Surg Flashcards
Start a vascular exam by asking…
any pain or tenderness in abdomen or legs
Importance of atrial fibrillation for lower limb vascular exam?
emboli causing PVD
Inspection for vascular exam…
Scars (graft in thigh), chronic venous insufficiency (legs), ulcers (feet, heels, ankles, toes),
where does femoral artery become politeal?
opening of adductor magnus, the adductor hiatus
palpate the femoral artery at…
midpoint of inguinal ligament between ASIS, pubic symphysis
bruit in abdomen means stenosis of what…
abdo aorta, renal or mesenteric arteries
where is popliteal anatomically?
in between heads of gastrocnemius
borders of hesselbachs triangle and what hernias go through here
medial: lat wall of rectus abdominus
inferior: inguinal ligament
laterally: inferior epigastric vessels
direct hernias
where do indirect hernias pass through
deep inguinal ring… lateral to epigastric vessels
deep inguinal ring/tunica vaginalis is originally derived from…
peritoneum
4 Causes of peritonitis…
Blood, bowel contents, pus, inflammed or perforated organ/viscus
Features of peritonitis
constant pain, worse with cough, movement, breathing
fever, tachy, tachypnoeic, abdo rigidness, absent bowel sounds
lying still!!!
Ix for peritonitis
FBC, UEC, LFT (clotting, group and hold), blood culture, urinalysis, CRP, Pregnancy test, Erect CXR, abdo XR
Low abdo pain Ddx by anatomy
appendicitis, ovary/uterus, bowel (caecum, ascending on left, decending, rectum on right), small bowel, ureters, hernias
What is meckels diverticulum?
congenital diverticulum near ileocaecal valve
What complications can meckels and therefore all diverticular have?
Infection, Rupture (haemorrhage, faecal peritonitis), obstruction
List some gynae causes of abdo pain
PID, ovarian cyst/torsion, ectopic pregnancy
Similair appendicitis Ddx
Perforated ulcer, ruptured AAA, Crohns, mesenteric adenitis
Diverticular disease is only symptomatic in what percentage…
10-30%
Perforation of diverticuli can cause 2 things…
faecal peritonitis or walled off as abscess
Another complication of diverticular disease is
stricture
Ddx epigastric pain by anatomy
AAA, biliary, pancreatitis, PUD, epigastric hernia
Air under diaphragm on CXR=
perforated viscus (but not seen in 30% of perforated ulcers- do CT to rule out)
4 cardinal features of intestinal obstruction
colicky pain, vomiting, absolute constipation, distension (CCVD)
3 main causes of small bowel obstruction
ADHESIONS!, hernia, caecal cancer
others= crohns, worms, gallstone
abdo X-ray signs of small vs large bowel obstruction
SBO= central loops with valvulae conniventes runnign across whole lumen of bowel LBO= loops in periphery, haustra don't cross whole lumen
progression of colicky pain to continuous + fever and tachycardia in SBO=
treatment=
ischaemia =/- perforation—> peritonitis
urgent laparotomy
3 main Causes LBO
Cancer, Diverticular stricture, volvulus
Sigmoid volvulus on abdo XR looks like
sausage, no air in rectum
Suspect pseudo-obstruction when…
Next step to Dx
still air in rectum even though loops of bowel are dilated
Gastrograffin NOT barium enema
Apple core is characteristic of what Dx…
Obstructing colonic cancer
What to suspect if patient has AF and has severe abdo pain without distension
Ischaemic bowel due to emboli from AF
Sx of mild ischaemic bowel
diarrhoea, mild abdo pain
Rx for mild vs serious (sudden onset, pyrexia, unwell)
Mild: IVI, analgesia, antibiotics, close obs
Severe- rescuscitate, IVI, O2, Abx, laparotomy and resection of non-viable bowel
What should always be examined in male with lower abdo pain?
Testes!!
How does testicular torsion present
lower abdo pain +/- vomiting (not necessarily testicular pain)
What Dx to not miss in older patients with loin to groin pain who have never had before?
Leaking AAA- retroperitoneal haematoma can irritate
Pseudomembraneous colitis caused by which bug…
C.diff
Do UTIs cause abdo pain generally?
NO!
Top 3 causes of LBO
Malignancy 60%, Diverticuli 20%, Volvulus 5%
What type of patients do pseudoobstruction occur in?
Severly ill, elderly
Early and late symptoms for LBO
Early: change in bowel habit, distension, los of appetite
Late: absolute constipation, vomiting, colicky pain
Physical signs of LBO
Febrile, tachy, ill, hypotensive, distended, tender abdo, absent or obstructed bowel sounds
Ix for LBO
FBC, UEC, LFT, clotting, group and hold
Abdo XR, erect CXR to exclude free gas, gastrograffin,
Important investigation for malignancy in LBO
CT, endoscopy to take biopsy
Mx for LBO
Resuscitate: IVI, urinary catheter Analgesia Decompress: NG tube Establish diagnosis Definitive surgery, temp stoma, stent
Describe hartmanns procedure
Recto-sigmoid resection with closure of rectal stump and formation of end colostomy
When use a colonic stent?
Temporising or palliative procedure
Mx of volvulus
stiff rectal tube passed with sigmoidoscope through twist–>imediate relief. surgery if ischaemic
Mx pseudoobstruction
NBM, IVI, NG tube
Correct biochem abnormality, treat infection
Consider colonic stimulants eg erythro, metoclopramide
If conservative fails go surgical
peroneal artery is a branch of which artery?
posterior tibial
5 patterns of arterial disease
stenosis, thrombosis, emoblus, aneurysm, dissection (STEAD)
Stenosis of aorta-illiac segment usually cause loss of which pulse
femoral, but foot pulses may still be detected
Most common artery to cause claudication
SFA
SFA obstruction makes which pulses reduced
politeal, foot (femoral above it intact)
More “distal” arterial disease usually occurs for what patients?
diabetes, very elderly (80+)
most diseases are proximal
Prevalence of PAD
For men: 10% at 65, 25% at 75… half this for women
Main risk factors for PAD
Smoking, Diabetes, hypertension, lipids
Ddx of leg pain on walking
OA, Caludication, Spinal stenosis, peripheral neuropathy
What symptom indicates severe ischaemia?
rest pain
IX for lower limb PVD
FBC, UEC, BSL, lipids.
ABI, duplex, angio if severe
ABI normal values
.95-1.1
ABI rest pain value, critical ischaemia value
.3-.6
<.3
What condition is ABI unreliable for and why?
Diabetes, arteries uncompressible
When to treat PAD?
Depends on symptom severity
Mx of PAD for symptom control
Smoking cessation, exercise, statin (although meds generally ineffective)
Mx PAD to prevent systemic complication
Smoking, weight loss, BP control, lipid control
Aspirin, ACE
Surgical options for PAD
Angioplasty, bypass, endarterectomy, amputation
Macrovascular complications of diabetes
IHD, Stroke, PVD
Microvascular complications of diabetes
Retinopathy, nephropathy, neuropathy
High ABIs can be misleading in which condition?
diabetes
Diabetic foot ulcers are usually…
at pressure points, painless, punched out, still have palpable foot pulses
Approach to diabetic foot ulcer
Abx–>Debride–>amputate
Ix for carotid artery stenosis
CT head, duplex, CT angio
Mx for carotid stenosis
asymptomatic= none
0-70% stenosis= aspirin
>70%= carotid endarterectomy
Complications of carotid stenosis
TIA, stroke
Amaurosis fugax..
mono-ocular visual loss due to retinal artery emboli/blockage/vasospasm
Normal abdo aorta diameter
2cm
Clinically signigicant AAA is how big
5.5cm
AAA can be diagnosed by
ultrasound
Mx of AAA (monitoring)
1-2 years if small, 6-12 months if >4cm
Venous disease comprises 4 main diseases…
DVT, post thrombotic, varicose, ulceration
Skin changes characteristic venous disease
haemosidderin, hair loss, shiny skinExamin
Assess varicose veins by which Ix
duplex
Mx varicose (only if symptomatic)
compression stockings, surgery
Describe ulcer by looking at 3 things…
surrounding skin, ulcer edge (elevated, punched out, gradual), ulcer base (granulation, sloughy, necrotic)
3 questions to approach pre-op workup for each system…
Example in each system
Is there a problem in this system that could affect recovery?
How should I investigate it?
How can I minimize potential impact of this problem?
Resp- Sx cough–>investigate
Cardio- meds
Renal- dehydration/renal failure, fluid balance
Gastro- NGT, fasting
Coag- warfarin reversal
All unresolved infections need to be investigated before surg. t/f
true. Abx for pneumonia/UTI, Echo for cardio Sx
General pre-op workup
Fast for 6 hours prior to GA
Consider- pre-hydration, ECG, CXR, Bloods (Group and Hold, cross match, Coags, FBC, UEC, LFT), other imaging as appropriate
Consent
Book theatre
Anaesthetics consult
Prophylactic Abx, TEDS, subcut heparin, calf compressors
Mark side of operation, follow theatre protocol, time in/out etc, clean operating enviro, scrub in
Boundaries of anterior triangle of neck
midline, sternoclediomastoid, mandible
Boundaries of posterior triangle of neck
sternocleidomastoid, trapezius, clavicle
Post op fever at day 0-2 likely
SIRS
Mx for post op fever day 0-2
observe, paracetamol, NO cultures!
unless >40–>emergency, malignant hyperexia (call anaesthetist)
Fever at day 1-3, consider…
Aspiration, AMI, PE
Investigating fever day 1-3 post op
ECG, CXR, bloods, ABG, CTPA/VQ
Fever at day 4-7, consider
infections- wound, line, urine, internal (send everything for culture)
Fever at day 7+ when patient had bowel anastamosis, likely…
anastomotic leak–>spiking sawtooth fevers
How to treat anastamotic leak?
IVI, NBM, CT, Abx
Post op pain management. call the…
acute pain team
Principle of pain management without pain team
regular paracetamol + NSAID (if no contraindication), with stronger opiate for breakthrough
Post op N+V usually caused by…
opiates
List of post op complications
bleeding, fever, pain, N+V, low urine output, constipation/ileus, wound issues, stoma issues
Ideal minimum urine output?
.5mL/kg/hr, often just 30mL/hr
Causes low urine output (3 cats)
Pre-renal- dehydration, haemorrhage, pump fail (eg AMI, CCF), vasodilation (sepsis)
Renal- ATN (drugs, ischaemia)
Post-renal- retention due to drugs, pain, prostatism
Most common cause low urine output? But must also exclude…
dehydration, HAEMORRHAGE!
How many mL of blood loss needed for BP change?
1500mL (30% blood volume)
Causes of post-op ileus
sympathetic drive from pain, response to surgery. opaites, electrolyte disturbance
Manage post-op ileus
Exclude mechanical obstruction and support patient (IVI, analgesia, NBM, NGT, IDC, fluid balance- electrolyte balance)
try enema 2-3 days
if prolongs 7-10 days, confirm ileus with CT and initiate TPN
Wound dehiscince management
Swab MC&S, remove clips/sutures, debride, irrigate, re-pack. start Abx
Mx for constipation
fleet enema, suppositeries
if no bowel anastamosis give coloxyl, lactulose
Mx for post op diarrhoea
mostly self limiting, but assess hydration (UE, Mg), send stool MC&S with request C.diff
Venous ulcers pathophysiology
valve incompetence, thrombosis of vein thrombophlebitis–>venous hypertension–>ischaemia
Venous ulcers description
superficial, irregular, painless
Associated skin with venous insufficiency
bluish/purple, hemosiderrin (from long standing stasis)
Arterial ulcer pathophysiology
From inadequate blood supply, common on pressure points
Arterial ulcers are a contraindication to…
compression therapy
Arterial ulcer description
More distal, pain at rest, regular shape. Punched out, very painful
Surrounding skin for arterial ulcer
blanched, shiny tight skin due to under perfusion, loss of hair
Arterial vs venous beurgers test?
Arterial= +ve
Mx venous ulcers
regular exercise, compression stocking
What is more common venous or arterial ulcer?
Venous by far (70%)
Skin temp for venous vs arterial ulcer?
venous is warm, arterial is cold
Complications of varicose veins
pain, dermatitis, ulcers, bleeding, clots
Mx varicose veins
exercise, compression, elevation
stripping, endovenous ablation
How does Charcot foot occur?
Peripheral neuropathy–>loss of pain and sensation–>repeated joint injury
What to suspect for assymetric leg swelling
DVT, compartment syndrome
Causes of DVT
compression, trauma, cancer, infection, stroke, HF, nephrotic syndrome
RFs for DVT
surgery, immobilization, smoking, ovesity, flying, OCP!!!!
Ix for DVT
D-dimer, doppler US
Sx DVT
assymetrical swelling, pain, redness
testing varicose veins
put fingers on saphenofemoral opening and tap varicose vein or ask for a cough
Cause of midline neck swelling
Thyroid, thyroglossal cyst, submental LNs, dermoid cyst, chondroma
Thyroglossal cyst vs thyroid goitre?
Thyroglossal moves on poking tongue out, goitre moves on swallowing
Causes of anterior triangle swelling
LNs, branchial cyst, carotid aneurysm, laryngocoele, pharyngeal pouch
Structures in anterior triangle
Internal carotid, lingual, facial arteries, superior thyroid, occipital arteries
Laryngeal nerve, hypoglossal nerve, lingual nerve, hypoglossal nerve
Causes of submandibular triangle swelling
submandibular gland, sialedenitis, LNs, neoplasma, salivary stones
Posterior triangle structures
accesory nerve, phrenic nerve, cervical plexus, brachial plexus
subclavian artery, suprascapular artery, transverse cervical artery
scalene muscles, inferior belly of omohyoid
Causes of lumps in posterior traingle
Lymphoma, LNs, metastasis, cervical rib, subclavian artery aneurysm, cystic hydromas, lymphangioma, pharyngeal pouch
Lateral neck swellings causes by anatomy
LNs
Salivary gland (stone, tumour)- submandib, parotid
Skin: sebaceous cyst, lipoma, cancer
Lymphatics: cystic hygroma
Carotid aneurysm: pulsatile, rarely a tumour
Pharynx: pharyngeal pouch
Ix for swelling
FNA
Causes of conductive hearing loss
Blockage, drum perforation, ossicle infection/osteoscleorsis, inadequate eustachian tube ventilation due to effusion from nasopharyngeal carcinoma
Causes of sensironeural hearing loss
Defect in cochlea, cochlear nerve or more central pathway Drugs: gentamycin, chloroquine Post infective: measles, mumps, flu Menieres Disease Presbyacusis (old age)
Cancers for hearing loss
nasopharyngeal carcinoma, acoustic neuroma, chloesteatoma
Positive rinne test is normal/abnormal hearing?
normal
Webers test conductive loss=
sensory loss=
louder in affected ear
louder in unaffected ear
What is osteosclerosis?
Heritable disease where ossicles overgrow causing conductive loss, tinnitus, vertigo
Ear bones
maleus, incus, stapes
hammer, anvil, stirrup
picture of ear right side is ant/posterior
anterior
Whisper is how many decibels?
20dB
loud music is howmany decibels?
80-120dB
Audiogram points
air conduction better than bone
all points above 20dB
When no gap between air and bone conduction what does this mean?
sensory hearing loss
Which hernia is more common
indirect (80%)
Can clinically differentiate hernias?
NO
Pre-hepatic jaundice cause?
Haemolytic anaemia, malaria
Hepatic cause jaundice
Gilberts, hepatitis, cirrhosis, paracetamol
Post hepatic cause jaundice
Gallstones, biliary cirrhosis, cholangiocarcinoma, pancreatitis
Mcburneys point in
1/3 ASIS to umbilicus
Rosvings sign is
press in LLQ and pain goes to Mcburney
Gastro causes clubbing
Inflammatory bowel ((UC, crohns), Cirrhosis, Coeliac disease
Leuconychia sign of?
Chronic liver disease
Palmar erythema and spider naevi caused by what?
Elevated estrogen- can be pregnancy, RA, thyrotoxicosis, liver disease
Dupytrens DDx
alcohol, diabetes, liver disease
Wilson’s disease sign
kayser fleischer rings (green ring in cornea periphery)
Glossitis and angular stomatitis causes
iron deficiency, vitamin B12 deficiency
Abdo distension (5 Fs)
Fat, fluid, fetus, flatus (obstruction), tumour
Hepatomegaly causes
Alcoholic fatty liver, lymphoma, leukaemia, Hepatocellular carcionma, metastases, RHF, haemochromatosis, amyloid
Hepatosplenomegaly causes
chronic liver with protal hypertension, lymphoma, leukaemia, CMV, EBV, amyloid, SLE
