Surgery Flashcards
1
Q
Vomiting + Bradypnoea
What acid-base disturbance?
A
Metabolic Alkalosis with Partial Respiratory Compensation
Loss of fluid - Na, K, H and Cl
Hypoventilation occurs - Retains CO2
2
Q
Bicarbonate threshold for metabolic acidosis or metabolic alkalosis
A
<22 mmol/l = metabolic acidosis or renal compensation for respiratory alkalosis
>26mmol/l = metabolic alkalosis or renal compensation for respiratory acidosis
3
Q
What is the end result after pylorus preserving pancreaticoduodenectomy?
A
Pylorus of stomach attached to the small intestine
Pancreas attached to small intestine
Bile duct attached to small intestine
4
Q
Acute appendicitis
Which antibiotic?
When should be given?
A
Co-Amoxiclav (or other broad spectrum)- to reduce SSI.
Be given at diagnosis and continued til operation at least.
5
Q
Why give imipenem to Acute pancreatitis patients?
A
In the case of patients with pancreatitic necrosis, Imipenem can be given and has been shown to reduce the risk of superimposed infection
6
Q
Hemiarthroplasty vs Dynamic Hip Screw
A
Hemiarthroplasty - Performed in intracapsular fractures due to the blood supply to the head of femur being threatened
Intracapsular - Edge of femoral head to insertion of capsule at hip joint
Dynamic Hip Screw - performed in extracapsular femoral fractures.
7
Q
Hip Fracture Scoring System?
A
Garden System
Type I - Stable fracture with impaction
II - compelte fracture but undisplaced
III - Displaced fracture but has boney contact
IV - Complete boney disruption
8
Q
What hip fractures would you use intramedullary devices for?
A
Reverse oblique
Transverse
Subtrochanteric
9
Q
What is a marjolin’s ulcer?
A
SCC occuring at site of chronic inflammation or previous injury
10
Q
Straight lines appear crooked or wavey:
i) Yellow round spots in bruch’s membrane
Rx
ii) choroidal neovscularisation, serous fluid leakage, blood.
Rx
A
i) Early age-related macular degeneration: - these spots are known as drusen. Previously dry age-related macular degeneration
Rx - Smoking cessation, supplementation with beta carotene, vit a, vit c and vit e
ii) Late age-related macular degeneration. Previously wet age-related macular degeneration
Rx - photocoagluation, anti VEGF, photodynamic therapy
11
Q
Dx and Rx for Degenerative Cervical Myelopathy?
A
Dx:
MRI
CT in MRI contraindication (CT Myelogram)
Rx:
Decompressive surgery
12
Q
Hypertensive retinopathy classification
A
Keith Wagener’s Classification
I - Arteriolar narrowing and tortuosity. Increased light reflex
II - Arteriovenous nipping
III - Cotton wool exudated. Flame and blot haemorrahges
IV - Papilloedema
13
Q
Which humerus fracture is radial nerve damage most common from?
A
Fracture of the shaft of the humerous
14
Q
Meniere’s Disease
Acute management
LT Management
A
Acute - Prochlorperazine - buccal or IM
LT Management - betahistine or vestibular relaxation
15
Q
Rfs for Testicular cancer (5)
Dx
A
Cryptorchidism
Infertility
Kinefelter’s
Mumps Orchitis
FH
Dx - Ultrasound
16
Q
Tear Drop Plaques
A
Guttate psoriasis
- think strep throat
17
Q
Asymptomatic pink patches
A
Ptyriasis Rosacea
Look for herald patch in the question
18
Q
Itching around toes
Dx
Rx
A
Dx - Athlete’s foot usually especially if young
Rx - Topical Micanozole
19
Q
Supraventricular Tachycardias
Dx
Rx
A
Dx - narrow complex tachycardia
Rx - If stable - Vagal manouveres them IM Adenosine (Verapamil in asthmatics)
If unstable - Electric cardioversion
20
Q
Main indications for placing a chest tube in pleural infection? (3)
A
i) Frankly purulent or turbit pleural fluid
ii) Presence of organisms from pleural fluid samples
iii) pleural fluid ph <7.2
21
Q
What to send pleural fluid sample offf for? (5)
A
i) pH
ii) Protein,
iii) LDH,
iv) Cytology
v) Microbiology
22
Q
Light’s Criteria
When is it applied?
What are the criteria?
A
Applied when protein level is between 25-35 g/L
Light’s Criteria:
i) plerual fluid protein divided by serum protein >0.5
ii) pleural fluid LDH divided by serum LDH >0.6
iii) pleural fluid LDH more than two-thirds the upper limit of normal serum LDH
23
Q
Pleural Fluid Findings:
Low glucose? - 2
Raised Amylase - 2
Heavy blood staining - 3
A
Low glucose: TB, Rheumatoid ARthritis
Raised Amylase - Pancreatitis, Oesophageal perforation
Heavy blood staining - TB, Mesothelioma, Pulmonary embolism
24
Q
Nasal polyps associations? (6)
A
Asthma
Aspirin Sensitivity
Infective Sinusitis
CF
Kartagener’s (Primary ciliary dyskinesia)
Churg - Strauss Syndrome
25
**Gag Reflex:**
**Afferent component**
**Efferent component**
Afferent - Glossopharyngeal nerve CN IX
Efferent - Vagus Nerve CN X
26
**Post Splenectomy Blood Film (4 features)**
* Howell Jolly Body
* Pappenheimer Bodies
* Target Cells
* Irregularly contracted erythrocytes
27
Contraindications to Sildenafil (3)
Side effects of Sildenafil (5)
MOA of Sildenafil
CIs :
i) Pt. Taking nitrates (or nicorandil)
ii) Hypotension
iii) stroke/MI within 6 months
SEs:
i) Visual Disturbances
ii) Nasal congestion
iii) Flushing
iv) GI Side effects
v) Headache
MOA - Phosphodiesterase Type V Inhibitor
28
**MOA:**
**Carbimazole vs Propylthiouracil**
Carbimazole - This blocks thyroid peroxidase from coupling and iodinating tyrosine residues on TG
Propylthiouracil - Same central effect as carbimazole but additionally prevents peripheral conversion of T4 to T3
29
**Subcapital Fracture of the HIP : AKA?**
**Treatment?**
Intracapsular
Treated with hemiarthroplasty (in elderly)
Internal fixation ( in young)
30
**Investigation modality of choice for pancreatic cancer?**
**HRCT**
Ultrasound sensitivity - **60% - 90%**
31
Bubbly urine
Underlying cause?
Enterovesical fistula
Can be caused by colorectal malignancy.
32
i) Incidence (peak) ii) Germ or non germ? iii) RFs for bvoth
**Teratoma**
**Vs**
**Seminoma**
**Teratoma :**
i) Incidence - 25 year old
ii) Germ - "Non-seminoma" (others - yolk sac, embyronal, choriocarcinoma)
**Seminoma:**
i) Incidence - 35 year old
ii) Germ - "Seminoma)
**RFs -** cryptorchidism, infertility, FH, Kinefelter, Mumps,
**Non Germ Cell tumours -** Leydig cell tumour, sarcoma
33
**Most common form of renal malignancy**
34
**Chest Drain for:**
**Haemothorax**
**Pneumothorax**
**Surgical exploration?**
**Haemothorax -** 36F due to clot formation in smaller drains
**Pneumothorax -** 14 F usually used
**Surgical exploration -** warranted if \>1500 ml blood is drained immediately
35
**Commencement of hormone therapy in prostate cancer:**
What drugs (2)?
Why not only 1?
**Drugs:**
Goserelin Acetate - GnRH Analogue
Flutamide/ cypotoreton acetate - Anti-androgen
**Flutamide** protects against the **flare effect** which is essentially where **GnRH analogues** cause a transient increase in **LH Levels,** this is then followed by downregulation of sex hormones.
36
**PSA Testing:**
**How long after:**
Prostate biopsy?
Proven Urinary infection?
DRE?
Vigorous exercise?
Ejaculation?
6 weeks of a prostate biopsy
4 weeks following a proven urinary infection
1 week of digital rectal examination
48 hours of vigorous exercise
48 hours of ejaculation
37
**PSA Upper Limits:**
50-59
60-69
70\>
50-59: 3.0
60-69: 4.0
70\>: 5.0
38
**Cherry red lesion seen PR/ on anal verge in child:**
**what is it?**
**implication?**
**Juvenile Polyp/ Hamartoma**
These often signify the presence of an underlying familial polyposis condition
39
**Pelvic fracture + displaced prostate +perineal/penis oedema or haematoma**
**Urinary retention + perineal haematoma + blood at meatus**
**Pelvic fracture + displaced prostate perineal/penis oedema or haematoma -** membranous urethral rupture
**Urinary retention + perineal haematoma + blood at meatus -** Bulbar urethrl rupture - associated with straddle injuries (cycle)
40
**Mx of BPH**
**And side effects**
Watchful waiting
**medical**
**Alpha 1 antagonists** (tamsulosin, alfuzosin)
- decrease smooth muscle tone in bladder and prostate.
- SEs - dizzeness, postural hypotension, dry mouth
**5a reductase inhibitors** (finasteride)
- stops testosterone being converted to DHT (causes prostate hypertrophy
- erectile dsyfunction, reduce libido, ejaculatory dysfunction, gynaecomastia **all related to testosterone/ oestrogen! Makes sense**
41
**Renal Stones:**
**i) rank them in order of most - least common**
**ii) state whether opaque or not**
**iii) Mean urine pH?**
Calcium Oxolate - **opaque**
Mixed/ oxolate and phosphate - **opaque**
Triple phosphate - **opaque**
calcium phosphate - **opaque (normal/ alkaline)**
urate - **radio lucent (ACIDIC URINE)**
cysteine - **semi- opaque (Ground glass)**
xanthine - **lucent**
struvate - mildly opaque (**Alkaline urine)**
42
**Lump found posterior to the testicle is morel ikely to be a ...**
Epidymal Cyst
43
**FUlminant UC:**
pancoloproctectomy or subtotal colectomy?
**Subtotal colectomy**
- removal of the rectum increases risk of comploications signifiacntly
44
**Breast cancer prognosis index?**
**Components of it?**
**Nottingham Prognostic Index**
- Tumur size x 0.2 + lymph node score + grade score
45
**Fluid resuss in burns?**
**Threshold : Adults , children**
**Initial fluid calculation**
**Fluids after 24 hours**
\>15% burns in adults \>10% burns in children
**Initial fluid calculation -**
**parkland's formula - 4 ml x %burns area x bw in kg**
Give 50% in first 8 hours and 50% in next 16 hours
**after 24 hours**
- adminiter colloids
- more crystalloids
- more fluids neede in elctric/ inhalation injuries
46
**Two terrible ADR of suxamethonium**
**Sux -** Depolarising NMB
Malignant Hyperthermia - Dantrolene and cooling blankets
Pseudocholinsterase Deficiency - impending respiratory arrest. Need to have mechanical ventilation until drug has washed out
47
**Eponymous Fractures**
Colles'
Smiths'
Bennett's
Monteggia's
Galeazzi
Pott's
Barton's
Jone's
Dancer's (pseudo-jones)
Lisfranc's
Colles' - transverse fracture of radius, 1 inch proximal to radio-carpal joint, dorsal displacement and angulation (fall onto extended outstratched hand)
Smiths' - Volar angulation of distal radius fragment. (falling backwards onto the palm of an outstretched hand/ falling with wrists flexed)
Bennett's - intra articular fracture of first carpo metacarpal joint. (impact on flexed metacarpal, caused by fist fights)
Monteggia's - dislocation of proximal radioulnar joint in assocation with ulna fracture (outstretched hand with forced pronation)
Galeazzi - radial shaft fracture with dislocation of distal radioulnar joint
Pott's - bimallelar ankle fracture (forced foot eversion)
Barton's - distal radius fracture with radiocarpal dislocation (extended pronated wrist)
Jone's - fifth metatarsal fracture
Dancer's (pseudo-jones) - fifth meta tarsal fracture
Lisfranc's - disuption of lisfranc ligament (tarsal metatarsal joint. **widening of first and second metatarsal space/ midfoot dislocation)**
48
**Colles' Fracture**
transverse fracture of radius, 1 inch proximal to radio-carpal joint, dorsal displacement and angulation (fall onto extended outstratched hand)
49
**Smiths'**
Volar angulation of distal radius fragment. (falling backwards onto the palm of an outstretched hand/ falling with wrists flexed)
50
**Bennett's**
intra articular fracture of first carpo metacarpal joint. (impact on flexed metacarpal, caused by fist fights)
51
**Monteggia's**
Dislocation of proximal radioulnar joint in assocation with ulna fracture (outstretched hand with forced pronation)
52
**Galeazzi**
radial shaft fracture with dislocation of distal radioulnar joint
53
**Pott's**
bimallelar ankle fracture (forced foot eversion)
54
**Barton's**
distal radius fracture with radiocarpal dislocation (extended pronated wrist)
55
**Jone's**
fifth metatarsal fracture
56
**Dancer's (pseudo-jones)**
fifth meta tarsal fracture
57
**Lisfranc's**
- disuption of lisfranc ligament (tarsal metatarsal joint. widening of first and second metatarsal space/ midfoot dislocation)
58
**Dx of COPD**
**(2 features)**
FEV1/FVC \<70%
Symptoms suggestive of COPD
59
**Rx for VT**
**Medication (2)**
**Interventional (Short term, long term)**
**DIfferentiating between VT and SVT**
**Medication -** Amiodarone and Lidocaine
**Interventional -** Cardioversion short term, Pacing long term
**Differentiating-** Capture beats and Fusion beats seen in VT
Capture - SAN transiently syncs with ventricles so **normal QRS duration** is seen
Fusion - where **sinus** and **ventricular** beats coincide to produce a hybrid complex
60
**Borders of the Femoral Canal**
**Lateral**
**Medial**
**Anterior**
**Posterior**
Contents?
Lateral - Femoral Vein
Medial - Lacunar Ligament
Anterior - Inguinal ligament
Posterior - Pectineal Ligament
Lies medial to the femoral sheath
Contents - Lymphatic vessels and Cloquet's Lymph node
**Higher risk of strangulation than Inguinal hernia.**
61
**Breast Cancer Rx**
DCIS - Indication for mastectomy / WLE?
Radiotherapy - Indication in WLE / Mastectomy
Hormonal therapy - Tamoxifen use vs aromatase inhibitor use (letrozole)
DCIS - **Mastectomy if \>4cm**
Radiotherapy - **WLE - always radiotherapy** / **Mastectomy** radiotherapy if **T3-T4 tumour**
Hormonal therapy - Tamoxifen use in **pre and peri-menopausal women** / aromatase inhibitor use - **for post menopausal women** (letrozole)
62
**Shock**
**Narrow pulse pressure suggestive of?**
**Widened pulse pressure suggestive of?**
**NPP -** Hypovolaemic shock due to sympathetic stimulation
**WPP** - distributive shock due to peripheral vasodilation
63
**Familial Polyposis Syndromes**
Say the polyp burden, inheritance pattern, cancer risk and type of polyp
**APC mutations**
**mut Y human homologue mutation**
**STK11 (LKB1) mutation**
**PTEN mutation**
**DNA mismatch repair mutations genes**
**APC mutations**
FAP, AD inheritance, \>100 colonic adenomas with a **very** high cancer risk (100%)
If polyposis is found upon screening family members/ sporadic cases---\> **resection + ileo-anal pouch** or **if low rectal polyp burden sub-total colectomy + IRA**
**mut Y human homologue mutation**
MYH associated polyposis, **chromosome 1p** autosomal recessive inheritance with a **very high cancer (and breast cancer risk) risk but later onset than FAP**
**Sub total colectomy + IRA**
**STK11 (LKB1) mutation**
Peutz-jehgers, **chromosome 19** autosomal dominant with a moderataely icnreased risk of - breast, ovarian, cervical, pancreatic, testicular, CRC, and gastric cancer.
**polyps are hamartomas**
**PTEN mutation**
Cowden disease, **chromosome 10q22** autosomal dominant with a **high** cancer risk at any site including CRC.
**multiple intestinal hamartomas and trichilemmomas**
**DNA mismatch repair mutations genes**
HNPCC (Lynch Syndrome), **increased risk of** CRC, Endometrial, Gastric. CRC - more likely to be right sided
considered for prophylactic surgery as with FAP
64
**Ab treatment in acute pancreatitis?**
**Why?**
Imipenem
If pancreatic necrosis to prevent superinfection
65
History differentiating between **paget's** and **nipple eczema?**
Paget - primary in the nipple then spreads to areolar
Eczema - primary in the areolar and later invovles the nipple
66
**What drugs should PAD patients be on?**
First line:
Clopidogrel + Statin
If can't tolerate clopidogrel then aspirin
67
**SCC of the oesophagus assocaited with?**
**Achalasia**
Little history of GORD/Barrett's as this would indicate adenocarcinoma
68
**Tumour markers in**
**Seminoma**
**Non-seminomatous**
Testicular Cancers
Seminoma - AFP Normal, HCG elevated SOMETIMES, LDH eleveated SOMETIMES
Non-seminomatous - AFP, HCG elevated often
69
**Bochdalek Hernia**
**Vs**
**Morgagni Hernia**
**Bochdalek** Hernia
Left sided diaphragmatic hernia usually containing the **stomach**
**Morgagni** Hernia
Right sided diaphragmatic hernia usually containing the **transverse colon**
70
**Which artery is at risk with i) duodenal ulcer?**
**ii) lesser curve gastric ulcer?**
i) Gastro-duodenal arterry
ii) Left gastric artery
71
**Thyroid biomarkers**
**TPO Antiobdies**
**TSH R Antibodies**
**TG Antibodies**
**Calcitonin**
**TPO Antiobdies -** **Hashimoto's** (+grave's)
**TSH R Antibodies -** **Grave's**
**TG Antibodies -** Doesn't distinguish between cancers but used in monitoring cancer follow up
**Calcitonin -** Medullary carcinoma of thyroid
72
**Cystine Stones?**
AR Disorder of transmembrane cystine transport
73
74
**Fournier Gangrene?**
**Fournier gangrene - Necrotising Fascitis of the perineum**
- background immunosuppression
- Polymicrobial (e-coli + bacteroides working together)
purple black skin discolouration, crepitus, septic shock , blisters
75
**Mx of sigmoid volvulus? (1st, 2nd, 3rd line)**
**Associations**
1 - Rigid sigmoidoscopy with flatus tube decompression
2 - percutaneous colostomy
3 - Hartmann's for perforation
**Associations**
Elderly, constipated, chagas
76
**Mx of caecal volvulus**
Usually right hemicolectomy
77
**Biologic for GISTS?**
Imatinib
Only if KIT positive
78
**EGF positive colorectal cancers**
Cetuximab ( Epidermal growth factor inhibitor)
79
Lichen sclerosis of male genital area?
3 associations
**Balanitis Xerotica Obliterans**
**Associations**
- phimosis
- SCC
- Predisposition to infection
80
**Most common cause of epiddymo orchitis**
**Mx**
Chlamydia
Mx
IM Ceftriaxone (500mg)
Doxy PO ( 100mg BD for 10-14 days)
81
Which blood product is greatest associated with TRALI?
Plasma components
82
**Hernias:**
**Below and lateral to pubic tubercle**
**Above and medial to pubic tubercle**
**Below and lateral to pubic tubercle**
Femoral Hernia
**Above and medial to pubic tubercle**
Inguinal Hernia
83
**US Findings in liver masses?**
i) hyperechoic
ii) Mixed echoity and heterogeneous texture
iii) Fluid filled cavity / hyper echoic walls
iv) Fluid filled structure with poorly defined boundaries
v) Ultrasound showing septa
vi) Large anechoic, fluid filled area with irregular margins,
i) hyperechoic - **Haemangioma**
ii) Mixed echoity and heterogeneous texture - **Liver cell adenoma**
iii) Fluid filled cavity / hyper echoic walls - **Liver abscess (** hyperechoic walls if chronic **)**
iv) Fluid filled structure with poorly defined boundaries - **Amoebic Abscess**
v) Ultrasound showing septa - **Hydatid Cyst**
vi) Large anechoic, fluid filled area with irregular margins, - **Cystadenoma**
84
**Where should you not use lidocaine/adrenaline mixtures?**
In extremities due to risk of ischaemia
85
Tender lump around areola and discharge
Mammary Duct ectasia
86
Hard, irregular non-malignant breast lump
Fat necrosis
87
**Hypertrophic vs keloid scar**
Both disorders of excessive collagen
**Keloid scars extend beyond boundaries of the original injuries but hypertrophic scars do not**
88
**Deceleration injuries**
**Contained Haematoma**
**Widened Mediastinum**
**Persistent hypotension**
Aortic Rupture
89
Acute urinary retention immediate management (2 things)
Catheterisation + Urgent referral to Urology
90
**Sites of deceleration injury**
Aorta (Transection, rupture)
GI (Duodenal-jejunal flexure disruption)
Pulmonary Contusion
Cardiac Contusion
91
**Schiller Duval bodies**
Yolk sac tumours
- resemble glomeruli
92
**lowest gleason score consistent with prostate cancer**
6
Two samples taken for gleason scoring and it is the sum of the two most common histological patterns seen
**Higher the score** ---\> the more agressive the cancer and greater risk for metastasis
93
**When do you give WRT surgerY?**
**LMWH**
**Fondaparinux**
**Dabigatran**
**Rivaroxaban**
LMWH - 6-12 hours after surgery
Fondaparinux - 6 hours after surgery
Dabigatran - 14 hours after surgery
Rivaroxaban - 6-10 hours after surgery
94
**Hormonla therapy in bresat cancer?**
Pre and peri menopausal women --\> Tamoxifen for 5 years
Post menopausal women - Anostrazole (aromatae in hibitor)
95
**Spondylolisthesis**
**Sponydlolysis**
Spondylolisthesis - one vertebra anteriorly dislocates over another
Spondyolysis - defect or stress fracture in pars interarticularis of vertebral arch
96
**Schuerrman's disease**
Juvenile osteochondrosis of the spine (osteonecrosis of the spine followed by endochondral ossification)
97
**CRC Screening**
**FOB kits every 2 years**
**60-74 years in England**
**50 - 74 years in Scotland**
Abnormal results sent for colonoscopy
98
**Margin required for Anterior Resection in rectal tumours**
2 cm distal clearance margin from dentate line
4-5 cm of the anal verge
99
**Patho behind Pilonidal Sinus**
**Rx?**
Hair debris creates skin sinuses---\> lined be squamous epithelium but contain granulation tissue
**Rxz**
Difficult to treat ---\> Treat abscess in the initial stage with Abx and drainage
**Bascom procedure -** excision of sinus and obliteration of cavity
**Karydakis procedure -** Excision of natal cleft
100
**Barton's Fracture**
**Distal radius fracture --\> with radiocarpal dislocation**
101
**Intraarticular fracture of first MCP**
Bennett's
- fist fights
102
Barium or gastrograffin for looking for anastamotic leaks?
Gastrograffin
Barium is more toxic
103
Single large tortuous arterile in the sub mucosa
rare cause of upper GI bleeding
Dieulafoy lesion
104
**Treatment for BPH**
**MOAs**
**And**
**SEs**
**Surgical Mx**
**Alpha 1 antagonists (tamsulosin Alfuzosin)**
- Decrease SM tone
- dizzi, postural hypotension, dry mouth, depression
**5 alpha reductase inhibitors**
- Blocks test--\> DHT conversion (reduces prostate volume and slows disease progression)
- Erectile Dysfunciton, reduced libido, ejaculation problems, gynaecomastia
**Surgial Mx - TURP**
105
Left sided chest pai nfollowing vomiting
Rx
Boerrhave's Syndrome ---\> the perforation normally effects the left side
Dx - CT and ocntrast
Rx
- \<12 hours primary repair
12- 24 hours : fistuala creation with T tube
\>24 hours ---\> fulminent medastinitis = fatal
106
**Procedures in Gastric Ca**
Proximally sited \>5-10 cm from the OG Junction
\<5 cm from OG junction
Junctional tumours
Proximally sited \>5-10 cm from the OG Junction - Subtotal Gastrectomy
\<5 cm from OG junction - Total gastrectomy
Junctional tumours - Gastro-oesophagectomy
Lymph node clearance is required (particularly Japanese adopt this practice)
+ adj chemo
107
**Mx after Sx for Degenerative Cervical myelopathy?**
**why?**
Ongoing follow up
- disease can recur on adjacent spinal levels
- surgery can alter spinal dynamics predisposing to other pathologies
108
Blurred vision:
Post transplant/immunosuppessed
Rx?
**CMV Retinitis**
**- cotton wool spots**
**-infiltrates**
**- haemorrahges**
**Rx - IV Ganciclovir**
109
**Pathology in acute tubular necrosis**
Caused by - prolonged ischaemia or toxins
The tubules usually act to concentrate urine and retain sodium.
**SO**
Low urinary osmolality (not cocentrating urine)
Raised urinary sodium (not retaining them)
110
What is the RIFLE criteria used for?
What is it?
**AKI CLassification**
111
**Urinary Sodium in :**
**pre renal uraemia**
**ATN**
\<20 mmol/mol in Pre renal uraemia
- the kidneys try to retain sodium in order to maintain the circulatory volume
\>30 mmol/mol in ATN
- tubules no longer able to retain sodium due to cellular damage
112
**Example of GPIIb/IIIa receptor antagonist**
**When do you use?**
Abciximab, Tirofiban
Used when the 6 month CV risk is high (\>3%) post ACS and imminent PCI is planned (96 hours)
113
**Cause of normal pressure hydrocephalus**
**Imaging?**
Reduced CSF resorption in arachnoid villi
- due to: head injury, SAH, meningitis
Imaging - enlarged fourth ventricle
absence of subtantial sulcal atrophy
114
**Rx of long QT syndrome**
**Normal QT?**
Mx:
if QTc \<500 ms = Propanolol (dont use sotalol - as can exacerbate)
If QTx \>500 ms = ICD
115
**Where is the coarctation of aorta in adults?**
**Signs?**
After the left subclavian artery emerges from the aorta
- so both upper limbs will have higher pressures/ earlier pulses than the femorals
Signs:
- HF in children, hypertension in adults
- Mid systolic murmur (heard best over the back)
- Neurofibromatosis, turner's syndroem
116
**Brown looking macrophages on colonoscopy?**
Melanosis Coli
Associated with laxative abuse
117
**DIabetic medication MOA:**
**DPP4 inhibitors**
**GLP 1 mimetics**
**Thiazelidinones**
**Sulfonylureas**
**BIguanadine**
**DPP4 inhibitors**
Gliptins.
Increase GLP1 levels by inibiting DPP4 which is an enzyme that usually increases GLP1 Levels --\> reduce glucagon levels/ stimulate insulin release---\> reduce glucose
**GLP 1 mimetics** (Exanatide)
ncreases GLP1 Levels --\> reduce glucagon levels/ stimulate insulin release---\> reduce glucose
**Thiazelidinones** (Pioglitazone)
Activate nuclear receptors --\> increasing transcription of enzymes--\> ultimately leading to increased fat storage in adipocytes causing cellular mechanism to require carbohydrate oxidation
**Sulfonylureas** (Glimepiride, gibenclamide, gliclazide)
Bind and close ATP sensitive K+ channels on beta cells---\> cause depolarisation ---\> release of insulin
**BIguanadine** (Metformin)
Increases insulin sensitivity
118
Hypopigmented areas and subungual fibromas
Tuberous Sclerosis
Hypopigmented = ash leaf spot
roughened patches of skin over lumbar spine (Shagreen patches)
adenoma sebaceum (angiofibromas): butterfly distribution over nose
subungual fibromata
café-au-lait spots rare
119
**Blood in diarrhoea**
**which IBD?**
UC
More bloody diarrhoea than crohn's..
120
**QRISK \>10%**
Offer Statin Therapy
121
**Causes of primary Hyper PTHism**
**(four causes --\> first two account for 95%)**
Adenoma
Hyperplasia
Multiple Adenoma
Carcinoma
122
**Diabetic Management in acute period following MI?**
IV insulin to allow for tight glycaemic control --\> Digami Study
123
**Diabetic Diagnosis**
HbA1c
Fasting Glucose
Random Glucose
GTT
HbA1c:
\<=41 normal. \>= 48 diabetes
Fasting Glucose:
\<=6 normal. \>= 7 diabetes
Random Glucose:
\>=11.1 diabetes
GTT:
\<=7.7 normal. \>=11.1 diabetes
124
**Hypocalcaemia ECG Changes**
**Most common**
**Then other two**
QTc Prolongation
AF, TDP
125
**Displacement of ureters**
**Medially**
**Laterally**
Medially - retroperitoneal fibrosis
Laterally- Retroperitoneal malignacies
126
Hyperosmolar load ---\> enters jejunum --\> drags more water in by osmosis
Distension, pain, diarrhoea
**Dumping Syndrome**
127
**Anorectal Abscess causes**
E. Coli
Staph Aureus
Locations: 2 Ps and 2 Is
Perianal, Ischiorectal, Pelvirectal, Intersphincteric
128
**Anal Fistulae**
**Goodsall's Rule?**
**Types of fistula?**
**Goodsall's Rule**
- Transverse line through anus.
- Fistulas occuring anterior to tihs = short radial tract
- Fistulas occuring posterior to this = curvelinear route to psoterior line
**Types of fistula - Intersphincteric (doesn't go through external anal sphincter), transphincteric (through ext anal sphincter), suprasphincteric, etra sphincteric , superficial**
If opening of fistula is within anal verge = superficial fistula
129
**What is hesselbach's triangle?**
Medial - Rectus Abdominus
Lateral - inferipor epigastric vessels
Infeiror - inguinal ligament
**Hernias occuring within hesselbach's triangle are usually direct**
130
**Permissive Hypotension**
Term used to descrieb the allowance for a lower systolic bp as long as the patient is able to speak etc.
Anything about \>70 mm Hg in patients who have suspected AAA rupture, Aortic dissection = **don't give fluids** as this can worsen teh situation
Surgery is what these patients need
131
**What investigations for rectal bleeding**
**Baseline**
DRE
Proctosigmoidoscopy
Rectal manometry testing for people with refractory fissure in ano to prevent continence issues
132
NHS Breast screening programme
Every 3 years from 47-73
133
**Cytoreductive drugs in RCC**
Alpha interferon
IL-2
TK-I (Sorafenib, sunitinib)
134
Clear cell histological pattern
RCC
135
Why do solitary rectal ulcers ago?
Due to chronic constpiaton / straining
136
Sentinel anal pile
Ulcer
Enlarged anal papillae
Chronic fissure (\>6 weeks)
137
**FOBT:**
**Screening**
**Diagnostic tool**
Screening: 2 yearly between 60 and 74
\>=50 Unexplained abdo pain or Weight loss
\<60 IDA or bowel habit change
\>= 60 anaemia
138
**Urinary Stones:**
Hypercalciuria
Hyperoxaluria
Hypocitraturia
Hyperuricosuria
Disorder of a transmembranous transporter leading to reduced absorption of?
Extensive tissue breakdown
Low urinary pH
Renal tubular Acidosis - WHich types?
Proteus infections
High urinary pH
**Urinary Stones:**
Hypercalciuria - **Calcium Oxolate**
Hyperoxaluria - **Calcium Oxolate**
Hypocitraturia - **Calcium oxolate (** citrate forms complexes solubilising calcium)
Hyperuricosuria - **Uric Acid stones**
Disorder of a transmembranous transporter leading to reduced absorption (GI and renal) of **Cystine** - **Cystine Stones**
Extensive tissue breakdown - **Uric Acid** think about the urea being released in TL syndrome
Low urinary pH - **Uric Acid**
Renal tubular Acidosis - **Calcium Phosphate ( types 1 and 3 RTAcidosis)**
Proteus infections - **Struvite**
High urinary pH - **Calcium Phosphate, Struvite (notably more alkali than calcium phosphate)**
139
**Rubber manufacture**
What other risk factors?
What type of Ca?
Other Ca of same organ?
**TCC of bladder**
**RFs-** Smoking, Aniline dyes ( textiles) , rubber manufacture, cyclophosphamide
**SCC of bladder**
- significantly rarer in Western societies
**RFs -** BCG vaccine, Schistosomiasis, Smoking
140
**Which type of shock has a reduced Systemic Vascular Resistance?**
**What else is unique?**
Distrubitive shock - Septic, anaphylactic, neurogenic
**Distrubitive Shock** Also has a **normal/increased CO** - other types of shock have **Increased SVR + Decreased CO**
141
**Why does neurogenic shock occur**
Often due to - **high spinal cord transection**
**Leading to** - decreases Sympathetic tone or increased parasympathetic tone
---\> decreased peripheral vascular resistance ---\> reduced preload
**Use peripheral vasoconstrictors**
142
**Blunt cardiac injury and cardiogenic shock?**
**Likely site of injury and proposed management?**
Usually right heart is effected and it's respective chamber/ valve injuries
- Managed conservatively where possible with osbervations and ECG/ Echo
- Surgical repair using cardiopulmonary bypass +/- intra-aortic balloon pump as bridge to surgery
143
**Haematuria + Elevated Hb?**
Think about RCC (the haematuria might be due to renal vein thrombosis)
144
**Renal Scans:**
Identifies cortical defects, ectopic or abhorrent kidneys
Filtered at level of glomerulus so provides infromation about GFR
Secreted by tubular cells so useful for renal imaging of patietns with known renal impairment
Assess bladder reflux using contrast media (via catheter)
Past used technique for finding calculi
Currently used technique for finding calculi
Malignancy assessing
**DMSA -** Identifies cortical defects, ectopic or abhorrent kidneys
**DTPA -** Filtered at level of glomerulus so provides infromation about GFR
**MAG- 3-** Secreted by tubular cells so useful for renal imaging of patietns with known renal impairment
**Micturating cystourethrogram-** Assess bladder reflux using contrast media (via catheter)
**IV Urography -** Past used technique for finding calculi
**CT KUB -** Currently used technique for finding calculi
**CT/PET -** Malignancy assessing
145
**Suture types**
**Absorbable**
Vicryl
Dexon
PDS
**Non absorbable**
Silk
Prolene
Ethilon
Novafil
146
147
**Why does BPH cause haematuria**
Due to hypervascularity of the prostate gland
148
**Drugs + haematuria?**
**TN/IN**
**only TN**
TN/ IN - Aminoglycosides (gentamicin), Chemotherapy (cyclophosphamide)
TN - NSAIDs, Penicillin, Sulphonamides
149
**Adsons test for cervical rib**
Lateral flexion of neck away from affected arm + traction of the affected arm = absent radial pulse
150
**testicular torsion:**
cremesteric reflex preserved
cremescteric reflex absent
pyrexia
cremesteric reflex preserved - appendage torsion
cremescteric reflex absent - spermatic cord torsion
pyrexia - not torsion
151
152
**Aged 65 and over with head injury?**
CT scan within 8 hours unless another clinical feature makes one within one hour more prudent
153
**Causes of bilateral / unilateral hydropnephropsis**
Bilatera;
SUPER
**Stenosis of the urethra**
**Urethral Valve**
**Prostate**
**extensive bladder tumour**
**retroperitoneal fibrosis**
Unilateral
PACT
**Pelvic Ureteric Obstruction**
**Aberrant Renal Vessels**
**Calculus**
**Tumours of renal pelvis**
154
**Ix for hydronephrosis**
USS first - identifies hydronephrosis
**Intravenous urethrogram** - Position of the blockage
Pyelography -
CT Scan is the most sensitive diagnostic
155
**Most common rx for acute cholectstitis**
IV Abx + Lap Chole within 1 week
156
**Magnesium ammonium phsophate stones**
STRUVITE
STAG HORN
157
**Smokers breast disease?**
Periductal mastitis
- recurrent infections
- periareolar or subareolar
158
**Neuroblastoma**
**vs**
**Nephroblastoma**
Neuroblastoma
- originate from adrenals
- Calcified
Nephroblastoma
- Wilm's
- originate from the renals, associated with
- hypertensive
159
**Following TURP:**
**Hyponatraemia**
**Fluid Overload**
**TUR SYNDROME -** venous destruction and absorption of irrigation fluid
**RFs -** \> surgical time, \> height of bag, \>resection, \>blood loss, \>irrigation fluid used, perforation, bad CHF
Triad of :
hYponatraemia
Fluid overload
Glycine toxicity
**Fluid restrict and treat hyponatraemia**
160
**Which stones are NOT opaque on x ray? (3)**
Semi opaque - Cystine
Radio lucent - Urate and Xanthine
161
Greasy Scale
Keratin Plugging
Seborrheic keratosis
162
**Mealnocytic Derm Lesions?**
**Appear at/soon after birth**
**Circular macules**
**Nodules arising from a previous macule**
**Develop over few months in children- pink/red**
**AD Inherited naevi \*CDKN2A mutation increases risk of melanoma\***
Congenital melanocytic naevi - **Appear at/soon after birth**
Junctional naevi - **Circular macules**
Compound naevi- **Nodules arising from a previous macule**
Spitz Naevi - **Develop over few months in children- pink/red**
Atypical naeuvs syndrome - **AD Inherited naevi \*CDKN2A mutation increases risk of melanoma\***
163
Central punctum containing sebum:
**If lined with Epidermis?**
**Sheath hair follicle?**
**If lined with Epidermis?** - Epidermoid Cyst
**Sheath hair follicle? -** Pilar Cyst
164
**Colonic Cancer Surgery:**
Acute obstruction ?
Chemotherapuetic regime?
Radiotherapy?
APER or Anterior Resection?
Acute Perforation?
**Acute obstruction ?** - Resect or stent --\> either end stoma/ or primary anastamosis with an experience surgeon. Whereas in rectal defunctioning loop colostomy.
**Chemotherapuetic regime?** - combination of 5FU and oxaliplatin
**Radiotherapy** - Only for rectal cancer as the rectum is an extraperitoneal structure. Used for T4 ( long course), and T3 tumours.
**APER or Anterior Resection?** - APER in the situation where tumour is located within 6 cm of the anal verge
**Acute perforation** - Basically dont anastamose. End colostomy (as with hartmann's procedure)
165
**Mx of PAD (non acute)**
**Conservative:**
Exercise therapy to enhance collateral formation
Optimisation of comorbidities
Stop Smoking
Diet
**Medical:**
**Atorvo 80mg**
**Clopidogrel 75 mg Daily**
Naftidrofurl Oxalate - Vasodilator
Clistoazol - PDI III Inhibitor (vasodilator and antiplatelet)
**Interventional.Surgical:**
Angioplasty - Dependent on TASC Clasfficiation
Stenting - Dependent on TASC Classification
Bypass Surgery
Amputation
166
**Indirect vs Direct Inguinal Hernia**
**Indirect:** (Bubonocele, Funicular, Complete) **Lateral to the inferior epigastric vessels**
Due to patent processus vaginalis (failure of closure of deep ring)
Surrounded by internal spermatic fascia
Can reach scrotum ( complete)
**DirecT: Medial to the inferior epigsatric vessels**
Weak point in transversalis fascia of abdominal wall - **hesselbach triangle** (Inguinal ligament, inferior epigastric artery, rectus abdominus)
Can't reach scrotum
167
168
**What do you co prescribe with GnRH Agonist for the first few weeks?\>**
Anti androgen such as **cyproterone acetate**
This is because there is initial stimulation of LH leading to increased testosterone levels
169
**Porta hepatis**
Is a fissure on inferior surface of liver where:
Left/ Right hepatic ducts
hepatic artery
portal vein
**Compression due to lymphadenopathy can cause jaundice**
170
171
**What airway adjunct would you use to facilitate long term weaning?**
Tracheostomy
172
**Joint prosthesis:**
**Cx**
**Causes for revision**
**Cx**
- VTE
- Fracture intra-op
- Nerve damage (sciatic nerve if posterior approach)
**Causes for revision**
- aseptic loosening
- pain
- fractured/dislocated prosthesis
- infection
173
**Protein defect in marfan's**
Fibrillin ---\> component of elastin
174
175
**Distinguishing between Monomere segment and drum perf?**
Monomere segment = healed drum perf
**Monomere segment ---\> moves with valsava**
176
**Myopic**
**Hypermetropic**
Myopic - shortsightedness
Negative refractory error as the image focuses before the retina
Need concave shape lens
Hypermetropia - longsightedness
Positive refractory error as the image focuses after the retina.
Need convex lens
177
**What is gonioscopy?**
178
**Rx of ear wax**
1. Olive Oil Drops
2. Sodium Bicarb Drops
3. Microsuction ( preffered to syringing)
179
180
**Phalen's vs Reverse Phalen's**
Reverse Phalen's = Prayer hands
Phalen's = Reverse prayer hands
Looking for the same pathology and keep for a minute
181
**Borders:**
**What is the deep inguinal ring**
**Borders of the inguinal canal**
**What is the femoral ring**
**Borders of the femoral canal**
**Femoral Triangle**
**hesselbach's triangle**
**Inferior Lumbar Triangle**
**Superior Lumbar Triangle**
**Borders of the adductor canal**
**Calot's triangle**
**Deep Inguinal ring -** oval shaped opening in the transersalis fascia
**Inguinal Canal -**
Floor - inguinal ligament, lacunar ligament medially.
Roof - Arching fibres of internal oblique and transversus abdominus
Anteriorly - External oblique aponeurosis (and internal oblique). Superficial ring allows exits here
Posteriorly - Conjoint tendon medially and fascia transversalis. Deep ring permits entry through the fascia transversalis here)
**Femoral ring -** Beginning if femoral canal.
Anterior - inguinal ligament
Posterior - pectinal ligmanet
Medially - lacunar ligament
Laterally - Femoral vein
**Borders of femoral canal - Continuous with the femoral ring so same borders**
Contains lymph node of cloquet + other lymphatic structures
**Femoral Triangle -**
Superiorly - Inguinal ligament
Sartorius - Medially
Adductor Longus - Laterally
**Hesselbach's triangle** - Defect through which direct inguinal hernias often occurs
Inferiorly - Inguinal ligament
Medially - Lateral border of rectus abdominus
Lateraly - Inferior epigastric artery / vein
**Inferior Lumbar Triangle**
Inferiorly - Iliac Crest
Postero-Medially - Latissumus Dorsi
Antero-Laterally - External Oblique
**Superior Lumbar Triangle**
Superiorly - 12th rib
Medially - Quadratus Lumborum
Laterally - Internal Oblique
Roof - External Oblique
Floor - Transveralis fascia
**Borders of the adductor canal**
Anterio-medial - Sartorius
Antero-lateral - Vastus Medialis
Posterior - Adductor longus+ Magnus
**Calot's triangle** (Hepatobiliary triangle - cystic artery in the middle somewhere)
Inferoior - cystic duct
Medial - common hepatic duct
Superior - inferior surface of the liver
182
Stensen's Duct
Warthon's Duct
Stensen's duct - drains parotid. opens into vestibule of mouth near the upper 2nd molar
Warthon's duct - drain's submandibular and sublingual glands and emerges at the base of the tongue
183
**Hypercalcaemia**
**\<3.0**
**\>3.0**
\<3.0 - start with fluids
\>3.0 - fluids and bisphosphonate
184
**Morgagni**
**vs**
**Bochdalek**
Diaphragmatic hernias
**Morgagni -** right sided herniating right colon usually
**Bochdalek -** Left sided herniating stomach usually (BochdaLEFT)
185
**Looks clinically like a hip fracture**
**Orthogonal X Ray veiws are negative**
**What next?**
NICE SAYS:
Occult hip fractures with negative X rays should be investigated with an MRI
(this is not always practical so CT scanning is often used..)
186
187
**how do you use a tonometer**
**When is a tonometer not reliable**
Line up the two semi circles and where they line up is the IOP
Not reliable where the cornea is thin
- When this is the case they need to undertake **phasing** which involves a full day of IOP monitoring
188
**Optic dic diameters**
**What is the optic cup**
**What is the optic disc**
**Glaucoma - what happens to optic disc**
Normal optic disc is about 1.7-2.0 mm
**Optic Cup -** Seen as central on the fundoscopy and is where the optic nerve fibres involute
**optic disc -** Periphery of the optic area
- The optic cup grows so the cup:disc ratio increases
Cup is the bit in the middle
189
**Prophylactic Colectomy**
**FAP or LYNCH**
FAP - definitely have one
Lynch (HNPCC) - can have one but depends on polyp load
- Usually have Right sided colorectal Ca
190
**Why do you digitate the stoma site with a gloved ky jellied finger?**
Looking for blood, stenosis and polyps
191
**Presumed pathology in anal fissures (non-crohn's)**
Presumed to be due to **hypertonic internal sphincter**
## Footnote
**- this is why the surgery that is eventually offered is an internal sphincterotomy**
192
**What are haemorrhoids**
Therapeutic options
If there is PR bleeding and you see haemorrhoids what else should you do
Dilated vascular cushions in the lower anal canal that can become **increased** due to **straining** and **congestion.**
They have a **normal physiological role** in maintaining continence and contribute to the resting pressure of the anal canal
Classified using Banov Classification
**Rx**
Conserv - Increase fibre, reduce straining
Interventional - Barron's Banding, Injection sclerotherapy, haemorrhoid stapling, Haemorrhoidectomy +/- ligation of contributing vessels
**Bleeding** even if you see haemorrohids warrants further investigation!
193
194
**What splint for scaphoid fracture**
Futura splint
195
**What to immobilise in context of closed fracture**
Proximal and distal joint
196
# Define:
**Varus**
**Valgus**
Varus - Medial angulation of distal segment of bone/joint
(varus the pig)
Valgus - lateral angulation of distal segment of bone/joint
197
**Genu Valgum?**
Knock knees
- Valgus angulation of the tibia in relation to the knee/femur
198
**Signs associated with patellar dislocation**
High riding patella
Knock Knee (Genu valgum)
Tibial torsion
199
**Schatzker classification**
Tibial PLateau Fracatures
1/2 - Lateral Condyle (young)
3 - Depressed fracture not complete
4 - medial condyle
5 - both condyles
6- high energy communited fracture
200
**OA Paracetomal And topical nsaid for which joints?**
Knee and hand
201
**Calcium pyrophosphate dihydrate**
Pseudogout
**RFs -**
Haemochromatosis / wilsons
Hypomagnasaeamia/ Hypophospohataemia
Hypothyroidism
Acromegaly
Hyperparathyroidism
**XR - chondrocalcinosis**
**Joint aspriation - Positively birefringent rhomboid shaped crystals**
202
**T Score interpretation**
T score is compared wiht normal young healthy people
\> - 1.0 - normal
-1.0 - -2.5 - osteopenia
\<-2.5 - osteoporosis
203
**Mild**
**Moderate**
**Severe**
**NPDR**
**PDR**
**Mild** - \>1 microaneurysm
**Moderate** - \>3 microaneurysm
Hard Exudate
blot haemorrhages
Cotton wool spots
Venous beading looping
intraretinal microvascular abnormalities
**Severe -**
Blot haemorrhages and microaneurysms in 4 quadrants
Venous beading in at least 2 quadrants
IRMAs in at least 1 quadrant
**PDR-** Retinal neovascularisation
204
**Key side effects of prostalgandin analogues?**
Iris pgimentation
Periocular pigmentation
Eyelash lengthening
205
**Horner's syndroem causes**
**S**
**T**
**C**
Ptosis, anhidrosis, Meiosis, Enopthalmus
**Central - S's (hypothalamus to cervical spine)**
**Face, arm and trunk anhidrosis**
Stroke, Syringomyelia, MS, Tumour, encephalitis
**Preganglionic - T's (Spinal foramina to superior cervical ganglion)**
**Face Anhidrosis**
Pancoast TUmour, Thyroidectomy, Truama, Cervical Rib
**Postganglionic -** **C's** (**Superior cervical ganglion through the carotid sheath to CN V1, To sympathetic fibres to levater palpebri + sphincter pupillae + ?sweat glands of face)**
Nb not the salivatory glands because there are PNS
**No anhidrosis? - maybe their can be depending on the cause?**
**CAROTID -** aneurysm, dissection, tumour
**Cavernous sinus thrombosis (CN V1 runs through this)**
Cluster headache
206
**Definition: Sinus**
Blind ending tract lined by either granulation or epithelial tissue which opens onto an epithelial surface
207
**Why is albumin low in IBD?**
**So called protein losing enteropathy**
- Generalised bowel inflammation can lead to erosions ---\> protein losing enteropathy. So LFTs will show hypoalbuminaemia
208
**GRUM**
**Monteggia**
**Galeazzi?**
**Galeazzi -** Distal **radial** fracture with dislocation at the radio-ulnar joint
**Monteggia -** Proximal **ulnar** fracture with dislocation of head of radius
209
**Fluid Challenge - how much fluid**
500 ml NS if No PMH / evidence of HF
250 ml NS if HO HF/ Evidence of HF
210
**Staging of Crohn's Disease**
**Ix**
Acutely - CXR/AXR (look for perf, megacolon etc.)
More comprehensive staging:
Colonscopy
Capsule enteroscopy
Push enteroscopy
MRI enterocolysis
Barium follow through
211
**Approached for femoral hernia (3)**
Lockwood - Low approach (oblique) Below the inguinal ligament
Letheisen - oblique approach (over the inguinal ligament)
Mcevedy - Longitudinal approach (High) through the inguinal ligament
212
**Deciding whether someone needs an ankle x ray or not**
Ottawa ankle rules
Mallelolar pain + 1 of:
Medial malleolus tenderness
lateral malleolus tenderness
Unable to walk four steps at time of injury and upon assessment
213
**Flamingo tinged tympanic membrane**
**Progressive conductive deafness**
**Rx?**
Otosclerosis
AD condition that runs in families and is present from 30s
**Rx - Hearing aids and Stapedectomy**
214
Stapes fixation at oval window?
Otosclerosis
- replacement of normal bone my vasccular spongy bone
215
**Drusen vs exudates vs pan retinal coagulation**
Drusen - orangey, ill defined edges, look around macula
Exudates - yellow looking, well defined edges, look for other retinal changes, **should be leakage -** look for blot haemorrhages
pan retinal coagulation - very well defined, lots of them,
216
**Dx AND Mx of Compartment syndrome**
Intracomaprtment pressure \>20 mmHg **and** definitely if \>40 mmHg
Mx - Extensive and prompt fasciotomies
Agressive IV fluid to present myoglobinuria mediated AKI
Have 4-6 hours before musclce dies as a result of this micro(note not macro) vascular compression
217
**Mx for Weber Classification fractures**
Distal fracture - consrevative management in all age grousp with Below knee plaster cast up to mid foot
Proximal Weber B/C or Maissoneuve fracture ---\> If old conservative measures. If young will need suergery due to the instability of the fracture
218
**When to start allopurinal for gout?**
Two attacks in 12 months
tophi
renal disease
uric acid stones
prophylaxis if on diuretics/chemotherapy drugs
2 weeks after attack ahs settles
Nsaid/ colchicine cover while therapy is being initiated
219
**What might you see on funduscopy in amyaurosis fugax?**
Exudates - Cholesterol emboli
220
Photophobia
Red eye
Uveitis
Not so much seen in glaucoma
221
**special hip fracture managmenet mnemonic**
RST give IM
Reverse oblique
subtrochanteric
transverse
Mx - with IM Device
222
223
**mx of sudden onsent SNHL**
High dose oral steroids striaght away for 7 days
Referral to ENT where:
Pure tone audiometry testing
MRI scan looking for vestbular schawannoma
Consideration for intra-tympanic steroids
224
**Laparoscopic hernia repair techniques**
Open repair is still the criteria standard but well trained surgeons achieve better pain results using laparoscopic approaches.
TEP (Total Extraperitoneal Approach) and TAPP (Transabdominal preperitoneal approach)
**TEP**
- Cut made infrainguinally or curvalinearly
- a dissecting baloon is advanced midline to the pubic symphsis underneath the rectus muscle and inflated so as to see the **posterior rectus sheath** to achieve dissection then removed
- Laparascope (port jsut beneath umbilicus) and two additional ports made along the arcuate line
- Cooper (pectineal ligament) dissected. NB inguinal vessels in this region so need to be careful
- Direct and femoral hernias can be reduced here but indirect hernias require further exploration and dissection away from the spermatic cord.
- Sac can be reduced or can be ligated.
- Mesh can be introduced overlying the spermatic cord and is fixated between the ASIS and the pubics symphysis
**TAPP**
- Infraumbiliacl incision is made mindful of the umbilical stalk (Inflated with CO2 now)
- Two more trochars are placed - one at umbilical and one lateral to the rectus
- Small peritoneal incision made --\> careful dissection of the spermatic cord from the hernial defect
- Mesh is fixed to the pubis or the cooper ligament
225
226
**Disorders of the umbilicus in neonates**
**Painful erythematous ?**
**Brown discharge?**
**STraw coloured discharge**
Ompholitis - Painful erythematous
Patent vitello-intestinal duct - Brown discharge
Straw coloured - Persitetn Urachus
227
228
**Rectal Cancer**
What resection and when
Other adjuvant treatments
**Resection -** TME + \>12 LN need to be excised following vasc supply
High anterior resection / low anterior resection - \>6 cm from anal vergem \> 2 m for sphincter complex/anorectal ring
APR - When malignancy is 6cm from anal verge / \<2 cm from the sphincter complex/ anorectal ring
Minimal resection - Carcinoma in situ/ T1
T3/T4 are given adjuvant chemo radiotherapy/brachytherapy
229
**Site of cancer . excision . anastamosis**
**Emergency surgery. What do you do and what stoma**
Caecum, ascending, proximal transverse - Right hemicolectomy + ileocolic anastamosis
Distal transverse - Descending colon - Left hemi colectomy + colo-colon anastamosis
SIgmoid - High anterior resection - Colo-rectal anastamosis
**rectal -** always +TME
Upper rectum - anterior resection - colo-rectal anastamosis
Low rectum - low/ultra low anterior resection - colo rectal anastamosis but inititally with defunctioning loop ileostomy.
\<2 cm from sphincter complex - Abdomino perineal resection - End colostomy
**Emergency**
**Rectal obstruction** Loop colostomy
**Sigmoid obstruction - Hartmann's** Emergency resection of bowel affected. Distal stump formation and proximal end ostomy formation
**Colonic obstruction -** Resection of portion of bowel + primary anastamosis
