Surgery Flashcards
Most common type of esophageal cancer?
Squamous cell CA
MEN Syndrome
MEN 1….PPP
MEN 2A..MPP (med, ca, Pheo,Parathyroid)
MEN 2B..MMP *med. CA, Mucosal nueroma, Pheo)
what is the screening in place for prostate cancer?
ALL men >50….voluntary yearly PSA
Pt with family history of prostate cancer, when to start screening if concerned?
40 years
Steroid regiment for steroid dependent individual going for surgery
100mg IV preop….
100mg IV intra op
100mg iv upto 24 hrs post op
then oral steroids when tolerated
hard throid nodule with elevated TSH, think?
Hashimotos thyroiditis
5 tests for the knee
- ACL ==Lachman test
- PCL==posterior draw test and posterior sag
- Meniscus injury ==Mcmurray test
- Collateral ligament== Varus and valgus test
- Patellar disloc==patellar apprehension test
Best ABX to cover abdominal surgery prophylactic?
Metronidazole +
Gent or cephazolin
Which Hernia is unlikely to strangulate?
Direct Hernias
MCC of acute limb ischemia?
Thrombosis
Tension pneumothorax, where to place needle and tube?
Needle = 2 intercoastal space mid clavicular
Tube = 5 th ICS mid Axillary
Pt with abdominal trauma, hemodynamically unstable, what to do?
FAST
Fracture of mid shaft of humerus, what nerve is affected?
Radial Nerve
Suspected urethral injury, what to do?
Retrograde Urethrogram
Common Peroneal nerve damage sign?
foot drop….inability to dorsiflex
Any male or post menopausal female with iron deficiency, what to do?
Refer for colonoscopy
Unknown hx of tetanus vaccination, what to do?
give both IVIG and toxoid
Unilateral neck mass with no symptom, most likely diagnosis
Multinodular goiter
Bilateral neck mass with no symptom, most likely diagnosis
Adenocarcinoma or carcinoma
Tx of choice for Pleomorphic Adenomas?
Superficial paroidectomy
Most common cardiac tumor?
Myxoma
MC complication of TURP?
UTI
Followed by bleeding
1st investigation in suspected esophageal malignancy?
Barium swallow
MC cause of bone tumor in pelvis of young adult?
Metastatic tumor
Tx of calcified gall bladder (porcelain)
Prophylactic cholecystectomy
Pt present to ER after blunt force trauma, FAST or CT?
Stable = CT Unstable = FAST
Which drug gives rebound htn when stopped suddenly?
clonidine (an alpha blocker)
Migratory superficial thrombophlebitis and DVT, suspect?
Pancreatic cancer
MC cause of large bowel obstruction in Australia?
Colon Cancer
Most useful inv. for detecting gallstones?
US
Melanoma and clear margins for excision
depth of 1mm —1cm clear margin required
2 - 4 mm —-1-2cm margin required
4mm —2cm margin required
when do you do prophylactic cholecystectomy?
gallstone >3cm or porcelin gallbladder
Pt after trauma presents to ER after lucid interval, suspect?
Epidural hematoma
investigation of choice in recurrent kidney stones?
US + X Ray
How to monitor secondary spread in seminoma?
LDH Lactate dehydrogenase
First line investigation for chronic pancreatitis? (2)
CT, if unavailble use US
Tx of Duputrens contracture?
Open fasciectomy
Liver and Pancreas
Amebic Liver Abscess
Causative organism……
Entameba Histolytica
Usually singe and located at upper lobe
Anchovy paste fluid
Abdominal pain, dysentery and bloody diarrhea
RUQ pain
Fever and chills
with travel History to endemic area vvvvvv imp
common presentation
Entameba Histolytica
Wbcs in Entameba Histolytica
increased
Stool analysis in Entameba Histolytica
trophozoites
CT Entameba Histolytica
cystic lesions
TTT Entameba Histolytica
ORAL METRONIDAZOLES
HYDATIC CYST
Causative organism
Initial Inv?
Best Inv?
Echinococcus granulosus
US
CT
Definitive host for HYDATIC CYST
dog
Many cases are asymptomatic
Abd pain, fever, and may be jaundice
CT presentation of HYDATIC CYST
Egg shell calcification of hepatic cyst
one big cyst with multiple daughter cysts
Risk for HYDATIC CYST if rutured
anaphylaxis if ruptured
if CT does not reveal it (HYDATIC CYST) do?
Serology
TTT of HYDATIC CYST
SURGERY under cover of albendazole
Liver malignancy
Primary shows?
Increased alpha fetoprotein
Less common than metastasis
CT in primary Liver malignancy
SOLITARY LESION
TTT of primary Liver malignancy
SURGERY, CHEMOTHERAPY, AND
INTRAHEPATIC EMBOLIZATION
Secondary Liver malignancy is from?
the colon
Much more common than primary
CT in Secondary Liver malignancy shows?
MULTIPLE SPOTS
HEPATIC ADENOMA is related to
OCP use
Benign rare tumour
Normal liver function test and alpha feto protein
Acute pancreatitis
Causes
Gall stones…Alcohol
Others…….trauma, infection, increase lipids TIL
Acute pancreatitis
Complications:
1 - Pseudocyst…..most common complications
Timing …………..within weeks,
Cp…………………..epigastric MASS,
Fate………………..usually resolve spontaneously
HAPPy PAD
When to drain Pseudo cyst??:
If persists more than 6 wks , size more than 6 cm, or if infected
How to drain Pseudo cyst?.
Endoscopic internal drainage to stomach
Most common early complication of Acute Pancreatitis
2 - ARF…………
Most common cause of acute pancreatitis
stones
Most common complication overall of acute pancreatitis?
pseudocyst
TTT of acute pancreatitis?
conservative
PANCREATIC CANCER Presentation
Sex……….usually male Age………old Most cancer causes death within 5 years Risk factors……SMOKING, DM, ALCOHOL Dull abdominal pain radiating to back Weight loss If at head…………deep jaundice Recurrent thrombophlebitis
Investigations of PANCREATIC CANCER:
Serum bilirubin
increased(direct)
DILATATION OF GALL BLADDER
what inv to do?
US…
MASS AT HEAD OF PANCREAS
BEST ( inv of choice) for Pancreatic cancer?
CT
TTT of Pancreatic cancer
Surgery…whipple’s operation
Symptomatic ttt of pancreatic cancer
stent
Causes of CHRONIC PANCRATITIS (2)
alcoholism…..cystic fibosis…
Levels of Amylase and lipase in chronic pancreatitis?
normal
CT of CHRONIC PANCRATITIS shows?
THE BEST …..calcification
TTT of CHRONIC PANCRATITIS
PANCREATIC ENZYMES REPLACEMENT
Nephrolithiasis Presentation
Sudden onset flank pain
Colicky pain referred to the scrotum
Nausea and vomiting
Hematuria
Imaging Investigation of Nephrolithiasis:
Best:
In pregnancy
Before surgery what imaging?
Tx?
Best………… (non contrast) CT
Pregnant with renal stones………ultrasound
…….X-Ray
Best analgesic outside the hospital………NSAIDS
Most kidney stones are visible
majority are radiopaque
MOST COMMON renal stones?
Ca oxalate
Uric acid are what kind of stones?
radiolucent
Struvite stone……….alkaline urine………proteus
Treatment of kidney stones
Excess rehydration and thiazide with all cases
ureteric stones :
First line of ttt
Ureteroscopic laser lithotripsy for stones at any level
Kidney stones
If less than 2 cm
ESWL
Kidney stones More than 2 cm
Percutaneous nephrolithotripsy
Staghorn stone
Open nephro- or pyelo-Lithotomy
Young pt complains of flank pain asking for strong analgesic first step
drug screen by urine analysis ……take sample in front of you
Kidney stones Recurrence rate
50% within 5 years
Definitive treatment of:
ureteric stones :
First line of ttt
Ureteroscopic laser lithotripsy for stones at any level
Kidney stones tx
<0.5 conservative
If less than0.5 - 2 cm………ESWL
More than 2 cm……… Percutaneous nephrolithotripsy
Staghorn stone………………….. Open nephro- or pyelo-lithotomy
Indications of surgery with renal stones:
1 - obstruction and infection ….. Most absolute indication…vvvvvvvvvvvvvvvv imp
2 - too large to pass
3 - pain cannot be controlled
Inv that should be done before going to surgery on renal stones
X-Ray….vvvvvv imp
Most common cause of fever after urology procedure…
ttt
bacteremia Urosepsis
Empirical antibiotics……….amoxycillin and gentamycin
Renal cell carcinoma presentation
INV
TTT
Triad of;
Flank pain
Hematuria
Renal mass
CT
Biopsy……..(better to be avoided)
………..surgery ( Total Nephrectomy)…vvv imp
Incidental discovery of renal mass:
IF OLD AGE:
First step
Imaging of choice for surveillence
TTT of choice
……….active surveillance
………CT
………Total nephrectomy
When laparoscopic partial nephrectomy can be done??????
1-small tumour in one kidney (less than 4cm)
2- Cancer in both kidneys
3-only one working kidney.
What if metastasis of renal mass???
Total nephrectomy followed by immunotherapy
Young pt with renal mass , what to do?
Partial Nephrectomy
Active surveillance is NOT generally recommended for young patients
Causes of Kidney injury
blunt trauma in the abdomen
Presentation of Kidney Injury:
Inv…
TTT
Hematuria
Flank pain
……CT with contrast
……..most cases heal conservatively….imp
If unstable……….laparotomy
Rupture of urethra
HISTORY OF TRAUMA
Investigation……
Blood at urethral meatus……key word
Never ever insert a catheter
……retrogradeurothrography
Polycystic kidney disease
Two types:
Infantile………..AR………early mortality
Adult……..AD
Clinical picture of PKD
Strong association
Investigation…
First………
Best
TTT:
Age………usually above 50
PAINLESS HEMATURIA
Hypertension
Bilateral flank mass
Intracranial berry aneurysm……SAH
..US
…CT
TTT of hypertension
Most common cause of death in PKD
renal failure
Inv of choice In PKD
CT
Acute prostatitis presentation
Best inv…
TTT……
Fever, chills, ++WBC Urinary urgency and dysuria Tender prostate ………..mid stream urine collection ……ANTIBIOTICS
BPH Presentation
Investigation……
TTT….
Male usually above 50 ys Frequency Nocturia…….first symptom Hesitancy Weak stream Hypertrophy usually start at central zone PR…………smooth and firm enlargement
…….US………to detect hydronephrosis
Alpha blocker eg: prazocin
TURP
Surgery
Complications of TURP:
UTI
Bleeding (2nd common)…….important.]
Clot retention and clot colic
TURP Syndrome:
Hyponatremia and water intoxication (TO AVOID THIS ….limit length of the procedure is limited to less than one hour,.[6]
Bladder neck stenosis
Urinary incontinence
Retrograde ejaculation
PRASTATIC CANCER presentation
RISK factor
Most common malignancy in men
Age …….usually above 70
…..FH, increased fat in diet
SAME PICTURE AS BPH
Type of PROSTATIC CANCER
adenocarcinoma
PR of PROSTATIC CANCER
hard and asymmetry
Complications of PROSTATIC CANCER
spread to vertebrae…….osteoblastic lesions…..back pain
Sequence of investigations for PRASTATIC CANCER???
1st step………PSA
2nd step…….transrectal US
TTT for Prastatic Cancer :
Very old patient and not fit for surgery……….WATCHFUL WAITING
Guidelines of prostate cancer ttt
Treatment of choice if of Prostate Cancer if:
FOCAL
LOCALLY ADVANCED
METASTATIC
RECURRENT
Focal ……………..radical prostatectomy
Locally advanced……radiation
Metastatic………androgen ablation
Recurrent………..hormonal therapy
According to Gleason score:
Less than/equal to 6 …
Less than/equal to 7…
Less than/equal 8-10…
Less than or equal to 6…………active surveillance or radical prostatectomy
7 ……………radical prostatectomy or Radation
8-10………..androgen ablation
According to PSA:
If less than 10
If less than 10 ……….active surveillance
Screening for Prostatic cancer
Not recommended
Done by PR and PSA
What if the patient asked for prostate screening???
First step……..Counseling
Second step………Do it
DD multiple myeloma VS prostatic cancer??
both of them
old age male with back pain
Multiple myeloma will display
hypercalcemia……vvv imp
Prostate cancer will display
normal or high calcium
So…..if old male with back pain and normal calcium NEVER CHOSE MM
VARICOLCELE
primary. ..
secondary. ..
Primary……….usually at left side
Secondary……….due to malignancy
Clinical picture of VARICOLCELE
Age... Type of Pain... Examination... Complication... Investigation TX
Age………..young
Asymptomatic or dragging pain
EXAMINATION……….bag of worm sensation
Complication……..hypofertility , and thrombosis
Investigation………semen analysis and doppler
TTT…………CONSERVATIVE
SURGERY WITH SEMEN ABNORMALITY
1ry Varicecole
Young/Old Patient?
Gradual/Sudden onset
Empty/Full Scrotum?
Inv?
1ry……..young patient
gradual onset
empty on elevation of scrotum
inv………US
2ry Varicecole
Young/Old Patient?
Gradual/Sudden onset
Empty/Full Scrotum?
Inv?
2ry……..old patient
sudden onset
does not empty
inv………CT
Hydrocele What is it? Complication? CP? Investigation? TX?
Collection of serous fluid in procesus vaginalis
Primary or secondary
CP……..PAINLESS scrotal swelling
Complication……..infection, hge,
Investigation………….transillumination
US
TTT ASPIRATION OR SURGERYHYDROCELE IN PEDIATRICS
TEST
TTT
TEST………TRANSILLUMINATION (POSITIVE)
US
NEVER TO TTT ANY INFANT BEFORE FIRST YEAR ………………REASSURE THE MOTHER
ADULTS;
Usually secondary
TTT…….ASPIRATION PLICATION OF TUNICA ALBUGINEA
Acute epididymo - orchitis
Age...? Most Common Causative Organism? Sexually Active young less than 35 =? Investigation? Treatment?
Age …………middle age
Most common Causative organism……E-COLI
Sexually active young less than 35………chlamydia
Fever, pain, swelling, redness
Elevation of testis does decrease pain
Investigation………..urine analysis and culture
TREATMENT ……………….antibiotics eg; cefotriaxone
Epididymal cyst and spermatocele
Cp:
Painless small scrotal swelling
Epididymal cyst and spermatocele Exam:
Purely scrotal swelling…… you can get above it
Epididymal cyst and spermatocele Site
above and behind the testis
Cystic and translucent
Epididymal cyst and spermatocele TTT:
Small….. no ttt…………review after 3-6 months
Large,,,,surgery……transscrotal
Additional notes:* Delete?*****
Translucent lesions in the scrotum……hydrocele and epididymal cyst
Spermatocele……radio opaque
How to deal with epididymal cyst in sequence???
First step
First step………examination
Second step of dealing with an epididymal cyst
Second step………US
Third step of dealing with an epididymal cyst
Third step…………tumour markers
Fourth step of dealing with an epididymal cyst
Fourth step………review after 3-6 months
If u decide to ttt an epdidymal cyst
transscrotal approach
Torsion of testis
Age?
Predisposing Factor?
Age……………5-15
Predisposing factor………….transverse lying
Clinical picture of torsion of testis
Complication..?
History of trauma Sudden severe pain at the testis Swelling, pain and redness Nausea and vomiting and may be shock Elevation of the testis doesnot relieve the pain Complication…………..gangrene
TTT… of torsion of testis
URGENT SURGERY……..LESS THAN 6 HOURS
Undescended testis
CLINICAL PICTURE
Empty scrotum
Complications of Undescended testis
Sterility
Trauma
Torsion
Malignancy
Association of undescended testis
.indirect inguinal hernia
TTT
SURGERY IS A MUST BEFORE FIRST YEAR
TESTICULAR CANCER
Age ?
Symptoms?
Young male 20-30 years
Painless enlargement of testis
Loss of testicular sensation
Spread……….lung and paraaortic LN
TYPES of Testicular Cancer
SEMINOMA………GOOD PROGNOSIS
Non seminoma……bad prognosis
Tumor Markers
AFP
Increase with non seminoma
always normal with seminoma
Tumor Markers
B-HCG
Choriocarcinoma 100%
SEMINOMA 10%
Investigation for testicular Cancer
What to use for metastasis
Can you do a needle Biopsy
US……BEST
CT chest………for metastasis
NEVER to do needle biopsy…….spread of cancer
TTT of SEMINOMA…
.RADIOSENSITIVE
SURGERY
TTT of NON SEMINOMA
CHEMO AND SURGERY
If metastasis TTT
chemo and surgery
Any young male with painless enlargement of testes is _____________ until proven otherwise
Any young male with painless enlargement of testes is CANCER TESTIS until proven otherwise
Hematuria
Types:
Macroscopic:
Common sources
Bladder Cancer (painless)
urethra
Kidney(Polycystic Kidney)
Prostate
Painful Hematuria………… stones , infection or Kidney Infarction
Investigations (hematuria)
IV Urography
Pseudo Hematuria
Foods, Drugs , Porphyrins, Free Hemoglobin. Myoglobin
Most common cause of painless hematuria
bladder cancer
Best inv for the bladder
cystoscopy and biopsy
Second most common cause of painless hematuria
cancer kidney
Best inv for the kidney
CT
Most common cause of painful hematuria
stones
Inv of choice for the stone
CT without contrast
If immigrant + painful hematuria
shistosomiasis
If immigrant + painless hematuria
cancer bladder
1st inv in hematuria
urine culture and sensitivity
If normal(1st inv of hematuria)
.US
Inv of choice for painless hematuria
cystoscopy
Inv of choice for cancer kidney
CT
Inv of choice for renal stones
CT KUB
Inv of choice for renal stones in PKD
US KUB
Carcinoid syndrome
products:
Vasoactive substance (serotonin, histamine)
C/P of carcinoid syndrome
Flushing , diarrhea , wheezes
Serotonin induce fibrosis for tricuspid , pulmonary
Abdominal Pain
Carcinoid tumor
Sites :
1-Appendix……………most common site
2-terminal ileum
Carcinoid tumor
Investigation:
24 hour urine 5-HIAA
Carcinoid tumor
Treatment :
1- octreotide
2- < 2cm Reassure > 2cm hemicolectomy + 5FU(chemotherapy
Inflammatory Bowl Disease
C/P:
Fever , Diarrhea , WT , Abdominal pain , Bleeding
ulcerative colitis Lead to Colon Cancer after _ - __ years
ulcerative colitis Lead to Colon Cancer after 8-10 years
Ulcerative Colitis
Treatment :
Outpatient?
Admission?
Outpatient mild Attack
Admission severe Attack
Medical treatment for Ulcerative Colitis
Sulfasalazine main stay TTT
Corticosteroid
Immunosuppressive Drugs : (ulterative colitis)
Azathioprine
-Cyclosporin
Surgery if fail medical TTT
Crohn’s
Most common cause of perianal fistula
abscess
Most common cause of multiple or recurrent anal fistulae
crohn’s
Cause of low lying fistula
Crohn’s
TTT of anal fissure with Crohn’s
infliximab
Coeliac Disease ( Gluten Sensitive Enteropathy ) most common age
Any age ( children 9-18 months)
Causes of Coeliac Disease
genetic
C/P of Coeliac Disease:
Previously healthy infant
FTT ( wasting buttocks ) + fatigue
-Malabsorption Steatorrhea + abdominal distension
- Iron and Folate Deficiency Anemia
Investigations of Coeliac Disease :
Golden Standerd?
Duodenal Biopsy golden standard…..atrophic villi
IG Antiendomysial AB
IGA Transglutamines
IGA Antigliadin for screening
Complications of Coeliac Disease :
Most feared?
Skin?
-Intestinal Lymphoma…….MOST FEARED COMPLICATION
Skin………..dermatitis herpetiformis
association (coeliac disease)
Type 1 DM , IGA deficiency , Autoimmune Thyroiditis , Dermatitis herpitiformis,Osteoporosis
Management of Coeliac Disease :
Gluten free diet
vitamin replacement , Pneumococcal Vaccine
Dapsone ……..for dermatitis herpetiformis
Acute gastric dilatation
CAUSES:
Post operative
Fractures
Septicemia,
Acute gastric dilatation cp:
Hiccough, vomiting and upper abd. Pain
Acute gastric dilatation TTT:
MAINLY naso gastric suction
no surgery
Lung Abscess
Causes:
Aspiration due to Alcoholism or intubation
Lung Abscess C/O:
Anaerobic Bacteria
Aerobic Bacteria eg. Klebsiella in alcoholism
Lung Abscess C/P:
Purulent cough + Hemoptysis
Lung Abscess Investigations:
X-ray……..air fluid level
Lung Abscess Treatment :
Antibiotic?
If not improved?
Physiotherapy
Antibiotic,,,,,,,,main TTT……….. clindamycin
If not improved……..transpleural drainage….vvvvimp
Empyema
Cause…
Lung infections…..most common cause
Empyema Symptoms :
Fever, cough, shortness of breath, and pleurisy.
Empyema Inv:
X-ray
Empyema Treatment : (2 )
1- Intravenous antibiotics…….. cephalosporins ,metronidazole and penicillins
Clindamycin for patients who are allergic to penicillin.
2-chest tube
If complex empyema………chest tube is a must…vvvvvvimp
Epidermoid cyst (sebaceous cyst ) C/P:
Firm to soft regular lump
Found in hairy skin central punctum
Complication of epidermoid cyst
Inflammation
Management fo epidermoid cyst
Before puberty?
Small?
Trouble/Infected?
Before puberty —– Polyposis coli
Small —— Leave it
Troubling or infected ——- Surgery (under local anesthesia)
.commonest for acute pancreatitis
.
Gall stones…
commonest for chronic pancreatitis
Alcoholism…
Clinical presentation of acute pancreatitis
SEVERE EPIGASTRIC ABDOMINAL PAIN RADIATING TO THE BACK
Nausea, vomiting, and tenderness
CULLEN SIGN……..bluish discoloration around umbilicus
GREY TURNER SIGN……bluish discoloration at flanks
In colon surgery, where do you want INR?
,<1.5
MC cancer post transplant?
Squamous cell
Aside from immobilization after surgery, what is the other risk factor for VTE?
Cardiac failure
2 situations where tetanus toxoid should be considered
- unknown vacination hx
2. less than 3 doses
When to give tetanus IVIG?
when wound is dirty
Most important sign of orbital fracture?
Diplopia
MC presentating symptom of ampullary carcinoma?
Obstructive jaundice
Pt develops acute limb ischemia and required a procedure, what to do for life?
warfarin for life
Presentation of chronic Pancreatitis?
Chronic epigastric abd pain
Malabsorption……….diarrhea and steatorrhea
Weight loss and DM
A pop and immediate swelling of knee, think?
ACL
You can get above a painless scrotal mass, suspect?
Testicular tumor
What to do when u suspect testicular tumor?
Color doppler
Organism responsible for cholecystitis?
ecoli
Tx of house maids knee (prepartella bursitis)
Steroid injection in prepatella bursa
Mortality rate of ruptured AAA?
80%
What to do when you suspect esophageal cancer? (3)
- barium swallow
- scope and biopsy
- CT chest and abdomen
Pt can not lift hand above head,,,,,this is called?
Impingement syndrome (rotator cuff injury)
fluid replacement in burns?
4 X numbers given…eh 4 x Weight X burn area
4 x 80kg x 15
MC fracture to eye
Orbital floor fracture
Head injury with Lucid interval, Think?
Epidural. Luci on top!
Pt with paradoxical breathing, how to avoid impending doom?
Intubate and ventilate
Pt with vascular claudication, when do you refer?
Rest Pain
Old male with back pain and normal/high calcium never chose…
Multiple Myeloma
