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Y4 Medicine > Surgery > Flashcards

Surgery Flashcards

1
Q

Clinical features of Appendicitis

A

Abdo pain - initially central then RIF (<24hrs)
McBurney’s point tenderness
Rosving’s sign = LIF palpation causes RIF pain
PR exam causes pain in RIF
Rebound tenderness/percussion tenderness
Anorexia, N&V, Pyrexia

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2
Q

Diagnostic criteria for Appendicitis

A

Largely a clinical diagnosis (based on Sx + Raised CRP/ESR).

Consider a USS to rule out gynaecologist pathology or CT scan to rule out other differentials.
if symptoms are present but inflammatory markers are normal = diagnostic laparotomy.

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3
Q

Management of Appendicitis

A

Urgent admission + surgical referall
Give prophylactic IV antibiotics + appendectomy

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4
Q

Causes of bowel obstruction

A

Small bowel adhesions (following surgery, endometriosis etc)
Hernia
Malignancy
Volvulus
Diverticular disease
Strictures (crohns)
Intususspetion

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5
Q

At what age does intususseption usually present?

A

6 months - 2 years

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6
Q

Investigations for suspected bowel obstruction

A

Abdo Xray - this shows a distended bowel (>3cm small bowel, >6cm colon, >9cm rectum)
Confirmation of diagnosis = CT contrast

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7
Q

What ABG findings are common in bowel obstruction

A

Metabolic alkalosis (due to vomitting) + Raised lactate (due to bowel ischemia) + Hypokalemia

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8
Q

What investigation should be used to rule out bowel perforation

A

Erect CXR

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9
Q

Management of a bowel obstruction

A
  1. A-E assessment + stabilisation. Think Drip + Suck: Keep patient NBM. Give IV fluids + added K+ if hypokalemic. NG tube with free drainage.
    Consider emergency resection / exploratory surgery if patient is unstable
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10
Q

What medication should be avoided in bowel obstruction

A

Senna
Metaclopramide

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11
Q

Clinical Features of bowel obstruction

A

Green, bilious vomitting
Abdo pain + distension
Absolute constipation + absence of flatulence
Tinkling bowel sounds (in early obstruction) or absent bowel sounds (in late obstruction/ileus)

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12
Q

What classic sign is seen on Abdo Xray in a volvulus

A

Coffee bean sign (loss of haustra)

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13
Q

Femoral hernia description

A

Location = Below + Lateral to pubic tubercle. Through femoral ring into femoral canal
High risk of strangulation

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14
Q

Indirect inguinal hernia

A

Bowel herniates through deep inguinal ring into inguinal canal

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15
Q

Direct inguinal hernia

A

Bowel herniates through hesslebach’s triangle into inguinal canal

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16
Q

How to differentiate between indirect + direct inguinal hernias

A

Reduce the hernia and apply pressure to the deep inguinal ring (midpoint from ASIS to pubic tubercle). An indirect hernia will remain reduced whereas direct will not.
(think - because the indirect one gets pushed back up above the deep inguinal ring so won’t come back down)

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17
Q

Clinical Features of diverticular disease

A

Lower left abdominal pain
Constipation
Rectal bleeding
May have fever + systemic upset + palpable abdominal mass (particularly in an abscess has formed)

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18
Q

Management of chronic Diverticular disease

A

High fibre diet + good hydration
Bulk forming laxatives (e.g isphagula hulk)
Avoid stimulant laxatives - Senna
Surgical resection if severe

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19
Q

Management of acute diverticulitis

A

Uncomplicated = Amoxicillin 5 days + Liquid diet
Severe (or Sx for >72hrs) = Hospital admission for IV Ceftriaxone + Metronidazole

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20
Q

Classification of haemorrhoids

A

1st degree = no prolapse
2nd degree = prolapse when straining + return on relaxing
3rd degree = prolapse when straining, do not return on relaxing but can be pushed back in
4th degree = permanently prolapsed

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21
Q

Anatomical location of haemorrhoids

A

Mainly at 3, 7 and 11 o’clock.

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22
Q

Anal Fissue anatomical loation

A

Usually in the posterior midline (6 or 12 oclock)

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23
Q

Management of anal fissures

A

Soften stools with bulk forming laxatives
Topical LA
Chronic fissures = Topical GTN and surgery if not responsive in 8 weeks.

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24
Q

Gold standard investigation for peri-anal abscess

A

Trans-perineal USS

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25
Q

Kochers abdominal scar

A

Right subcostal margin
Purpose = Cholecystectomy

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26
Q

Lanz abdominal scar

A

RIF
Purpose = Appendicectomy

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27
Q

Rutherford Morrison scar

A

Renal transplant

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28
Q

Post-splenectomy prophylaxis

A

Vaccinations - needed 2 weeks before splenectomy - Hib + Men ACWY + Annual influenza + Pneumococcal 5yrly.
Penecillin V for at least 2 years
Aspirin

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29
Q

UK breast cancer screening programme

A

Mammogram offered every 3 years to women aged 50-70 (+/-3yrs) based on GP lists.
High risk patients get annual mammograms (age 40-49 if mod risk, 40-59 if high risk, 40-69 if BRCA +ve)

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30
Q

Types of breast cancer

A

Ductal (invasive or in-situ)
Lobular (invasive or in-situ)

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31
Q

Paget’s disease of the nipple

A

Eczemoid changes to the nipple secondary to breast cancer (usually invasive carcinoma)
Invx = punch biopsy

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32
Q

BRCA1

A

Mutation on chromosome 14
70% of pts develop breast cancer & 50% develop ovarian cancer. Also increased risk of bowel and prostate cancer

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33
Q

BRCA2

A

Mutation on chrosome 13
60% develop breast cancer & 20% ovarian cancer

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34
Q

2ww referall criteria for suspected breast cancer

A

Age >30 with unexplained breast lump, lump in axilla or skin changes suggestive of BC
Age >50 with unilateral nipple changes

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35
Q

Routine referall for suspected breast cancer

A

Unexplained lump in pt <30yrs.

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36
Q

Breast cancer tumor marker

A

Ca15-3

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37
Q

Indications for wide local excision of breast cancer

A

Solitary lesion
Peripheral location
Tumor <4cm in size
Large breast
DCIS <4cm

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38
Q

Indications for mastectomy in breast cancer

A

Multifocal tumor
Central tumor
Large lesion
Small breast
DCIS >4cm

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39
Q

Indications for whole breast uniltateral radiotherapy in breast cancer

A

After wide local excision
After mastectomy for stage T3/4 tumor

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40
Q

Treatment of ER +Ve breast cancer

A

Premenopausal = Tamoxifen
Postmenopausal = Anastrazole/lenestrazole

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41
Q

Side effects of tamoxifen

A

Endometrial cancer
VTE
Menopausal symptoms
Weight gain
Discharge

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42
Q

Side effects of Anastrazole

A

Hot flushes
Vaginal dryness
Bone pain
Skin rash
Hair thinning

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43
Q

indiction for biological therapy in BC

A

HER2 +ve cancer.
Trastuzumab - contraindicated in heart disorders

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44
Q

Scoring system for prognosis of breast cancer

A

Nottingham prognostic index
Tumor size x 0.2 + Lymph node score + Grade score

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45
Q

Fibroadenomas

A

Benign tumor of a whole lobule from stromal/epithelial cells .

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46
Q

Non tender mobile firm breast lumps typically in 15-30yr olds.

A

Fibroadenoma

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47
Q

Management of Fibroadenoma

A

If <3cm then watch & wait
If > 3cm = surgical excision

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48
Q

Lumpy breast + Cyclical breast pain in middle aged women

A

Fibroadenosis

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49
Q

Classic presentation/findings of a breast cyst

A

Smooth, discrete lump which may fluctuate with menstruation.
Mammogram shows ‘halo’ sign

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50
Q

Irregular firm fixed lump following trauma to the breast

A

Fat necrosis

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51
Q

Most common cause of nipple discharge (+/- blood) in 20-40yr olds

A

Intraductal papilloma

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52
Q

Mammary duct ectasia

A

Dilation of large breast ducts
Sx = thick green nipple discharge. May have tender lump around the areola.

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53
Q

Periductal mastitis

A

Mammary duct ectasia + infection
Smoking is a risk factor
Management = Antibiotics + drainage

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54
Q

Management of mastitis

A

Continue breast feeding
+ Flucoxacillin 10-14 days if systemically unwell or if symptoms don’t improve <24hrs.

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55
Q

Management of breast abscess

A

Antibiotics + USS guided incision/drainage

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56
Q

Abdominal aortic aneurysm

A

Diameter >3cm

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57
Q

AAA Screening in UK

A

Men aged 65yrs get a single abdominal USS
If <3cm = no further action
3 - 4.4 cm = Rescan annually
4.5 - 5.4cm = Rescan every 3 months
>5.5cm or if symptomatic / growing by >1cm per year = 2ww referal to vascular surgery

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58
Q

Treatment of AAA

A

Endovascular repair
If haemodynamically unstable = open repair

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59
Q

Clinical Presentation of Ruptured AAA

A

Severe central abdo pain radiating to the back
Pulsatile expansile mass in the abdomen
Cardiovascular shock

60
Q

Aching/burning sensation in the legs precipitated by walking. Symptoms relieved by rest.

A

Intermittent claudication

61
Q

ABPI 0.6-0.9

A

Intermittent claudication

62
Q

ABPI 0.3 - 0.6

A

Critical limb ischemia

63
Q

ABPI >1.2

A

Calcified / Stiffened arteries (think diabetes)

64
Q

Pain in foot at rest for > 2 weeks + Ulceration + Gangrene. Pt sleeps with legs hanging out of the bed

A

Critical limb ischemia

65
Q

Features of Acute limb threatening ischemia

A

Pale
Pulseless
Painfull
Paralysed
Paraesthetic
Perishingly cold

ABPI <0.3

66
Q

Management of intermittent claudication

A

Lifestyle measures
Supervised exercise programme
Preventative meds = Statin + Clopidogrel

67
Q

Management of critical limb ischemia

A

Endovascular revascularisation with angioplasty/stenting
OR
Surgical bypass with vein graft if: Long segment lesion / lesion of femoral artery / infra-popliteal disease
OR
Amputation if unfit

68
Q

Management of acute limb threatening ischemia

A

Analgesia (IV opioids)
IV heparin
Immediate vascular review
for thrombolysis/surgery/amputation

69
Q

Rutherford classification

A

Scoring system to determine if an ischemic limb is viable or not
1 = viable.
4 = Irreversible. Profound sensory loss + inaudible pulses

70
Q

Arterial ulcer description

A

Deep punched out lesion. Pale/Necrotic wound. Located on pressure points.
Surrounding tissue = cold shiny + pale with absent hair, no palpable pulses + prolonged CRT

71
Q

Shallow, irregular ulcer with granulation, exudative material + brown pigmentation. Located on the gaiter area

A

Venous ulcer

72
Q

Deep punched out necrotic lesion on plantar surface of hallux

A

Neuropathic ulcer

73
Q

Great saphenous vein vs Small saphenous vein

A

Both are superficial leg veins
Great saphenous = Medial
Small saphenous = Posterior

74
Q

Indicators of venous insufficiency

A

C1: Reticular veins

75
Q

Indicators of venous insufficiency

A

C1: Reticular veins
C2: Varicose veins
C3: Oedema
C4: Haemosiderin pigmentation
C5: Active venous ucer

76
Q

Management of Varicose veins

A

Conservative = leg elevation + weight loss + exercise + graduated compression stockings
Invasive Tx = Endothermal ablation / Foam sclerotherapy
Surgery = Ligation / Stripping

77
Q

Burgers disease

A

Small vessel vasculitis
RF = Smoking
Extremity ischmia + superficial thrombophlebitis + raynauds
(typically young male who smokes with extremity ischemia)

78
Q

Causes of Upper urinary tract obstruction

A

Stones
Tumours
Strictures
Bladder tumor
Ureterocoele

79
Q

Causes of lower urinary tract obstruction

A

BPH
Prostate tumour
Bladder neck cancer
Urethra strictures
Neurogenic bladder

80
Q

Symptoms of obstructive uropathy

A

Upper = Loin - Groin pain + Oliguria / Anuria
Lower = LUTS + Suprapubic pain + Palpable bladder
Impaired renal function tests

81
Q

Management of obstructive uropathy

A

Upper = Nephrostomy
Lower = Urethral/suprapubic catheter

82
Q

Complications of obstructive uropathy

A

Post renal AKI
CKD
Infection
Retention
Overflow incontinence
Hydronephrosis

83
Q

Acute urinary retention

A

Sudden onset of inability to urinate
RF = Male + age >60yrs

Causes = BPH / Urethral obstruction / Medications / Neurological disease / Post-op

84
Q

Which medications are most likely to cause acute urinary retention

A

Anticholingergics
TCAs
Antihistamines
Opioids
Benzodiazepines

85
Q

Classification of haemorrhoids

A

1st degree = no prolapse
2nd degree = prolapse when straining + returning on relaxing
3rd degree = prolapse when straining, do not return on relaxing
4th degree = permanently prolapsed

86
Q

Types of Chronic urinary retention

A
  1. High pressure = Impaired renal function + bilateral hydronephrosis.
  2. Low pressure = Normal renal function + no hydronephrosis
87
Q

Clinical Presentation of Renal cell carcinoma

A

Haematuria
Flank pain
Palpable mass

88
Q

Types of renal cell carcinoma

A

Clear cell - 80%.
Papillary
Chromophobe

89
Q

Wilm’s tumour

A

Tumor affecting the kidney in children, typically age <5years

90
Q

Risk factors for renal cell carcinoma

A

Smoking
Obesity
HTN
ESRF
Von Hippel-Lindau Disease
Tuberous sclerosis

91
Q

Where does Renal cell carcinoma tend to spread?

A

Locally - to gerota’s fascia, adrenals, spleen or colon
Renal vein (causing L sided varicocele) then IVC
Cannonball metastases = mets in lung fields.

92
Q

Paraneoplastic features of RCC

A

Polycythemia - due to secretion of EPO
Hypercalcemia
Hypertension
Stauffer’s syndrome = abnormal LFTs without liver mets

93
Q

1st line investigation for renal cell carcinoma

A

CT TAP

94
Q

Management of Renal cell carcinoma

A

1st line = Nephrectomy
- Partial if <7cm
- Total if >7cm

2nd line = Arterial embolisation / Percutaneous cryotherapy / Radiofrequency ablation / Chemo + Radiotherapy (sunitinib)

95
Q

Common sites of obstruction in renal stones

A

Pelvic-ureteric junction
Pelvic brim
Vesico-ureteric junction

96
Q

Most common renal stone

A

Calcium oxalate stone
= opaque on radiograph.

97
Q

Which renal stone is commonly formed due to Alkaline urine

A

Struvite stones - these appear like opaque staghorn caniculi.

98
Q

1st line investigation for renal stones

A

CT KUB

99
Q

Management of renal stones

A

IM Diclofenac +/- Abx if infection present
Stone <5mm will pass
Stone <2cm = lithotripsy
Stone <2cm + pregnant = uretoscopy + stents
Complex / staghorn caniculi = percutaneous nephrolithiotomy

100
Q

Prevention of Oxalate stones

A

Reduce urinary oxalate secretion using cholestyramine / pyroxidine

101
Q

Prevention of Uric acid stones

A

Allopurinol & urinary alkalisation (e.g bicarbonate)

102
Q

Risk factors for Transitional cell bladder cancer

A

Smoking
Exposure to aniline dyes / aromatic amines (textile industry / rubber manufacture)
Cyclophosphamide
Thiazolidinediones (PPAR-gamma agonsits)

103
Q

Risk factors for squamous cell bladder cancer

A

Schistosomiasis
Smoking
Thiozolidinediones

104
Q

Clinical Presentation of bladder cancer

A

Painless microscopic haematuria

105
Q

2ww referral criteria for bladder cancer

A

Age >45yrs + unexplained visible haematuria
Age >60 + microscopic haematuria + Dysuria/raised WCC

106
Q

Investigation for bladder cancer

A

Cystoscopy +/- biopsy

107
Q

Management options for bladder cancer

A
  1. TUBT - transurethral resection of bladder cancer
    + Adjuvant intravesical chemotherapy
  2. Radical cystectomy - for stages T2 +
108
Q

What is the occupational risk factor for bladder cancer

A

Textile/printing industry (due to aline dyes) or Rubber manufacture / rubber factories

109
Q

Management of Lower urinary tract infection

A

Simple UTI = 3 days Nitrofuantoin/trimethorpim
Men = 7 days (if recurrent refer to urology)
Pregnant ladies = Nitrofuantoin/amoxicillin 7 days even if asymptomatic

110
Q

Management of UTI in children

A

Age <3 months = refer to paediatrics
Age > 3 months + Upper UTI = Consider admission + Oral cefaclor/ceftriazone/co-amox for 10 days
Age > 3 months + lower UTI = Abx for 3 days

111
Q

Management of pyelonephritis

A

Cephalosporin (e.g cefaclor/ceftriaxone) or Quinolone (e.g amoxicilln) for 10-14 days

112
Q

Interstitial cystitis

A

chronic inflammation of the bladder leading to a chronic lower UTI (> 6 weeks) + suprapubic pain

113
Q

Cystoscopy findings with interstitial cystitis

A

Hunner lesions /Granulation

114
Q

Symptoms of BPH

A

Voiding - Weak stream / intermittent stream / straining / hesitancy / terminal dribling / incomplete emptying
Storage - urgency / frequency / urge incontinence / nocturia

115
Q

What should the prostate feel like on examination

A

Smooth, symettrical + slightly soft with preservation of the central sulcus

116
Q

Management of BPH

A

1st line = Tamsulosin
2nd line = Finasteride - indicated if significantly enlarged prostate with high risk of progression

117
Q

MOA & Side effects of Tamsulosin

A

Moa = Alpha-1 antagonist. It decreases smooth muscle tone of the prostate/bladder
SEs = Postural hypotension / Drowsiness / Dyspnoea / Cough

*Caution in patients undergoing cataract surgery due to risk of floppy iris syndrome

118
Q

MOA & Side effects of Finasteride

A

MOA = 5 alpha reductase inhibitor (essentially stops the conversion of testosterone into dihydrotestosterone which prevents prostatic growth)
SEs = Impotence / Decreased libido / Ejaculation disorders / Gynaecomastia

119
Q

Symptomatic relief for BPH

A

Tolterodine (anti-muscarinic) - if overactive bladder

120
Q

Complications of Transurethral resection of the prostate

A

TURP syndrome = hyponatremia + hyperammonia (CNS disturbance). Caused by absorption of irrigation fluid during surgery
Urethral strictures
Retrogade ejaculation
Perforation

121
Q

Histology of Prostate cancer

A

95% are adenocarcinomas located in the peripheral zone of the prostate

122
Q

What does prostate cancer feel like?

A

Hard, craggy, irregular prostate with a loss of the central sulcus

123
Q

Causes of false +ve BPH

A

Prostatitis
UTI
BPH
Vigorous DRE

124
Q

1st line investigation for prostate cancer

A

Multiparametric MRI

125
Q

Staging system for prostate cancer

A

Gleason score

126
Q

Management of Prostate cancer

A

Low risk = active surveillence (regular core biopsies)
High risk = External radiotherapy, Brachytherapy, Surgery, Hormonal therapies

127
Q

Indications for radical prostatectomy

A

Localised disease

128
Q

Hormonal therapy options for prostate cancer

A

GnRH agonists e.g gosrelin (initially causes a 2-3week rise in testosterone so symptoms may worsen at first)
Non-steroidal anti-androgens: Bicalutamide
Androgen synthesis inhibitor: Abiraterone

129
Q

Chemotherapy agent used in prostate cancer

A

Docetaxel

130
Q

What does prostatitis feel like

A

Tender, enlarged + boggy prostate

131
Q

Management of prostatitis

A

Acute = Oral Ciprofloxacin/Trimethoprim for 2-4 weeks
Chronic = Tamsulosin + Abx

132
Q

Causes of Epididymo-orchitis

A

E.coli
Chlamydia / Gonorrhoea
Mumps

133
Q

Clinical Presentation of epididymo-orchitis

A

Unilateral testicle pain + dragging sensation.
Swelling + tenderness
Pain relieved by testicular elevation
May have urethral discharge if STI present

134
Q

Management of epididymo-orchitis

A

Unknown organism = IM Ceftriazone + Doxycycline for 10-14days
Low risk of STI = Ofloxacin 14 days
High risk of STI = refer to GUM

135
Q

Risk Factors of Testicular torsion

A

Bell clapper deformity
Teenage boy

136
Q

USS findings in testicular torsion

A

Whirlpool sign

137
Q

Management of Testicular torsion

A

Bilateral orchiplexy
Orchidectomy if nectrotic

138
Q

Painless soft scrotal swelling which can be transilluminated

A

Hydrocoele

139
Q

What can a left sided varicocele indicate?

A

Renal cell carcinoma

140
Q

Scrotal swelling with throbbing pain which is worse on standing. Scrotal mass feels like a bag of worms and dissapears when lying down

A

Varicocoele

141
Q

What is concerning about a varicocoele that does not dissapear on lying down

A

May indicate a retroperitoneal tumour or Renal cell carcinoma

142
Q

Types of Testicular cancer

A

Seminomas
Non-seminomas e.g teratomas

143
Q

Clinical presentation of testicular cancer

A

Painless, non-tender lump on testes
Hard + irregular + non-fluctuant
No translumination
May have gynaecomastic (may indicate a leydig cell tumor)

144
Q

Tumor markers in Testicular cancer

A

Beta-hcg (raised in both types)
Alpha fetoprotein = non-seminomas
LDH = germ cell tumours

145
Q

Testicular cancer staging system

A

Royal marsden criteria

Y4 Medicine (22 decks)

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