Surgery Flashcards

1
Q

Ascending cholangitis cause?

A

Bacterial infection, typically E.coli, of the biliary tree

*a life-threatening infection of the biliary tree caused by bacterial invasion, usually secondary to obstruction. The obstruction allows bile to become stagnant, creating an environment for bacterial proliferation and infection.

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2
Q

Most common predisposing factor to ascending cholangitis?

A

Gallstones

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3
Q

Charcot’s triad for ascending cholangitis?

A
  1. Fever
  2. RUQ pain
  3. Jaundice
  4. (+ hypotension and confusion = Reynolds’ pentad)
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4
Q

Ascending cholangitis Ix?

A

US to look for bile duct dilatation and bile stones

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5
Q

Ascending cholangitis Rx?

A
  1. IV Abx
  2. ERCP after 24-48 hours to relieve any obstruction
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6
Q

Head injury, lucid interval?

A

Extradural (epidural) haematoma

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7
Q

Primary brain injury types?

A
  1. Focal = contusion/haematoma
  2. Diffuse = diffuse axonal injury
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8
Q

Contusion types?

A

Coup vs. contre-coup

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9
Q

Intracranial haematoma types?

A
  1. Extradural
  2. Subdural
  3. Intracerabral
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10
Q

Secondary brain injury?

A

When cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury. The normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia

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11
Q

Cushing’s reflex?

A

Hypertension and bradycardia in response to raised ICP, occurs late, usually a pre-terminal event

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12
Q

RFs for subdural haematoma?

A
  1. Age
  2. Alcoholism
  3. Anticoagulation
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13
Q

Head injury, fluctuating confusion?

A

Subdural haematoma

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14
Q

Medical benefits of circumcision?

A
  1. Reduces risk of penile cancer
  2. Reduces risk of UTI
  3. Reduces risk of STIs incl. HIV
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15
Q

Medical indications for circumcision?

A
  1. Phimosis
  2. Recurrent balanitis
  3. Balanitis xerotica obliterans
  4. Paraphimosis
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16
Q

First linke Ix for prostate cancer?

A

Multiparametric MRI

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17
Q

Complications of TRUS biopsy?

A
  1. Sepsis
  2. Pain
  3. Fever
  4. Haematuria and rectal bleeding
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18
Q

Multiparametric MRI for prostate cancer interpretation?

A

Reported using 5 point Likert scale
1. If >=3 then prostate biopsy is offered
2. If 1-2 then d/w pt pros and cons of having a biopsy

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19
Q

Most common malignancy in men 20-30 years?

A

Testicular cancer

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20
Q

95% of testicular cancers are?

A

Germ cell tumours

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21
Q

Germ cell types?

A
  1. Seminomas
  2. Non-seminomas
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22
Q

Non-seminoma types?

A
  1. Embryonal
  2. Yolk sack
  3. Teratoma
  4. Choriocarcinoma
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23
Q

Non-germ cell tumour types?

A
  1. Leydig cell tumours
  2. Sarcomas
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24
Q

Peak incidence of teratomas?

A

25 y/o

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25
Peak incidence of seminomas?
35 y/o
26
RFs for testicular cancer?
1. Infertility (x3) 2. Cryptorchidism 3. FHx 4. Klinefelter's 5. Mumps orchitis
27
Testicular cancer features?
1. Painless lump (most common) 2. Pain (minority) 3. Hydrocele 4. Gynaecomastia (increased oestrogen:androgen ratio)
28
Seminoma marker?
hCG elevated in 20%
29
Non-seminoma marker?
AFP and/or beta-hCG elevated in 80-85%
30
Germ cell tumour marker?
LDH in 40%
31
Testicular cancer Dx?
US
32
Testicular cancer Rx?
1. Depends whether seminoma or non-seminoma 2. Orchidectomy 3. Chemo and radio depending on staging and tumour type
33
Testicular cancer prognosis?
1. 5 year survival for seminomas 95% and teratomas 85% if stage 1
34
Immediate CT Head indications?
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
35
CT scan within 8 hours indications?
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
36
Anti-oestrogen drugs?
1. Selective oestrogen receptor modulators (SERM) 2. Aromatase inhibitors
37
SERM example?
Tamoxifen
38
Tamoxifen use?
Oestrogen-receptor positive breast cancer
39
SERM side effects?
1. Menstrual disturbance = vaginal bleeding, amenorhhoea 2. Hot flushes 3. VTE 4. Endometrial Cancer
40
Aromatase inhibitor examples?
Anastrozole and letrozole, reduce peripheral oestrogen synthesis
41
When are aromatase inhibitors used?
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
42
Aromatase inhibitor s/e?
1. Osteoporosis (Do DEXA before) 2. Hot flushes 3. Arthralgia, myalgia 4. Insomnia
43
Breast screening mushkies?
1. 50-70 y/o 2. Mammogram every 3 years 3. >70 make own appointments
44
Only one relative with breast cancer referral criteria?
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)
45
Breast cancer risk factors?
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
46
Haemorrhoid location?
3,7,11 o clock position
47
Haemorrhoid treatment?
Conservative, rubber band ligation, haemorrhoidectomy
48
Anal fissure mushkies?
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
49
Proctitis causes?
Crohn's, UC, C.diff
50
Anal fistula mushkies?
1. Usually due to previous ano-rectal abscess 2. Goodsalls rule determines location
51
Most common anal cancer?
SCC
52
Most common rectal cancer?
Adenocarcinoma
53
Solitary rectal ulcer?
Associated with chronic straining and constipation. Histology shows mucosal thickening, lamina propria replaced with collagen and smooth muscle (fibromuscular obliteration)
54
Solitary rectal ulcer management?
Biopsy of lesion mandatory
55
Most common cause of breast abscess in lactational women?
S. aureus
56
Breast abscess management?
1. Either I&D or needle aspiration under US 2. Abx should also be given
57
Femoral hernia definition?
When part of abdominal viscera pass into femoral canal, via the femoral ring
58
Femoral hernia features?
Groin lump inferolateral to the pubic tubercle, typically non-reducible, cough impulse often absent
59
Femoral hernia epidemiology?
1. Less common than inguinal 2. 3F:1M (esp. in multiparous women)
60
Femoral hernia Dx?
Clinical, although US is an option
61
Femoral hernia complications?
1. Incarceration (cannot be reduced) 2. Strangulation (surgical emergency, more common in femoral) 3. Bowel obstruction 4. Bowel ischaemia and resection due to above
62
Femoral hernia management?
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
63
Strangulated hernia?
Blood supply to the herniated tissue is compromised, leading to ischaemia or necrosis
64
Most common cause of scrotal swelling in primary care?
Epididymal cyst
65
Epididymal cyst features?
1. Separate from body of the testicle 2. Posterior to the testicle
66
Epididymal cyst associated conditions?
1. PCKD 2. CF 3. vHL
67
Epididymal cyst Dx and Rx?
1. Dx = US 2. Rx = Usually supportive but surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts
68
Hydrocele definition and classification?
1. Accumulation of fluid within the tunica vaginalis 2. Communicating and non-communicating
69
Communicating hydrocele?
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
70
Non-communicating hydrocoele?
Caused by excessive fluid production within the tunica vaginalis
71
Hydrocoele secondary causes?
1. Epididymo-orchitis 2. Testicular torsion 3. Testicular tumours
72
Hydrocoele features?
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
73
Hydrocoele Dx?
May be clinical but US required if doubt od testis cant be palpated
74
Hydrocoele management?
1. Infants = repaired if not resolving spontaneously by 1-2 years 2. Adults = conservative, further investigation
75
Varicocoele mushkies?
1. Abnormal enlargement of testicular veins 2. Usually asymptomatic but may be important as they are associated with subfertility 3. 80% left hand side
76
Varicocele Dx?
US with Doppler studies
77
Varicocele Rx?
1. Usually conservative 2. Occasionally surgery is required if pt troubled by pain
78
Anal fissure definition?
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.
79
Anal fissure RFs?
1. Constipation 2. IBD 3. STI e.g. HIV, syphilis, herpes
80
Anal fissure features?
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
81
Acute anal fissure (<1 week) management?
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
82
Chronic anal fissure management?
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
83
Inguinal hernia location?
Superior and medial to pubic tubercle
84
Inguinal hernia mushkies?
1. 75% of abdominal wall hernia 2. 95% male 3. Men have 25% lifetime risk of developing an inguinal hernia
85
Inguinal hernia features?
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
86
Direct hernia?
Through posterior wall of the inguinal canal
87
Indirect hernia?
Through the inguinal canal
88
Inguinal hernia management?
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)
89
Open inguinal hernia repair department for work and pensions advice?
Return to non-manual work after 2-3 weeks and following laparoscopic rpair after 1-2 weeks
90
Spouted stoma?
Small bowel stomas so irritant contents not in contact with skin
91
Flush with skin stoma?
Colonic stoma
92
Breast cancer management x5?
1. Surgery 2. Radiotherapy 3. Hormone therapy 4. Biological therapy 5. Chemotherapy
93
Breast cancer women without palpable axillary lymphadenopathy at presentation?
1. Should have pre-op US before primary surgery 2. if positive should have sentinel node biopsy to assess nodal burden
94
Breast cancer women with palpable axillary lymphadenopathy?
Axillary node clearance indicated at primary surgery, may lead to arm lymphoedema and functional arm impairment
95
Wide local excision indications?
1. Solitary lesion 2. Peripheral tumour 3. Small tumour in large breast 4. DCIS < 4cm
96
Mastectomy indications?
1. Multifocal tumour 2. Central tumour 3. Large lesion in small breast 4. DCIS > 4cm
97
Radiotherapy in breast cancer?
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
98
Hormonal therapy for breast cancer?
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.
99
Biological therapy for breast cancer?
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
100
Chemotherapy in breast cancer?
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
101
BPH RFs?
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
102
LUTS?
1. Voiding symptoms = SHIT 2. Storage symptoms = FUN 3. Post-micturition dribbling 4. Complications = UTI, retention, obstructive uropathy
103
BPH Ix?
1. Urine dipstick 2. Bloods = U&S, PSA 3. Urinary frequency-volume chart for 3 days 4. IPSS
104
IPSS?
International Prostate Symptom Score = to classify LUTS and QoL 1. 0-7 = mildly symptomatic 2. 8-19 = moderately symptomatic 20-35 = severely symptomatic
105
BPH Rx?
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
106
Alpha-1 antagonist for BPH mushkies?
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
107
Alpha 1 antagonist s/e?
1. Dizziness 2. Postural hypotension 3. Dry mouth 4. Depression
108
5a-reductase for BPH muskies?
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%
109
5a-reductase s/e?
1. Erectile dysfunction 2. Reduced libido 3. Ejaculation problems 4. Gynaecomastia
110
Diabetic surgery preparations?
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%
111
Thyroid surgery prep?
Vocal cord check
112
Thoracic duct surgery prep?
Cream
113
Carcinoid tumour surgery prep?
Octreotide
114
Thyrotoxicosis surgery prep?
Lugol's iodine/medical therapy
115
Pt on steroids having surgery?
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
116
Sudden onset sensorineural hearing loss?
Refer within 24h to ENT for urgent assessment and consideration of steroids
117
Most common cancer in adult males?
Prostate Ca
118
Most common cause of death due to cancer in men?
1. Lung 2. Prostate
119
Prostate cancer RFs?
1. Increasing age 2. Obesity 3. Afro-Caribbean 4. FHx
120
Prostate cancer features?
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
121
Acute pancreatitis causes?
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
122
Haemorrhoids features?
1. Painless rectal bleeding most common 2. Pruritis 3. Pain, not significant unless thrombosed 4. Soiling may occur with 3rd/4th degree
123
Haemorrhoid external vs. internal?
1. External = originates below dentate line, prone to thrombosis, may be painful 2. Internal = originates above dentate line, do not generally cause pain
124
Haemorrhoid Grading?
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
125
Haemorrhoid management?
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
126
Acute thrombosed external haemorrhoid Rx?
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
127
PSA referral threshold?
Men aged 50-69 years should be referred if the PSA is >= 3.0 ng/ml OR there is an abnormal DRE
128
PSA levels may be raised by?
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)
129
PSA sensitivity and specificity?
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
130
General anaesthetic classification?
1. Inhaled 2. IV
131
Inhaled anaesthetics?
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
132
IV Anaesthetics?
1. Propofol 2. Thiopental 3. Etomidate 4. Ketamine
133
Propofol mushkies?
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
134
Thiopental mushkies?
1. A babriburate, so potentiates GABA 2. Laryngospasm 3. High lipid soluble so quickly affects brain
135
Etomidate mushkies?
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
136
Ketamine mushkies?
1. Blocks NMDA receptors 2. Disorientation, hallucinations 3. Acts as dissociative anaesthetic, doesnt cause drop in BP so useful in trauma
137
Vasectomy failure rate?
1 in 2000
138
Vasectomy mushkies?
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
139
Most common type of breast cancer?
Invasive ductal cancer (AKA No Special Type)
140
Breast cancer types?
1. Invasive ductal carcinoma 2. Invasive lobular carcinoma 3. DCIS 4. LCIS
141
Paget's disease of the nipple?
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.
142
Inflammatory breast cancer?
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
143
Breast cancer 2ww referral?
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
144
Faecal Immunochemical Test (FIT) screening?
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
145
Colonoscopy after FIT screening?
1. 50% normal exam 2. 40% polyps 3. 10% Malignancy
146
Inguinal hernias more common on which side?
Right
147
Paraumbilical hernia?
Asymmetrical bulge - half the sac is covered by skin of the abdomen directly above or below the umbilicus
148
Spigelian hernia?
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)
149
Obturator hernia?
A hernia which passes through the obturator foramen. More common in females and typical presents with bowel obstruction
150
Richter hernia?
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
151
Congenital inguinal hernia mushkies?
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
152
Infantile umbilical hernia?
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
153
Chronic pancreatitis causes?
1. 80% alcohol 2. Genetic = CF, haemochromatosis 3. Ductal obstruction = tumours, stones, structural (pancreas divisum + annular pancreas)
154
Chronic pancreatitis features?
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
155
Chronic pancreatitis Ix?
1. AXR = Pancreatic calcification in 30% 2. CT = pancreatic calcification, sensitivity 80%, specificity 85% 3. Functional test = faecal elastase
156
Chronic pancreatitis management?
1. Pancreatic enzyme supplements 2. Analgesia 3. Antioxidants
157
Assessment of pancreatic exocrine function?
Faecal elastase
158
Fibroadenoma features?
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
159
Fibroadenoma Rx?
1. If >3cm surgical excision is usual 2. Phyllodes tumours should be widely excised (mastectomy if lesion is large)
160
Breast cyst features?
1. 7% of all Western females 2. Smooth discrete lump (may be fluctuant) 3. Small increased risk of breast cancer (esp. if younger)
161
Breast cyst Rx?
1. Aspiration 2. Those which are bloodstained or persistently refill should be biopsied or excised
162
Sclerosing adenosis features?
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
163
Sclerosing adenosis Rx?
Should be biopsied, excision not mandatory
164
Epithelial hyperplasia features?
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
165
Epithelial hyperplasia Rx?
1. No atypical features --> conservative 2. Atypical features --> close monitoring or surgical resection
166
Fat necrosis features?
1. 40% have traumatic aetiology 2. Physical features mimic carcinoma 3. Mass may increase in size initially
167
Fat necrosis Rx?
Imaging and core biopsy
168
Duct papilloma features?
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
169
Duct papilloma Rx?
Microdochectomy
170
Renal colic initial management?
1. NSAID e.g. IM diclofenac 2. Alpha adrenergic blocker to aid ureteric stone management
171
Renal colic Bloods?
1. Urine dip and culture 2. FBC, U&E, CRP, Calcium/urate 3. Clotting if percutaneous intervention planned, cultures if pyrexial
172
Renal colic imaging?
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
173
Renal stones Initial Rx?
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.
174
Therapeutic selection for renal stones?
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
175
ESWL process?
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.
176
Ureteroscopy process?
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.
177
Percutaneous nephrolithotomy procedure?
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.
178
Prevention of calcium stones?
1. High fluid intake 2. Low animal protein, low salt diet 3. Thiazide diuretics (increase distal tubular calcium reabsorption)
179
Prevention of oxalate stones?
1. Cholestyramine reduces urinary oxalate secretion 2. Pyridoxine reduces urinary oxalate secretion
180
Prevention of uric acid stones?
1. Allopurinol 2. Urinary alkalization e.g. oral bicarbonate
181
Fibroadenosis mushkies?
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
182
Mammary duct ectasia mushkies?
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
183
Mammary duct ectasia mushkies?
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
184
Penile cancer usual type?
SCC
185
Penile cancer risk factors?
1. HIV 2. HPV 3. Genital warts 4. Poor hygeine 5. Phimosis 6. Paraphimosis 7. Balanitis 8. Age >50
186
Penile cancer Rx?
1. Radiotherapy 2. Chemotherapy 3. Surgery
187
Penile cancer prognosis?
50% at 5 years
188
Chancroid cause?
Haemophlus ducreyi
189
Most common cause of SAH?
Traumatic SAH
190
Causes of spontaneous SAH?
1. Berry aneurysm = 85%, ass. ADPKD, EDS, CoA 2. AVM 3. Pituitary apoplexy 4. Arterial dissection 5. Mycotic aneurysms 6. Perimesencephalic (idiopathic venous bleed)
191
SAH features?
1. Thunderclap headache 2. N&V 3. Meningism 4. Coma 5. Seizures 6. Sudden death 7. ECG changes including ST elevation
192
Confirmation of SAH?
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
193
After spontaneous SAH confirmed, what to do?
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)
194
SAH Rx?
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
195
Complications of aneurysmal SAH?
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
196
Important predictive factors in SAH?
1. Conscious level on admission 2. Age 3. Amount of blood visible on CT head
197
When is clipping of SAH used instead of coiling?
More evidence of raised ICP e.g. haemodynamic instability or change in GCS
198
Abdominal wound dehiscence Rx?
1. Coverage of wound with saline impregnated gauze 2. IV broad spectrum Abx 3. Analgesia, IVF, arrangements made for return to theatre
199
Abdominal wound dehiscence types?
1. Superficial = skin wound alone fails 2. Complete = failure of all layers
200
Overactive bladder Rx?
Antimuscarinic e.g. oxybutynin, tolterodine and darifenacin
201
What is urinary frequency-volume chart helpful for?
Distinguishing between urinary frequency, polyuria, nocturia and nocturnal polyuria
202
Predominantly voiding symptoms Rx?
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
203
Overactive bladder Rx?
1. Conservative = fluid intake, bladder retraining 2. Antimuscarinic = oxybutynin, tolterodine, darifenacin 3. Mirabegron considered if first line drugs fail
204
Nocturia Rx?
1. Advise about moderating fluid intake at night 2. Furosemide 40mg in late afternoon 3. Desmopressin
205
Epididymo-orchitis causes?
1. Young = chlamydia and gonorrhoea 2. Older = E> coli
206
Epididymo-orchitis features?
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
207
Most important DDx of epididymo-orchitis?
Testicular torsion
208
Epididymo-orchitis Ix?
Guided by age 1. Young = assess for STIs 2. Older = MSU for culture
209
Epididymo-orchitis Rx?
If organism unknown = Ceftriaxone 500mg IM single dose + doxycycline 100mg BD 10-14 days
210
Fluctuating confusion/consciousness?
Subdural haematoma
211
Normal infrarenal aorta diameter after 50 years?
1.5cm in females, 1.7cm in males
212
AAA diameter?
>3cm considered aneurysmal
213
AAA Rfs?
1. Smoking and HTN 2. Syphilis and CTD e.g. ED1, Marfans
214
AAA screening?
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.
215
Superficial thrombophlebitis mushkies?
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.
216
Superficial thrombophlebitis Rx?
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
217
Criteria for brainstem death testing?
1. Deep coma of known aetiology 2. Reversible causes excluded 3. No sedation 4. Normal electrolytes
218
Testing for brain death?
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)
219
Brainstem death testing done by?
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)
220
Small bowel obstruction amylase levels?
Amylase elevated
221
Most common cause of SBO?
1. Adhesions 2. Hernias
222
SBO features?
1. Diffuse, central abdominal pain 2. N&V, typically bilious 3. Constipation with complete obstruction and lack of flatulence 4. Tinkling bowel sounds
223
SBO Ix?
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
224
SBO Rx?
1. NBM, IVF, NG Tube 2. Some patients settle with conservative but will otherwise require surgery
225
Raised ICP Rx?
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
226
Raised ICP monitoring?
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
227
Unilaterally dilated pupil, sluggish/fixed?
3rd nerve compression secondary to tentorial herniation
228
Bilaterally dilated pupils, sluggish/fixed?
Poor CNS perfusion or bilateral 3rd nerve palsy
229
Unilateral dilated or equal pupils, cross reactive (Marcus-Gunn)?
Optic nerve injury
230
Bilaterally constricted pupils?
1. Opiates 2. Pontine lesions 3. Metabolic encephalopathy
231
Unilateral constricted pupil, light response preseved?
Sympathetic pathway disruption
232
Pts whose colorectal tumours lie below peritoneal reflection?
Should have mesorectum evaluated with MRI
233
Why are most colorectal cancer surgeries tailored around resection of particular lymphatic chains?
Lymphatic drainage of the colon follows the arterial supply
234
Common colonic cancer chemo?
5FU and oxaliplatin
235
Rectal cancer surgeries?
1. Anterior resection 2. AP resection (very low tumours)
236
Caecal, ascending or proximal transverse colon cancer --> resection and anastomosis?
1. Right hemicolectomy 2. Ileo-colic anastomosis
237
Distal transverse, descending colon cancer --> resection and anastomosis?
1. Left hemicolectomy 2. Colo-colon anastomosis
238
Sigmoid colon cancer --> resection and anastomosis?
1. High anterior resection 2. Colo-rectal
239
Upper rectum cancer --> resection and anastomosis?
1. Anterior resection 2. Colo-rectal
240
Low rectum cancer --> resection and anastomosis?
1. Low anterior resection 2. Colo-rectal +/- defunctioning stoma
241
Anal verge cancer --> resection and anastomosis?
Abdomino-perineal excision of the rectum, no anastomosis
242
TME?
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)
243
When are AP resections used?
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.
244
Bilious vomiting in neonates?
1. Duodenal atresia 2. Malrotation with volvulus 3. Jejunal/ileal atresia 4. Meconium ileus 5. NEC
245
Duodenal atresia mushkies?
1. 1/5000, higher in Down's 2. A few hours after birth 3. AXR = double bubble study, contrast study may confirm 4. Duodenoduodenostomy
246
Malrotation with volvulus mushkies?
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
247
Jejunal/ileal atresia mushkies?
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
248
Meconium ileus mushkies?
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
249
What size fibroadenoma should be excised?
>3cm
250
Volvulus definition?
Torsion of the colon around its mesenteric axis resulting in compromised blood flow and closed loop obstruction
251
Most common volvulus?
Sigmoid
252
Sigmoid volvulus associations?
1. Older patients 2. Chronic constipation 3. Chagas disease 4. Neurological = Parkinsons, DMD 5. Psychiatric = Schizophrenia
253
Caecal volvulus associations?
1. All ages 2. Adhesions 3. Pregnancy
254
Sigmoid volvulus Dx?
AXR = Coffee bean sign, air-fluid level
255
Caecal volvulus Dx?
SBO on AXR
256
Sigmoid volvulus Rx?
Rigid sigmoidoscopy with rectal tube insertion
257
Caecal volvulus Rx?
Usually operative, right hemicolectomy often needed
258
Colorectal cancer 2ww referral indications?
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)
259
Urgent 2ww 'consideration'?
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
260
FIT test recommendations for pts with new symptoms who do not meet the 2 week criteria?
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
261
Bladder cancer (transitional cell) risk factors?
1. Smoking (most important) 2. Exposure to aniline dyes 3. Rubber manufacture 4. Cyclophopshamide
262
Bladder SCC RFs?
1. Schistosomiasis 2. Smoking
263
Priapism definition?
Persistent penile erection >4 hours and not associated wiht sexual stimulation
264
Priapism classification?
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
265
Priapism epidemiology?
1. Bimodal, 5-10 and 20-50 y/o
266
Priapism causes?
1. Idiopathic 2. Sickle cell/other haemoglobinopathies 3. ED medication e.g. Sildafenil 4. Trauma 5. Medication = Prescribed (antis), recreational (cocaine, cannabis, ecstasy)
267
Priapism features?
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
268
Priapism Ix?
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.
269
Priapism Rx?
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
270
Once daily insulin dose on day of and day before surgery?
Reduce dose by 20%
271
Colorectal cancer tumour marker?
CEA
272
Treatment of testicular torsion?
If a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral
273
When should COCP/HRT be stopped before surgery?
4 weeks before
274
Elective hip replacement VTE prophylaxis?
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
275
Elective knee replacement VTE prophylaxis?
Aspirin (75 or 150 mg) for 14 days or LMWH for 14 days combined with anti-embolism stockings until discharge or Rivaroxaban
276
Fragility fracture sof pelvis/hip/proximal femur VTE prophylaxis?
1 month
277
Sulfonylureas on day of surgery?
1. Omit on day of surgery 2. If they take BD, can have afternoon dose if operation is in morning
278
Malignant hyperthermia?
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)
279
Peripheral arterial disease comorbidity treatment
1. HTN 2. DM 3. Obesity
280
Initial Peripheral arterial disease management?
1. Atorvastatin 80mg and Clopidogrel 75mg 2. Exercise training
281
Severe PAD/Critical limb ischaemia treatment?
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)
282
When do you amputate for PAD?
Pts with critical limb ischaemia who are not suitable for other interventions e.g. angioplasty or bypass surgery
283
Drugs licenses for PAD?
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