Surgery (5) Flashcards
How to perform Burger’s test?
- With the patient lying supine lift their leg until their heel becomes pale
- The angle at which the heel becomes pale is Buerger’s angle
*If the heel does not go pale then this is a normal test
- Keep the pale heel in the air for 30 seconds
- At the patient to sit up and hang their legs over the side of the bed and watch their feet
*A positive test: pallor then reactive hyperaemia
(redness) which implies significant peripheral arterial disease
Ix in suspected Peripheral Arterial Disease
- Bedside – ECG (detect any cardiovascular changes), urine dipstick (looking for glucose as possible DM)
- Bloods – FBC (anaemia causing pallor), U&Es (peripheral arterial disease associated with renal artery stenosis and CKD), blood glucose/HbA1c (DM), lipids
- Imaging - USS Doppler (detect peripheral pulses). Ankle-brachial pressure index (ABPI) to confirm diagnosis.
Ranges of ABPI
- Normal: 1.0-1.2
- 0.5-0.9 = claudication
- <0.5 = critical ischaemia
*>1.3 = hardening of vessels due to abnormal calcium accumulation (diabetes)
Management of peripheral arterial disease
Conservative
- Education
- Manage lifestyle risk factors
- Stop smoking
- Diet and weight management
- Exercise (supervised exercise programme to all people with intermittent claudication, or unsupervised exercise of 30 minutes 3-5 times per week where patients exercise until the onset of symptoms, then rest to recover)
Medical
- Symptomatic treatment with vasodilators → naftidrofuryl oxolate
- Manage cardiovascular risk (antiplatelet CLOPIDOGREL, lipid, hypertension, diabetes)
Surgical
• If no symptomatic improvement from exercise programme –> can be referred to surgery
for consideration of angioplasty or bypass surgery.
Presentation of acutely ischaemic limb
Painful
Pulseless
Pale
Perishingly cold
Paresthesia
Paralysis
Possible AAA screening findings and their management
Which antiplatelet is a choice in Peripheral Arterial Disease?
Clopidogrel
Cut of values for PSA
Causes of raised PSA
- BPH
- DRE
- Recent ejaculation
- UTI
- Prostatitis
- Prostate Ca
Conservative management in BPH
- Education
- IPSS score to guide need for medical management
- Reduce caffeine and alcohol intake
- Bladder training (e.g. increase time between voiding)
Medical management of BPH and its SEs
Alpha-blockers e.g.Tamsulosin → relax prostate smooth muscle
- Offer if IPSS ≧8
- SE: hypotension, drowsiness, depression
5-alpha-reductase inhibitors e.g. Finasteride
→ inhibit conversion of testosterone to DHT
- Offer if patients has LUTS and a prostate estimated to be >30g or a PSA ≧1.4ng/mL and a high risk of progression
- SE: erectile dysfunction, gynecomastia
Surgical management of BPH
Surgical (usually required for a large prostate/failure to respond to medical therapy)
- Open prostatectomy
- Transurethral resection of the prostate
When to suspect prostate cancer? (2)
Refer men using a suspected cancer pathway referral (for an appointment within 2 weeks) for prostate cancer if:
- their prostate feels malignant on digital rectal examination
- their PSA levels are above the age-specific reference range
The most common type of prostate cancer
95% adenocarcinoma
Scoring system in prostate cancer and its meaning
Gleason grading system
- two grades awarded 1 for most dominant grade (on scale of 1-5) and 2 for second most dominant grade (scale 1-5)
- The two added together give the Gleason score
- Where 2 is best prognosis and 10 the worst
Management of prostate cancer
