Surgery Flashcards
1
Q
Screening outcomes for abdominal aortic aneurysms
A
<3 cm - no further action
3 - 4.4cm - rescan every 12 months
4.5 - 5.4cm - rescan every 3 months
≥ 5.5cm - refer within 2 weeks to vascular surgery for probable intervention
2
Q
Causes of acute pancreatitis
A
- Gallstones
- Ethanol
- Trauma
- Steroids
- Mumps
- Autoimmune, Ascaris infection
- Scorpion venom
- Hypertriglyceridaemia, hyperchylomicronaemia, hypercalcaemia, hypothermia
- ERCP
- Drugs
3
Q
Drugs causing acute pancreatitis
A
- Azathioprine
- Mesalazine
- Didanosine
- Bendroflumethiazide
- Furosemide
- Pentamidine
- Steroids
- Sodium valproate
4
Q
Fasting before surgery
A
- Clear fluids 2 hours
- Non-clear fluids/foods 6 hours
5
Q
Perioperative management of diabetics on insulin
A
- If good glycaemic control and undergoing minor procedures, managed during op period with adjustment of usual income
- If long fasting period of more than one issed meal, or poorly controlled diabetes, variable rate insulin infusion
6
Q
Management of anti-diabetic drugs day prior to admission for elective surgery
A
Take as normal (unless OD insulin, then reduce dose by 20%)
7
Q
Management of metformin on day of operation
A
If taken OD or BD - take as normal
If taken TDS - omit lunchtime dose
8
Q
Management of sulfonylureas on day of operation (morning operation)
A
If taken OM - omit dose
If taken BD - omit morning dose
9
Q
Management of sulfonylureas on day of operation (afternoon operation)
A
If taken OM - omit dose
If taken BD - omit both doses
10
Q
Management of DPP IV inhibitors (-gliptins) on day of operation?
A
Take as normal
11
Q
Management of GLP-1 inhibitors (-tides) on day of operation?
A
Take as normal
12
Q
Management of SGLT-2 inhibitors (-flozins) on day of operation?
A
Omit on day of surgery
13
Q
Management of OD insulin on day of operation?
A
Reduce dose by 20%
14
Q
Management of twice daily biphasic or ultra-long acting insulins on day of operation
A
Halve usual morning dose, leave evening dose unchanged
15
Q
Special preparation before thyroid surgery
A
Vocal cord check
16
Q
Special preparation before parathyroid surgery
A
Consider methylene blue to identify gland
17
Q
Special preparation before sentinel node biopsy
A
Radioactive marker/patent blue dye
18
Q
Special preparation before surgery involving thoracic duct
A
Consider administration of cream
19
Q
Special preparation before phaeochromocytoma surgery
A
Alpha and beta blockade
20
Q
Special preparation before surgery for carcinoid tumour
A
Need covering with octreotide
21
Q
Special preparation before colorectal cases
A
Bowel preperation
22
Q
Special preparation before surgery for thyrotoxicosis
A
Lugols iodine/medical therapy
23
Q
Features duodenal ulcer
A
Epigastric pain relieved by eating
24
Q
Features gastric ulcer
A
Epigastric pain worsened by eating
25
Features appendicitis
Pain initially central abdomen before localising to right iliac fossa
Tachycardia
Low grade pyrexia
Tenderness in RIF
26
What is Rovsing's sign, and when seen
More pain in RIF than LIF when palpating LIF
Seen in appendicits
27
Features acute pancreatitis
Severe epigastric pain
Vomiting
28
What is Cullen's sign, when seen
Periumbilical discolouration
Acute pancreatitis
29
What is Grey-Turner's sign, when seen
Flank discolouration
Acute pancreatitis
30
Features biliary colic
Pain in RUQ radiating to back and interscapular region
May follow fatty meal
31
Acute cholecystitis features
History of gallstones symptoms
Continuous RUQ pain
Fever
32
Murphys sign and when seen
Arrest of inspiration on palpation of RUQ
Acute cholecystitis
33
Diverticulitis features
Colicky pain, typically LLQ
Fever
34
Abdominal aortic aneurysm features
Severe central abdominal pain radiating to back
Presentation may be catastrophic (sudden collapse) or subacute (persistent severe abdominal pain with developing shock)
35
Intestinal obstruction features
Vomiting
BNO
Tinkling BS
36
Location inguinal hernia
Above and medial to pubic tubercle
37
Location femoral hernia
Below and lateral pubic tubercle
38
Demographic inguinal hernia
95% male
39
Risk of strangulation inguinal hernia
Rare
40
Demographic femoral hernia
More common in women, particularly multiparous
41
Risk of strangulation femoral hernia
High
42
Features umbilical hernia
Symmetrical bulge under umbilicus
43
Features paraumbilical hernia
Asymmetrical bulge, half sac covered by skin of abdomen directly above or below the umbilicus
44
Features epigastric hernia
Lump in midline between umbilicus and xiphisternum
45
What is spigelian hernia
Hernia through spigelian fascia, which is aponeurotic layer between rectus abdominis muscle medially and semilunar line laterally
46
What is obturator hernia
Hernia passes through obturator foramen (medial thigh)
47
Demographic obturator hernia
More common in women
48
Presentation obturator hernia
Typically presents with bowel obstruction
49
What is Richter hernia
Rare
Only antimesenteric border of bowel herniates through fascial defect
50
Presentation Richter hernia
Strangulation without symptoms of obstruction
51
Mechanism congenital inguinal hernia
Indirect hernia resulting from patent processus vaginalis
52
Management congenital inguinal hernia
Surgically repaired soon after diagnosis as risk of incarceration
53
Risk factors infantile umbilical hernia
Premature
Afro-Caribbean
54
Management infantile umbilical hernia
Monitor - vast majority resolve without intervention before 4-5 years, complications are rare
55
Risk factors abdominal wound dehiscence
Malnutrition
Vitamin deficiencies
Jaundice
Steroid use
Major wound contamination, e.g. faecal peritonitis
Poor surgical technique
56
Treatment abdominal wound dehiscence
Coverage of wound with saline impregnated gauze
IV broad spectrum antibiotics
Analgesia
IV fluids
Return to theatre
57
Psoas sign and where seen
Pain on extending hip
Retrocaecal appendicitis
58
Blood findings appendicitis
Raised inflammatory markers
Neutrophil-predominant leucocytosis
59
Role of urinalysis in appendicitis
Exclude pregnancy, renal colic, and UTI
In appendicitis, may show mild leucocytosis but no nitrates
60
Management appendicitis
Appendicectomy with prophylactic IV antibiotics
61
Purpose of IV antibiotics in appendicectomy
Reduce wound infection rates
62
What is required in perforated appendicitis
Copious abdominal lavage
63
Complications acute pancreatitis
Peripancreatic fluid collections
Pseudocysts
Pancreatic necrosis
Pancreatic abscess
Haemorrhage
ARDS
64
Incidence peripancreatic fluid collection
25%
65
Features peripancreatic fluid collections
Located in or near pancreas
Lack wall of granulation or fibrous tissue
May resolve or develop into pseudocysts or abscesses
66
Management peripancreatic fluid collection
Since may resolve, avoid aspiration and drainage - may precipitate infection
67
How do pancreatic pseudocysts develop after acute pancreatitis
Result from organisation of peripancreatic fluid collection, may or may not communicate with ductal system.
Collection walled by fibrous or granulation tissue
68
When do pseudocysts occur after acute pancreatitis
Typically 4+ weeks
69
Bloods pancreatic pseudocyst
75% mild elevation of amylase
70
Investigations pancreatic pseudocyst
CT
ERCP
MRI
Endoscopic USS
71
Management pancreatic pseudocysts
Observation up to 12 weeks - up to 50% resolve
Treatment with endoscopic or surgical cystogastrostomy or aspiration
72
Location pancreatic necrosis complicating acute pancreatitis
May involve pancreatic parenchyma and surrounding fat
73
Management pancreatic necrosis
Sterile necrosis managed conservatively
Early necrosectomy high mortality, should be avoided if possible
74
What is pancreatic abscess
Intra-abdominal collection of pus associated with pancreas, but absence of necrosis
Typically result from infected pseudocyst
75
Management pancreatic abscess
Transgastric drainage or endoscopic drainage
76
What causes haemorrhage post-pancreatitis
Infected necrosis may involve vascular structures with resultant haemorrhage, may occur de novo or result of surgical necrosectomy
77
Acute pancreatitis management
Fluid resuscitation
Analgesia
Nutrition
78
Fluid resuscitation in acute pancreatitis
Aggressive early hydration with crystalloids, aim UO >0.5ml/kg/hour
79
Analgesia in acute pancreatitis
IV opioids usually required
80
Nutrition acute pancreatiits
Not routinely NBM unless clear reason
Enteral nutrition offered to anyone with moderate severe or severe acute pancreatitis within 72h of presentation
81
Role of parenteral nutrition in acute pancreatitis
Should only be used if enteral nutrition failed or contraindicated
82
Role of antibiotics in acute pancreatitis
Prophylactic antibiotics not routinely offered
Used in infected pancreatic necrosis
83
Criteria mild acute pancreatitis
No organ failure, no local complications
84
Criteria moderately severe acute pancreatitits
No or transient organ failure (<48 hours), possible local complications
85
Criteria severe acute pancreatitis
Persistent organ failure, possible local complications
86
Indications for surgery acute pancreatitis
- Gallstones
- Obstructed biliary system due to stones
- Fail to settle with necrosis and worsening organ dysfunction
- Infected necrosis
87
Management acute pancreatitis caused by gallstones
Early cholecystectomy
88
Management acute pancreatitis with obstructed biliary system due to stones
Early ERCP
89
Management acute pancreatitis with necrosis and worsening organ dysfunction
Debridement or fine needle aspiration
90
Management acute pancreatitis with infected necrosis
Radiological drainage or surgical necrosectomy
91
ASA 1
Normal healthy patient
Non-smoker, no or minimal alcohol use
92
ASA 2
Patient with mild systemic disease without substantiative functional limitations
E.g. smoker, social alcohol drinker, pregnancy, obesity, well controlled diabetes/hypertension
93
ASA 3
Patient with severe systemic disease
Substantiative functional limitations, one or more moderate to severe diseases
94
ASA 4
Severe systemic disease that is constant threat to life
95
ASA 5
Moribund patient not expected to survive without the operation
96
ASA 6
Declared brain-dead patient for organ retrieval
97
Management acute anal fissure
Soften stool - dietary advice, bulk-forming laxatives, if not tolerated then lactulose
Lubricants, e.g. petroleum jelly
Topical anaesthetic
98
Management chronic anal fissure
Acute treatments continued
Topical GTN
If not effective after 8 weeks, referral for sphincterotomy or botulinum toxin
99
100
Location of anal fissure
90% posterior midline (if other location, consider underlying cause e.g. Crohn's)
101
Most common organisms anorectal abscess
E. coli
Staph aureus
102
Causes rectal prolapse
Childbirth
Rectal intussusception
103
Causes solitary rectal ulcer
Chronic staining and constipation
104
Histology solitary rectal ulcer
Mucosal thickening
Lamina propria replaced with collagen and smooth muscle
105
Types of anti-oestrogen drugs
SERM (selective oestrogen receptor modulators)
Aromatase inhibitors
106
Example SERM
Tamoxifen
107
Role of tamoxifen
Oestrogen receptor positive breast cancer treatment
108
Adverse effects tamoxigen
Menstrual disturbance - vaginal bleeding, amenorrhoea
Hot flushes
VTE
Endometrial cancer
109
Examples aromatase inhibitors
Anastrozole
Letrozole
110
Mechanism of action aromatase inhibitors
Reduce peripheral oestrogen synthesis
111
Role aromatase inhibitors
Treatment of oestrogen receptor +ve breast cancer in post-menopausal women
112
Adverse effects aromatase inhibitors
Osteoporosis
Hot flushes
Arthralgia, myalgia
Insomnia
113
Most common organism ascending cholangitis
E coli
114
Features ascending cholangitis
RUQ pain
Fever
Jaundice
(Charcots triad)
Hypotension
Confusion
(Reynolds' pentad)
115
First line investigation ascending cholangitis
Ultrasound - bile duct dilatation and stones
116
Management ascending cholangitis
IV antibiotics
ERCP after 24-48 hours
117
Features fibroadenoma
Mobile, firm breast lump
118
Risk of malignancy fibroadenoma
No increased risk of malignancy
119
Treatment fibroadenoma
Surgical excision if >3cm
120
Features breast cyst
Smooth discrete lump, may be fluctuant
121
Risk of malignancy breast cyst
Small increased risk of breast cancer, especially if younger
122
Management breast cyst
Cysts should be aspirated
123
When does breast cyst need biopsy/excision
If aspirate blood stained or persistently refill
124
Sclerosing adenosis presentation
Breast lump or breast pain
Mammographic changes - may mimic carcinoma
125
Sclerosing adenosis malignancy risk
No increase in malignancy risk
126
Treatment sclerosing adenosis
Lesions should be biopsied, excision not mandatory
127
Epithelial hyperplasia presentation
Variable, from generalised lumpiness to discrete lump
128
Epithelial hyperplasia malignancy risk
Increased risk of malignancy, particularly if atypical features or family history
129
Treatment epithelial hyperplasia
If no atypical features, conservative management
If atypical features, either close monitoring or surgical resection
130
Causes fat necrosis
40% cases traumatic aetiology
131
Management fat necrosis
Imaging and core biopsy
132
Presentation duct papilloma
Usually present with nipple discharge
Large papillomas may present with mass
133
Duct papilloma risk of malignancy
No increased risk of malignancy
134
Management duct papilloma
Microdochectomy
135
First line treatment BPH
Alpha 1 antagonists, e.g. tamsulosin, alfuzosin
136
Mechanism of action alpha 1 antagonists in BPH
Decrease smooth muscle tone of prostate and bladder
137
Adverse effects alpha 1 antagonists
Dizziness
Postural hypotension
Dry mouth
Depression
138
Other treatment options BPH
5 alpha reductase inhibitors e.g. finasteride
Antimuscarinics
Surgery
139
Role of finasteride BPH
Indicated if significantly enlarged prostate and high risk of progression
140
Advantage of finasteride over tamsulosin
Cause reduction in prostate volume, so may slow progression
141
Limitation of finasteride BPH
Symptoms don't improve for 6 months
142
Adverse effects finasteride
Erectile dysfunction
Reduced libido
Ejaculation problems
Gynaecomastia
143
Role of antimuscarinics BPH
If mixture of storage symptoms and voiding symptoms persisting after treatment with alpha blocker alone
144
Examples antimuscarinic used in BPH
Tolterodine
Darifenacin
145
Drugs causing gallstones
Fibrates
COCP
146
Features biliary colic
Right upper abdominal pain, worse after eating and after fatty foods, may radiate to right shoulder/interscapular region
Nausea and vomiting common
147
Management biliary colic
Elective laparoscopic cholecystectomy
148
AXR duodenal atresia
Double bubble sign
149
Investigation findings malrotation with volvulus
Upper GI contrast - DJ flexure more medially placed
USS - abnormal orientiation of SMA and SMV
150
Treatment malrotation with volvulus
Ladd's procedure
151
AXR jejunal/ileal atresia
Air-fluid levels
152
Treatment jejunal/ileal atresia
Laparotomy with primary resection and anastomosis
153
AXR findings mec ileus
Air fluid level
154
Treatment mec ileus
Surgical decompression
Serosal damage may need segmental resection
155
Incidence mec ileus in cystic fibrosis
15-20%
156
AXR NEC
Dilated bowel loops
Pneumatosis
Portal venous air
157
Treatment NEC
Conservative and supportive if non-perf
Laparotomy and resection in perforation or ongoing deterioration
158
RF transitional cell bladder cancer
Smoking - most important in Western countries
Aniline dyes, e.g. printing and textile industry workers
Rubber manufacture
Cyclophosphamide
159
RF squamous cell bladder cancer
Schistosomiasis
Smoking
160
Criteria for brain stem death testing
- Deep coma of known aetiology
- Reversible causes excluded
- No sedation
- Normal electrolytes
161
Testing for brain death
Fixed pupils, dont respond to light
No corneal reflex
Absent oculo-vesticular reflexes
No response to supraorbital pressure
No cough reflex to bronchial stimulation, or gagging response to pharyngeal stimulation
No observed respiratory effort in response to disconnection of ventilator
162
How are oculo-vesticular reflexes tested in brain death
No eye movements following the slow injection of at least 50ml of ice-cold water into each ear in turn
163
Requirements for doctors performing brain stem death testing
Two doctors on two occasions
Both experienced in brain stem death testing
At least 5 years post-grad experience
One must be a consultant
Neither can be member of transplant team
164
Most common organism causing breast abscess in lactational women
Staphylococcus aureus
165
Presentation breast abscess
Tender, fluctuant mass in lactating women
166
Management breast abscess
I&D or needle aspiration
Antibiotics should be given
167
Determination of surgical management in breast cancer with no palpable lymphadenopathy
Should have pre-op axillary ultrasound before their primary surgery. If negative, should have sentinal node biopsy to assess nodal burden
168
Surgical management breast cancer with palpable lymphadenopathy
Axillary node clearance at primary surgery
169
SEs axillary node clearance in breast cancer
Arm lymphodema and functional arm impairment
170
Indications for mastectomy breast cancer
Multifocal tumour
Central tumour
Large lesion in small breast
DCIS >4cm
171
Indications for wide local excision breast cancer
Solitary lesion
Peripheral tumour
Small lesion in large breast
DCIS <4cm
172
Who is offered radiotherapy breast cancer
All wide local excision
If mastectomy, T3-4 tumours and 4+ positive axillary nodes
173
Who is offered hormonal therapy breast cancer
Hormone receptor positive tumours
174
Hormone therapy breast cancer
Tamoxifen in pre- and peri-menopausal women
Aromatase inhibitors e.g. anastrozole in post-menopausal women
175
Why are aromatase inhibitors offered to post-menopausal women with ER+ve breast cancer
Aromatisation accounts for majority of oestrogen production in this group
176
SE's tamoxifen
Increased risk of endometrial cancer
Increased risk VTE
Menopausal symptoms
177
Most common type of biological therapy breast cancer
Trastuzumab (herceptin)
178
Who is offered herceptin
HER2 positive (only useful in 20-25%)
179
Herceptin contraindication
History of heart disorders
180
2WW breast cancer referral criteria
- 30+ unexplained breast lump
- 50+ unilateral nipple discharge, retraction, or other changes of concern
181
Criteria consider 2WW referral breast cancer
Skin changes suggesting breast cancer
30+ unexplained lump in axilla
182
Non-urgent breast referral criteria
Under 30 with unexplained breast lump with or without pain
183
Breast cancer risk factors
BRCA1/2 mutation
Nulliparity, first pregnancy >30 years
Early menarche, late menopause
COCP, combined HRT
Past breast cancer
Not breastfeeding
Ionising radiation
p53 mutation
Obesity
Previous surgery for benign breast disease
184
NHS breast cancer screening programme schedule
Mammogram 3 yearly in 50-70y/o
185
Who needs referring for familial breast cancer
If one first or second degree relative with breast cancer and:
Age of diagnosis <40 years
Bilateral breast cancer
Male breast cancer
Ovarian cancer
Jewish ancestry
Sarcoma in relative younger than age 45 years
Glioma or childhood adrenal cortical carcinomas
Complicated patterns of multiple cancers at young age
Paternal history of breast cancer (2+ relatives on fathers side)
186
Which patients should be referred for early screening due to family history of breast cancer
- 1st relative diagnosed with breast cancer younger than 40
- 1st degree male related diagnosed with breast cancer
- 1st degree relative with bilateral breast cancer (if 1st primary diagnosed younger than 50)
- 2 1st relatives, or 1 1st + 1 2nd
- 1 1/2nd relative breast cancer + 1 1/2nd relative ovarian cancer
- 3 2nd degree breast cancer any age
187
Most common types of breast cancer
Invasive ductal carcinoma (most common)
Invasive lobular carcinoma
Ductal carcinoma in situ
Lobular carcinoma in situ
188
Invasive carcinoma vs carcinoma in situ (breast)
Carcinoma in situ has not spread beyond local tissue, invasive carcinoma has
189
What is Paget's disease of nipple
Eczematous change of nipple associated with underlying breast malignancy
190
Cause inflammatory breast cancer
Cancerous cells block lymph drainage resulting in inflamed appearance of breast
191
Features fibroadenoma
Discrete, non-tender, highly mobile breast lumps - 'breast mice'
192
Fibroadenoma demographic
Common in women under 30
193
Features fibroadenosis
Lumpy breasts
May be painful
Symptoms may worsen prior to menstruation
194
Demographic fibroadenosis
Middle aged women
195
Features mammary duct ectasia
Tender lump around areola
May be green nipple discharge
If ruptures, may cause local inflammation - 'plasma cell mastitis'
196
Demographic mammary duct ectasia
Most common around menopause
197
What is duct papilloma
Local areas of epithelial proliferation in large mammary ducts
198
Presentation duct papilloma
Blood stained discharge
199
Is duct papilloma malignant?
No - hyperplastic lesions rather than malignant/premalignant
200
Demographic fat necrosis
Obese women with large breasts
201
Features fat necrosis
Initial inflammatory response
Lesion firm and round, may develop into hard, irregular breast lump
May mimic breast cancer, so further investigation always warranted
202
Causes chronic pancreatitis
Alcohol excess - 80% of cases
Cystic fibrosis
Haemochromatosis
Ductal obstruction - tumours, stones, structural abnormalities
203
Features chronic pancreatitis
Pain worse 15-30 mins after meal
Steatorrhoea (5-25 years after onset of pain)
Diabetes mellitus (20 years after onset of pain
204
Abdominal XR chronic pancreatitis
Pancreatic calcification in 30% of cases
205
Abdominal XR vs CT in chronic pancreatitis
CT more sensitive at detecting pancreatic calcification - 80%
206
Functional tests chronic pancreatitis
Faecal elastase - used if imaging inconclusive
207
Management chronic pancreatitis
Pancreatic enzyme supplements
Analgesia
Antioxidants
208
Staging investigations newly diagnosed colorectal cancer
CEA
CT CAP
Entire colon colonoscopy or CT colonography
If tumour below peritoneal reflection, MRI of mesorectum
209
Surgical options colonic cancer presenting with obstruction
Stent or resection
210
Indications right hemicolectomy colon cancer
Caecal, ascending, or proximal transverse colon tumour
211
Indications for left hemicolectomy colon cancer
Distal transverse or descending colon tumour
212
Indications for high anterior resection colon cancer
Sigmoid colon tumour
213
Indications for anterior resection colon cancer
Rectal tumour
214
Indications for abdomino-perineal excision colon cancer
Anal verge tumour
215
Role of chemo colon cancer
Used in neoadjuvant setting (particularly rectal cancer), adjuvant setting, and metastatic disease
216
Role of radiotherapy colon cancer
Predominantly rectal cancers in neoadjuvant or adjuvant setting
217
Targeted therapies used in colon cancer
Bevacizumab
Cetuximab
Particularly used in metastatic disease
218
What is Hartmann's procedure
Resection of sigmoid colon and end colostomy fashioned
219
When should FIT test guide referral colorectal cancer
- Abdominal mass
- Change in bowel habit
- Iron deficiency anaemia
- Age 40+ with unexplained weight loss and abdo pain
- Age under 50 with rectal bleeding and abdominal pain or weight loss
- Age 50+ with unexplained rectal bleeding, abdominal pain, or weight loss
- Age 60+ with anaemia
220
Who does not need FIT test before 2WW colorectal cancer referral
Rectal mass
Unexplained anal mass
Unexplained anal ulceration
221
What to do if negative FIT test (done for symptoms)
Safety netting
Referring on suspected cancer pathway if ongoing significant concern, e.g. abdo mass
222
Colorectal cancer screening programme - who and when
All men and women 60-74 years (50-74 in Scotland), ever 2 years
223
What to do with abnormal FIT results (screening)
Offer colonoscopy
224
When is FIT test recommended (not meeting 2WW criteria)
≥ 50 with unexplained abdominal pain or weight loss
< 60 with changes in bowel habit or iron deficiency anaemia
≥ 60 with anaemia
225
ECG findings hyperkalaemia
Peaked or 'tall tented' T waves
Loss of P wabes
Broad QRS complexes
Sinusoidal wave pattern
Ventricular fibrillation
226
Features epididymal cysts
Seperate from body of testicle
Found posterior to testicle
227
Conditions associated with epididymal cysts
- PKD
- Cystic fibrosis
- Von-Hippel-Lindau syndrome
228
Most common organism causing epididymo-orchitis
Chlamydia trachomatis and Neisseria gonorrhoae in sexually active younger adults
E. coli in older adults
229
Features epididymo-orchitis
Unilateral testicular pain and swelling
230
Management epididymo-orchtis
If STI most likely, refer GUM. If unknown organism, ceftriaxone IM + doxycycline PO
If enteric organisms most likely, send MSU and oral quinolone
231
Features femoral hernia
Lump within groin, mildly painful
Inferolateral to pubic tubercle
Normally non-reducible
Cough impulse often absent (due to small size of femoral ring)
232
Epidemiology femoral hernias
Less common than inguinal - 5% of abdominal hernias
More common in women, more common in multiparous
233
Investigation femoral hernia
Diagnosis usually clinical, ultrasound if doubt
234
Complications femoral hernia
Incarceration
Strangulation
Bowel obstruction → ischaemia
235
Presentation femoral hernia strangulation
Lump tender and non-reducible
Systemically unwell patient
236
Management femoral hernias
Surgical repair necessary - laparoscopic or laparotomy
237
Indication for fluid resuscitation in burns
>15% TBSA burns (10% in children)
238
Why is fluid resuscitation needed in burns
Most fluid is lost 24 hours after the injury
In first 8-12 hours, fluid shifts from intravascular to interstitial fluid compartments, so circulatory volume compromised
239
Calculation for fluid resuscitation in burns
Total fluid requirement in 24 hours = 4ml x TBSA % x weight (kg)
Deduct fluids already given
240
Over what time period is fluid resuscitation given in burns
50% in first 8 hours
50% in next 16 hours
Starting point time of injury
241
What is the goal of fluid resuscitation in burns?
UO 0.5 - 1.0 ml/kg/hour
242
How should fluids be managed after the initial 24 hours in burns
Colloid infusion at rate of 0.5ml x TBSA x weight
Maintenance crystalloid (usually dex/saline) continued at rate of 1.5ml x TBSA x weight
243
What kind of burns might require more fluids
High tension electrical injuries and inhalation injuries
244
What should be monitored in burns
- Packed cell volume
- Plasma sodium
- Base excess
- Lactate
245
Examples volatile liquid anaesthestics
Isoflurane
Desflurane
Sevoflurane
246
Adverse effects volatile liquid anaesthetics
Myocardial depression
Malignant hyperthermia
247
Adverse effects nitrous oxide
May diffuse into gas filled compartments → increase in pressure, so avoid in certain conditions e.g. pneumothorax
248
Adverse effects propofol
Pain on injection
Hypotension
249
Adverse effects thiopental
Laryngospasm
250
Adverse effects etomidate
Primary adrenal suppression
Myoclonus
251
Adverse effects ketamine
Disorientation
Hallucinations
252
Use volatile liquid anaesthetics
Induction and maint anaesthesia
253
Use nitrous oxide
Maintenance anaesthesia
Analgesia, e.g. during labour
254
Use propofol
Induction general anaesthesia
In ICU for ventilated patients
Some anti-emetic properties (useful if high risk of PONV)
255
Properties of thiopental
Highly lipid soluble, so quickly affects brain
256
Features etomidate
Causes less hypotension than propofol and thiopental during induction, therefore used in cases of haemodynamic instability
257
Features ketamine
Acts as dissociative anaesthetic
Doesn't cause drop in BP, so useful in trauma
258
Features haemorrhoids
Painless rectal bleeding (most common)
Pruritis
Pain - usually not significant unless thrombosed
Soiling (3rd/4th degree)
259
Internal vs external haemorrhoids
External originate below dentate line, prone to thrombosis and may be painful
Internal originate above dentate line, do not generally cause pain
260
Grade I internal haemorrhoids definition
Do not prolapse out of the anal canal
261
Grade II internal haemorrhoids definition
Prolapse on defecation, but reduce spontaneously
262
Grade III internal haemorrhoids definition
Can be manually reduced
263
Grade IV internal haemorrhoids definition
Cannot be reduced
264
Primary care management haemorrhoids
Soften stools - increase dietary fibre and fluid intake
Topical local anaesthetic
Topical steroids
265
Outpatient surgical management haemorrhoids
Rubber band ligation
Injection sclerotherapy
266
When is surgery used in haemorrhoids
Large symptomatic haemorrhoids which do not respond to outpatient treatments
267
Presentation acutely thrombosed external haemorrhoids
Significant pain
Purplish, oedematous, tender subcutaneous perianal mass
268
Management acutely thrombosed external haemorrhoids
If present within 72 hours, referral for excision
Otherwise, manage with stool softeners, ice packs, analgesia
269
Where is bleeding extradural haemorrhage
Between dura mater and skull
Most occur in temporal region as skull fracture cause a rupture of middle meningeal artery
270
Causes extradural haemorrhage
Acceleration-deceleration trauma
Blow side of head
271
Features extradural haemorrhage
Raised ICP
Some patients may have lucid interval
272
Where is bleeding subdural haematoma
Outermost meningeal layer
Most around frontal and parietal lobes
273
Risk factors subdural haematoma
Old age
Alcoholism
274
Cause diffuse axonal injury
Mechanical shearing following deceleration, causing disruption and tearing of axons
275
What causes secondary brain injury
When cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury.
Normal cerebal autoregulatory processes are disrupted following trauma, rendering brain more susceptible to blood flow changes and hypoxia
276
Management life threatening ICP rise whilst theatre/transfer sorted
IV mannitol/furosemide
277
Management diffuse cerebral oedema
May require decompressive craniotomy
278
Management skull fractures
Depressed skull fractures that are open require formal surgical reduction and debridement
Closed injuries can be managed non-operatively if minimal displacement
279
When is ICP monitoring used in head injury
Appropriate if GCS 3-8 and normal CT scan
Mandatory if GCS 3-8 and abnormal CT scan
280
Cause of hyponatraemia in head injury
Most likely SIADH
281
Minimum cerebral perfusion pressure in adults
70mmHg
282
Minimum cerebral perfusion pressure in children
40-70mmHg
283
Cause of unilaterally dilated, sluggish/fixed pupil in head injury
3rd nerve compression secondary to tentorial herniation
284
Cause of bilaterally dilated, sluggish/fixed pupil in head injury
Poor CNS perfusion
Bilateral 3rd nerve palsy
285
Cause of pupils cross reactive to light
Optic nerve injury
286
Cause of bilaterally constricted pupils
Opiates
Pontine lesions
Metabolic encephalopathy
287
Cause of unilaterally constricted pupils
Sympathetic pathway disruption
288
Criteria for CT head within 1 hour
GCS <13 on initial assessment
GCS <15 2 hours post injury
Suspected open or depressed skull fracture
Any sign of basal skull fracture
Post-traumatic seizure
Focal neurological deficit
More than 1 episode of vomiting
289
Criteria for CT head within 8 hours of injury
Adults with any of following that have had some loss of consciousness or amnesia since injury:
- Age 65 or older
- Any history of bleeding or clotting disorders including anticoagulants
- Dangerous mechanism of injury (fall over 1m/5 stairs)
- More than 30 mins retrograde amnesia of events immediately before head injury
If patient on warfarin
290
What is a hiatus hernia
Herniation of part of stomach above the diaphragm
291
Types of hiatus hernia
Sliding (95%) - GI junction moves above the diaphragm
Rolling - GI junction remains below, but seperate part of stomach herniates through oesophageal hiatus
292
Features hiatus hernia
Heartburn
Dysphagia
Regurgitation
Chest pain
293
Investigation hiatus hernia
Barium swallow - most sensitive
294
Management hiatus hernia
Conservative management - weight loss
Medical management - PPI
Surgical management only in symptomatic rolling hernia
295
Cause hydatid cysts
Tapeworm parasite Echinococcus granulosus
296
Pathophysiology hydatid cysts
Outer fibrous capsule formed containing multiple smaller daughter cysts. These cysts are allergens causing type 1 hypersensitivity reaction
297
Location hydatid cysts
90% in liver and lungs
298
Cause of morbidity hydatid cysts
- Cyst bursting
- Infection
- Organ dysfunction - biliary, bronchial, renal, and CSF outflow obstruction
299
Investigation hydatid cysts
Ultrasound first line
CT best to differentiate from amoebic and pyogenic cysts
Serology
300
Treatment hydatid cysts
Surgery
301
Consideration surgery for hydatid cysts
Cyst walls must not be ruptured during removal, and contents sterilised first
302
What is hydrocele
Accumulation of fluid in tunica vaginalis
303
Types of hydrocele
Communicating
Non-communicating
304
Cause communicating hydrocele
Patency of processus vaginalis allowing peritoneal fluid to drain into scrotum
305
Who gets communicating hydroceles
Newborns
306
Outcome communicating hydroceles
Usually resolve in first few months of life
307
Cause non-communicating hydroceles
Excessive fluid production within tunica vaginalis
May develop secondary to epididymo-orchitis, testicular torsion, testicular tumours
308
Features hydrocele
Soft, non-tender swelling of hemiscrotum
Usually anterior to and below testicle
Swelling confined to scrotum - can get above mass
Transilluminates
309
Diagnosis hydrocele
Clinical, but USS required if any doubt about diagnosis, or underlying testis can't be palpated
310
Management hydrocele
Usually conservative approach
311
Presentation inguinal hernias
95% men
Groin lump superior and medial to pubic tubercle, disappears on pressure/lying down
Discomfort and ache, often worse with activity, severe pain uncommon
312
Management inguinal hernia
Treat even if asyptomatic - mesh repair. Unilateral open, bilateral/recurrent laparoscopic
313
Time off work inguinal hernia
Return to non-manual work after 2-3 weeks in open repair, 1-2 laparoscopic
314
Causes lidocaine toxicity
IV or excess administrationRi
315
Risk factors lidocaine toxicity
Liver dysfunction
Low protein states
316
Treatment local anaesthetic toxicity
IV 20% lipid emulsion
317
Drug interactions lidocaine
Beta blockers
Ciprofloxacin
Phenytoin
318
Features of lidocaine toxicity
Initially CNS over-activity then depression
Cardiac arrhythmiasa
319
Use of cocaine hydrochloride
Limited use in ENT surgery - applied topically to nasal mucosa, rapid onset of action and causes marked vasoconstriction
320
Use of bupivacaine
Wound infiltration at conclusion of surgical procedures for long duration analgesic effect
321
Limitation of bupivacaine
Cardiotoxic, so contraindicated in regional blockage in case tourniquet fails
322
Bupivacaine vs levobupivicaine
Levobupivicaine is less cardiotoxic and causes less vasodilation
323
Use of prilocaine
Agent of choice in IV regional anaesthesia (less cardiotoxic than other ages)
324
Affect of adrenaline with local anaesthetic
Can be added to local anaesthetic, prolongs duration of action at site of injection and permits high doses
325
Contraindications adrenaline use with local anaesthetic
MAOI or TCA use
326
Options for management of predominantly voiding LUTS in men
- Conservative management
- Alpha blocker
- 5 alpha reductaes inhibitor
- Antimuscarinic
327
Conservative measures voiding LUTS in men
- Pelvic floor muscle training
- Bladder training
- Prudent fluid intake
- Containment products
328
When to offer alpha blocker voiding LUTS men
Moderate or severe symptoms
329
When to offer 5-alpha reductase inhibitor voiding LUTS men
If prostate is enlarged and patient considered high rik of progression
330
How to manage voiding LUTS when prostate enlarged and moderate/severe symptoms
Both alpha blocker and 5 alpha reductase inhibitor
331
When should antimuscarinic be offered voiding LUTS men
If mixed symptoms of voiding and storage not responding to alpha blocker
332
First line treatment predominantly overactive bladder symptoms men
Conservative measures - moderating fluid intake, bladder retraining
333
Second line treatment predominantly overactive bladder symptoms men
Anti muscarinic drugs - oxybutynin, tolterodine, darifenacin
334
Third line treatment predominantly overactive bladder symptoms men
Mirabegron
335
Treatment options nocturia in men
Moderating fluid intake at night
Furosemide 40mg late afternoon
Desmopressin
336
Adverse effects suxamethonium
Hyperkalaemia
Malignant hyperthermia
Lack of acetylcholinesterase
337
Adverse effects atracurium
Facial flushing
Tachycardia
Hypotension
338
What nerve injury posterior triangle lymph node biopsy
Accessory nerve
339
What nerve injury Lloyd Davies stirrups
Common peroneal nerve
340
What nerve injury thyroidectomy
Laryngeal nerve
341
What nerve injury anterior resection of rectum
Hypogastric autonomic nerves
342
What nerve injury axillary node clearance
Long thoracic nerve, thoracodorsal nerve, intercostobrachial nerve
343
What nerve injury inguinal hernia surgery
Ilioinguinal nerve
344
What nerve injury varicose vein surgery
Sural and saphenous vein
345
What nerve injury posterior approach to hip
Sciatic nerve
346
What nerve injury carotid endarterectomy
Hypoglossal nerve
347
Features acute limb threatening ischaemia
Pale
Pulseless
Painful
Paralysed
Paresthetic
Cold
348
Initial management acute limb threatening ischaemia
Analgesia - IV opioids
IV unfractionated heparin - prevent propagation, particularly it not suitable for immediate surgery
349
Definitive management options acute limb threatening ischaemia
Intra-arterial thrombolysis
Surgical embolectomy
Angioplasty
Bypass surgery
Amputation (if irreversible ischaemia)
350
Features intermittent claudication
Aching or burning in leg muscles following walking - typically predictable distance before symptoms start, usually relieved within minutes of stopping, not present at rest
351
First line investigation intermittent claudication
Duplex USS
352
Investigation prior to intervention intermittent claudication
Magnetic resonance angiography MRA
353
Interpretation of ABPI
1 normal
0.6-0.9 claudication
0.3-0.6 rest pain
<0.3 impending ischaemia
354
Non-surgical management peripheral arterial disease
Quit smoking
Treat co-morbidities, e.g. hypertension, diabetes, obesity
Atorvastatin 80mg
Clopidogrel
Exercise training
355
Treatment severe PAD/critical limb ischaemiar
Endovascular or surgical revascularisation
356
Indications endovascular revascularisation PAD/critical limb ischaemia
Short segment stenosis (<10cm)
Aortic iliac disease
High risk patients
357
Surgical techniques severe PAD/critical limb ischaemia
Surgical bypass with autologous vein/prosthetic material or endarterectomy
358
Indications surgical revascularisation severe PAD/critical limb ischaemia
Long segment lesions (>10cm)
Multifocal lesions
Lesions of common femoral artery
Purely infrapopliteal disease
359
Drugs used in peripheral artery disease
Naftidrofuryl oxalate - sometimes used for patients with poor quality of life
360
Role of amputation in peripheral artery disease
Only in patients with critical limb ischaemia not suitable for other interventions such as angio or bypass surgery
361
Causes priapism
Idiopathic
Sickle cell disease, other haemoglobinopathies
Erectile dysfunction medication, e.g. sildenafil, other PDE-5 inhibitor
Trauma
Drugs - cocaine, cannabis, ecstasy
362
Features suggestive of non ischaemic priapism
Non painful erection or erection that is not fully rigid
History of trauma to genital region or perineal region
363
Investigations priapism
Cavernosal blood gas analysis
Dopper or duplex ultrasonography (assess for blood flow in penis)
FBC and tox screen
364
Interpretation cavernosal blood gas in priapism
In ischaemic priapism, pO2 and pH reduced, pCO2 increased
365
First line treatment ischaemic priapism
If >4 hours, aspiration of blood from cavernosa combined with injection of saline flsuh to clear viscous blood that has pooled
366
Second line treatment ischaemic priapism
Intracavernosal injection of vasoconstrictive agent such as phenylephrine, repeat at 5 minute intervals
367
Third line treatment ischaemic priapism
Consider surgical options
368
Treatment non-ischaemic priapism
Not medical emergency, normally suitable for observation as first line option
369
Pathophysiology non-ischaemic priapism
Due to high arterial inflow, typically due to fistula formation often either as a result of congenital or traumatic mechanisms
370
DRE findings prostate cancer
Asymmetrical, hard, nodular enlargement with loss of median sulcus
371
First line investigation prostate cancer
Multiparametric MRI
372
Interpretation of multiparametric MRI for prostate cancer
Results reported using 5-point Likert scale - if ≥3, prostate biopsy. If score 1-2, d/w patients pros and cons of having biopsy
373
Complications TRUS prostate biopsy
Sepsis
Pain
Fever
Haematuria and rectal bleeding
374
Who should have PSA testing
Men with suspected prostate cancer
Men older than 50 who ask for PSA test
375
PSA level for referral <40
Use clinical judgement
376
PSA level for referral 40-49
>2.5
377
PSA level for referral 50-59
>3.5
378
PSA level for referral 60-69
>4.5
379
PSA level for referral 70-79
>6.5
380
PSA level for referral >79
Use clinical judgement
381
Causes for PSA rise
BPH
Prostatitis and UTI
Ejaculation
Vigorous exercise
Urinary retention
Instrumentation of urinary tract
382
How long to wait to test PSA after prostatitis/UTI treatment
6 weeks
383
How long to wait to test PSA after ejaculation
48 hours
384
How long to wait to test PSA after vigorous exercise
48 hours
385
Preferred method for detecting free air in abdomen
CT
386
Most common histological subtype renal cell cancer
Clear cell
387
Risk factors renal cell cancer
Middle age men
Smoking
Von Hippel-Lindau syndrome
Tuberous sclerosis
388
Features renal cell cancer
Classic triad:
- Haematuria
- Loin pain
- Abdominal mass
Pyrexia of unknown origin
Endocrine effects
Paraneoplastic hepatic dysfunction syndrome
Varicocele
Stauffer syndrome
389
Endocrine effects of renal cell cancer
May secrete:
- EPO → polycythaemia
- PTH related protein → hypercalcaemia
- Renin
- ACTH
390
Features varicocele in renal cell cancer
Majority left sided
Caused by tumour compressing veins
391
What is Stauffer syndrome
Paraneoplastic syndrome associated with renal cell cancer, typically presents with cholestasis/hepatosplenomegaly, thought to be due to raised IL-6
392
Management renal cell cancer - confined
Partial or total nephrectomy
393
Other treatments used in renal cell cancer
Alpha-interferon and IL-2 - used to reduce tumour size and treat mets
394
Analgesic of choice renal colic
Diclofenac
395
Analgesic if diclofenac not suitable/ineffective
IV paracetamol
396
Role alpha blockers in renal stones
Consider for distal ureteric stones less than 10mm in size
397
Imaging renal stones
Non-contrast CT KUB
398
How quickly CT KUB in renal stones
If fever, solitary kidney, or diagnostic uncertainty, immediately
Otherwise, within 24 hours of admission
399
Role of ultrasound renal stones
Used in pregnant women and children
400
Management of renal stones
Watchful waiting if <5mm and asymptomatic
5-10mm shockwave lithotripsy
10-20mm shockwave lithotripsy or uteroscopy
>20mm percutaneous nephrolithotomy
401
Management ureteric stones
<10mm - shockwave lithotripsy +/- alpha blockers
10-20mm ureteroscopy
402
Indications for intervention in stones <5mm
Ureteric obstruction
Renal developmental abnormality, e.g. horseshoe kidney
Previous renal transplant
403
Management ureteric obstruction due to stones with infection
Urgent surgical decompression - nephrostomy tube placement, insertion of ureteric catheters, ureteric stent placement
404
Risks with shockwave lithotripsy
Solid organ injury from shockwaves
Fragmentation of larger stones → ureteric obstruction
Uncomfortable - needs analgesia during and after
405
Indications for ureteroscopy in renal stones
For people where lithotripsy contraindicated, e.g. pregnant women, and complex stone disease
406
What happens in ureteroscopy
Uretoscope pased thrgouh ureter and into renal pelvis. In most cases, stent left in situ for 4 weeks after procedure
407
What happens in percutaneous nephrolithotomy
Access gained to renal collecting system, then intra corporeal lithotripsy or stone fragmentation performed and stone fragments removed
408
Prevention of calcium renal stones
High fluid intake
Add lemon juice to water
Avoid carbonated drinks
Limit salt intake
Potassium citrate
Thiazide diuretics
409
Prevention oxalate renal stones
Cholestyramine
Pyridoxine
410
Prevention uric acid stones
Allopurinol
Urinary alkalinsation, e.g. oral bicarb
411
Class I shock parameters
<750ml blood loss (<15%)
HR <100, BP normal
RR 14-20
UO >35ml/hr
412
Class II shock parameters
750-1500ml blood loss (15-30%)
HR >100, BP normal
RR 20-30
UO 20-30ml/hr
Anxious
413
Class III shock parameters
1500-2000ml blood loss (30-40%)
HR >120, BP decreased
RR 30-40
UO 5-15ml/hr
Confused
414
Class IV shock parameters
>2000ml blood loss (>40%)
HR >140, BP decreased
RR >35
UO <5ml/hr
Lethargic
415
Causes of shock in trauma patients
Haemorrhage (most likely)
Tension pneumothorax
Spinal cord injury
Myocardial contusion
Cardiac tamponade
416
What arterial pressure required to generate palpable femoral pulse
>65mmHg
417
418
Hb target in haemorrhage
70-80 if no risk factors for tissue hypoxia
100 if risk factors
419
Pathophysiology neurogenic shock
Spinal cord transection (usually) results in interruption to autonomic nervous system → decreased sympathetic tone or parasympathetic tone → decrease in peripheral vascular resistance mediated by marked vasodilation
420
Treatment neurogenic shock
Peripheral vasoconstrictors
421
Causes cardiogenic shock
In medical - ischaemic heart disease
In trauma - direct myocardial trauma or contusion
422
Treatment cardiogenic shock
Largely supportive
TTE to look for pericardial fluid or direct myocardial injury
Sometimes need surgical repair
423
What kind of trauma → cardiogenic shock is more likely to need surgical repair
Blunt trauma - right side of heart more likely to be affected with chamber and/or valve rupture
424
What might be required as bridge to surgery in cardiogenic shock caused by trauma requiring repair
Intra-aortic balloon pump
425
AXR SBO
Distended small bowel loops (>3cm) with fluid levels
426
Causes SAH
Head injury (most common)
Intracranial aneurysm (berry aneurysms)
Arteriovenous malformation
Pituitary apoplexy
Mycotic (infective) aneurysms
427
Conditions associated with berry aneurysms
Hypertension
Adult PKD
Ehlers-Danlos syndrome
Coarctation of the aorta
428
ECG changes SAH
ST elevation
429
First line investigation SAH
Non-contrast CT head
430
Findings non-contrast CT head in SAH
Acute blood (hyperdense/bright) typically distributed in basal cisterns, sulci, and in severe cases ventricular system
431
When to do LP in SAH
If CT head done more than 6 hours from symptom onset and is normal. LP should be done at least 12 hours from symptom onset (allow time for development of xantochromia)
If CT head done within 6 hours of symptom onset and normal, no LP
432
LP findings SAH
Xanthochromia
Normal or raised opening pressure
433
Investigations in confirmed SAH
CT intracranial angiogram
+/- digital subtraction angiogram (catheter angio)
434
Supportive management SAH
- Bed rest
- Analgesia
- VTE prophylaxis
- Discontinuation of antithrombotics (reversal if anticoagulated)
435
Drug treatment SAH
Nifedipine - prevent vasospasm
436
Indications for surgery SAH
SAH caused by intracranial aneurysms - risk of rebleeding, so ideally within 24 hours
437
Surgical options aneurysmal SAH
Most treated with coiling by IR
Minority need craniotomy and clipping by neurosurg
438
Complications aneurysmal SAH
Re-bleeding
Hydrocephalus
Vasospasm (delayed cerebral ischaemia)
Hyponataemia
Seizures
439
When does re-bleeding occur aneurysmal SAH
Most common in first 12 hours
440
Presentation re-bleeding aneurysmal SAH
Sudden worsening of neurological symptoms
441
Investigation rebleeding aneurysmal SAH
Repeat CT head
442
Treatment hydrocephalus secondary to aneurysmal SAH
External ventricular drain
Sometimes needs long term VP shunt
443
When does vasospasm occur aneurysmal SAH
7-14 days after onset
444
Management vasospasm after aneurysmal SAH
Euvolaemia
Vasopressor
445
Cause hyponatraemia aneurysmal SAH
Most likely SIADH
446
Timeframe acute subdural haemorrhage
Symptoms within 48 hours of injury, rapid neurological deterioration
447
Timeframe subacute subdural haemorrhage
Days to weeks post-injury, gradual progression
448
Timeframe chronic subdural haemorrhage
Weeks to months, may not recall specific injury
449
Classic presentation SDH
Head trauma (minor to severe) → lucid interval → gradual decline in consciousness
450
Neurological symptoms SDH
Altered mental status - range from mild confusion to deep coma, fluctuations common
Focal neurological deficit - weakness on one side of body, aphasia, visual field defects
Headache - localised to one side, worsen over time
Seizures
451
Physical examination findings SDH
Papilloedema
Pupil changes - unilaterally dilated pupil on side of haematoma (compression of CN 3)
Gait abnormality - ataxia, unilateral weakness
Hemiparesis/hemiplegia
452
Behavioura/cognitive change SDH
Memory loss (esp in chronic)
Perosnality changes - irritability, apathy, depression
Cognitive impairment - difficulty with attention, problem solving, other executive functions
453
CT findings acute SDH
Crescenteric collection, not limited by suture lines, hyperdense
Large SDH cause midline shift/herniation
454
Management acute SDH
Small/incidental SDH observed conservatively
Surgical options - monitoring ICP, decompressive craniectomy
455
Cause chronic SDH
Rupture of small bridging veins within subdural space, causing slow bleeding
456
Risk factors chronic SDH
Elderly
Alcoholic
Brain atrophy → fragile or taut bridging veins
457
Presentation chronic SDH
Weeks to months progressive confusion, reduced consciousness, neuro deficit
458
CT findings chronic SDH
Crescenteric shape not restricted by suture lines, HYPOdense (dark) - in contrast to acute
459
Management chronic SDH
If incidental or small, conservative management
If confused, associated neuro deficit, or severe imaging findings - surgical decompression with burr holes
460
Management superficial thrombophlebitis
NSAIDs - topical mild, oral more severe
Topical heparinoids in superficial
Compression stockings
Low molecular weight heparin
461
Investigation superficial thrombophlebitis
If affects proximal long saphenous vein, should have USS to exclude concurrent DVT
462
Investigation prior to compression stockings
ABPI
463
Nerves at risk in pelvic cancer surgery
Pelvic autonomic nerves
464
Nerves at risk during upper limb fracture repairs
Ulnar and median nerves
465
Structure at risk during thoracic surgery
Thoracic duct
466
Structure at risk during thyroid surgery
Parathyroid glands
467
Structure at risk during colonic resection/gynaecological surgery
Ureters
468
Structure at risk when Verres needle is used to establish pneumoperitoneum
Bowel (perforation)
469
Structure at risk during parotidectomy
Facial nerve
470
Structure at risk when ligating splenic hilum
Tail of pancreas
471
Structure at risk during re-do open hernia surgery
Testicular vessels
472
Structure at risk during liver mobilisation
Hepatic veins
473
Investigation to look for anastomatic leak
CT scanning with luminal contrast
Gastrograffin enema if rectal leak
474
Use of peritoneal fluid analysis to look for post-op complications
Peritoneal fluid U&E in suspected ureteric injury
Peritoneal fluid amylase if pancreatic injury suspected
475
Most common type of testicular cancer
Germ cell (95%)
476
Examples non-germ cell testicular cancers
Leydig cell tumours
Sarcomas
477
Types of germ-cell testicular cancers
Seminomas
Non seminomas - embryonal, yolk sac, teratoma, choriocarcinoma
478
Risk factors testicular cancer
Infertility
Undescended testicle
Family history
Klinefelters
Mumps orchitis
479
Tumour markers seminomas
hCG
480
Tumour markers non-seminomas
AFP
beta-hCG
LDH
481
First line diagnosis testicular cancer
Ultrasound
482
Skin changes with varicose veins
Varicose eczema
Haemosiderin deposition → hyperpigmentation
Lipodermatosclerosis → hard/tight skin
Atrophie blanche → hypopigmentation
483
Invesetigation varicose veins
Venous duplex ultrasound - will demonstrate retrograde flow
484
Conservative treatment varicose veins
Leg elevation
Weight loss
Regular exercise
Graduated compression stockings
485
Reasons for referral secondary care varicose veins
Significant/troublesome lower limb symptoms, e.g. pain, discomfort, swelling
Previous bleeding from varicose veins
Skin changes secondary to chronic venous insufficiency
Superficial thrombophlebitis
Active or healed venous ulcer
486
Secondary care treatments for varicose veins
Endothermal ablation (radiofrequency ablation or endovenous laser treatment)
Foam sclerotherapy
Surgery - ligation or stripping
487
When safe to have unprotected sex after vasectomy
After 2x semen analysis, usually 12 weeks
488
When to stop COCP before surgery
4 weeks before
489
Post procedure VTE prophylaxis elective hip surgery
LMWH 10 days → aspirin 75-150mg further 28 days, or
LMWH 28 days + anti-embolism stockings until discharge, or
Rivaroxiban
490
Post procedure VTE prophylaxis elective knee replacement
Aspirin 75-150mg 14 days or
LMWH 14 days + anti-embolism stockings until discharge or
Rivaroxiban
491
VTE prophylaxis fragility fractures pelvis, hip, proximal femur
1 month, either LWMH or fondaparinux
492
Features suggesting sigmoid (over caecal) volvulus
Older patients
Chronic constipation
Chagas disease
Neurological conditions, e.g. Parkinson's, DMD
Psychiatric conditions, e.g. schizophrenia
493
Features suggesting caecal (over sigmoid) volvulus
All ages
Adhesions
Pregancy
494
Sigmoid volvulus AXR
Large dilated loop of colon, often with air fluid levels, coffee bean sign
495
Caecal volvulus AXR
SBO may be seen
496
Management sigmoid volvulus
Rigid sigmoidoscopy with rectal tube insertion
497
Management caecal volvulus
Right hemicolectomy
