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Finals > Surgery > Flashcards

Surgery Flashcards

1
Q

What investigations are needed pre breast surgery

A

Need to determine if axillary lymphadenopathy
- if no lymphadenopathy do USS
- if palpable lymphadenopathy or sentinel node biopsy positive then need to resect

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2
Q

What is problem of axillary lymph node removal

A

Lymphoedema
Functional arm impairment

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3
Q

What do if USS of axillary lymph nodes negative

A

Sentinel lymph node biopsy in the operation

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4
Q

What tumour characteristics imply mastectomy over wide local excision

A

Multifocal tumour
Central location
Large lesion in small breast
DCIS over 4cm

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5
Q

Who is radiotherapy offered to in breast cancer

A

All woman whove had
- Had wide local excision
- Had T3-T4 mastectomy
Aim to reduce recurrence

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6
Q

What determines the choice of hormonal therapy in breast cancer

A

Pre or peri menopausal give tamoxifen
Post menopausal give letrozole

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7
Q

First line investigation for testicular cancers

A

USS

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8
Q

What tumour markers are released by the testicular cancers

A

Seminomas= HcG- but most often not elevated
Non-seminomas- AFP and HCG
LDH produced by most germ cell tumours and seminomas

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9
Q

Who is eligible for AAA screening

A

Men get a single abdo USS when they reach 65
Risk is 9:1 compared to women

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10
Q

How does follow-up from AAA screening work

A

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

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11
Q

What makes an aneurysm low vs high rupture risk

A

Low
- under 5.5cm
- asymptomatic

High
- over 5.4cm
- symptomatic
- enlarging by over 1 cm a year

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12
Q

Management of low risk AAA

A

Elective vascular review
Rescan based on size
Optimise CVD rfx

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13
Q

Management of high risk AAA

A

Includes symptomatic and enlarging by 1cm a year
- refer within 2 weeks
- elective endovascular repair

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14
Q

How manage over 45 yo male who is treated for a UTI but the haematuria persists

A

Refer to urology under 2ww

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15
Q

What are 2 urological 2ww pathways

A

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

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16
Q

Risk factors for RCC

A

Middle aged men
Smoking
Von-hippel lindau
Tuberous sclerosis
APCKD- only slight increase tho

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17
Q

How can RCC present

A

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

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18
Q

Management of RCC

A

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

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19
Q

What is ABPI

A

Ankle brachial pressure index is ratio of systolic blood pressure in the leg to that of arm

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20
Q

What is a normal ABPI

A

0.9-1.2

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21
Q

What ABPI indicates PAD vs severe disease

A

0.5-0.8- PAD
<0.5- severe disease

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22
Q

What can cause ABPI>1.2

A

Calcified, stiff arteries especially in elderly and DM with PAD

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23
Q

What are the types of lower urinary tract symptoms

A

Obstructive (voiding)
- weak flow
- straining
- hesitancy
- incomplete emptying
Storage
- urgency
- frequency
- incontinence
- nocturia
Post micturition
- dribbling
Complications
- retention
- UTI
- obstructive uropathy

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24
Q

How does tamsulosin and doxazoscin work

A

Alpha-1-antagonist
Reduces muscle tone of prostate and bladder

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25
Q

Side effects of tamsulosin

A

Dizziness
Dry mouth
Depression
Postural hypotension

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26
Q

How does finasteride work

A

5 alpha reductase inhibitors
Blocks conversion of DTH to testosterone which reduces prostate volume

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27
Q

Side effects of finasteride

A

Erectile dysfunction
Reduced libido
Gynaecomastia

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28
Q

What is management of predominantly voiding symptoms

A

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

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29
Q

What do if man has an enlarged prostate and is at high risk of progressing

A

Finasteride

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30
Q

When are both finasteride and tamsulosin indicated

A

bothersome moderate-to-severe voiding symptoms and prostatic enlargement

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31
Q

What is critical limb ischaemia

A

End stage of peripheral vascular disease when symptoms are present at rest. Associated with ulcers and gangrene

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32
Q

What are the 6 Ps

A

Pulseless
Paralysis
Parasthesia
Perishingly cold
Pain
Pale

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33
Q

What indicates embolus over thrombous as cause of acute limb ischaemia

A

Sudden onset with no preceding pain
AF or recent MI
Aneurysm proximal to pain
No evidence of contralateral symptoms

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34
Q

Initial acute limb ischaemia management

A

ABC
IV opioids
IV unfractionated heparin particularly if awaiting intervention (ischaemia takes 6 hours for leg to become unviable)
Vascular review for surgical intervention

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35
Q

First line investigation for suspected prostate cancer

A

Multiparametric MRI

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36
Q

What is used to determine if do transrectal ultrasound guided biopsy based off multiparametric MRI

A

Likert scale
If 3 or more then do TRUS
If 1-2 discuss with patient doing one

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37
Q

How to differentiate psychogenic cause from organic in case of erectile dysfunction

A

Psychogenic will have;
Sudden onset
Decreased libido
Major life events
Good erection by self

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38
Q

Investigation for erectile dysfunction

A

Measure morning testosterone and assess 10 year cardiovascular risk
If testosterone low or borderline then do full hormone profile

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39
Q

First line for erectile dysfunction

A

Phosphodiesterase type 5 inhibitor like sildenafil/viagra

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40
Q

What do if sildenafil contraindicated

A

Use vacuum erection device

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41
Q

What do if present with erectile dysfunction they have always had from puberty

A

Refer to urology

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42
Q

Breast cancer 2WW referral

A

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

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43
Q

What is done if predominantly storage problems

A

Lifestyle bladder training
First drug is oxybutynin

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44
Q

What do if mixed voiding and storage symptoms

A

Alpha blocker first
Second line add oxybutynin

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45
Q

What is used to manage thrombophlebitis

A

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

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46
Q

Investigation for superficial thrombophlebitis

A

Arrange a duplex USS to rule out DVT

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47
Q

Problems of thrombophlebitis

A

Can lead to DVT
May indicate underlying DVT

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48
Q

How to investigate acute limb ischaemia

A

Initially do doppler
Then move onto duplex

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49
Q

Discharge differene between duct ectasia and intraductal papilloma

A

Duct ectasia= green and thick
Intraductal papilloma= clear or bloody

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50
Q

What does ultrasound of axillary lymph nodes showing snowstorm sign show

A

Ruptured implant
This is the leakage of silicone which enters lymphatics

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51
Q

What analgesia use for renal stones

A

NSAIDs
IM if need admission

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52
Q

Imaging for renal stones

A

Non contrast CTKUB to do within 14 hours

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53
Q

Management of kidney stone under 5mm

A

Watchful waiting for 4 weeks
Unless renal transplant, obstruction or renal anatomical abnormality

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54
Q

Management if obstructed kidney stone with infection

A

IV abx
Renal decompression with nephrostomy tube placement

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55
Q

Management of stones under 2cm

A

Lithotripsy
If pregnant uteroscopy

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56
Q

Management of complex renal calculi including staghorn

A

Percutaneous nephrolithotomy

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57
Q

What renal tumour is associated with chemicals from the textiles industry

A

Transitional cell

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58
Q

Management of ruptured abdominal aorta

A

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

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59
Q

Who should be referred to urology for prostate cancer

A

50-69
- PSA over 3
- abnormal DRE

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60
Q

Normal PSA range

A

50-59= under 3
60-69= under 4
Over 70= under 5

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61
Q

What falsely raises PSA

A

Prostatisis/UTI- wait 4 weeks
Ejaculation in last 2 days
Vigorous exercise in last 2 days

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62
Q

What organisms causes epididymo orchitis

A

Either local spread of STI
- chlamydia
- gonorrhoea
From bladder
- E coli

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63
Q

Investigations for epididymo orchitis

A

If young
- assess for UTI
If older
- MSU and urine dip

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64
Q

Management of epididymo orchitis

A

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

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65
Q

What do if recurrent balanitis

A

Circumcision

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66
Q

Management of hydrocele

A

Do USS to exclude cancer
Conservative approach

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67
Q

Management of varicocele

A

If mild then conservative
If large and symptomatic can consider surgery

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68
Q

How does fat necrosis present

A

Fat women with large breasts
Typically follows trauma
Irregular firm lump
Nipple changes seen

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69
Q

Presentation of acute prostatitis

A

Pain can be back, rectum or abdominal
Fever
Pain on defaecation
Voiding symptoms
Tender boggy prostate on examination

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70
Q

Management of prostatitis

A

Quinolone 14 days

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71
Q

Management for localised prostate cancer

A

If not advanved
- Can use watchful waiting
- Radical prostatectomy
- Radiotherapy
If more advanced
- radiotherapy
- prostatectomy
- hormone therapy

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72
Q

Complication of prostatectomy

A

Erectile dysfunction

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73
Q

Side effects of prostate radiotherapy

A

Proctitis
Bladder and colon cancer risk increased

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74
Q

What is main option for metastatic prostate cancer

A

Hormone therapy

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75
Q

Hormone therapy for prostate cancer

A

Aim is to reduce testosterone
GNRH agonists (goserelin) but this can initially cause flare of tumour

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76
Q

What causes urethral stricture

A

Idiopathic
Post STI
Penile fractures
Catheters

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77
Q

Management of urethral stricture

A

Dilation

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78
Q

What is complication post relief of retention

A

Diuresis which may lead to hypovolaemia, hyponatraemia

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79
Q

What can cause intermittent 10/10 pain in testicules

A

It is possible to get intermitten torsion which self resolves
Must treat with emergency fixation

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80
Q

Complications of transurethral resection of prostate syndrome

A

TURP syndrome
Urethral stricture
Retrograde ejaculation
Perforation of prostate

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81
Q

What is in TURP syndrome

A

Leakage of irrigation fluid (glycine) enters bloods causing a triad of
- hyponatraemia (dilutional)
- fluid overload
- glycine toxicity

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82
Q

If AFP and HCG not raised, what tumour is most likely cause

A

Seminoma

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83
Q

What is most common cause of testicular lump

A

Epididymal cyst

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84
Q

What is presentation of epididymal cyst

A

Separate from body of the testicle
Posterior to testicle
Painless lump

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85
Q

What are the types of urinary retention

A

Chronic
- low pressure
- high pressure
Acute

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86
Q

What causes acute onset pain in testes with retained cremasteric function

A

Torsion of testicular appendage

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87
Q

Gold standard investigation for AAA

A

CT Angio

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88
Q

Investigation if want to intervene on intermittent claudication

A

MRI angiogram

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89
Q

What is anti-platelet for PAD

A

Clopidogrel
Given for all patients with evidence of PAD

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90
Q

Medications given for PAD

A

Everyone is given atorvastatin 80mg and clopidogrel

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91
Q

Management of critical limb ischaemia

A

Urgent vascular referral
Analgesia
Urgent revascularisation
- endovascular angioplasty
- endarterectomy
- bypass
- amputation

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92
Q

What is management if fixed mottling of leg

A

Amputation

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93
Q

What is marjolins ulcer

A

A squamous cell carcinoma which occurs at the site of chronic inflammation such as ulcers

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94
Q

What can be done for severe intermittent claudication

A

Endovascular revascularisation
- angioplasty
Surgical revascularisaton
- endarterectomy
- bypass with autologous vein

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95
Q

What differentiates between doing endovascular vs open revascularisation on PAD

A

Endovascular indications
- stenosis under 10cm
- only 1 lesion
- around the iliac area

Surgical indications
- over 10cm
- multifocal lesions
- common femoral and more distally

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96
Q

If pain in buttocks on walking, in what vessel is there stenosis

A

Iliac

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97
Q

If there is pain in calves which artery is being affected

A

Superficial femoral

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98
Q

What may cause an ulcer to increase in size

A

Squamous cell carcinoma

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99
Q

Complications of varicose veins

A

Bleeding
Thrombophlebitis
Venous ulceration
DVT

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100
Q

What skin changes are seen in varicose veins and venous ulcers

A

Haemosiderin deposition-> hyperpigmentation
Lipodermatosclerosis-> hard/tight skin
Atrophie blanche-> hypopigmentation

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101
Q

Investigation for varicose veins

A

Venous duplex USS showing retrograde venous flow

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102
Q

Management of varicose veins

A

First line
- compressoin stockings
- weight loss
- exercise
- emollient
- elevate legs

If referred
- endothermal ablation
- surgery
- foam sclerotherapy

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103
Q

When refer to secondary care for varicose veins

A

Significant bothersome symptoms
Previous bleeding from varicose veins
Skin changes suggesting venous insufficiency
Superficial thrombophlebitis
Active or healed venous ulcer

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104
Q

What is cervical rib

A

When an extra rib can develop from the seventh vertebra

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105
Q

Presentation of subclavian steal syndrome

A

Come on when using arm
Syncope
Lightheadedness
Neuro symptoms can vary
Arm symptoms like crmaping on use or signs of PAD

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106
Q

What is rib notching on CXR indicative of

A

Aortic coarctation

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107
Q

Management of PAD

A

Atorvastatin 80mg
Clopidogrel
Exercise training

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108
Q

Investigation of choice by vascular for PAD

A

MR angio
In the legs MR angio> CT as vessels are smaller

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109
Q

Presentation of cervical rib

A

Compression of brachial plexus can lead to neuro symptoms in hand and arm
Worse when arms above head

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110
Q

Sudden onset collapse and cold, painful arm

A

Axillary artery embolus

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111
Q

What do for someone with terminal unresectable pancreatic cancer causing jaundice

A

Biliary stenting

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112
Q

What imaging is needed in pancreatitis

A

USS early to determine if cause is gallstones which will affect maangement

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113
Q

When is a right hemi-colectomy done

A

Caecal cancer
Ascending colon
Proximal transverse

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114
Q

When is a left hemi-colectomy indicated

A

Distal transverse colon
Descending colon

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115
Q

What operation is done for a sigmoid cancer

A

High anterior resection

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116
Q

What operation is done for high and mid rectum cancers

A

Anterior resection with total mesorectal fat excision

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117
Q

What is an anterior resection

A

Where remove all of the sigmoid/rectum depending on cancer location

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118
Q

What is a total mesorectal excision

A

Where remove all of the fat and lymph/blood around the rectum

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119
Q

What operation is done for anal cancer

A

Abdomino-perineal excision of the rectum with end colostomy bag

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120
Q

What operation is done in low rectal cancers

A

If within 5cm of of anal verge then APE

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121
Q

What do if HNPCC causing cancer

A

Panproctocolectomy which removes all of the colon to anus. End ileostomy prementantly created

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122
Q

What operation is done for sigmoid rupture and diverticulitis

A

Hartmanns

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123
Q

What counts as clear fluids

A

Water
Black tea or coffee
Ice lollies
Juice without pulp

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124
Q

Triad for gastric volvulus

A

Non-bilious vomiting
Pain
Failed attempts at getting NG tube in

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125
Q

What is management of fibroadenoma

A

Leave alone unless over 3cm when surgical excision can be used

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126
Q

What causes pain and swelling of the testis post urological intervention

A

Epididymo orchitis

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127
Q

When are hartmanns done

A

Emergency rupture or diverticulitis

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128
Q

What is a hiatus hernia

A

Herniation of stomach above diaphragm

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129
Q

How are most hiatus hernias found

A

Incidentally on endoscopy as nature of smyptoms makes them be investigated

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130
Q

What is best test for hiatus hernia

A

Barium swallow

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131
Q

Management of hiatus hernia

A

Conservative- all patients weight loss etc
If needed omeprazole or if reallt needed if very sympomatic- laprascopic fundoplication

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132
Q

What is ASA 1

A

Healthy non-smoking or minimal alcohol

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133
Q

What is ASA 2

A

Mild diseases without substantive functional limitation

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134
Q

Examples of ASA 2

A

Current smoker
Controlled DM and HTN
Mild lung disease

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135
Q

What is ASA 3

A

Patient with severe systemic disease

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136
Q

Examples of ASA 3

A

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

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137
Q

What is ASA 4

A

Patient with severe disease that is constant threat to life

138
Q

What are examples of ASA 4

A

Severely reduced EF
Sepsis
DIC
ongoing cardiac ischaemia

139
Q

Who should be considered for enteral feeding

A

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

140
Q

Complications of enteral feeding

A

Diarrhoea
Aspiration
Hyperglycaemia
Refeeding

141
Q

What is abdominal wound dehiscence

A

When the wound opens up and organs poke through
Can either de superficial or deep

142
Q

Management of abdominal wound dehiscence

A

Place sterile gauze over it
IV antibiotics
IV fluids
Take to surgery for definitive management

143
Q

What is a ballotable abdo mass after suspected kidney stones

A

Hydronephrosis

144
Q

What causes unilateral hydronephrosis

A

PACT
Pelvic-ureteric obstruction
Aberrant renal vessels
Calculi
Tumours of renal pelvis

145
Q

What is imaging of choice for hydronephrosis

A

USS

146
Q

Management of acute hydronephrosis

A

Nephrostomy

147
Q

Management of chronic hydronephrosis

A

Ureteric stent

148
Q

What stoma is created for anterior resection

A

Loop ileostomy

149
Q

What feeding method is indicated if oesophagectomy

A

Feeding jejunostomy

150
Q

What is best feeding method if head injury

A

NG tube

151
Q

When do anastamotic leaks occur most often

A

5-7 days after the surgery

152
Q

What is investigation for anastamotic leak

A

CT

153
Q

Most common cause of infected surgical wound

A

S aureus

154
Q

If TPN is required then where does it go through

A

Central line as very phlebitic

155
Q

When are gastrograffin enemas done post bowel surgery

A

4 weeks

156
Q

What is investigation for priapism

A

Cavernosal blood gas to determine if priapism is ischaemic or not

157
Q

Management of ischaemic priapism

A

Aspirate blood and flush with saline

158
Q

Management of non-ischaemic priapism

A

Observation

159
Q

Most important daily investigation if post op ileus

A

U&Es

160
Q

How often are people screened for breast cancer

A

Every 3 years between 50 and 70
Done with mammography

161
Q

What are BMI ranges for ASA

A

30-40= ASA 2
Over 40= ASA 3

162
Q

What stones are radiolucent

A

Xanthine
Urate

163
Q

Management of femoral hernia

A

Surgical repair as soon as possible (2 weeks) due to risk of strangulation

164
Q

How assess patency of a bladder repair

A

Cystogram- passes radio-opaque dye into bladder and then assess if leakage

165
Q

If GCS less than 8 what do with regards to imaging

A

Get neurosurgical review even before scan

166
Q

What operation can you do in UC to avoid a stoma

A

Panproctocolectomy and ileoanal pouch
Can only be done in elective capacity though

167
Q

What operation is done for toxic megacolon in UC

A

Sub total colectomy as removing rectum too risky

168
Q

What operation is done in crohns if severe perianal disease (abscesses and fistulae)

A

Proctectomy

169
Q

Management of bladder cancer

A

Low grade or superficial- transurethral resection of the superficial lesion
High grade- cystectomy

170
Q

What is cause of fever in surgical patient within 24 hours and systemically well

A

Physiological change

171
Q

What is main complication of radical prostatectomy

A

ED

172
Q

What is kochers scar

A

Below right costal margin for open cholecystectomy

173
Q

What is incision for whipples procedure

A

Rooftop which goes all the way under the costal margin

174
Q

What is mcevedys incision for

A

Femoral hernia

175
Q

How does periductal mastitis present

A

Redness under the nipple
Lump expressive of pus sometimes
Pain

176
Q

What is main risk factor for periductal mastitis

A

Smoking

177
Q

What is letrozole vs tamoxifen

A

Tamoxifen= SERM
Letrozole= aromatase inhibitor

178
Q

Main side effect of aromatase inhibitors

A

Osteoporosis
NOTE tamoxifen is protective against it

179
Q

How should surgical wounds be washed post surgery in general

A

For the first 48 hours= sterile saline
Post 48 hours= shower

180
Q

Where on operating list should diabetics be

A

First

181
Q

What causes bloody breast discharge in a young woman most commonly

A

Intraductal papilloma

182
Q

How does local anaesthetic toxicity present

A

Muscle twitching
Drowsy
Hypotension
Bradycardia

183
Q

How is lidocaine toxicity treated

A

Lipid emulsion

184
Q

Patient after bariatric surgery complains of light headedness and crampy abdo pain

A

Dumping syndrome

185
Q

What is dumping syndrome

A

A complication people get after a gastric bypass caused by food entering intestines too quickly
- get crampy abdo pain
- lightheadedness
- diarrhoea

186
Q

What is constituent of stones if staghorn calculus

A

Struvite

187
Q

Post ERCP, patient has abdo pain and very unwell

A

Pancreatitis

188
Q

Who does duct ectasia occur in

A

Perimenopausal women who are undergoing breast involution
Smokers

189
Q

Difference in number of ducts duct ectasia and intraductal papilloma occur in

A

Duct ectasia- multiple
Intraductal papilloma- one

190
Q

What does halo sign suggest about a breast lesion

A

Standard rule is that they are benign
- breast cyst most commonly

191
Q

What does blurred vision after a facial trauma suggest

A

Depressed fracture of zygoma

192
Q

What is pilonidal disease

A

Where sinuses and cysts form in upper natal cleft of buttocks

193
Q

Who does pilonidal disease occur in

A

Young men

194
Q

How manage asymptomatic pilonidal disease

A

Hygiene measures in that area

195
Q

How manage acute pilonidal disease

A

Incision and drainage

196
Q

How manage recurrent pilonidal disease

A

Pilonidal cystectomy

197
Q

What are investigations for varicocele

A

USS
Semen analysis as infertility assocated

198
Q

Management of seminoma vs teratoma

A

Orchidectomy and sperm banking for both
Radiotherapy for seminoma
Chemo for teratoma

199
Q

When consider manual detorsion for testicular torsion if surgery will be dealyed

A

If not going to be done within 6 hours

200
Q

What drugs can be given for kidney stones

A

Tamsulosin- can help movement of stone
Cyclizine for antiemetic
Diclofenac IM or IV paracetamol

201
Q

What volume on USS suggets retention

A

600ml

202
Q

What is management of acute urinary retention

A

If clots then 3 way catheter
If not then 2 way foley

203
Q

Causes of acute urinary retention

A

Alcohol
Anticholinergics
Constipation
Prostate problems

204
Q

What is main side effect of tamoxifen

A

VTE

205
Q

Post vasectomy what need to do

A

Measure semen analysis before stop using contraception to determine azoospermia

206
Q

What is decompression haematuria

A

Once catheterise someone in retention they can get normal haematuria which just needs monitoring

207
Q

What is imaging for a breast lesion

A

Under 40= USS
Over 40= mammogram

208
Q

What is classical presentation of inflammatory breast cancer

A

Progressive erythema and oedema of the breast without fever, raised inflammatory markers etc

209
Q

What is surgical approach for male breast cancer

A

Mastectomy

210
Q

What does perinephric and periureteric fat stranding suggest

A

Calculous

211
Q

What is a 1cm spherical mass on the testis that transilluminates

A

Epididymal cyst
Hydrocele would surround whole testis

212
Q

What management in an old person with lots of comorbidities who has breast cancer

A

Avoid surgery obviously
Avoid radiotherapy too as risk of causing lung disease
Immunotherapy main one to use

213
Q

What do if patient on warfarin is about to undergo emergency surgery

A

If immediate
- four-factor prothrombin complex
If 6-8 hours
- IV vitamin K

214
Q

What is leriche syndrome

A

Where atherosclerosis in distal aorta or proximal iliac
Presents with
- erectile dysfunction
- absent femoral pulses
- claudication in buttocks and thighs

215
Q

Why is chemo given before breast surgery

A

To downstage tumour allowing for breast conserving surgery

216
Q

Can you give IM diclofenac if history of peptic ulcer disease

A

No- still can affect stomach

217
Q

What can raise amylase other than pancreatitis

A

SBO
Upper GI bleed
Mesenteric ischaemia

218
Q

What does tenderness in right side of abdomen on DRE suggest

A

Appendicitis

219
Q

What does a boggy sensation on DRE suggest with RIF pain suggest

A

Pelvic abscess

220
Q

How to diagnose appendicitis

A

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

221
Q

What is rosvings sign

A

Palpate LIF get pain in RIF if appendicitis

222
Q

What is psoas sign

A

Pain on extending hip if retrocaecal appendix

223
Q

What does spouted stoma mean

A

That it is raised away from skin
Seen in ileostomies to avoid skin irritation from acidic faeces at this point

224
Q

Differentiating between ileostomies and colostomies

A

Ileostomy- will be raised away from skin to avoid irritation from faeces which still acidic

225
Q

What does adjuvant mean

A

Applied after initial treatment for cancer

226
Q

When is hormonal treatment for breast cancer given

A

Adjuvant for 5 years

227
Q

If after breast surgery a woman wants to prevent recurrence but does not want to do treatment for a long time what do

A

Radiotherapy

228
Q

What are adjuvant breast surgery options

A

Radiotherapy
Hormonal treatment

229
Q

What does a very large post void volume suggest

A

Acute on chronic retention

230
Q

What on ECG is most worrying for hyperkalaemia

A

Sinusoidal or sine wave appearance as indicates K+ over 9

231
Q

Which nerve likely to get injured in carotid endarterectomy

A

Hypoglossal

232
Q

In axillary node clearance what nerve could be injured

A

Long thoracic

233
Q

How minimise adhesions post operative

A

Use laparoscopic approach

234
Q

Operations where X match 2-6 units

A

Total gastrectomy
Oophorectomy
Oesophagectomy
Elective AAA repair
Cystectomy
Hepatectomy

235
Q

When only do G&S pre op

A

Elective C section
Appendicectomy
Laparoscopic cholecystectomy
Thyroidectomy

236
Q

When only X match 2 units

A

Hip replacement

237
Q

What are the 3 pre-emptive preoperative options for managing blood transfusions

A

G&S
X match 2 units
X match 6 units

238
Q

If get breast pain related to menses but no lumpiness what is this called

A

Cyclical mastalgia

239
Q

Management of cyclical mastalgia

A

Supportive bra
Simple analgesia

240
Q

What are 3 parts to the WHO surgical safety checklist

A

Sign in- pre anaesthesia
Time out- pre first cut
Sign out- before patient leaves room

241
Q

LP findings in SAH

A

Normal or raised opening pressure
Bilirubin/xanthochromia

242
Q

Why give nimodipine for SAH

A

Prevent vasospasm

243
Q

How can differentiate arterial from neuropathic ulcer in a diabetic patient

A

Pain in arterial

244
Q

How differentiate between a loop and end colostomy on examination

A

Loop colostomies have 2 openings

245
Q

What do for low grade prostate cancers for elderly man with comorbidities

A

Watchful waiting

246
Q

Where can PAD affect

A

Buttocks
Quads
Calves

247
Q

Difference between intermittent claudication and critical limb ischaemia

A

Symptoms of ischaemia present at rest vs on exertion
Get gangrene, ulcers etc in critical limb ischaemia

248
Q

Definition of gangrene

A

Necrosis due to ischaemia

249
Q

What muscle groups can intermittent cluadication affect

A

Buttocks
Quads
Calves

250
Q

What use to asess ABPI

A

Doppler not sphygmo whatever

251
Q

Management of intermittent claudication

A

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

252
Q

When refer intermittent claudication to secondary care

A

If exercise programme and CVD rfx been enforced for over 3 months but STILL no improvement in sx

253
Q

If decline surgical referral for intermittent claudication what do

A

Give naftidrofuryl oxalate

254
Q

What causes stiff vessels

A

Vasculitis
Elderly
DM
RA

255
Q

MOA of naftidrofuryl oxalate

A

5-HT2 antagonist which vasodilates peripheral tissues

256
Q

What use if clopidogrel CI for PAD

A

Aspirin

257
Q

Definitive options for acute limb ischaemia after initial management

A

Endovascular thrombolysis or thrombectomy
Open thrombectomy
Bypass
Amputation

258
Q

Causes of arterial emboli

A

Mural thrombous post MI
AF
Aneurysm- abdominal aorta eg

259
Q

Management options for ruptured abdominal aortic aneurysm

A

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

260
Q

Features of arterial ulcers

A

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

261
Q

Important complication of neuropathic ulcers

A

Osteomyelitis

262
Q

Management of arterial ulcers

A

Urgent vascular referral for revascularisation
Do not debride

263
Q

Assessments of all ulcers

A

Bedside- examination, ABPI, doppler
Bloods- assess CVD rfx- lipids and HbA1c

264
Q

Management of venous ulceration

A

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

265
Q

What can be given alongside compression bandaging for venous ulcers

A

Pentoxifylline to help ulcer healing

266
Q

Features of venous ulcers

A

In gaiter area
Rolled edges
Bleed easily
Haemosederin deposition
Lipodermatosclerosis
Atrophie blanche (hypopigmentation)
Wine bottle deformity of calf

267
Q

First line for varicose veins

A

Unless require referral to secondary care
- compression stockings
- elevate legs
- exercise
- emollients
- weight loss

268
Q

Other name for buergers disease

A

Thromboangiitis obliterans

269
Q

Presentation of thromboangiitis obliterans

A

Young male
SMOKER
Painful raynauds/blue discolouration of thumbs/toes
Leads to gangrene and ulcers

270
Q

Treatment of buergers/thromboangiitis

A

Stop smoking completely- usually very curative
Can use IV iloprost

271
Q

Investigation for buergers

A

Angiography will show corkscrew collateral vessels and narrowing of vessels

272
Q

Management of fibrocystic changes

A

Recommend supportive bra
NSAID analgesia

273
Q

Breast cyst presentation

A

Soft lump
Can move
Painful

274
Q

Management of single breast cyst

A

Refer for full assessment
Aspiration to exclude cancer
To alleviate symptoms can aspirate or excise

275
Q

Galactocele presentation

A

Women who just stopped breastfeeding
Lump under areolar

276
Q

Management principles of benign breast lumps

A

Exclude cancer
Typically conservative but if growing or smyptomatic then can remove

277
Q

Investigations for fat necrosis

A

Can mimic breast cancer on imaging so need biopsy to confirm benign

278
Q

Management of phyllodes tumour

A

Remove

279
Q

Causes of lactational mastitis

A

Staph aureus most commonly
ALSO just from blockageof ducts

280
Q

Lactational mastitis management

A

Keep breastfeeding and analgesia
If persists over 24 hours add fluclox or erythromycin

281
Q

What do with breastfeeding if abscess

A

Continue feeding

282
Q

Duct ectasia presentation

A

Smoker
Perimenopausal
Green discharge
Pain
Lump

283
Q

Management of duct ectasia

A

Conservative- supportive bra and analgesia
If very problematic do excision

284
Q

Management of ductal papilloma

A

Excision and histology analysis

285
Q

Intraductal papilloma presentation

A

Bloody discharge
Lump
Pain

286
Q

If someone is identified as being high risk for breast cancer what can be done for them

A

Genetic testing
Annual mammograms

287
Q

Management of lymphoedema from axillary node removal

A

Massage and exercises to drain the lymphatic system
Compression bandages
Weight loss if overweight

288
Q

Best imaging for viewing breast cancers

A

MRI

289
Q

What do if USS identifies lymph nodes in breast cancer assessment

A

USS guided biopsy

290
Q

What can genetic profilling be used for in breast cancer

A

In women who are young, ER positive can be used to predict mortality

291
Q

What is a hartmanns procedure

A

Proctosigmoidectomy where remove portion of bowel then create colostomy leaving recto-anal stump which is “hartmanns pouch”

292
Q

What operation can be done for UC

A

Pan proctocolectomy with either end ileostomy or ileoanal pouch

293
Q

What is a j pouch

A

Ileo-anal pouch which means ileum acts as a rectum
Done electively for UC after panproctocolectomy

294
Q

If vomiting and in pain but can’t get NG tube in, what is cause

A

Gastric volvulus

295
Q

Abdo XR coffee bean sign

A

Sigmoid volvulus

296
Q

Best imaging for volvulus

A

CT

297
Q

Who does sigmoid vs caecal volvulus occur in

A

Sigmoid= old and common
Caecal= young and rare

298
Q

When stop warfarin before surgery

A

5 days

299
Q

When start warfarin again post surgery

A

That evening or day after if haemodynamically stable

300
Q

If on warfarin, what is acceptable INR to operate

A

Less than 1.5

301
Q

Under what circumstances would you not leave a renal stones under 5mm alone

A

Transplant
Obstruction
Anatomical abnormality

302
Q

Investigation for RCC

A

Contrast CT

303
Q

RCC paraneoplastic syndromes

A

Stauffer syndrome
Polycythaemia form EPO
ACTH
PTHrp

304
Q

What is an IV urogram

A

X ray with IV contrast in the renal tract

305
Q

Typical bladder cancer presentation

A

Painless haematuria

306
Q

Investigation for bladder cancer

A

Cystoscopy

307
Q

Rfx for bladder cancer

A

Transitional cell (95%)- dyes from textiles, smoking
Squamous cell (rare)- schistosomiasis

308
Q

Urge incontinence management

A

1st- 6 weeks bladder training
2nd- anticholinergic like oxybutynin or tolterodine
3rd- mirabregon or 2nd if elderly and frail

309
Q

Stress incontinence in women

A

1st- pelvic floor training
2nd- surgical
3rd- duloxetine

310
Q

Physiological cause of urge incontinence

A

Overactive bladder from detrusor activity- parasympathetic overactivity

311
Q

What is included in the conservative measures offered first line for voiding symptoms

A

Pelvic muscle training
Fluid intake advice

312
Q

What is indicated if mixed urge and voiding symptoms

A

Tamsulosin and oxybutynin

313
Q

Most likely organism for prostatitis

A

E coli

314
Q

Non primary care treatment options for BPH

A

Catheterisation
TURP

315
Q

What do if voiding symptoms fail to respond to medical treatment

A

Urology referral for consideration of TURP or catheterisation

316
Q

What is gold standard investigation for prostate cancer

A

Transrectal ultrasound guided prostate biopsy showing adenocarcinoma

317
Q

Staging and grading prostate cancer

A

Staging- TMN
Grading- gleason

318
Q

How investigate for bony metastases

A

Isotope bone scan with technetium bisphosphonate

319
Q

Causes of erectile dysfunction

A

Hormonal
- hypogonadism- chemo, mumps, STI, iron, torsion
- prolactin
- thyroid
Vascular- leriche, DM
Psychological
Drugs- SSRIs, steroids, finasteride, goserelin
Post TRUS, prostatectomy

320
Q

Types of testicular cancer

A

Seminomas
Non-seminomas
- germ cell- choriocarcinoma, teratoma, yolk sac
- non-germ cell- leydig, sertoli

321
Q

What type of testicular tumour produces LDH

A

Germ cell and sometimes seminoma

322
Q

Which testicular tumour causes gynaecomastia

A

Leydig cell

323
Q

Most common testicular cancer

A

Seminoma

324
Q

Chronic prostatitis presntation

A

Symptoms present for over 3 months
- pain in prostate
- painful defaecation
- LUTS
- erectile dysfunction

325
Q

What is used if unable to insert foley catheter for lower urinary obstruction

A

Use coude catheter which has more rigid end

326
Q

Main side effects of tamsulosin

A

Postural drop- dizziness etc
Dry mout and eyes

327
Q

What determines whether failed TWOC

A

Post residual volume

328
Q

Oesophageal cancer management

A

Surgery ideally
If metastasised then palliative and stent

329
Q

Chronic prostatitis management

A

NSAIDS
Laxatives
4-6 weeks of doxycycline

330
Q

If have cystectomy what is made for long term urination

A

Urostomy or ileal conduit
Section of bowel removed and a pouch made of it to collect urine from ureters

331
Q

After transurethral resection of bladder cancer what is given

A

Intra vesical BCG for 6 weeks

332
Q

What suggests renal cancer as cause of varicocele

A

When lie supine it does not drain

333
Q

What do if varicocele does not drain when lie supine

A

USS of KUB as indicates RCC

334
Q

Dysphagia with weight loss differentials

A

Carcinoma
Achalasia but over longer period and not as much

335
Q

If have constipation secondary to opiates what use

A

Senna- stimulant laxative

336
Q

If undergoing bariatric surgery what investigation is important to be done

A

Digital subtraction arteriography which show if good collaterals off distal arteries

337
Q

What do if woman presents with sudden onset facial hair

A

Urgent endocrine referral to rule out cancer

338
Q

What do for woman who presents with testosterone really high

A

Urgent endocrine referral to rule out cancer

339
Q

Age distribution of testicular cancer

A

20-35: teratoma
35-45: seminoma
Over 60: lymphoma

340
Q

Staging investigation for testicular cancer

A

CT CAP

341
Q

What is use of tumour markers in testicular cancer

A

Follow up for recurrence

342
Q

What stoma is formed for hartmanns

A

End colostomy
Although it can be reversed it is not a loop stoma as the rectal pouch is sewn up

Finals (29 decks)

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