fissure If symptoms don't improve after 12-24 hours of effective milk removal If culture indicates infection

Answer 30

Oral flucloxacillin for 10-14 days

Answer 31

Staphylococcus aureus

Answer 32

Breastfeeding or expressing

Answer 33

It may develop into a breast abscess, which requires incision and drainage

Answer 34

Physiological: During breastfeeding Galactorrhoea: Commonly caused by emotional events or drugs (e.g. histamine receptor antagonists) Hyperprolactinaemia: Often caused by pituitary tumours (microadenomas or macroadenomas) Mammary duct ectasia: Most common in menopausal women, typically results in thick, green discharge, more common in smokers Carcinoma: Often blood-stained, may present with an underlying mass or axillary lymphadenopathy Intraductal papilloma: More common in younger patients, may cause blood-stained discharge without a palpable lump

Answer 35

Examine the breast to determine if there is a mass lesion All mass lesions should undergo Triple assessment

Answer 36

M for mammography followed by a numerical code: 1: No abnormality 2: Abnormality with benign features 3: Indeterminate, probably benign 4: Indeterminate, probably malignant 5: Malignant

Answer 37

Exclude endocrine disease Nipple cytology is unhelpful Advise smoking cessation for duct ectasia Total duct excision may be required for severe symptoms of duct ectasia

Answer 38

A common condition in up to 25% of normal female breasts Typically presents with nipple discharge, often thick and green More common in women over 50 Not the same as periductal mastitis A normal variant of breast involution

Answer 39

Occurs at a younger age than duct ectasia May present with inflammation, abscess, or mammary duct fistula Strongly associated with smoking Treatment typically involves antibiotics, with abscesses requiring drainage

Answer 40

A growth of papilloma in a single duct Usually presents with clear or blood-stained discharge originating from a single duct Does not increase the risk of malignancy

Answer 41

Commonly associated with lactational mastitis, usually caused by Staphylococcus aureus Treatment involves antibiotics and ultrasound-guided aspiration Overlying skin necrosis may require surgical debridement A mammary duct fistula may develop as a complication

Answer 42

Rare in Western countries, usually secondary to tuberculosis Affects women later in childbearing years Chronic breast or axillary sinus may be present in up to 50% of cases Diagnosis is made by biopsy, culture, and histology

Answer 43

An eczematoid change of the nipple associated with an underlying breast malignancy Present in 1-2% of patients with breast cancer In half of these patients, it is associated with an underlying mass lesion 90% of patients with a mass lesion will have invasive carcinoma 30% of patients without a mass lesion will have underlying carcinoma The remainder will have carcinoma in situ Differs from eczema of the nipple as it primarily involves the nipple before spreading to the areola

Answer 44

Diagnosis is made by punch biopsy Mammography and ultrasound of the breast are also used

Answer 45

Treatment depends on the underlying lesion (e.g., surgery for carcinoma)

Answer 46

Ileostomy: Location: Right iliac fossa Appearance: Spouted Output: Liquid Colostomy: Location: Varies, more likely on the left side of the abdomen Appearance: Flushed Output: Solid

Answer 47

An embolism causing occlusion of an artery supplying the small bowel, often the superior mesenteric artery Commonly associated with atrial fibrillation

Answer 48

Severe, sudden onset abdominal pain Pain out of proportion to physical exam findings

Answer 49

Immediate laparotomy, especially if signs of advanced ischemia (e.g., peritonitis or sepsis) are present Poor prognosis if surgery is delayed

Answer 50

Squamous cell carcinoma (SCC) (80% of cases) Other types include melanomas, lymphomas, and adenocarcinomas

Answer 51

HPV infection (HPV16 or HPV18 subtypes) Anal intercourse and a high lifetime number of sexual partners Men who have sex with men HIV infection and immunosuppressive medications Women with a history of cervical cancer or cervical intraepithelial neoplasia (CIN) Smoking

Answer 52

Perianal pain and bleeding A palpable lesion Faecal incontinence Rectovaginal fistula in neglected female cases

Answer 53

Digital rectal examination and anoscopy with biopsy Imaging (CT, MRI, endo-anal ultrasound, PET) HIV testing

Answer 54

A longitudinal or elliptical tear in the squamous lining of the distal anal canal. Acute if present for less than 6 weeks, chronic if present for more than 6 weeks.

Answer 55

Constipation Inflammatory bowel disease Sexually transmitted infections (e.g., HIV, syphilis, herpes)

Answer 56

Painful, bright red rectal bleeding 90% occur on the posterior midline If located elsewhere, consider underlying causes like Crohn's disease

Answer 57

Soften stool with a high-fiber diet and plenty of fluids First-line: bulk-forming laxatives (lactulose if not tolerated) Lubricants such as petroleum jelly before defecation Topical anaesthetics and analgesia

Answer 58

Continue above techniques First-line treatment: topical glyceryl trinitrate (GTN) If ineffective after 8 weeks, consider referral for surgery (sphincterotomy) or botulinum toxin

Answer 59

Location: 3, 7, 11 o'clock positions Internal or external Treatment: Conservative Rubber band ligation Haemorrhoidectomy

Answer 60

Presents with painful rectal bleeding Location: midline (posterior midline 90%) & 12 o'clock position, distal to the dentate line Chronic fissure (> 6 weeks) presents with: Ulcer Sentinel pile Enlarged anal papillae

Answer 61

Crohn's disease Ulcerative colitis Clostridioides difficile

Answer 62

Common organisms: E. coli, Staph aureus Positions: Perianal Ischiorectal Pelvirectal Intersphincteric

Answer 63

Usually results from a previous anorectal abscess Types: Intersphincteric Transsphincteric Suprasphincteric Extrasphincteric Goodsall’s rule helps determine the location

Answer 64

Associated with childbirth and rectal intussusception May be internal or external

Answer 65

Extremely common In children: often related to worms In adults: may be idiopathic or associated with conditions like haemorrhoids

Answer 66

Squamous cell carcinoma is the most common Unlike adenocarcinoma in the rectum

Answer 67

Associated with chronic straining and constipation Histology: mucosal thickening, lamina propria replaced with collagen and smooth muscle (fibromuscular obliteration)

Answer 68

Change in bowel habits (e.g., constipation, diarrhoea, alternating between both, frequent bowel movements) Rectal bleeding (bright red or melena) Abdominal pain and discomfort (due to tumour obstruction or inflammation) Unexplained weight loss (sign of advanced disease) Anaemia (fatigue, weakness, shortness of breath due to chronic bleeding) Bowel obstruction (severe abdominal pain, nausea, vomiting in advanced cases)

Answer 69

Carcinoembryonic antigen (CEA) test CT of the chest, abdomen, and pelvis Full colon evaluation with colonoscopy or CT colonography MRI of the mesorectum for tumours below the peritoneal reflection

Answer 70

Resectional surgery is the primary treatment for colon cancer Anastomosis following resection (depends on blood supply, mucosal apposition, and no tissue tension) Obstruction management: stenting or resection (avoiding defunctioning stomas in modern practice)

Answer 71

Caecal, ascending, or proximal transverse colon: Right hemicolectomy (Ileo-colic anastomosis) Distal transverse, descending colon: Left hemicolectomy (Colo-colon anastomosis) Sigmoid colon: High anterior resection (Colo-rectal anastomosis) Upper rectum: Anterior resection (TME) (Colo-rectal anastomosis) Low rectum: Anterior resection (Low TME) (Colo-rectal anastomosis with optional defunctioning stoma) Anal verge: Abdomino-perineal excision of rectum (no anastomosis)

Answer 72

Emergency resections often lead to an end colostomy due to high risk of anastomosis failure, especially with perforation Hartmann's procedure: sigmoid colon resection with an end colostomy, which may be reversed later Ileo-colic anastomoses are safer in the emergency setting and typically do not require defunctioning stomas

Answer 73

Use of Faecal Immunochemical Test (FIT) for referral in these cases: Abdominal mass Change in bowel habit Iron-deficiency anaemia Age 40+ with unexplained weight loss and abdominal pain Age <50 with rectal bleeding and unexplained symptoms (abdominal pain, weight loss) Age 50+ with unexplained rectal bleeding, abdominal pain, or weight loss Age 60+ with anaemia, even without iron deficiency

Answer 74

Referral should be made through the suspected cancer pathway

Answer 75

Safety netting is recommended If ongoing concern (e.g., abdominal mass), refer on the suspected cancer pathway Continued investigation is crucial to reach a definitive diagnosis

Answer 76

Ages 60-74 (England) or 50-74 (Scotland) are routinely screened every 2 years Individuals aged over 74 can request screening Eligible individuals receive FIT tests via post

Answer 77

The FIT test detects human haemoglobin in stool to check for occult blood Abnormal results lead to an offer of colonoscopy

Answer 78

Patients ≥ 50 with unexplained abdominal pain or weight loss Patients < 60 with changes in bowel habit or iron deficiency anaemia Patients ≥ 60 with anaemia, even without iron deficiency

Answer 79

Screening for colorectal cancer can reduce mortality by 16%. Most cancers develop from adenomatous polyps, which can be detected early through screening.

Answer 80

Diverticular disease involves the herniation of colonic mucosa through the muscular wall of the colon. The usual site is between the taenia coli, where vessels pierce the muscle to supply the mucosa, sparing the rectum (which lacks taenia).

Answer 81

Altered bowel habit Rectal bleeding Abdominal pain

Answer 82

Diverticulitis Haemorrhage Fistula development Perforation and faecal peritonitis Abscess formation Diverticular phlegmon

Answer 83

Colonoscopy, CT cologram, or barium enema can identify diverticular disease. In acutely unwell patients, plain abdominal films and an erect chest x-ray help identify perforation. Abdominal CT scan with oral and intravenous contrast is used to identify acute inflammation and local complications like abscess formation.

Answer 84

Increase dietary fibre intake Mild diverticulitis: Managed conservatively with antibiotics. Peri-colonic abscesses: Should be drained surgically or radiologically. Recurrent episodes requiring hospitalization: Segmental resection may be needed. Hinchey IV perforations (faecal peritonitis): Require resection and stoma, with a high risk of post-operative complications and HDU admission. Less severe perforations: Managed by laparoscopic washout and drain insertion.

Answer 85

Diverticulitis is the infection of a diverticulum, an out-pouching of the intestinal mucosa. The presence of diverticula is referred to as diverticulosis, and when these cause symptoms, it is called diverticular disease. Diverticula are usually found in the sigmoid colon, though in Asian patients, they may be found in the right colon.

Answer 86

Age Lack of dietary fibre Obesity, especially in younger patients Sedentary lifestyle

Answer 87

Intermittent abdominal pain, particularly in the left lower quadrant Bloating Change in bowel habit: constipation or diarrhoea

Answer 88

Severe abdominal pain in the left lower quadrant (right lower quadrant in some Asian patients) Nausea and vomiting (20-60%) due to ileus or complicated diverticulitis Change in bowel habit: constipation (50%) or diarrhoea (25%) Urinary frequency, urgency or dysuria (10-15%) due to bladder irritation PR bleeding Complications: Pneumaturia or faecaluria (suggests colovesical fistula) Vaginal passage of faeces or flatus (suggests colovaginal fistula)

Answer 89

Low-grade pyrexia Tachycardia Tender left iliac fossa (LIF) Palpable mass (in 20% of cases, due to inflammation or abscess) Reduced bowel sounds Guarding, rigidity, and rebound tenderness (suggests complicated diverticulitis with perforation)

Answer 90

FBC: Raised WCC CRP: Raised Erect CXR: May show pneumoperitoneum in cases of perforation AXR: May show dilated bowel loops, obstruction, or abscesses CT: Best modality to identify abscesses Colonoscopy: Should be avoided initially due to the increased risk of perforation in diverticulitis

Answer 91

Managed with oral antibiotics, a liquid diet, and analgesia.

Answer 92

If symptoms do not settle within 72 hours, or if the patient presents with more severe symptoms, hospital admission is required for IV antibiotics.

Answer 93

Dukes' classification describes the extent of spread of colorectal cancer.

Answer 94

Dukes' A: Tumour confined to the mucosa 5-year survival: 95% Dukes' B: Tumour invading the bowel wall 5-year survival: 80% Dukes' C: Lymph node metastases 5-year survival: 65% Dukes' D: Distant metastases 5-year survival: 5% (20% if resectable)

Answer 95

Haemorrhoidal tissue is part of the normal anatomy that contributes to anal continence. These mucosal vascular cushions are found in the left lateral, right posterior, and right anterior portions of the anal canal (at the 3 o'clock, 7 o'clock, and 11 o'clock positions respectively). Haemorrhoids occur when this tissue becomes enlarged, congested, and symptomatic.

Answer 96

Painless rectal bleeding (most common symptom) Pruritus (itching) Pain: usually not significant unless thrombosed Soiling: may occur with third or fourth degree piles

Answer 97

External: Originate below the dentate line and are prone to thrombosis, may be painful. Internal: Originate above the dentate line and generally do not cause pain.

Answer 98

Grade I: Do not prolapse out of the anal canal. Grade II: Prolapse on defecation but reduce spontaneously. Grade III: Can be manually reduced. Grade IV: Cannot be reduced.

Answer 99

Soften stools: Increase dietary fibre and fluid intake. Topical treatments: Local anaesthetics and steroids may be used for symptom relief. Outpatient treatments: Rubber band ligation is superior to injection sclerotherapy. Surgery: Reserved for large, symptomatic haemorrhoids that do not respond to outpatient treatments. Newer treatments: Doppler-guided haemorrhoidal artery ligation and stapled haemorrhoidopexy.

Answer 100

Typically present with significant pain and a purplish, oedematous, tender subcutaneous perianal mass. If presenting within 72 hours, referral for excision should be considered. If after 72 hours, managed with stool softeners, ice packs, and analgesia. Symptoms typically settle within 10 days.

Answer 101

Ischaemic colitis is an acute but transient compromise in blood flow to the large bowel. This reduced blood flow can lead to inflammation, ulceration, and haemorrhage.

Answer 102

It is more likely to occur in 'watershed' areas such as the splenic flexure, which are located at the borders of the territories supplied by the superior and inferior mesenteric arteries.

Answer 103

'Thumbprinting' on abdominal x-ray, which is due to mucosal oedema and haemorrhage.

Answer 104

Large bowel obstruction occurs when the passage of food, fluids, and gas through the large intestines becomes blocked.

Answer 105

Tumour (60% of cases), particularly in distal colonic and rectal tumours. Volvulus. Diverticular disease.

Answer 106

Absence of passing flatus or stool. Abdominal pain. Abdominal distention. Nausea and vomiting (late symptom, may suggest more proximal lesion). Peritonism may be present if associated with bowel perforation.

Answer 107

Abdominal x-ray: Diagnostic if the diameter is greater than 10-12 cm for the caecum, 8 cm for the ascending colon, or 6.5 cm for the recto-sigmoid. CT scan: High sensitivity and specificity (over 90%) for identifying obstruction and its aetiology.

Answer 108

Nil by mouth (NBM). IV fluids. Nasogastric tube with free drainage. If perforation is suspected, IV antibiotics and emergency surgery may be required. If no perforation, conservative management can be trialled for up to 72 hours before considering further intervention.

Answer 109

Emergency surgery is needed if there is peritonitis or bowel perforation. Resection of the perforated or ischaemic bowel and addressing the underlying cause of the obstruction may be performed.

Answer 110

A perianal abscess is a collection of pus within the subcutaneous tissue around the anus, typically originating from the tissue surrounding the anal sphincter.

Answer 111

Pain around the anus, worse on sitting. Hardened tissue in the anal region. Pus-like discharge from the anus. If longstanding, features of systemic infection may be present.

Answer 112

Typically colonised by gut flora such as E. coli. Staphylococcus aureus infections are more likely to be skin-related.

Answer 113

Inspection and digital rectal examination. Colonoscopy and blood tests may be used to investigate the underlying cause. MRI and transperineal ultrasound are used in complex cases or when complications are suspected, with MRI being the gold standard

Answer 114

Inflammatory bowel disease (IBD), especially Crohn's disease. Diabetes mellitus, due to its effect on wound healing. Underlying malignancy, increasing the risk of abscess formation and perforation.

Answer 115

Incision and drainage under local anaesthetic. Wound can be packed or left open to heal in 3-4 weeks. Antibiotics may be used if there is systemic upset but are not helpful for wound healing.

Answer 116

Bright red blood is usually from the rectum or anal canal. Dark red blood suggests a proximal source. Malaena (black, tarry stools) indicates blood from a gastro-duodenal source.

Answer 117

Painful bright red rectal bleeding post-defecation in small volumes. Associated with constipation. Muco-epithelial defect, usually midline posteriorly (anterior fissures more likely due to underlying disease).

Answer 118

Bright red rectal bleeding post-defecation. No blood mixed with stool. Bleeding seen on toilet paper or as drops in the pan. Proctoscopy may reveal internal haemorrhoids that are often impalpable.

Answer 119

Bright red or mixed blood with stool. Associated with altered bowel habit, malaise, fissures, and abscesses. Proctoscopy may show indurated mucosa and skip lesions.

Answer 120

Bright red blood mixed with stool. Associated with diarrhoea, weight loss, and nocturnal incontinence. Colonoscopy reveals continuous mucosal lesions.

Answer 121

Bright red blood mixed with stool. Associated with altered bowel habits, tenesmus, and possible metastatic symptoms. Proctoscopy reveals a fixed or mobile mucosal abnormality.

Answer 122

Digital rectal examination. Procto-sigmoidoscopy as the minimal test. In young patients with suspected haemorrhoids, sigmoidoscopy may suffice.

Answer 123

If symptoms suggest inflammatory bowel disease or altered bowel habits. If sigmoidoscopy does not provide a clear diagnosis or the patient is not young.

Answer 124

First-line: GTN ointment (0.2%) or diltiazem cream applied topically. If unsuccessful, consider Botulinum toxin injections. Internal sphincterotomy may be required if treatments fail.

Answer 125

Lifestyle advice (e.g., increased fiber). Small internal haemorrhoids: injection sclerotherapy or rubber band ligation. External haemorrhoids: haemorrhoidectomy. Modern procedures: HALO procedure and stapled haemorrhoidectomy.

Answer 126

Anterior resection or abdomino-perineal excision. Total mesorectal excision (TME) is standard of care. Most resections below the peritoneal reflection require a defunctioning ileostomy. Preoperative radiotherapy is often required.

Answer 127

Proctocolectomy (surgical resection of the colon and rectum). Subtotal colectomy may be performed in emergency cases of poorly controlled colitis that fail to respond to medical therapy.

Answer 128

Malignant transformation or dysplastic transformation of the colonic epithelium. Longstanding UC with risk of cancer.

Answer 129

Subtotal colectomy with creation of an end ileostomy. Rectum may be stapled off or left in situ if the bowel is very oedematous.

Answer 130

Ileoanal pouch procedure, but only if the rectum is still in situ. This is not typically possible after proctectomy.

Answer 131

Surgical resection improves symptoms but does not provide a cure. Surgery may be indicated for complications such as fistulae, abscesses, and strictures.

Answer 132

Significant pain. A tender lump around the anus.

Answer 133

Purplish, oedematous, and tender subcutaneous perianal mass.

Answer 134

Referral for excision may be considered.

Answer 135

Use of stool softeners, ice packs, and analgesia. Symptoms typically settle within 10 days.

Answer 136

Torsion of the colon around its mesenteric axis, leading to compromised blood flow and closed-loop obstruction.

Answer 137

Sigmoid volvulus (80% of cases). Caecal volvulus (20% of cases).

Answer 138

Older patients. Chronic constipation. Chagas disease. Neurological conditions (e.g., Parkinson's disease, Duchenne muscular dystrophy). Psychiatric conditions (e.g., schizophrenia).

Answer 139

Adhesions. Pregnancy

Answer 140

Constipation. Abdominal bloating. Abdominal pain. Nausea/vomiting.

Answer 141

Large bowel obstruction with a dilated loop of colon and often air-fluid levels. Presence of coffee bean sign.

Answer 142

Small bowel obstruction.

Answer 143

Rigid sigmoidoscopy with rectal tube insertion.

Answer 144

Operative management, often requiring right hemicolectomy.

Answer 145

Duodenal ulcers: Epigastric pain relieved by eating. Gastric ulcers: Epigastric pain worsened by eating. Features of upper gastrointestinal haemorrhage (e.g., haematemesis, melena).

Answer 146

Initial pain in the central abdomen before localising to the right iliac fossa (RIF). Anorexia, tachycardia, low-grade pyrexia. Rovsing's sign: More pain in RIF than LIF when palpating LIF.

Answer 147

Severe epigastric pain, often due to alcohol or gallstones. Vomiting common. Tenderness, ileus, and low-grade fever may be present. Rare signs include Cullen's sign (periumbilical discolouration) and Grey-Turner's sign (flank discolouration).

Answer 148

RUQ pain radiating to the back and interscapular region, often following a fatty meal. Obstructive jaundice may cause pale stools and dark urine.

Answer 149

Continuous RUQ pain. Fever, raised inflammatory markers, and white cells. Murphy's sign: Arrest of inspiration on palpation of RUQ.

Answer 150

Colicky pain typically in the LLQ. Fever, raised inflammatory markers, and white cells.

Answer 151

Severe central abdominal pain radiating to the back. May present catastrophically (e.g., sudden collapse) or sub-acutely with persistent severe pain and developing shock. History of cardiovascular disease may be present.

Answer 152

History of malignancy or previous operations. Vomiting and no recent bowel movements. ‘Tinkling’ bowel sounds.

Answer 153

Acute coronary syndrome. Diabetic ketoacidosis. Pneumonia. Acute intermittent porphyria. Lead poisoning.

Answer 154

Appendicitis: More pain in the right iliac fossa (RIF) when palpating the left iliac fossa (LIF).

Answer 155

Cholecystitis: Right scapular pain or discomfort due to gallbladder inflammation.

Answer 156

Cholecystitis: Arrest of inspiration upon palpation of the RUQ (right upper quadrant).

Answer 157

Pancreatitis or other intra-abdominal haemorrhage: Periumbilical discolouration (bruising).

Answer 158

Pancreatitis or other retroperitoneal haemorrhage: Flank discolouration (bruising).

Answer 159

History of malignancy/previous operations Vomiting Not opened bowels recently Tinkling bowel sounds

Answer 160

History of alcohol excess Cardiac failure

Answer 161

History of prostate problems Dullness to percussion around the suprapubic area

Answer 162

Older female Pelvic pain Urinary symptoms (e.g., urgency) Raised CA125 Early satiety, bloating

Answer 163

Palpable lump Cough impulse Pain Obstruction (more common in femoral hernias) Strangulation (may compromise bowel blood supply, leading to infarction)

Answer 164

Accounts for 75% of abdominal wall hernias 95% of patients are male Lifetime risk of 25% in men Located above and medial to the pubic tubercle Strangulation is rare

Answer 165

Located below and lateral to the pubic tubercle More common in women, particularly multiparous ones High risk of obstruction and strangulation Surgical repair required

Answer 166

Symmetrical bulge under the umbilicus

Answer 167

Asymmetrical bulge Half the sac is covered by skin above or below the umbilicus

Answer 168

Lump in the midline between the umbilicus and the xiphisternum Risk factors include extensive physical training, coughing, and obesity

Answer 169

Hernia through the obturator foramen More common in females, typically presents with bowel obstruction

Answer 170

Indirect hernias from a patent processus vaginalis Occur in around 1% of term babies, more common in premature babies and boys 60% right-sided, 10% bilateral Should be surgically repaired soon after diagnosis due to the risk of incarceration

Answer 171

Symmetrical bulge under the umbilicus More common in premature and Afro-Caribbean babies The majority resolve without intervention before age 4-5 years Complications are rare

Answer 172

Acute appendicitis is the most common acute abdominal condition requiring surgery, particularly in young people aged 10-20 years.

Answer 173

Peri-umbilical pain (visceral stretching) radiating to the right iliac fossa (RIF) due to localized parietal peritoneal inflammation. The migration of pain from the centre to RIF is a strong indicator. Pain often worsens on coughing or going over speed bumps. Children often cannot hop on the right leg due to pain.

Answer 174

Vomiting (usually once or twice, marked vomiting is unusual). Diarrhoea is rare but may occur with pelvic appendicitis or abscess. Mild pyrexia (37.5–38°C); higher temperature suggests other conditions like mesenteric adenitis. Anorexia is very common.

Answer 175

Generalized peritonitis or localized peritonism (if perforation has occurred). Rebound tenderness, percussion tenderness, guarding, and rigidity. Retrocaecal appendicitis may have fewer signs. Psoas sign: pain on extending the hip (if retrocaecal appendix). Digital rectal examination may reveal a boggy sensation in pelvic abscess or right-sided tenderness with a pelvic appendix.

Answer 176

Raised inflammatory markers (neutrophil-predominant leucocytosis in 80-90%). Urine analysis: excludes pregnancy in females, renal colic, and UTI. Mild leucocytosis may be seen in appendicitis but no nitrites. Imaging: Ultrasound in females for pelvic organ pathology; CT scan used in the US but not widely in the UK due to radiation concerns.

Answer 177

Appendicectomy via open or laparoscopic approach (laparoscopic is now preferred). Prophylactic intravenous antibiotics to reduce wound infection. Perforated appendicitis requires copious abdominal lavage. Appendix mass: broad-spectrum antibiotics and consideration for interval appendicectomy. In elderly patients, be cautious of caecal malignancy or perforated sigmoid diverticular disease. Antibiotics alone: Successful in many cases, but often requires longer hospital stay, and 20% of patients may need appendicectomy within 12 months.

Answer 178

Found in autoimmune thyroid diseases 100% of patients with Hashimoto's thyroiditis Present in 70% of patients with Graves' disease

Answer 179

Found in individuals with Graves' disease Present in 95% of Graves' disease patients

Answer 180

Not useful for distinguishing between different thyroid diseases May be used for follow-up in thyroid cancer patients

Answer 181

Released from parafollicular cells of the thyroid Elevated levels are often found in medullary thyroid carcinoma

Answer 182

A congenital undescended testis that fails to descend into the scrotum by 3 months of age At birth, 5% of boys may have an undescended testis; by 3 months, the incidence drops to 1-2% Postnatal descent occurs in most cases

Answer 183

Patent processus vaginalis Abnormal epididymis Cerebral palsy Mental retardation Wilms' tumor Abdominal wall defects (e.g., gastroschisis, prune belly syndrome)

Answer 184

A retractile testis can be manually moved into the scrotum and stays there when released If the testis returns rapidly to the inguinal canal, surgery may be indicated

Answer 185

Reduces the risk of infertility Allows for examination of the testis for testicular cancer Prevents testicular torsion Improves cosmetic appearance Males with undescended testes are 40 times more likely to develop testicular cancer (seminoma) Intra-abdominal testes have a 50% risk of testicular cancer

Answer 186

Orchidopexy is recommended between 6 to 18 months of age Involves inguinal exploration, mobilization of the testis, and implantation into a dartos pouch Intra-abdominal testis should be evaluated laparoscopically Late presentation in teenage years may require orchidectomy due to non-functioning testis and increased malignancy risk

Answer 187

Peaked or 'tall-tented' T waves

Answer 188

Peaked or 'tall-tented' T waves (occurs first) Loss of P waves Broad QRS complexes Sinusoidal wave pattern Ventricular fibrillation

Answer 189

Use gastric feeding unless there is upper GI dysfunction (then use duodenal or jejunal tube)

Answer 190

Check NG placement using aspiration and pH Check post-pyloric tubes with AXR

Answer 191

PEG can be used 4 hours after insertion, but should not be removed until >2 weeks after insertion

Answer 192

Consider preoperative enteral feeding if the patient is malnourished, has unsafe swallowing, inadequate oral intake, and a functional GI tract

Answer 193

Occurs when part of the bowel or other abdominal viscera passes into the femoral canal The femoral canal is a potential space in the anterior thigh that can be occupied by herniated contents via the femoral ring

Answer 194

A lump in the groin, usually mildly painful Inferolateral to the pubic tubercle, distinguishable from inguinal hernias which are supermedial to the pubic tubercle Typically non-reducible, but can be reducible in some cases Cough impulse is often absent due to the small femoral ring

Answer 195

Surgical repair is necessary due to the risk of strangulation Can be done laparoscopically or via laparotomy Hernia support belts/trusses should not be used due to the risk of strangulation In an emergency, laparotomy may be required

Answer 196

Low risk of strangulation

Answer 197

Low risk of strangulation

Answer 198

High risk of strangulation

Answer 199

Herniation of part of the stomach above the diaphragm

Answer 200

Sliding hiatus hernia: gastroesophageal junction moves above the diaphragm (95% of cases) Rolling (paraoesophageal) hiatus hernia: gastroesophageal junction remains below the diaphragm, but a separate part of the stomach herniates through the oesophageal hiatus

Answer 201

Obesity Increased intraabdominal pressure (e.g. ascites, multiparity)

Answer 202

Heartburn Dysphagia Regurgitation Chest pain

Answer 203

Barium swallow

Answer 204

Endoscopy (often finds the hiatus hernia incidentally)

Answer 205

Conservative management: weight loss Medical management: Proton pump inhibitors (PPI) therapy Surgical management: indicated mainly for symptomatic paraesophageal hernias

Answer 206

Groin lump Located superior and medial to the pubic tubercle Disappears on pressure or when the patient lies down Discomfort and ache, often worse with activity; severe pain is uncommon Strangulation is rare

Answer 207

Surgery is recommended for medically fit patients

Answer 208

Open surgery

Answer 209

Laparoscopic surgery

Answer 210

Cholangiocarcinoma Hepatocellular carcinoma Hepatoblastoma Sarcomas (rare) Lymphomas Carcinoids (most often secondary, but primary can occur)

Answer 211

Metastatic disease

Answer 212

Hepatocellular carcinoma (75% of primary liver tumors)

Answer 213

Chronic liver disease, especially cirrhosis and chronic hepatitis B infection

Answer 214

CT and MRI (usually both)

Answer 215

AFP is elevated in almost all cases of hepatocellular carcinoma

Answer 216

Surgical resection

Answer 217

Cholangiocarcinoma

Answer 218

Primary sclerosing cholangitis

Answer 219

Jaundice (by the time of presentation, most cases are not resectable)

Answer 220

CA 19-9 CEA CA 125

Answer 221

CT/MRI and MRCP

Answer 222

Surgical resection (though often not possible due to local invasion or lobar atrophy)

Answer 223

History of antecedent vomiting followed by vomiting of a small amount of blood Little systemic disturbance or prior symptoms

Answer 224

Longstanding history of dyspepsia Often overweight patients Uncomplicated hiatus hernias should not cause dysphagia or haematemesis

Answer 225

Severe chest pain without cardiac diagnosis Signs of pneumonia without convincing history History of vomiting Erect chest X-ray shows infiltrate or effusion in 90% of cases

Answer 226

Progressive dysphagia Often associated with weight loss Little to no history of previous GORD symptoms

Answer 227

Progressive dysphagia May have a history of GORD or Barrett’s oesophagus

Answer 228

Longer history of dysphagia, often non-progressive Usually associated with GORD symptoms Lack of systemic features seen with malignancy

Answer 229

Episodic, non-progressive dysphagia Retrosternal pain may accompany the episodes

Answer 230

Upper GI endoscopy

Answer 231

If upper GI endoscopy fails to demonstrate a mechanical stricture, these tests, along with radiological contrast swallows, help in diagnosis

Answer 232

Pain radiating to right iliac fossa Anorexia Typically short history Diarrhoea and profuse vomiting are rare

Answer 233

Often long history Signs of malnutrition Change in bowel habit, especially diarrhoea

Answer 234

More common in children Causes include Adenoviruses, Epstein-Barr virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans, and Yersinia spp. Higher temperature than appendicitis Enlarged mesenteric lymph nodes on laparotomy

Answer 235

May present with both left and right sided disease Clinical history may be similar to appendicitis, with some change in bowel habit A CT scan may help refine diagnosis

Answer 236

A congenital abnormality present in about 2% of the population Typically 2 feet proximal to the ileocaecal valve May be lined by ectopic gastric mucosal tissue, causing bleeding

Answer 237

Usually produces upper quadrant pain but can be lower Sharp, sudden onset of pain May present with pain in the right iliac fossa

Answer 238

Right iliac fossa pain if right-sided Can cause bowel obstruction

Answer 239

Seldom localised to right iliac fossa Complete large bowel obstruction with caecal distension may cause pain before perforation

Answer 240

Adhesions, often following previous surgery Hernias are the next most common cause

Answer 241

Diffuse, central abdominal pain Nausea and vomiting Typically bilious vomiting 'Constipation' with complete obstruction and lack of flatulence Abdominal distension, especially with lower levels of obstruction 'Tinkling' bowel sounds (more common in early obstruction)

Answer 242

Abdominal x-ray Distended small bowel loops with fluid levels Small bowel is considered dilated if >3cm in diameter

Answer 243

CT scan More sensitive, particularly in early obstruction

Answer 244

NBM (Nil by mouth) IV fluids Nasogastric tube with free drainage Some patients may settle with conservative management Surgery may be required if conservative management fails

Answer 245

Protrusion of viscera or abdominal contents through the superficial inguinal ring Typically consists of small bowel, though not always Can enter the inguinal canal either directly or indirectly

Answer 246

Reducible hernia: The herniated tissue can be pushed back into the abdomen Incarcerated hernia: The hernia cannot be reduced, and there is a risk of strangulation

Answer 247

A surgical emergency where the blood supply to the herniated tissue is compromised Can cause ischemia or necrosis of the bowel, potentially leading to permanent tissue loss or perforation Occurs in about 1 in 500 inguinal hernia cases

Answer 248

Episodes of pain in a hernia previously asymptomatic Irreducible hernias

Answer 249

Pain Fever Increase in the size of the hernia or erythema of overlying skin Peritonitic features (guarding, localized tenderness) Bowel obstruction (distension, nausea, vomiting) Bowel ischemia (bloody stools)

Answer 250

Imaging is not necessary but can be useful to exclude other pathologies Abdominal X-ray or CT may be used to assess for obstruction Erect chest X-ray is recommended for suspected perforation Full blood count and arterial blood gas analysis may show: Leukocytosis Raised lactate

Answer 251

Immediate surgery (open or laparoscopic) with mesh repair Any dead bowel must be removed Avoid manual reduction of strangulated hernias, as it may lead to peritonitis

Answer 252

Deep coma of known aetiology Reversible causes excluded No sedation Normal electrolytes

Answer 253

Fixed pupils unresponsive to light No corneal reflex Absent oculo-vestibular reflexes (no eye movements after ice-cold water injection into ears) No response to supraorbital pressure No cough reflex to bronchial stimulation or gagging to pharyngeal stimulation No respiratory effort after ventilator disconnection for 5 minutes (or longer, ensuring CO2 levels rise to at least 6.0 kPa)

Answer 254

Test performed by two doctors with at least 5 years of post-graduate experience One of the doctors must be a consultant Neither doctor can be a member of the transplant team if organ donation is being considered The test should be done on two separate occasions

Answer 255

GCS < 13 on initial assessment GCS < 15 at 2 hours post-injury Suspected open or depressed skull fracture Any sign of basal skull fracture (e.g., haemotympanum, 'panda' eyes, CSF leakage from ear or nose, Battle's sign) Post-traumatic seizure Focal neurological deficit More than 1 episode of vomiting

Answer 256

Age 65 or older History of bleeding or clotting disorders (including anticoagulants) Dangerous mechanism of injury (e.g., pedestrian/cyclist struck by motor vehicle, occupant ejected from vehicle, fall >1 metre or 5 stairs) More than 30 minutes' retrograde amnesia before the injury

Answer 257

Perform a CT head scan within 8 hours of the injury if no other indications for immediate CT head scan

Answer 258

Focal (e.g., contusion, haematoma) Diffuse (e.g., diffuse axonal injury)

Answer 259

Occurs due to mechanical shearing following deceleration, causing disruption and tearing of axons

Answer 260

Caused by factors like cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation It exacerbates the original injury by disrupting cerebral autoregulation, making the brain more susceptible to blood flow changes and hypoxia

Answer 261

Hypertension and bradycardia Often a pre-terminal event in the context of raised intracranial pressure

Answer 262

Bleeding between the dura mater and the skull, often from acceleration-deceleration trauma or a blow to the side of the head Typically caused by rupture of the middle meningeal artery, especially in the temporal region

Answer 263

Features of raised intracranial pressure Possible lucid interval

Answer 264

Bleeding between the dura mater and the outermost meningeal layer, commonly around the frontal and parietal lobes Risk factors include old age, alcoholism, and anticoagulation

Answer 265

Slower onset of symptoms compared to epidural haematomas Fluctuating confusion and consciousness

Answer 266

Sudden occipital headache, often due to a ruptured cerebral aneurysm Can also occur in traumatic brain injury

Answer 267

A collection of blood within the substance of the brain Causes include hypertension, vascular lesions, cerebral amyloid angiopathy, trauma, brain tumour, or infarct Patients present similarly to ischaemic stroke

Answer 268

Often managed conservatively by stroke physicians Large clots in patients with impaired consciousness may require surgical evacuation

Answer 269

Hydrocephalus is the accumulation of cerebrospinal fluid (CSF) in the ventricular system of the brain, caused by an imbalance between CSF production and absorption

Answer 270

Headache (worse in the morning, lying down, and during valsalva) Nausea and vomiting Papilloedema Coma (in severe cases)

Answer 271

Increase in head circumference due to unclosed skull sutures Bulging and tense anterior fontanelle 'Sunsetting' eyes (failure of upward gaze) due to compression of the superior colliculus of the midbrain

Answer 272

Obstructive ('non-communicating') hydrocephalus Non-obstructive ('communicating') hydrocephalus

Answer 273

Structural pathology blocking CSF flow Causes include tumours, acute haemorrhage (e.g., subarachnoid or intraventricular haemorrhage), and developmental abnormalities (e.g., aqueduct stenosis)

Answer 274

Imbalance in CSF production and absorption Can be due to increased CSF production (e.g., choroid plexus tumour) or failure of reabsorption at the arachnoid granulations (e.g., meningitis or post-haemorrhagic)

Answer 275

A form of non-obstructive hydrocephalus with large ventricles but normal intracranial pressure Classic triad: dementia, incontinence, and disturbed gait

Answer 276

CT head (fast and shows adequate resolution of the brain and ventricles)

Answer 277

MRI is used for more detailed investigation, particularly when an underlying lesion is suspected

Answer 278

Diagnostic and therapeutic: allows for CSF sampling, opening pressure measurement, and CSF drainage to reduce pressure

Answer 279

External ventricular drain (EVD), typically inserted into the right lateral ventricle, draining into a bag at the bedside

Answer 280

Ventriculoperitoneal shunt (VPS), which diverts CSF from the ventricles to the peritoneum

Answer 281

It may cause brain herniation due to differences in cranial and spinal pressures

Answer 282

An intracranial haemorrhage where blood accumulates within the subarachnoid space, deep to the subarachnoid layer of the meninges

Answer 283

Intracranial aneurysm (saccular 'berry' aneurysms), accounting for around 85% of cases

Answer 284

Hypertension Adult polycystic kidney disease Ehlers-Danlos syndrome Coarctation of the aorta

Answer 285

Sudden-onset severe headache ('thunderclap') Occipital headache, peaking within 1-5 minutes Nausea and vomiting Meningism (photophobia, neck stiffness) Coma and seizures ECG changes including ST elevation

Answer 286

Non-contrast CT head

Answer 287

Acute blood appears hyperdense (bright) on CT, often in the basal cisterns, sulci, and sometimes the ventricular system

Answer 288

If CT head is normal within 6 hours of symptom onset, no LP is needed If CT is done >6 hours after onset and is normal, perform an LP at least 12 hours after symptom onset to check for xanthochromia (red blood cell breakdown) Xanthochromia and normal or raised opening pressure in CSF suggest SAH

Answer 289

Supportive care (bed rest, analgesia) Venous thromboembolism prophylaxis Discontinuation of antithrombotics (reversal of anticoagulation if present) Nimodipine to prevent vasospasm Surgical intervention within 24 hours (coiling by interventional neuroradiologists or craniotomy and clipping by neurosurgeons)

Answer 290

Re-bleeding (most common in the first 12 hours) Hydrocephalus (treated with external ventricular drain or ventriculoperitoneal shunt) Vasospasm (delayed cerebral ischaemia, typically 7-14 days after onset) Hyponatraemia (due to SIADH) Seizures

Answer 291

A collection of blood deep to the dural layer of the meninges, an extra-axial (extrinsic) lesion Can be unilateral or bilateral

Answer 292

Acute: Symptoms develop within 48 hours, rapid neurological deterioration Subacute: Symptoms develop within days to weeks, gradual progression Chronic: Develop over weeks to months, common in the elderly, may not recall specific injury

Answer 293

Neurological symptoms: Altered mental status (confusion to coma), focal deficits (weakness, aphasia), headache, seizures Physical findings: Papilloedema, pupil changes (unilateral dilated pupil), gait abnormalities, hemiparesis/hemiplegia Behavioral/cognitive changes: Memory loss, personality changes, cognitive impairment Other: Nausea, vomiting, drowsiness, signs of increased ICP (Cushing's triad)

Answer 294

Acute: Rapid neurological deterioration, often after high-impact trauma Chronic: Gradual onset of confusion, reduced consciousness, or neurological deficits over weeks to months

Answer 295

High-impact trauma, often associated with other brain injuries

Answer 296

Crescentic collection, hyperdense (bright) compared to the brain May show mass effect (midline shift, herniation)

Answer 297

Conservative observation Surgical options include monitoring intracranial pressure or decompressive craniectomy

Answer 298

Rupture of small bridging veins due to brain atrophy, commonly in elderly and alcoholic patients Can also occur in infants (e.g., shaken baby syndrome)

Answer 299

Crescentic collection, hypodense (dark) compared to brain Mass effect without restriction by suture lines

Answer 300

Surgical decompression with burr holes if there is confusion, neurological deficit, or severe imaging findings

Answer 301

Age at presentation: Few hours after birth Diagnosis: AXR shows double bubble sign, contrast study may confirm

Answer 302

Treatment: Duodenoduodenostomy

Answer 303

Age at presentation: Usually 3-7 days after birth, may present with peritoneal signs and haemodynamic instability in cases of volvulus with compromised circulation Diagnosis: Upper GI contrast study (DJ flexure more medially placed), USS may show abnormal orientation of SMA and SMV

Answer 304

Treatment: Ladd's procedure

Answer 305

Age at presentation: Usually within 24 hours of birth Diagnosis: AXR shows air-fluid levels

Answer 306

Treatment: Laparotomy with primary resection and anastomosis

Answer 307

Age at presentation: Typically in the first 24-48 hours of life with abdominal distension and bilious vomiting Diagnosis: AXR shows air-fluid levels, sweat test to confirm cystic fibrosis

Answer 308

Treatment: Surgical decompression, segmental resection if there is serosal damage

Answer 309

Age at presentation: Usually second week of life Diagnosis: Dilated bowel loops on AXR, pneumatosis, and portal venous air

Answer 310

Treatment: Conservative and supportive for non-perforated cases, laparotomy and resection for perforated or deteriorating cases

Answer 311

Right upper quadrant pain, may radiate to the right shoulder Fever and signs of systemic upset Murphy's sign: inspiratory arrest upon palpation of the right upper quadrant Liver function tests are typically normal, but deranged LFTs may indicate Mirizzi syndrome

Answer 312

Gallstone impacted in the distal cystic duct, causing extrinsic compression of the common bile duct

Answer 313

Ultrasound

Answer 314

Intravenous antibiotics Cholecystectomy, preferably early laparoscopic cholecystectomy within 1 week of diagnosis (as per NICE guidelines)

Answer 315

Alcohol Gallstones

Answer 316

Autodigestion of pancreatic tissue by pancreatic enzymes, leading to necrosis

Answer 317

Severe epigastric pain, may radiate to the back Vomiting Epigastric tenderness, ileus, and low-grade fever on examination Rare periumbilical discolouration (Cullen's sign) and flank discolouration (Grey-Turner's sign)

Answer 318

Serum amylase, raised in 75% of patients (typically > 3 times the upper limit of normal) Serum lipase, more sensitive and specific than amylase

Answer 319

Gallstones Ethanol Trauma Steroids Mumps (other viruses include Coxsackie B) Autoimmune (e.g. polyarteritis nodosa), Ascaris infection Scorpion venom Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia ERCP Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)

Answer 320

Peripancreatic fluid collections Occur in 25% of cases

Answer 321

Located in or near the pancreas and lack a wall of granulation or fibrous tissue May resolve or develop into pseudocysts or abscesses Aspiration and drainage are best avoided as they may precipitate infection

Answer 322

Result from organisation of peripancreatic fluid collections Walled by fibrous or granulation tissue Typically occur 4 weeks or more after an attack of acute pancreatitis Most are retrogastric 75% associated with persistent mild elevation of amylase

Answer 323

Most resolve on their own, can be observed for 12 weeks If symptomatic, treatment options include endoscopic or surgical cystogastrostomy or aspiration

Answer 324

Involves both the pancreatic parenchyma and surrounding fat Severity linked to the extent of parenchymal necrosis and overall necrosis Sterile necrosis is managed conservatively initially

Answer 325

Intraabdominal collection of pus associated with the pancreas, but without necrosis Typically occurs as a result of infected pseudocyst Treatment options include transgastric drainage or endoscopic drainage

Answer 326

Aggressive early hydration with crystalloids In severe cases, 3-6 litres of third-space fluid loss may occur Aim for a urine output of > 0.5mls/kg/hr Helps relieve pain by reducing lactic acidosis

Answer 327

Pain is often severe and is a key priority of care Intravenous opioids are typically required for adequate pain control

Answer 328

Patients should not routinely be made nil-by-mouth unless there is a clear reason (e.g. vomiting) Enteral nutrition should be offered within 72 hours for moderately severe or severe cases Parenteral nutrition should be used only if enteral nutrition fails or is contraindicated

Answer 329

Gallstones-induced pancreatitis: Early cholecystectomy Obstructed biliary system due to stones: Early ERCP Necrosis with worsening organ dysfunction: Debridement, sometimes with fine needle aspiration Infected necrosis: Either radiological drainage or surgical necrosectomy, depending on local expertise

Answer 330

Gallstones

Answer 331

Right upper quadrant (RUQ) pain Fever Jaundice Seen in about 20-50% of patients

Answer 332

Hypotension Confusion In addition to the three features of Charcot's triad

Answer 333

Ultrasound to assess bile duct dilation and bile duct stones

Answer 334

Intravenous antibiotics Endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve obstruction

Answer 335

Fat (obesity due to enhanced cholesterol synthesis and secretion) Female (2-3 times more common in women due to estrogen affecting HMG-CoA reductase) Fertile (pregnancy) Forty (age)

Answer 336

Colicky right upper quadrant abdominal pain Worse postprandially, especially after fatty foods Pain radiating to the right shoulder/interscapular region Nausea and vomiting No fever Normal liver function tests and inflammatory markers

Answer 337

Ultrasound

Answer 338

Elective laparoscopic cholecystectomy

Answer 339

CT contrast swallow

Answer 340

Thoracotomy and lavage Primary repair is usually feasible

Answer 341

Insertion of a T tube to create a controlled fistula between the oesophagus and skin

Answer 342

Primary sclerosing cholangitis

Answer 343

Persistent biliary colic symptoms Anorexia, jaundice, and weight loss Palpable mass in the right upper quadrant (Courvoisier sign) Periumbilical lymphadenopathy (Sister Mary Joseph nodes) Left supraclavicular adenopathy (Virchow node)

Answer 344

Raised CA 19-9 levels

Answer 345

Faecal elastase test

Answer 346

80% respond to H. pylori eradication if low-grade

Answer 347

Haemodynamic instability/shock Raised intracranial pressure Acute intestinal obstruction with dilated bowel loops (e.g., > 4 cm) Uncorrected coagulopathy

Answer 348

Pre-hepatic: Bilirubin: Normal or high ALT/AST: Normal Alkaline phosphatase: Normal Hepatic: Bilirubin: High ALT/AST: Elevated (often very high) Alkaline phosphatase: Elevated but seldom very high Post-hepatic: Bilirubin: High to very high ALT/AST: Moderate elevation Alkaline phosphatase: High to very high

Answer 349

Escherichia coli (E. coli) is the most commonly isolated pathogen.

Answer 350

Recent urinary tract infection Urogenital instrumentation Intermittent bladder catheterisation Recent prostate biopsy

Answer 351

Pain referred to the perineum, penis, rectum, or back Obstructive voiding symptoms Fever and rigors Digital rectal examination: Tender, boggy prostate gland

Answer 352

14-day course of a quinolone (as per the BNF) Consider screening for sexually transmitted infections

Answer 353

Bladder ultrasound with a volume of >300 cc confirms the diagnosis. If the history and examination are consistent, the diagnosis may still be confirmed despite an inconsistent bladder scan.

Answer 354

Decompress the bladder via catheterisation. Measure urine drained in the first 15 minutes: <200 cc: No acute urinary retention. 400 cc: Leave the catheter in place. Between 200 and 400 cc: Further case-specific management. Investigate the underlying cause based on the likely cause (e.g. UTI, BPH, neurological, or gynaecological causes).

Answer 355

Voiding (obstructive) symptoms: Weak or intermittent urinary flow Straining Hesitancy Terminal dribbling Incomplete emptying Storage (irritative) symptoms: Urgency Frequency Urgency incontinence Nocturia Post-micturition dribbling

Answer 356

Dipstick urine: To assess for infection or hematuria. U&Es: Particularly if chronic retention is suspected. PSA: Should be done if there are obstructive symptoms or concerns about prostate cancer. Urinary frequency-volume chart: Should be maintained for at least 3 days. International Prostate Symptom Score (IPSS): 20-35: Severely symptomatic 8-19: Moderately symptomatic 0-7: Mildly symptomatic

Answer 357

Watchful waiting: For mild symptoms. Alpha-1 antagonists (e.g., tamsulosin, alfuzosin): First-line treatment for moderate-to-severe voiding symptoms (IPSS ≥ 8). Improve symptoms in ~70% of men. Adverse effects: Dizziness, postural hypotension, dry mouth, depression. 5 alpha-reductase inhibitors (e.g., finasteride): Indicated for significantly enlarged prostates at high risk of progression. Reduces prostate volume and may slow disease progression, though symptom improvement may take up to 6 months. Adverse effects: Erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia. Combination therapy: Alpha-1 antagonist + 5 alpha-reductase inhibitor, recommended for bothersome moderate-to-severe symptoms with prostatic enlargement. Antimuscarinics (anticholinergic drugs) (e.g., tolterodine, darifenacin): May be used if storage and voiding symptoms persist after treatment with alpha-blockers alone.

Answer 358

Transurethral resection of the prostate (TURP): A common surgical option for BPH.

Answer 359

Phimosis (tight foreskin that cannot be retracted). Recurrent balanitis (inflammation of the glans penis). Balanitis xerotica obliterans (chronic inflammation leading to scarring). Paraphimosis (inability to return a retracted foreskin to its normal position).

Answer 360

Epididymal cysts are the most common cause of scrotal swellings seen in primary care. They are separate from the body of the testicle. Typically located above and posterior to the testicle.

Answer 361

Diagnosis may be confirmed with an ultrasound.

Answer 362

Epididymo-orchitis is an infection of the epididymis and/or testes, resulting in pain and swelling. Most commonly caused by local spread of infections from the genital tract (e.g., Chlamydia trachomatis, Neisseria gonorrhoeae) in sexually active younger adults or from the bladder (E. coli) in older adults with a low-risk sexual history.

Answer 363

Unilateral testicular pain and swelling. Urethral discharge may be present, but urethritis is often asymptomatic. Factors suggesting testicular torsion: Patients under 20 years old, Severe pain and acute onset.

Answer 364

The most important differential is testicular torsion, which needs to be excluded urgently to prevent ischaemia of the testicle.

Answer 365

In younger adults, assess for sexually transmitted infections (STIs). In older adults with a low-risk sexual history, send a mid-stream urine (MSU) for microscopy and culture.

Answer 366

If an STI is suspected, advise urgent referral to a local specialist sexual health clinic. If the organism is unknown, the BASHH recommends: Ceftriaxone 500mg intramuscularly (single dose), Plus doxycycline 100mg orally twice daily for 10-14 days. If enteric organisms are suspected, send an MSU as above, and empirically treat with an oral quinolone (e.g., ofloxacin) for 2 weeks. Further investigations may be recommended to exclude any underlying structural abnormalities.

Answer 367

Organic causes are favoured by: Gradual onset of symptoms, Lack of tumescence, Normal libido. Psychogenic causes are favoured by: Sudden onset of symptoms, Decreased libido, Good quality spontaneous or self-stimulated erections, Major life events, Relationship problems, Previous psychological issues, History of premature ejaculation

Answer 368

10-year cardiovascular risk calculation by measuring lipid and fasting glucose serum levels. Free testosterone measurement (morning, 9–11am). If low or borderline, repeat with FSH, LH, and prolactin levels. If abnormal, refer to endocrinology for further assessment. Testosterone measurement: universal testing is recommended by the British Society for Sexual Medicine and the European Association of Urology.

Answer 369

PDE-5 inhibitors (e.g., sildenafil/'Viagra') are first-line treatment for all patients (unless contraindicated). Sildenafil can be purchased over-the-counter without a prescription.

Answer 370

Vacuum erection devices are recommended as first-line treatment.

Answer 371

A hydrocele is the accumulation of fluid within the tunica vaginalis. Two types: Communicating hydrocele: Caused by patency of the processus vaginalis, allowing peritoneal fluid to drain into the scrotum. Common in newborn males (5-10%) and usually resolves in the first few months. Non-communicating hydrocele: Caused by excessive fluid production within the tunica vaginalis.

Answer 372

Soft, non-tender swelling of the hemi-scrotum. Typically anterior to and below the testicle. The swelling is confined to the scrotum. You can get "above" the mass on examination. It transilluminates with a pen torch. The testis may be difficult to palpate if the hydrocele is large.

Answer 373

Diagnosis is usually clinical, but an ultrasound is required if there's any doubt about the diagnosis or if the underlying testis cannot be palpated.

Answer 374

Infantile hydroceles: Usually repaired if not resolved by 1-2 years of age. In adults, a conservative approach may be taken, depending on the severity of the presentation. Further investigation (e.g., ultrasound) is warranted to exclude any underlying cause such as a tumour.

Answer 375

Unilateral: Pelvic-ureteric obstruction (congenital or acquired) Aberrant renal vessels Calculi Tumours of the renal pelvis Bilateral: Stenosis of the urethra Urethral valve Prostatic enlargement Extensive bladder tumour Retro-peritoneal fibrosis

Answer 376

Ultrasound: Identifies the presence of hydronephrosis and can assess the kidneys. IVU (Intravenous Urography): Assesses the position of the obstruction. Antegrade or retrograde pyelography: Allows treatment. If renal colic is suspected, CT scan is used (majority of stones detected this way).

Answer 377

Remove the obstruction and drainage of urine. Acute upper urinary tract obstruction: Nephrostomy tube. Chronic upper urinary tract obstruction: Ureteric stent or pyeloplasty.

Answer 378

Priapism is a persistent penile erection lasting longer than 4 hours, not associated with sexual stimulation. It can be classified into two types: Ischaemic: Due to impaired vasorelaxation and reduced vascular outflow, leading to congestion and trapping of de-oxygenated blood in the corpus cavernosa. Non-ischaemic: Due to high arterial inflow, typically caused by fistula formation (congenital or traumatic).

Answer 379

Persistent erection lasting over 4 hours. Pain localized to the penis. History of known haemoglobinopathy or use of relevant medications. Non-painful erection or not fully rigid erection suggestive of non-ischaemic priapism. History of trauma to the genital or perineal region suggests non-ischaemic priapism.

Answer 380

Cavernosal blood gas analysis: Differentiates ischaemic (reduced pO2 and pH, increased pCO2) from non-ischaemic priapism. Doppler/duplex ultrasonography: Assesses blood flow in the penis as an alternative to blood gas analysis. Full blood count and toxicology screen: Assess for underlying causes.

Answer 381

Ischaemic priapism: Medical emergency, aspiration of blood from cavernosa after 4 hours, often combined with saline flush. If unsuccessful, intracavernosal injection of phenylephrine (vasoconstrictor), repeated at 5-minute intervals. Surgical options if medical therapy fails. Non-ischaemic priapism: Not a medical emergency, usually managed with observation.

Answer 382

Early prostate cancers: Few symptoms. Metastatic disease: May present as bone pain. Locally advanced disease: May present as pelvic pain or urinary symptoms.

Answer 383

Prostate Specific Antigen (PSA) Test Digital Rectal Examination (DRE) Transrectal Ultrasound (USS) (+/- biopsy) MRI/CT and bone scan for staging.

Answer 384

Normal upper limit for PSA: 4 ng/ml. False positives may be caused by: prostatitis, UTI, BPH, vigorous DRE. Free:Total PSA ratio: If <20%, it is suggestive of cancer, and a biopsy is advised.

Answer 385

95% adenocarcinoma. In situ malignancy may be found adjacent to cancer, requiring multiple biopsies to confirm. Often multifocal, with 70% in the peripheral zone. Graded using the Gleason grading system: Two grades (1 for dominant, 2 for second most dominant). Gleason score: 2 (best prognosis) to 10 (worst prognosis). Lymphatic spread: First to obturator nodes, then to seminal vesicles and distant sites.

Answer 386

Watch and Wait: Suitable for elderly, multiple co-morbidities, low Gleason score. Radiotherapy: Curative and palliative options. Similar survival to surgery. Risk of radiation proctitis and rectal malignancy. Surgery: Radical prostatectomy (surgical removal of the prostate). Common side effect: erectile dysfunction. Robotic surgery is increasingly used. Hormonal Therapy: Testosterone stimulates prostate tissue. Options include bilateral orchidectomy, LHRH analogues, and anti-androgens. Active Surveillance: Preferred for low-risk men (clinical stage T1c, Gleason score 3+3, PSA density <0.15 ng/ml/ml). Requires multiple biopsies and re-biopsy. Radical treatment if disease progression occurs.

Answer 387

Often asymptomatic in early stages due to cancers developing in the periphery of the prostate. Possible symptoms include: Bladder outlet obstruction: hesitancy, urinary retention. Haematuria (blood in urine) and haematospermia (blood in semen). Pain: back, perineal, or testicular. Digital rectal examination (DRE): asymmetrical, hard, nodular enlargement with loss of median sulcus.

Answer 388

Transrectal ultrasound-guided (TRUS) biopsy.

Answer 389

Multiparametric MRI.

Answer 390

Considered in men with suspected prostate cancer. Offered to men older than 50 years who request a PSA test.

Answer 391

Haematuria. Loin pain. Abdominal mass.

Answer 392

Partial or total nephrectomy depending on tumour size. T1 tumors (≤ 7 cm) typically treated with partial nephrectomy.

Answer 393

Pain management and medical therapy: NSAIDs are recommended as the analgesia of choice (e.g., diclofenac), but risks of cardiovascular events should be considered. If NSAIDs are contraindicated or insufficient, IV paracetamol is recommended. For severe pain in patients requiring admission, intramuscular diclofenac is suggested for rapid relief. Alpha blockers: Promote smooth muscle relaxation and dilation of the ureter to ease stone passage, recommended for distal ureteric stones <10 mm.

Answer 394

Urine dipstick and culture. Serum creatinine and electrolytes (check renal function). FBC/CRP (to assess infection). Calcium/urate levels (look for underlying causes). Stone analysis should be done after stone passage. Clotting if percutaneous intervention is planned and blood cultures if signs of sepsis.

Answer 395

Non-contrast CT KUB is the preferred imaging, to be performed within 24 hours of admission. If a patient has a fever, a solitary kidney, or if the diagnosis is uncertain, an immediate CT KUB should be done. CT KUB has a sensitivity of 97% and specificity of 95% for ureteric stones. Ultrasound is used for pregnant women and children, though its sensitivity is around 45% and specificity is 90%.

Answer 396

Stones < 5mm: Watchful waiting (most pass spontaneously). 5-10mm: Shockwave lithotripsy. 10-20mm: Shockwave lithotripsy or ureteroscopy. > 20mm: Percutaneous nephrolithotomy. Ureteric stones: <10mm: Shockwave lithotripsy + alpha blockers. 10-20mm: Ureteroscopy.

Answer 397

Stones < 5mm usually pass within 4 weeks. More intensive treatment is needed for ureteric obstruction, renal developmental abnormalities (e.g., horseshoe kidney), or previous renal transplant. Ureteric obstruction with infection is a surgical emergency and requires system decompression via nephrostomy tube, ureteric catheters, or ureteric stent placement.

Answer 398

Calcium stones: High fluid intake. Add lemon juice to water. Avoid carbonated drinks and limit salt intake. Potassium citrate may be beneficial. Thiazide diuretics (increase distal tubular calcium resorption). Oxalate stones: Cholestyramine reduces urinary oxalate secretion. Pyridoxine reduces urinary oxalate secretion. Uric acid stones: Allopurinol. Urinary alkalinization (e.g., oral bicarbonate).

Answer 399

Most common cause of scrotal swellings in primary care. Separate from the body of the testicle. Located posterior to the testicle. Associated conditions: Polycystic kidney disease. Cystic fibrosis. Von Hippel-Lindau syndrome. Diagnosis is confirmed by ultrasound. Management: Usually supportive. Surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts.

Answer 400

Abnormal enlargement of the testicular veins. Often asymptomatic, but associated with infertility. More common on the left side (over 80%). Classically described as a 'bag of worms'. Associated with subfertility.

Answer 401

Diagnosis is confirmed with ultrasound with Doppler studies.

Answer 402

Usually conservative. Surgery may be required if the patient experiences pain. Debate exists on the effectiveness of surgery for treating infertility.

Answer 403

Painless lump (most common presenting symptom). Pain (in a minority of men). Hydrocele. Gynaecomastia (due to increased oestrogen:androgen ratio). Germ-cell tumours → hCG → Leydig cell dysfunction → increases both oestradiol and testosterone production, but oestradiol rise is relatively greater. Leydig cell tumours → directly secrete oestradiol and convert androgen precursors to oestradiols.

Answer 404

Seminomas: hCG may be elevated in around 20%. Non-seminomas: AFP and/or beta-hCG elevated in 80-85%. LDH is elevated in 40% of germ-cell tumours.

Answer 405

Ultrasound.

Answer 406

Orchidectomy (surgical removal of the testicle). Chemotherapy and radiotherapy may be given depending on staging and tumour type.

Answer 407

Twist of the spermatic cord leading to testicular ischaemia and necrosis. Most common in males aged between 10 and 30 years, with peak incidence between 13-15 years.

Answer 408

Severe pain of sudden onset. Referred pain to the lower abdomen. Nausea and vomiting may occur. On examination: Swollen, tender testis retracted upwards. Skin may be reddened. Cremasteric reflex is lost. Prehn's sign (elevation of the testis does not ease the pain).

Answer 409

Urgent surgical exploration. If a torted testis is identified, both testes should be fixed, as the bell clapper testis condition is often bilateral. Bilateral orchidopexy

Answer 410

Decreased urinary stream. Incomplete bladder emptying. Less common symptoms include: Spraying of urinary stream. Dysuria.

Answer 411

Uroflowmetry. Ultrasound postvoid residual (PVR) measurement.

Answer 412

Dilation. Endoscopic urethrotomy.

Answer 413

A simple operation, usually performed under local anaesthesia (some cases with general anaesthesia). The patient can go home after a couple of hours.

Answer 414

Doesn't work immediately. Semen analysis needs to be performed twice (usually at 12 weeks) before unprotected sex can be resumed.

Answer 415

A single abdominal ultrasound is recommended for males aged 65.

Answer 416

< 3 cm: Normal, no further action. 3 - 4.4 cm: Small aneurysm, rescan every 12 months. 4.5 - 5.4 cm: Medium aneurysm, rescan every 3 months. ≥ 5.5 cm: Large aneurysm, refer within 2 weeks to vascular surgery for probable intervention.

Answer 417

Abdominal ultrasound surveillance (timed based on aneurysm size). Optimize cardiovascular risk factors (e.g. stop smoking).

Answer 418

Refer within 2 weeks to vascular surgery for probable intervention. Elective endovascular repair (EVAR) or open repair if unsuitable. EVAR: A stent is placed via the femoral artery to prevent blood collection in the aneurysm. A complication of EVAR is an endo-leak, where the stent fails to exclude blood from the aneurysm, often presenting without symptoms on follow-up.

Answer 419

1.5 cm in females. 1.7 cm in males after the age of 50 years.

Answer 420

Venous hypertension secondary to chronic venous insufficiency. Other causes include calf pump dysfunction or neuromuscular disorders.

Answer 421

Located above the ankle. Typically painless.

Answer 422

Deep venous insufficiency is related to previous DVT. Superficial venous insufficiency is associated with varicose veins.

Answer 423

Doppler ultrasound to look for reflux. Duplex ultrasound to examine anatomy and flow of veins.

Answer 424

4-layer compression banding after exclusion of arterial disease or surgery. If ulcers fail to heal after 12 weeks or are >10 cm², skin grafting may be needed.

Answer 425

Toes and heel. They have a deep, punched-out appearance. Typically painful with possible gangrene.

Answer 426

Cold with no palpable pulses. Low ABPI measurements.

Answer 427

Intermittent claudication. Critical limb ischaemia. Acute limb-threatening ischaemia.

Answer 428

Pale. Pulseless. Painful. Paralysed. Paraesthetic. 'Perishing with cold'.

Answer 429

Handheld arterial Doppler examination. If Doppler signals are present, ankle-brachial pressure index (ABI) should be obtained.

Answer 430

Thrombus: Pre-existing claudication with sudden deterioration. No obvious source for emboli. Reduced or absent pulses in contralateral limb. Evidence of widespread vascular disease (e.g., MI, stroke, TIA, previous surgery). Embolus: Sudden onset of painful leg (< 24 hours). No history of claudication. Clinically obvious source of embolus (e.g., atrial fibrillation, recent MI). Normal pulses in contralateral limb. Evidence of proximal aneurysm (e.g., abdominal or popliteal).

Answer 431

ABC approach. Analgesia: IV opioids are often used. IV unfractionated heparin to prevent thrombus propagation, especially if the patient is not suitable for immediate surgery. Vascular review.

Answer 432

Intra-arterial thrombolysis. Surgical embolectomy. Angioplasty. Bypass surgery. Amputation: for patients with irreversible ischaemia.

Answer 433

Rest pain in the foot for more than 2 weeks. Ulceration. Gangrene. Patients often report hanging their legs out of bed at night to ease the pain.

Answer 434

ABPI < 0.5.

Answer 435

1: Normal. 0.6-0.9: Claudication. 0.3-0.6: Rest pain. <0.3: Impending (severe ischaemia).

Answer 436

Aching or burning in the leg muscles following walking. Patients can typically walk for a predictable distance before the symptoms start. Symptoms are usually relieved within minutes of stopping. Not present at rest.

Answer 437

Check the femoral, popliteal, posterior tibialis, and dorsalis pedis pulses. Check ankle-brachial pressure index (ABPI). Duplex ultrasound is the first-line investigation. Magnetic resonance angiography (MRA) should be performed prior to any intervention.

Answer 438

A statin, with atorvastatin 80 mg recommended.

Answer 439

Clopidogrel (preferred over aspirin).

Answer 440

Severe, central abdominal pain radiating to the back. Pulsatile, expansile mass in the abdomen. Patients may be shocked (hypotension, tachycardia) or may have collapsed.

Answer 441

Surgical emergency: Immediate vascular review for emergency surgical repair. If haemodynamically unstable, diagnosis is clinical—go straight to theatre. If haemodynamically stable, a CT angiogram may be used to confirm the diagnosis and assess suitability for endovascular repair.

Answer 442

Dilated, tortuous, superficial veins due to incompetent venous valves. Most commonly occur in the legs due to reflux in the great saphenous vein and small saphenous vein.

Answer 443

Aching, throbbing. Itching.

Answer 444

Venous duplex ultrasound to demonstrate retrograde venous flow.

Answer 445

Leg elevation. Weight loss. Regular exercise. Graduated compression stockings.

Answer 446

Significant symptoms (pain, discomfort, swelling). Previous bleeding from varicose veins. Skin changes due to chronic venous insufficiency. Superficial thrombophlebitis. Active or healed venous leg ulcer.

Answer 447

Endothermal ablation (radiofrequency or endovenous laser treatment). Foam sclerotherapy (irritant foam induces vein closure). Surgical treatments (ligation or stripping).

Answer 448

IM diclofenac

Answer 449

age > 55 years hypocalcaemia hyperglycaemia hypoxia neutrophilia elevated LDH and AST

Answer 450

oral antibiotics at home for a few days, if that doesnt work then you give Intravenous ceftriaxone and metronidazole

Answer 451

surgical repair asap

Answer 452

tamoxifen - pre+peri menopausal aromatase inhibitor - post menopausal

Answer 453

nimodipine

Answer 454

SIADH -> hyponatraemia

Answer 455

Sigmoid volvulus = coffee bean Caecal volvulus = looks like a foetus

Answer 456

calcium oxalate calcium phosphate triple phosphate

Answer 457

cystine stones

Answer 458

urate xanthine

Answer 459

tumour (colon cancer)

Answer 460

GnRH agonists

Answer 461

'tumour flare' - causes a paradoxical increase in LH initially before falling, leading to bone pain, bladder obstruction etc Anti androgen can help reduce this

Answer 462

increased SVR (vasoconstriction in response to low BP) increased HR (sympathetic response) decreased cardiac output decreased blood pressure

Answer 463

increased SVR increased HR decreased cardiac output decreased blood pressure

Answer 464

occurs when the peripheral vascular dilatation causes a fall in SVR similar response may occur in anaphylactic shock, neurogenic shock reduced SVR increased HR normal/increased cardiac output decreased blood pressure

Answer 465

renal colic - loin to groin pain

Answer 466

biliary stenting

Answer 467

treat even if asymptomatic with mesh repair

Answer 468

laparoscopic mesh repair

Answer 469

open mesh repair

Answer 470

burr holes

Answer 471

decompressive craniectomy

Answer 472

Spout + Permanent = End Ileostomy Spout + Temporarary = Loop Ileostomy No Spout (flush) = Colostomy Spout + urine in bag = Ileal conduit Urine and faeces are irritant to the skin (so create spout). Colostomy contents are hard faeces so less likely to cause irritation to the skin (so can be flush to skin).

Answer 473

Genitofemoral nerve

Answer 474

saline or hartmanns

Answer 475

nephrostomy - urgently relieve the obstruction causing kidney pressure

Answer 476

venous insufficiency -> venous ulcer formation

Answer 477

produced cholestatic picture ie ALP super high

Answer 478

1 month after

Answer 479

Vigorous exercise, ejaculation, and digital rectal examination

Answer 480

Urgent US to exclude other things

Answer 481

ureteroscopy

Answer 482

mumps causes orchitis if they have previously had mumps when they were a child, orchitis doesnt happen so it has to be epididymo orchitis

Answer 483

Wallace's Rule of Nine: Each of the following is 9% of the body when calculating surface area % if a burn: Head + neck, each arm, each anterior part of leg, each posterior part of leg, anterior chest, posterior chest, anterior abdomen, posterior abdomen

Answer 484

T - CT M - MRI

Answer 485

The sigmoid colon is directly supplied by the sigmoid arteries, which branch directly from the inferior mesenteric artery.

Answer 486

Superior mesenteric artery

Answer 487

The peripheral zone

Answer 488

LMWH and compression stockings to prevent DVT

Answer 489

implant rupture

Answer 490

panproctocolectomy - get rid of it all

Answer 491

elevated uric acid

Answer 492

spincterotomy

Answer 493

hyperchloraemic metabolic acidosis