Surgery Flashcards by Mark Arnel Marquez

True or False:

CEA is not a tumor marker

True

CEA should not be requested as a screening tests for CRCA. Instead, colonoscopy should be done for a patient highly suspicious for CRCA.
CEA is then used after surgery to assess response and prognosis.

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Greatest RIsk Factors

Colorectal CA
Bladder
Ovarian
Ectopic Pregnancy

Colorectal CA - age
Bladder - smoking
Ovarian - family history
Ectopic Pregnancy - PID

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A 60-year old man has a history of constipation now presents with fever, tachycardia, acute onset of severe left iliac fossa pain, tenderness and guarding.
Likely diagnosis?
Most appropriate management?

Acute diverticulitis
Start IV antibiotics

***Remember: guarding = peritonitis; Admit and start IV abx

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A 40-year old female presents with a painful swelling on her right groin. SHe has been having vomiting and abdominal distennsion and not been able to pass stool for 2 days. This groin lump is below the inguinal ligament on the right groin.
Likely Diagnosis?

Femoral Hernia

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32-year old man + uncomplicated lap chole + At present: RUQ pain with guarding, fever, tachycardia + elevated WBC and CRP
Most appropriate investigation

CT abdomen

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Painful, fluctuating mass over the breast or near the nipple

Nipple Abscess

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Brown/ Green/ Colored discharge per nipple

Duct ectasia

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History of trauma + firm, round, solitary, localised lump

Fat necrosis

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20-40 year old + bleeding per nipple + skin changes

Ductal Papilloma

Investigation: Galactogram

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Old woman + bleeding per nipple + ulceration + eczema-like changes + itching

Paget’s disease of the breast and nipple

Investigation: Punch biopsy

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Firm, non-tender, mobile mass in the breast of a young (15-30)

Fibroadenoma

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Mastalgia, increase in the breast size, lumpiness (increased nodularity) of the breast, reproductive age + appears during or before menses and disappears after menses

Fibroadenosis

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Fixed, irregular, hard, painless lump + nipple retraction + Peau d’orange + local fixed or firm axillary LN

Breast cancer

Investigation: Core biopsy

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Offensive yellow discharge near the nipple + history of abscess

Ductal (Mammary) fistula

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Prolonged redness around the areola + hx of using antibiotics which improved the symptom + smoker + greenish discharge per nipple +

Periductal mastitis

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Investigation for Zenker’s diverticulum (pharyngeal pouch)

Barium swallow (NOT endoscopy as it has risk of perforation)

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Elective surgery + Hgb < 10

Defer surgery

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Elective surgery + Hgb < 8

Transfuse then Defer surgery

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Emergency Surgery + Hgb < 10

Proceed with surgery

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Emergency Surgery + Hgb < 8

Transfuse then proceed with surgery

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Initial management of hypercalcemia

FLUIDS (then bisphosphonates)

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Bone pain due to metastases

Radiotherapy then bisphosphonates

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Post-MI, when to undergo elective surgery?

After 6 months

***Remember that patients s/p MI should not undergo surgery for at least 6 mos after MI

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Important RF for anastomotic leak

***Remember other important RF for anastomotic leak such as immunocompromised state (DM, smoking, prolonged use of steroids)

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5-10 days post-op + patient experienced pain in the anastomotic site + fever + reduced bowel sounds

Anastomotic Leak | Diagnostic: CT scan of the abdomen and pelvis with contrast

Old age + painless bleeding per rectum + altered bowel habits + anemia + weight loss

Colon CA Colonoscopy ***Left-sided presents with fresh blood while right-sided presents with IDA (Right side has wider diameter; right-sided CA is less likely to present with obstructive symptoms)

S/P thyroidectomy + hypocalcemia features | Management?

Calcium gluconate 10% 10mL

S/P thyroidectomy + airway obstruction in the first 24 hours | Management?

Open the surgical incision to evacuate the hematoma

S/P thyroidectomy + hoarseness of voice

Unilateral injury to the RLN

s/p thyroidectomy + aphonia and airway obstruction

Bilateral injury to the RLN

s/p thyroidectomy + dysphonia (loss of high-pitch) OR mono-toned voice

Injury to the External Laryngeal Nerve (or EXTERNAL branch of the superior LARYNGEAL NERVE)

Sudden onset of severe abdominal pain + Tenderness + history of AF or MI + high lactate

Acute Mesenteric Ischemia O2, IVF, Analgesic, Antibiotics, Urgent surgery

Gradual onset (over hours) of abdominal pain + moderately severe + starts at the left iliac fossa + bloody diarrhea

Conservative or surgical

When should we offer prophylactic mastectomy?

BIOPSY: atypical hyperplasia or LCIS FAMILY HISTORY: strong fam hx of BRCA PAST MEDICAL HISTORY: previous BRCA in one breast GENETICS: BRCA1 or BRCA2

If there is a strong fam hx or BRCA mutations, how would you advice on screening for breast cancer?

Aged 40-70, mammogram every year ***Remember that Mammogam is offered for all women aged 50-70 every 3 years.

Commonest breast tumor in adolescene and young women + firm, painless, non-tender, mobile breast mass + breast mice Diagnosis? Diagnostic?

Fibroadenoma | Clinicall + Ultrasound + FNAC

Superficial or Simple or Low perianal fistula

Fistulotomy (Lay Open)

Deep or Complex or High Fistula + fistula that crosses internal and external sphincters

Seton suture + Ligation of intersphincteric fistula tract

Axillary LN clearance can lead to this condition wherein there redness and swelling of the upper limb

Upper limb lymphoedema

Treatment for upper limb lymphoedema secondary to axillary LN clearance

Physiotherapy and arm exercise

Tender mass near the anus + tender, swollen, erythematous with throbbing pain that is worse on sitting + fever + constipation Diagnosis? Management? Risk Factor?

Anorectal Abscess I&D + Antibiotics DM, Immunocompromised

What value needs to be satisfied to decide on reinserting catheter if a patient presents with post-operative oliguria?

PVRV > 500 mL

Histopathology: invasive intradu Histopathology: invasive intraductal carcinoma of the breast extending to the epithelium

Breast cancer

In situ carcinoma involving the nipple epidermis

Paget’s disease

Encapsulated adipocytes within a fibrotic stroma

Hamartoma

Proliferation and expansion of the stroma with low cellularity

Fibroadenoma

A well-circumscribed lump with clear margins and separate from the surrounding fatty tissue. There are overgrowths of fibrous and glandular tissue

Fibroadenoma

Duct-like epithelium surrounded by fibrous bridging

Fibroadenoma

Cystic formations with mild epithelial hyperplasia (fibrosis, epitheliosis and cystic formation)

Fibrocystic changes (Fibroadenosis)

Pre-op management of a known diabetic type II on OHA before a major surgery

Stop OHA before surgery

Pre-op management of a known diabetic type II on OHA before a minor surgery

Continue the same routine

Pre-op management of a known diabetic type I on INSULIN before a major surgery

Start sliding scale insulin IV before surgery and continue until diet per mouth is re-established OR Start IV Insulin, Dextrose and saline

Pre-op management of a known diabetic type I on INSULIN before a minor surgery

Omit insulin on the day of surgery

No gastric bubbles

Esophageal atresia

Single bubble

Gastric/Pyloric Atresia

Double-bubble

Duodenal Atresia

Triple Bubble

Jejunal Atresia

A pregnant woman attends for anomaly scan at 31-weeks AOG. She has polyhydramnios. Ultrasound showed no fetal gastric bubbles.

Esophageal atresia

Most appropriate step in the management of a bleeding diverticulitis

Urgent Admission into the surgical ward

Post abdominal surgery + epigastric fullness + nausea and vomiting + tenderness + hypotension + tachycardia Diagnosis? Mgt?

Acute Gastric Distension NGT for decompression

An important risk factor for Carpal Tunnel Syndrome due to fluid retention

Pregnancy

Also known as flexor retinaculum or anterior annular ligament

Carpal Tunnel Ligament

Extremely painful especially on defecation + patient refuses rectal exam + blood streaks in the stools + constipation and straining

Anal fissure

First-line management of an acute anal fissure

High-fibre diet with increased OFI | Bulk-forming laxatives

Prophylactic antibiotic prior to colectomy

30 mins prior to procedure or during induction of anesthesia: CEFUROXIME + METRONIDAZOLE

ABOVE and medial to the pubic tubercle vs. BELOW and LATERAL to the pubic tubercle

Inguinal Hernia vs. Femoral Hernia

Hepatomegaly + palpable liver + weight loss + history of cirrhosis + tiredness + RUQ pain Diagnosis? Tumor marker?

Hepatocellular carcinoma | AFP

Throbbbing anal pain esp on defecation and on sitting + gradual pain with increasing severity + tender swelling/mass around the anus that might be erythematous with or without fever + No blood

Perianal abscess | I&D

Patient s/p thyroid surgery develops shortness of breath and stridor. First step?

Cut the subcutaneous sutures

Greatest risk factors for colorectal cancer

Old Age | Family History

Old age + anemia + bleeding per rectum + weight loss + left lower abdominal mass or pain Diagnosis?

Sigmoid Carcinoma

Old age + anemia + weight loss + right lower abdominal mass or pain

Cecal carcinoma

Between sigmoid and cecal carcinoma, which is more likely to present with bleeding per rectum and why?

Cecal CA is LESS likely to show bleeding per rectum as bleeding in the cecum has longer travel and it incorporates in the feces. Also, it is MORE LIKELY to present with obstructive symptoms.

What are the common sites of ischemic colitis?

Splenic flexure and Rectosigmoid colon

Most appropriate investigation on a fluid-filled mass in the midline of the neck below the hyoid bone of a child. This moves upward on tongue protrusion and swallowing.

Ultrasound (NOT FNAC)

Differentiate presentation of oropharyngeal carcinoma from oesophageal carcinoma

Esophageal carcinoma: old age + gradually worsening dysphagia + long-standing gastric reflux (Upper GI endoscopy + biopsY) Oropharyngeal CA: old age + otalgia + dysphagia + lesion/ulcer at the back of the tongue + palpable, non-tender cervical lymphadenopathy

Important site of spreading of a tonsillar cancer

Mandible

A patient with known case of tonsillar cancer presents with pain in the throat with trismus

Think of cancer spreading to the mandible

Severe trismus + drippling of saliva + otalgia + hot potato voice + uvular deviation + red and inflamed bulge beside the tonsil

Quinsy or peritonsillar abscess

Magic number in terms of management of anal fissure

6 weeks: Acute anal fissure - Less than 6 weeks Chronic anal fissure - more than 6 weeks

First-line treatment for a chronic anal fissure

Topical GTN

Passes through the deep and the superficial inguinal ring and lies LATERAL to the inferior epigastric artery

Indirect inguinal hernia

Passes through the Posterior wall of the inguinal canal

Direct inguinal hernia

A patient who is NOT BREATHING after exposed to burn + failed intubation Next step? What structure should be pierced?

Cricothyroidotomy Cricothyroid membrane

CXR findings of an intestinal obstruction

Multiple air-fluid levels

Abdominal pain + distention + tenderness + empty rectum + noisy hyperactive bowel sounds + constipation Diagnosis? X-ray findings? Next best step?

Intestinal Obstruction Multiple air-fluid levels Urgent refer to surgical ward

Back pain + weight loss + history of smoking or alcohol + obstructive jaundice (elevated TB, B2; pale stool, dark urine and itching; elevated ALP); abnormal LFT; HYPERGLYCEMIA + palpable gallbladder

Carcinoma of the head of the pancreas

Prognostic investigation for cancer of the head of the pancreas?

CA 19-9

Investigation of choice for CA of head of the pancreas? | Initial diagnostic of choice?

HRCT UTZ

In patient with CA of the head of the pancreas with no proven metastasis, what is the management?

Whipple’s resection (pancreaticoduodenectomy)

CA of the head of the pancreas + metastasis | Management?

Palliative ERCP with stent

Screening for CRCA

FIT for 60-74 years q2years

Screening for BRCA

For high Risk: mammogram annually for aged 40-70 | For all women aged 50-70, mammogram every 3 years

Screening for cervical cancer

PAP smear Every 3 years for aged 25-49; every 5 years for 50-64

The most common causative organism for breast abscess

S. aureus

Bleeding at the time of surgery Diagnosis? Management?

Primary Hemorrhage | Replace blood or return to theatre if severe

Bleeding within 24 hours after surgery (e.g., while in the RR) Diagnosis? Management?

Reactionary Hemorrhage Replace blood; Wound re-exploration (possible slipping of ligatures)

Surgical bleeding 1-2 weeks post-op

Secondary hemorrhage Admit and IV antibiotics (usually due to necrosis of blood vessels)

Most common site of vaginal fistula?

Rectovaginal fistula

If very high suspicion for bile leak, diagnostic of choice?

ERCP

If low suspicion of bile leak and high suspicion of abscess

CT abdomen

Management for cyclical mastalgia

Advise patient to wear a supportive bra OR Advise better-fitting bra in the day and soft support bra at night OR Paracetamol

ATLS Class 1 of Shock

Blood loss - less than 750mL or less than 15% BP - normal HR - 60-100 bpm RR - 14-20cpm

ATLS Class 2 of Shock

Blood Loss 15-30% or 750-1500ml BP normal HR 101-120 RR 21-30

ATLS Class 3 of Shock

Blood Loss of 1500-2000mL (30-40%) BP decreased HR 121-140 RR 31-40

ATLS Class 4 of Shock

Blood Loss of >2000mL (>40%) BP decreased HR > 140 bpm RR >35cpm

Other name for that structure that needs releasing in a carpal tunnel syndrome

``` Transverse carpal ligament OR Flexor retinaculum OR Anterior annular ligament ```