Surgery Flashcards
Extra intestinal features of IBD inc disease activity ones
- anterior uveitis
- primary sclerosing cholangitis
- pyoderma gangrenosum
- finger clubbing
disease activity:
- arthritis
- episcleritis
- erythema nodosum
- osteoporosis
Sigmoid vs caecal volvulus and mx of each
Sigmoid: coffee bean sign + large bowel obstruction
Caecal: embryo sign + small bowel obstruction
If caecal operative surgery, if sigmoid endoscopic decompression via rectal tube insertion + sigmoidoscopy
Symptoms and signs of hepatocellular carcinoma
Symptoms:
- RUQ pain
- pruritus
- B symptoms
Signs:
- jaundice
- bruising
- confusion
- hepatomegaly
- ascites
Management of upper gi bleeds: supportive, variceal, non variceal, PUD
- Supportive: iv fluids, transfusion, analgesia, endoscopy within 24 hours
- Variceal: terlipressin, abx quinolone, endoscopy + ligation, if doesn’t work then transjugular intrahepatic portosystemic shunt, if still not then sengstaken tube. Prophylaxis via propranolol
- Non variceal: ppi
- PUD: adrenaline injections, cauterisation
Pancreatic cancer symptoms + signs + ix vs cholangiocarcinoma
Pancreatic:
- Symptoms: pruritus, weight loss, abdo pain, diabetes, pancreatitis
- Signs: painless jaundice, abdo mass (hepatomeg if mets, enlarged gb, epigastric mass), steatorrhoea, migratory thrombophlebitis (trousseau sign)
- Ix: LFTs (cholestatic pic so inc ALP/yGGT), Ca199, USS abdo, gold standard HRCT shows dilated CBD + pancreatic ducts so double duct sign)
Cholangiocarcinoma:
- Symptoms: persistent biliary colic, anorexia, abdo pain, steatorrhoea, pruritus
- Signs: jaundice, enlarged gb, periumbilical lymphadenopathy (sister Mary Josephs nodes), virchows node
- Ix: LFTs (cholestatic so inc ALP/yGGT), ca199, uss, MRCP gold standard
Symptoms and signs of gastric cancer
Symptoms:
- early satiety
- abdo pain
- melena
- n+v
- b symptoms
Signs:
- left supraclavicular lymphadenopathy (trosiers sign)
- acanthosis nigricans
- epigastric mass
Ottawa rules to have an Ankle xray
medial or lateral malleolus tenderness
inability to walk 4 steps
Knee injuries:
- meniscal injury
- collateral injury
- cruciate injury
- meniscal: twisting and weight bearing injury where medial more prone. Symptoms worst when straightening knee. Apleys test +
- collateral: side of knee contact injury with mcl more common
- cruciate: ACL more common and needs surgical reconstruction. Lachmans + and drawers test. PCL when dashboard injury and post sag sign and drawers test
Causes of post operative pyrexia
0-5 days: uti, pneumonia, skin infection
>5 days: vte, wound infection, anastomotic leak
Risk factors for post operative ileus
Intestinal handling
Decreased post op movement
Opioids
Electrolyte abnormalities
What’s in qSOFA score
rr>21
altered mental state
sys bp <100
What diabetic medications do we omit day of surgery
metformin (lunch time dose)
gliflozins
sulfonylureas (morning dose)
What is in WHO checklist
Patient has confirmed: Site, identity, procedure, consent
Site is marked
Anaesthesia safety check completed
Pulse oximeter is on patient and functioning
Does the patient have a known allergy?
Is there a difficult airway/aspiration risk?
Is there a risk of > 500ml blood loss (7ml/kg in children)?
1) Before the induction of anaesthesia (sign in)
2) Before the incision of the skin (time out)
3) Before the patient leaves the operating room (sign out)
IV anaesthetics
- propofol
- thiopental
- etomidate
- ketamine
- propofol: painful injection, hypotension. Also antiemetic effects
- thiopental: laryngospasm
- etomidate: adrenal suppression, myoclonus. Used if haem instability as doesn’t cause hypotension
- Ketamine: hallucinations, also used in haem instability as doesn’t cause reduction in bp
Inhaled anaesthetics:
- isoflurane/sevoflurance
- nitrous oxide
- isof: myocardial depression, malig hyperthermia
- NO: don’t use in pneumothorax
Local anaesthetics:
- lidocaine
- cocaine
- bupivacaine
- lidocaine: arrhythmia. Treat toxicity with 20% lipid emulsion
- cocaine: arrythmias, tachycardia
- bupivacaine: long duration action, cardiotoxic
Can add adrenaline to these drugs to prolong duration action. Contraind if MAOIs/TCAs or use on extremities
Muscle relaxants:
- suxamethonium
- atracurium
- suxamethonium: fast onset + short duration action. Hyperkal, malig hyperthermia, apnoea if lack of acetylcholinesterase. Can’t use if eye problems as can inc IOP
- atracurium: lasts 30 mins, reverse by neostigmine. Facial flushing, tachyc, hypotension
ASA grades
1 - normal
2 - mild disease, smoker, social drinker, bmi 30-40
3 - functional limitations/poorly controlled, bmi >40
4 - <3 months cvs accident
5 - likely to die without operation
Drugs which cause pancreatitis
azathioprine
mesalazine
bendroflumethiazide
furosemide
steroids
sodium valproate
How to distinguish PAD from spinal stenosis
Stenosis pain better walking uphill/leaning forwards
Bicycle test to distinguish - if symptoms present then not spinal stenosis
What is the Simmonds triad (achilles tendon rupture)
Palpate
Examine angle of declination at rest
Calf squeeze test
Needs orthodontist referral!!
First line vs gold standard for perianal abscesses
1st line: clinical dre
gold: transperineal uss
Management for discitis
8 weeks IV abx
ECHO
How to tell difference between biliary colic, acute cholecystitis, and ascending cholangitis
biliary colic: ruq pain worse after eating only
acute cholecystitis: fever, murphys sign + (when hand on gb ask them to breath in and they stop bc of pain)
ascending cholangitis: also jaundice, hypotension, confusion. Deranged LFTs (inc ALP/yggt)
First line for gallstones
Gold standard
1st line: USS
Gold: MRCP
Main blood finding in mesenteric infarction
High lactate / wcc
Needs urgent surgery
1st line mx for wound dehiscence
Definitive
1st line: cover with sterile gauze, Iv abx, iv fluids, analgesia
gold s: theatre
Most common fractures causing compartment syndrome
tibial
suprachondylar (humerus)
Location of hernias:
- umbilical
- paraumbilical
- epigastric
- spigelian
- richters
- umbilical: under umbilicus
- paraumbilical: asymmetrical directly above or below umbilicus
- epigastric: midline between umbilical and xiphisternum
- Spigelian: semilunar line
- Richters: strangulation without bowel obstruction symptoms
Bilious vomiting in neonates differentials
Nec enterocolitis: 2nd week life
Meconium ileus: 48 hours post, DISTENSION + bilious vomiting
Intestinal atresia: uss, vomit straight after foods
Malrotation: 7 days post, ladds procedure
Medical diseases needing circumcision
phimosis
recurrent balanitis
balanitis xerotica obliterans
paraphimosis
Management for prostate cancer - local vs mets
Local: watchful wait, active surveillance, prostatectomy, external beam radiotherapy, brachytherapy
Mets: ghrh agonists goserelin + cyproterone acetate 3 days before to reduce tumour flare, or bicalutamide androgen rec blocker
Gold standard ix for renal cell carcinoma
CT abdo pelvis
Most common type of renal cell carcinoma
clear cell
Management for colitis vs crohns
colitis:
induce remission: rectal mesalazine, 4 weeks after oral mesalazine, pred. If severe and on IV hydrocortisone and if doesn’t work add on Ciclosporin
Crohns:
induce remission: pred
maintenance: stop smoking, azathioprine, mercaptopurine
Monteggia fracture
Bennetts fracture
Galeazzi fracture
Bartons fracture
Monteggia fracture: ulnar fracture + radioulnar dislocation
Bennetts fracture: thumb metacarpal fracture
Galeazzi fracture: radial shaft fracture + radioulnar dislocation
Bartons fracture: colles/smiths with radiocarpal dislocation
Ix and mx for suspected renal stones in pregnant woman
USS
ureteroscopy
CT scan within 1 hour vs 8 hours criteria
1 hour: >1 episode vomiting, suspected fracture, gas <13, seizure, neuro deficit
8 hours: >65, anticoags, dangerous injury, >30 mins amnesia
What kidney stones can you see on xray vs can’t
Which stones are alkaline and which is acidic
Can see opaque on xray: calcium oxalate, calcium phosphate, struvite
Can’t see radiolucent ones: urate, cystine
Alkaline: stuvite
Uric acid: acid
When to send off MSU for uti
> 65
hematuria
preg
male
child
Haematuria ix for visible vs non visible
if visible + luts and suspect bladder then cystoscopy
if visible and not sure what it is then uss
if visible and suspect rcc then ct urogram
Forced eversion vs inversion ankle injury
Inversion: anterior talofibular ligament sprain
Eversion: deltoid ligaments
First line ix for PAD
Gold s
1st line: duplex USS
Gold s: CT angiogram
First line ix for acute limb ischaemia
Gold s
1st line: handheld doppler arterial uss
gold s: CT angiogram
Age for abdominal USS screening
65
When to do endovascular revascularisation (angioplasty + stent) vs surgical revascularisation (bypass, endarterectomy)
endovasc revasc: short segment stenosis <10cm, aortic iliac disease, high risk patients
surgical: long segment lesions >10cm, multifocal lesions, common femoral artery, infrapopliteal
Management of superficial thrombophlebitis
compression stockings
lmwh 30 days (if contraindicated then 8-12 days oral nsaids)
Management for carotid artery disease
dual anti platelet - clopidogrel and aspirin
carotid endarterectomy If stenosis >50% + SYMPTOMS
Needs carotid duplex uss or ct angiography
Leriche syndrome triad of symptoms
ED, buttock pain, absent femoral pulses/atrophy of legs
Symptoms buergers disease
25-35 year old man who smokes
painful blue fingers + ulcers
Nipple eczema vs pagets disease
nipple eczema starts at areolar then involves nipple
paget is nipple first then areola
Side effects of hormonal breast cancer treatment
Tamoxifen (ER antagonism, pre menopausal) : hot flushes, endometrial cancer
Anastrozole (aromatase inhibitor reduces oestrogen synthesis, post): osteoporosis, arthralgia
Trastuzumab Herceptin
Fat necrosis sign on USS
Breast cyst sign
Fat: hyper echoic
Cyst: halo
Symptoms of mammary duct ectasia vs intraductal papilloma
Ectasia: post meno yellow discharge
Papilloma: pre meno bloody discharge
Risk factors for testicular cancer
undescended testes,
fx
infertility
Klinefelter’s syndrome
mumps orchitis
What to prescribe if mixed voiding and storage symptoms in man who hasn’t responded to alpha blocker tamsulosin
tolterodine
darifenacin
Test to find out function of pancreas in chronic pancreatitis
faecal elastase - used if imaging inconclusive
What is boerhaaves syndrome
spontaneous rupture of oesophagus after lots of vomiting which can cause mediastinitis.
Needs CT contrast swallow and thoracotomy and lavage if <12 hours or T tube insertion to create fistula between skin and oesophagus
Contraindications to laparoscopic surgery
shock
inc icp
intestinal obstruction uncorrected coagulopathy
Complications of gastrectomy
dumping syndrome
rebound hypoglycaemia
early satiety
iron deficiency anaemia
osteoporosis
vit b12 deficiency
Complications of diverticular disease
Fistulas - colovesical (pneumaturia)
Strictures (laprotomy)
Peritonitis
Haemorrhage
Abscess (if <5cm abx, if >5cm drain)
Most common cause of large bowel obstruction
cancer
When to stop ppi before ogd
2 weeks before
Cancers associated with Lynch syndrome
colorectal
endometrial
pancreatic
gastric
Sign of bowel necrosis on CT
Pneumatosis intestinalis
Less contrast infiltration
Abdo pain post op pre 5 days vs post 5 days
pre: ileus
post: anastomotic leak
What is toxic megacolon
Chronic dilatation of colon where high risk of perforation
Management of acute diverticulitis
Home with oral abx, liquid diet, analgesia
If no improvement in 72 hours admit for iv ceftriaxone and metronidazole
Thrombosed haemorrhoid management
if <72 hours excise
If >72 hours bulk forming, ice, analgesia
Biopsy findings of gastric cancer
signet ring cells
Do you remove gallstones if assymptomatic
nope
Staging for cancer in pelvis
mri (ct + staging laproscopy îs for more abdomen)
Prevention of each kidney stone
ca - thiazides
struvite - ammonium chloride
urate - allopurinol
cystine - penicillamine
gold standard for venous insufficiency
duplex uss
apbi after this
fontaine classification for pad
- assymp
- intermittent claudication
- rest pain
- necrosis or gangrene
Most common risk factor for transitional cell bladder cancer
smoking
(others aniline dyes, rubber, cyclophosphamide, schistosomiasis)
First line ix for bladder ca
Gold s
1st line: urine dip (haematuria?)
Gold s: cystoscopy + biopsy
Causative organisms for epididymo orchitis
Chlamydia trachomatis
neisseria gonorrhoeae
ecoli
GS ix for AVN hip
mri
GS ix for psoas abscess
CT abdo
Features of staph aures
gram +
coag +
Abdominoperineal resection vs low anterior resection
abdop: anus, rectum and sigmoid
ant: if malig in upper 2/3 rectum
Tibial shaft fracture cast type
above knee cast
Salter Harris fracture types
1: physis
2: physis + metaphysis
3: physis + epiphysis
4. physis + epiphysis + metaphysis
5: crush injury of physis
3,4,5 need surgery
Prolapsed disc signs
L3 root compression: sensory anterior thigh, weak hip flexion/knee extension, reduced knee reflex, + femoral stretch
L4: ant knee + med malleolus sensory loss, weak knee extension, reduced knee reflex, + femoral stretch
L5: sensory loss dorsum foot, weak foot dorsiflexion, + sciatic stretch
S1: sensory loss posterolat leg + lat foot, weak planter flexion, reduced ankle reflex, + sciatic stretch
Prolapsed disc mx
nsaid + ppi
if no improvement after 6 weeks mri
Artery causing AVN head if NOF
medial circumflex artery
Sign of osteoporotic vertebral fracture on xray
wedging
NV testing for hand nerves
radial: thumb extension
ulnar: thumb adduction
median: thumb abduction
Common sites for osteomyelitis in adults vs child
adult: epiphysis
child: metaphysis
Mx for Gardens 1/2 NOF
cannulated screw!!
What is neuralgia paraesthetica
compression lateral femoral cutaneous nerve
Mx malignant hyperthermia
iv dantrolene
MRSA mx
nasal mupirocin + chlorhexadine 5 days
Types of post op haemorrhage
prim within op
reactive within 24 hours
secondary 7-10 days
remember to assess perfusion as bp is a late sign!!
Classes of haemorrhagic shock
1: <750ml
2: 750-1500ml, hr 100-120,
3: 1500-2000ml, 30-40% blood loss, bp decreased
4: >2000ml, >40%, HR/RR>40, UNCONSCIOUS
Metabolic abnormality if too much iv fluids
Hyperchloraemic metabolic acidosis
Meds that cause ED
b blockers
ssris
antiepileptics
Complications of TURP
T ur syndrome : hyponat, fluid overload
U rethral stricture/UTI
R etrograde ejaculation
P erforation of the prostate
GS ix in appendicitis in F vs M
F: uss
M: CT (unless thin + classic symptoms)
How to minimise bleeding risk pre-op
stop anticoag + d assay
coag screen, fbc
hydrate + monitor fluid balance
cannonball metastases
RCC
Periop steroid mx
Hydrocortisone 100 mg by IV injection should be given at induction of anaesthesia in adult patients with adrenal insufficiency from any cause, followed by a continuous infusion of hydrocortisone until the patient can take double their usual oral glucocorticoid dose by mouth
Sepsis 6
- IV access + bloods + cultures
- Escalate to senior
- Monitor NEWS + urine output
- Give IV fluids
- Give abx + source control
- Give oxy
Sepsis screening
- think if looks unwell, risk factors, or NEWS2>4
- confirm infection suspected
- look for organ dysfunction via sofa, news2
Axillary node screening for breast cancer
palpable nodes before surgery = clearance
non palp = offer uss axillary before surgery = + clearance
if uss - then sentinel node biopsy
if can’t find sentinel node then 3 random nodes test
Mx PAD (chronic limb ischaemia)
supervised exercised programme to make collateral arteries
clopidogrel + statin
endovascular angioplasty + stent or open bypass
A-E mx for acute limb ischaemia
supportive - oxygen, analgesia, fluids etc
unfractionated heparin
contact vascular surgeons for revascularisation via thrombectomy/thrombolysis etc
