Surgery Flashcards
Features of traumatic aortic rupture?
Deceleration injuries
Contained haematoma (persistent hypotension)
Widened mediastinum (CXR)
May be depression of bronchi +/- tracheal deviation
Borders of the femoral canal?
Lateral: Femoral vein
Medial: Lacunar ligament
Anterior: Inguinal ligament
Posterior: Pectineal ligament
Contents of femoral canal?
Lymphatic vessels
Cloquet’s lymph node
When should LP done in suspected SAH?
12 hours after onset of headache
What would you find on biopsy in temporal arteritis?
Temporal artery intimal proliferation with skip lesions
How often to scan a triple A of 3 - 4.4 cm?
Rescan every 12 months
How often to scan a triple A of 4.5 - 5.4 cm?
Rescan every 3 months
What to do if AAA >=5.5cm?
Refer within 2 weeks to vascular surgery for probable intervention
first-line investigation for suspected prostate cancer?
Multiparametric MRI
What is a large hyperechoic lesion of the liver in the presence of normal AFP likely to be?
Haemangioma
Which renal stones are radio-lucent?
urate + xanthine stones
What does a pelvic fracture and highly displaced prostate suggest?
Membranous urethral rupture
What does a pelvic fracture and lower abdominal peritonism suggest?
Bladder rupture
Surgical tx for distal 2/3rds transverse or descending colon cancer?
left hemicolectomy
What surgery is used to excise upper rectal tumours?
high anterior resection
Who is suxamethonium contraindicated in?
Patients with penetrating eye injuries or acute narrow angle glaucoma (increases intra-ocular pressure)
What is a Richter hernia and how does it present?
Only the antimesenteric border of the bowel herniates through the fascial defect
Characterised by the absence of symptoms of obstruction even in the presence of strangulation, as the bowel lumen is patent while bowel wall is compromised
What does an ABPI > 1.2 indicate?
may indicate calcified, stiff arteries. This may be seen with advanced age or PAD
What does an ABPI 1 - 1.2 indicate?
Normal
What does an ABPI <0.9 indicate?
likely PAD. Values < 0.5 indicate severe disease which should be referred urgently
What is the best agent for induction of anaesthesia in a haemodynamically unstable agent?
Ketamine
What severe side effect is important to be aware of when using etomidate anaesthetic agent?
Adrenal suppression
Surgery / sulfonylureas on day of surgery?
Omit on the day of surgery
Exception is morning surgery in patients who take BD - they can have the afternoon dose
How to calculate the nottingham prognostic index for breast cancer?
Tumour Size x 0.2 + Lymph node score + Grade score
Colorectal cancer referral guidelines?
patients >= 40 years with unexplained weight loss AND abdominal pain
patients >= 50 years with unexplained rectal bleeding
patients >= 60 years with iron deficiency anaemia OR change in bowel habit
tests show occult blood in their faeces
Where is a gastrostomy and what is it used for?
Epigastrium
Gastric decompression or fixation
Feeding
Where is a loop jejunostomy and what is it used for?
Anywhere
Seldom used as very high output
May be used following emergency laparotomy with planned early closure
Where is a percutaneous jejunostomy and what is it used for?
LUQ
Usually performed for feeding purposes and site in the proximal bowel
Where is a loop ileostomy and what is it used for?
RIF
Defunctioning of colon e.g. following rectal cancer surgery
Does not decompress colon (if ileocaecal valve competent)
Where is an end ileostomy and what is it used for?
RIF
Usually following complete excision of colon or where ileocolic anastomosis is not planned
May be used to defunction colon, but reversal is more difficult
Where is an end colostomy and what is it used for?
RIF/LIF
Where a colon is diverted or resected and anastomosis is not primarily achievable or desirable
Where is a loop colostomy and what is it used for?
Anywhere
To defunction a distal segment of colon
Since both lumens are present the distal lumen acts as a vent
Where is a caecostomy and what is it used for?
RIF
Stoma of last resort where loop colostomy is not possible
Where is a mucous fistula and what is it used for?
Anywhere
To decompress a distal segment of bowel following colonic division or resection
Where closure of a distal resection margin is not safe or achievable
Tx for anal fissures not responding to conservative tx?
Referral for sphincterotomy or botulinum toxin
Mx of thrombosed haemorrhoid if presentation within 72hrs?
Haemorrhoidectomy
Which operation is used in an emergency for bowel cancer?
Hartmann’s procedure
A syndrome consisting of a PTEN mutation and intestinal hamartomas?
Cowden disease
A syndrome which may be present in a patient with multiple intestinal hamartomas and pigmentation spots around the mouth?
Peutz-Jeghers syndrome
A syndrome which causes right sided colonic tumours at a young age?
Lynch syndrome
Mackler’s triad (Boerrhave’s)?
Severe vomiting
Dyspnoea
Chest pain
Diagnostic ix in boerhaave’s?
CT contrast swallow
Most common type of renal cell carcinoma?
Adenocarcinoma
Which anaesthetic agent should not be used in pneumothorax?
Nitrous oxide
Pre-op hydrocortisone doses for pts on long term steroid therapy?
Minor procedure under local: no supplementation required
Moderate procedure: 50mg hydrocortisone before induction and 25mg every 8h for 24h
Major surgery: 100mg hydrocortisone before induction and 50mg every 8h for 24h, thereafter halving dose every 24h until maintenance dose reached
Tx for malignant HTN as a SE of suxamethonium?
Dantrolene
What is Mirizzi’s syndrome?
When a gallstone in the cystic duct causes compression on the common hepatic duct, resulting in jaundice
Blockage of which duct in the biliary tree does not cause jaundice?
Cystic duct/gall bladder neck
What vein should TPN be administered into?
Central vein e.g. subclavian (phlebitic)
Tx for acute cholecystitis?
intravenous antibiotics + early laparoscopic cholecystectomy within 1 week of diagnosis
Tx for ascending cholangitis?
ERCP
What plt level indicates need for platelet transfusion for thrombocytopenia before surgery/ an invasive procedure?
<50×109/L for most patients
50-75×109/L if high risk of bleeding
<100×109/L if surgery at critical site
Who do you not give plt transfusions to?
Chronic bone marrow failure
ITP
HIT
TTP
Typical presentation of anterior uveitis?
painful red eye associated with reduced visual acuity, photophobia, a small pupil and ciliary flush
Typical presentation of Acute angle closure glaucoma?
severe pain (may be ocular or headache) decreased visual acuity, patient sees haloes semi-dilated fixed pupil hazy cornea eye feels hard on palpation
What do you see in the urine of someone with acute tubular necrosis?
granular, muddy-brown urinary casts
Classic triad in acute interstitial nephritis?
What would you see in the urine?
Rash
Fever
Eosinophilia
Urine - white cell casts
What is the Parkland formula for fluid resuscitation in burns?
Volume of fluid = total body SA of burn (%) x weight (Kg) x 4ml
50% given in first 8 hours
50% given in next 16 hours
Common causes of a sudden painless loss of vision
ischaemic/vascular (e.g. thrombosis, embolism, temporal arteritis –> occlusion of central retinal vein and occlusion of central retinal artery)
vitreous haemorrhage
retinal detachment
retinal migraine
Features of Central retinal vein occlusion?
What is seen on fundoscopy?
incidence increases with age, more common than arterial occlusion
severe retinal haemorrhages are usually seen on fundoscopy
Causes of Central retinal vein occlusion?
glaucoma
polycythaemia
hypertension
Features of Central retinal artery occlusion?
afferent pupillary defect
‘cherry red’ spot on a pale retina
Causes of Central retinal artery occlusion?
Thromboembolism (from atherosclerosis)
Arteritis (e.g. temporal arteritis)
Features of Vitreous haemorrhage?
sudden visual loss, dark spots
Causes of Vitreous haemorrhage?
diabetes, bleeding disorders, anticoagulants
What usually precedes retinal detachment?
Flashes of light or floaters
Anal cancer triad?
PR bleed
Pruritis ani
Incontinence
Criteria for THR rather than hemi-arthroplasty?
Independent
Mobile (1 mile max with a stick)
Not cognitively impaired
Vaccinations normally given a few weeks prior to splenectomy?
HIB vaccine
Streptococcus pneumonia vaccine
Meningococcal A, B and C vaccine
RFs for transitional cell carcinoma?
Smoking
Dyes
Analgesic abusers (phenacetin)
CIs to MRI?
Anything metal - pacemaker, recent hip replacement <6 weeks, aneurysm clip
Relative CIs:
Confusion
Infection
Pregnant (1st trimester)
Where does the facial nerve exit the skull?
Stylomastoid foramen
What is Heerfort’s syndrome?
a rare manifestation of sarcoidosis characterized by the presence of facial nerve palsy, parotid gland enlargement, anterior uveitis, and low grade fever
Most common parotid malignancy?
Mucoepidermoid carcinoma
Which branch of the facial nerve is responsible for lacrimation?
Greater superficial petrosal nerve branch
Which artery is usually the cause of posterior nose bleeds?
Sphenopalatine artery - branch of the internal maxillary artery
5 vessels which supply Kiesselbach’s plexus in the anterior nasal septum?
superior labial, anterior ethmoidal, posterior ethmoidal, greater palatine and sphenopalatine arteries
Causes of presenile cataracts?
Steroids Uveitis DM High myopia Significant trauma
What triad do you see on fundoscopy of Retinitis pigmentosa?
arteriolar attenuation
bone–spicule peripheral retinal pigmentation
waxy optic disc pallor
Cup to disc ratio in Primary open angle glaucoma?
> 0.6
Causes of optic disc contour to become indistinct/blurry?
Optic neuritis
Anterior ischaemic optic neuropathy
Papilloedema
Proliferative diabetic retinopathy tx?
pan retinal laser photocoagulation
Diabetic macular oedema tx?
intravitreal injections of anti-VEGFs
What is the name for transparent conjunctival swelling inferior to the cornea?
Chemosis
If the eye is proptotic, and the proptosis is pulsatile with an audible bruit, what diagnosis do you suspect?
Carotico-cavernous fistula
Which is the appropriate treatment for acute angle closure glaucoma?
IV acetazolamide Prostaglandin analogue eye drops Beta blocker eye drops Pilocarpine eye drops Topical steroids
3 causes of an abnormally large pupil?
pharmacological
third nerve palsy
acute glaucoma
Incompetence of which vein would be noted from the groin to the medial aspect of the lower leg?
long saphenous vein
Incompetence of which vein would be noted from the popliteal fossa along the calf to the lateral malleolus?
short saphenous vein
What level does the aorta bifurcate?
L4
What is the normal insensible loss from a pt per day?
50 ml/h (or about 0.5 – 1.0 ml/kg/h)
What is the daily sodium requirement?
1-2 mmol/kg
What is the daily potassium requirement?
0.5 – 1mmol/kg
421 rule of maintenance fluids?
4mls/kg/hr for the first 10kg, 2mls/kg/hr for next 10kg and 1ml/kg/hr for the remaining weight
Mx of thrombosed haemorrhoids >72 hours?
stool softeners, ice packs and analgesia
Tx for renal Stone burden of less than 2cm in aggregate?
lithotripsy
Tx for Ureteric calculi less than 5mm?
Expectant mx
Tx for Stone burden of less than 2cm in pregnant females?
Ureteroscopy
Tx for Complex renal calculi and staghorn calculi?
Percutaneous nephrolithotomy
Tx for stone causing obstruction/infective signs?
Percutaneous nephrostomy
+ IV abx
Leriche syndrome?
Athersclerotic occlusion of abdo aorta and iliacs
Buttock claudication and wasting
Erectile dysfunction
Absent femoral pulses
Buerger’s disease?
Acute inflammation of blood vessels in hands and feet
Ulceration and gangrene
Younger males who are heavy smokers
What are cotton wool spots?
pre-capillary arteriolar occlusion, leading to retinal infarction
What are the fluid requirements for maintenance fluids?
25-30 ml/kg/day of water and
approximately 1 mmol/kg/day of potassium, sodium and chloride and
approximately 50-100 g/day of glucose to limit starvation ketosis
Meds for prophylaxis of kidney stones?
Calcium stones - thiazide diuretics
Urate stones - allopurinol, bicarb to promote urinary alkalinisation
Oxalate stones - pyridoxine/cholestyramine
Features of papilloedema on fundoscopy?
Venous engorgement: usually first sign
Loss of venous pulsation (but many normal patients may have no pulsation)
Blurring of optic disc margin
Elevation of optic disc
Loss of optic cup
Paton’s lines: concentric/radial retinal lines cascading from the optic disc
Small haemorrhages
Surgery for cholesteatoma?
Canal wall up mastoidectomy
Indications for a TIPS procedure?
Actively bleeding oesophageal varices refractory to other tx
Gastric/ectopic varices
Refractory ascites
Budd-Chiari syndrome
Absolute CIs for TIPS procedure?
CCF Severe TR Severe pulmonary HTN Polycystic liver disease Sepsis
Tx if someone grows MRSA on nasal swab pre-op?
Nasal mupirocin + chlorhexidine for skin
Borders of the safe triangle?
Base of the axilla
Lateral edge pectoralis major
5th intercostal space
Anterior border of latissimus dorsi
What to do if you see a unilateral nasal polyp?
Refer to ENT
Tx for small bilateral nasal polyps?
saline nasal douche and intranasal steroids
Initial mx for abdominal wound dehiscence?
coverage of the wound with saline impregnated gauze + IV broad-spectrum antibiotics
Causes of unilateral hydronephrosis? PACT
Pelvic-ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis
Causes of bilateral hydronephrosis? SUPER
Stenosis of the urethra Urethral valve Prostatic enlargement Extensive bladder tumour Retro-peritoneal fibrosis
What kind of polyps in IBD?
Pseudopolyps (actually just swollen areas of bowel)
Congenital cause for primary lymphoedema?
Milroy disease
Tx of local anaesthetic toxicity?
IV 20% lipid emulsion
Maximum total local anaesthetic doses?
Lignocaine 1% plain - 3mg/ Kg - 200mg (20ml)
Lignocaine 1% with 1 in 200,000 adrenaline - 7mg/Kg - 500mg (50ml)
Bupivicaine 0.5% - 2mg/kg- 150mg (30ml)
What is dumping syndrome and what is it a complication of?
Complication of gastric surgery
Occurs due to a hyperosmolar load rapidly entering the proximal jejunum. Osmosis drags water into the lumen, causing lumen distension (pain) and diarrhoea. Excessive insulin release also occurs and results in hypoglycaemic symptoms.
1st line ix for suspected bladder cancer?
Flexible cystoscopy
Acceptable post void residual volume?
<50 ml in patients aged < 65 years
< 100ml in patients aged > 65 years
Definition of chronic urinary retention?
> 500ml within the bladder after voiding
What volume suggests acute-on-chronic urinary retention?
Post-catheterisation urine volume of >800 ml
What does perinephric fat stranding suggest?
pyelonephritis
What does periureteric fat stranding suggest?
passed stones
Medical indications for circumcision?
phimosis
recurrent balanitis
balanitis xerotica obliterans
paraphimosis
RF for Renal transitional cell carcinoma?
exposure to chemicals in the textile, plastic and rubber industry
What is Rigler’s triad and what are the components?
Demonstrates gallstone ileus
SBO
Pneumobilia
Ectopic gallstones
Causes of pneumobilia?
Gallstone ileus Emphysematous cholecystitis Pyogenic cholecystitis Post-ERCP Post-cholecystectomy Blunt abdo trauma Incompetent sphincter of Oddi
What is Bouveret syndrome?
Gastric outlet obstruction secondary to impacted gallstones
Features of carcinoid syndrome?
Paroxysmal flushing
Diarhhoea
Bronchospasm
Abdo pain - precipitants include alcohol, stress and caffeine
Tx for carcinoid syndrome?
Surgical resection
Symptomatic tx: octreotide
Ix for urethral stricture?
Retrograde Urethography
Tx of mumps orchitis?
Analgesia and bed rest
Tx of epididymo-orchitis?
Abx
Drug cause of epididymitis?
Amiodarone
How does anhydrosis determine the site of the lesion in Horner’s syndrome?
just face = pre-ganglionic lesion: Pancoast’s, cervical rib
head, arm, trunk = central lesion: stroke, syringomyelia
absent = post-ganglionic lesion: carotid artery
Ramsay hunt tx?
Oral aciclovir and steroids
Herpes zoster opthalmicus tx?
Oral aciclovir
Otitis externa mx?
Mild: topical acetic acid 2% spray
More severe: 7 days of abx eardrops +/- steroid eardrops
Tx for acute necrotizing ulcerative gingivitis?
Paracetamol + PO metronidazole + chlorhexidine mouthwash
Samter’s triad?
asthma + aspirin sensitivity + nasal polyposis
Audiogram findings for hearing loss?
Normal = anything above 20dB
a) conductive hearing loss = fall in air conduction + normal bone conduction
b) sensorineural loss = fall in air + fall in bone (to the same level)
c) mixed = conductive + sensorineural = 2x fall in air + 1x fall in bone
Causes of gingival hyperplasia? PANIC
Phenotoin AML Nifidipine infection - bacterial Ciclosporins
Tx of acute otitis media with perforation?
Oral abx
Complication of TIPS procedure?
exacerbation of hepatic encephalopathy
Lemon yellow tinge… Dx?
Pernicious anaemia
How is severity of Clostridium difficile infection determined?
WCC
Normal = mild
Raised but <15 = moderate
>15 = severe
Features of Scheuermann’s disease?
Epiphysitis of the vertebral joints - Xray: epiphysial plate disturbance and anterior wedging
Affects teens
Progressive kyphosis
Features of Spondylolisthesis?
Athletic female teens
O/E: one spinous process might feel more or less prominent
One vertebra is displaced relative to its immediate inferior vertebral body
Xray: Scotty dog
Mx of adults with hydrocele?
Urgent USS to exclude tumour if 18-40 or testes not palpable
Which muscle relaxant is used for rapid sequence induction for intubation?
Suxamethonium
Tx for RCC?
Tumour <7cm: partial nephrectomy
Tumour >7cm: total nephrectomy
Mets: Alpha-interferon
What to do for patients with symptoms which do not meet 2WW criteria for bowel cancer but have new worrying symptoms?
Faecal immunochemical test
What 2 vessels does a TIPS procedure connect?
hepatic vein to the portal vein
How is Chronic urinary retention classified?
high pressure urinary retention if renal function is impaired or if there is hydronephrosis
low pressure if not
Best ix for distal anastamotic leaks post colorectal surgery?
gastrografin enema
Which tumours press on the frontal lobe?
Meningioma
Which tumours press on the cerebellum?
Astrocytoma
What catheter do you use for neurogenic bladder?
Clean intermittent catheterisation
