Surgery Flashcards
A 47 year old man is admitted via the Emergency Department with severe right sided loin pain. This has been coming in ‘Waves’ for the past 3 hours and has now become unbearable. The admitting doctor decides to write him up for some analgesia. What would e the most appropriate drug to prescribe at this stage?
(A) Paracetamol 1g Oral (B) Co-Codamol 30mg Oral (C) Dihydrocodeine 50mg IM (D)Diclofenac 75mg IM (E) Paracetamol1g IV
(D) Diclofenac 75mg IM
Guidelines continue to recommend the use of intramuscular Diclofenac in the acute management of renal colic.
Diclofenac IM is the most effective analgesia in acute renal colic and this is recommended by NICE. The other options are all effective forms of analgesia, however they are not recommended as first line in acute renal colic.
A 57 year old woman with a recent diagnosis of breast cancer is found to be positive for a BRCA1 mutation in genetic screening. She has a strong family history of breast cancer, with both her mother and her aunt receiving treatment for the condition at a young age.
She is concerned that she may have passed the gene onto her son and daughter. She is also concerned that her sister may have the gene, given her family history.
In counselling this lady, which of the following is the most appropriate statement with regards to her family inheriting the BRCA1 gene?
(A) Sister and Daughter have a 50% chance of inheriting the gene who,st her son has a 25% risk.
(B) Both children and her sister have a 25% chance of inheriting the gene
(C) Both children and her sister have a 50% chance of inheriting the gene
(D) Both children have a 25% chance of inheriting the gene whilst her sister has a 25% chance
(E) Both children and her sister have a 100% chance of inheriting the gene
(C) Both children and her sister have a 50% chance of inheriting the gene
While BRCA1 and BRCA2 mutations only account for 5-10% of breast cancers, it is reasonable to suspect a genetic component when there is a strong family history of any form of malignancy. BRCA gene mutations are almost always heterozygous and are inherited in an autosomal dominant fashion. As such, having one parent with the mutation results in a 50% chance of that gene being passed onto a child.
A 20 year old African lady undergoes an open appendicectomy. She is reviewed for an unrelated problem 8 months later. On abdominal inspection, the wound site is covered by a shiny, dark, protuberant scar tissue that projects beyond the limits of the skin incision.
Which of the following is the most likely underlying process?
(A) Hypertrophic scar (B) Keloid scar (C) Marjorlins ulcer (D) Repeated episodes of wound sepsis (E) Mycosis fungicides
(B) Keloid scar
Keloid scars extend beyond the limits of the incision. Mycosis fungicides is a cutaneous T. cell lymphoma.
A 55 year old man is found unconscious in the middle of a road. He has cuts and bruises on his body and appears to have been hit by a car. On examination, his skin is warm and flushed, with normal reactive pupils and no signs of respiratory distress. ECG on arrival to the emergency department shows a sinus bradycardia.
Blood Pressure = 80/50mmHg
Heart Rate = 60bpm
Temperature = 36.5 Celsius
Which of the following is most likely the cause for this man’s presentation?
(A) Haemorrhagic shock (B) Cardiogenic shock (C) Spinal shock (D) Septic shock (E) Anaphylactic shock
(C) Spinal shock
Spinal cord transecting after trauma can present with shock
Haemorrhagic/Cardiogenic can be ruled out - despite the low BP, his skin is warm to the touch.
Septic can be ruled out - his temperature is normal and it is too early for infection of this severity to have set in.
Anaphylactic shock can be ruled out as there appears to be no presence of an allergen.
In this case, the man’s low heart rate alongside warm and flushed peripheries indicates spinal shock as the underlying cause. Following spinal cord damage, spinal shock can occur. This is due to a loss of sympathetic outflow resulting in hypotension and bradycardia as well as warm peripheries due to vasodilation and the inability to vasoconstrict.
Haemorrhagic shock is a common cause of shock after trauma, however you would expect a raised heart rate in response to volume loss and not a sinus bradycardia.
Cardiogenic shock occurs most commonly after an MI and is caused by an inability of the heart to meet the demands of the body. An ECG showing sinus bradycardia with no ST change paired with warm skin and a well perfumed patient hints away from this. If this man was in Cardiogenic shock he would be peripherally shut down.
Septic shock is caused by an inflammatory response to infection resulting in fluid shifts from the intravascular to the extra vascular components. While not always necessary in sepsis, you would expect a raised temperature. You would also expect the heart rate to have risen in an attempt to accommodate for the falling blood pressure.
Anaphylactic shock occurs in response to systemic vasodilation causing low blood pressure. This occurs in response to an obvious antigen which is not present in this case and again you would not expect to see a sinus bradycardia.
