Surgery 10 Flashcards
List some aspects of assessing the fluid status of a patient.
Capillary refill Heart rate BP lying/standing JVP Skin turgor Mucus membranes Urine output (and U&E) Consciousness
Which type of fluid should be used in patients with cardiac or renal failure?
5% dextrose
AVOID fluids with sodium because these patients will be retaining sodium
What is the normal output you would expect to see from an ileostomy?
10-15 mL/kg/day = 700 mL/day
NOTE: high output is > 1000 mL/day
List some different types of enteral nutrition.
Polymeric (e.g. osmolite) - intact proteins, starches, long-chain free fatty acids
Disease-specific - branched chain AAs in hepatic encephalopathy
Elemental - simple AAs and oligo/monosaccharides (requires minimal absorption so used in abnormal GIT (e.g. CD))
What are the components of a secondary survey?
Allergies Medications PMH Last ate/drank Events
What are the different types of burn and how do they present?
Superficial (first degree, epidermis) - red without blisters, dry and painful
Superficial partial thickness (second degree, involves dermis) - red with blisters, moist, very painful
Deep partial thickness (second degree, involves dermis) - yellow/white, may be blistering, feels like pressure
Full thickness (third degree, through dermis) - stiff, white/brown, no blanching, painless
Fourth-degree (into fat, muscle, bone) - black, eschars, dry and painless
What are the phases of fracture healing?
Bleeding into fracture site (haematoma)
Inflammation (cytokine and growth factor release leading to formation of granulation tissue)
Proliferation (of osteoblasts and fibroblasts, laying down cartilage and bone to form soft callus)
Consolidation (endochondrial ossification of woven bone to lamellar bone)
Remodelling (based on mechanical forces - Wolff’s law)
What are the three types of fracture based on aetiology?
Traumatic
Stress (bone fatigue due to repetitive strain)
Pathological (normal forces on diseased bone)
What are the main methods of reducing a fracture?
Manipulation/closed reduction
Traction (not used now)
Open reduction (accurate reduction in surgery)
What are the main methods of holding a fracture?
Non-rigid (slings, elastic support)
Plaster
External fixation (fragments held in position by pins/wires connected to external frame)
Internal fixation (pins, plates, screws, IM nails)
List some causes of reflex sympathetic dystrophy.
Fractures
Carpal tunnel disease
Operations for Dupuytren’s contracture
Presentation: hyperalgesia, allodynia, vasomotor symptoms, weakness, dystonia (NOT traumatised area affected - usually neighbouring area)
What is Shenton’s line?
Curved line from the inferior border of superior pubic ramus and along the inferomedial border of the neck of the femur
Should be continuous and smooth
Irregularity suggests fracture or dislocation
NOTE: Klein’s line is the line going along the superior surface of the neck of the femur (it should bisect the head of the femur)
What is a Barton fracture?
Oblique intra-articular fracture involving the dorsal aspect of the distal radius with dislocation of the radio-carpal joint
Outline the management of a suspected scaphoid fracture.
Scaphoid plaster (beer glass position) Re-X ray after 10 days to decide how long the plaster should stay there for
What is impingement syndrome?
Entrapment of supraspinatus tendon and subacromial bursa between the acromion and greater tuberosity of the humerus
I.e. either due to subacromial bursitis or supraspinatus tendonitis
DDx: supraspinatus tear, acromioclavicular joint OA
Outline the management of impingement syndrome.
Conservative: rest and physiotherapy
Medical: NSAIDs, subacromial bursa steroid injection
Surgical: arthroscopic acromioplasty
Describe the examination findings of a complete rotator cuff tear.
Shoulder tip pain
Full range of passive motion
Inability to abduct the arm
Active abduction possible after passive abduction to 90 degrees
Outline the Ottawa rules regarding ankle fractures.
Ankle X-ray should only be requested if there is pain in the malleolar zone + any of:
- tenderness along distal 6 cm of posterior tib/fib including posterior tip of malleoli
- inability to bear weight both immediately and in ED
How are ankle fractures managed?
Weber A - boot or below knee PoP
Non-displaced B/C - below-knee PoP
Displaced B/C - closed reduction and PoP, ORIF if closed reduction fails
What is the ‘unhappy triad’ in orthopaedics?
ACL
MCL
Medial meniscus
NOTE: sometimes referred to as a blown knee
List some different types of osteochondrosis.
NOTE: osteochondrosis is when interruption of a blood supply to a bone is interrupted leading to osteonecrosis followed by later regrowth of the bone resulting in deformity (usually affects children and adolescents)
Scheuermann’s disease - wedge-shaped vertebrae causing exaggerated thoracic kyphosis
Kohler’s disease - navicular bone, limp
Kienboch’s disease - lunate bones, impaired grip
Friedberg disease - 2nd and 3rd metatarsal heads (pain)
Panner’s disease - capitulum of humerus
List some causes of avascular necrosis of bone.
Fracture Dislocation Sickle cell disease SLE Drugs (e.g. steroids)
What are the contents of the carpal tunnel?
FDS - 4 tendons
FDP - 4 tendons
Flexor Pollicis Longus - 1 tendon
Median nerve
NOTE: palmar cutaneous branch of median nerve travels superficial to the flexor retinaculum so CTS will spare sensation over the thenar eminence
List some causes of Dupuytren’s contracture.
Alcoholism Idiopathic (most common) Epilepsy and medications (phenytoin) Diabetes mellitus Smoking Peyronie's disease
What is Chilaiditi sign?
A loop of bowel between the liver and the diaphragm gives the impression of pneumoperitoneum
How are perforated peptic ulcers repaired?
Duodenal - abdominal washout and omental patch repair
Gastric - excise ulcer and repair defect
Partial gastrectomy is sometimes requires
NOTE: the omentum may seal the perforation spontaneously in some cases
List some causes of obstructive jaundice.
Gallstones Pancreatic cancer Cholangiocarcinoma PSC/PBC Drugs (co-amoxiclav, OCP)
Describe the anatomy of the anal canal.
4 cm long from levator ani to anal verge
Upper 2/3 - columnar, insensate, internal iliac nodes, superior rectal artery and vein
Lower 1/3 - squamous, sensate, middle and inferior rectal arteries and veins, superficial inguinal nodes
NOTE: dentate line is the squamomucosal junction; white line is where anal canal becomes normal skin
What are haemorrhoids?
Dilated anal cushions arising above the dentate line (not painful)
Positioned at 3, 7 and 11 o’clock (position of three major arteries feeding the venous plexus)
May become strangulated by the anal sphincter
Define fistula.
An abnormal tract between two epithelial surfaces
NOTE: a sinus is a blind-ending tract lined by epithelial or granulation tissue, opening onto an epithelial surface
What are the two types of rectal prolapse?
Type 1: Mucosal Prolapse - partial prolapse of redundant mucosa
Type 2: Full Thickness Prolapse - more common, elderly females with poor O&G history
What are the boundaries of the anterior and posterior triangles of the neck?
Anterior: anterior margin of SCM, midline, ramus of the mandible
Posterior: posterior margin of SCM, anterior margin of trapezius, middle 1/3 of clavicle
Outline the national breast cancer screening programme.
Every 3 years from 47-73 years
Mammography (craniocaudal and oblique)
List some complications of mastectomy.
Haematoma
Seroma
Long-thoracic nerve damage (winging)
Lymphoedema
Which classification system is used for limb ischaemia?
Fontaine 1 - asymptomatic 2 - intermittent claudication 3 - ischaemic rest pain 4 - ulceration/gangrene
NOTE: Rutherford is another classification system
List some sources of emboli that could cause acute limb ischaemia.
AF
Valve disease
Iatrogenic (surgery, angioplasty)
Paradoxical (via PFO)
Outline the management of acute limb ischaemia.
NBM IV UFH (prevent clot propagation) Embolectomy (if failed, try thrombolysis and consider reconstruction/amputation)
NOTE: once the acute situation has been dealt with, investigate to find a source of the embolus (ECG, echo, aorta ultrasound)
List some causes of aneurysms.
CONGENITAL: ADPKD, Marfan’s, Ehlers-Danlos
ACQUIRED: atherosclerosis, trauma, inflammatory (takayasu’s aortitis), syphilis
What are the different types of skin graft?
Split Thickness: includes epidermis and part of dermis
Full Thickness: includes epidermis and entire dermis
Composite: contains skin and underlying cartilage or other tissues
NOTE: they can also be classified based on the donor (autograft - same individual, allogeneic - same species, xenogeneic - different species, prosthetic - synthetic material)
List some differentials for bilateral leg swelling.
Increased venous pressure: RHF, venous insufficiency, drugs (CCB)
Decreased oncotic pressure: nephrotic syndrome, HF, protein losing enteropathy
Lymphoedema
Myxoedema (pretibial)
List some causes of urinary tract obstruction.
LUMINAL: stones, blood clots
MURAL: tumour, neuromuscular dysfunction
EXTRAMURAL: prostate enlargement, abdominal mass, retroperitoneal fibrosis
List the main subtypes of renal adenocarcinoma.
Clear cell carcinoma (MOST COMMON)
Papillary
Chromophobe
Collecting duct
Outline the management of bladder cancer based on stage.
Tis, Ta, T1 = superficial –> intravesical mitomycin and BCG, diathermy via TURBT
T2, T3 = invasive –> radical cystectomy + ileal conduit
T4 = palliative –> chemotherapy, long-term catheterisation
Outline the management options for prostate cancer.
Conservative: active monitoring
Medical: LHRH analogues (goserelin), anti-androgens (cyproterone acetate)
Radical prostatectomy
Brachytherapy
Outline the management of otitis externa.
Ear drops containing steroid and antibiotic
NOTE: malignant otitis media can lead to osteomyelitis so requires surgical debridement and IV antibiotics
What are the different types of otitis media?
Acute
Otitis Media with effusion (glue ear) - effusion after symptom regression
Chronic - effusion lasting > 3 months (if bilateral) or > 6 months (if unilateral)
Chronic suppurative otitis media - ear discharge with hearing loss and evidence of drum perforation
List some causes of tinnitus.
Meniere's disease Acoustic neuroma Otosclerosis Noise-induced Head injury Drugs (aspirin, loop diuretics)
NOTE: all patients with unilateral tinnitus should have an MRI
List some causes of vertigo.
VESTIBULAR: BPPV, Meniere’s, Labyrinthitis
CENTRAL: acoustic neuroma, MS, stroke
DRUGS: gentamicin, loop diuretics
What is Meniere’s disease?
Dilation of the endolymph spaces of the membranous labyrinth
Causes progressive SNHL, vertigo, tinnitus and aural fullness
Which medications are often used to treat vertigo?
Cyclizine
Betahistine
