Surgery Flashcards
Sx of anal fissures?
Bright red, painful rectal bleeding.
Typically seen in the posterior midline. Associated with constipation
Mx of anal fissures?
If <1 week soften stool, give topical analgesics and lubricate before defecation
If chronic use topical GTN 1st line. If ineffective after 8 weeks consider sphincterotomy surgery
What should you always test for first in a woman of child-bearing age with an acute abdomen?
Pregnancy test!
Even if they deny sexual activity
How can you differentiate between hypertrophic and keloid scars?
Hypertrophic = confined to the boundaries of the original wound
Keyloid = extend beyond the boundaries of the original wound
How do we manage oestrogen receptor positive breast cancer?
Tamoxifen if pre- or peri-menopausal
Aromatase inhibitors e.g. anastrozole if post-menopausal
How do we manage HER-2 positive breast cancer?
Herceptin
Which chemo is indicated in node positive and node negative breast cancer?
Node positive = FEC-D
Node negative = FEC
What are the 3 causes of a snow storm sign?
On USS of the axillary lymph nodes = breast implant rupture
On USS of the uterus = hydatiform mole
On CXR = thyroid metastases to the lungs
What is the most common type of breast cancer?
Invasive ductal carcinoma, no special type
Sx and Mx of a psoas abscess
Lower back pain, tender groin mass, fever and pain exacerbated on hip extension
Mx = percutaneous drainage or surgery
Where do you find a direct inguinal hernia? Who are they commonly seen in? What is the strangulation risk?
Superior and medial to the pubic tubercle and Medial to the inferior epigastric artery
Seen in adult males
Low risk of strangulation
Where do you find an indirect inguinal hernia? Who are they commonly seen in? What is the strangulation risk?
Superior and medial to the pubic tubercle and Lateral to the inferior epigastric artery
Seen in adult and infant males
Low risk of strangulation
Where do you find a femoral hernia? Who are they commonly seen in? What is the strangulation risk?
Below the inguinal ligament and lateral to the pubic tubercle.
Seen in adult females
High risk of strangulation
Which drugs can be given to reduce the formation of calcium renal stones?
Thiazide like diuretics
Which drugs can be given to reduce the formation of urate renal stones?
Bicarbonate or allopurinol
Which drugs can be given to reduce the formation of oxalate renal stones?
cholestyramine or pyridoxine
Mx of SAH?
Supportive measures, nimodipine to prevent vasospasm and intracranial coiling if there is an aneurysm
What are the symptoms of hypocalcaemia?
Tetany (muscle twitching, cramps and spasms), perioral paraesthesia and QT interval prolongation
Trousseau’s sign = carpopedal spasm of BP cuff inflation
Chvostek’s sign = twitching of the facial muscle when you tap on the parotid gland
What is Boerhaave’s syndrome? How do we investigate and treat?
Oesophageal rupture secondary to vomiting.
Tearing chest pain and s/c emphysema
Ix = CT contrast swallow
Mx = Thoracotomy and lavage
How can we differentiate clinically between Boerhaave’s syndrome and a Mallory-Weiss tear?
Boerhaave’s presents with s/c emphysema and non-bloody vomit
Mallory-Weiss will have bloody vomit
How do we calculate the fluid requirements in 24hrs in burns patients?
4ml x (total burn area (%) x BW (kg))
Give 50% over the first 8 hours and then the other 50% over the next 16.
Fluid choice = Haartmans
Which side do varicoceles occur most commonly on?
Left
Sx and Mx of acute mesenteric iscahemia?
Sudden onset severe abdo pain which is out of proportion with the clinical findings on BG of AF or increased clot risk
Mx = immediate laparotomy
Sx of ischaemic colitis?
Sudden onset abdo pain (less severe than acute mesenteric ischaemia), seen alongside bloody diarrhoea. Will often resolve spontaneously
Can you give sulfonylureas on the day of surgery?
No - omit
If AM surgery and patient has a BD dose can have the afternoon dose (so long as they are eating)
What is the difference between a fibroadenoma and fibroadenosis?
Fibroadenoma = non-tender mobile lump seen in those <30
Fibroadenosis = lumpy painful breasts seen in middle aged women. Pain is worse prior to menstruation
Sx of a thrombosed haemarrhoid?
Significantly pain and tender lump. Will be oedematous, purple and seen in the subcutaneous tissue
Mx of thrombosed haemorrhoid?
<72hrs = surgical excision
>72hrs = stool softeners, ice pack and analgesia
What is superficial thrombophlebitis? Mx?
Thrombosis of one of the superficial veins
Mx = PO NSAIDs or LMWH and compression stocking
What is Balanitis Xerotica Obliterans
The male version of lichen sclerosis. It can lead to phimosis and increased risk of squamous cell carcinoma
Describe how the LFTs and inflammatory markers will appear in biliary colic?
Normal!
Describe how the LFTs and inflammatory markers will appear in cholecystitis?
LFTs are normal but CRP is raised
Which is the investigation and which is the management out of ERCP and MRCP?
MRCP = Ix
ERCP = Mx
Broadly, how do we distinguish between biliary colic, acute cholecystitis and ascending cholangitis?
Biliary colic = pain
Acute chole = pain and fever
Ascending cholangitis = pain, fever and jaundice
When should you surgically excise a breast fibroadenoma?
If it is >3cm
Which is the best anaesthetic drug to use in trauma?
Ketamine as it does not drop the BP
Which is the best anaesthetic drug to use in those at high risk of post-op vomiting?
Propofol as it has anti-emetic effects
What are the 2 most common causes of acute pancreatitis?
Gall stones and alcohol abuse
Sx and Mx of acute pancreatitis?
Sx = epigastric pain which radiates to the back +/- shock
Mx = aggressive fluid resuscitation, analgesia and do not routinely make NBM
When do pigmented gallstones occur?
Due to XS haemolysis secondary to haemolytic anaemia e.g. in sickle cell or liver cirrhosis
What do you do if CT head is normal but you suspect SAH?
If <6 hours post Sx onset = seek alternative diagnosis
If >6 hours post Sx onset = do LP after 12 hours (to look for xanthochromia)
Who should you not give nitrous oxide to in trauma?
Those with suspected pneumothorax - it can lead to tension pneumothorax
What is the safest Mx option in those with UC who have developed a megacolon?
Subtotal colectomy
What is Paget’s disease of breast?
Intraductal carcinoma associated with reddening and thickening of the areola/nipple - can look like eczema
When is Etomidate a good anaesthetic to use? What side effect can it cause?
In those with cardiac pathology as it causes less hypotension
Can lead to adrenal suppression
What is malignant hypertension?
A genetic reaction to -flurane anaesthetics
Causes increased end-tidal CO2, increased body temperature, diaphoresis and muscle contraction
What is post-operative ileus?
A common complication of bowel surgery
Sx = abdo pain, bloating, vomiting and not passing stools
What is mammary duct ectasia?
Tender breast lump around the areola with green nipple discharge seen in peri-menopausal/menopausal women
Which clotting factors reverse warfarin and are found in prothrombin complex?
II, VII, IX and X
Describe hiatus hernias?
95% are sliding
Sx = heart burn, dysphagia, regurgitation and chest pain
Ix = barium swallow
Mx = PPIs
Describe testicular torsion?
Acutely painful and swollen testicle, will be retracted and the cremasteric reflex is lost. Prehn’s sign is negative (elevation of the testicle will not relieve the pain)
Mx involves surgical fixation of both testes
How should you manage renal calculi which have lead to acute kidney obstruction?
Nephrostomy
What is the 1st line Ix of a testicular mass?
USS
Ix of epididymo-orchitis?
If young sexually man = NAAT for STI
If older/not sexually active = MSU for UTI
How do we reduce the risk of recurrence in women who have had a wide local excision for breast CA?
Whole breast radiotherapy
Ix of hydronephrosis?
USS
How do you manage urinary retention secondary to UTI?
Insert a urinary catheter
NOT if there is renal stones causing the retention
How are AFP and Beta hCG affected in testicular tumours?
In seminomas the AFP and Beta hCG are normal, in teratomas and yolk sac tumours they are raised
Which type of surgery is contraindicated in acute intestinal obstruction with dilated bowel loops?
Laparoscopic surgery
What must be done before vasectomy can be used as a contraceptive method?
Semen analysis, this is done at 12 weeks
Which gender sterilisation is more effective?
Male
How common is chronic testicular pain in vasectomy?
5-30%
How can heart failure cause weight loss?
Cardiac cachexia can occur if heart failure is poorly controlled as there is gut oedema
What can precipitate ureteric stones?
Dehydration e.g. secondary to diarrhoea and vomiting
How can you localise the torsion in ?testicular torsion?
Torsion of the spermatic cord = loss of the cremasteric reflex
Torsion of the testicular appendage = preserved cremasteric reflex
Which type of renal cell cancer is associated with polycythaemia?
Renal adenocarcinoma
What is Nephroblastoma?
Also known as a Wilm’s tumour it occurs in those under 4 years old and may metastasise to the lungs
Where do transitional cell carcinomas normally occur?
In the renal pelvis, the ureters, the urethra or the bladder
What should you consider in frank haematuria in a pregnant women who has had a previous placenta praevia or a C-section?
Placenta Percreta
True or false, renal vein thrombosis is often seen in renal cell cancer?
True!
What is the age cut off for 2WW in an unexplained breast lump?
> 30 = 2WW
<30 = not 2WW but can be offered non-urgent breast clinic refferal
Ix of varicose veins?
Venous duplex USS - will show retrograde venous flow
What is the most common cause of AKI? What causes it?
Acute Tubular Necrosis
Caused by ischaemia e.g. sepsis/shock or nephrotoxins e.g. secondary to rhabdomyolysis
Sx and Ix of acute tubular necrosis?
AKI, hypotension and renal impairment in the presence of a risk factor
Ix = raised urea, creatinine and potassium
Muddy brown/granular casts seen in urine
Ix of renal stones?
Non-contrast CT KUB
Which type of drug is tamulosin/alfuzosin? When are they used?
Alpha-1 antagonists
Used 1st line in the Mx of BPH
What type of drug is finasteride? When is it used?
5-alpha reductase inhibitor. Used 2nd line in BPH or 1st line if there is a significantly enlarged prostate or high risk of progression
What is the most common form of prostate cancer?
Adenocarcinoma
Which ABPI indicated peripheral artery disease? How should you manage?
<0.9 = PAD, <0.5 = critical limb ischaemia
Start the patient on clopidogrel and atorvastatin and offer exercise training 1st line
Mx oestrogen receptor positive breast cancer?
If pre-menopausal or peri-menopausal = tamoxifen
If post-menopausal = anastrazole
Describe chronic pancreatitis?
Most commonly caused by alcohol XS
Sx = pain worse 15-30mins after a meal, steatorrhoea and DM
Ix = CT with IV contrast and faecal elastase (will be low)
Mx = enzyme supplements, analgesia and antioxidants
What should you consider if a woman complains of blood stained discharge from the breasts?
Papiloma
What should you always do in post-operative ileus?
Check and replace electrolytes
Describe an epididymal cyst?
A scrotal swelling which is palpated separately from the body of the testicle. Often found posteriorly to the testicle it is the most common cause of scrotal swelling in primary care
What can often be the presenting complaint in testicular cancer?
Testicular lump or gyanecomastia
What is the recommended pain relief for renal stones?
IM Diclofenac
Where should you give TPN into?
A central vein e.g. subclavian
Mx of rectal tumour?
Anterior resection unless on the anal verge then do an abdomino-perineal resection
Mx of a sigmoid colon tumour?
High anterior resection
Mx of distal transverse or descending colon tumour?
L hemicolectomy
Mx of caecal, ascending or proximal transverse colon tumour?
R hemicolectomy
Mx of sigmoid perforation or bowel obstruction caused by a tumour?
Hartmann’s procedure
Mx of BPH causing urinary frequency/urgency?
Oxybutynin as there is likely to also be an overactive bladder
Mx of severe PAD or critical limb ischaemia?
Is stenosis <10cm or aortic iliac disease = endovascular revascularisation
If stenosis >10cm or lesion of the common femoral artery = femoral artery bypass graft
Which types of shock can cause warm peripheries?
Distributive shock (neurogenic, septic or anaphylactic shock)
What is the most common causative organism in ascending cholangitis?
E.coli
What should you suspect in a patient with diverticulitis Sx and pneumaturia or faecaluria?
Colovesical fistula
What should you offer to those with chronic pancreatitis annually?
HbA1c monitoring
1st line Ix of decreased ABPI?
Duplex USS.
Before any interventions perform MR angiography
How do NSAIDS affect bone healing?
They slow it down
Where is the location of the stenosis in buttock claudication and calve claudication respectively?
Buttock claudication = ileac artery stenosis
Calve claudication = femoral artery stenosis
Mx of free fluid in the abdomen after trauma?
If minimal free fluid and haemodynamically stable = conservative Mx
If severe or haemodynamically unstable = laparotomy
Mx of a varicocoele?
Conservative unless there is pain then Mx with surgery
Mx of bladder carcinoma in situ?
Trans-urethral removal of bladder tumour
Mx of invasive bladder carcinoma?
Radical cystecomy
What is decompression haematuria?
Haematuria which may occur after catheterisation of chronic urinary retention. So long as the pt is stale no management is required
Mx of stress incontinence where pelvic floor exercises fail?
Duloxetine
Mx of local anaesthetic toxicity?
Lipid emulsion
Mx of mastitis?
1st line = continue breast feeding
If there is systemic illness, nipple fissures or Sx are not improving after 12-24 hours of effective milk removal give PO flucloxacillin for 10-14 days
Continue breast feeding whilst on Abx
True or false, ACS can present with abdo pain?
TRUE!
Do ECG if you are suspicious
Which type of testicular cancer has the best prognosis?
Seminomas
What does blockage of the cystic duct cause?
RUQ pain but no jaundice
Umbilical vs paraumbilical hernias?
Umbilical hernias = symmetrical and below the umbilicus
Paraumbilical hernias = asymmetrical, may be above or below the umbilicus
What is an epigastric hernia?
Found between the umbilicus and xiphisternum
True or false, beta blockers can cause ED?
TRUE
What are the stages of haemorrhagic shock?
Stage I = <15% blood loss, is fully compensated for
Stage II = 15-30% blood loss, increased HR
Stage III = 30-40% blood loss, increased HR, low BP and confusion
Stage IV >40% blood loss, increased HR, severely low BP and LOC
What should you consider as the diagnosis in men with urinary problems and a Hx of Gonnorhoea?
Urethral stricture
What does an ABPI indicate?
Vessel calcification, often secondary to DM
How can you assess Hep B with the antibodies?
HBsAg = current infection
HbeAg = marker of infectivity
Anti-HBs = immunity (either a previous exposure or immunisation, is negative in chronic disease)
Anti-HBc = previous or current infection IgM if infection is current or recent (last 6/12), IgG if chronic
What will indicate Hep B immunisation?
Anti-HBs positive, everything else is negative
What will indicate previous Hep B infection?
Anti-HBc positive, HBsAg negative if not a carrier, positive if now a carrier
How do haemangiomas appear on USS?
They are hyperechoic
What is the most common renal tumour?
Renal adenocarcinoma
What is periductal mastitis?
A recurrent breast infection seen in smokers. Mx = co-amoxiclav
What is Mandor’s disease of breast?
Thrombophlebitis of the breast veins
