Surgery Flashcards

Question

Peak incidence of seminomas?

Answer 1

1. Infertility (x3) 2. Cryptorchidism 3. FHx 4. Klinefelter's 5. Mumps orchitis

Answer 2

1. Painless lump (most common) 2. Pain (minority) 3. Hydrocele 4. Gynaecomastia (increased oestrogen:androgen ratio)

Answer 3

hCG elevated in 20%

Answer 4

AFP and/or beta-hCG elevated in 80-85%

Answer 5

LDH in 40%

Answer 6

1. Depends whether seminoma or non-seminoma 2. Orchidectomy 3. Chemo and radio depending on staging and tumour type

Answer 7

1. 5 year survival for seminomas 95% and teratomas 85% if stage 1

Answer 8

1. GCS <13 on initial assessment 2. GCS <15 at 2 hours post-injury 3. Suspected open or depressed skull fracture 4. Any sign of basal skull fracture 5. Post-traumatic seizure 6. Focal neurological deficit 7. More than 1 episode of vomiting

Answer 9

Have experienced some LOC or amnesia since injury: 1. >65 y/o 2. Anticoagulants or bleeding disorder 3. Dangerous MOI, >1m, <5 stairs 3. >30mins retrograde amnesia of events immediately before head injury

Answer 10

1. Selective oestrogen receptor modulators (SERM) 2. Aromatase inhibitors

Answer 11

Oestrogen-receptor positive breast cancer

Answer 12

1. Menstrual disturbance = vaginal bleeding, amenorhhoea 2. Hot flushes 3. VTE 4. Endometrial Cancer

Answer 13

Anastrozole and letrozole, reduce peripheral oestrogen synthesis

Answer 14

Peripheral aromatisation accounts for the majority of oestrogen production in postmenopausal women and therefore anastrozole is used for ER +ve breast cancer in this group

Answer 15

1. Osteoporosis (Do DEXA before) 2. Hot flushes 3. Arthralgia, myalgia 4. Insomnia

Answer 16

1. 50-70 y/o 2. Mammogram every 3 years 3. >70 make own appointments

Answer 17

age of diagnosis < 40 years bilateral breast cancer male breast cancer ovarian cancer Jewish ancestry sarcoma in a relative younger than age 45 years glioma or childhood adrenal cortical carcinomas complicated patterns of multiple cancers at a young age paternal history of breast cancer (two or more relatives on the father's side of the family)

Answer 18

1. BRCA1/BRCA2 (40% lifetime risk of breast or ovarian cancer) 2. 1st degree relative premenopausal relative with breast cancer 3. Nulliparity, 1st pregnancy >30 y/o 4. Early menarche, late menopause 5. COCP, combined HRT 6. Previous breast cancer 7. Not breastfeeding 8. Ionising radiation 9. p53 gene mutations 10. Obesity 11. Previous surgery for benign disease

Answer 19

3,7,11 o clock position

Answer 20

Conservative, rubber band ligation, haemorrhoidectomy

Answer 21

1. Typically presents with painful rectal bleeding 2. Location = midline 6 (posterior midline 90%) and 12 o clock position, distal to dentate line 3. Chronic fissure > 6/52: Ulcer, sentinel pile, enlarged anal papillae

Answer 22

Crohn's, UC, C.diff

Answer 23

1. Usually due to previous ano-rectal abscess 2. Goodsalls rule determines location

Answer 24

Adenocarcinoma

Answer 25

Associated with chronic straining and constipation. Histology shows mucosal thickening, lamina propria replaced with collagen and smooth muscle (fibromuscular obliteration)

Answer 26

Biopsy of lesion mandatory

Answer 27

1. Either I&D or needle aspiration under US 2. Abx should also be given

Answer 28

When part of abdominal viscera pass into femoral canal, via the femoral ring

Answer 29

Groin lump inferolateral to the pubic tubercle, typically non-reducible, cough impulse often absent

Answer 30

1. Less common than inguinal 2. 3F:1M (esp. in multiparous women)

Answer 31

Clinical, although US is an option

Answer 32

1. Incarceration (cannot be reduced) 2. Strangulation (surgical emergency, more common in femoral) 3. Bowel obstruction 4. Bowel ischaemia and resection due to above

Answer 33

1. Surgical repair necessary due to risk of strangulation 2. Support belts/trusses should not be used 3. Laparotomy may be needed in an emergency

Answer 34

Blood supply to the herniated tissue is compromised, leading to ischaemia or necrosis

Answer 35

Epididymal cyst

Answer 36

1. Separate from body of the testicle 2. Posterior to the testicle

Answer 37

1. PCKD 2. CF 3. vHL

Answer 38

1. Dx = US 2. Rx = Usually supportive but surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts

Answer 39

1. Accumulation of fluid within the tunica vaginalis 2. Communicating and non-communicating

Answer 40

Patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life

Answer 41

Caused by excessive fluid production within the tunica vaginalis

Answer 42

1. Epididymo-orchitis 2. Testicular torsion 3. Testicular tumours

Answer 43

1. Soft, non-tender swelling of the hemiscrotum usually anterior to and below the testicle 2. Confined to scrotum, can't get above it 3. Transilluminates with pen torch

Answer 44

May be clinical but US required if doubt od testis cant be palpated

Answer 45

1. Infants = repaired if not resolving spontaneously by 1-2 years 2. Adults = conservative, further investigation

Answer 46

1. Abnormal enlargement of testicular veins 2. Usually asymptomatic but may be important as they are associated with subfertility 3. 80% left hand side

Answer 47

US with Doppler studies

Answer 48

1. Usually conservative 2. Occasionally surgery is required if pt troubled by pain

Answer 49

Anal fissures are longitudinal or elliptical tears of the squamous lining of the distal anal canal. If present for less than 6 weeks they are defined as acute, and chronic if present for more than 6 weeks.

Answer 50

1. Constipation 2. IBD 3. STI e.g. HIV, syphilis, herpes

Answer 51

1. Painful, bright red, rectal bleeding 2. Around 90% anal fissures occur on the posterior midline, if found elsewhere then consider underlying cause e.g. Crohn's

Answer 52

1. Soften stool (high fibre, high fluid, bluk forming laxatives 1st, lactulose 2nd) 2. Lubricants e.g. petroleum jelly before defecation 3. Topical anaesthetics 4. Analgesia

Answer 53

1. As per acute 2. Topical GTN 1st line 3. If not effective after 8 weeks then secondary care referral for sphincterotomy or botulinum toxin

Answer 54

Superior and medial to pubic tubercle

Answer 55

1. 75% of abdominal wall hernia 2. 95% male 3. Men have 25% lifetime risk of developing an inguinal hernia

Answer 56

1. Groin lump superomedial to pubic tubercle that disappears on pressure or when lying down 2. Discomfort and ache often worse with activity 3. Strangulation is rare

Answer 57

Through posterior wall of the inguinal canal

Answer 58

Through the inguinal canal

Answer 59

1. Treat medically fit pts even if asymptomatic 2. Truss if not fit for surgery 3. Mesh repair is associated with lowest recurrence rate (unilateral usually done open, bilateral and recurrent usually laparoscopically)

Answer 60

Return to non-manual work after 2-3 weeks and following laparoscopic rpair after 1-2 weeks

Answer 61

Small bowel stomas so irritant contents not in contact with skin

Answer 62

Colonic stoma

Answer 63

1. Surgery 2. Radiotherapy 3. Hormone therapy 4. Biological therapy 5. Chemotherapy

Answer 64

1. Should have pre-op US before primary surgery 2. if positive should have sentinel node biopsy to assess nodal burden

Answer 65

Axillary node clearance indicated at primary surgery, may lead to arm lymphoedema and functional arm impairment

Answer 66

1. Solitary lesion 2. Peripheral tumour 3. Small tumour in large breast 4. DCIS < 4cm

Answer 67

1. Multifocal tumour 2. Central tumour 3. Large lesion in small breast 4. DCIS > 4cm

Answer 68

Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds. For women who've had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes

Answer 69

Adjuvant hormonal therapy is offered if tumours are positive for hormone receptors. For many years this was done using tamoxifen for 5 years after diagnosis. Tamoxifen is still used in pre- and peri-menopausal women. In post-menopausal women, aromatase inhibitors such as anastrozole are used for this purpose*. This is important as aromatisation accounts for the majority of oestrogen production in post-menopausal women and therefore anastrozole is used for ER +ve breast cancer in this group.

Answer 70

1. Most commonly trastuzumab (Herceptin), only useful in 20-25% of tumours that are HER2 positive 2. Herceptin cannot be used in pts with a history of heart disorders

Answer 71

Cytotoxic therapy may be used either prior to surgery ('neoadjuvanant' chemotherapy) to downstage a primary lesion or after surgery depending on the stage of the tumour, for example, if there is axillary node disease - FEC-D is used in this situation

Answer 72

1. Age = 50% of 50 year old men will have evidence of BPH and 30% will have symptoms, 80% of 80 year old men have evidence of BPH 2. Ethnicity = Black > White > Asian

Answer 73

1. Voiding symptoms = SHIT 2. Storage symptoms = FUN 3. Post-micturition dribbling 4. Complications = UTI, retention, obstructive uropathy

Answer 74

1. Urine dipstick 2. Bloods = U&S, PSA 3. Urinary frequency-volume chart for 3 days 4. IPSS

Answer 75

International Prostate Symptom Score = to classify LUTS and QoL 1. 0-7 = mildly symptomatic 2. 8-19 = moderately symptomatic 20-35 = severely symptomatic

Answer 76

1. Watchful waiting 2. A1 antagonists = Tamsulosin, alfuzosin 3. 5a reduce inhibitor = Finasteride 4. Combination therapy of the above 5. If a mixture of storage and voiding symptoms that persists after treatment with alpha blocker alone, then an antimuscarinic e.g. tolterodine or darifenacin may be used 6. TURP

Answer 77

1. Tamsulosin, alfuzosin 2. Decrease smooth muscle tone of the prostate and bladder 3. Considered first line if IPSS >=8 4. Improve symptoms in 70% men

Answer 78

1. Dizziness 2. Postural hypotension 3. Dry mouth 4. Depression

Answer 79

1. Finasteride 2. Block conversion of testosterone to DHT, which is known to induce BPH 3. Indicated if pt has significantly enlarged prostate and is considered to be at high risk of progression 4. Unlike a1 antagonists causes a reduction in prostate volume and hence may slow disease progression, but takes time and symptoms may not improve for 6 months 5. May also decrease PSA concentration by up to 50%

Answer 80

1. Erectile dysfunction 2. Reduced libido 3. Ejaculation problems 4. Gynaecomastia

Answer 81

1. Diabetic on insulin with good glycaemic control can be managed with normal regimen 2. Long surgery/poorly controlled diabetes will need VRII 3. Omit SGLT2is (gliflozins) 4. Reduce once daily insulin dose by 20%

Answer 82

Vocal cord check

Answer 83

Octreotide

Answer 84

Lugol's iodine/medical therapy

Answer 85

1. Minor procedure under local = no supplementation required 2. Moderate procedure = 50mg hydrocortisone before induction and 25mg every 8h for 24h 3. Major surgery = 100mg hydrocortisone before induction and 50mg every 8h for 24h, thereafter halving dose every 24h until maintenance dose reached

Answer 86

Refer within 24h to ENT for urgent assessment and consideration of steroids

Answer 87

Prostate Ca

Answer 88

1. Lung 2. Prostate

Answer 89

1. Increasing age 2. Obesity 3. Afro-Caribbean 4. FHx

Answer 90

1. Bladder outlet obstruction = hesitancy, urinary retention 2. Haematuria, haematospermia 3. Pain: back, perineal or testicular 4. DRE = asymmetrical, hard nodular enlargement with loss of median sulcus

Answer 91

GET SMASHED G = Gallstones E = Ethanol T = Trauma S = Steroids M = Mumps A = Autoimmune e.g. PAN, Ascaris S = Scorpion Venom H = Hypertriglyceridaemia/calcaemia, hypothermia E = ERCP D = Azathioprine, bendroflumethiazide, furosemide, mesalazine, pentamidine, steroids, sodium valproate

Answer 92

1. Painless rectal bleeding most common 2. Pruritis 3. Pain, not significant unless thrombosed 4. Soiling may occur with 3rd/4th degree

Answer 93

1. External = originates below dentate line, prone to thrombosis, may be painful 2. Internal = originates above dentate line, do not generally cause pain

Answer 94

1. Grade I = dont prolapse out of anal canal 2. Grade II = prolapse on defecation but reduce spontaneously 3. Grade III = can be manually reduced 4. Grade IV = cannot be reduced

Answer 95

1. Soften stools = increase dietary fibre and fluid intake 2. Topical LA and steroid cream for symptoms 3. OP treatments = Rubber band ligation superior to injection sclerotherapy 4. Surgery reserved for large symptomatic haemorrhoids which do not respond to OP treatments 5. Newer treatment = Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy

Answer 96

1. Typically present with significant pain 2. Examination reveals a purplish, oedematous, tender subcutaneous perianal mass 3. If pt presents within 72 hours then referral to be be considered for excision. Otherwise patients can usually be managed with stool softeners, ice packs and analgesia. Symptoms usually settle within 10 days

Answer 97

Men aged 50-69 years should be referred if the PSA is >= 3.0 ng/ml OR there is an abnormal DRE

Answer 98

1. BPH 2. Prostatitis and UTI (PSA 1m after Rx) 3. Ejaculation (wait 48h) 4. Vigorous exercise (wait 48h) 5. Urinary retention 6. Instrumentation of urinary tract 7. After DRE (1 week) 8. Prostate biopsy (wait 6w)

Answer 99

1. 20% with prostate cancer have normal PSA 2. 33% of men with a PSA of 4-10 ng/ml will be found to have prostate cancer. With a PSA of 10-20 ng/ml this rises to 60% of men

Answer 100

1. Inhaled 2. IV

Answer 101

1. Volatile liquid = isoflurane, desflurane, sevoflurane --> myocardial depression, malignant hyperthermia --> used for induction and maintenance of anaesthesia 2. Nitrous oxide --> avoided in pneumothorax as can diffuse into gas filled body compartments --> used for maintenance of anaesthesia and analgesia

Answer 102

1. Propofol 2. Thiopental 3. Etomidate 4. Ketamine

Answer 103

1. Potentiates GABA 2. Pain on injection due to activation of pain receptor TRPA1, hypotension 3. Anti-emetic effect 4. Induction agent for GA, also used in ICU for ventilated pts

Answer 104

1. A babriburate, so potentiates GABA 2. Laryngospasm 3. High lipid soluble so quickly affects brain

Answer 105

1. Potentiates GABA 2. Primary adrenal suppression (secondary to reversibly inhibiting 11β-hydroxylase), myoclonus 3. Causes less hypotension than propofol and thiopental during induction and is therefore often used in cases of haemodynamic instability

Answer 106

1. Blocks NMDA receptors 2. Disorientation, hallucinations 3. Acts as dissociative anaesthetic, doesnt cause drop in BP so useful in trauma

Answer 107

1. Simple operation, can be done under LA, go home after a few hours 2. Doesn't work immediately 3. Semen analysis needs to be performed twice following before unprotected sex (usually at 16 and 20 weeks) 4. Complications = bruising, haematoma, infection, sperm granuloma, chronic testicular pain (5-30% men) 5. Success rate of reversal is 55% if done within 10 years, 25% after more than 10 years

Answer 108

Invasive ductal cancer (AKA No Special Type)

Answer 109

1. Invasive ductal carcinoma 2. Invasive lobular carcinoma 3. DCIS 4. LCIS

Answer 110

An eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer. In half of these patients, it is associated with an underlying mass lesion and 90% of such patients will have an invasive carcinoma. 30% of patients without a mass lesion will still be found to have an underlying carcinoma, usually intraductal. The remainder will have carcinoma in situ.

Answer 111

Cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast. This accounts for around 1 in 10,000 cases of breast cancer

Answer 112

1. Aged 30 or over and have an unexplained breast lump with or without pain 2. Aged 50 and over with one of in one nipple: discharge, retraction, or other changes of concern 3. CONSIDER if skin changes that suggest breast cancer or over 30 and unexplained lump in axilla

Answer 113

1. Every 2 years for 60-74 y/o, and 50 to 74 y/o in Scotland. Pts aged over 74 may request screening 2. Eligible pts sent FIT via post 3. Pts with abnormal results are offered colonoscopy

Answer 114

1. 50% normal exam 2. 40% polyps 3. 10% Malignancy

Answer 115

Asymmetrical bulge - half the sac is covered by skin of the abdomen directly above or below the umbilicus

Answer 116

1. Also known as lateral ventral hernia 2. Rare and seen in older patients 3. A hernia through the spigelian fascia (the aponeurotic layer between the rectus abdominis muscle medially and the semilunar line laterally)

Answer 117

A hernia which passes through the obturator foramen. More common in females and typical presents with bowel obstruction

Answer 118

1. A rare type of hernia where only the antimesenteric border of the bowel herniates through the fascial defect 2. Richter's hernia can present with strangulation without symptoms of obstruction

Answer 119

1. Indirect hernias resulting from a PPV 2. 1% of term babies 3. More common in premature and boys 4. 60% right, 10% bilateral 5. Should be surgically repaired soon after diagnosis as at risk of incaceration

Answer 120

1. Symmetrical bulge under umbilicus 2. More common in premature and Afro-Caribbean 3. Vast majority resolve without intervention before 4-5 y/o 4. Complications are rare

Answer 121

1. 80% alcohol 2. Genetic = CF, haemochromatosis 3. Ductal obstruction = tumours, stones, structural (pancreas divisum + annular pancreas)

Answer 122

1. Pain worse 15-30 minutes after meal 2. Steatorrhoea (symptoms of pancreatic insufficiency usually develops 5-25 years after onset of pain) 3. DM develops in majority, typically occurs more than 20 years after symptoms begin

Answer 123

1. AXR = Pancreatic calcification in 30% 2. CT = pancreatic calcification, sensitivity 80%, specificity 85% 3. Functional test = faecal elastase

Answer 124

1. Pancreatic enzyme supplements 2. Analgesia 3. Antioxidants

Answer 125

Faecal elastase

Answer 126

1. Mobile, firm breast lumps 2. 12% of all breast masses 3. Over a 2 year period 30% will get smaller 4. No increased risk of malignancy

Answer 127

1. If >3cm surgical excision is usual 2. Phyllodes tumours should be widely excised (mastectomy if lesion is large)

Answer 128

1. 7% of all Western females 2. Smooth discrete lump (may be fluctuant) 3. Small increased risk of breast cancer (esp. if younger)

Answer 129

1. Aspiration 2. Those which are bloodstained or persistently refill should be biopsied or excised

Answer 130

1. AKA Radial scars and complex sclerosing lesions 2. Usually presents as breast lump or pain 3. Mammographic changes mimic carcinoma 4. Local distortion of lobular unit without hyperplasia 5. No increased risk of malignancy

Answer 131

Should be biopsied, excision not mandatory

Answer 132

1. Generalised lumpiness/discrete lump 2. Increased cellularity of terminal lobular unit, atypical features may be present 3. Atypical features and FHx Breast Ca increases risk of malignancy

Answer 133

1. No atypical features --> conservative 2. Atypical features --> close monitoring or surgical resection

Answer 134

1. 40% have traumatic aetiology 2. Physical features mimic carcinoma 3. Mass may increase in size initially

Answer 135

Imaging and core biopsy

Answer 136

1. Usually present with blood stained nipple discharge 2. Large papillomas may present as mass 3. Discharge originates from single duct usually 4. No increased risk of malignancy, are hyperplastic lesions

Answer 137

Microdochectomy

Answer 138

1. NSAID e.g. IM diclofenac 2. Alpha adrenergic blocker to aid ureteric stone management

Answer 139

1. Urine dip and culture 2. FBC, U&E, CRP, Calcium/urate 3. Clotting if percutaneous intervention planned, cultures if pyrexial

Answer 140

1. Non-contrast CT KUB within 14 hours 2. If fever/solitary kidney/uncertain diagnosis then immediate CT KUB (to exclude ruptured AAA) 3. CT KUB has sensitivity of 97% and specificity of 95% for stones

Answer 141

Stones < 5 mm will usually pass spontaneously. Lithotripsy and nephrolithotomy may be for severe cases. Most renal stones measuring less than 5mm in maximum diameter will typically pass within 4 weeks of symptom onset. More intensive and urgent treatment is indicated in the presence of ureteric obstruction, renal developmental abnormality such as horseshoe kidney and previous renal transplant. Ureteric obstruction due to stones together with infection is a surgical emergency and the system must be decompressed. Options include nephrostomy tube placement, insertion of ureteric catheters and ureteric stent placement.

Answer 142

1. Ureteric calculi <5mm = manage expectantly 2. Complex renal calculi and staghorn calculi = percutaneous nephrolithotomy 3. Stone burden of less than 2cm in aggregate = lithotripsy 4. Stone burden of less than 2cm in pregnant females = ureteroscopy

Answer 143

A shock wave is generated external to the patient, internally cavitation bubbles and mechanical stress lead to stone fragmentation. The passage of shock waves can result in the development of solid organ injury. Fragmentation of larger stones may result in the development of ureteric obstruction. The procedure is uncomfortable for patients and analgesia is required during the procedure and afterwards.

Answer 144

A ureteroscope is passed retrograde through the ureter and into the renal pelvis. It is indicated in individuals (e.g. pregnant females) where lithotripsy is contraindicated and in complex stone disease. In most cases a stent is left in situ for 4 weeks after the procedure.

Answer 145

In this procedure, access is gained to the renal collecting system. Once access is achieved, intra corporeal lithotripsy or stone fragmentation is performed and stone fragments removed.

Answer 146

1. High fluid intake 2. Low animal protein, low salt diet 3. Thiazide diuretics (increase distal tubular calcium reabsorption)

Answer 147

1. Cholestyramine reduces urinary oxalate secretion 2. Pyridoxine reduces urinary oxalate secretion

Answer 148

1. Allopurinol 2. Urinary alkalization e.g. oral bicarbonate

Answer 149

1. AKA Fibrocystic diease, benign mammary dysplasia 2. More common in middle aged women 3. Lumpy breasts which may be painful, symptoms may worsen prior to menstruation

Answer 150

1. Dilatation of the large breast ducts 2. Most common around the menopause 3. May present with a tender lump around the areola +/- green nipple discharge 4. If ruptures may cause local inflammation, sometimes referred to as plasma cell mastitis

Answer 151

1. Dilatation of the large breast ducts 2. Most common around the menopause 3. May present with a tender lump around the areola +/- green nipple discharge 4. If ruptures may cause local inflammation, sometimes referred to as plasma cell mastitis

Answer 152

1. HIV 2. HPV 3. Genital warts 4. Poor hygeine 5. Phimosis 6. Paraphimosis 7. Balanitis 8. Age >50

Answer 153

1. Radiotherapy 2. Chemotherapy 3. Surgery

Answer 154

50% at 5 years

Answer 155

Haemophlus ducreyi

Answer 156

Traumatic SAH

Answer 157

1. Berry aneurysm = 85%, ass. ADPKD, EDS, CoA 2. AVM 3. Pituitary apoplexy 4. Arterial dissection 5. Mycotic aneurysms 6. Perimesencephalic (idiopathic venous bleed)

Answer 158

1. Thunderclap headache 2. N&V 3. Meningism 4. Coma 5. Seizures 6. Sudden death 7. ECG changes including ST elevation

Answer 159

1. CT head = negative for SAH in 7% 2. LP = performed at least 12 hours following symptom onset 3. Referral to NSX ASAP after SAH confirmed

Answer 160

Identify causative pathology that needs urgent treatment 1. CT intracranial angiogram to identify vascular lesion e.g. aneurysm or AVM 2. +/- digital subtraction angiogram (catheter angiogram)

Answer 161

Depends on causative pathology 1. Intracranial aneurysms are at risk of rebleeding and therefore require prompt intervention, preferably within 24 hours 2. Coiling by interventional radiologist 3. Craniotomy and clipping by BSX 4. Until the aneurysm is treated, the patient should be kept on strict bed rest, well-controlled blood pressure and should avoid straining in order to prevent a re-bleed of the aneurysm 5. Vasospasm is prevented using a 21-day course of nimodipine (a calcium channel inhibitor targeting the brain vasculature) and treated with hypervolaemia, induced-hypertension and haemodilution 6. Hydrocephalus is temporarily treated with an external ventricular drain (CSF diverted into a bag at the bedside) or, if required, a long-term ventriculo-peritoneal shunt

Answer 162

1. Re-bleeding (10%, most common in first 12 hours), if suspected then repeat CT, associated with 70% mortality 2. Vasospasm, 7-14 days after onset 3. Hyponatraemia due to SIADH 4. Seizures 5. Hydrocephalus 6. Death

Answer 163

1. Conscious level on admission 2. Age 3. Amount of blood visible on CT head

Answer 164

More evidence of raised ICP e.g. haemodynamic instability or change in GCS

Answer 165

1. Coverage of wound with saline impregnated gauze 2. IV broad spectrum Abx 3. Analgesia, IVF, arrangements made for return to theatre

Answer 166

1. Superficial = skin wound alone fails 2. Complete = failure of all layers

Answer 167

Antimuscarinic e.g. oxybutynin, tolterodine and darifenacin

Answer 168

Distinguishing between urinary frequency, polyuria, nocturia and nocturnal polyuria

Answer 169

1. Conservative = muscle training, bladder training, prudent fluid intake 2. Moderate/severe = alpha blocker 3. Big prostate/high risk of progression = 5a reductase inhibitor 4. Mixed symptoms of voiding and storage not responding to alpha blocker = add antimuscarinic

Answer 170

1. Conservative = fluid intake, bladder retraining 2. Antimuscarinic = oxybutynin, tolterodine, darifenacin 3. Mirabegron considered if first line drugs fail

Answer 171

1. Advise about moderating fluid intake at night 2. Furosemide 40mg in late afternoon 3. Desmopressin

Answer 172

1. Young = chlamydia and gonorrhoea 2. Older = E> coli

Answer 173

1. Unilateral testicular pain and swelling 2. Urethral discharge may be present, but urethritis is often asymptomatic 3. Factors suggesting testicular torsion including patients <20 years, severe pain and an acute onset

Answer 174

Testicular torsion

Answer 175

Guided by age 1. Young = assess for STIs 2. Older = MSU for culture

Answer 176

If organism unknown = Ceftriaxone 500mg IM single dose + doxycycline 100mg BD 10-14 days

Answer 177

Subdural haematoma

Answer 178

1.5cm in females, 1.7cm in males

Answer 179

>3cm considered aneurysmal

Answer 180

1. Smoking and HTN 2. Syphilis and CTD e.g. ED1, Marfans

Answer 181

In the UK, all men aged 65 years are offered aneurysm screening with a single abdominal ultrasound. Screening has shown to decrease death from abdominal aortic aneurysm by 44% over 4 years.

Answer 182

Superficial thrombophlebitis, as the name suggests describes the inflammation associated with thrombosis of one of the superficial veins, usually the long saphenous vein of the leg. This process is usually non-infective in nature but secondary bacterial infection may rarely occur resulting in septic thrombophlebitis. Around 20% with superficial thrombophlebitis will have an underlying deep vein thrombosis (DVT) at presentation and 3-4% of patients will progress to a DVT if untreated. The risk of DVT is partly linked to the length of vein affected - an inflammed vein > 5 cm is more likely to have an associated DVT.

Answer 183

1. LMWH for 30 days or fondaparinux for 45 days 2. If LMWH C/I, 8-12 days oral NSAID 3. Compression stocking (ABPI first) 4. US to exclude concurrent DVT 5. Pts with superficial thrombophlebitis at, or extending towards, the sapheno-femoral junction can be considered for therapeutic anticoagulation for 6-12 weeks

Answer 184

1. Deep coma of known aetiology 2. Reversible causes excluded 3. No sedation 4. Normal electrolytes

Answer 185

1. Fixed pupils, no corneal reflex, absent oculo-vestibular reflexes, no response to supra-orbital pressure 2. No cough reflex to bronchial stimulation or gagging response to pharyngeal stimulation 3. No observed respiratory effort in response to disconnection of the ventilator for long enough (typically 5 minutes) to ensure elevation of the arterial partial pressure of carbon dioxide to at least 6.0 kPa (6.5 kPa in patients with chronic carbon dioxide retention). Adequate oxygenation is ensured by pre-oxygenation and diffusion oxygenation during the disconnection (so the brain stem respiratory centre is not challenged by the ultimate, anoxic, drive stimulus)

Answer 186

Two appropriately experienced doctors on two separate occasions. Both should be experienced in performing brain stem death testing and have at least 5 years post-graduate experience. One of them must be a consultant. Neither can be a member of the transplant team (if organ donation contemplated)

Answer 187

Amylase elevated

Answer 188

1. Adhesions 2. Hernias

Answer 189

1. Diffuse, central abdominal pain 2. N&V, typically bilious 3. Constipation with complete obstruction and lack of flatulence 4. Tinkling bowel sounds

Answer 190

1. AXR = distended small bowel loops with fluid level, considered dilated if small bowel is >3cm in diameter 2. CT is definitive and more sensitive, particularly in early obstruction

Answer 191

1. NBM, IVF, NG Tube 2. Some patients settle with conservative but will otherwise require surgery

Answer 192

1. IV mannitol/furosemide whilst a/w theatre 2. Difffuse cerebral oedema may require decompressive craniotomy 3. Open depressed skull fractures may require formal surgical reduction

Answer 193

1. Appropriate in GCS 3-8 with normal CT scan 2. Mandatory in GCS 3-8 with abnormal CT scan 3. Minimum of cerebral perfusion pressure of 70mmHg in adults 4. Minimal cerebral perfusion pressure of 40-70mmHg in children

Answer 194

3rd nerve compression secondary to tentorial herniation

Answer 195

Poor CNS perfusion or bilateral 3rd nerve palsy

Answer 196

Optic nerve injury

Answer 197

1. Opiates 2. Pontine lesions 3. Metabolic encephalopathy

Answer 198

Sympathetic pathway disruption

Answer 199

Should have mesorectum evaluated with MRI

Answer 200

Lymphatic drainage of the colon follows the arterial supply

Answer 201

5FU and oxaliplatin

Answer 202

1. Anterior resection 2. AP resection (very low tumours)

Answer 203

1. Right hemicolectomy 2. Ileo-colic anastomosis

Answer 204

1. Left hemicolectomy 2. Colo-colon anastomosis

Answer 205

1. High anterior resection 2. Colo-rectal

Answer 206

1. Anterior resection 2. Colo-rectal

Answer 207

1. Low anterior resection 2. Colo-rectal +/- defunctioning stoma

Answer 208

Abdomino-perineal excision of the rectum, no anastomosis

Answer 209

In surgery of rectal cancer, in addition to excision of the rectal tube an integral part of the procedure is a meticulous dissection of the mesorectal fat and lymph nodes (total mesorectal excision/ TME)

Answer 210

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.

Answer 211

1. Duodenal atresia 2. Malrotation with volvulus 3. Jejunal/ileal atresia 4. Meconium ileus 5. NEC

Answer 212

1. 1/5000, higher in Down's 2. A few hours after birth 3. AXR = double bubble study, contrast study may confirm 4. Duodenoduodenostomy

Answer 213

1. Incomplete rotation during embryogenesis 2. 3-7 days after birth, volvulus with compromised circulation may result in peritoneal signs and haemodynamic instability 3. Upper GI contrast study may show DJ flexure is more medially placed, USS may show abnormal orientation of SMA and SMV 4. Ladd's procedure

Answer 214

1. 1/3000, vascular insiffuciency in utero 2. Usually within 24 hours of birth 3. AXR = air fluid level 4. Laparotomy with primary resection and anastomosis

Answer 215

1. 1/5000, 20% with CF 2. 24-48 hours of life with abdominal distension and bilious vomiting 3. AXR = air-fluid levels, sweat test for CF 4. Surgical decompression, serosal damage may require segmental resection

Answer 216

Torsion of the colon around its mesenteric axis resulting in compromised blood flow and closed loop obstruction

Answer 217

1. Older patients 2. Chronic constipation 3. Chagas disease 4. Neurological = Parkinsons, DMD 5. Psychiatric = Schizophrenia

Answer 218

1. All ages 2. Adhesions 3. Pregnancy

Answer 219

AXR = Coffee bean sign, air-fluid level

Answer 220

SBO on AXR

Answer 221

Rigid sigmoidoscopy with rectal tube insertion

Answer 222

Usually operative, right hemicolectomy often needed

Answer 223

1. Patients >= 40 years with unexplained weight loss AND abdominal pain 2. Patients >= 50 years with unexplained rectal bleeding 3. Patients >= 60 years with iron deficiency anaemia OR change in bowel habit 4. Tests show occult blood in their faeces (see below)

Answer 224

1. Rectal or abdominal mass 2. Unexplained anal mass or anal ulceration 3. Patients < 50 years with rectal bleeding AND any of the following unexplained symptoms/findings: abdominal pain, change in bowel habit, weight loss, iron deficiency anaemia

Answer 225

1. Patients >= 50 years with unexplained abdominal pain OR weight loss 2. Patients < 60 years with changes in their bowel habit OR iron deficiency anaemia 3. Patients >= 60 years who have anaemia even in the absence of iron deficiency

Answer 226

1. Smoking (most important) 2. Exposure to aniline dyes 3. Rubber manufacture 4. Cyclophopshamide

Answer 227

1. Schistosomiasis 2. Smoking

Answer 228

Persistent penile erection >4 hours and not associated wiht sexual stimulation

Answer 229

1. Ischaemic = impaired vasorelaxation resulting in trapping of de-oxygenatedblood within the corpus cavernosa 2. Non-ischaemic = high arterial inflow, typically due to fistula formation often either as the result of congenital or traumatic mechanisms

Answer 230

1. Bimodal, 5-10 and 20-50 y/o

Answer 231

1. Idiopathic 2. Sickle cell/other haemoglobinopathies 3. ED medication e.g. Sildafenil 4. Trauma 5. Medication = Prescribed (antis), recreational (cocaine, cannabis, ecstasy)

Answer 232

1. Erection >4 hours 2. Pain localised to penis 3. Non-painful/not fully rigid suggests non-ischaemic priapism 4. History of trauma to genital or perineal region = suggestive of non-ischaemic priapism

Answer 233

1. Cavernosal blood gas analysis to differentiate between ischaemic and non-ischaemic: in ischaemic priapism pO2 and pH would be reduced whilst pCO2 would be increased 2. Doppler or duplex ultrasonography: this can be used as an alternative to blood gas analysis to assess for blood flow within the penis. 3. A full blood count and toxicology screen can be used to assess for an underlying cause of the priapism. 4. Diagnosis of priapism is largely clinical, with investigations helping to categorise into ischaemic and non-ischaemic as well as assessing for the underlying cause.

Answer 234

1. Non-ischaemic = not a medical emergency and is normally suitable for observation as a 1st line option 2. Ischaemic = medical emergency. If the priapism has lasted longer than 4 hours, the first-line treatment is aspiration of blood from the cavernosa, this is often combined with injection of a saline flush to help clear viscous blood that has pooled. If aspiration and injection fails, then intracavernosal injection of a vasoconstrictive agent such as phenylephrine is used and repeated at 5 minute intervals. If medical therapy fails then surgical options can be considered

Answer 235

Reduce dose by 20%

Answer 236

If a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral

Answer 237

4 weeks before

Answer 238

LMWH for 10 days followed by aspirin (75 or 150 mg) for a further 28 days or LMWH for 28 days combined with anti-embolism stockings until discharge or Rivaroxaban

Answer 239

Aspirin (75 or 150 mg) for 14 days or LMWH for 14 days combined with anti-embolism stockings until discharge or Rivaroxaban

Answer 240

1. Omit on day of surgery 2. If they take BD, can have afternoon dose if operation is in morning

Answer 241

A rare, serious side effect of volatile liquid anaesthetics (isoflurane, desflurane, sevoflurane), which cause all skeletal muscle to rapidly contract, including during a neuromuscular blockade. MH is a genetic disorder, manifesting due to calcium overload in the skeletal muscle causing sustained muscular contraction and rhabdomyolysis, resulting in excess anaerobic metabolism causing acidosis. End-tidal CO2 increases as a result, along with body temperature which causes diaphoresis (excess sweating)

Answer 242

1. HTN 2. DM 3. Obesity

Answer 243

1. Atorvastatin 80mg and Clopidogrel 75mg 2. Exercise training

Answer 244

1. Endovascular revascularisation (short segments of stenosis (<10cm), aortic iiac disease and high risk patients) 2. Surgical revascularisation (long segment lesions >10cm, multifocal lesions, lesions of common femoral artery and purely infrapopliteal disease)

Answer 245

Pts with critical limb ischaemia who are not suitable for other interventions e.g. angioplasty or bypass surgery

Answer 246

1. Naftidrofuryl oxalate: vasodilator, sometimes used for patients with a poor quality of life 2. Cilostazol: phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects - not recommended by NICE

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Surgery Flashcards

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