Surgery Flashcards
When do we use tamoxifen?
Tamoxifen is used in the management of oestrogen receptor-positive breast cancer in pre or peri-menopausal women
A 42 yr old F presents worried due to a FH of breast ca and ovarian ca. What is the management?
Referral to secondary care
How do we treat oestrogen positive breast cancer?
Oestrogen positive means it has hormone receptor and that’s when you use anastrozole or letrozole in post-menopausal women, or tamoxifen in pre- or peri-menopausal women.
How do we treat HER receptor positive cancer?
Her2 positive is positive for human epifermal growth receptor 2 (HER2) and indicates treatment with herceptin
What is the most common type of breast cancer?
Invasive ductal carcinoma (no special type)
How does an epidydimal cyst present?
These are common in middle-aged men and feature a swelling posterior and separate from the body of the testicle. They are benign, and the diagnosis can be confirmed by ultrasound. Management is generally conservative.
How do germ-cell tumours present?
Germ-cell tumour presents as a firm and typically painless lump on the testicle. They are the most common malignancy in younger males, but the incidence then decreases with age. Other risk factors include infertility, cryptorchidism, mumps orchitis, and Klinefelter syndrome. There may be associated hydrocele and gynaecomastia due to an increased oestrogen to androgen ratio.
What is varicocele?
Varicocele is an abnormal enlargement of the testicular veins that is classically felt as a ‘bag of worms’ within the scrotum. It is more common on the left side and can be associated with subfertility.
How do we diagnose varicocele?
Diagnosis can be confirmed on ultrasound with Doppler studies.
How do we manage varicocele?
Management is generally conservative unless the patient is having issues with pain or subfertility.
How do we manage chronic anal fissures?
Topical glyceryl trinitrate
When should you stop the COCP prior to surgery?
1/12
When do we perform a low anterior resection surgery?
Low anterior resection is the operation of choice for this patient and patients whose malignancy lies in the upper two thirds of their rectum. This surgery involves resection of the area of malignancy, followed by anastomosis.
When do we perform abdominoperineal resections?
abdominoperineal resections, which involve the removal of the anus, rectum and section of sigmoid colon, are used for tumours located in the distal one third of the rectum.
How do we manage obstructive urinary caliculi?
Patients with obstructive urinary calculi and signs of infection require urgent renal decompression and IV antibiotics due to the risk of sepsis
Why can we give alpha blockers in renal colic?
Alpha blockers like tamsulosin can help the stone pass
What is fibroadenosis?
Most common in middle-aged women
‘Lumpy’ breasts which may be painful. Symptoms may worsen prior to menstruation
What is Stellwag’s sign?
Stellwag sign is reduced blinking seen in Grave’s disease (from exophthalmos)
What is the blood loss like with haemorrhoids?
Post defecatory rectal bleeding that is noted in the toilet pan and on toilet paper is often haemorroidal in nature
What can increase the risk of breast cancer?
HRT, early menarche, late menopause and COCP all increase the risk of breast cancer whereas multiple pregnancy and breastfeeding reduce the risk
Which antigen do we use to monitor patients with colorectal ca?
Carcinoembryonic antigen
What is administered in most cases of SAH?
Nimodipine
How do we manage hernias in babies?
Congenital hernias
inguinal: repair ASAP
umbilical: manage conservatively
Which type of resection is used for a Caecal, ascending or proximal transverse colon malignancy?
R hemicolectomy
Which type of resection is used for a distal transverse/descending colon malignancy?
L hemicolectomy
Which type of resection is used for a sigmoid colon malignancy?
High anterior resection
Which type of resection is used for a upper rectum malignancy?
Anterior resection (TME)
Which type of resection is used for a low rectum malignancy?
Anterior resection (Low TME)
Which type of resection is used for an anal verge malignancy?
Abdomino-perineal excision of rectum
Which operation: known sigmoid colon tumour that was graded as T3N0M0. Surgeons recommended surgery as the first line treatment for this and it was scheduled for next week. However, he has just been brought to the emergency department with intense abdominal pain, which was found to be due to a perforation.
Hartmann’s - leads to end colostomy
What is diffuse axonal injury?
Diffuse axonal injury occurs when the head is rapidly accelerated or decelerated. There are 2 components:
- Multiple haemorrhages
- Diffuse axonal damage in the white matter
Up to 2/3 occur at the junction of grey/white matter due to the different densities of the tissue. The changes are mainly histological and axonal damage is secondary to biochemical cascades. Often there are no signs of a fracture or contusion.
How do we manage metformin prior to surgery?
Surgery / metformin on day of surgery:
OD or BD: take as normal
TDS: miss lunchtime dose
assumes only one meal will be missed during surgery, eGFR > 60 and no contrast during procedure
What is the key side effect of aromatase inhibitors?
Aromatase inhibitors (e.g. anastrozole) may cause osteoporosis
DEXA scan prior to initiation
How does duodenal ulcer present?
episodic epigastric pain that is relieved by eating.
How do we manage sulfonylureas prior to surgery?
Surgery / sulfonylureas on day of surgery:
omit on the day of surgery
exception is morning surgery in patients who take BD - they can have the afternoon dose
How do we manage asymptomatic inguinal hernia?
Studies looking at conservative management tend to find that many patients become symptomatic and eventually have surgery anyway. As this patient is medically fit most clinicians would refer for surgical repair
How does extradural haematoma present?
This is due to the classic presentation of a ‘lucid interval’ following head trauma, where the patient initially loses consciousness, regains it and appears well for a period of time before deteriorating again.
What is the pathophysiology in extradural haematoma?
Extradural haematomas typically occur when there is a tear in the middle meningeal artery, often following a skull fracture. The bleeding accumulates between the dura mater and the skull, leading to increased intracranial pressure and neurological deficits.
What is cerebral contusion?
A cerebral contusion is less likely in this case as it refers to bruising of brain tissue following blunt force trauma. While cerebral contusions can cause loss of consciousness and neurological deficits, they do not typically present with a lucid interval. Cerebral contusions are more commonly associated with diffuse axonal injury or coup-contrecoup injuries.
How do we manage hiatus hernia?
Majority do not need surgical repair
How does duct papilloma present?
This patient is presenting with a unilateral bloody discharge and a small lumpy mass. This is most likely to be a duct papilloma. These occur in middle-aged women and develop in the lactiferous ducts just below the nipple. They form a lumpy mass and are associated with a bloody discharge.
What is mammary duct ectasia?
Mammary duct ectasia is a benign breast condition in which the milk ducts beneath the nipple become inflamed and dilated. Patients usually present with an angry, erythematous breast with a creamy or green discharge. It occurs most often in women during or after menopause.
What is the most common cause of epididymo-orchitis?
Chlamydia
How do we manage hydroceles in infants?
Communicating hydroceles are common in newborn males and often resolve spontaneously
How do we manage fibroadenoma?
Current guidance states that, for a young female with small fibroadenomas - less than 3cm on imaging - a biopsy is not required if a straightforward diagnosis. The most appropriate step is to reassure and monitor. Over the next 2 years, 30% will get smaller. There is no increase in the risk of breast cancer.
How do we grade haemorrhoids?
Grade I haemorrhoids are those which do not prolapse outside the anal canal. They may bleed but are only visible via proctoscopy, therefore this grade does not match with the patient’s symptoms of prolapsing piles which need manual reduction.
Grade II haemorrhoids are those that prolapse during defecation but reduce spontaneously afterwards. As our patient has to manually reduce his piles following defecation, his condition cannot be categorised as Grade II.
The correct answer is Grade III. In the classification of internal haemorrhoids, Grade III refers to haemorrhoids that prolapse during bowel movements and require manual reduction. This grading system is based on the extent of prolapse and the requirement for manual reduction.
Grade IV is wrong as well. These are haemorrhoids that are permanently prolapsed and cannot be manually reduced back into the anal canal. In this scenario, the man can still manually reduce his piles after defecation so he would not be classified as having Grade IV haemorrhoids.
What are sitz baths used for?
Sitz baths are a form of hydrotherapy where the patient sits in warm water up to their hips. While they can provide temporary relief from symptoms such as itching, burning or discomfort associated with haemorrhoids, they do not address the underlying issue of increased pressure on the anal cushions due to hard stools and straining.
