Surgery Flashcards
What investigations are needed pre breast surgery
Need to determine if axillary lymphadenopathy
- if no lymphadenopathy do USS
- if palpable lymphadenopathy or sentinel node biopsy positive then need to resect
What is problem of axillary lymph node removal
Lymphoedema
Functional arm impairment
What do if USS of axillary lymph nodes negative
Sentinel lymph node biopsy in the operation
What tumour characteristics imply mastectomy over wide local excision
Multifocal tumour
Central location
Large lesion in small breast
DCIS over 4cm
Who is radiotherapy offered to in breast cancer
All woman whove had
- Had wide local excision
- Had T3-T4 mastectomy
Aim to reduce recurrence
What determines the choice of hormonal therapy in breast cancer
Pre or peri menopausal give tamoxifen
Post menopausal give letrozole
First line investigation for testicular cancers
USS
What tumour markers are released by the testicular cancers
Seminomas= HcG- but most often not elevated
Non-seminomas- AFP and HCG
LDH produced by most germ cell tumours and seminomas
Who is eligible for AAA screening
Men get a single abdo USS when they reach 65
Risk is 9:1 compared to women
How does follow-up from AAA screening work
Under 3cm= no action
3-4.4cm (small) = rescan every 12 months
4.5-5.4cm (medium) = rescan every 3 months
5.5cm and higher= refer within 2 weeks to vascular surgery
What makes an aneurysm low vs high rupture risk
Low
- under 5.5cm
- asymptomatic
High
- over 5.4cm
- symptomatic
- enlarging by over 1 cm a year
Management of low risk AAA
Elective vascular review
Rescan based on size
Optimise CVD rfx
Management of high risk AAA
Includes symptomatic and enlarging by 1cm a year
- refer within 2 weeks
- elective endovascular repair
How manage over 45 yo male who is treated for a UTI but the haematuria persists
Refer to urology under 2ww
What are 2 urological 2ww pathways
45 and over with isolated visible haematuria or persistent post UTI haematuria
60 and over with non-visible haematuria along with dysuria or a raised WCC
Risk factors for RCC
Middle aged men
Smoking
Von-hippel lindau
Tuberous sclerosis
APCKD- only slight increase tho
How can RCC present
Classic triad- haematuria, abdo pain and abdo mass
PUO
Varicocele as obstructing veins
Endocrine- EPO causing polycythaemia, ACTH and PTHrp
Cholestasis from stauffer syndrome
Renal vein thrombosis
Management of RCC
Mainstay is surgery
- under 7cm can do partial nephrectomy
- over 7cm total nephrectomy
Immune modulators
- IL-2
- interferon alpha
Biologics
- receptor tyrosine kinase inhibitors- sorafenib
- ipilimumab
- novolimumab
What is ABPI
Ankle brachial pressure index is ratio of systolic blood pressure in the leg to that of arm
What is a normal ABPI
0.9-1.2
What ABPI indicates PAD vs severe disease
0.5-0.8- PAD
<0.5- severe disease
What can cause ABPI>1.2
Calcified, stiff arteries especially in elderly and DM with PAD
What are the types of lower urinary tract symptoms
Obstructive (voiding)
- weak flow
- straining
- hesitancy
- incomplete emptying
Storage
- urgency
- frequency
- incontinence
- nocturia
Post micturition
- dribbling
Complications
- retention
- UTI
- obstructive uropathy
How does tamsulosin and doxazoscin work
Alpha-1-antagonist
Reduces muscle tone of prostate and bladder
Side effects of tamsulosin
Dizziness
Dry mouth
Depression
Postural hypotension
How does finasteride work
5 alpha reductase inhibitors
Blocks conversion of DTH to testosterone which reduces prostate volume
Side effects of finasteride
Erectile dysfunction
Reduced libido
Gynaecomastia
What is management of predominantly voiding symptoms
First line- conservative measures or active monitoring
Second line if IPSS over 8 then alpha blocker
If fails to respond consider referral for surgery or catheter
What do if man has an enlarged prostate and is at high risk of progressing
Finasteride
When are both finasteride and tamsulosin indicated
bothersome moderate-to-severe voiding symptoms and prostatic enlargement
What is critical limb ischaemia
End stage of peripheral vascular disease when symptoms are present at rest. Associated with ulcers and gangrene
What are the 6 Ps
Pulseless
Paralysis
Parasthesia
Perishingly cold
Pain
Pale
What indicates embolus over thrombous as cause of acute limb ischaemia
Sudden onset with no preceding pain
AF or recent MI
Aneurysm proximal to pain
No evidence of contralateral symptoms
Initial acute limb ischaemia management
ABC
IV opioids
IV unfractionated heparin particularly if awaiting intervention (ischaemia takes 6 hours for leg to become unviable)
Vascular review for surgical intervention
First line investigation for suspected prostate cancer
Multiparametric MRI
What is used to determine if do transrectal ultrasound guided biopsy based off multiparametric MRI
Likert scale
If 3 or more then do TRUS
If 1-2 discuss with patient doing one
How to differentiate psychogenic cause from organic in case of erectile dysfunction
Psychogenic will have;
Sudden onset
Decreased libido
Major life events
Good erection by self
Investigation for erectile dysfunction
Measure morning testosterone and assess 10 year cardiovascular risk
If testosterone low or borderline then do full hormone profile
First line for erectile dysfunction
Phosphodiesterase type 5 inhibitor like sildenafil/viagra
What do if sildenafil contraindicated
Use vacuum erection device
What do if present with erectile dysfunction they have always had from puberty
Refer to urology
Breast cancer 2WW referral
Over 30 with unexplained lump
Over 50 with discharge, retraction or any other change in 1 breast
Skin changes indicative of cancer
Lump in axilla if over 30
What is done if predominantly storage problems
Lifestyle bladder training
First drug is oxybutynin
What do if mixed voiding and storage symptoms
Alpha blocker first
Second line add oxybutynin
What is used to manage thrombophlebitis
Consider vasc referral if long saphenous vein or high suspicion of DVT
Mild- topical NSAIDS with warm compresses
Severe- oral NSAIDS
Use compression stockings too to reduce DVT progression (check ABPI)
Consider LMWH too
Investigation for superficial thrombophlebitis
Arrange a duplex USS to rule out DVT
Problems of thrombophlebitis
Can lead to DVT
May indicate underlying DVT
How to investigate acute limb ischaemia
Initially do doppler
Then move onto duplex
Discharge differene between duct ectasia and intraductal papilloma
Duct ectasia= green and thick
Intraductal papilloma= clear or bloody
What does ultrasound of axillary lymph nodes showing snowstorm sign show
Ruptured implant
This is the leakage of silicone which enters lymphatics
What analgesia use for renal stones
NSAIDs
IM if need admission
Imaging for renal stones
Non contrast CTKUB to do within 14 hours
Management of kidney stone under 5mm
Watchful waiting for 4 weeks
Unless renal transplant, obstruction or renal anatomical abnormality
Management if obstructed kidney stone with infection
IV abx
Renal decompression with nephrostomy tube placement
Management of stones under 2cm
Lithotripsy
If pregnant uteroscopy
Management of complex renal calculi including staghorn
Percutaneous nephrolithotomy
What renal tumour is associated with chemicals from the textiles industry
Transitional cell
Management of ruptured abdominal aorta
Immediate vascular review
Control BP (do not want too high)
If haem unstable take straight to surgery for laparotomy
If stable may take to CT to assess if can do endovascular repair
Who should be referred to urology for prostate cancer
50-69
- PSA over 3
- abnormal DRE
Normal PSA range
50-59= under 3
60-69= under 4
Over 70= under 5
What falsely raises PSA
Prostatisis/UTI- wait 4 weeks
Ejaculation in last 2 days
Vigorous exercise in last 2 days
What organisms causes epididymo orchitis
Either local spread of STI
- chlamydia
- gonorrhoea
From bladder
- E coli
Investigations for epididymo orchitis
If young
- assess for UTI
If older
- MSU and urine dip
Management of epididymo orchitis
If young/STI suspected
- refer to GUM who will prescribe Ceftriaxone IM one dose and Doxycycline BD 14 days
If older and E coli suspected
- oral quinolone for 14 days
What do if recurrent balanitis
Circumcision
Management of hydrocele
Do USS to exclude cancer
Conservative approach
Management of varicocele
If mild then conservative
If large and symptomatic can consider surgery
How does fat necrosis present
Fat women with large breasts
Typically follows trauma
Irregular firm lump
Nipple changes seen
Presentation of acute prostatitis
Pain can be back, rectum or abdominal
Fever
Pain on defaecation
Voiding symptoms
Tender boggy prostate on examination
Management of prostatitis
Quinolone 14 days
Management for localised prostate cancer
If not advanved
- Can use watchful waiting
- Radical prostatectomy
- Radiotherapy
If more advanced
- radiotherapy
- prostatectomy
- hormone therapy
Complication of prostatectomy
Erectile dysfunction
Side effects of prostate radiotherapy
Proctitis
Bladder and colon cancer risk increased
What is main option for metastatic prostate cancer
Hormone therapy
Hormone therapy for prostate cancer
Aim is to reduce testosterone
GNRH agonists (goserelin) but this can initially cause flare of tumour
What causes urethral stricture
Idiopathic
Post STI
Penile fractures
Catheters
Management of urethral stricture
Dilation
What is complication post relief of retention
Diuresis which may lead to hypovolaemia, hyponatraemia
What can cause intermittent 10/10 pain in testicules
It is possible to get intermitten torsion which self resolves
Must treat with emergency fixation
Complications of transurethral resection of prostate syndrome
TURP syndrome
Urethral stricture
Retrograde ejaculation
Perforation of prostate
What is in TURP syndrome
Leakage of irrigation fluid (glycine) enters bloods causing a triad of
- hyponatraemia (dilutional)
- fluid overload
- glycine toxicity
If AFP and HCG not raised, what tumour is most likely cause
Seminoma
What is most common cause of testicular lump
Epididymal cyst
What is presentation of epididymal cyst
Separate from body of the testicle
Posterior to testicle
Painless lump
What are the types of urinary retention
Chronic
- low pressure
- high pressure
Acute
What causes acute onset pain in testes with retained cremasteric function
Torsion of testicular appendage
Gold standard investigation for AAA
CT Angio
Investigation if want to intervene on intermittent claudication
MRI angiogram
What is anti-platelet for PAD
Clopidogrel
Given for all patients with evidence of PAD
Medications given for PAD
Everyone is given atorvastatin 80mg and clopidogrel
Management of critical limb ischaemia
Urgent vascular referral
Analgesia
Urgent revascularisation
- endovascular angioplasty
- endarterectomy
- bypass
- amputation
What is management if fixed mottling of leg
Amputation
What is marjolins ulcer
A squamous cell carcinoma which occurs at the site of chronic inflammation such as ulcers
What can be done for severe intermittent claudication
Endovascular revascularisation
- angioplasty
Surgical revascularisaton
- endarterectomy
- bypass with autologous vein
What differentiates between doing endovascular vs open revascularisation on PAD
Endovascular indications
- stenosis under 10cm
- only 1 lesion
- around the iliac area
Surgical indications
- over 10cm
- multifocal lesions
- common femoral and more distally
If pain in buttocks on walking, in what vessel is there stenosis
Iliac
If there is pain in calves which artery is being affected
Superficial femoral
What may cause an ulcer to increase in size
Squamous cell carcinoma
Complications of varicose veins
Bleeding
Thrombophlebitis
Venous ulceration
DVT
What skin changes are seen in varicose veins and venous ulcers
Haemosiderin deposition-> hyperpigmentation
Lipodermatosclerosis-> hard/tight skin
Atrophie blanche-> hypopigmentation
Investigation for varicose veins
Venous duplex USS showing retrograde venous flow
Management of varicose veins
First line
- compressoin stockings
- weight loss
- exercise
- emollient
- elevate legs
If referred
- endothermal ablation
- surgery
- foam sclerotherapy
When refer to secondary care for varicose veins
Significant bothersome symptoms
Previous bleeding from varicose veins
Skin changes suggesting venous insufficiency
Superficial thrombophlebitis
Active or healed venous ulcer
What is cervical rib
When an extra rib can develop from the seventh vertebra
Presentation of subclavian steal syndrome
Come on when using arm
Syncope
Lightheadedness
Neuro symptoms can vary
Arm symptoms like crmaping on use or signs of PAD
What is rib notching on CXR indicative of
Aortic coarctation
Management of PAD
Atorvastatin 80mg
Clopidogrel
Exercise training
Investigation of choice by vascular for PAD
MR angio
In the legs MR angio> CT as vessels are smaller
Presentation of cervical rib
Compression of brachial plexus can lead to neuro symptoms in hand and arm
Worse when arms above head
Sudden onset collapse and cold, painful arm
Axillary artery embolus
What do for someone with terminal unresectable pancreatic cancer causing jaundice
Biliary stenting
What imaging is needed in pancreatitis
USS early to determine if cause is gallstones which will affect maangement
When is a right hemi-colectomy done
Caecal cancer
Ascending colon
Proximal transverse
When is a left hemi-colectomy indicated
Distal transverse colon
Descending colon
What operation is done for a sigmoid cancer
High anterior resection
What operation is done for high and mid rectum cancers
Anterior resection with total mesorectal fat excision
What is an anterior resection
Where remove all of the sigmoid/rectum depending on cancer location
What is a total mesorectal excision
Where remove all of the fat and lymph/blood around the rectum
What operation is done for anal cancer
Abdomino-perineal excision of the rectum with end colostomy bag
What operation is done in low rectal cancers
If within 5cm of of anal verge then APE
What do if HNPCC causing cancer
Panproctocolectomy which removes all of the colon to anus. End ileostomy prementantly created
What operation is done for sigmoid rupture and diverticulitis
Hartmanns
What counts as clear fluids
Water
Black tea or coffee
Ice lollies
Juice without pulp
Triad for gastric volvulus
Non-bilious vomiting
Pain
Failed attempts at getting NG tube in
What is management of fibroadenoma
Leave alone unless over 3cm when surgical excision can be used
What causes pain and swelling of the testis post urological intervention
Epididymo orchitis
When are hartmanns done
Emergency rupture or diverticulitis
What is a hiatus hernia
Herniation of stomach above diaphragm
How are most hiatus hernias found
Incidentally on endoscopy as nature of smyptoms makes them be investigated
What is best test for hiatus hernia
Barium swallow
Management of hiatus hernia
Conservative- all patients weight loss etc
If needed omeprazole or if reallt needed if very sympomatic- laprascopic fundoplication
What is ASA 1
Healthy non-smoking or minimal alcohol
What is ASA 2
Mild diseases without substantive functional limitation
Examples of ASA 2
Current smoker
Controlled DM and HTN
Mild lung disease
What is ASA 3
Patient with severe systemic disease
Examples of ASA 3
Poorly controlled DM, HTN and COPD
Alcohol dependance
Moderate EF reduction
BMI over 40
Active hepatitis
History of stroke or MI over 3 months ago
Renal disease on regular dialysis
What is ASA 4
Patient with severe disease that is constant threat to life
What are examples of ASA 4
Severely reduced EF
Sepsis
DIC
ongoing cardiac ischaemia
Who should be considered for enteral feeding
Patients identified as being malnourished
- BMI under 18.5
- unintentional weight loss over 3-6 months
AT RISK of malnutrition
- havent really eaten in 5 days
- poor absorption
- high nutrient losses
Complications of enteral feeding
Diarrhoea
Aspiration
Hyperglycaemia
Refeeding
What is abdominal wound dehiscence
When the wound opens up and organs poke through
Can either de superficial or deep
Management of abdominal wound dehiscence
Place sterile gauze over it
IV antibiotics
IV fluids
Take to surgery for definitive management
What is a ballotable abdo mass after suspected kidney stones
Hydronephrosis
What causes unilateral hydronephrosis
PACT
Pelvic-ureteric obstruction
Aberrant renal vessels
Calculi
Tumours of renal pelvis
What is imaging of choice for hydronephrosis
USS
Management of acute hydronephrosis
Nephrostomy
Management of chronic hydronephrosis
Ureteric stent
What stoma is created for anterior resection
Loop ileostomy
What feeding method is indicated if oesophagectomy
Feeding jejunostomy
What is best feeding method if head injury
NG tube
When do anastamotic leaks occur most often
5-7 days after the surgery
What is investigation for anastamotic leak
CT
Most common cause of infected surgical wound
S aureus
If TPN is required then where does it go through
Central line as very phlebitic
When are gastrograffin enemas done post bowel surgery
4 weeks
What is investigation for priapism
Cavernosal blood gas to determine if priapism is ischaemic or not
Management of ischaemic priapism
Aspirate blood and flush with saline
Management of non-ischaemic priapism
Observation
Most important daily investigation if post op ileus
U&Es
How often are people screened for breast cancer
Every 3 years between 50 and 70
Done with mammography
What are BMI ranges for ASA
30-40= ASA 2
Over 40= ASA 3
What stones are radiolucent
Xanthine
Urate
Management of femoral hernia
Surgical repair as soon as possible (2 weeks) due to risk of strangulation
How assess patency of a bladder repair
Cystogram- passes radio-opaque dye into bladder and then assess if leakage
If GCS less than 8 what do with regards to imaging
Get neurosurgical review even before scan
What operation can you do in UC to avoid a stoma
Panproctocolectomy and ileoanal pouch
Can only be done in elective capacity though
What operation is done for toxic megacolon in UC
Sub total colectomy as removing rectum too risky
What operation is done in crohns if severe perianal disease (abscesses and fistulae)
Proctectomy
Management of bladder cancer
Low grade or superficial- transurethral resection of the superficial lesion
High grade- cystectomy
What is cause of fever in surgical patient within 24 hours and systemically well
Physiological change
What is main complication of radical prostatectomy
ED
What is kochers scar
Below right costal margin for open cholecystectomy
What is incision for whipples procedure
Rooftop which goes all the way under the costal margin
What is mcevedys incision for
Femoral hernia
How does periductal mastitis present
Redness under the nipple
Lump expressive of pus sometimes
Pain
What is main risk factor for periductal mastitis
Smoking
What is letrozole vs tamoxifen
Tamoxifen= SERM
Letrozole= aromatase inhibitor
Main side effect of aromatase inhibitors
Osteoporosis
NOTE tamoxifen is protective against it
How should surgical wounds be washed post surgery in general
For the first 48 hours= sterile saline
Post 48 hours= shower
Where on operating list should diabetics be
First
What causes bloody breast discharge in a young woman most commonly
Intraductal papilloma
How does local anaesthetic toxicity present
Muscle twitching
Drowsy
Hypotension
Bradycardia
How is lidocaine toxicity treated
Lipid emulsion
Patient after bariatric surgery complains of light headedness and crampy abdo pain
Dumping syndrome
What is dumping syndrome
A complication people get after a gastric bypass caused by food entering intestines too quickly
- get crampy abdo pain
- lightheadedness
- diarrhoea
What is constituent of stones if staghorn calculus
Struvite
Post ERCP, patient has abdo pain and very unwell
Pancreatitis
Who does duct ectasia occur in
Perimenopausal women who are undergoing breast involution
Smokers
Difference in number of ducts duct ectasia and intraductal papilloma occur in
Duct ectasia- multiple
Intraductal papilloma- one
What does halo sign suggest about a breast lesion
Standard rule is that they are benign
- breast cyst most commonly
What does blurred vision after a facial trauma suggest
Depressed fracture of zygoma
What is pilonidal disease
Where sinuses and cysts form in upper natal cleft of buttocks
Who does pilonidal disease occur in
Young men
How manage asymptomatic pilonidal disease
Hygiene measures in that area
How manage acute pilonidal disease
Incision and drainage
How manage recurrent pilonidal disease
Pilonidal cystectomy
What are investigations for varicocele
USS
Semen analysis as infertility assocated
Management of seminoma vs teratoma
Orchidectomy and sperm banking for both
Radiotherapy for seminoma
Chemo for teratoma
When consider manual detorsion for testicular torsion if surgery will be dealyed
If not going to be done within 6 hours
What drugs can be given for kidney stones
Tamsulosin- can help movement of stone
Cyclizine for antiemetic
Diclofenac IM or IV paracetamol
What volume on USS suggets retention
600ml
What is management of acute urinary retention
If clots then 3 way catheter
If not then 2 way foley
Causes of acute urinary retention
Alcohol
Anticholinergics
Constipation
Prostate problems
What is main side effect of tamoxifen
VTE
Post vasectomy what need to do
Measure semen analysis before stop using contraception to determine azoospermia
What is decompression haematuria
Once catheterise someone in retention they can get normal haematuria which just needs monitoring
What is imaging for a breast lesion
Under 40= USS
Over 40= mammogram
What is classical presentation of inflammatory breast cancer
Progressive erythema and oedema of the breast without fever, raised inflammatory markers etc
What is surgical approach for male breast cancer
Mastectomy
What does perinephric and periureteric fat stranding suggest
Calculous
What is a 1cm spherical mass on the testis that transilluminates
Epididymal cyst
Hydrocele would surround whole testis
What management in an old person with lots of comorbidities who has breast cancer
Avoid surgery obviously
Avoid radiotherapy too as risk of causing lung disease
Immunotherapy main one to use
What do if patient on warfarin is about to undergo emergency surgery
If immediate
- four-factor prothrombin complex
If 6-8 hours
- IV vitamin K
What is leriche syndrome
Where atherosclerosis in distal aorta or proximal iliac
Presents with
- erectile dysfunction
- absent femoral pulses
- claudication in buttocks and thighs
Why is chemo given before breast surgery
To downstage tumour allowing for breast conserving surgery
Can you give IM diclofenac if history of peptic ulcer disease
No- still can affect stomach
What can raise amylase other than pancreatitis
SBO
Upper GI bleed
Mesenteric ischaemia
What does tenderness in right side of abdomen on DRE suggest
Appendicitis
What does a boggy sensation on DRE suggest with RIF pain suggest
Pelvic abscess
How to diagnose appendicitis
Neutrophil predominant leukocytosis on FBC
Can diagnose clinically in young thin males
If female do USS first to rule out gynae pathology
NO DEFINITIVE IMAGING RULES
If USS negative consider CT
What is rosvings sign
Palpate LIF get pain in RIF if appendicitis
What is psoas sign
Pain on extending hip if retrocaecal appendix
What does spouted stoma mean
That it is raised away from skin
Seen in ileostomies to avoid skin irritation from acidic faeces at this point
Differentiating between ileostomies and colostomies
Ileostomy- will be raised away from skin to avoid irritation from faeces which still acidic
What does adjuvant mean
Applied after initial treatment for cancer
When is hormonal treatment for breast cancer given
Adjuvant for 5 years
If after breast surgery a woman wants to prevent recurrence but does not want to do treatment for a long time what do
Radiotherapy
What are adjuvant breast surgery options
Radiotherapy
Hormonal treatment
What does a very large post void volume suggest
Acute on chronic retention
What on ECG is most worrying for hyperkalaemia
Sinusoidal or sine wave appearance as indicates K+ over 9
Which nerve likely to get injured in carotid endarterectomy
Hypoglossal
In axillary node clearance what nerve could be injured
Long thoracic
How minimise adhesions post operative
Use laparoscopic approach
Operations where X match 2-6 units
Total gastrectomy
Oophorectomy
Oesophagectomy
Elective AAA repair
Cystectomy
Hepatectomy
When only do G&S pre op
Elective C section
Appendicectomy
Laparoscopic cholecystectomy
Thyroidectomy
When only X match 2 units
Hip replacement
What are the 3 pre-emptive preoperative options for managing blood transfusions
G&S
X match 2 units
X match 6 units
If get breast pain related to menses but no lumpiness what is this called
Cyclical mastalgia
Management of cyclical mastalgia
Supportive bra
Simple analgesia
What are 3 parts to the WHO surgical safety checklist
Sign in- pre anaesthesia
Time out- pre first cut
Sign out- before patient leaves room
LP findings in SAH
Normal or raised opening pressure
Bilirubin/xanthochromia
Why give nimodipine for SAH
Prevent vasospasm
How can differentiate arterial from neuropathic ulcer in a diabetic patient
Pain in arterial
How differentiate between a loop and end colostomy on examination
Loop colostomies have 2 openings
What do for low grade prostate cancers for elderly man with comorbidities
Watchful waiting
Where can PAD affect
Buttocks
Quads
Calves
Difference between intermittent claudication and critical limb ischaemia
Symptoms of ischaemia present at rest vs on exertion
Get gangrene, ulcers etc in critical limb ischaemia
Definition of gangrene
Necrosis due to ischaemia
What muscle groups can intermittent cluadication affect
Buttocks
Quads
Calves
What use to asess ABPI
Doppler not sphygmo whatever
Management of intermittent claudication
DONE IN PRIMARY CARE
Clopidogrel and atorvostatin
Maximise CVD rfx
Exercise programme
Re assess in 3 months after exercise programme
- if symptoms not improved refer to vascular for potential surgical intervention
- if declines surgery give naftidrofuryl oxalate
When refer intermittent claudication to secondary care
If exercise programme and CVD rfx been enforced for over 3 months but STILL no improvement in sx
If decline surgical referral for intermittent claudication what do
Give naftidrofuryl oxalate
What causes stiff vessels
Vasculitis
Elderly
DM
RA
MOA of naftidrofuryl oxalate
5-HT2 antagonist which vasodilates peripheral tissues
What use if clopidogrel CI for PAD
Aspirin
Definitive options for acute limb ischaemia after initial management
Endovascular thrombolysis or thrombectomy
Open thrombectomy
Bypass
Amputation
Causes of arterial emboli
Mural thrombous post MI
AF
Aneurysm- abdominal aorta eg
Management options for ruptured abdominal aortic aneurysm
Endovascular repair via femoral artery if stable or history of CVD
Laparotomy especially when unstable
Palliative care to be discussed depending on patients status and comorbidities
Features of arterial ulcers
Occur on the toes and heel
Typically have a ‘deep, punched-out’ appearance
Painful
There may be areas of gangrene
Cold with no palpable pulses
Low ABPI measurements
Important complication of neuropathic ulcers
Osteomyelitis
Management of arterial ulcers
Urgent vascular referral for revascularisation
Do not debride
Assessments of all ulcers
Bedside- examination, ABPI, doppler
Bloods- assess CVD rfx- lipids and HbA1c
Management of venous ulceration
Measure ABPI to ensure can use compressoin therapy
Clean then compression therapy
Can consider adding pentoxifylline alongside which helps healing
Consider referral to tissue viability nurses for wound cleaning etc
What can be given alongside compression bandaging for venous ulcers
Pentoxifylline to help ulcer healing
Features of venous ulcers
In gaiter area
Rolled edges
Bleed easily
Haemosederin deposition
Lipodermatosclerosis
Atrophie blanche (hypopigmentation)
Wine bottle deformity of calf
First line for varicose veins
Unless require referral to secondary care
- compression stockings
- elevate legs
- exercise
- emollients
- weight loss
Other name for buergers disease
Thromboangiitis obliterans
Presentation of thromboangiitis obliterans
Young male
SMOKER
Painful raynauds/blue discolouration of thumbs/toes
Leads to gangrene and ulcers
Treatment of buergers/thromboangiitis
Stop smoking completely- usually very curative
Can use IV iloprost
Investigation for buergers
Angiography will show corkscrew collateral vessels and narrowing of vessels
Management of fibrocystic changes
Recommend supportive bra
NSAID analgesia
Breast cyst presentation
Soft lump
Can move
Painful
Management of single breast cyst
Refer for full assessment
Aspiration to exclude cancer
To alleviate symptoms can aspirate or excise
Galactocele presentation
Women who just stopped breastfeeding
Lump under areolar
Management principles of benign breast lumps
Exclude cancer
Typically conservative but if growing or smyptomatic then can remove
Investigations for fat necrosis
Can mimic breast cancer on imaging so need biopsy to confirm benign
Management of phyllodes tumour
Remove
Causes of lactational mastitis
Staph aureus most commonly
ALSO just from blockageof ducts
Lactational mastitis management
Keep breastfeeding and analgesia
If persists over 24 hours add fluclox or erythromycin
What do with breastfeeding if abscess
Continue feeding
Duct ectasia presentation
Smoker
Perimenopausal
Green discharge
Pain
Lump
Management of duct ectasia
Conservative- supportive bra and analgesia
If very problematic do excision
Management of ductal papilloma
Excision and histology analysis
Intraductal papilloma presentation
Bloody discharge
Lump
Pain
If someone is identified as being high risk for breast cancer what can be done for them
Genetic testing
Annual mammograms
Management of lymphoedema from axillary node removal
Massage and exercises to drain the lymphatic system
Compression bandages
Weight loss if overweight
Best imaging for viewing breast cancers
MRI
What do if USS identifies lymph nodes in breast cancer assessment
USS guided biopsy
What can genetic profilling be used for in breast cancer
In women who are young, ER positive can be used to predict mortality
What is a hartmanns procedure
Proctosigmoidectomy where remove portion of bowel then create colostomy leaving recto-anal stump which is “hartmanns pouch”
What operation can be done for UC
Pan proctocolectomy with either end ileostomy or ileoanal pouch
What is a j pouch
Ileo-anal pouch which means ileum acts as a rectum
Done electively for UC after panproctocolectomy
If vomiting and in pain but can’t get NG tube in, what is cause
Gastric volvulus
Abdo XR coffee bean sign
Sigmoid volvulus
Best imaging for volvulus
CT
Who does sigmoid vs caecal volvulus occur in
Sigmoid= old and common
Caecal= young and rare
When stop warfarin before surgery
5 days
When start warfarin again post surgery
That evening or day after if haemodynamically stable
If on warfarin, what is acceptable INR to operate
Less than 1.5
Under what circumstances would you not leave a renal stones under 5mm alone
Transplant
Obstruction
Anatomical abnormality
Investigation for RCC
Contrast CT
RCC paraneoplastic syndromes
Stauffer syndrome
Polycythaemia form EPO
ACTH
PTHrp
What is an IV urogram
X ray with IV contrast in the renal tract
Typical bladder cancer presentation
Painless haematuria
Investigation for bladder cancer
Cystoscopy
Rfx for bladder cancer
Transitional cell (95%)- dyes from textiles, smoking
Squamous cell (rare)- schistosomiasis
Urge incontinence management
1st- 6 weeks bladder training
2nd- anticholinergic like oxybutynin or tolterodine
3rd- mirabregon or 2nd if elderly and frail
Stress incontinence in women
1st- pelvic floor training
2nd- surgical
3rd- duloxetine
Physiological cause of urge incontinence
Overactive bladder from detrusor activity- parasympathetic overactivity
What is included in the conservative measures offered first line for voiding symptoms
Pelvic muscle training
Fluid intake advice
What is indicated if mixed urge and voiding symptoms
Tamsulosin and oxybutynin
Most likely organism for prostatitis
E coli
Non primary care treatment options for BPH
Catheterisation
TURP
What do if voiding symptoms fail to respond to medical treatment
Urology referral for consideration of TURP or catheterisation
What is gold standard investigation for prostate cancer
Transrectal ultrasound guided prostate biopsy showing adenocarcinoma
Staging and grading prostate cancer
Staging- TMN
Grading- gleason
How investigate for bony metastases
Isotope bone scan with technetium bisphosphonate
Causes of erectile dysfunction
Hormonal
- hypogonadism- chemo, mumps, STI, iron, torsion
- prolactin
- thyroid
Vascular- leriche, DM
Psychological
Drugs- SSRIs, steroids, finasteride, goserelin
Post TRUS, prostatectomy
Types of testicular cancer
Seminomas
Non-seminomas
- germ cell- choriocarcinoma, teratoma, yolk sac
- non-germ cell- leydig, sertoli
What type of testicular tumour produces LDH
Germ cell and sometimes seminoma
Which testicular tumour causes gynaecomastia
Leydig cell
Most common testicular cancer
Seminoma
Chronic prostatitis presntation
Symptoms present for over 3 months
- pain in prostate
- painful defaecation
- LUTS
- erectile dysfunction
What is used if unable to insert foley catheter for lower urinary obstruction
Use coude catheter which has more rigid end
Main side effects of tamsulosin
Postural drop- dizziness etc
Dry mout and eyes
What determines whether failed TWOC
Post residual volume
Oesophageal cancer management
Surgery ideally
If metastasised then palliative and stent
Chronic prostatitis management
NSAIDS
Laxatives
4-6 weeks of doxycycline
If have cystectomy what is made for long term urination
Urostomy or ileal conduit
Section of bowel removed and a pouch made of it to collect urine from ureters
After transurethral resection of bladder cancer what is given
Intra vesical BCG for 6 weeks
What suggests renal cancer as cause of varicocele
When lie supine it does not drain
What do if varicocele does not drain when lie supine
USS of KUB as indicates RCC
Dysphagia with weight loss differentials
Carcinoma
Achalasia but over longer period and not as much
If have constipation secondary to opiates what use
Senna- stimulant laxative
If undergoing bariatric surgery what investigation is important to be done
Digital subtraction arteriography which show if good collaterals off distal arteries
What do if woman presents with sudden onset facial hair
Urgent endocrine referral to rule out cancer
What do for woman who presents with testosterone really high
Urgent endocrine referral to rule out cancer
Age distribution of testicular cancer
20-35: teratoma
35-45: seminoma
Over 60: lymphoma
Staging investigation for testicular cancer
CT CAP
What is use of tumour markers in testicular cancer
Follow up for recurrence
What stoma is formed for hartmanns
End colostomy
Although it can be reversed it is not a loop stoma as the rectal pouch is sewn up
