Surg Flashcards
1
Q
Start a vascular exam by asking…
A
any pain or tenderness in abdomen or legs
2
Q
Importance of atrial fibrillation for lower limb vascular exam?
A
emboli causing PVD
3
Q
Inspection for vascular exam…
A
Scars (graft in thigh), chronic venous insufficiency (legs), ulcers (feet, heels, ankles, toes),
4
Q
where does femoral artery become politeal?
A
opening of adductor magnus, the adductor hiatus
5
Q
palpate the femoral artery at…
A
midpoint of inguinal ligament between ASIS, pubic symphysis
6
Q
bruit in abdomen means stenosis of what…
A
abdo aorta, renal or mesenteric arteries
7
Q
where is popliteal anatomically?
A
in between heads of gastrocnemius
8
Q
borders of hesselbachs triangle and what hernias go through here
A
medial: lat wall of rectus abdominus
inferior: inguinal ligament
laterally: inferior epigastric vessels
direct hernias
9
Q
where do indirect hernias pass through
A
deep inguinal ring… lateral to epigastric vessels
10
Q
deep inguinal ring/tunica vaginalis is originally derived from…
A
peritoneum
11
Q
4 Causes of peritonitis…
A
Blood, bowel contents, pus, inflammed or perforated organ/viscus
12
Q
Features of peritonitis
A
constant pain, worse with cough, movement, breathing
fever, tachy, tachypnoeic, abdo rigidness, absent bowel sounds
lying still!!!
13
Q
Ix for peritonitis
A
FBC, UEC, LFT (clotting, group and hold), blood culture, urinalysis, CRP, Pregnancy test, Erect CXR, abdo XR
14
Q
Low abdo pain Ddx by anatomy
A
appendicitis, ovary/uterus, bowel (caecum, ascending on left, decending, rectum on right), small bowel, ureters, hernias
15
Q
What is meckels diverticulum?
A
congenital diverticulum near ileocaecal valve
16
Q
What complications can meckels and therefore all diverticular have?
A
Infection, Rupture (haemorrhage, faecal peritonitis), obstruction
17
Q
List some gynae causes of abdo pain
A
PID, ovarian cyst/torsion, ectopic pregnancy
18
Q
Similair appendicitis Ddx
A
Perforated ulcer, ruptured AAA, Crohns, mesenteric adenitis
19
Q
Diverticular disease is only symptomatic in what percentage…
A
10-30%
20
Q
Perforation of diverticuli can cause 2 things…
A
faecal peritonitis or walled off as abscess
21
Q
Another complication of diverticular disease is
A
stricture
22
Q
Ddx epigastric pain by anatomy
A
AAA, biliary, pancreatitis, PUD, epigastric hernia
23
Q
Air under diaphragm on CXR=
A
perforated viscus (but not seen in 30% of perforated ulcers- do CT to rule out)
24
Q
4 cardinal features of intestinal obstruction
A
colicky pain, vomiting, absolute constipation, distension (CCVD)
25
3 main causes of small bowel obstruction
ADHESIONS!, hernia, caecal cancer
| others= crohns, worms, gallstone
26
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
```
27
progression of colicky pain to continuous + fever and tachycardia in SBO=
treatment=
ischaemia =/- perforation---> peritonitis
| urgent laparotomy
28
3 main Causes LBO
Cancer, Diverticular stricture, volvulus
29
Sigmoid volvulus on abdo XR looks like
sausage, no air in rectum
30
Suspect pseudo-obstruction when...
| Next step to Dx
still air in rectum even though loops of bowel are dilated
| Gastrograffin NOT barium enema
31
Apple core is characteristic of what Dx...
Obstructing colonic cancer
32
What to suspect if patient has AF and has severe abdo pain without distension
Ischaemic bowel due to emboli from AF
33
Sx of mild ischaemic bowel
diarrhoea, mild abdo pain
34
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
35
What should always be examined in male with lower abdo pain?
Testes!!
36
How does testicular torsion present
lower abdo pain +/- vomiting (not necessarily testicular pain)
37
What Dx to not miss in older patients with loin to groin pain who have never had before?
Leaking AAA- retroperitoneal haematoma can irritate
38
Pseudomembraneous colitis caused by which bug...
C.diff
39
Do UTIs cause abdo pain generally?
NO!
40
Top 3 causes of LBO
Malignancy 60%, Diverticuli 20%, Volvulus 5%
41
What type of patients do pseudoobstruction occur in?
Severly ill, elderly
42
Early and late symptoms for LBO
Early: change in bowel habit, distension, los of appetite
Late: absolute constipation, vomiting, colicky pain
43
Physical signs of LBO
Febrile, tachy, ill, hypotensive, distended, tender abdo, absent or obstructed bowel sounds
44
Ix for LBO
FBC, UEC, LFT, clotting, group and hold
| Abdo XR, erect CXR to exclude free gas, gastrograffin,
45
Important investigation for malignancy in LBO
CT, endoscopy to take biopsy
46
Mx for LBO
```
Resuscitate: IVI, urinary catheter
Analgesia
Decompress: NG tube
Establish diagnosis
Definitive surgery, temp stoma, stent
```
47
Describe hartmanns procedure
Recto-sigmoid resection with closure of rectal stump and formation of end colostomy
48
When use a colonic stent?
Temporising or palliative procedure
49
Mx of volvulus
stiff rectal tube passed with sigmoidoscope through twist-->imediate relief. surgery if ischaemic
50
Mx pseudoobstruction
NBM, IVI, NG tube
Correct biochem abnormality, treat infection
Consider colonic stimulants eg erythro, metoclopramide
If conservative fails go surgical
51
peroneal artery is a branch of which artery?
posterior tibial
52
5 patterns of arterial disease
stenosis, thrombosis, emoblus, aneurysm, dissection (STEAD)
53
Stenosis of aorta-illiac segment usually cause loss of which pulse
femoral, but foot pulses may still be detected
54
Most common artery to cause claudication
SFA
55
SFA obstruction makes which pulses reduced
politeal, foot (femoral above it intact)
56
More "distal" arterial disease usually occurs for what patients?
diabetes, very elderly (80+)
| most diseases are proximal
57
Prevalence of PAD
For men: 10% at 65, 25% at 75... half this for women
58
Main risk factors for PAD
Smoking, Diabetes, hypertension, lipids
59
Ddx of leg pain on walking
OA, Caludication, Spinal stenosis, peripheral neuropathy
60
What symptom indicates severe ischaemia?
rest pain
61
IX for lower limb PVD
FBC, UEC, BSL, lipids.
| ABI, duplex, angio if severe
62
ABI normal values
.95-1.1
63
ABI rest pain value, critical ischaemia value
.3-.6
| <.3
64
What condition is ABI unreliable for and why?
Diabetes, arteries uncompressible
65
When to treat PAD?
Depends on symptom severity
66
Mx of PAD for symptom control
Smoking cessation, exercise, statin (although meds generally ineffective)
67
Mx PAD to prevent systemic complication
Smoking, weight loss, BP control, lipid control
| Aspirin, ACE
68
Surgical options for PAD
Angioplasty, bypass, endarterectomy, amputation
69
Macrovascular complications of diabetes
IHD, Stroke, PVD
70
Microvascular complications of diabetes
Retinopathy, nephropathy, neuropathy
71
High ABIs can be misleading in which condition?
diabetes
72
Diabetic foot ulcers are usually...
at pressure points, painless, punched out, still have palpable foot pulses
73
Approach to diabetic foot ulcer
Abx-->Debride-->amputate
74
Ix for carotid artery stenosis
CT head, duplex, CT angio
75
Mx for carotid stenosis
asymptomatic= none
0-70% stenosis= aspirin
>70%= carotid endarterectomy
76
Complications of carotid stenosis
TIA, stroke
77
Amaurosis fugax..
mono-ocular visual loss due to retinal artery emboli/blockage/vasospasm
78
Normal abdo aorta diameter
2cm
79
Clinically signigicant AAA is how big
5.5cm
80
AAA can be diagnosed by
ultrasound
81
Mx of AAA (monitoring)
1-2 years if small, 6-12 months if >4cm
82
Venous disease comprises 4 main diseases...
DVT, post thrombotic, varicose, ulceration
83
Skin changes characteristic venous disease
haemosidderin, hair loss, shiny skinExamin
84
Assess varicose veins by which Ix
duplex
85
Mx varicose (only if symptomatic)
compression stockings, surgery
86
Describe ulcer by looking at 3 things...
surrounding skin, ulcer edge (elevated, punched out, gradual), ulcer base (granulation, sloughy, necrotic)
87
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
88
All unresolved infections need to be investigated before surg. t/f
true. Abx for pneumonia/UTI, Echo for cardio Sx
89
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
90
Boundaries of anterior triangle of neck
midline, sternoclediomastoid, mandible
91
Boundaries of posterior triangle of neck
sternocleidomastoid, trapezius, clavicle
92
Post op fever at day 0-2 likely
SIRS
93
Mx for post op fever day 0-2
observe, paracetamol, NO cultures!
| unless >40-->emergency, malignant hyperexia (call anaesthetist)
94
Fever at day 1-3, consider...
Aspiration, AMI, PE
95
Investigating fever day 1-3 post op
ECG, CXR, bloods, ABG, CTPA/VQ
96
Fever at day 4-7, consider
infections- wound, line, urine, internal (send everything for culture)
97
Fever at day 7+ when patient had bowel anastamosis, likely...
anastomotic leak-->spiking sawtooth fevers
98
How to treat anastamotic leak?
IVI, NBM, CT, Abx
99
Post op pain management. call the...
acute pain team
100
Principle of pain management without pain team
regular paracetamol + NSAID (if no contraindication), with stronger opiate for breakthrough
101
Post op N+V usually caused by...
opiates
102
List of post op complications
bleeding, fever, pain, N+V, low urine output, constipation/ileus, wound issues, stoma issues
103
Ideal minimum urine output?
.5mL/kg/hr, often just 30mL/hr
104
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
105
Most common cause low urine output? But must also exclude...
dehydration, HAEMORRHAGE!
106
How many mL of blood loss needed for BP change?
1500mL (30% blood volume)
107
Causes of post-op ileus
sympathetic drive from pain, response to surgery. opaites, electrolyte disturbance
108
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
109
Wound dehiscince management
Swab MC&S, remove clips/sutures, debride, irrigate, re-pack. start Abx
110
Mx for constipation
fleet enema, suppositeries
| if no bowel anastamosis give coloxyl, lactulose
111
Mx for post op diarrhoea
mostly self limiting, but assess hydration (UE, Mg), send stool MC&S with request C.diff
112
Venous ulcers pathophysiology
valve incompetence, thrombosis of vein thrombophlebitis-->venous hypertension-->ischaemia
113
Venous ulcers description
superficial, irregular, painless
114
Associated skin with venous insufficiency
bluish/purple, hemosiderrin (from long standing stasis)
115
Arterial ulcer pathophysiology
From inadequate blood supply, common on pressure points
116
Arterial ulcers are a contraindication to...
compression therapy
117
Arterial ulcer description
More distal, pain at rest, regular shape. Punched out, very painful
118
Surrounding skin for arterial ulcer
blanched, shiny tight skin due to under perfusion, loss of hair
119
Arterial vs venous beurgers test?
Arterial= +ve
120
Mx venous ulcers
regular exercise, compression stocking
121
What is more common venous or arterial ulcer?
Venous by far (70%)
122
Skin temp for venous vs arterial ulcer?
venous is warm, arterial is cold
123
Complications of varicose veins
pain, dermatitis, ulcers, bleeding, clots
124
Mx varicose veins
exercise, compression, elevation
| stripping, endovenous ablation
125
How does Charcot foot occur?
Peripheral neuropathy-->loss of pain and sensation-->repeated joint injury
126
What to suspect for assymetric leg swelling
DVT, compartment syndrome
127
Causes of DVT
compression, trauma, cancer, infection, stroke, HF, nephrotic syndrome
128
RFs for DVT
surgery, immobilization, smoking, ovesity, flying, OCP!!!!
129
Ix for DVT
D-dimer, doppler US
130
Sx DVT
assymetrical swelling, pain, redness
131
testing varicose veins
put fingers on saphenofemoral opening and tap varicose vein or ask for a cough
132
Cause of midline neck swelling
Thyroid, thyroglossal cyst, submental LNs, dermoid cyst, chondroma
133
Thyroglossal cyst vs thyroid goitre?
Thyroglossal moves on poking tongue out, goitre moves on swallowing
134
Causes of anterior triangle swelling
LNs, branchial cyst, carotid aneurysm, laryngocoele, pharyngeal pouch
135
Structures in anterior triangle
Internal carotid, lingual, facial arteries, superior thyroid, occipital arteries
Laryngeal nerve, hypoglossal nerve, lingual nerve, hypoglossal nerve
136
Causes of submandibular triangle swelling
submandibular gland, sialedenitis, LNs, neoplasma, salivary stones
137
Posterior triangle structures
accesory nerve, phrenic nerve, cervical plexus, brachial plexus
subclavian artery, suprascapular artery, transverse cervical artery
scalene muscles, inferior belly of omohyoid
138
Causes of lumps in posterior traingle
Lymphoma, LNs, metastasis, cervical rib, subclavian artery aneurysm, cystic hydromas, lymphangioma, pharyngeal pouch
139
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
140
Ix for swelling
FNA
141
Causes of conductive hearing loss
Blockage, drum perforation, ossicle infection/osteoscleorsis, inadequate eustachian tube ventilation due to effusion from nasopharyngeal carcinoma
142
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)
```
143
Cancers for hearing loss
nasopharyngeal carcinoma, acoustic neuroma, chloesteatoma
144
Positive rinne test is normal/abnormal hearing?
normal
145
Webers test conductive loss=
| sensory loss=
louder in affected ear
| louder in unaffected ear
146
What is osteosclerosis?
Heritable disease where ossicles overgrow causing conductive loss, tinnitus, vertigo
147
Ear bones
maleus, incus, stapes
| hammer, anvil, stirrup
148
picture of ear right side is ant/posterior
anterior
149
Whisper is how many decibels?
20dB
150
loud music is howmany decibels?
80-120dB
151
Audiogram points
air conduction better than bone
| all points above 20dB
152
When no gap between air and bone conduction what does this mean?
sensory hearing loss
153
Which hernia is more common
indirect (80%)
154
Can clinically differentiate hernias?
NO
155
Pre-hepatic jaundice cause?
Haemolytic anaemia, malaria
156
Hepatic cause jaundice
Gilberts, hepatitis, cirrhosis, paracetamol
157
Post hepatic cause jaundice
Gallstones, biliary cirrhosis, cholangiocarcinoma, pancreatitis
158
Mcburneys point in
1/3 ASIS to umbilicus
159
Rosvings sign is
press in LLQ and pain goes to Mcburney
160
Gastro causes clubbing
Inflammatory bowel ((UC, crohns), Cirrhosis, Coeliac disease
161
Leuconychia sign of?
Chronic liver disease
162
Palmar erythema and spider naevi caused by what?
Elevated estrogen- can be pregnancy, RA, thyrotoxicosis, liver disease
163
Dupytrens DDx
alcohol, diabetes, liver disease
164
Wilson's disease sign
kayser fleischer rings (green ring in cornea periphery)
165
Glossitis and angular stomatitis causes
iron deficiency, vitamin B12 deficiency
166
Abdo distension (5 Fs)
Fat, fluid, fetus, flatus (obstruction), tumour
167
Hepatomegaly causes
Alcoholic fatty liver, lymphoma, leukaemia, Hepatocellular carcionma, metastases, RHF, haemochromatosis, amyloid
168
Hepatosplenomegaly causes
chronic liver with protal hypertension, lymphoma, leukaemia, CMV, EBV, amyloid, SLE
