Surgery Flashcards
Which anatomical structure is implicated in most cases of anterior epistaxis?
Kiesselbach Plexus
Outline the Paradise criteria for tonsillectomy.
- ≥7 episodes of tonsillitis in the past 12 months
- ≥5 episodes of tonsillitis per year for 2 years
- ≥3 episodes of tonsillitis per year for 3 years
- ≥2 peritonsillar abscesses at any point in the patient’s life (≥1 in children)
How should an asymptomatic thyroglossal cyst be managed?
Excision (as there is a risk of infection if left untreated)
What is the best investigation for confirming a diagnosis of bacterial tonsillitis?
Throat Swab for Microscopy and Culture
What is the most appropriate management option for viral pharyngitis?
Symptomatic Management
Analgesia (paracetamol, ibuprofen)
Difflam® Spray
How should a secondary post-tonsillectomy bleed be managed?
Admit for ENT review
May require antibiotics or exploration in theatre
Which features are considered by the Centor criteria?
Age
Fever
Tonsillar Exudate
Cervical Lymphadenopathy
Absence of Cough
What is the best investigation for confirming a diagnosis of bacterial tonsillitis?
Throat Swab for Microscopy and Culture
What is the most appropriate management option for viral pharyngitis?
Symptomatic Management
Analgesia (paracetamol, ibuprofen)
Difflam® Spray
What are the indications for adenoidectomy?
Recurrent otitis media with effusion (glue ear)
Nasal obstruction
Chronic rhinosinusitis
Chronic sinusitis
Obstructive sleep apnoea
Aside from modifying risk factors, what other management option is commonly used for intermittent claudication?
Structured Exercise Programme
For further information:
NICE guidelines on peripheral arterial disease: https://www.nice.org.uk/guidance/cg147
Outline the Fontaine classification for chronic limb ischaemia.
Fontaine A: Asymptomatic
Fontaine B1: Symptoms when walking more than 200 metres
Fontaine B2: Symptoms when walking less than 200 metres
Fontaine C: Rest pain
Fontaine D: Evidence of tissue loss (ulcers and gangrene)
What is the first step in assessing a patient with suspected peripheral artery disease?
Ankle Brachial Pressure Index
For further information:
NICE guideline on peripheral arterial disease: diagnosis and management https://www.nice.org.uk/guidance/cg147/chapter/Recommendations#diagnosis
Outline the Fontaine classification for chronic limb ischaemia.
Fontaine A: Asymptomatic
Fontaine B1: Symptoms when walking more than 200 metres
Fontaine B2: Symptoms when walking less than 200 metres
Fontaine C: Rest pain
Fontaine D: Evidence of tissue loss (ulcers and gangrene)
Aside from modifying risk factors, what other management option is commonly used for intermittent claudication?
Structured Exercise Programme
For further information:
● NICE guidelines on peripheral arterial disease: https://www.nice.org.uk/guidance/cg147
Which surgical approach is most appropriate for a patient with critical limb ischaemia and unilateral iliac disease (i.e. complete occlusion of one common iliac artery)?
Femoral-Femoral Crossover
What is a feature of non-viability of a limb in a patient with acute limb ischaemia?
Complete paralysis or paraesthesia
Fixed mottling
How should an abdominal aortic aneurysm measuring 4.9 cm in diameter upon screening be managed?
Invite for repeat ultrasound in 3 months
What is the first investigation that would be performed in a patient with a suspected ruptured abdominal aortic aneurysm?
Abdominal Ultrasound Scan
Which diagnosis should you always consider in a patient who is haemodynamically unstable and has presented with acute abdominal pain?
Ruptured Abdominal Aortic Aneurysm
How does intermittent claudication present?
Leg pain on exertion that is relieved by rest
Describe the typical presenting features of varicose veins.
Unsightly, distended veins usually around the calves
May be associated with some itching and discomfort
Worsened by prolonged standing
What is an appropriate intervention for a patient with severe varicose veins who is not suitable for a general anaesthetic?
Injection Sclerotherapy
What initial imaging modality is used in the assessment of varicose veins?
Duplex Ultrasound Scan
What surgical intervention is most commonly performed to treat a Dupuytren’s contracture that is affecting a patient’s quality of life?
Fasciectomy
What are the indications for weight loss surgery?
● BMI > 40 kg/m2, OR BMI > 35 kg/m2 AND have at least one other significant disease (e.g. type 2 diabetes mellitus) which could be improved with weight loss
● The patient has failed to achieve sustained weight loss with all other non-surgical management
● The patient is fit enough for anaesthesia and surgery
● The patient will receive intensive management in a specialist centre
● The patient must commit to long-term follow-up
What is the initial imaging modality that is used in the assessment of patients with critical limb ischaemia?
Duplex Ultrasound Scan
What is the most important initial investigation to request in a patient with progressive dysphagia?
OGD
What is likely to be the most appropriate treatment option for a T2N1M0 oesophageal cancer?
Oesophagectomy and chemotherapy
What are the features of aortoiliac occlusive disease (Leriche syndrome)?
Buttock claudication
Absent leg pulses
Erectile dysfunction
What is Fournier’s gangrene and how does it present?
Necrotising fasciitis of the perineum
Presents with out of proportion pain in the perineum and features of sepsis
How is a large full-thickness tear of the subscapularis muscle likely to be managed?
Arthroscopic Tendon Repair
What are the main presenting features of compartment syndrome?
Out of proportion pain within limb
Sensory deficit
Usually occurs in the context of trauma
Which diagnostic tests may be used in the diagnosis of compartment syndrome?
It is primarily a clinical diagnosis, however, compartmental needle manometry and MRI may aid diagnosis.
How should lower limb compartment syndrome be managed?
Two-incision four-compartment fasciotomy
How does compartment syndrome of the anterior compartment of the leg manifest?
Foot drop
Numbness of interweb spaces of the first and second toes
NOTE: the deep peroneal nerve runs through the anterior compartment
What are the clinical features of aortic dissection?
Sudden-onset severe chest pain that radiates to the interscapular region
Unequal arm pulses
Aortic regurgitation
Consequences of involvement of the branches of the aorta (e.g. stroke)
What is the gold-standard imaging modality for aortic dissection?
CT Aortogram
What blood pressure target should be set in patients with aortic dissection?
Systolic blood pressure 100-110 mm Hg.
Which scoring systems are used for aortic dissection?
Stanford A: Originates in the ascending aorta
Stanford B: Originates distal to the left subclavian artery.
DeBakey Type 1: originates in ascending aorta and continues to at least the aortic arch, often more distally.
DeBakey Type 2: The dissection is confined to the ascending aorta.
DeBakey Type 3: The dissection originates distal to the left subclavian artery and rarely extends proximally, but often extends distally.
What is the initial investigation used to investigate possible carotid artery stenosis?
Carotid Doppler Ultrasound Scan
When is a carotid endarterectomy indicated?
Symptoms (i.e. stroke or TIA in the hemisphere supplied by the affected carotid artery)
50-99% stenosis
Describe the characteristics of an arterial ulcer.
Punched-out appearance
Painful
Usually at the peripheries of the feet (e.g. in between the toes)
What initial investigation is important to conduct in any patient with a leg ulcer?
ABPI - allows assessment of arterial insufficiency
What is the first step in the management of compartment syndrome?
Urgent Fasciotomy
What is lipodermatosclerosis?
Subcutaneous fibrosis and hardening of the skin of the lower legs – this leads to a “upside-down champagne bottle” like appearance with narrowing of the distal limb.
What is the most appropriate initial step in the management of acute limb ischaemia?
IV Heparin
Outline the possible outcomes of abdominal aortic aneurysm screening.
< 3 cm: Discharged from screening programme
3.0-4.4 cm: Yearly USS
4.5-5.4 cm: 3-monthly USS
> 5.5 cm: Consideration for surgical repair
Patients should also be considered for surgical repair if the aneurysm is growing by more than 1 cm per year or if the aneurysm is symptomatic
What are the two main surgical approaches for managing an abdominal aortic aneurysm?
Open Repair (preferred option in otherwise fit patients as it is associated with a lower rate of reintervention)
Endovascular Aneurysm Repair
How does acute limb ischaemia present?
Acute-onset leg pain
Palor
Cold
Pulseless
Paralysis or paraesthesia
Which interventions can be used to revascularise an acutely ischaemic leg that is still viable?
Embolectomy
Local intra-arterial thrombolysis
Bypass
Angioplasty
What are some of the manifestations of a Stanford type A dissection?
Sudden-onset tearing chest pain
New aortic regurgitation (early diastolic murmur)
Myocardial ischaemia (due to coronary artery involvement)
What is the first step in assessing a patient with suspected peripheral artery disease?
Ankle Brachial Pressure Index
For further information:
● NICE guideline on peripheral arterial disease: diagnosis and management https://www.nice.org.uk/guidance/cg147/chapter/Recommendations#diagnosis
Which cancer is associated with left-sided varicoceles?
Renal Cell Carcinoma
How are hydroceles in newborns managed?
Most resolve spontaneously within 1 year of life
If it fails to resolve by 1 year, referral to paediatric surgery should be considered
Which investigation should be requested in patients with a persistent varicocele?
CT Abdomen and Pelvis (to rule out an intra-abdominal mass)
What is phimosis?
Pathological non-retractile foreskin (the vast majority of boys should be able to retract their foreskin by the age of 16 years)
Outline the indications for urgent referral to urology in patients with a varicocele.
Fails to reduce when lying down
Sudden-onset, new varicocele in a man over the age of 40 years
Right-sided varicocele
Outline the examination findings you would expect in a patient with an epididymal cyst.
Fluctuant swelling superior and separate to the testis
Transilluminates (if large enough)
Which intervention should be used for large renal stones (> 20 mm)?
Percutaneous Nephrolithotomy
Which surgical approach is used for non-obstructive distal ureteric calculi?
Ureteroscopic Lithotripsy
Which cancer is associated with left-sided varicoceles?
Renal Cell Carcinoma
How are hydroceles in newborns managed?
Most resolve spontaneously within 1 year of life
If it fails to resolve by 1 year, referral to paediatric surgery should be considered
Which investigation should be requested in patients with a persistent varicocele?
CT Abdomen and Pelvis (to rule out an intra-abdominal mass)
What is phimosis?
Pathological non-retractile foreskin (the vast majority of boys should be able to retract their foreskin by the age of 16 years)
Outline the indications for urgent referral to urology in patients with a varicocele.
Fails to reduce when lying down
Sudden-onset, new varicocele in a man over the age of 40 years right-sided variocele
Outline the examination findings you would expect in a patient with an epididymal cyst.
Fluctuant swelling superior and separate to the testis
Transilluminates (if large enough)
Which clinical features would raise suspicion of a diagnosis of a testicular torsion as opposed to a different cause of acute testicular pain?
Absent cremasteric reflex
Testicle is high in the scrotum and with a horizontal lie
Prehn’s sign negative
What is the most appropriate treatment option for symptomatic but uncomplicated phimosis with no evidence of balanitis?
Application of 0.05% betamethasone ointment
What is the most important first step in the management of acute urinary retention?
Catheterise
How does bladder cancer tend to present?
Painless macroscopic haematuria
What is the most important investigation to arrange in a patient with suspected bladder cancer?
Cystoscopy
How are primary hydroceles in infants usually managed?
Watchful Waiting
Which reflex is often tested when assessing a patient with suspected testicular torsion?
Cremasteric reflex (presence can help rule out a diagnosis of testicular torsion)
How should superficial, high-risk bladder tumours be managed?
Repeat TURBT with intravesical BCG treatment
What is the most important intervention to perform in the case of an infected and obstructive urinary system?
Percutaneous Nephrostomy
How should any case of suspected testicular torsion be managed?
Urgent referral to urology for consideration of exploratory surgery with bilateral fixation of the testicles
How should a 22 mm non-obstructing stone in the renal pelvis be managed?
Percutaneous Nephrolithotomy
What is the most appropriate treatment option for a patient with BPH who has failed to respond to medical therapy?
Transurethral Resection of the Prostate (TURP)
NOTE: transurethral incision of the prostate may be considered in mild-to-moderate BPH (prostate mass < 30 g)
How should a patient with a salvageable testicular torsion be surgically managed?
Unilateral orchidopexy (of affected testicle) and contralateral fixation
How is a muscle-invasive bladder tumour normally managed surgically?
Radical Cystectomy
Which investigation should be urgently arranged in patients with an acquired hydrocele?
Testicular Ultrasound Scan (to rule out underlying malignancy)
What is the gold-standard investigation for a suspected urinary tract calculus?
Non-Contrast CT KUB
What is the most appropriate management option for a stone at the pelviureteric junction that is 15 mm in size?
Ureteroscopy
NOTE: extracorporeal shockwave lithotripsy is more appropriate for stones that are under 10 mm
Which investigation is important in a patient with acute urinary retention who has evidence of an AKI on their blood tests?
Renal Ultrasound Scan
What are some intermediate measures that can be taken to prevent urinary retention in a patient who is awaiting a TURP?
Long-Term Catheter
Intermittent Self-Catheterisation
Which examination should be performed first in a patient with suspected benign prostatic hyperplasia?
Digital Rectal Examination
When is an anterior resection used for colorectal cancer?
When the tumour lies more than 5 cm above the anal verge
Which surgical approach is used for tumours of the ascending colon?
Right Hemicolectomy
What is the mainstay of managing acute cholecystitis?
Laparoscopic cholecystectomy within 1 week of presentation
https://pathways.nice.org.uk/pathways/gallstone-disease#content=view-node%3Anodes-management
Describe the clinical features of oesophageal perforation.
History of forceful vomiting preceding the onset of symptoms
Chest/neck/upper abdominal pain
Haemodynamic instability
Respiratory distress
Fever
Subcutaneous emphysema
How does acute cholecystitis manifest?
Right upper quadrant pain
Nausea and vomiting
Fever
What is the most appropriate first-line investigation for acute cholecystitis?
Ultrasound Abdomen
How can you clinically assess an inguinal hernia to see whether it is direct or indirect?
The hernia should be reduced, a finger should be placed over the deep inguinal ring (just above the midpoint of the inguinal ligament) and the patient should be asked to cough (increase intra-abdominal pressure). If the hernia reappears, it suggests the hernia is direct (passing through a weak point in the posterior wall of the inguinal canal). If it does not reappear, it is suggestive of an indirect inguinal hernia.
How should a strangulated inguinal hernia be managed?
Emergency Surgery (to reduce the hernia, repair the defect and resect any non-viable bowel)
What are the boundaries of the inguinal canal?
Anterior Wall: aponeurosis of the external oblique, reinforced laterally by the internal oblique muscle
Posterior Wall: transversalis fascia
Superior Wall (roof): transversalis fascia, internal oblique and transversus abdominis
Inferior Wall (floor): inguinal ligament thickened medially by the lacunar ligament
What are the boundaries of Hesselbach’s triangle?
Medial: lateral border of the rectus abdominis
Lateral: inferior epigastric vessels
Inferior: inguinal ligament
What subsequent investigation should a patient undergo after having a positive FIT result?
Colonoscopy
How does acute cholecystitis manifest?
Right upper quadrant pain
Nausea and vomiting
Fever
What is the most appropriate first-line investigation for acute cholecystitis?
Ultrasound Abdomen
How can you clinically assess an inguinal hernia to see whether it is direct or indirect?
The hernia should be reduced, a finger should be placed over the deep inguinal ring (just above the midpoint of the inguinal ligament) and the patient should be asked to cough (increase intra-abdominal pressure). If the hernia reappears, it suggests the hernia is direct (passing through a weak point in the posterior wall of the inguinal canal). If it does not reappear, it is suggestive of an indirect inguinal hernia.
How should a strangulated inguinal hernia be managed?
Emergency Surgery (to reduce the hernia, repair the defect and resect any non-viable bowel)
What are the boundaries of the inguinal canal?
Anterior Wall: aponeurosis of the external oblique, reinforced laterally by the internal oblique muscle
Posterior Wall: transversalis fascia
Superior Wall (roof): transversalis fascia, internal oblique and transversus abdominis
Inferior Wall (floor): inguinal ligament thickened medially by the lacunar ligament
What are the boundaries of Hesselbach’s triangle?
Medial: lateral border of the rectus abdominis
Lateral: inferior epigastric vessels
Inferior: inguinal ligament
What subsequent investigation should a patient undergo after having a positive FIT result?
Colonoscopy
Which surgical approach is likely to be used for a tumour of the hepatic flexure?
Right hemicolectomy with ileocolic anastomosis
Which cancers are patients with HNPCC at increased risk of developing?
Colorectal Cancer (nearly 100%)
Endometrial Cancer (~60%)
Gastric Cancer (~10%)
Ovarian Cancer (~10%)
How do femoral hernias and inguinal hernias differ?
Femoral hernias are inferior and lateral to the pubic tubercle
Inguinal hernias are superior and medial to the pubic tubercle
Femoral hernias are more common in women and have an increased risk of incarceration and strangulation
What diagnosis should you consider in a patient who continues to have fevers despite antibiotic therapy after having an appendicectomy?
Appendicular Abscess
Intra-Abdominal Collection
What is the first-line management option for excessive output stomas?
Loperamide
PPI (e.g. omeprazole)
What are the components of the Glasgow-Imrie criteria?
PaO2
Age
WCC
Calcium
Urea
LDH
Albumin
Glucose
Which treatment options are typically used for Grade 2 haemorrhoids?
Rubber band ligation
Injection sclerotherapy
Topical hydrocortisone (for perianal itching)
How can TPN lead to cholestasis?
No food will be entering the intestines so various hormones that promote biliary motility (e.g. cholecystokinin) will not be produced, resulting in cholestasis.
Outline the measures that can be taken to reduce the risk of postoperative atelectasis?
Incentive Spirometry
Early Mobilisation and Physiotherapy
What is a pilonidal sinus?
Chronic inflammatory condition caused by an ‘ingrown hair’ usually in the natal cleft of the buttocks.
The insertion of hair into the skin initiates an inflammatory response which leads to the formation of a sinus tract deep into the tissue. This will usually present as a painful swelling with purulent, foul-smelling discharge.
What are the ways in which the biliary system can be decompressed in a patient with ascending cholangitis secondary to an obstructing CBD stone?
Percutaneous Cholecystostomy
Percutaneous Transhepatic Cholangiography with Stent Insertion
ERCP
Endoscopic Ultrasound-Guided Biliary Drainage
Describe how direct and indirect inguinal hernias can be distinguished clinically.
Once a hernia has been reduced, applying pressure over the midpoint of the inguinal ligament will occlude the deep inguinal ring, so, in cases of indirect inguinal hernias, the lump will not reappear. If the lump reappears upon coughing, that is suggestive of a direct inguinal hernia.
What are the components of the Glasgow-Imrie criteria for acute pancreatitis?
PaO2 < 8 kPa
Age > 55 years
Neutrophils (WCC) > 15x109/L
Calcium < 2 mmol/L
Renal function: urea > 16 mmol/L
Enzymes: LDH > 600 IU/L
Albumin < 32 g/L
Sugar (serum glucose) > 10 mmol/L
Outline the grading of internal haemorrhoids.
Grade I: does not prolapse
Grade II: spontaneously reduces
Grade III: can be reduced manually
Grade IV: irreducible
What is the most important investigation to request in a patient with suspected oesophageal cancer?
Upper GI Endoscopy and Biopsy
How does diverticulitis usually present?
Left iliac fossa pain and tenderness
Diarrhoea (may contain blood)
Fever
What is the imaging modality of choice for suspected acute diverticulitis?
CT Abdomen and Pelvis with Contrast
Describe the appearance of a sigmoid volvulus on an abdominal X-ray.
Coffee bean sign
Describe the classical presentation of biliary colic.
Right upper quadrant pain that tends to come on after having a fatty meal
Abdomen is usually soft and not particularly tender
Pale stools
What is the usual first-line imaging modality in patients with suspected biliary colic?
Ultrasound Abdomen
NOTE: it can be technically difficult to perform in patients with a large body habitus
What is the most appropriate investigation in ascending cholangitis?
ERCP
How does a perianal abscess manifest?
Pain on defecation
On examination, a red and tender fluctuant swelling would be seen.
What is the gold-standard investigation for suspected anal fistulae?
MRI
What is the best management option for a perianal abscess that has not resolved with antibiotics?
Incision and Drainage
What is an ileal conduit?
Small segment of ileum is brought to the abdominal wall to create a stoma and the ureters are connected to the internal loose end of that section of ileum.
This is usually performed to allow urinary drainage in patients who have undergone a radical cystectomy
Describe Kocher’s incision.
Curved incision just below the right costal margin that is usually used for open cholecystectomies.
What is Dunphy’s sign?
Pain in acute appendicitis elicited by coughing.
It is caused by rubbing of the inflamed peritoneum.
Which hormonal therapy should be offered to patients with HER2 positive breast cancer?
Trastuzumab (Herceptin®)
Which common type of benign breast tumour enlarges in response to hormones (e.g. hormone replacement therapy)?
Fibroadenoma
For further information:
● NICE guideline on mastitis, breast abscess and differential diagnoses: https://cks.nice.org.uk/topics/mastitis-breast-abscess/diagnosis/differential-diagnosis/
Which referral should be made for a patient under the age of 30 years with a suspected fibroadenoma?
Non-urgent referral to breast clinic (within 6 weeks)
For further information:
● NICE guideline on referral for breast cancer: https://cks.nice.org.uk/topics/breast-cancer-recognition-referral/management/referral-for-breast-cancer/
How does rectal prolapse tend to present?
Initially present with a lump that protrudes through the anus on straining and retracts when standing up
Eventually progresses to continuous prolapse that requires manual reduction
What are the indications for bariatric surgery on the NHS?
BMI over 50 kg/m2 (first line)
BMI over 40 kg/m2 (when lifestyle and medical treatment has failed)
BMI between 35 and 40 kg/m2 with a significant comorbidity (e.g. type 2 diabetes mellitus)
Consider bariatric surgery if the BMI is less than 35 kg/m2and they have a recent diagnosis of type 2 diabetes mellitus
For further information:
● NICE guidelines on Obesity – identification, assessment and management https://www.nice.org.uk/guidance/cg189/chapter/1-recommendations#surgical-interventions
● NHS website on weight loss surgery https://www.nhs.uk/conditions/weight-loss-surgery/
What are the indications for bariatric surgery on the NHS?
BMI over 50 kg/m2 (first line)
BMI over 40 kg/m2 (when lifestyle and medical treatment has failed)
BMI between 35 and 40 kg/m2 with a significant comorbidity (e.g. type 2 diabetes mellitus)
Consider bariatric surgery if the BMI is less than 35 kg/m2and they have a recent diagnosis of type 2 diabetes mellitus
For further information:
● NICE guidelines on Obesity – identification, assessment and management https://www.nice.org.uk/guidance/cg189/chapter/1-recommendations#surgical-interventions
● NHS website on weight loss surgery https://www.nhs.uk/conditions/weight-loss-surgery/
What is a sleeve gastrectomy?
Surgical excision of the majority (about 80%) of the stomach.
The remainder of the stomach is closed to create a tube-shaped stomach.
The stomach is therefore much smaller so patients feel full much quicker and eat less.
For further information:
● NICE guidelines on Obesity – identification, assessment and management https://www.nice.org.uk/guidance/cg189/chapter/1-recommendations#surgical-interventions
● NHS website on weight loss surgery: https://www.nhs.uk/conditions/weight-loss-surgery/
How does a breast abscess present?
Painful, red and swollen breast
Palpable lump
Systemic upset (fever)
For further information:
● NICE guidelines on mastitis and breast abscesses: https://cks.nice.org.uk/topics/mastitis-breast-abscess/
What is usually performed for a suspected breast abscess?
Ultrasound-Guided Fine Needle Aspiration
For further information:
● BMJ best practice on mastitis and breast abscess https://bestpractice.bmj.com/topics/en-gb/1084/investigations#firstOrder
What is a gallstone ileus?
Condition in which a gallstone passes through a cholecystoduodenal fistula into the small bowel and causes an obstruction (usually in the distal ileum)
What is the definitive management option for gallstone ileus?
Enterotomy to extract the obstructing gallstone
Why is an ECG useful in patients with suspected intestinal ischaemia?
To check for atrial fibrillation (major risk factor for the development of intestinal ischaemia)
What is the mainstay of managing acute mesenteric ischaemia caused by an embolus?
Embolectomy by interventional radiology
Transcatheter thrombolysis
Which investigation is most useful to request in a patient presenting for the first time with bowel obstruction?
CT Abdomen and Pelvis with Contrast
How does a perforated peptic ulcer tend to present?
Acute onset severe epigastric pain
Tachycardia
Abdominal rigidity
For further information:
● NICE guideline on Dyspepsia – proven peptic ulcer https://cks.nice.org.uk/topics/dyspepsia-proven-peptic-ulcer/
What initial investigation is important to perform in patients with a suspected gastrointestinal perforation?
Erect Chest X-Ray
How is a perforated peptic ulcer usually managed?
Emergency Laparotomy
How should breast lumps be investigated further?
Triple Assessment (clinical examination, imaging, biopsy)
For further information see:
● NICE guidelines on Breast cancer – recognition and referral: https://cks.nice.org.uk/topics/breast-cancer-recognition-referral/
Outline how fibrocystic disease is managed.
It is a benign condition so is usually managed conservatively (warm compress, well-fitting bra, simple analgesia)
Particularly large cysts can be aspirated if they continue to cause troublesome symptoms
What are the indications for making a 2-week wait referral for a breast lump?
Aged over 30 years with an unexplained breast lump with or without pain
Aged over 50 years with unilateral nipple discharge, retraction or other changes of concern
Consider referral if there are skin changes that suggest underlying breast malignancy (e.g. peau d’orange)
Consider referral if aged over 30 years with an unexplained lump in the axilla
For further information:
● NICE guidelines on breast cancer – recognition and referral: https://cks.nice.org.uk/topics/breast-cancer-recognition-referral/
How are suspected intraductal papillomas usually managed?
Triple assessment likely followed by surgical excision
What is the first step in assessing a patient with suspected peripheral artery disease?
Ankle Brachial Pressure Index
For further information:
● NICE guideline on peripheral arterial disease: diagnosis and management https://www.nice.org.uk/guidance/cg147/chapter/Recommendations#diagnosis
How do haemorrhoids tend to present?
Painless rectal bleeding
Fresh red blood that may be noted on wiping
Which examination should be performed first in a patient with suspected benign prostatic hyperplasia?
Digital Rectal Examination
What are the classical presenting features of pancreatic cancer?
Painless jaundice
Abdominal discomfort
Weight loss
Which imaging modalities tend to be used in the initial assessment of suspected pancreatic cancer?
Ultrasound Abdomen (to demonstrate biliary dilation and potentially visualise a tumour at the head of the pancreas)
CT Abdomen and Pelvis (produces better resolution images of the pancreas and allows the resectability to be determined)
How should grade IV internal haemorrhoids be managed?
Surgical Haemorrhoidectomy
What is the preferred surgical approach for patients with few morbidities who have a rectal prolapse?
Rectopexy
What investigation should be ordered urgently in the patient with suspected toxic megacolon?
CT Abdomen and Pelvis with Contrast
What is the preferred imaging modality for patients under the age of 35 years with a breast lump?
Ultrasound
How can internal haemorrhoids be visualised?
Proctoscopy
What is the initial imaging modality that is used in acute appendicitis?
Ultrasound Abdomen
How should patients on warfarin who are due to undergo major surgery with a high bleeding risk be managed?
Stop 5 days before surgery and change to low molecular weight heparin.
What imaging modality is most appropriate for a patient presenting with evidence of perforated diverticulitis?
CT Abdomen and Pelvis
NOTE: an erect chest X-ray can be useful in some instances to check for air under the diaphragm
How does an anal fissue classically present?
Pain upon defecation
Blood on toilet paper
Background of constipation
Outline the initial management of an anal fissure.
Laxatives if the patient has a background of constipation that may be contributing to the fissure
Topical analgesia (e.g. lidocaine)
How does a hiatus hernia usually present?
Persistent epigastric discomfort (dyspepsia) and heartburn
Which surgical procedure is commonly performed for patients with a hiatus hernia?
Nissen Fundoplication
How does a Mallory-Weiss tear usually present?
Streaks of blood in vomitus
Begins after a bout of violent retching or vomiting
Usually relatively mild and self-limiting
What is a sleeve gastrectomy?
Surgical excision of the majority (about 80%) of the stomach.
The remainder of the stomach is closed to create a tube-shaped stomach.
The stomach is therefore much smaller so patients feel full much quicker and eat less.
For further information:
NICE guidelines on Obesity – identification, assessment and management https://www.nice.org.uk/guidance/cg189/chapter/1-recommendations#surgical-interventions
NHS website on weight loss surgery: https://www.nhs.uk/conditions/weight-loss-surgery/
How does a perforated peptic ulcer tend to present?
Acute onset severe epigastric pain
Tachycardia
Abdominal rigidity
For further information:
NICE guideline on Dyspepsia – proven peptic ulcer https://cks.nice.org.uk/topics/dyspepsia-proven-peptic-ulcer/
What initial investigation is important to perform in patients with a suspected gastrointestinal perforation?
Erect Chest X-Ray
How is a perforated peptic ulcer usually managed?
Emergency Laparotomy
How does a breast abscess present?
Painful, red and swollen breast
Palpable lump
Systemic upset (fever)
For further information:
NICE guidelines on mastitis and breast abscesses: https://cks.nice.org.uk/topics/mastitis-breast-abscess/
What is usually performed for a suspected breast abscess?
Ultrasound-Guided Fine Needle Aspiration
For further information:
BMJ best practice on mastitis and breast abscess https://bestpractice.bmj.com/topics/en-gb/1084/investigations#firstOrder
Which hormonal therapy should be offered to patients with HER2 positive breast cancer?
Trastuzumab (Herceptin®)
Which common type of benign breast tumour enlarges in response to hormones (e.g. hormone replacement therapy)?
Fibroadenoma
For further information:
NICE guideline on mastitis, breast abscess and differential diagnoses: https://cks.nice.org.uk/topics/mastitis-breast-abscess/diagnosis/differential-diagnosis/
Which referral should be made for a patient under the age of 30 years with a suspected fibroadenoma?
Non-urgent referral to breast clinic (within 6 weeks)
For further information:
NICE guideline on referral for breast cancer: https://cks.nice.org.uk/topics/breast-cancer-recognition-referral/management/referral-for-breast-cancer/
How does rectal prolapse tend to present?
Initially present with a lump that protrudes through the anus on straining and retracts when standing up
Eventually progresses to continuous prolapse that requires manual reduction
How should breast lumps be investigated further?
Triple Assessment (clinical examination, imaging, biopsy)
For further information see:
NICE guidelines on Breast cancer – recognition and referral: https://cks.nice.org.uk/topics/breast-cancer-recognition-referral/
Outline how fibrocystic disease is managed.
It is a benign condition so is usually managed conservatively (warm compress, well-fitting bra, simple analgesia)
Particularly large cysts can be aspirated if they continue to cause troublesome symptoms
What are the indications for making a 2-week wait referral for a breast lump?
Aged over 30 years with an unexplained breast lump with or without pain
Aged over 50 years with unilateral nipple discharge, retraction or other changes of concern
Consider referral if there are skin changes that suggest underlying breast malignancy (e.g. peau d’orange)
Consider referral if aged over 30 years with an unexplained lump in the axilla
For further information:
NICE guidelines on breast cancer – recognition and referral: https://cks.nice.org.uk/topics/breast-cancer-recognition-referral/
How are suspected intraductal papillomas usually managed?
Triple assessment likely followed by surgical excision
What is a gallstone ileus?
Condition in which a gallstone passes through a cholecystoduodenal fistula into the small bowel and causes an obstruction (usually in the distal ileum)
What is the definitive management option for gallstone ileus?
What is the definitive management option for gallstone ileus?
Why is an ECG useful in patients with suspected intestinal ischaemia?
To check for atrial fibrillation (major risk factor for the development of intestinal ischaemia)
What is the mainstay of managing acute mesenteric ischaemia caused by an embolus?
Embolectomy by interventional radiology
Transcatheter thrombolysis
Describe the usual clinical features of small bowel obstruction.
Acute-onset abdominal pain
Abdominal distension
Absolute constipation
Vomiting (may be bilious)
What features would you expect to see on an abdominal X-ray in a patient with large bowel obstruction?
Peripheral dilated loops of large bowel
Colonic diameter of over 6 cm
Visible haustral folds
What is the mainstay of managing a patient with large bowel obstruction who is haemodynamically unstable following suspected perforation?
Emergency Laparotomy
What is the ultrasound appearance of a hydatid cyst?
Homogeneously hypoechogenic thin-walled cyst which may be septated and may have daughter lesions
Which diagnosis should be considered in a patient presenting with a fever and right upper quadrant pain within weeks of a cholecystectomy?
Liver abscess
Why is an arterial blood gas performed in patients with suspected acute pancreatitis?
The PaO2 can be a useful indicator of acute respiratory distress syndrome (which is an important complication of acute pancreatitis)
Which imaging modality is most appropriate for assessing pancreatic necrosis?
CT Abdomen
How is steatorrhoea secondary to pancreatic exocrine insufficiency managed?
Pancrelipase (form of pancreatic enzyme replacement therapy)
How can duodenal ulcers be distinguished clinically from gastric ulcers?
Pain usually occurs a few hours after food intake
NOTE: duodenal ulcers are much more common than gastric ulcers
How is Helicobacter pylori infection treated?
Triple Therapy
This consists of a proton pump inhibitor (e.g. omeprazole) and two antibiotics (amoxicillin and either clarithromycin or metronidazole)
What is the most definitive treatment option for haemorrhoids?
Haemorrhoidectomy
What is the best imaging modality for suspected bowel obstruction?
CT Abdomen and Pelvis with Contrast
Which operation is likely to be performed in a patient with a caecal tumour?
Right Hemicolectomy with Ileocolic Anastomosis
Outline the degrees of haemorrhoids.
1st Degree - haemorrhoids that do NOT prolapse
2nd Degree - prolapse with defecation but reduce spontaneously
3rd Degree - prolapse and require manual reduction
4th Degree - prolapse that CANNOT be reduced
How is asymptomatic stage 0 or stage 1 sarcoidosis managed?
No treatment required
How does small bowel obstruction tend to present?
Abdominal pain and distension
Vomiting
Absolute constipation
How should a breast abscess be managed?
Refer to general surgeons for consideration of incision and drainage
How can you clinically distinguish between small and large bowel obstruction?
It is difficult to distinguish clinically
Vomiting happens later in large bowel obstruction
It is largely based on the presence of risk factors (e.g. previous operations leading to adhesions)
Outline some differences between oesophageal adenocarcinoma and oesophageal squamous cell carcinoma.
Adenocarcinoma tends to affect the lower oesophagus and be associated with GORD
Squamous cell carcinoma tends to affect the mid-oesophagus and be associated with smoking and alcohol excess
Which differential should you consider in a patient with pancreatitis who becomes increasingly tachypnoeic and hypoxic?
Acute Respiratory Distress Syndrome
What is one of the most common associated symptoms in patients with acute appendicitis?
Anorexia (complete loss of appetite)
What is the outcome of a Hartmann’s procedure?
End Colostomy
Rectal Stump
How is a high-output stoma initially managed?
Restrict oral fluids
IV fluids to treat dehydration
Loperamide (or codeine)
Sometimes PPIs and histamine antagonists are used
How is urobilinogen generated?
Conjugated bilirubin is excreted by the liver into the biliary tree and, subsequently, the small intestine
The action of intestinal flora on conjugated bilirubin generates urobilinogen
Urobilinogen is then reabsorbed into the circulation and excreted in the urine
Low urinary urobilinogen is suggestive of an obstruction in the biliary tree
Outline how the time that a patient develops a fever after undergoing an operation can provide an indication of the likely underlying cause.
1-2 days post op: respiratory or part of physiological inflammatory response to surgery
3-5 days post-op: respiratory or urinary tract
5-7 days: surgical site infection, venous thromboembolism, anastomotic leak
What are the clinical manifestations of cauda equina syndrome?
Sudden-onset back pain
Lower limb weakness
Urinary retention and faecal incontinence
Lax anal tone
Saddle anaesthesia
How should mild lactational mastitis be managed?
Encourage the patient to continue breastfeeding
NOTE: antibiotics may be considered if the symptoms fail to improve with continued milk expression
What are the main clinical features of a fibroadenoma?
Small, firm, mobile lump in the breast
Usually found in young women
What are some side-effects of aromatase inhibitors used as hormonal treatment for ER-positive breast tumours?
Osteoporosis
Menopausal symptoms
Joint pain
Describe the schedule offered by the NHS Breast Cancer Screening Programme.
Every 3 years from the age of 50-71 years
Outline the indications for referral via the 2-week wait pathway to the breast clinic.
Being aged over 30 years with an unexplained breast lump and being aged over 50 years with unilateral nipple discharge or retraction.
Referral should also be considered in patients with skin changes suggestive of breast cancer (e.g. tethering, puckering, peau d’orange).
What is an intraductal papilloma?
An epithelial proliferation within the mammary ducts
Often presenting with blood nipple discharge
Outline the criteria for offering a total hip replacement in patients with a displaced intracapsular neck of femur fracture
Able to mobilise outside with no more than the use of a stick
Not cognitively impaired
Medically fit for anaesthesia and the procedure.
Describe the clinical tests used to identify a supraspinatus tear.
Reduction in abduction of the shoulder below 90 degrees
Positive Jobe’s (empty can) test
Describe the presentation of subacromial impingement syndrome.
Progressive pain which is exacerbated by abduction, notably between 60° - 120° (known as a painful arc)
Positive Hawkins-Kennedy test
What is the next step in the management of adhesive capsulitis in a patient who has not seen any improvement in their symptoms after a course of physiotherapy?
Intra-articular Steroid Injection
What is a Dupuytren’s contracture?
Benign proliferation of myofibroblasts within the fascial bands of the hand
It presents with painful nodules in the palm with associated digital contracture
How should a suspected scaphoid fracture be managed if there remains a high degree of clinical suspicion despite a normal initial X-ray?
Immobilisation in thumb splint for 10-14 days and repeat X-ray
What advice should be given to someone that has sustained an acute knee injury?
Protect
Rest
Ice
Compress
Elevate
When should patients who have undergone a knee replacement start physiotherapy?
A physiotherapist or occupational therapist should offer rehabilitation, on the day of surgery if possible and no more than 24 hours after surgery
https://pathways.nice.org.uk/pathways/joint-replacement#path=view%3A/pathways/joint-replacement/knee-replacement.xml&content=view-node%3Anodes-post-operative-rehabilitation
What is a Segond fracture?
An avulsion fracture of the proximal lateral tibia that is pathognomonic of an anterior cruciate ligament tear
What is a Baker’s cyst?
A sac of synovial fluid that can form in the popliteal fossa secondary to damage to the joint (e.g. osteoarthritis)
What does Trendelenberg sign suggest?
Weakness of hip abductors (often due to superior gluteal nerve injury)
Which nerve is most commonly affected by tight below-knee plaster casts?
Common peroneal nerve (resulting in foot drop)
How does a Baker’s cyst present?
Discomfort behind the knee
Fluctuant, non-tender swelling within the popliteal fossa
Which nerve is most likely to be damaged during an elective knee replacement?
Common peroneal nerve
Outline the Ottawa ankle rules.
Inability to weight bear immediately after the injury and in A&E
Tenderness at the lateral malleolus (or posterior edge of fibula)
Tenderness at the medial malleolus (or posterior edge of tibia)
Outline the Ottawa ankle rules.
Inability to weight bear immediately after the injury and in A&E
Tenderness at the lateral malleolus (or posterior edge of fibula)
Tenderness at the medial malleolus (or posterior edge of tibia)
Which classification system is used to determine the stability of the ankle joint in an ankle fracture?
Weber classification
When is a hemiarthroplasty indicated for the management of a neck of femur fracture?
A hemi-arthroplasty is indicated in displaced intracapsular fractures where the patient is older than 65 years of age but is not deemed to be fit enough to qualify for a total hip replacement (i.e. cognitive impairment, mobilising with more than 1 stick, significant comorbidities).
What is a Maisonneuve fracture?
Term used to describe the combination of a proximal fibular fracture and an unstable ankle fracture and/or fracture of medial malleolus
What is a Smith fracture?
Fracture of the distal radius with volar displacement of the distal fracture component. It is usually sustained after falling on a flexed wrist.
What is the mainstay of managing a Barton fracture?
In a Barton fracture, the fracture extends into the radiocarpal joint so it usually requires open reduction and internal fixation.
Outline the main steps involved in managing an open fracture.
Administer antibiotics
Tetanus prophylaxis
Transfer to theatre within 24 hours
How does carpal tunnel syndrome manifest?
Sensory: Reduced sensation across lateral half of palm and the first three digits.
Motor: Weakness of muscles of thenar eminence and lateral two lumbricals. Results in weakness of pinch grip.
Which clinical tests are used to help diagnose carpal tunnel syndrome?
Tinel Test
Phalen Test
What are the main X-ray features of osteoarthritis?
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
What is the first-line management option for pain caused by osteoarthritis?
Paracetamol and topical NSAIDs
How does adhesive capsulitis present?
Shoulder pain associated with a reduced range of both active and passive movement, especially in flexion and external rotation
Which types of ankle fracture tend to require surgical correction?
Weber C Fractures
Weber A and B fractures with talar shift, open fractures and if there is evidence of neurovascular compromise
Which other injury often occurs alongside an ACL injury?
Lateral meniscal tear
Which nerve innervates the main abductors of the hip?
Superior Gluteal Nerve
What is a Girdlestone procedure?
A radical operation that involves removing the head of the femur. It is occasionally used in patients where previous arthroplasty or fixation has failed or become infected. It may also be considered in patients with recurrent dislocation.
What DEXA scan result is diagnostic of osteoporosis?
T score of less than -2.5
Which muscle relaxant usually needs to be given at higher doses in patients with myasthenia gravis who are undergoing surgery?
Suxamethonium (patients with myasthenia gravis have an increased resistance to depolarising neuromuscular blockers)
Which commonly used anaesthetic agent does not need to be labelled when a syringe is drawn up?
Propofol (due to its milky white colour)
Which anaesthetic induction agent is best in an agitated child with a needle phobia?
Sevoflurane (inhalational anaesthetic)
What is the definition of the minimum alveolar concentration (MAC) with regards to inhalational anaesthetics?
Minimum alveolar concentration of inhaled anaesthetic that prevents a motor response to a painful stimulus in 50% of subjects
What is the mechanism of action of metaraminol?
Alpha-1 Adrenergic Receptor Agonist
It primarily causes an increase in blood pressure
Which drugs can be administered to reverse neuromuscular blockade by rocuronium at the end of an operation?
Sugammadex
OR
Neostigmine (acetylcholinesterase inhibitor)
AND
Glycopyrronium bromide (muscarinic antagonist that attenuates the bradycardic effects of neostigmine)
What are the main indications for rapid sequence induction?
Insufficient fasting (e.g. in emergencies)
Inability to protect own airway before administration of anaesthesia (e.g. intracranial injury)
Abdominal pathology (e.g. obstruction or GORD)
Delayed gastric emptying (e.g. opioids)
Pregnancy
What is the gold standard technique for determining whether a patient has been sufficiently pre-oxygenated?
End-Tidal Oxygen Concentration is more than 90%
What does CSF leakage when an epidural catheter is inserted suggest?
The tip of the catheter is in the subarachnoid space.
Which technique is used for monitoring depth of anaesthesia in a patient undergoing total intravenous anaesthesia?
EEG
How is malignant hyperthermia treated?
Dantrolene (ryanodine receptor antagonist)
Which anaesthetic agents are associated with causing malignant hyperthermia?
Inhalational anaesthetics (e.g. sevoflurane)
Depolarising neuromuscular blockers (e.g. suxamethonium)
What is the easiest way of assessing whether a patient is sufficiently paralysed during general anaesthesia?
Visual assessment of transient fasciculations (usually seen first on the forehead)
What is the mechanism of action of rocuronium?
Non-depolarising muscle relaxant (acetylcholine receptor antagonist)
What is suxamethonium apnoea?
Prolonged effects of suxamethonium due to reduced activity of plasma cholinesterase (also known as pseudocholinesterase and butyrylcholinesterase).
Which type of airway instrument is used to maintain a definitive airway?
Endotracheal Tube
Why are tracheostomies often performed in patients who will require a prolonged ventilatory wean?
It is more comfortable than an endotracheal tube and, hence, allows sedation to be reduced whilst maintaining the ability to provide ventilatory support.
How is suxamethonium apnoea treated?
Wait until the effects of the drug have worn off
Sedate the patient to prevent the development of awareness whilst paralysed
Secure the airway and ventilate the patient
What underlying defect causes suxamethonium apnoea?
Reduced activity of plasma cholinesterase (also known as butyrylcholinesterase or pseudocholinesterase)
What is the gold standard technique for determining whether an endotracheal tube is in the correct place?
Capnography (End Tidal CO2)
How can the effects of propofol be reversed?
Vasopressors can be used to amend the hypotension
There is no antidote for propofol
Which feature of nitrous oxide means that it cannot be used as a sole inhalational induction agent?
Its MAC is greater than 100
Why is cricoid pressure applied during rapid sequence induction?
To occlude the oesophagus and reduce the risk of aspiration
When does the ‘Sign In’ component of the WHO Surgical Safety Checklist take place?
Before the induction of anaesthesia
How can the pCO2 be reduced in a ventilated patient?
IWhat is the mechanism of action of suxamethonium?ncrease tidal volume
Increase respiratory rate
Decrease inspiratory: expiratory ratio
What is the mechanism of action of suxamethonium?
Depolarising muscle relaxant
It causes persistent stimulation of the acetylcholine receptor at the neuromuscular junction which results in desensitisation and the cessation of transmission through the neuromuscular junction.
Which instrument should be used to facilitate intubation if a good view of the larynx is achieved but the ETT is not passing easily through the vocal cords?
Bougie
What is the mechanism of action of neostigmine?
Competitive acetylcholinesterase inhibitor
It reduces the breakdown of acetylcholine and, hence, increases its synaptic concentrations
It is used as a reversal agent for non-depolarising neuromuscular blockers (e.g. rocuronium)
Describe the haemodynamic effects of ephedrine.
Increase heart rate
Increase blood pressure
NOTE: it has alpha- and beta-adrenergic effects
How do you convert the dose of oral morphine to parenteral morphine?
Divide the oral morphine dose by 2
What GCS warrants intubation?
8 or less
Briefly outline the ASA grades.
1: Normal healthy patient
2: Mild systemic disease
3: Severe systemic disease that is not a constant threat to life
4: Severe systemic disease that is a constant threat to life
5: Moribund patient that is not expected to survive with or without surgery
What is sugammadex used for?
Reversal of rocuronium or vecuronium
Which airway devices have a cuff?
Laryngeal mask airway
Endotracheal tube
Which scoring system is used to assess a patient’s ease of intubation during pre-operative assessment?
Mallampati Score
What is a post-dural puncture headache?
Headache that develops after spinal anaesthesia. Penetrating the dura and arachnoid mater leads to leakage of CSF into the subarachnoid space. This causes a reduction in the hydrostatic pressure in the subarachnoid space, which then causes traction across the meninges. This produces symptoms such as neck stiffness.
Which anaesthetic drug is commonly associated with causing emergency delirium in children?
Sevoflurane
Which anaesthetic agent is known to increase blood pressure and is hence contraindicated in patients with untreated hypertension?
Ketamine
Which drug can be mixed with propofol to reduce pain during administration?
Lidocaine
How do you determine the breakthrough dose of morphine?
⅙ to 1/10 the total daily dose of morphine
How should doses of depolarising neuromuscular blockers be adjusted in patients with myasthenia gravis?
Decrease dose (as there are fewer acetylcholine receptors to block)
Which type of vascular access is best when long-term treatment is required (i.e. several months)?
PICC Line (can stay in for up to 18 months)
What are the clinical features of malignant hyperthermia?
Hypercapnia (increased end-tidal CO2)
Muscle rigidity
Arrhythmias
Hyperkalaemia
Raised creatine kinase
