Surgery Flashcards
occlusion of which artery can cause acute mescenteric ischemia?
superior mesenteruc artery
classical PMHx finding for Pt with acute mesenteric ischemia
Afib
classical Px of mesenteric ischaemia
abdo pain severe and out of keeping with exam findings
Tx for mesenteric ischemia
immediate laparotmy
Px of anal fissures
painful bright red rectal bleeding
where are 90% of anal fissures found? what should be considered if they’re found elsewhere?
- on the posterior line
- alternate cause like Crohn’s
Mx of acute anal fissure
soften stool (dietary advice), bulk-forming laxative like (lactulose)
fissures are distal to the __________
dentate line
Tx options for haemorrhoids
- conservative
- rubber band ligation
- haemorrhoidectomy
diverticulitis Mx
- mild attacks
- severe/recurrent attacks
- perforations
- mild attacks: increase dietary fibre intake, Mx with Abx
- severe/recurrent attacks: segmental resection
- perforations: resection + stoma
suspected abscess in diverticulitis - Ix of choice?
CT
If diverticulitis doesn’t settle with orab abx for 72h?
admit for IV abx
______________ classification describes the extent of spread of colorectal cancer
Dukes’
external/vs internal haemorrhoids:
external originate below dentate line
internal originate above dentate line
xray finding for ischaemic colitis
thumbprinting
most common cause of LBO + other causes
tumour
volvulus, diverticular disease
Ix of choice for LBO?
Abdo XRAY - intra-peritoneal gas indicates colonic perforation
CT scan
most common type of hernia? where does it occur?
inguinal hernia
superior and medial to public tubercle
extensive physical training or coughing (from lung diseases), obesity can cause which hernia
epigastric hernia
which hernia in children needs immediate surgical repair? which resolves by itself in 4-5years?
immediate repair: congenital inguinal hernia
self resolving: infantile umbilical hernia
Cryptorchidism Mx
orchidopexy at 6-18m of age
most bladder cancers are _____ cell carcinomas
transitional
most sensitive test for hiatus hernia
barium swallow
electrolyte imbalances caused by blood transfusion
- hypoC - FFP and platelets have citrate –> chelate calcium
- hyperK
Leading cause of transfusion related deaths
Transfusion related lung injury
Upper GI bleed - 2nd line if OGD fails?
pH and manometry studies with contrast
cholecystitis - Ix and Tx
US
early laparoscopic cholecystectomy
lab Ix for acute pancreatitis
hypocalcaemia
hyperglycaemia
hypoxia
neutrophilia
elevated LDH and AST
raised amylase, lipase
acute pancreatitis causes
Gallstones
Ethanol
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
ERCP
Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)
Boerjaave’s syndrome - Dx and Tx
subcutaneous emphysema on chest wall
diagnosis is CT contrast swallow
Thoracotomy and lavage (within 12h) or insertion of T tube
Courvoisier sign
a palpable mass in the right upper quadrant (Cholangiocarcinoma)
__________ can be used to measure exocrine pancreatic function in chronic pancreatitis
faecal elastase
C/I to laparoscopic surgery
haemodynamic instability/shock
raised intracranial pressure
acute intestinal obstruction with dilated bowel loops (e.g. > 4 cm)
uncorrected coagulopathy
jaundiced Pt with malignancy: Mx
a stent will need to be inserted
digital rectal examination: tender, boggy prostate gland =
Acute bacterial prostatitis
Acute bacterial prostatitis Tx
- 14-day course of a quinolone (ciprofloxacin)
- STI screen
Ix for BPH
- U&Es
- PSA
urinary frequency-volume chart - IPSS
Mx for BPH
- alpha-1 antagonist: tamsulosin
decreases smooth muscle tone of the prostate and bladder - 5 alpha-reductase inhibitor: finasteride
blocks conversion of testosterone to dihydrotestosterone [start if high risk of progression] - TURP
[bladder cancer]
- RFs for transitional cell carcinomas
- RFs for squamous cell carrcinomas
- RFs for transitional cell carcinomas: smoking, exposure to aniline dyes
- RFs for squamous cell carrcinomas: schistomiasis
what happens when catheterised after chronic urinary retention?
decompression haematuria
It is important to exclude ____________prior to circumcision as the foreskin may be used in surgical repair
hypospadias
suspected epididymo-orchitis: what must you exclude?
torsion
Ix for erectile dysfunction
- 10 year cardiovascular risk, lipid, glucose
- free testosterone
Mx of erectile dysfunction
- PDE-5 inhibitors: sildenafil (Viagra)
- Vacuum erection devices
features of hydrocele. Ix?
- soft, non-tender swelling aterior to and below the scrotum
- you can get above the mass on examination
- transilluminates
Dx clinically but can do US to exclude underlying cause.
In babies can resolve spontaneously by 1-2 years.
Hydropnephrosis: causes of unilateral/bilateral
Unilateral: PACT
- Pelvic-ureteric obstruction (congenital or acquired)
- Aberrant renal vessels
- Calculi
- Tumours of renal pelvis
Bilateral: SUPER
- Stenosis of the urethra
- Urethral valve
- Prostatic enlargement
- Extensive bladder tumour
- Retro-peritoneal fibrosis
Ix for hydronephrosis
- US
- CT scan to detect stones
Mx of hydronephrosis
- remove obstruction, drain urine
- Acute obstruction: nephrostomy tube
- Chronic obstruction: ureteric stent/pyeloplasty
how to differentiate between ischemic and non-ischemic priapasm
Cavernosal blood gas analysis
1st line Ix for suspected prostate cancer
multiparametric MRI
most common type of renal cell cancer
clear cell
renal colic Mx
- Pain relief: NSAIDs, IV paracetamol if NSAID C/I
- for distal urteteric stones <10mm in size: alpha blockers
Imaging
- non-contrast KUB
- if pregnant woman/children: USS
If stone is <5mm and asymptomatic: watchful waiting
5-10 mm: shockwave lithotripsy
10mm - 20mm: shockwave lithiotripsy OR ureteroscopy
>20mm: percutaneous nephrolithotomy
Uretic stones:
- shcokwave lithiotripsy/alpha-blockers if <10mm
- 10-20mm: urteteroscoopy
ureteric obstruction from stones + infection =
surgical emergency!! decompress (nephrostomy tube placement, insertion of ureteric catheters and ureteric stent placement)
preventing renal stones
calcium: high fluids, low salt, potassium citrate, thiazide diuretics (increase distal tubular calcium resorption)
oxalate: cholesystramine
uric acid: allopurinol
renal tubular acidosis is a RF for
renal stones
_______ may be the presenting feature of testicular cancer
_______ may be the presenting feature of renal cancer
hydrocele
varicocele
screening AAA
a single abdominal ultrasound for males aged 65
AAA Mx
1. rescan every 3 months:
2. urgent 2 week referral to vascular surgery:
- rescan every 3 months: 4.5-5.4cm
- urgent 2 week referral to vascular surgery: >5.5cm
other than >5.5cm, what else makes an AAA at high risk of rupture
enlarging >1cm/year
Tx for AAA
elective endovascular repair (EVAR)
___________________is suggestive of critical limb ischaemia.
An ankle-brachial pressure index (ABPI) of < 0.5
Patients often report hanging their legs out of bed at night to ease the pain.
PAD Mx
Atorvastatin 80mg + clopidogrel + exercise training
Surgical: endovascular/surgical revascularization
The following are all NICE criteria for referring a patient to secondary care for consideration of interventional treatment of varicose veins as laid out in the NICE CKS summary:
significant/troublesome lower limb symptoms e.g. pain, discomfort or swelling
previous bleeding from varicose veins
skin changes secondary to chronic venous insufficiency (e.g. pigmentation and eczema)
superficial thrombophlebitis
an active or healed venous leg ulcer
how can you tell there is a subcutaneous emphysema on CXR?
You can see the striations of pec major lateral to the right lung field. Pec major is only visible if there is subcut emphysema.
For a young patient who has always had difficulty achieving an erection –>
referral to urology is appropriate
Scrotal swelling you can’t get above:
inguinal hernia
An ________ may cause bubbly urine
enterovesical fistula
an enterovesical fistula is frequently a result of colorectal malignancy
A sinusoidal ECG pattern is indicative of
severe hyperkalaemia
what blood test abnormalities would TPN cause?
TPN is known to result in derangement of liver function tests
strangulated primary unilateral inguinal hernias are usually repaired via ________ approach
an open
what type of amnesia is an indication for a CT head scan?
Over 30 minutes retrograde amnesia is an indication for a CT scan following a head injury, not anterograde amnesia
_______is a recognised complication of enteral feeding
Diarrhoea
inguinal hernia Mx rules for children
< 6 weeks old = correct within 2 days
< 6 months = correct within 2 weeks
< 6 years = correct within 2 months
pain during flexion and a palpable nodule at the base of her right ring finger are classic signs of
trigger finger
A 19-year-old man is attacked outside a club and beaten with a baseball bat. He sustains a blow to the right side of his head. He is brought to the emergency department and a policy of observation is adopted. His Glasgow coma score (GCS) deteriorates and he becomes comatose. Which of the following haemodynamic parameters is most likely to be present?
Hypertension and bradycardia are seen prior to coning. The brain autoregulates its blood supply by controlling systemic blood pressure.
Fast and weak- there’s a leak. Slow and strong-something in the head wrong
Pt becomes apnoeic after anesthesia - most likely cause? (esp if FHx)
suxomethonium apnoea
SBO + tingling down medial left thigh + tender mass per rectum?
obturator hernia
Pt needs twice as much propofol to be induced for surgery + becomes confused after and develops seizure
post-alcohol withdrawal, give IV lorazepam
A painful, non-healing ulcer secondary to trauma in a woman with a past medical history of vascular disease (myocardial infarction) =
PAD
Mx of acute limb ischemia
1. without motor dysfunction
2. with motor dysfunction
- without motor dysfunction: IV heparin
- with motor dysfunction: urgent embolectomy
A 52-year-old female patient is brought to the emergency department with altered mental status and decreased responsiveness. She is at risk for airway obstruction due to her tongue falling back. Which airway adjunct is most appropriate for this patient?
oropharyngeal, used for Pts with decreased responsiveness
