Surgery Flashcards
1
Q
Features of traumatic aortic rupture?
A
Deceleration injuries
Contained haematoma (persistent hypotension)
Widened mediastinum (CXR)
May be depression of bronchi +/- tracheal deviation
2
Q
Borders of the femoral canal?
A
Lateral: Femoral vein
Medial: Lacunar ligament
Anterior: Inguinal ligament
Posterior: Pectineal ligament
3
Q
Contents of femoral canal?
A
Lymphatic vessels
Cloquet’s lymph node
4
Q
When should LP done in suspected SAH?
A
12 hours after onset of headache
5
Q
What would you find on biopsy in temporal arteritis?
A
Temporal artery intimal proliferation with skip lesions
6
Q
How often to scan a triple A of 3 - 4.4 cm?
A
Rescan every 12 months
7
Q
How often to scan a triple A of 4.5 - 5.4 cm?
A
Rescan every 3 months
8
Q
What to do if AAA >=5.5cm?
A
Refer within 2 weeks to vascular surgery for probable intervention
9
Q
first-line investigation for suspected prostate cancer?
A
Multiparametric MRI
10
Q
What is a large hyperechoic lesion of the liver in the presence of normal AFP likely to be?
A
Haemangioma
11
Q
Which renal stones are radio-lucent?
A
urate + xanthine stones
12
Q
What does a pelvic fracture and highly displaced prostate suggest?
A
Membranous urethral rupture
13
Q
What does a pelvic fracture and lower abdominal peritonism suggest?
A
Bladder rupture
14
Q
Surgical tx for distal 2/3rds transverse or descending colon cancer?
A
left hemicolectomy
15
Q
What surgery is used to excise upper rectal tumours?
A
high anterior resection
16
Q
Who is suxamethonium contraindicated in?
A
Patients with penetrating eye injuries or acute narrow angle glaucoma (increases intra-ocular pressure)
17
Q
What is a Richter hernia and how does it present?
A
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
18
Q
What does an ABPI > 1.2 indicate?
A
may indicate calcified, stiff arteries. This may be seen with advanced age or PAD
19
Q
What does an ABPI 1 - 1.2 indicate?
A
Normal
20
Q
What does an ABPI <0.9 indicate?
A
likely PAD. Values < 0.5 indicate severe disease which should be referred urgently
21
Q
What is the best agent for induction of anaesthesia in a haemodynamically unstable agent?
A
Ketamine
22
Q
What severe side effect is important to be aware of when using etomidate anaesthetic agent?
A
Adrenal suppression
23
Q
Surgery / sulfonylureas on day of surgery?
A
Omit on the day of surgery
Exception is morning surgery in patients who take BD - they can have the afternoon dose
24
Q
How to calculate the nottingham prognostic index for breast cancer?
A
Tumour Size x 0.2 + Lymph node score + Grade score
25
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
26
Where is a gastrostomy and what is it used for?
Epigastrium
Gastric decompression or fixation
Feeding
27
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
28
Where is a percutaneous jejunostomy and what is it used for?
LUQ
| Usually performed for feeding purposes and site in the proximal bowel
29
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)
30
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
31
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
32
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
33
Where is a caecostomy and what is it used for?
RIF
| Stoma of last resort where loop colostomy is not possible
34
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
35
Tx for anal fissures not responding to conservative tx?
Referral for sphincterotomy or botulinum toxin
36
Mx of thrombosed haemorrhoid if presentation within 72hrs?
Haemorrhoidectomy
37
Which operation is used in an emergency for bowel cancer?
Hartmann's procedure
38
A syndrome consisting of a PTEN mutation and intestinal hamartomas?
Cowden disease
39
A syndrome which may be present in a patient with multiple intestinal hamartomas and pigmentation spots around the mouth?
Peutz-Jeghers syndrome
40
A syndrome which causes right sided colonic tumours at a young age?
Lynch syndrome
41
Mackler's triad (Boerrhave's)?
Severe vomiting
Dyspnoea
Chest pain
42
Diagnostic ix in boerhaave's?
CT contrast swallow
43
Most common type of renal cell carcinoma?
Adenocarcinoma
44
Which anaesthetic agent should not be used in pneumothorax?
Nitrous oxide
45
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
46
Tx for malignant HTN as a SE of suxamethonium?
Dantrolene
47
What is Mirizzi's syndrome?
When a gallstone in the cystic duct causes compression on the common hepatic duct, resulting in jaundice
48
Blockage of which duct in the biliary tree does not cause jaundice?
Cystic duct/gall bladder neck
49
What vein should TPN be administered into?
Central vein e.g. subclavian (phlebitic)
50
Tx for acute cholecystitis?
intravenous antibiotics + early laparoscopic cholecystectomy within 1 week of diagnosis
51
Tx for ascending cholangitis?
ERCP
52
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
53
Who do you not give plt transfusions to?
Chronic bone marrow failure
ITP
HIT
TTP
54
Typical presentation of anterior uveitis?
painful red eye associated with reduced visual acuity, photophobia, a small pupil and ciliary flush
55
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
```
56
What do you see in the urine of someone with acute tubular necrosis?
granular, muddy-brown urinary casts
57
Classic triad in acute interstitial nephritis?
| What would you see in the urine?
Rash
Fever
Eosinophilia
Urine - white cell casts
58
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
59
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
60
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
61
Causes of Central retinal vein occlusion?
glaucoma
polycythaemia
hypertension
62
Features of Central retinal artery occlusion?
afferent pupillary defect
| 'cherry red' spot on a pale retina
63
Causes of Central retinal artery occlusion?
Thromboembolism (from atherosclerosis)
| Arteritis (e.g. temporal arteritis)
64
Features of Vitreous haemorrhage?
sudden visual loss, dark spots
65
Causes of Vitreous haemorrhage?
diabetes, bleeding disorders, anticoagulants
66
What usually precedes retinal detachment?
Flashes of light or floaters
67
Anal cancer triad?
PR bleed
Pruritis ani
Incontinence
68
Criteria for THR rather than hemi-arthroplasty?
Independent
Mobile (1 mile max with a stick)
Not cognitively impaired
69
Vaccinations normally given a few weeks prior to splenectomy?
HIB vaccine
Streptococcus pneumonia vaccine
Meningococcal A, B and C vaccine
70
RFs for transitional cell carcinoma?
Smoking
Dyes
Analgesic abusers (phenacetin)
71
CIs to MRI?
Anything metal - pacemaker, recent hip replacement <6 weeks, aneurysm clip
Relative CIs:
Confusion
Infection
Pregnant (1st trimester)
72
Where does the facial nerve exit the skull?
Stylomastoid foramen
73
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
74
Most common parotid malignancy?
Mucoepidermoid carcinoma
75
Which branch of the facial nerve is responsible for lacrimation?
Greater superficial petrosal nerve branch
76
Which artery is usually the cause of posterior nose bleeds?
Sphenopalatine artery - branch of the internal maxillary artery
77
5 vessels which supply Kiesselbach's plexus in the anterior nasal septum?
superior labial, anterior ethmoidal, posterior ethmoidal, greater palatine and sphenopalatine arteries
78
Causes of presenile cataracts?
```
Steroids
Uveitis
DM
High myopia
Significant trauma
```
79
What triad do you see on fundoscopy of Retinitis pigmentosa?
arteriolar attenuation
bone–spicule peripheral retinal pigmentation
waxy optic disc pallor
80
Cup to disc ratio in Primary open angle glaucoma?
>0.6
81
Causes of optic disc contour to become indistinct/blurry?
Optic neuritis
Anterior ischaemic optic neuropathy
Papilloedema
82
Proliferative diabetic retinopathy tx?
pan retinal laser photocoagulation
83
Diabetic macular oedema tx?
intravitreal injections of anti-VEGFs
84
What is the name for transparent conjunctival swelling inferior to the cornea?
Chemosis
85
If the eye is proptotic, and the proptosis is pulsatile with an audible bruit, what diagnosis do you suspect?
Carotico-cavernous fistula
86
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
```
87
3 causes of an abnormally large pupil?
pharmacological
third nerve palsy
acute glaucoma
88
Incompetence of which vein would be noted from the groin to the medial aspect of the lower leg?
long saphenous vein
89
Incompetence of which vein would be noted from the popliteal fossa along the calf to the lateral malleolus?
short saphenous vein
90
What level does the aorta bifurcate?
L4
91
What is the normal insensible loss from a pt per day?
50 ml/h (or about 0.5 – 1.0 ml/kg/h)
92
What is the daily sodium requirement?
1-2 mmol/kg
93
What is the daily potassium requirement?
0.5 – 1mmol/kg
94
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
95
Mx of thrombosed haemorrhoids >72 hours?
stool softeners, ice packs and analgesia
96
Tx for renal Stone burden of less than 2cm in aggregate?
lithotripsy
97
Tx for Ureteric calculi less than 5mm?
Expectant mx
98
Tx for Stone burden of less than 2cm in pregnant females?
Ureteroscopy
99
Tx for Complex renal calculi and staghorn calculi?
Percutaneous nephrolithotomy
100
Tx for stone causing obstruction/infective signs?
Percutaneous nephrostomy
| + IV abx
101
Leriche syndrome?
Athersclerotic occlusion of abdo aorta and iliacs
Buttock claudication and wasting
Erectile dysfunction
Absent femoral pulses
102
Buerger's disease?
Acute inflammation of blood vessels in hands and feet
Ulceration and gangrene
Younger males who are heavy smokers
103
What are cotton wool spots?
pre-capillary arteriolar occlusion, leading to retinal infarction
104
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
105
Meds for prophylaxis of kidney stones?
Calcium stones - thiazide diuretics
Urate stones - allopurinol, bicarb to promote urinary alkalinisation
Oxalate stones - pyridoxine/cholestyramine
106
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
107
Surgery for cholesteatoma?
Canal wall up mastoidectomy
108
Indications for a TIPS procedure?
Actively bleeding oesophageal varices refractory to other tx
Gastric/ectopic varices
Refractory ascites
Budd-Chiari syndrome
109
Absolute CIs for TIPS procedure?
```
CCF
Severe TR
Severe pulmonary HTN
Polycystic liver disease
Sepsis
```
110
Tx if someone grows MRSA on nasal swab pre-op?
Nasal mupirocin + chlorhexidine for skin
111
Borders of the safe triangle?
Base of the axilla
Lateral edge pectoralis major
5th intercostal space
Anterior border of latissimus dorsi
112
What to do if you see a unilateral nasal polyp?
Refer to ENT
113
Tx for small bilateral nasal polyps?
saline nasal douche and intranasal steroids
114
Initial mx for abdominal wound dehiscence?
coverage of the wound with saline impregnated gauze + IV broad-spectrum antibiotics
115
Causes of unilateral hydronephrosis? PACT
Pelvic-ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis
116
Causes of bilateral hydronephrosis? SUPER
```
Stenosis of the urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro-peritoneal fibrosis
```
117
What kind of polyps in IBD?
Pseudopolyps (actually just swollen areas of bowel)
118
Congenital cause for primary lymphoedema?
Milroy disease
119
Tx of local anaesthetic toxicity?
IV 20% lipid emulsion
120
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)
121
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.
122
1st line ix for suspected bladder cancer?
Flexible cystoscopy
123
Acceptable post void residual volume?
<50 ml in patients aged < 65 years
| < 100ml in patients aged > 65 years
124
Definition of chronic urinary retention?
>500ml within the bladder after voiding
125
What volume suggests acute-on-chronic urinary retention?
Post-catheterisation urine volume of >800 ml
126
What does perinephric fat stranding suggest?
pyelonephritis
127
What does periureteric fat stranding suggest?
passed stones
128
Medical indications for circumcision?
phimosis
recurrent balanitis
balanitis xerotica obliterans
paraphimosis
129
RF for Renal transitional cell carcinoma?
exposure to chemicals in the textile, plastic and rubber industry
130
What is Rigler's triad and what are the components?
Demonstrates gallstone ileus
SBO
Pneumobilia
Ectopic gallstones
131
Causes of pneumobilia?
```
Gallstone ileus
Emphysematous cholecystitis
Pyogenic cholecystitis
Post-ERCP
Post-cholecystectomy
Blunt abdo trauma
Incompetent sphincter of Oddi
```
132
What is Bouveret syndrome?
Gastric outlet obstruction secondary to impacted gallstones
133
Features of carcinoid syndrome?
Paroxysmal flushing
Diarhhoea
Bronchospasm
Abdo pain - precipitants include alcohol, stress and caffeine
134
Tx for carcinoid syndrome?
Surgical resection
| Symptomatic tx: octreotide
135
Ix for urethral stricture?
Retrograde Urethography
136
Tx of mumps orchitis?
Analgesia and bed rest
137
Tx of epididymo-orchitis?
Abx
138
Drug cause of epididymitis?
Amiodarone
139
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
140
Ramsay hunt tx?
Oral aciclovir and steroids
141
Herpes zoster opthalmicus tx?
Oral aciclovir
142
Otitis externa mx?
Mild: topical acetic acid 2% spray
| More severe: 7 days of abx eardrops +/- steroid eardrops
143
Tx for acute necrotizing ulcerative gingivitis?
Paracetamol + PO metronidazole + chlorhexidine mouthwash
144
Samter's triad?
asthma + aspirin sensitivity + nasal polyposis
145
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
146
Causes of gingival hyperplasia? PANIC
```
Phenotoin
AML
Nifidipine
infection - bacterial
Ciclosporins
```
147
Tx of acute otitis media with perforation?
Oral abx
148
Complication of TIPS procedure?
exacerbation of hepatic encephalopathy
149
Lemon yellow tinge... Dx?
Pernicious anaemia
150
How is severity of Clostridium difficile infection determined?
WCC
Normal = mild
Raised but <15 = moderate
>15 = severe
151
Features of Scheuermann's disease?
Epiphysitis of the vertebral joints - Xray: epiphysial plate disturbance and anterior wedging
Affects teens
Progressive kyphosis
152
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
153
Mx of adults with hydrocele?
Urgent USS to exclude tumour if 18-40 or testes not palpable
154
Which muscle relaxant is used for rapid sequence induction for intubation?
Suxamethonium
155
Tx for RCC?
Tumour <7cm: partial nephrectomy
Tumour >7cm: total nephrectomy
Mets: Alpha-interferon
156
What to do for patients with symptoms which do not meet 2WW criteria for bowel cancer but have new worrying symptoms?
Faecal immunochemical test
157
What 2 vessels does a TIPS procedure connect?
hepatic vein to the portal vein
158
How is Chronic urinary retention classified?
high pressure urinary retention if renal function is impaired or if there is hydronephrosis
low pressure if not
159
Best ix for distal anastamotic leaks post colorectal surgery?
gastrografin enema
160
Which tumours press on the frontal lobe?
Meningioma
161
Which tumours press on the cerebellum?
Astrocytoma
162
What catheter do you use for neurogenic bladder?
Clean intermittent catheterisation
