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surgery Flashcards

1
Q

ecg changes in SAH

A

ST elevation

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2
Q

SAH investigations:

A

within 6hr= CT head
if -ve –> no LP

If >6hr –> CT head then if -ve LP

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3
Q

SAH CT

A

xanthochromia

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4
Q

mastectomy wide local excusuin criteria (2)
what is needed after wide local excision?

A

Matectomy:
- multifocal tumor, central tumor
- large lesion in small breast
- DCIS> 4cm

Wide Local excusion
- solitary lesion
- peripheral tumor
- small lesion in large breast
- DCIS<4

ALWYAS RADIOTHERAPY 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

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5
Q

Hormonal therapy breast cancer (1)
biological therapy (1)

A

Tamoxifen is still used in pre- and peri-menopausal women. In post-menopausal women, aromatase inhibitors such as anastrozole are used.

trastuzumab (Herceptin) - HER 2 +ve

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6
Q

ASA I–> V I

A

ASA I A normal healthy patient Healthy, non-smoking, no or minimal alcohol use
ASA II A patient with mild systemic disease Mild diseases only without substantive functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, pregnancy, obesity (BMI 30 - 40), well-controlled Diabetes Mellitus/Hypertension, mild lung disease
ASA III A patient with severe systemic disease Substantive functional limitations; One or more moderate to severe diseases. Examples include (but not limited to): poorly controlled Diabetes Mellitus/Hypertension, COPD, morbid obesity (BMI > 40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, End-Stage Renal Disease (ESRD) undergoing regularly scheduled dialysis, history (>3 months) of Myocardial infarction, Cerebrovascular accidents
ASA IV A patient with severe systemic disease that is a constant threat to life Examples include (but not limited to): recent (< 3 months) of Myocardial infarction, Cerebrovascular accidents, ongoing cardiac ischaemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis
ASA V= not expected to survive e.g. AAA rupture
ASA VI= brain dead

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7
Q

Renal stone

A

Renal stones
watchful waiting if < 5mm and asymptomatic
5-10mm shockwave lithotripsy
10-20 mm shockwave lithotripsy OR ureteroscopy
> 20 mm percutaneous nephrolithotomy
Uretic stones
shockwave lithotripsy +/- alpha blockers>< 10mm shockwave lithotripsy +/- alpha blockers
10-20 mm ureteroscopy

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8
Q

Uriteric obstruction due to stones –> management=

A

decompression (an emergency)

Options include nephrostomy tube placement, insertion of ureteric catheters and ureteric stent placement.

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9
Q

management of ureteric stones:
calcium (6)
oxalate stones (2)
uric stones (2)

A

Calcium stones may be due to hypercalciuria, which is found in up to 5-10% of the general population.
high fluid intake
add lemon juice to drinking water
avoid carbonated drinks
limit salt intake
potassium citrate may be beneficial NICE
thiazides diuretics (increase distal tubular calcium resorption)

Oxalate stones
cholestyramine reduces urinary oxalate secretion
pyridoxine reduces urinary oxalate secretion

Uric acid stones
allopurinol
urinary alkalinization e.g. oral bicarbonate

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10
Q

Bious vomiting in neonates: (age, diagnosis and treament)
duodenal atresia

A

few hours after birth
AXS+ double bubbl
duodenoduodenostomy

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11
Q

Bious vomiting in neonates: (age, diagnosis and treament) malrotation with volvulus

A

malrotation
3-7 days after birth
upper GI –> DJ flexure medial placed or USS abnormal sotation
LADD procedure

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12
Q

Bious vomiting in neonates: (age, diagnosis and treament) jejunal / ileul atresia

A

within 24hr birth
AXR air level
laparotomy with resection

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13
Q

Bious vomiting in neonates: (age, diagnosis and treament)

meconium ileum

A

24-48hr
AXR fluid levels, sweat test= CF
surgical deompression

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14
Q

Bious vomiting in neonates: (age, diagnosis and treament)
necrotising enterocolitis

A

second week of life
dilated bowel loops AXR
pneumatosis
conservative , laparotomy if worsening

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15
Q

investigation for prostate cancer if PSA raised

A

Multiparametric MRI

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16
Q

Incarcerated vs strangulated hernia

A

incarcerated femoral hernia would present as a non-reducible mass inferolateral to the pubic tubercle. These hernias are at high risk of strangulation but they have not lost their blood supply yet. The sick appearance of the patient, accompanied by symptoms of necrosis such as vomiting and bloody stool indicates that strangulation has occurred.

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17
Q

femoral vs inguinal hernia

A

inferolateral to the pubic tubercle, from inguinal hernias which are supermedial to the pubic tubercle

Femoral: Given the small size of the femoral ring, a cough impulse is often absent.

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18
Q

management BPG

A
  • watchful waiting
    -alpha-1 antagonists (tamsulosin, alfuzosin
  • 5 alpha- reductase inhibits (finasteride)
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19
Q

5 alpha-reductase inhibitors e.g. finasteride:
how do they work? (1)
how long do they take to work (1)

A

block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH
indicated if the patient has a significantly enlarged prostate and is considered to be at high risk of progression
unlike alpha-1 antagonists causes a reduction in prostate volume and hence may slow disease progression. This however takes time and symptoms may not improve for 6 months

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20
Q

5 alpha-reductase inhibitors e.g. finasteride:
adverse effects

A

erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia

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21
Q

peripheral vascular disease management medical (2)
if severe (2)
when to amputate (1)
other licensed drugs (2)

A

clopidogrel and atorvastatin

if severe:
endovascular revascularization
percutaenous transluminal angioplasty +/- stent placement
endovascular techniques are typically used for short segment stenosis (e.g. < 10 cm), aortic iliac disease and high-risk patients
surgical revascularization
surgical bypass with an autologous vein or prosthetic material
endarterectomy
open surgical techniques are typically used for long segment lesions (> 10 cm), multifocal lesions, lesions of the common femoral artery and purely infrapopliteal disease

Amputation should be reserved for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty of bypass surgery.

Drugs licensed for use in peripheral arterial disease (PAD) include:
naftidrofuryl oxalate: vasodilator, sometimes used for patients with a poor quality of life
cilostazol: phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects - not recommended by NICE

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22
Q

What is the most appropriate stoma to create which will allow this whilst being easiest to reverse in the future?

A

loop ileostomy

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23
Q

Ileostomy vs colonsocpy

A

Ileostomy: R iliac fossa, spouted, liquid

Colostomy: varied location, flushed, solid

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24
Q

CT head within 1 hr

A

GCS < 13 on initial assessment
GCS < 15 at 2 hours post-injury
suspected open or depressed skull fracture
any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
post-traumatic seizure.
focal neurological deficit.
more than 1 episode of vomiting

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25
Q

When to give steroids pre surgery

A

As a rule of thumb:
Minor procedure under local: no supplementation required
Moderate procedure: 50mg hydrocortisone before induction and 25mg every 8h for 24h
Major surgery: 100mg hydrocortisone before induction and 50mg every 8h for 24h, thereafter halving dose every 24h until maintenance dose reached.

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26
Q

Fasting/ oral fluids pre surgery

A

Oral fluids:
patients having surgery may drink clear fluids until 2 hours before their operation
drinking clear fluids before the operation can help reduce headaches, nausea and vomiting afterwards
clear fluids are water, fruit juice without pulp, coffee or tea without milk and ice lollies

Patients are generally advised to fast from non-clear liquids/food for at least 6 hours before surgery.

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27
Q

AAA screening

A

single screening scan age 65

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28
Q

Diabetes and surgery: what do to about
- lantus
- hypoglycaemics e.g. SGLT2

A

Lantus: reduce by 20%

SGLT2- omit on day of surgery but otherwise as normal

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29
Q

Surgery requiring special preparation:
thread surgery
parathyroid surgery
sentinel node biopsy
surgery of thoracic duct
phaeochromocytoma
surgery for carcinoid tumours
colorectal cases
thyrotoxicosis

A

Thyroid surgery; vocal cord check.
Parathyroid surgery; consider methylene blue to identify gland.
Sentinel node biopsy; radioactive marker/ patent blue dye.
Surgery involving the thoracic duct; consider administration of cream.
Pheochromocytoma surgery; will need alpha and beta blockade.
Surgery for carcinoid tumours; will need covering with octreotide.
Colorectal cases; bowel preparation (especially left sided surgery)
Thyrotoxicosis; lugols iodine/ medical therapy.

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30
Q

AAA screeening
<3cm
3-4.4cm
4.5-5.4cm
>=5.5cm

A

<3cm= no action
2-4.4= 12 monthly rescan
4.5- 5.4= rescan every 3 months
>=5.5= refer within 2 weeks to vascular surgery

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31
Q

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. E
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.

A

extradural

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32
Q

Suspected prostate cancer: what investigation not to do?

A

biopsy as –> spreads the tumor

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33
Q

soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
the swelling is confined to the scrotum, you can get ‘above’ the mass on examination

A

hydrocele

transilluminates with a pen torch
the testis may be difficult to palpate if the hydrocele is large

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34
Q

Hydrocele:
when to do US?

A

to exclude any underlying cause such as a tumour

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35
Q

Local anesthetic toxicity:
treatment (1)
features (2)

A

IV 20% lipid emulsion
cardiovascular and neurological deterioration after local anaesthetic administration

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36
Q

doses of anaesthetic:
lignocaine
bupivacaine
prilocaine

A

Lignocaine 3mg/Kg 7mg/Kg
Bupivacaine 2mg/Kg 2mg/Kg
Prilocaine 6mg/Kg 9mg/Kg

LARGER DOSE WITH ADRENALINE

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37
Q

investigations for venous insufficiency

A

venous duplex ultrasound

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38
Q

reasons to refer to secondary care for venous insufficiency

A

significant/troublesome lower limb symptoms e.g. pain, discomfort or swelling
previous bleeding from varicose veins
skin changes secondary to chronic venous insufficiency (e.g. pigmentation and eczema)
superficial thrombophlebitis
an active or healed venous leg ulcer

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39
Q

when to refer hydroceles in babies

A

if there >1 year

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40
Q

PAD management

A

clopidogrel NOT aspirin
and statin 80mg

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41
Q

blood-stained nipple discharge

A

Duct papilloma

42
Q

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

A

Mammary duct ectasia

43
Q

CTKUB contrast or non con contrast

A

non-contrast

44
Q

fissure not responding to conservative treatment

A

spintcterotomy

45
Q

risk factors for penile cancer

A

Human immunodeficiency virus infection
Human papillomavirus virus infection
Genital warts
Poor hygiene
Phimosis
Paraphimosis
Balanitis
Age >50

46
Q

Surgery / metformin on day of surgery:

A

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

47
Q

clinical signs of superficial thrombophlebitis affecting the proximal long saphenous vein - what to do?

A

venous US of legs

48
Q

Propofol - what else does it do other than anaesthetic

A

anti-emetic

49
Q

BPH:
management

A

1st= alpha-1 antagonist (tamsulosin, alfuzosin)- decrease smooth muscle tone of the prostate and bladder

2nd= 5 alpha-reductase inhibitors e.g. finasteride (block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH)
may also decrease PSA concentrations by up to 50%
side-effects: erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia

50
Q

Hernias in children:
Congenital inguinal hernia
Infantile umbilical hernia

A

Congenital inguinal hernia= repair surgically asap as risk of incarceration
Infantile umbilical hernia= The vast majority resolve without intervention before the age of 4-5 years

51
Q

a collection of pancreatic fluid enclosed by fibrous or granulation tissue, which forms as a consequence of acute pancreatitis.

A

pseudocyst
(Often occurs 6 weeks post pancreatitis, located behind the stomach)

52
Q

Pancreatitis complications:
- peripancreatic fluid collections
- pseudocysts
- pancreatic necrosis
- pancreatic abscess
- haemorrhage

A
  • peripancreatic fluid collections: 25% of pancreatitis, fluid around pancreas. no fibrous/ granulation tissue
    may –> psydocyst or abscess but don’t treat as may self resolve
  • pseudocysts: fibrous, collection behind stomach, occurs 4 weeks post pancreatitis, (retrograstric), 75% have persistent raised amylase. investigation with CT, ERCP, MRI or endoscopy USS
    management= observe or treat with endoscopic or surgical cystogasatrostomy
  • pancreatic necrosis: try to manage conservatively. some will sample
  • pancreatic abscess: collection of pus. NO necrosis. typically pseudocyst –> infected–> abscess. transgastric drainge
  • haemorrhage: if infected necrosis –> vascular structure. –> Grey Turners sign

ARDS= systemic side effect

53
Q

raised ICP- Cushings treat

A

hypertension, bradycardia, and irregular breathing
(often occurs late and is pre-terminal)

54
Q

Often results from acceleration-deceleration trauma or a blow to the side of the head. occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery.
lucid interval

A

epidural haematoma (EXTRADURAL)

55
Q

Head injury:
Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes.

Risk factors include old age, alcoholism and anticoagulation.

Slower onset of symptoms than a epidural haematoma. There may be fluctuating confusion/consciousness

A

Subdural

56
Q

Muscle relaxants:
suxamethonium

A

Depolarising neuromuscular blocker
Inhibits action of acetylcholine at the neuromuscular junction
Degraded by plasma cholinesterase and acetylcholinesterase
Fastest onset and shortest duration of action of all muscle relaxants
Produces generalised muscular contraction prior to paralysis
Adverse effects include hyperkalaemia, malignant hyperthermia and lack of acetylcholinesterase

57
Q

Hiatus hernia:
most sensitive test (1)
management (2)

A

barium swallow is the most sensitive test
given the nature of the symptoms many patients have an endoscopy first-line, with a hiatus hernia being found incidentally

MANAGEMENT:
all patients benefit from conservative management e.g. weight loss
medical management: proton pump inhibitor therapy
surgical management: only really has a role in symptomatic paraesophageal hernias (Ie when stomach rgough a different hole in diaphragm)

58
Q

Following a complete prostatectomy, what should the PSA upper limit be? (1)
for others? (4)

A

undetectable (<0.2ng/ml)
depends on age:
40–49 > 2.5
50–59 > 3.5
60–69 > 4.5
70–79 > 6.5

59
Q

Acute limb ischaemia:
initial management (3)
definitive (5)

A

vascular review
IV heparin
IV opioids

intra-arterial thrombolysis
surgical embolectomy
angioplasty
bypass surgery
amputation: for patients with irreversible ischaemia

60
Q

Surgery / sulfonylureas on day of surgery:

A

omit on the day of surgery
exception is morning surgery in patients who take BD - they can have the afternoon doseM

61
Q

Metformin and surgery

A

metformin should be taken as usual on the day before and on the day of elective surgery. The exception is three times daily dosing, where the lunchtime dose should be omitted on the day of surgery.

62
Q

% blood loos before BP drops in haemorrahge

A

30-40%
Class iii shock

62
Q

VTE management post hip replacement

A

dalteparin (LMWH) 6 hr after surgery + TED stockings

63
Q

Screening colon cancer

A

Screening kits are sent every 2 years to all patients aged 60-74 years in England, 50-74 years in Scotland.

64
Q

anaesthetic agent causing laryngospasm

A

Thiopental

65
Q

most common cause bladder cancer

A

SMOKING&raquo_space;» aniline dyes

66
Q

haemorrhoids that prolapse during bowel movements and require manual reduction: what grade

A

grade III

67
Q

haemorrhoids that are permanently prolapsed and cannot be manually reduced back into the anal canal

A

Grade IV

68
Q

haemorrhoids are those that prolapse during defecation but reduce spontaneously afterwards

A

Grade II

69
Q

Abdominal wound dehiscence

A

saline impregnated gauze + IV broad-spectrum antibiotics

70
Q

Priapism: investigations

A

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.
Doppler or duplex ultrasonography: this can be used as an alternative to blood gas analysis to assess for blood flow within the penis.
A full blood count and toxicology screen can be used to assess for an underlying cause of the priapism.
Diagnosis of priapism is largely clinical, with investigations helping to categorise into ischaemic and non-ischaemic as well as assessing for the underlying cause.

71
Q

Priapism: Rx

A

if >4 hr –> aspiration from cavernous and flush

If fails –>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.

Non-ischaemic priapism is not a medical emergency and is normally suitable for observation as a first-line option.

72
Q

Fibroadeoma; when to surgically remove

A

if >3cm

73
Q

Testicular lump:
separate from the body of the testicle
found posterior to the testicle

A

Epididymal cysts

Associated conditions
polycystic kidney disease
cystic fibrosis
von Hippel-Lindau syndrome

74
Q

Epididymal cysts: how to confirm diagnosis (1)
management (1)

A

US

Management is usually supportive but surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts.

75
Q

Epididymal cyst. vs hydrocele

A

Hydrocele and epididymal cysts are types of testicular lumps and swellings: Hydrocele is a swelling caused by fluid around the testicle. Epidydimal cysts are lumps caused by a collection of fluid in the epididymis, which is a long-coiled tube behind the testicles.

76
Q

How is severity of pancreatitis defined?

A

presence of organ failure OR local complications

77
Q

SAH:
management if stable?

A

Coiling of the aneurysm by an interventional radiologist

78
Q

useful test of exocrine function in chronic pancreatits

A

faecal elastase

79
Q

Anal tissue:
<1 week (3)
>1 week (3)

A

Management of an acute anal fissure (< 1 week)
soften stool
dietary advice: high-fibre diet with high fluid intake
bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried
lubricants such as petroleum jelly may be tried before defecation
topical anaesthetics
analgesia

Management of a chronic anal fissure
the above techniques should be continued
topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure
if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin

80
Q

Burns:
Parkland formula

A

Volume = SA% x weight x 4ml

81
Q

hernia superior and medial to the pubic tubercle

A

inguinal hernia

82
Q

coffee-bean sign + bowel obstruction

A

Sigmoid Volvos

management: sigmoid volvulus: rigid sigmoidoscopy with rectal tube insertion
caecal volvulus: management is usually operative. Right hemicolectomy is often needed

83
Q

rectal tomour: most common operation

A

Anterior resection

BUT Rectal cancer on the anal verge → Abdomino-perineal excision of rectum

84
Q

management for asymptomatic + reducible inguinal hernias

A

routine referral surgical repair

85
Q

emergency colorectal surgery

A

In the emergency setting where the bowel has perforated the risk of an anastomosis is much greater, particularly when the anastomosis is colon-colon. In this situation, an end colostomy is often safer and can be reversed later. When resection of the sigmoid colon is performed and an end colostomy is fashioned the operation is referred to as a Hartmann’s procedure. Whilst left-sided resections are more risky, ileo-colic anastomoses are relatively safe even in the emergency setting and do not need to be defunctioned.

86
Q

Sigmoid colon cancer resection

A

high anterior researction

87
Q

Distal transverse, descending colon

A

Left hemicolectomy

88
Q

Caecal, ascending or proximal transverse colon

A

Right hemicolectomy

89
Q

An obese woman presents with an irregular lump on the lateral aspect of her right breast associated with skin tethering. Biopsy excludes a malignant cause.

A

Fat necrosis

90
Q

GREEN NIPPLE DISCHARGE

A

Mammary duct ectasia

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

91
Q

A 35-year-old woman complains of ‘lumpy’ breasts. Her symptoms are worse in the premenstrual period.

A

Fibroadenosis
(fibrocystic disease, benign mammary dysplasia)

92
Q

Unilaterally dilated
sluggish/ fixed

A

3rd nerve compression secondary to tentorial herniation

93
Q

Tamoxifen is used to treat what breast cancer type

A

oestrogen receptor-positive breast cancer in pre-menopausal women

94
Q

ulcer RELIEVED by eating

A

DUODENAL

95
Q

Prevention of renal stones:
calcium (4)
oxalate (2)
uric acid (2)

A

Calcium stones may be due to hypercalciuria, which is found in up to 5-10% of the general population.
high fluid intake
add lemon juice to drinking water
avoid carbonated drinks
limit salt intake
potassium citrate may be beneficial NICE
thiazides diuretics (increase distal tubular calcium resorption)

Oxalate stones
cholestyramine reduces urinary oxalate secretion
pyridoxine reduces urinary oxalate secretion

Uric acid stones
allopurinol
urinary alkalinization e.g. oral bicarbonate

96
Q

incarcerated vs strangulated hernia

A

strangulated= v sick

An incarcerated femoral hernia would present as a non-reducible mass inferolateral to the pubic tubercle. These hernias are at high risk of strangulation but they have not lost their blood supply yet. The sick appearance of the patient, accompanied by symptoms of necrosis such as vomiting and bloody stool indicates that strangulation has occurred.

Strangulated –> ischaemic + necrotic = BAD

97
Q

finasteride how long to take to work for BPH (5 alpha-reductase inhibitors, 2nd line treatment )

A

Finasteride treatment of BPH may take 6 months before results are seen

98
Q

prednisolone pre surgery: what to do

A

Hydrocortisone supplementation is required prior to surgery for patients taking prednisolone

99
Q

TPN nutrition

A

The definitive option in those patients in whom enteral feeding is contra indicated
Individualised prescribing and monitoring needed
Should be administered via a central vein as it is strongly phlebitic
Long term use is associated with fatty liver and deranged LFT’s

100
Q
A

MSRA (17 decks)

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