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Medicine > Surgery > Flashcards

Surgery Flashcards

1
Q

Fat Embolism Syndrome

A

Occurs when fat enters the blood stream. Fat embolism most commonly occurs as a result of fractures of bones such as the femur or pelvis. Once fat particles enter the blood circulation, it can lodge at various sites of the body, most commonly in the lungs but can be other sites as well (brain, skin, eyes kidney, liver)

Respiratory: Tachycardia, tachypnoea, dyspnoea, hypoxia, pyrexia

Dermatological: Petechial rash

Neurological: Confusion and agitation

=> SOB, petechial rash, decreased level of conciousness

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2
Q

What is the national screening program for abdominal aortic aneurysm in the UK?

A

In the UK, all men aged 65 years are offered aneurysm screening with a SINGLE abdominal ultrasound.

  • Single abdo USS at 65 years old.
    If 3cm - 4.4cm - yearly follow up
    If 4.5cm - 5.4cm - 3 monthly scans
    If >5.5cm - referred within 2 weeks for surgical repa
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3
Q

What are the indications for aneurysm surgery?

A

The three criteria for aneurysm surgery are:
• An asymptomatic aneurysm larger than 5.5 cm in diameter.

  • An asymptomatic aneurysm which is enlarging by more than 1 cm per year.
  • A symptomatic aneurysm. This is the only criteria, apart from emergency rupture, which requires urgent surgery rather than an elective procedure.
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4
Q

What is the action taken for screening outcomes in AAA depending on the width of the aorta?

A

< 3cm: Normal, no further action
3 - 4.4 cm: Small aneurysm, rescan every 12 months
4.5 - 5.4cm: medium aneurysm, rescan every 3 months
>= 5.5cm : Refer within 2 weeks to vascular surgery for probable intervention. treat with elective endovascular repair (EVAR) or open repair if unsuitable.

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5
Q

Which risk factor has the strongest association to development of peripheral arterial disease?

A

Smoking.

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6
Q

The NHS Breast Screening Programme is provided for which age group and how frequently?

A

The NHS Breast Screening Programme is offered to women between the ages of 50-70 years. Women are offered a mammogram every 3 years. After the age of 70 years women may still have mammograms but are ‘encouraged to make their own appointments.

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7
Q

Tumour marker for breast cancer?

A

CA15-3 (monitoring breast cancer)

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8
Q

How would you differentiate Paget’s disease of the nipple from eczema of the nipple?

A

Paget’s disease differs from eczema of the nipple in that it involves the nipple primarily and only latterly spreads to the areolar, the opposite occurs in eczema).

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9
Q

Adverse effects of tamoxifen?

A
  • Menstrual disturbance: vaginal bleeding, amenorrhoea
  • Hot flushes
  • Venous thromboembolism
  • Endometrial cancer
  • Osteoporosis
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10
Q

When is radiotherapy given in breast cancer management?

A

Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds. For women who’ve had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes.

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11
Q

What adjuvant hormonal therapy is used in oestrogen receptor positive postmenopausal women?

A

In post-menopausal women, aromatase inhibitors such as Anastrozole are used for this purpose. This is important as aromatisation accounts for the majority of oestrogen production in post-menopausal women and therefore anastrozole is used for ER +ve breast cancer in this group.

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12
Q

What adjuvant hormonal therapy is used in oestrogen receptor positive pre-menopausal, peri-menopausal women?

A

Tamoxifen is used in pre- and peri-menopausal women, given for 5 years.

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13
Q

What is triple negative breast cancer?

A

Triple-negative breast cancer is cancer that tests negative for estrogen receptors, progesterone receptors, and excess HER2 protein.

These results mean the growth of the cancer is not fueled by the hormones estrogen and progesterone, or by the HER2 protein. Triple-negative breast cancer is considered to be more aggressive and have a poorer prognosis than other types of breast cancer, mainly because there are fewer targeted medicines that treat triple-negative breast cancer.

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14
Q

What drug is given for HER2 positive breast cancer?

A

The most common type of biological therapy used for breast cancer is Trastuzumab (Herceptin). It is only useful in the 20-25% of tumours that are HER2 positive

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15
Q

What are the risk factors for breast cancer?

A
  • BRCA1, BRCA2 genes - 40% lifetime risk of breast/ovarian cancer
  • 1st degree relative premenopausal relative with breast cancer (e.g. mother)
  • Nulliparity, 1st pregnancy > 30 yrs (twice risk of women having 1st child < 25 yrs)
  • Early menarche, late menopause
  • Combined hormone replacement therapy
  • Combined oral contraceptive use
  • Past breast cancer
  • Not breastfeeding
  • Ionising radiation
  • p53 gene mutations
  • Obesity
  • Previous surgery for benign disease
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16
Q

Causes of acute pancreatitis?

A

Gallstones
Ethanol
Trauma

Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
ERCP
Drugs (azathioprine, Mesalazine, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, Sodium Valproate)

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17
Q

What is the most sensitive blood test for diagnosis of acute pancreatitis?

A

Serum lipase.

Amylase may give both false positive and negative results. Serum lipase is both more sensitive and specific than serum amylase. It also has a longer half life.

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18
Q

Charcot’s triad of ascending cholangitis?

Reynold’s pentad?

A
  1. Fever
  2. Right upper quadrant pain
  3. Jaundice
  4. Confusion
  5. Hypotension
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19
Q

What is Mirizzi syndrome?

A

A gallstone impacted in the distal cystic duct causing extrinsic compression of the common bile duct. one of the rare times that cholecystitis may present with jaundice

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20
Q

How do you manage acute cholecystitis?

A

Analgesia, intravenous fluids, intravenous antibiotics.
NICE now recommend early laparoscopic cholecystectomy, within 1 week of diagnosis. Previously, surgery was delayed for several weeks until the inflammation has subsided.

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21
Q

What is the ginkgo leaf sign?

A

Ginkgo leaf sign indicates subcutaneous emphysema, it is a radiographic appearance seen with extensive subcutaneous emphysema of the chest wall. Gas outlines the fibers of the pectoralis major muscle and creates a branching pattern that resembles the branching pattern in the veins of a ginkgo leaf.

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22
Q

What is the most appropriate advice to give a patient about eating and drinking before an operation under GA?

A

The Royal College of Anaesthetists recommend that patients should have no food for 6 hours before the induction of general anaesthesia. Patients should be allowed to drink water or other clear fluids until 2 hours before the induction of general anaesthesia. This is to reduce the likelihood of pulmonary aspiration of gastric contents.

2-6 rule

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23
Q

What is paralytic ileus and what causes it?

A

Paralytic ileus is a common complication after surgery involving the bowel, especially surgeries involving handling of the bowel. There is no peristalsis resulting in pseudo-obstruction. Paralytic ileus causes constipation and bloating. On auscultation of the abdomen with a stethoscope, no bowel sounds are heard because the bowel is inactive.

A temporary paralysis of a portion of the intestines occurs typically after abdominal surgery. Since the intestinal content of this portion is unable to move forward, food or drink should be avoided until peristaltic sound is heard by auscultation of the area where this portion lies.

Deranged electrolytes can contribute to the development of paralytic ileus, so it is important to check potassium, magnesium and phosphate. As the bowel is not functioning as normal it is better to replace electrolytes intravenously.

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24
Q

What is Cushing’s reflex?

A

It is a physiological nervous system response to increased intracranial pressure (ICP) that results in Cushing’s triad of increased blood pressure, irregular breathing, and bradycardia.

(Opposite of shock)

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25
Q

Symptoms of subarachnoid haemorrhage?

A
  • Headache: typically sudden-onset (‘thunderclap’ or ‘baseball bat’), severe (‘worst of my life’) and occipital
  • Nausea and vomiting
  • Meningism (photophobia, neck stiffness)
  • Coma
  • Seizures
  • Sudden death
  • ECG changes including ST elevation may be seen
26
Q

How would you confirm a diagnosis of subarachnoid haemorrhage?

A

Computed tomography (CT) head:

  • Acute blood (hyperdense/bright on CT) is typically distributed in the basal cisterns, sulci and in severe cases the ventricular system.
  • CT is negative for SAH (no blood seen) in 7% of cases.

Lumbar puncture:

  • Used to confirm SAH if CT is negative.
  • LP is performed at least 12 hours! following the onset of symptoms to allow the development of xanthochromia (the result of red blood cell breakdown).
  • Xanthochromia helps to distinguish true SAH from a ‘traumatic tap’ (blood introduced by the LP procedure).
  • As well as xanthochromia, CSF findings consistent with subarachnoid haemorrhage include a normal or raised opening pressure

Referral to neurosurgery to be made as soon as SAH is confirmed!

27
Q

What are some of the signs of a basal skull fracture?

A 
Battle's sign – post-auricular bruising
Raccoon eyes – bruising around the eyes
CSF rhinorrhea
CSF otorrhea
Hemotympanum
28
Q

Lucid interval is found in which type of head injury?

A

Extradural haemorrhage

29
Q

What is the screening process for colorectal cancer in the UK?

A
  • The NHS now has a national screening programme offering screening every 2 years to all men and women aged 60 to 74 years in England. Patients aged over 74 years may request screening
  • Eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post, a type of faecal occult blood (FOB) test which uses antibodies that specifically recognise human haemoglobin (Hb).
  • Patients with abnormal results are offered a colonoscopy
30
Q

Which tumour marker is used to monitor the progression of colon cancer and response to treatment?

A

Carcinoembryonic antigen (CEA). This is used to monitor progression of disease rather than diagnosis due to poor specificity.

31
Q

Toxic megacolon is usually seen in which condition?

A

Ulcerative colitis

32
Q

What is Beck’s triad?

A

Beck’s triad is a collection of three medical signs associated with acute cardiac tamponade, a medical emergency when excessive fluid accumulates in the pericardial sac around the heart and impairs its ability to pump blood.

Hypotension
Muffled heart sounds
Raised JVP

Other features:
- dyspnoea
- tachycardia
- an absent Y descent on the JVP - this is due to the limited right ventricular filling
- Pulsus paradoxus - an abnormally large drop in BP during inspiration!
- Kussmaul’s sign - much debate about this
ECG: electrical alternans

33
Q

What tumour markers is most helpful in identifying an individual with hepatocellular carcinoma?

A

Hepatocellular carcinoma is commonly diagnosed with imaging and an elevated alpha fetoprotein. Biopsy may seed the tumour and should be avoided.

34
Q

What is the maximum normal diameter in small bowel and large bowel?

A

Small bowel = 35mm

Large bowel = 55mm

35
Q

What is a hiatus hernia and what are the two types?

A

A hiatus hernia describes the herniation of part of the stomach above the diaphragm.

There are two types:

  • Sliding: accounts for 95% of hiatus hernias, the gastroesophageal junction moves above the diaphragm
  • Rolling (paraoesophageal): the gastroesophageal junctions remains below the diaphragm but a separate part of the stomach herniates through the oesophageal hiatus
36
Q

What is the anatomical location of a femoral hernia?

A
  • Below and lateral to the pubic tubercle
  • More common in women, particularly multiparous ones
  • High risk of obstruction and strangulation
  • Surgical repair is required
37
Q

What are the features of testicular torsion?

A

Twist of the spermatic cord resulting in testicular ischaemia and necrosis. Most common in males aged between 10 and 30 (peak incidence 13-15 years)

  • Pain is usually severe and of sudden onset
  • The pain may be referred to the lower abdomen
  • Nausea and vomiting may be present
  • Swollen, tender testis retracted upwards. The skin may be reddened
  • Cremasteric reflex is lost
  • Elevation of the testis does not ease the pain (Prehn’s sign)
38
Q

What is Prehn’s sign?

A

According to Prehn’s sign, the physical lifting of the testicles relieves the pain of epididymitis but not pain caused by testicular torsion.

39
Q

What are the medications used to treat benign prostatic hyperplasia?

A

Alpha-1 antagonists e.g. Tamsulosin, alfuzosin
- Considered first line

5 alpha-reductase inhibitors e.g. Finasteride

40
Q

Symptoms of renal cancer?

A

Classical triad: haematuria, loin pain, abdominal mass

  • pyrexia of unknown origin
  • left varicocele (due to occlusion of left testicular vein)
  • endocrine effects: may secrete erythropoietin (polycythaemia), parathyroid hormone (hypercalcaemia), renin, ACTH
41
Q

What is a varicocele?

A

A varicocele is an abnormal enlargement of the testicular veins. They are usually asymptomatic but may be important as they are associated with infertility.

  • Varicoceles are much more common on the left side (> 80%).
  • classically described as a ‘bag of worms’
  • subfertility

Diagnosis: ultrasound with Doppler studies

Management:

  • Usually conservative
  • Occasionally surgery is required if the patient is troubled by pain. There is ongoing debate regarding the effectiveness of surgery to treat infertility
42
Q

What are the risk factors for transitional cell carcinoma of the bladder?

A

Risk factors for transitional cell carcinoma of the bladder include:

  • Smoking
  • Exposure to aniline dyes in the printing and textile industry: examples are 2-naphthylamine and benzidine
  • Rubber manufacture
  • Cyclophosphamide
43
Q

What is the analgesia of choice for management of acute renal colic?

A

Diclofenac IM is the first line analgesic in acute renal colic.

44
Q

What are the risk factors for squamous cell carcinoma of the bladder?

A

Schistosomiasis

Smoking

45
Q

Differences between an arterial ulcer and a venous ulcer?

A

Arterial ulcers: typically small, well-defined, deep ulcers that are very painful. These ulcers most commonly develop in the most peripheral regions of a limb (e.g. the ends of digits).

Venous ulcers: Typically large and shallow ulcers with irregular borders that are only mildly painful. These ulcers most commonly develop over the medial aspect of the ankle (gaiter region).

Venous ulcers differ significantly from arterial ulcers which are often significantly more painful, smaller in size and deeper with clearly defined borders.

46
Q

What is triple assessment in investigating breast lumps?

A
  1. Clinical examination
  2. Radiology: Ultrasound for <35 years, Mammography AND ultrasound for >35 years old.
  3. Histology/ Cytology (Fine needle aspiration or Core Biopsy)

Cystic lump –> Aspirate
Clear fluid –> Discard fluid and reassure
Bloody fluid –> Cytology
Solid lump –> Core biopsy

47
Q

Ix of choice for renal colic?

A

Non contrast CT KUB

48
Q

Mx for chronic anal fissure?

A

Topical glyceryl trinitrate.

It works by relaxing the internal anal sphincter, which reduces pressure and increases blood flow to promote healing of the fissure. Its side effects can include headaches or dizziness due to systemic absorption.

49
Q

Ix for suspected prostate cancer?

A

Miultiparametric MRI as a first-line investigation.

50
Q

Ix for chrocic venous insufficincy?

A

The investigation of choice of CVI is a venous duplex ultrasound scan, which would show retrograde venous flow due to incompetent venous valves.

51
Q

Ix of choice for suspected SAH?

A

Non-contrast CT head is the first-line investigation of choice for suspected subarachnoid haemorrhage.

52
Q

surgery for tumour of upper rectum?

A

An anterior resection is the operation most commonly performed for rectal tumours, apart from lower rectal tumours which are excised using an abdomino-perineal excision of the rectum.

53
Q

Abx treatment for epididymo-orchitis?

A

Suspected case of epididymo-orchitis, if an unknown organism, empirical treatments are Ceftriaxone 500mg IM single dose plus oral doxycycline 100mg twice daily for 10-14 days.

54
Q

Adverse effects of Tamoxifen?

A

Tamoxifen is a SERM which acts as an oestrogen receptor antagonist and partial agonist. It is used in the management of oestrogen receptor-positive breast cancer.

Adverse effects:
- Vaginal bleeding, amenorrhoea
- Hot flushes
- Venous thromboembolism
- Endometrial cancer

55
Q

Adverse effects of aromatase inhibitors?

A

Anastrozole and letrozole are aromatase inhibitors that reduces peripheral oestrogen synthesis. This is important as aromatisation accounts for the majority of oestrogen production in postmenopausal women and therefore anastrozole is used for ER +ve breast cancer in this group.

Adverse effects:
- Osteoporosis
NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer
- Hot flushes
- Arthralgia, myalgia
- Insomnia

56
Q

which test can be used to assess pancreatic exocrine function?

A

Faecal Elastase.

57
Q

Features of epididymal cyst?

A

Epididymal cysts are the most common cause of scrotal swellings seen in primary care.

  • Separate from the body of the testicle
  • Found posterior to the testicle

Associated conditions:
polycystic kidney disease
cystic fibrosis
von Hippel-Lindau syndrome

Diagnosis may be confirmed by ultrasound.
Management is usually supportive but surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts.

58
Q

Most common organism of breast abscess in lactating women?

A

Staphylococcus aureus is the most common cause of breast abscess in lactational women.

The typical presentation is with a tender, fluctuant mass in a lactating woman.

Mx:
either incision and drainage or needle aspiration (typically using ultrasound)
antibiotics should also be given

59
Q

Most common organism of breast abscess in non lactating women?

A

Group B streptococcus and klebsiella pneumoniae are causes of breast abscess in non-lactating women.

60
Q

Congenital umbilical hernia Mx?

A

Congenital hernias:

Inguinal hernia: repair ASAP
Umbilical hernia: Manage Conservatively

61
Q

How to manage wound dehiscence?

A

The initial management is treating with intravenous antibiotics, covering the wound with sterile gauze soaked in sterile saline to ensure the abdominal contents do not dry out and arranging for the patient to be taken to theatre for a wound repair.

Medicine (21 decks)

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