Surgery Flashcards
How much morphine should one administer to a patient?
“titrate to person’s repsonse”
Define Fistula
a fistula is an abnormal epithelized communication between two epithelium-lined surfaces that normally do not connect
Etiologies of Delirium
DETECTION!
Drug-related
Endocrine-metabolic
Traumatic
Epilepsy
Cerebrovascular
Tumour
Infection
Organ failure
Not otherwise specified (Heavy metal / insecticide poisoning)
DDx Acute Abdo Pain WITH and WITHOUT rebound tenderness
Tumour Markers for:
alpha-fetoprotein
beta-HCG
Beta-2 microglobulin
CA 15-3
CA 19-9
CA 125
CEA
CRP
PSA
SCC
α-fetoprotein = Hepatocellular carcinoma or Ovarian tumors
Beta-HCG = Hydatidiform mole, Choriovcarcinoma, and Gestational trophoblastic tumour. Nonseminomatous testicular cancer
Beta 2-Microglobulin Multiple myeloma
CA 15−3 = Breast cancer
CA 19−9 = Colon carcinoma. Pancreatic adenocarcinoma
CA 125 = Ovarian carcinoma, malignant epithelial tumours
CEA (carcinoembyronic antigen) = Colon and rectum carcinoma (found in 70% of them)
CRP, LDH = Malignant lymphoma
PSA = Prostate cancer
SCC = cervical, lung, rectal
Define Hernia
A HERNIA is a protrusion of an internal organ or part of an organ through a tear, hole or defect in the wall of a body cavity that normal contains it
A hernia is a protrusion of a viscus or part of a viscus through an abnormal congenital or acquired opening in its coverings
Incarceration vs Strangulation
Incarceration = The trapping of abdominal contents within the Hernia itself. The bulge cannot be reduced or pushed back. This could mean that intestine from within the abdomen is trapped in the hernia and the risk of injury to abdominal contents and intestine is increased
Strangulation = Injury to the blood circulation to the intestine caused by Incarceration. The Intestine will become gangrenous or die if not corrected early.
How can you categories groin lumps? Give examples
Anatomically: think MINT (Malformations, Inflammation, Neoplasia, Trauma)
Skin: sebaceous cyst, cellulitis, skin tumour
Subcutaneous tissue: lipoma
CT: fibroma
Inguinal/Femoral canals: hernias, hydroceles, undescended testes
Saphenous/Femoral veins: saphena varix, thrombophlebitis of saphenous/femoral vein (especially postpartum). Perforation
Iliac Aneurysm
Femoral nerve neurofibroma
Lymphatics: tumour of lymph node (e.g. Hodgkin’s disease), acute adenitis (e.g. lymphadenitis)
Psoas/Iliac muscle: psoas abscess (TB)
Bone: Hypertrophic osteoarthritis, contusion and fracture of the hip
What is saphena varix
a dilation of the saphenous vein at its junction with the femoral vein in the groin. It displays a cough impulse and may be mistaken for a femoral hernia. However it has a bluish tinge and disappears on lying down.
Contents of the spermatic cord
3 fascia: ext obl, cremasteric, int obl
3 art/vein: testicular, cremasteric, vas deferens
3 nerves: sympathetic, genital branch of the genitofemoral nerve, (ilioinguinal nerve but it is outside spermatic cord)
3 other structures: vas deferens, lymphatics, patent processus vaginalis (if present)
What are Charcot’s Triad and Reynold’s Pentad
Signs for Ascending Cholangitis
Charcot’s Triad: Fever, RUQ pain, Jaundice
Reynold’s Pentad: Charcot’s triad + shock, confusion
What conditions have excess mucus in stools
Ulcerative colitis, IBD, Crohn’s disease (less common but may indicate anal fissure), Bacterial infections (Camplyobacter, Salmonella, Shigella, Yersinia), Bowel obstructions
DDx of lower GI Bleeds
Ileum & Ileocecal Junction: Meckel’s diverticulum, small bowel obstruction, Crohn’s
Large Intestine: CRC, Mesenteric thrombosis/ischemic bowel, UC, angiodysplasia, Crohn’s (less frequently presents with bleeds), pancolitis (infectioous, chemotherapy or radiation induced)
Sigmoid: Diverticulosis, Sigmoid cancer, Bleeding post-polypectomy, polyps, IBD
Rectum and Anus: Hemorrhoids, Fissures, Rectal cancer, Anal varices, Polyps, Crohn’s or UC
Causes of Flappping Tremour
Hepatic encephalopathy
What is Glasgow’s Prognosis used in?
Evaluating the severity of pancreatiits
PANCREAS
PaO2 < 8kPa
Age > 55 yrs
Neutrophilia: WBC > 15x109 /L
Calcium < 2 mmol/L
Renal Function: urea > 16 mmol/L
Enzymes: LDH > 600 IU/L; AST > 200IU/L
Albumin: <32 g/L (serum)
Sugar: blood glucse > 10 mmol/L
fComplications of Pancreatitis
Early
1) ARDS
2) . Renal Failure
3) DIC
4) Hypocalcemia (Ca2+ collects in pancreatic calcium soap deposits)
5) High glucose (5% need insulin)
Late (>1 wk)
1) Pancreatic Pseudocyst (20%)
2) Pancreatic necrosis
3) Pancreatic abscess (usually E. coli, Pseudomonas)
4) Thrombosis (splenic and portal vein thrombosis )
5) Fistulate - normally close spontaneously
S&S of Acute Pancreatitis
Fever (chemical, not infectious)
nausea
vomiting
Tetany (transient hypocalceimia)
Jaundice
DIC (activation prothrombin by trypsin)
Grey Turner sign (flank hemorrhage)
Cullen’s sign (periumbilical hermorrage)
Compare Absolute vs. Relative Constipation
Absolute = not passing stool or flatus
Relative = not passing stool but passing flatus
What are the ATLS protocols for Xrays
3 X rays
1) Chest AP
2) Lateral C-spine
3) AP pelvis
CT = if you think there is a brain bleed
Causes of Constipation
Intraluminal (feces, foreign body (gallstones - cystoenteric fistula),
Mural (tumour, stricture)
Extraluminal (adhesions)
Causes of Small and Large Bowel Obstruction
Small bowel
1) 80% of the time due to adhesions (from surgery)
2) Hernia
3) Stricture (e.g. Crohn’s)
Large Bowel
1) CRC
2) Hernia
3) Volvulus
Beck’s Triad
Associated with cardiac tamponade
1) Distended neck veins (rising venous pressure)
2) Muffled heart sounds (sounds pass through fluid(
3) Hypotension
Complications of Stomas
Complications (10%)
- Stenosis - narrowing or stoma or cutaneous orifice usually due to small skin effect or chronic ischemia of stoma (Rx - dilation by probe dilators or refashioning of stoma by surgery)
- Retraction - usually due to tension on the bowel (convex stoma appliances, refhasioning of stoma by surgery)
- Necrosis - acute early complication due to compromised blood supply (Rx - re-operation to remake the stoma)
- Prolapse - Excessive spout length, due to loose skin defect or chronic effect of bowel peristalsis. More common in loop somtas. Rx - stoma appliance change or refashioning of stoma.
- Herniation: most common long-term stoma complication. Opening in abdo muscles. Rx - repair hernia, resisting stoma
- Peristomal dermatitis - spilling of contents onto skin or trauma of appliance changes. Rx - better stoma care, change of apppliance, topical anti-inflammatories
- Fluid and electrolyte imbalances: only a problem with ileostomies . Rx - control of high output (dietary modifications, use of anti-diarrheals, temporary use of isotonicoral fluids), IV replacement if severe
Grades of Hemorrhoids
Grade 1: project into anal canal, bleed but no prolapse
Grade 2: Prolapse on straining, spontaneous reduction
Grade 3: Prolapse, do not spontaneously reduce
Grade 4: cannot be reduced
Causes of dysphagia
Causes of Dysphagia
1. Systemic
CVA, MS, Polio, Parkinson’s, Guillian-Barre, Neuropathy, Myasthenia gravis
- Extramural
Tracheo-oesophageal fistula, large pharyngeal pouch, arch aortic aneurysm, carcinoma of bronchus, mediastinal lymphadenopathy, left atrial dilation, retrosternal goitre - Intramural
- Scleroderma, Chagas’ disease, Diffuse esophageal spasm, achalasia, carcinoma of esophagus, GORD scarring, caustic stricture, presbyoesophagus (dysmotility associated w/ old age) - Intraluminal
Food bolus, foreign body (child and phychiatric patient), polypoid tumour, esophagitism candidiasis
Causes of Upper GI Bleed
Esophagus
Esophageal carinoma, Acute reflux esophagitis, Mallory-Weiss syndrome, **Oseophagel varices **
Stomach Erosive gastritis (NSAIDs, alcohol), **gastric ulce**r, gastric cancer, gastric leiomyoma (rare), Dieulafoy's disease (rare), **acute gastritis**
Duodenum
Duodenal ulcer, aortoduodenal fistula
Risk Factors for Polyp —> cancer
Risk factors for malignant change in colonic polyps
Large size (> 2 cm 40% risk) - most important factor
Villous architecture - high risk in adenomas with villous adenomas > 4 cm
Multiple polyps
Dysplasia
Non-neoplastic polyps
General:
90% of epithelial polyps in large intestine
Found 1/2 over 60
Types
1) Hyperplastic polyps: 90% of epithelial polpys in large intestine. 30-50% > 60 yo
2) Hamartomas
Types: Juvenile retension polyps; Peutz-Jegher Polyposis
DDx of Hemoptysis
Airway Disease
Acute or Chronic Bronchitis, Bronchiectasis, Bronchogenic CA, Bronchial carinoid tumour
Parenchymal Disease
Pneumonia, TB, Lung abscess, Miscellaneous (Goodpasture’s, idiopathic pulmonary hemosiderosis,
Vascular disease
PE, elevated pulmonary venous pressure (LVF, mitral stenosis), vascular malformation
MIscellaneous
Imparied coagulation, pulmonary endometriosis
Empyema vs Abscess
Abscess: localized collection of pus and necrotic tissue anywhere in the body, surrounded and walled off by damaged and inflammed tissues.
Empyema (pyothorax): pus in pleural cavity, usually secondary to infection in the lun or in the space below the diaphragam.
An empyema is a collection of pus within a naturally existing anatomical cavity, such as the lung pleura. It must be differentiated from an abscess, which is a collection of pus in a newly formed cavity (due to an infectious/inflammatory state).
Common Causes Lower GI Bleed in
1) Children
2) Young Adults
3) Elderly
Children:
acute anal fissure, Meckel’s diverticulum, intussusception, ilieal tumours
Young adults
Colitis, Meckel’s diverticulum, anal fissure, hemorrhoids
Elderly
Neoplasia, diverticular disease, angiodysplasia
What are the following Surgical Scars
- Subcostal/Kocher’s: Choleocystectomy
- Right Paramedian: Laparotomy
-
Midline: Laparotomy
4: Nephrectomy/Loin: Renal surgery - Gridiron: Appendectomy
-
Laparoscopic:
Choleocystectomy, Appendectomy, Colectomies - Left Paramedian: Anterior rectal resection
- Transverse suprapubic/Pfannenstiel: Hysterectomy, Other pelvic surgery
- Inguinal hernia: Hernia repair
Meckel’s Diverticulum
Rule of 2s for Meckel’s Diverticulum:
2% of population
Symptomatic in 2% of cases
Found within 2 feet (10-90 cm) of the ileocecal valve
2 inches in length
Often present by 2 years of age (50% present by this age)
Can contain 2 types of epithelium (gastic and pancreatic)
*Remnant of the embryonic vitelline duct
Top Causes of Small Bowel Obstruction. What are the top 3?
Intraluminal: Intussusception, Gallstones
Intramural: Crohn’s, Radiation stricture, adenocarcinoma
Extramural: adhesions, incarcerated hernia, peritoneal carcinomatosis
Top Causes in Order: ABC
Adhesions
Buldge (Hernias)
Cancer (Neoplasm)
Common Causes Large Bowel Obstruction
Intraluminal: constipation
Intramural: Adenocarinoma, Diverticulitis, IBD stricture, Radiation stricture
Extramural: Volvulus
Top 3 Causes (in order)
Cancer
Diverticulitis
Volvulus
Clinical Features of Necrotizing Fasciitis
pain out of proportion to clinical findings and beyond border of erythema, edema, tenderness, ±crepitus (subcutaneous gas from anaerobes) ±fever
Late Findings: skin turns dusky blue and black (secondary to thrombosis and necrosis); induration, formation of bullae; ○ cutaneous gangrene, subcutaneous emphysema
Ix: a clinical diagnosis
Values for Ankle-Brachial Pressure Index
Think 3,6,9
Normal = ≥ 1
Claudication = 0.6-0.9
Rest Pain = 0.3-0.6
Impending gangrene ≤ 0.3
Beware of fasely high results due to incompressible vessels (calcification) as seen in upwards of 40% of diabetics. Think of this when ABPI > 1.2
Define Aneurysm
a sac formed by the dilatation of the wall of an artery, a vein, or the heart
Define Jaundice
a condition characterized by hyperbilirubinemia and deposition of bile pigments in the skin, mucous membranes, and sclera, with resulting yellow appearance of the patient
Complications of Hernial Repair
Break into Generalized and Specific
Hematoma (wound or scrotal)
Acute urinary retention
Wound infection
Chronic Pain
Testicular Pain and swelling leading ot testicular atrophy
Hernia recurrance (2%)
Define Intermittent Claudication
An aching pain in the leg muslces, usually the calf, that is precipitated by walking and relieved by rest
DDx Sore Throat
Streptococcal pharyngitis
Viral pharyngitis
Infectious Mononucleosis
Tonsilitis
Peritonsiliar abscess
Foreign body/trauma
Leukemia
Hodgkin’s disease
What are the RFs for Vascular Disease
Major: smoking, DM, hyperhomocysteinemia
Minor: HTN, hyperlipidemia, family Hx,obsesity, sedentary lifestyle, male gender
6 P’s of peripheral vascular disease
○ Pain: absent in 20% of cases due to prompt onset of anesthesia and paralysis
○ Pallor: within a few hours becomes mottled cyanosis
○ Paresthesia: light touch (small fibres) lost first then sensory modalities (large fibres)
○ Paralysis/Power loss: most important, heralds impending gangrene
○ Polar (cold)
○ Pulselessness: not reliable
Rx of Peripheral Vascular Disease
Conservative:
Risk factor modification (smoking cessation, treatment HTN, hyperlipdemia, and/or DM)
Exercise program (develops collateral circulation, improves exercise tolerance)
Foot care (especially DM)
Pharmacotherapy
Anti-platelet (clopidogrel)
Cilostazol (cAMP-phosphodiesterase inhibitor with anti-platelet and vasodilatory effects)
Pain Relief Opiate analgesia (morphine), supplemented by NSAIDs
Surgical
Indications: cladication interfering w/ lifestyle, rest pain. Pre-gangrene, gangrene
Options: stents, arterial bypass grafts (aortofemoral, axillofemoral, femoropoliteal)
Indications for Central Venous Catheter
FAT CAB
F - Fluids
A - Antiobiotics
T - TPN
C - Chemotherapy
A - Administration of Blood
B - Blood sampling
Complications of PTC
percutaneous transhepatic cholangiography
complications: bile peritonitis, chylothorax, pneumothorax, sepsis, hemobllla
Approach to CXR
Check Name, Date, AP or supine
A- Airway
B - Bones
C - Cardiomegaly/Cardiac shadow
D - Diaphragm
E - Effusion
F - Lung Fields
H - Hilium
A - Ariway w/ c-spine control
B- Breath sounds, chest expansion, sounds, percussion, ascultation, tracheal deviation
C - pulse, Beck’s triad
AP pelvis, Lateral C-spine, CXR
S&S of chronic liver disease
Clubbing, leuconychia, koilonychia, palmar erythema, Dupuytren’s contracture, spider naevi, purpura
Causes of Clubbing GI
Cirrhosis of liver, UC, Crohn’s disase, Celiac disease
Causes of leuconychia
Cirrhosis of liver and nephrotic syndrome
Causes of palmar erythema
Chronic liver disease, pregnancy, the contraceptive pill, rheumatoid arthritis
For first 3, due to increased levels of circulating estrogens. Chronic liver disease there is gonadal atrophy and depressed testosterone production. A larger proportion of testosterone is rapidly metabolised to estrogen
Causes of spider naevi. When can it indicate a problem
1-2 can be found in normal people in pregnancy, and in thyrotoxicosis. However, if more than 5 can indicate chronic liver disease
Causes of Angular Stomatitis
Vitamin B deficiences, Iron deficiency anemia
Drugs causing gynecomastia
_DISCO _
Digitalis
Isoniazid
Spirnolactone
Cimetidine
Oestrogen
(extra: methyldopa, anti-androgens (cyproterone acetate), gonadrolein analogue)
Define Transudate and Exudate
What are some causes of ascites
Transudate less than 30 g/L. Exudate greater than 30 g/L
Causes of ascites
Transudate:
Congestive Heart Failure
Chronic Liver Disease
Nephrotic Syndrome
Constrictive pericarditis
Hypoproteinaemia
Exudate
Intra-abdominal malignancy
Bacterial peritonitis
Tuberculous peritonitis
DDx for Hypercalcemia
- *1. Primary hyperparathyroidism
2. Malignancy: hematological, humoral, skeletal metastases (>90% 1 & 2)**
3. Renal disease: tertiary hyperparathyrodism
4. Drugs: calcium carbonate, milk-alkali syndrome, thiazide, lithium, theophylline, vitamin A/D intoxication
5. Familial hypocalciuric hypercalcemia
6. Granulomatous disease: sarcoidosis, TB
7. Thyroid disease: thyrotoxicosis
8. Adrenal disease: adrenal insufficiency, pheochromocytoma
9. Immobilization
Define Sinus
A blind-ending tract, typically lined by epithelial or granulation tissue, whihc oipens to an epithelial surface
Primary vs Secondary Vs Teritiary Hyperparathyroidism
Primary - excessive secretion of PTH by either an adenoma (~80% cases), hyperplasia (~20%), or rarely a carinoma (<1%) of the parathyroids
Secondary - Excess secretion and hyperplasia of PTH by the parathyroid glands in reponse to persistant hypocalcemia (e.g. chronic renal disase, vitamin D deficiency, or intestinal malabsorption syndromes)
Tertiary - autonomous secretion of PTH when the secondary stimulus has been removed (e.g. after renal transplant)
S&S of Parathyroid Diseaes
“Bones, stones, psychosis-based moans, and abdominal groans”
Bones
Osteitis fibrosa cystica
Osteoporosis
Chondrocalcinosis (can cause pseudogout)
Stones Renal stones (nephrolithiasis) ; polyuria
Moans
Psychosis, confusion, anxiety, coma
Abdominal groans
PUD, acute pancreatiis (Ca2+ stimulates phospholipase), constipation
Note: 50% are asymptomatic (esp in prolonged disease)
Rx of Hypercalcemia
- treatment depends on the Ca level and the symptoms; treat acute, symptomatic hypercalcemia aggressively
Increase Urinary Ca excretion (isotonic saine + furosemide (only if hypervolemic)
Dimish bone resorption (Bisphosphonates; cinacelet if not working)
Decrease gut absorption (corticosteriods in hypervitaminosis D and hematological malignancies)
Dialysis
Chelation: EDTA or IV phosphate (rarelty used)
If causes is primary/tertiary hyperparathyroidism - removal of glands!
Most common pathologic cause of hypocalcemia in the hospital
Hypomagnesemia:
Magnesium is a cofactor for adenylate cyclase.
Cyclic adenosine monophosphate (cAMP) is required for PTH activation.
C&C the follwing IV Fluids:
ECF
Ringer’s lactate
0.9 NS
0.45 NS
D5W
**ECF Ringer’s Lactate 0.9 NS **
**Na ** 142 130 154
**K ** 4 4 -
**Ca **4 3 -
**Mg ** 3 - -
**Cl ** 103 109 154
**HCO3 **27 28 -
- *Total **280- 273 308
- *(mOsm/L)** 310
How to approach a lump clinically
Look
A) Inspect (shape, colour)
B) Measure (distance from nearest bony prominence; dimensions)
Feel
ASK IF LUMP IS TENDER/PAINFUL
A) Temperature (run back of fingers along lump)
B) Surface (smooth, bosselated, rough)
C) Edge (clearly/poorly defined)
D) Consistency (stony-hard, rubbery, soft, spongy)
E) Surrounding (indurated, invaded, colour change)
PRESS
A) Pulsatility (expansive vs pulsatile)
B) Compressibility/reducibility
C) Percussion (dull, resonant)
MOVE
Try to move skin over lump (fixation?)
Try to move lymp in 2 planes at right angles (mobility)
Ask patient to tense underlying muscle (attached to muscle or beneath it)
LISTEN
Bruit, bowel soudns
TRANSLUMINATE
Press pen torch and an opaque tube on opposite sides of the lump
EXAMINE SURROUNDING TISSUES
Limbs/trunk - axilla
Head/neck -cervical
Causes of hypo and hyperthyroidism
Hyperthyroidism
Grave’s (younger patients, goitre diffusely enlarged w/ bruit), Multinodular goitre (older patients), Functioning adenoma (rare, most non-functioning)
Hypothyroidism
Primary myxoedema (autoimmune, no goitre) ; Hashimoto’s thyroiditiis (autoimmune, younger patients, rubbery goitre, early may present hyperthryoid)
What Qs can be asking in pt w/ lump/ulcer
1) When and how did you first notice it?
2) Has it changed since you first noticed it (bigger, smaller, same size, come and gone - does its appearance or consistency change over a period)?
3) What symptoms does it cause you (pain, nipple discharge)?
**4) Have you got any more lumps or have you had this before? - does it come on periodically (menstrual) **
5) What do you think it is?
What are some midline swellings of the nexk
Common:
Thyroid swelling, Thyroglossal cyst
Uncommon
Lymph nodes, sublingual dermoid cyst, plunging ranula, pharyngeal pouch, subhyoid bursa, carinoma of the larynx/trachea/esophagus
Describe the anatomical location of the midpoint of the inguinal ligament vs the mid-inguinal point
Mid-inguinal point: midway ASIS and pubic symphysis; location of femoral artery)
Midpoint of the inguinal ligament (midway ASIS and pubic tuercle: location of the deep ring)
Fibrocystic change vs Breast Cancer
Fibrocystic change Breast Ca
Often Bilateral Often unilateral
May have multiple nodes Usually single
Menstrual variation No menstrual variation
Cyclic pain & engorgement No CP or engorgement
May regress during pregnancy Does not regress
DDx Breast Mass
DDx for Breast Mass
- Breast Ca
- Fibrocytic changes
- Fat necrosis
- Papilloma/papilloatosis
- Galactocele
- Duct ectlasia
- Ductal/lobular hyperplasia
- Sclerosing adenosis
- Lipoma
- Neurofibroma
- Granulomatous mastitis (TB, Wegner’s, sarcoidosis)
- Abscess
- Silicone implant
What are the complications of hernia repair
General
Specific
Urinary retention
Bruising - ~30%
Pain - chronic groin pain persists in ~5%
Hematoma - 10%
Infection - 1%
Ischemic orchitis - 0.5% - thrombosis of pampiniform plexus
Recurrance <0.5%
Appendectomy Complications
Post-surgical complications of appendectomy (Bailey’s and Love’s):
- Wound infection (5-10%). Most common post-operative complication. Rx wound drainage and antibiotics as required
- Intra-abdominal abscess - relatively rare. CT and abdo U/S diagnose and allow percutaneous drainage. Laparotomy in patients with intra-abdominal sepsis
- Ileus - expected after surgery. May last numebr of days. If 4-5 days think intra-abdominal sepsis
- Portal pyaemia (pylephebilits): rare but serious complication of gangrenous appendicitis (high fever, rigors, jaundice. Caused by septacemia of portal venous system and leads to intrahepatic abscess. Tx: systemic Ab and percutaneous drainage of hepatic abscesses
- Adhesive intestinal obstruction: most common late complication
Hypertrophic Pyloric Stenosis
Most commonly affects boys aged 2–8 weeks
■ Characterised by projectile vomiting after feeds
■ Gastric peristalsis can be seen and a lump felt
■ Fluid and electrolyte disturbances must be corrected
before surgery
■ Pyloromyotomy splits the hypertrophied muscle leaving
the mucosa intact
3 Ps
- Palpable mass (70% - “olive”)
- Peristalsis visible
Projectile vomiting (2-4 weeks after birth)
Pemberton’s sign
Indicator of superior vena cava compression
Pemberton’s sign is the development of facial flushing,[1] distended neck and head superficial veins, inspiratory stridor and elevation of the jugular venous pressure (JVP) upon raising of the patient’s both arms above his/her head simultaneously, as high as possible (Pemberton’s maneuver).
C&C MEN conditions
MEN 1 (Werner’s syndrome)
- 3 P’s:
○ Parathyroid tumours (80-95%)
○ Pituitary tumours
○ Pancreatic endocrine tumours - Zollinger-Ellison syndrome, insulinomas, VIPomas, glucagonomas (rare)
○ Note: commonly presents with kidney stones and stomach ulcers
- 2 per 100,000
- Mutation is in a tumour suppressor gene
MEN 2A (Sipple’s syndrome)
- 2Ps
○ Parathyroid
○ Pheochromocytoma
○ Medullary thyroid carcinoma (secretes calcitonin) - 100% patients
MEN 2B
- 1 Ps
○ Pheochromocytoma
○ Medullary thyroid carinoma (secretes calcitonin)
○ Oral/intestinal ganglioneuromatosis (associated with marfanoid habitus)
Indications for Open Reduction
NO CAST
N - nonunion
O - open fracture
C - neurovascular compromise
A - intra-articular fracture
S - Salter-Harris 3,4,5
T - polytrauma
General Fracuture Complications
Local Early
Compartment syndrome
Neurological injury
Vascular injury
Infection
Implant failure
Frature blisters (formation of vesicles or bullae that occur on edematous skin overlying a fractured bone)
Systemic Early
DVT
Sepsis
PE
Fat emoblism
ARDS
Hemorrhagic shock
Local Late
Mal/non-union
AVN
Osteomyelitits
Heterotropic ossification (formation of bone in abnormal locations (e.g muscle), secondary to pathology
Post-traumatic arthritis/joint stiffness
Chronic regional pain syndrome type 1
Met Spread in Breast Cancer
bone > lungs > pleura > liver > brain
Indications for Open reduction
NO CAST
- *N**onunion
- *O**pen Fracture
- *C**ompromise of Blood Supply
- *A**rticular surface malalignment
- *S**atler-Harris grade III-IV fracture
- *T**rauma patients who need early ambulation
S&S of compartment Syndrome
Complications?
Initial Rx and definitive Rx
Symptoms: pain, paresthesia, and paralysis
Signs: pain on passive movement (out of proportion to injury), cyanosis or pallor, hypoesthesia (decreased sensation, decreased two point discrimination), firm compartment
Complications: muscle necrosis, nerve damage, contractures, myoglobinuria
Initial Rx: bivalve and split casts, remove constricting clothes/dressing, place extremity at heart level
Definitive Ix: Fasciotomy within 6 hours (6-8 max) if at all possible
Questions for a Breast Lump
Breast Lump
When did you notice the lump
How did you notice it
Has the lump changed since you first noticed it? How?
Is it painful
Have you had any breast lumps in the past
Has anyone in your family had any lumps
Hormonal Factors
Does the lump change with your menstrual cycle or at different times in the month
When did you start your periods? menarche If relevant - when did you stop your periods (menopause)
C&C Pleural Effusion vs Consolidation (lobar pneumonia)
Percussion Breath S Vocal R Added S
Consol Dull Bronchial Increased Crackles
Effusion Stoney Dull Vesicular Reduced/ Absent
reduced or Absent
absent
What is Volkmann’s contracture, what are the usual causes
Contracture of the forearm flexors secondary to forearm compartment syndrome
Causes: brachial artery injury, supracondylar humerus fracture, radius/ulnar fracture, crush injury, etc
What is a Marjolin’s ulcer
Marjolin’s ulcer refers to an aggressive ulcerating squamous cell carcinoma presenting in an area of previously traumatized, chronically inflamed, or scarred skin. They are commonly present in the context of chronic wounds including burn injuries, venous ulcers, ulcers from osteomyelitis, and post radiotherapy scars.
Appearance
Slow growth, painlessness (as the ulcer is usually not associated with nerve tissue), and absence of lymphatic spread due to local destruction of lymphatic channels
What is the lymphatic drainage of the breast
Lateral: axillary lymph nodes
Medial: parasternal nodes that run with the internal mammary artery
Initial Treatment of Open Fracture
- Prophylactic Ab to include IV gram +ve +/- anerobic coverage (cefazolin, cefoxitin/gentamicin)
- Surgical debridement
- Inoculation against tetanus
- Lavage wound < 6 hours postincident w/ high-pressure sterile irrigation
- Open reduction of fracture and stabilization (e.g. use of external fixation)
1) Most common type of breast cancer
2) Sites of breast cancer mets
3) Most common cause of bloody nipple discharge in a young woman
4) Most common breast tumour in patients younger than 30
1) Infiltrating ductal carcinoma
2) Lymph nodes (most common), lung/pleura, liver, bone, brain
3) Intraductal papilloma
4) Fibroadenoma
Why is mammography a more useful diagnostic tool in older women than in younger?
Breast tissue undergoes fatty replacement with age, making masses more visible. Younger women have more fibrous tissue, which makes mamograms harder to interpret
Ewing’s sarcoma
TKO Ewing
Twenty years old or younger Knee joint Onion skinning (X-ray - lytic lesion with periosteal reaction, calcified layering)
5 yr survival rate 50%
1) Best way to evaluate breast mass in woman < 30 yrs
2) Classic picutre of breast ca on mammography
1) Breast ultrasound
2) Spiculated mass
Preoperative staging workup in patient with Breast Ca
Bilateral mammogram (contralateral breast met)
CXR (lung met)
LFTs (liver meg)
Serum Ca2+, ALP (bone met/”bone pain” –> if +ve bone scan)
Other tests based on signs (e.g. head CT for focal neurological deficity (brain met))
Specific Complications of Breast surgery (modified radical mastectomy)
Ipsilateral arm lymphedema
Infection
Injury to nerves (long thoracic nerve, thoracodorsal nerve, medial pectoral nerve, lateral pectoral nerve)
Skin flap necrosis
Hematoma/seroma
Phantom Breast syndrome
Modified radical mastectomy
Indications: > 4 lymph nodes, plus chest wall involvement of tumour
Proceudre: Breast, axillary nodes (level II, 1), nipple removed.
Pec major and minor spared (hence modified)
Treatment of myoglobinuria
HAM
Hydration with IV fluids
Alkalization of urine with IV bicarbonate
Mannitol diureisis
Management of Hemorrhagic Shock
Secure airway and supply O2
Treat the cause of the Shock
Control external bleeding
Infusion of 1-2 L of NS/RL as rapidly as possible (2 large bore (14 gauge) IVs die open - give bolus until HR decreases, urine output picks up, and patient stabilizes. Maintenance 4-2-1 Rule. Replace lost blood volume ar 3:1 with crystalloid
Basal Skull Fracture
Battle’s sign: bruised mastoid process
Hemotympanum
Raccoon eyes (periorbital brusing)
CSF rhinorrhea/otorrhea
Rx Increased ICP
Elevate head of bed (up to 20 degrees if stable)
Intubate and hyperventilate (100% O2) to a PCO2 of 30-35 mmHg
Mannitol
consider paralysing meds if agitated/high airway pressures
Life Threatening Injuries found on Primary Survey and their management
HOT and FAT
Hemothorax massive (> 1500 mL in chest cavity)
CXR. Restore blood volume. Thoracotomy if: > 1500 mL blood loss, > 200 ml/hr continued drainage
Open pneumothorax. Hole > 2/3 tracheal diameter. Unequal breath sounds. Air-tight dressing sealed on 3 sides, chest tube, surgery.
Tension pneumothorax: clinical diagnosis. Respiratory distress, tachycardia, distended neck veins; Tracheal deviation away from pneumothorax; percussion hyperresonance; unilateral absence of breath sounds. Management: needle thracostomy - large bore needle (12G) cannula into 2nd ICS mid-clavicular line, followed by chest tube in 5th ICS, anterior axillary line
Flail chest: Free-floating segment of chest wall due to > 2 rib fractures, each at 2 sites. Paradoxical movement of flail segment. Decreased air entry on affected side. O2 + fluid therapy + pain control. Positive pressure ventilation. +- intubation and ventilation
Airway Obstruction: Anxiety, stridor, hoarseness, alterned mental status, apnea, cyanosis
Management: definitive airway management, intubate early
Tamponade (cardiac): clinical diagnosis. Beck’s triad, tachycardia, tachypnea, pulsus paradoxus, kussmaul’s sign (raise JVP on inspiration). IV fluids, pericardiocentesis, open thoracotomy
Bone Mets
BLT w/ Kosher Pickle
Breast
Lung
Thyroid
Kidney
Prostate
Breast & Prostate make up 2/3rds of bone mets
What should you add when finishing up on management of a patient
POSSET
Physio
Occupational therapy
Specialists (e.g. stoma care, breast care, speech therapist)
social workers
Education
Terminal acrea
Hand signs for thyroid (7 of them)
1) Increased Sweating (hyperthyroidism)
2) Palmar erythema (hyperthyroidism)
3) Thyroid acropachy (aka pseudoclubbing - seen in Graves)
4) Onycholysis (Plummer’s nails - detachment of the nail from the nail bed)
5) Areas of vitiligo (Grave’s)
6) Pulse - tachycardia or a fib (hyperthryoid), bradycardia (hypothyroid)
7) Fine Tremour
Indications for Thyroid Surgery w/ Goitre
Obstructive symptoms
Suspicion of malignancy
Cosmetic reasons
Thyrotoxicosis
Increasing size despite adequate thyroxine therapy
Retrosternal extension
Incisional Hernia RF
Obesity
Persistant postoperative cough
postoperative abdominal distension
1) Risk Factors Wound Infection
2) Infection rates based on type of surgery
Malnutrition (obesity, weight loss)
Metabolic disease (diabetes, uremia, jaundice)
Immunosuppresion (cancer, AIDS, steriods,chemotherapy, radiotherapy)
Colonisation and translocation in GI tract
Poor perfusion (systemic shock or local ischemia)
Foreign body material
Poor surgical technique (dead space, hematoma)
Infection rates based on type of surgery
Clean (no viscus opened): 1-2%
Clean-contaminated (viscus opened, minimal spillage): <10%
Contaminated (open viscus w/ spillage or inflammatory disease): 15-20%
Dirty (pus or perforation, or incision through abscess): <40%
Approach to Solid Organ Malignancy
Establish Tissue Diagnosis then look for:
Local Invasion
Local Regional Spread (lymphatics)
Systemic spread
Establish whether can achieve Oncologic Clearance - exicision w/ margins
Adjuvant Rx - if applicable
Extraintestinal manifestations of IBD
** Hematological disorders**:
iron deficiency and hemolytic anemia, leukocytosis, thrombocytosis, DVT
Skin:
erythema nodosum, pyoderma gangrenosum, apthous ulcers, drug reactions of erythema multiforme and finger clubbing)
Ocular:
iritis (CD > UC), uvetiis, episcleritis, superficial keratitis, blepharitis, retrobulbar neuritis
**Hepatic Disease** sclerosing cholangitis (UC 3-10%\> CD ~1%), pericholangitis, fatty infiltration
**Renal **
nephrolithiasis, glomerular nephritis, hypokalemic nephritis
**Arthopathy **
anklyosing spondylitis, sacroilitis, migratory monoarthropathy, peripheral arthritis in children
Define: anuria, oliguria, polyuria
Urine Volume
Average adult 1-2 L per day.
□ Excess of 2L is called polyuria
□ Oliguria = less than 500 mL/day
□ Anuria = 0-100 mL/day
Classification of Burns
** Superficial**: epidermis only (e.g. sunburn) (1st degree)
Present: dry, red areas that do not form blisters
Tx: keep clean, neosporin, pain meds
Healing time 3-6 days
Partial thickness:
1. Superfical: painful, blanches with pressures, blisters
Healing time 7-21/days
2. Deep: painless (preceptive to pressure only), blisters, does not blanch
Healing TIme > 21 days (usually requires surgical treament)
Rx: Remove blisters, apply antibiotic and dressing, pain meds. Silverlon (silver ion dressing - new treatment). Tend to heal w/ conservative management
** Full thickness**: all layers of the skin (3rd degree)
Painless, insensate, swollen, dry, mottled, white, and charred areas; often described as dry leather
Tx: early excision of eschar (within 1st wk burn) and split thickness skin grafting
Deep (fourth degree): to fat, muscle, even bone
Parkland’s Formula
Volume = TBSA (%) x Weight (kg) x 4ml
Used to estimate volume of crystalloid necessary for initial resuscitation of burn patient; half of calculated volume is given in first 8 hours (SINCE INITATION OF BURN), the rest in the next 16
What conditions classify a burn as major (when to refer)
2nd degree burns to > 20% BSA (10% TBSA in children and elderly)
3rd degree: >5% TBSA
Any burns involving face, hands, feet, perineum
Any burns with inhalation injury
look for carboxyhemoblobin (>60% has 50% mortality) - Rx 100% O2
Any burns with associated trauma
Any electrical burns
5 types of Syncope
- Vasomotor
- Cardiac
- CNS
- Metabolic
- Psychogenic
HEAD, HEART, VeSSELS
- *H**ypoxia/Hypoglycemia
- *E**pilepsy
- *A**nxiety
- *D**ysfunctional brainstem
Heart attack
Embolism (PE)
Aortic obstruction
Rhythm disturbance
Tachycardia
Vasovagal
Situational
Subclavian Steal
ENT (glossopharyngeal neurlagia)
Low systemic vascular resistance
Sensitive carotid sinus
Acute Rx of Pulmonary Edema
Acute Treatment of Pulmonary Edema
• treat acute precipitating factors (e.g. ischemia. arrhythmias)
• L - Lasix (furosemide) 40-500 mg IV
• M -morphine 2-4 mg IV- decreases anxiety and preload (venodilation)
• N- nitroglycerin- topical/IV/SL (decreases preload)
• 0-oxygen
• P- positive airway pressure (CPAP/BiPAP)- decreases preload and need for ventilation
• P - position - sit patient up with legs hanging down unless patient is hypotensive
Chronic Rx of CHF
ACE inhibitors*
Beta Blockers*
+/- Aldosterone antagonists* (if severe CHF)
Diuretic
+/- Inotrope
+/- Antiarrythmic
+/- Anticoagulant
* = mortality benefit
5 Most common Causes of CHF
- Coronary Artery Disease (60-70%)
- HTN
- Idiopathic (often in the form of dilated cardiomyopathy)
- Valvular (e.g. AS, AR, MR)
- Alcohol (may cause dilated cardiomyopathy)
Risk Factors for DVT
History of immobilization or prolonged hospitalization/bed rest
Recent surgery
Obesity
Prior episode(s) of venous thromboembolism
Lower extremity trauma
Malignancy
Use of oral contraceptives or hormone replacement therapy
Pregnancy or postpartum status
Stroke
1) S/E of Steriods
2) Cautions/Contraindications
1) Weight gain, cataracts/glaucoma, hyperglycemia, osteoporosis, avascular necrosis, PUD, infection susceptibility , easy infection, acne, hypokalemia, hypertension
2) active infection, osteoporosis, hypertension, gastric ulcer, diabetes, TB
Complications of Thyroidectomy
Intraoperative
- Bleeding
- Thyrotoxic storm
- Occurs if thyrotoxic patient has been inadequately prepared for thyroidectomy (extremely rare)
- Dehydration (IV fluids), hyperpyrexia (cooling with ice packs
- Laryngeal edema
- Most important cause: tension hematoma
- Trauma to larynx during anesthetic intubation and sugrical manipulation are important contributing factors (particularly if goiter highly vascular
- Pneumothorax
- Early
- Hypoparathyroidism leading to hypocalcemia
- Parathyroid insufficiency:
- < 1% of thyroidectomies. Present dramatically 2-5 days after surgery
- Hematoma
* Decompression. If fail intubate - Recurrent layrngeal nerve palsy
- 1.8% at 1 month, declining to 0.5% at 3 months post-op
- Permanent paralysis of external branch of superior laryngeal nerve more common because of proximity to superior thyroid artery
- Wound Infection: cellulitis
Late
- Hypothyroidism
* After subtotal thyroidectomy: usually occurs within 2 years (20-40% at 10 years) - Hypertrophic scarring
- Recurrence of thyroid disease
Define Asthma. What is the pathological triad?
Chronic, reversible inflammatory disorder of airways that causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough (particularly at night and/or early morning)
Triad
1) Airway obstuction: intermittent and reversible airway obstruction
2) Chronic inflammation: chronic bronchial inflammation and esosinophils
3) Hyperreactivity: bronchial smooth muscle hypertrophy and hyperreactivity
Drugs that can worsen asthma
1) Aspirin - NSAIDs (COX-1). PGE2 drops which increases leukotrienes. Interestingly, COX-2 is not a problem
2) Beta-blockers (B1 component causing bronchial smooth muscle contraction)
3) ACEI: increases bradykinin
What are exenatide and sitagliptin
Exenatide: long-acting glucagon-like peptide (GLP-1) agonist. GLP augments glucose-dependent insulin secretion
Sitagliptin: inhibits dipeptidyl peptidase (DPP-4) which breaks down GLP-1
Symptoms of Prolactinoma
Galactorrhea, visual changes, headache
Name some TCAs
S/E TCAs
What is TCA Toxicity?
Imipramine, clomipramine, amitriptyline
Presynpatic NT reuptake: tremour, insomnia
Cardiac fast Na channels: conduction defects, arrhythmias, hypotension
Central/Peripheral AChM: hyperthermia, flushing, dilated pupils intestinal ileus, urinary retension, sinus tachycardia
Peripheral alpha receptors: peripheral vasodilation (orthostatic hypotension)
Histamine 1 receptors: sedation
Toxicity: coma, convulsions, cardiotoxicity (3Cs)
What do you recommend to patient with exercise induced asthma
Asthmatics are to warm up 2x as long as others and take β2 agonist 10 min prior
S&S of PCOS
Lab Findings
Menstrual irregularities - Oligomenorrhea is the most common complaint.
Hirsutism, infertility, obesity (40-50%)
Lab FIndings
§ (1) LH:FSH ratio > 2
§ (2) Increased serum testosterone (free and total) and androstenedione (derived from adipose conversion of estrogen)
§ (3) Increased serum estrogen
§ Test to determine whether hypothalamic/pituitary or ovarian PCO
□ Give 5 day treatment with oral progesterone (e.g. Medroxyprogesterone acetate 10 mg 12-hourly)
® If PCOs, then progesterone will cause menstruation after treatment stopped
If Hypogonadotrophic hypogonadism, menstruation will not occur after withdrawal of treatment because endometrium is atrophic as a result of estrogen deficiency.
S&S of Serotonin Syndrome and Hypertensive Crisis.
What drugs ppt these
Serotonin Syndrome:
Symptoms:
neuromuscular excitation (hyper-reflexia, myoclonus, rigidity), ANS stimulation (hyperthermia, tachycardia, diaphoresis, tremour), altered mental status (agitation and confusion). Can be associated with SSRIs & TCAs, meperidine (opiate with metabolite SSRI), ephedrine (cold meds), amphetamine=
Hypertensive Crisis:
Symptoms: high BP, arrhythmia, exciation, hyperthermia. Associated with MAO. Drugs that can worsen: tyramine, TCA, alpha-1 agonists, levodopa
Antiphospholipid syndrome Clinical Features
§ Deep vein thrombosis — 32 percent
§ Thrombocytopenia — 22 percent
§ Livedo reticularis (L. Livedo = “bluish”) — 20 percent
§ Stroke — 13 percent
§ Superficial thrombophlebitis — 9 percent
§ Pulmonary embolism — 9 percent
§ Fetal loss — 8 percent
□ Due to thrombosis of placental bed vessels
§ Transient ischemic attack — 7 percent
§ Hemolytic anemia — 7 percent
What are Charcot’s Triad and Reynold’s Pentad
Both characteristic of cholangitis
Charcot’s Triad: fever, RUQ pain (biliary colic), jaundice (50-70%)
Reynold’s Pentad in patients with suppurative (severe) cholangitis: Charcot’s Triad + altered mental status and hypotension
Drugs that can 1) worsen and 2) fix Torsades de Pointes
1) procainamide, phenothiazides, TCAs, disopyramide
2) MgSO4
ACh effects in excess
SLUDGE : (ie, salivation, lacrimation, urinary incontinence, diarrhea, GI upset and hypermotility, emesis (vomiting)
Antibiotic that causes tendon rupture
Quinolones
Casues for post-operative fever
1 day - pneumonia or atelectasis
3 days - UTI
5 days - wound infection
7 days - DVT
Mnemonic: Wind, Water, Wound and Walk
Herbal Preparation that needs to be stopped 7 days before surgery
Hypoglycemic and Anti-coagulant effect of Ginseng requires that it needs to be stopped before surgery
Indications for cholecystectomy with assymptomatic gallstones
Diabetic, Calcified gallbladder (risk of malignancy), bariatic surgery, immunosuppressed, pediatric patient, sickle cell disease
Complications of Burns
Complications of burns
Immediate
Compartment syndrome from circumferential burns
Early
Hyperkalemia. Rx insulin or dextrose
-Acute Renal failure . Prevent by aggressive early resuscitation, ensuring high GFR wit fluid loading and diuretics, treat sepsis
Infection (beware of streptococcus). Rx infections
Stress ucler (Curling’s ulcer) prevent with H2 blocker of PPI prophylaxis)
Late
Contractures
Diagnostic Triad of Acute Pericarditis
Chest pain, friction rub, ECG Changes
ECG changes: initially ST elevation +/- depressed PR segment. 2-5 days later ST isoelectric with T wave flattening and inversion
Quartet of cardiac tamponade
Clinical Diagnosis:
Becks Triad (hypotension, increased JVP, distant (muffled) heart sounds) + pulsus paradoxus
DDx of Pulsus Paradoxsus
Constrictive percarditis
Severe obstructive pulmonary disease (e.g. asthma)
Tension pneumothorax
PE
Cardiogenic shock
Common Names Asthma Inhalers and how often to take.
1) Ventolin
2) Spiriva
3) Flovent
4) Serevent
1) Ventolin = albuterol (onset 5-15 min; duration 3-5 hrs)
Acute bronchospasm: 2 puffs inhaled PO q 4-6 hrs
Severe bronchospasm: nebulized
Exercise: 2 puffs inhaled 15-30 min before; up to 12 puffs/2 hours
2) Spiriva = tiotropium
Long-acting anticholinergic (>24 hours)
1 capsule per day.
3) Flovent = fluticasone (corticosteroid)
Asthma treatment: either inhaler or diskus. Though dosages vary between inhaler/diskus, both are 2 puffs PO BID
4) Serevent = long-acting B2 agonist (>12 hrs)
Asthma/COPD/Bronchospasm: 1 inhalation BID
DDx Hematuria
Tumours: renal cell carinomas, bladder transititional cell carinomcas, prostate adenocarcinoma
Trauma: post insertion of FOley catheter, after cystoscopy or after urethral injury in pelvic fractures
Infection: cystitis, prostatitis
Inflammation: nephritic syndrome
Mechanical: urinary stones
Medical: coagulopathies
Red herrings: ingestion of beetroot, jaundice causing dark urine
Hypoglycemia
1) Type 1 DM
2) Type II DM
3) Other:
Genetic defects (beta-cell function or insulin action)
DIseaes of pancreas (pancreatitis)
Endocrinopathies (acromegaly, Cushing syndrome)
Drugs (glucocorticoids, thiazides)
4) Gestational DM
Pitting vs non-pitting edema causes
Pitting:
1) intrasvascular hydrostatic pressure (CHF, portal hypertension)
2) decreased plasma oncotic pressure (nephrotic syndome, malnutrition, cirrhosis)
3) increased capillary leak (burns, trauma, infection)
Non-pitting
1) lymphatic obstruction
2) increased interstital oncotic pressure, albumin etc (e.g. myxedema seen in hyperthyroidism)
Complications of acute cholecystis
• gallbladder mucocele (hydrops) -long term cystic duct obstruction results in mucous accumulation in gallbladder (clear fluid)
• gangrene, perforation - result in abscess formation or peritonitis
• empyema of gallbladder - suppurative cholecystitis, pus in gallbladder + sick patient
• cholecystoenteric fistula, from repeated attacks of cholecystitis, can lead to gallstone ileus
• emphysematous cholecystitis - bacterial gas present in gallbladder lumen, wall or pericholecystic space (risk in diabetic patient)
§ Gas forming bacteria: clostridium, eschersia, staphylococcus, streptococcus, pseudeomonas, klebsiella
§ Typically males 50-70 yrs
§ Risk factors
□ Vascular compromise (obstruciton or stenosis of cystic artery (sole artery to gallbladde)
□ Gallstones
□ Immunosuppreion (diabetics)
□ Infection gas-producing bacteria
• Mirrizzi’s syndrome- extra-luminal compression of CBD/CHD due to large stone in cystic duct
Complications of Thyroidectomy
- Intraoperative
§ Bleeding
§ Thyrotoxic storm
§ Occurs if thyrotoxic patient has been inadequately prepared for thyroidectomy (extremely rare)
§ Dehydration (IV fluids), hyperpyrexia (cooling with ice packs
§ Laryngeal edema
§ Most important cause: tension hematoma
□ Trauma to larynx during anesthetic intubation and sugrical manipulation are important contributing factors (particularly if goiter highly vascular
§ Pneumothorax - Early
§ Hypoparathyroidism leading to hypocalcemia
§ Parathyroid insufficiency:
§ < 1% of thyroidectomies. Present dramatically 2-5 days after surgery
§ Hematoma
§ Decompression. If fail intubate
§ Recurrent layrngeal nerve palsy
§ 1.8% at 1 month, declining to 0.5% at 3 months post-op
§ Permanent paralysis of external branch of superior laryngeal nerve more common because of proximity to superior thyroid artery
§ Wound Infection: cellulitis - Late
§ Hypothyroidism
§ After subtotal thyroidectomy: usually occurs within 2 years (20-40% at 10 years)
§ Hypertrophic scarring
§ Recurrence of thyroid disease
Vitamin D toxicity
= signs of hypercalcemia
constipation, abdo pain, weight loss, polyuria, polydipsia
Boundaries of the femoral canal
Anteriorly: Inguinal ligament
Medially: Lacunar ligament
Laterally: Femoral vein
Posteriorly: Pectineal ligament
Boundaries of the Femoral Triangle
Superiorly: Inguinal ligament
Laterally: Medial border of sartarious muscle
Medially: Medial border of adductor longus
Floor: Iliacus, psoas, pectineus, adductor longus
Roof: Superficial fascia, great saphenous vein
Differential Diagnosis of Hepatomegaly
Most common - Mets, CCF, Cirrhosis and Infection
Infection (Hepatitis, IM, Hydatid Cysts, Ameoba, Schistomomiasis, Bacteria abscess, cholangitis, portal pyaemia)
Cellular Proliferation (Polycythemia, Leukemia, Lymphoma)
Cellular infiltrates (Amyloid, Sarcoid)
Metabolic (Hemochromatosis, Wilsons, galactosemia)
Neoplasm (Mets, Cholangiocarcinoma, Abscess, cysts, syphilltic gumma)
Congestive
Contents of the Spermatic Cord
3 fascia: external, cremastic and internal fascia
3 arteries: gonadal (from aorta), artery to vas deferens (inferior vesical artery), cremastic arter (inferior epigastric artery)
3 veins: testicular vein, vein of vas deferens, cremasteric veins
3 nerves:ilioinguinal (outside cord), sympathetic from t10-t11, gento branch of genitofemoral nerve
3 contents: vas deferens, lymph nodes and if present a patent processus vaginalis
Side effects of
Tamoxifene
Trastuzumab/Hercptin
Tamoxifene - VTE, endometrial ca
Trastuzumab - cardiotoxicity
Causes of Duputryens Contracture
DEAFEST PAIL
Diabetes
Epilepsy
Age
Family Hisotry/Fibromatosis
Epileptic Medications
Smoking
Trauma
Peyronie’s - fibrosis of corpus callosum
AIDS
Idiopathic (most common)
Liver Disease 2 to EtOH
Causes of Gynecomastia
Physiological - Puberty
Pathological
- Decreased androgens - reduced androgen production (hypogonadism), testicular atrophy (bilateral crytoorchidism, orchitis or bilateral torsion), Kleinfelters syndrome, hyperprolactenemia and renal failure
- Increased estrogens - increased secretion (lung and testicular ca.) and increased peripheral aromatization (liver, adrenal disease and thyrotoxicosis)
Portions - marijuana, amphetamines, diazepam, GI (cimetidine, ranitidine), antibiotics (metronidazole. ketoconazole, isoniazid), Cardiac (Verapamil, nifedipine, Spironolactone, ACEI, digoxin)
End colostomy (single lumen, flush with skin, firm brown contents)
Resection of part of colon, e.g.: due to carcinoma, diverticulitis, perforation
E.g.: Hartmann’s procedure - in emergency cases where primary anastomosis cannot be obtained - this can be reversed at a later date
E.g. Abdominoperineal resection for sigmoid carcinoma
Loop colostomy (two lumens, flush with skin, firm brown contents)
To allow the bowel to rest
Diverticulitis
Or rectal carcinoma which cannot be resected (so colostomy formed to prevent obstruction)
Or to defunction a healing anastomosis (e.g. following an anterior resection of the sigmoid and creation of a primary colo-rectal anastomosis)
This has largely been replaced by loop ileostomy (because it is easier to site, less bulky, and easier to surgically close)
End ileostomy (single lumen, spouted, liquid green/yellow contents)
Total colectomy
E.g.: due to Ulcerative Colitis or Familial Adenomatous Polyposis
Loop ileostomy (two lumens, spouted, liquid green/yellow contents)
Usually formed to allow the bowel to rest
Acute severe Diverticulitis
Rectal carcinoma which cannot be resected (to prevent obstruction)
Defunctioning of rectal/anal disease in a flare up of Crohn’s disease
Double barreled colostomy (two lumens not joined by tissue, flush with skin, firm brown contents)
Resection of bowel e.g.: due to carcinoma
Usually resection of caecum
Urostomy
This is a general term for the surgical diversion of the urinary tract. The main reasons for a urostomy are cancer of the bladder, neuropathic bladder, and resistant urinary incontinence
The bladder is usually removed, but this may depend on the underlying condition. Formation of an ileal conduit is the most common procedure, which constitutes isolation of a segment of ileum. One end of the ileum is closed and the two ureters are anastomosed to it. Finally, the open end of ileum is brought out onto the skin as an everted spout and will look similar to an end ileostomy. Urine drains almost constantly from the kidneys through the ureters and ileal conduit into a stoma bag
Complications of Breast Surgery
Specific
Psychological
Lymphedema
SHoulder pain
Sensory loss over inner aspect of lower arm (intercostal brachial nerve)
risk of local recurrence
Causes of amylase
- Pancreatic
○ Pancreatitis, pseudocyst, tumor, abscess, pancreatic duct obstruction, ascites, cancer - Non-pancreatic
○ Biliary tract disease, bowel obstruction/ishcemia, perforated or penetrating ulcer, ectopic pregnancy, chronic liver disease, aneurysm, peritonitis - Non-abdominal
○ Cancer (lung, esophagus), salivary gland lesions, renal transplant/insufficiency, burns, ketoacidosis
○ Macroamylasemia
Complications of appendicitis
Perforation leading to peritonotinits
Appendix Abscess
Appendix Mass (inflamed appendix becomes covered wiht omentum - diagnosed on CT - treat with surgery)
Casues of gastrointestinal perforation
Gastro-duodenal - duodenal ulcer
Large bowerl - CRC, diverticulitus, appendicits
Rigler’s sign
Gas on either side of the bowel - sign of perforation
Complications of burns
Immediate
Compartment syndrome from circumferential burns
Early
Hyperkalemia. Rx insulin or dextrose
Acute Renal failure . Prevent by aggressive early resuscitation, ensuring high GFR wit fluid loading and diuretics, treat sepsis
Infection (beware of streptococcus). Rx infections
Stress ucler (Curling’s ulcer) prevent with H2 blocker of PPI prophylaxis)
Late
Contractures
Psychological problems
Calculating TBSA w/ Burns
TBSA that is burned estimated by rule of nines as follows
Each upper limb: 9% (front and back 4.5% each) Each lower limb: 18% (front and back 9% each) Anterior and posterior trunk = 18% each Head and neck: 9% (front and back 4.5% each) Perineum and genitalia = 1%
Daily requirements for the following electrolytes (for 70 kg male)
Na
K
Ca
Na 70-100 mmol
K 60-70mmol
Ca 20 mmol
DDx Breast Lump
Physiological
Fibroadenosis
Neoplastic
Benign: Fibroadenoma, Duct papilloma, Phylloides tumour
Malignant: Primary Carcinoma, Secondary carcinoma
Trauma
Far necrosis
Infective
Cellulitis, Abscess
Define fibroadenoma
a focal area of stromal hyperplasia with epithelial proliferation
