Surgery 2 Flashcards
What is the difference between spondylolysis and spondylolisthesis?
Spondylolysis - usually affects L4/L5
Spondylolisthesis - occurs when one vertebra is displaced relative to its immediate inferior vertebral body, can result following a stress fracture or spondylolysis
What is Scheuermann’s disease?
What may be seen on XR (2)
Progressive kyphosis
Epiphyseal plate disturbance and anterior wedging
When to refer someone with cyclical mastalgia?
Pain has not responded to conservative measures after 3 months and is affecting quality of life
Associations for renal cell cancer (4)
Age and gender
RF
x2 conditions associated with it
Middle aged men
Smoking
Von Hippel Lindau syndrome
Tuberous sclerosis
RCC classical triad of symptoms
Haematuria
Loin pain
Abdominal mass
Other features of RCC (2)
Pyrexia of unknown origin
Varicocele (left sided)
What is Stauffer syndrome?
Cholestasis/ hepatosplenomegaly
(Paraneoplastic disorder associated with RCC)
More common in obese women with large breasts
May follow trivial or unnoticed trauma
Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
=
Fat necrosis
May present with blood stained discharge
Breast disorder
=
Duct papilloma
Green nipple discharge
Most common around menopause
Tender lump around areola
=
Mammary duct ectasia
Most common in middle-aged women
‘Lumpy’ breasts which may be painful. Symptoms may worsen prior to menstruation
=
Fibroadenosis
discrete, non-tender, highly mobile lumps
Fibroadenoma
Define priapism
Age at presentation (2)
Persistent penile erection lasting >4 hours
5-10yo
20-50yo
Causes of priapism (4)
Sickle cell
Medication e.g sildenafil
Cocaine
Trauma
Mx priapism
Ischaemic - medical emergency, aspiration and saline flush injection
Non ischaemic - observation
Circumcision reduces the risk of (3)
UTI
Penile cancer
STI
What is phimosis and paraphimosis?
Hypospadias
Phimosis - inability to retract skin
Paraphimosis - foreskin is retrsacted and unable to pull back to original position
Urethra opening not at end of penis
Bowel ca
Who should be referred? (4)
patients >= 40 years with unexplained weight loss AND abdominal pain
patients >= 50 years with unexplained rectal bleeding
patients >= 60 years with iron deficiency anaemia OR change in bowel habit
tests show occult blood in their faeces
Consider referral under 2ww bowel ca (3)
Rectal or abdominal mass
Unexplained anal mass/ ulceration
<50yo with rectal bleeding AND AP/change in bowel habit/ weight loss/ IDA
NHS screening programme for bowel ca
Every 2 years
Men and women aged 60-74 England, 50-74 in Scotland
Over 74yo can request
Who should receive a FIT test (outside of screening) (3)
patients >= 50 years with unexplained abdominal pain OR weight loss
patients < 60 years with changes in their bowel habit OR iron deficiency anaemia
patients >= 60 years who have anaemia even in the absence of iron deficiency
How long does lidocaine last?
1 hour
Name three absorbable suture materials (3)
How long before they disappear?
Vicryl
Dexon
PDS
7-10 days
When should you remove non absorbable sutures
Face
Scalp/limbs/chest
Hand/ foot/ back
3-5 days
7-10 days
10-14 days
What is the most common pituitary tumour?
Microadenoma versus macro in size
Prolactinoma
<1cm >1cm
Who should be referred early for bariatric surgery?
BMI 40-50
Types of restrictive bariatric surgery (3)
Lap adjustable gastric banding (1st line if BMI 30-39)
Sleeve gastrectomy (reduce stomach by 15%)
Intragastric balloon (can be left in for 6 months)
What is Paget’s disease?
Diagnostic test
Eczematoid changes of nipple associated with an underlying breast malignancy
Punch biopsy + mammography
How to tell the difference between Paget’s disease of the breast and eczema
Paget’s involves the nipple primarily and then spreads to areolar.
The opposite occurs in eczema
PAD mx (4)
- Stop smoking
- Statin 80mg atorvastatin
- Clopidogrel
- Exercise training (supervised)
RF for prostate ca (4)
Increasing age
Obesity
Afro-Caribbean
FH
1st line investigation for prostate ca
How are the results reported?
MR
5-point Likert scale
Likert scale interpretation
> =3 –> MR prostate biopsy
1-2 discuss pros and cons with pt r.e biopsy
What score is used to predict prognosis in prostate ca?
Gleason
Patients with superficial thrombophlebitis may also have a ?
DVT
Mx superficial thrombophlebitis (2)
If option 2 is CI then ?
Compression stockings
Consider LMWH for 30 days or fonda for 45 days
If LMWH is CI then PO NSAIDs for 8-12 days
Patients with superficial thrombophlebitis at, or extending towards, the sapheno-femoral junction can be considered for?
Therapeutic anticoagulation for 6-12 weeks
Often history of dysuria and urethral discharge
Swelling may be tender and eased by elevating testis
= which testicular swelling?
Usually caused by?
Epididymo-orchitis
Chlamydia
Single or multiple swelling
May contain clear or opalescent fluid (spermatoceles)
Usually occur over 40 years of age
Painless
Lie above and behind testis
It is usually possible to ‘get above the lump’ on examination
= which testicular condition?
Epidiymal cysts
Epididymal cysts are associate with? (3)
Ix
Mx
Polycystic kidney disease
CF
Von Hippel Lindau
US
Surgery
Causes of spontaneous SAH (3)
Intracranial aneurysm
AV malformation
Arterial dissection
How to prevent vasospasm in SAH
21 day course of nimodipine
Renal stones analgesia of choice
Ix
NSAID
Non contract CT KUB within 14 hours of admission
Mx renal stones
<5mm
<2cm
<2cm but pregnant
Complex renal calculi or staghorn
<5mm pass spontaneously (within 4 weeks)
<2cm = lithotripsy
<2cm but pregnant = ureteroscopy
Complex renal calculi or staghorn = percuteneous nephrolithotomy
If oxalate stones what two medications can be trialled to prevent reoccurrence?
Cholestyramine
OR
Pyridoxine
When may trastuzumab (Herceptin) be used in breast ca?
CI in which patients?
HER2 +ve patients
Hx of heart disorders
When may hormonal therapy be used in breast ca?
What (2) medications can be used and when?
ER+ve breast ca
Anastrozole if post menopausal
Tamoxifen if pre and peri
Who is recommended to have breast RT? (3)
Wide local excision
Mastectomy T3-T4
Four or more positive axillary nodes
Who is offered a wide local excision (WLE) or mastectomy
DCIS<4cm
DCIS>4cm
Large lesion, small breast
Small lesion, large breast
Peripheral versus central tumour
Multifocal versus solitary
WLE
Mast
Mast
WLE
WLE versus mast
Mast versus WLE
2ww breast criteria
30>= unexplained breast lump
50>= with discharge/retraction/ any changes
When to consider a 2ww for breast? (2)
Skin changes that suggest breast ca
OR
>=30 unexplained lump in axilla
Non urgent referral for breast in?
<30 with unexplained breast lump
RF breast ca (10)
- BRCA
- 1st degree relative pre-menopausal
- Nulliparity
- 1st pregnancy >30yo
- Early menarche
- Late menopause
- Combined HRT
- COCP
- Not breastfeeding
- Obesity
Screening programme breast:
50-70yo mammogram offered to females every 3 years
If the person concerned only has one first-degree or second-degree relative diagnosed with breast cancer they do NOT need to be referred unless any of the following are present in the family history (9)
age of diagnosis < 40 years
bilateral breast cancer
male breast cancer
ovarian cancer
Jewish ancestry
sarcoma in a relative <45yo
glioma or childhood adrenal cortical carcinomas
complicated patterns of multiple cancers at a young age
paternal hx of breast ca (two or more relatives on the father’s)
Who can be offered a breast clinic referral earlier than screening due to their FH?
one first-degree female relative diagnosed with breast cancer at younger than age 40 years
OR
one first-degree male relative diagnosed with breast cancer at any age
OR
one first-degree relative with bilateral breast cancer where the first primary was diagnosed at younger than age 50 years
OR
two first-degree relatives, or one first-degree and one second-degree relative, diagnosed with breast cancer at any age
OR
one first-degree or second-degree relative diagnosed with breast cancer at any age and one first-degree
OR
second-degree relative diagnosed with ovarian cancer at any age (one of these should be a first-degree relative)
OR
three first-degree or second-degree relatives diagnosed with breast cancer at any age
Breast ca classification (4)
Which is the most common?
Ductal versus lobular
Carcinoma in situ versus invasive
Invasive ductal (no special type) - most common
Invasive lobular
DCIS
LCIS
Obesity mx
BMI 25–29.9
- Diet and physical activity
- Consider starting drug treatment with BMI of 27 with RF (such as type 2 diabetes, hypertension, or dyslipidaemia)
Obesity mx
30-34.9
- Diet and exercise
- Consider drug rx if has RF
- Consider assessment for bariatric surgery
Obesity mx
>35
> 50
- Diet and exercise
- Consider drug treatment
- Bariatric surgery
- Bariatric is first line if BMI >50
Drug treatment for obesity (2)
- Orlistat BMI >28 with RF or BMI >30, discontinue after 12 weeks if ineffective (not lost at least 5% body weight)
- no restriction on how long it can be prescribed for. - Liraglutide BMI >27 with RF or BMI >30 as an adjunct to a reduced calorie diet and increased physical activity (prescribed in secondary care)
