Surgery

Question 1

what is the treatment of oesophageal varices?

Answer 1

sengstaken tube

somatostatin injection

Question 2

what are the causes, signs and treatment of oesophageal perforation?

Answer 2

may follow endoscopy

acute chest/abdominal pain
air in mediastinum and soft tissues

surgery in malignant cases
intubation in benign cases

Question 3

what are the features and treatment of stomach/duodenum perforation?

Answer 3

abdominal pain
rigidity
peritonism
shock
air under diaphragm (x-ray)
treatment - abx, resuscitate, repair

Question 4

what are the causes and treatment of stomach/duodenum bleeding?

Answer 4

causes - duodenal or gastric ulcer, erosions

treatment - transfusion, inject DU

Question 5

what are the features and complications of acute pancreatitis?

Answer 5

constant pain
vomiting
shock

complications; pseudocyst, phlegmon, abscess

Question 6

describe meckel’s diverticulum

Answer 6

rare
diverticulum of terminal ileum
can be lined by gastric epithelium
can perforate and present like appendicitis

Question 7

what are the causes, symptoms and treatment of intestinal obstruction?

Answer 7

causes; adhesions, hernia, tumour
presentation; colicky abdominal pain, vomiting, constipation
treatment; resuscitate, operate

Question 8

describe a mesenteric infarct

Answer 8

sudden occlusion of small bowel arterial supply
sudden onset of abdominal pain
shock
peritonitis

Question 9

describe acute diverticulitis

Answer 9

maximal in L colon
presentation; LIF pain, fever, tenderness, leukocytosis
treatment; antibiotics, fluids, rest

Question 10

what are the causes of appendicitis?

Answer 10

obstruction of the appendix
faecolith/mucous
foreign body
tumour
secondary bacterial infection

Question 11

what are the symptoms and signs of appendicitis?

Answer 11

crampy colicky abdominal pain that begins in the centre of the abdomen
becomes sharper and migrates to the RIF
maximal tenderness of McBurney's point
Rovsing's, psoas and obturator's sign
abdominal mass
nausea
vomiting
pyrexia
anorexia
diarrhoea
urinary symptoms
recent LRTI

Question 12

what is the differential diagnosis of appendicitis?

Answer 12

mesenteric adenitis
intussusception
meckels diverticulum
Crohn's disease
gastroenteritis
UTI/pyelonephritis/stone
diverticulitis
colorectal cancer
ectopic pregnancy
ovarian cyst
PID

Question 13

what are the components of the Alvarado score?

Answer 13

migratory RIF pain (1)
anorexia (1)
nausea and vomiting (1)
RIF tenderness (2)
rebound tenderness (1)
fever (1)
leucocytosis (2)
segmented neutrophils (1)
<5 indicates no appendicitis and >7 indicates appendicitis

Question 14

what investigations are performed to diagnose appendicitis?

Answer 14

predominately clinical diagnosis
WCC
urine
pregnancy test
plain abdo film
US appendix
US abdo/pelvis/renal tracts
CT

Question 15

what is the treatment of appendicitis?

Answer 15

initially observation, analgesia, rest, IV fluids
reassessment
consent for theatre
open/laparoscopic appendectomy

Question 16

what are the complications of appendicitis/appendectomy?

Answer 16

post-op ileus
infection of wound, abscess (failure of appendix stump ligation)
urinary retention
pneumonia
DVT
PE
long term - hernia, adhesions

Question 17

what are the 5 R’s of fluid balance?

Answer 17

re(assessment)
fluid resuscitation (if in shock)
routine maintenance
replacement
redistribution

Question 18

how is extracellular fluid divided?

Answer 18

1/5 intravascular

4/5 interstitial

Question 19

why are fluids given?

Answer 19

resuscitate by replacing lost volume
routine maintenance of daily requirements
replacement of deficits and ongoing losses
replace Hb
replace blood component
diluent for drugs
physical effect

Question 20

what are the daily prescriptions of water, Na and K?

Answer 20

water - 25-30 ml/kg/day
Na - 1 mmol/kg/day
K - 1 mmol/kg/day

Question 21

what are the indicators for fluid resuscitation?

Answer 21

SBP <100mmHg
CRT >2s
HR >90bpm
peripheries cold to touch
RR >20
NEWS >5

Question 22

what are the principles of fluid resuscitation?

Answer 22

identify cause of deficit
give a 500ml/15mins crystalloid fluid bolus (containing 130-154 mmol Na) rapid infusion
continue 250-500ml boluses until >2000ml
monitor immediate response
if the patient is no longer in shock reassess

Question 23

what are the principles of fluid maintenance?

Answer 23

assess fluid and electrolyte needs - history, exam, monitoring, investigations
meet requirements orally/enterally if possible
normal maintenance IV requirements -
25-30 ml/kg/day water
1 mmol/kg/day Na, K, Cl
50-100 mmol/kg/day glucose
reassess and monitor

Question 24

what are the routine fluid maintenance principles for children?

Answer 24

strictly by weight
100 ml/kg/day for first 10kg
50 ml/kg/day for second 10kg
20 ml/kg/day for the rest

Question 25

what are the daily requirements of Na?

Answer 25

1-2 mmol/kg/day up to a maximum of 150 mmol/day 1L normal saline

Question 26

what are the daily requirements of K?

Answer 26

1 mmol/kg/day usually about 60-70 mmol/day maximum infusion rate 10 mmol/hr

Question 27

what is a fluid script for a normal person with no outlying fluid requirements?

Answer 27

1L normal saline (contains 150 mmol Na) with 20 mmol KCl at 84 ml/hr 1L 5% dextrose with 40 mmol KCl at 84 ml/hr

Question 28

what is a fluid script for a normal person receiving 600ml oral intake and 400 paracetamol IV?

Answer 28

500ml normal saline with 20 mmol KCl at 42 ml/hr | 500ml 5% dextrose with 40 mmol KCl at 42 ml/hr

Question 29

how should you reassess to estimate fluid deficit?

Answer 29

``` symptoms and signs fluid balance chart urinary output biochemistry postural hypotension urine - osmolarity >300, Na <10 ```

Question 30

describe a very severe fluid deficit (>6L)

Answer 30

``` sunken eyes anuria leathery tongue hypotension HR >120 grossly disturbed electrolytes ```

Question 31

describe a mildly severe fluid deficit (4-6L)

Answer 31

``` dry mucous membranes HR >100 low BP severe oliguria raised urea and creatinine veins guttered peripheries cool ```

Question 32

how should excess fluid losses be replaced?

Answer 32

calculate estimated volume loss and replace with same volume of appropriate fluid always within the next 24hrs normal saline with K as required Hartmann's solution if K normal

Question 33

what products should be used for fluid resuscitation?

Answer 33

normal saline colloids (albumin, mannitol, dextran) blood products

Question 34

what products should be used for routine fluid maintenance?

Answer 34

normal saline 5% dextrose hartmann's about 30 ml/kg/day

Question 35

what products should be used for replacement of fluid deficits?

Answer 35

normal saline 5% dextrose hartmann's over 24 hours

Question 36

what products should be used to replace ongoing excessive losses?

Answer 36

normal saline; with K as required hartmann's; if K normal over 24 hours

Question 37

what are the causes of high serum osmolarity?

Answer 37

hyperglycaemia hypertonic infusions (glycerol, glycine, mannitol) hyperlipidaemia hyperproteinaemia

Question 38

what drugs cause hyponatraemia?

Answer 38

diuretics SSRI SNRI

Question 39

what are the causes of hypovolaemic hyponatraemia?

Answer 39

``` vomiting diarrhoea fluid shifts (burns, pancreatitis) diuretics salt wasting nephropathy (analgesics, polycystic disease, pyelonephritis) adrenal insufficiency ```

Question 40

what are the causes of isovolaemic hyponatraemia?

Answer 40

``` H2O intoxication (urine osmolarity <100 mOsm/kg) SIADH (urinary osmolarity >100 mOsm/kg) renal failure adrenal insufficiency hypothyroidism ```

Question 41

what are the causes of hypervolaemic hyponatraemia?

Answer 41

cirrhosis congestive heart failure nephrotic syndrome

Question 42

what is the treatment of hypovolaemic hyponatraemia?

Answer 42

restore volume - 1L normal saline / 2-4hrs | repeat Na in 1hr and continue if Na rising

Question 43

what is the treatment of isovolaemic hyponatraemia?

Answer 43

symptomatic - hypertonic saline, furosemide diuresis | asymptomatic - water restriction

Question 44

what is the treatment of hypervolaemic hyponatraemia?

Answer 44

treat underlying disorder | water restriction

Question 45

what are the causes of hyperkalaemia?

Answer 45

AKI/CKD drugs inhibiting RAAS (ACEi, ARBs, NSAIDs, heparin) drugs inhibiting K excretion (amiloride, spironolactone, eplerenone, trimethoprim) hyperkalaemic ATN (type IV) acidosis (lactic) digoxin poisoning suxamethonium exogenous K (K supplements in drugs) endogenous (burns, rhabdomyolysis, trauma)

Question 46

what are the causes and features of hypokalaemia?

Answer 46

under-prescription excessive loss can cause arrhythmias

Question 47

define a hernia

Answer 47

a part of an organ protruding through an opening in the cavity in which it is usually contained

Question 48

define an inguinal hernia

Answer 48

protrusion of the contents of the abdominal cavity or pre-peritoneal fat through a defect in the inguinal area

Question 49

what are the muscles of the abdominal wall?

Answer 49

internal and external oblique | transversus and rectus abdominus

Question 50

what are the contents of the spermatic cord (inguinal canal)?

Answer 50

``` vas testicular artery pampiniform plexus arteries to cremaster and vas genital branch of genitofemoral nerve lymphatics ```

Question 51

describe the deep ring of the inguinal canal

Answer 51

40% of the way from the pubic tubercle to the ASIS | medial to the femoral pulse

Question 52

describe the anatomical relations of the inguinal canal

Answer 52

``` oblique passage anterior wall; external oblique posterior wall; strong conjoint tendon flattened/closed by muscle contraction protected by thighs when hips flexed ```

Question 53

what are the risk factors for developing an inguinal hernia?

Answer 53

``` patent processus vaginalis AAA collagen disorder smoking COPD ascites long-term heavy work ```

Question 54

how do you examine a groin swelling?

Answer 54

``` examine supine inspect ask the patient to cough palpate for a swelling if not obvious attempt to reduce it gently identify anatomy ```

Question 55

what are the features of a hernia?

Answer 55

arises in the inguinal/groin region increases on coughing can be partially/fully reduced

Question 56

what is the difference between an inguinal or pubic hernia?

Answer 56

inguinal - above the pubic tubercle | pubic - below or lateral to the pubic tubercle

Question 57

what is the differential diagnosis of a hernia?

Answer 57

``` lower abdominal mass scrotal swelling lymph nodes femoral aneurysm saphena varix ```

Question 58

what are the complications of hernia surgery?

Answer 58

``` pain haematoma recurrence infection; wound, chest urinary retention thickened cord ```

Question 59

what patients have difficulty ventilating a face mask?

Answer 59

``` obese beards elderly >55 snorers edentulous ```

Question 60

what action should be taken for peri-operative medications?

Answer 60

NSAIDs - stop 48hrs pre-op warfarin - stop 5 day pre-op, commence on enoxaparin aspirin - stop 5 days pre-op clopidogrel - stop 7 days pre-op stop herbal medications, diuretics (unless severe HF), ACEi, ARBs (depends on hypotension risk), insulin, oral hypoglycaemics, vitamins, iron

Question 61

what are the causes of gallstone formation?

Answer 61

lithogenic bile stasis nidus

Question 62

what is the composition of gallstones?

Answer 62

mixed (cholesterol and calcium salts of bile pigment) pure cholesterol pure pigment

Question 63

describe biliary colic

Answer 63

caused by stones temporarily obstructing drainage of the gallbladder colicky abdominal pain, <24hrs caused by fatty meals, mucocoele

Question 64

what are the causes, features and consequences of cholecystitis?

Answer 64

physical/chemical irritation bacterial infection SIRS sepsis RUQ tenderness local peritonitism empyema perforation

Question 65

describe choledocholithiasis

Answer 65

stones in the common bile duct usually arise in gallbladder impaction leads to jaundice can be asymptomatic or lead to ascending cholangitis

Question 66

describe gallstone pancreatitis and its other causes

Answer 66

passing of calculus through the pancreatic head causes; gallstones, alcohol, trauma, steroids, mumps, autoimmune, scorpion sting, hypercalcaemia, hypertriglyceridaemia, ERCP, drugs

Question 67

describe gallstone ileus

Answer 67

distal small bowel obstruction | gas in biliary tree

Question 68

what investigations should be performed to diagnosis gallstones?

Answer 68

``` examination; tenderness Murphy's positivity SIRS jaundice ``` USS MRC

Question 69

what is the treatment of gallbladder calculi?

Answer 69

``` ursodeoxycholic acid multiple small cholesterol calculi recurrence when stopping treatment side effects open, laparoscopic, percutaneous cholecystectomy ```

Question 70

what are the complications of a cholecystectomy?

Answer 70

bile duct, blood vessels, bowel injury bleeding chest, wound infection

Question 71

what is the treatment of bile duct calculi?

Answer 71

ERCP | laparoscopic/open exploration of common bile duct

Question 72

define shock

Answer 72

acute alteration in circulation in which there is inadequate tissue perfusion leading to cellular hypoxia, dysfunction and failure of major organ systems

Question 73

what are the causes of hypo-perfusion?

Answer 73

``` inadequate preload inadequate myocardial contractility excessive afterload hypovolaemia excessive vasodilatation excessive systemic vascular resistance ```

Question 74

what are the causes of cardiogenic shock?

Answer 74

MI myocardial contusion cardiac failure arrhythmia

Question 75

what are the causes of hypovolaemic shock?

Answer 75

``` vomiting diarrhoea burns pancreatitis haemorrhage ```

Question 76

what are the causes of distributive shock?

Answer 76

septic neurogenic anaphylactic loss of regulation of vascular tone disordered vascular permeability; shifting of intravascular volume to the interstitium

Question 77

what are the causes of obstructive shock?

Answer 77

PE cardiac tamponade pneumothorax

Question 78

what is the pathophysiological response to shock?

Answer 78

increased catecholamine release activation of RAAS increased glucocorticoid and mineralocorticoid release activation of sympathetic nervous system

Question 79

describe the systemic response to shock

Answer 79

``` vasoconstriction increased blood flow to major organs increased CO increased RR and volume decreased urine output ```

Question 80

what are the symptoms of shock?

Answer 80

``` anxiety dizziness weakness nausea and vomiting thirst confusion chest pain fever rigors breathlessness ```

Question 81

what are the features of compensated shock?

Answer 81

``` tachycardia tachypnoea cold peripheries oliguria altered mental status ```

Question 82

what are the features of uncompensated shock?

Answer 82

``` hypotension rapid thready pulse peripheral cyanosis agitation confusion ```

Question 83

what features are specific to cardiogenic and obstructive shock?

Answer 83

elevated JVP

Question 84

what features are specific to distributive shock?

Answer 84

septic shock - pyrexia, warm peripheries | neurogenic shock - warm and dry peripheries

Question 85

what is the specific treatment of cardiogenic shock?

Answer 85

``` remove the cause of the cardiac shock; PCI valve replacement pacemaker interventional ablation ```

Question 86

what is the specific treatment of distributive shock?

Answer 86

antibiotics | vasopressors

Question 87

what is the specific treatment of obstructive shock?

Answer 87

pericardiocentesis | chest drain

Question 88

what is the specific treatment of hypovolaemic shock?

Answer 88

airway ventilation IV; crystalloid fluids then blood products locate bleeding; CT in blunt trauma, ruptured AAA, endoscopy in GI haemorrhage ICU; ventilation, isotrope administration, invasive BP monitoring

Question 89

what are the risk factors for colorectal carcinoma?

Answer 89

``` FAP (APC gene-5q) HNPCC (MMR gene) diet lifestyle bile acids ulcerative colitis crohn's PSC gastric surgery ```

Question 90

what are the signs and symptoms of a colorectal carcinoma?

Answer 90

RC - anaemia, weight loss, RIF mass rectal - change BO, rectal bleeding, tenesmus, mucous, PR mass L splenic flexure - change BO, crampy pain, obstruction sigmoid - change BO, rectal bleeding, obstruction, crampy pain

Question 91

what are the red flag criteria for colorectal carcinoma?

Answer 91

>60yrs, rectal bleeding or change in habit >6 weeks 40-60yrs, rectal bleeding and change in habit >6 weeks palpable abdominal mass palpable rectal mass anaemia

Question 92

what investigations are required to diagnose colorectal carcinoma?

Answer 92

``` FOB test (positive -> colonoscopy) endoscopy histopathology CT cologram barium enema CT abdo, pelvis, chest (20% mets at presentation) MRI pelvis (rectal cancer) ```

Question 93

what is the treatment of colorectal carcinoma?

Answer 93

``` colectomy resection APER liver/lung resection adjuvant or palliative chemotherapy short or long course radiotherapy ```

Question 94

define an aneurysm

Answer 94

abnormal dilatation of a blood vessel >50% of the expected diameter aorta >3cm weakness of the arterial wall - dilation of wall, thrombus in sac, perivascular inflammation

Question 95

what are the causes of aneurysms?

Answer 95

genetic and environmental factors inflammatory cell infiltrate extracellular matrix degradation by MMPs elastolysis

Question 96

what are the risk factors for developing an aneursym?

Answer 96

``` male collagen vascular diseases (Marfan's) age smoking HTN cardiovascular disease; athersclerosis FHx other large artery aneurysms; iliac, femoral, popliteal caucasian ```

Question 97

what are the symptoms and signs of an aortic aneurysm?

Answer 97

``` epigastric mass pulsatile and expansible tenderness abdominal pain radiates to back/groin intermittent claudication chronic/acute limb ischaemia retroperitoneal fibrosis malaise weight loss; inflammatory ```

Question 98

what are the symptoms and signs of aortic aneurysm rupture?

Answer 98

``` abdominal pain radiates to back/groin collapse/LOC abdominal pulsatile mass lumbar haematoma acute limb ischaemia shock bruits peripheral pulses ```

Question 99

what investigations are required for diagnosis of an aortic aneurysm?

Answer 99

abdominal exam US CT angiogram

Question 100

what is the treatment of an aortic aneursym?

Answer 100

surveillance endovascular repair (EVAR); minimally invasive conventional open repair; gold standard laparoscopic repair

Question 101

what are the complications of EVAR?

Answer 101

``` contrast nephropathy branch vessel occlusion limb occlusion endoleak late rupture endotension endograft migration, fracture, infection or occlusion ```

Question 102

what are the complications of AAA surgery?

Answer 102

hostile abdomen blood loss/clamp time branch vessel ischaemia

Question 103

what are the effects of poor pain management?

Answer 103

increased sympathetic activity (HR, BP, myocardial O2 demand, risk of ischaemia) poor respiratory function (poor cough, atelectasis, infection, hypoxia) anxiety insomnia immobility (increased DVT risk) risk of developing chronic pain

Question 104

describe pain transmission

Answer 104

initial trauma release of pain mediators (PG, bradykinins) neuronal transmission central through spinal cord cortical level processing

Question 105

describe the methods of analgesia

Answer 105

peripherally: NSAIDs - reduce inflammatory mediator production local anaesthetics - topical, infiltration, nerve block spinal cord level: opioids, local anaesthetics - modify/block nociceptive input cortical level: opioids, NSAIDs, other analgesics - block pain perception

Question 106

describe paracetamol

Answer 106

analgesic and anti-pyretic | inhibits PG synthesis, acts via serotonin pathways to produce analgesia

Question 107

describe NSAIDs

Answer 107

analgesic, anti-pyretic and anti-inflammatory inhibit COX to stop production of PG reduce opioid requirements in severe pain and opioid-related side effects

Question 108

what conditions require caution with NSAIDs?

Answer 108

bleeding disorders active PUD asthma severe renal impairment (renal blood flow helped by PG) severe hepatic impairment (hepatocellular toxicity) elderly (reduced elimination)

Question 109

describe codeine

Answer 109

acts on opioid receptors centrally 50% bioavailability in oral administration often given in combination with paracetamol prodrug metabolised in liver to morphine

Question 110

describe tramadol

Answer 110

weak opioid agonist increases noradrenaline and serotonin activity used as a step down from PCA side effects - nausea, vomiting, less respiratory depression

Question 111

describe potent opioid analgesia

Answer 111

includes morphine, diamorphine, oxycodone | bind to opioid receptors in brain and spinal cord

Question 112

what are the side effects of potent opioid analgesia?

Answer 112

sedation respiratory depression - may lead to respiratory arrest naloxone must be prescribed and available nausea and vomiting; anti-emetic should be prescribed pruritis reduced bowel motility urinary retention

Question 113

describe patient controlled analgesia

Answer 113

patient controlled pump small bolus lockout time

Question 114

describe the standard PCA regimen

Answer 114

morphine sulphate 250mg in 250ml bolus dose 1g in 1ml lockout time 5 minutes 4hrly limit 40mg alternate - fentanyl/oxycodone

Question 115

describe the problems with PCA

Answer 115

``` sedation respiratory depression nausea and vomiting itch pump failure tissued cannula unable to use ```

Question 116

what features require and contraindicate epidural analgesia?

Answer 116

``` major surgery pre-existing medical problems frail, elderly cognitively impaired unable to manage PCA ``` ``` patient refusal abnormal coagulation infection (local or systemic) previous back surgery abnormal anatomy ```

Question 117

describe epidural analgesia

Answer 117

catheter inserted into epidural space local anaesthetic with added opioid administered spinal level - blocks incoming pain receptors controlled by continuous infusion from a pump can be boosted by bolus request

Question 118

what are the benefits of opioid analgesia?

Answer 118

``` better analgesia reduced sedation reduced DVT or PE bowel motility less atelectasis less RTIs less cardiac mobility ```

Question 119

what are the disadvantages to opioid analgesia?

Answer 119

hypotension (sympathetic block) leg weakness (motor nerve block) haematoma (trauma) infection (CNS, epidural abscess)

Question 120

what are the causes of jaundice?

Answer 120

pre-hepatic - haematoma, haemolytic anaemia, spherocytosis, sickle cell hepatic - hepatitis, cirrhosis post-hepatic - gallstones, head of pancreas tumour

Question 121

what are the signs of jaundice?

Answer 121

``` yellow skin sclera scratch mark lymphadenopathy liver disease evidence abdominal tenderness abdominal mass ascites hepato/splenomegaly ```

Question 122

describe ERCP

Answer 122

inject dye into the duct in the biliary tree and pancreas so they can been seen on x-rays used to diagnose and treat gallstones, inflammatory strictures, leaks (trauma or surgery), cancer

Question 123

what is the management of surgical jaundice on admission?

Answer 123

fluids assess for sepsis monitor PT avoid/stop hepatotoxic drugs

Question 124

what are the causes of surgical jaundice?

Answer 124

gallstones malignant biliary tree tumours (cholangiocarcinoma) head of pancreas tumours benign biliary tree lesions (strictures)

Question 125

what are the causes of post-surgical bleeding?

Answer 125

coagulation defects surgical technique local factors

Question 126

what are the direct causes of coagulation-related post-surgical bleeding?

Answer 126

``` anticoagulation (warfarin) anti platelet (clopidogrel, aspirin) thrombocytopenia severe blood loss/transfusion obstructive jaundice long-term steroid therapy severe sepsis with DIC ```

Question 127

what is the management of post-surgical bleeding?

Answer 127

check coag and Hb discontinue anti-thrombotic therapy reverse coagulation defects (vitamin K, protamine sulphate, FFP, platelets) identify and control bleeding

Question 128

what is the prevention of post-surgical bleeding?

Answer 128

``` be aware of potential coagulation defects discontinue anti-thrombotic therapy vitamin K is jaundiced good surgical technique control infection leave drains in at-risk wounds ```

Question 129

what are the complications of a PE?

Answer 129

``` pleuritic chest pain cough dyspnoea haemoptysis pleural rub raised JVP low O2 saturations sinus tachycardia S1Q3T3 check blood gas confirm with CTPA ```

Question 130

what are the risk factors for developing respiratory post-surgical complications?

Answer 130

``` old age smoking obesity immobility sedation pre-existing lung disease myocardial disease ```

Question 131

what are the types of respiratory post-surgical complications?

Answer 131

``` atelectasis chest infection PE aspiration pleural effusion ARDS pneumothorax ```

Question 132

what are the risk factors for infectious post-surgical complications?

Answer 132

``` hypoxia diabetes immunosuppression malnutrition jaundice corticosteroid therapy obesity ```

Question 133

what are the signs of wound infection?

Answer 133

wound discharge erythema cellulitis

Question 134

what are the signs of intra-abdominal infection/abscess?

Answer 134

abdominal distension prolonged ileus increasing pain

Question 135

what are the signs of a post-surgical wound breakdown?

Answer 135

7-10 days post-op serous discharge superficial dehiscence abdominal contents protruding through wound

Question 136

what are the causes of post-surgical oliguria?

Answer 136

blocked catheter stress response to surgery renal hypoperfusion inadequate fluid intake

Question 137

define IBD

Answer 137

an abnormal immune response to gut organisms | ulcerative colitis and Crohn's disease

Question 138

describe ulcerative colitis

Answer 138

affected the mucosa and superficial mucosa of the large bowel only starts in rectum (always involved), extending upwards for a variable distance terminal ileum involvement; back wash ileitis

Question 139

describe Crohn's disease

Answer 139

may affect any part of the GI tract 20% - distal small bowel 25% - large bowel 45% - both ``` patchy, discontinuous wall thickening discrete, deep ulcers, often linear cobblestone mucosa fistulae and anal disease common granulatoma and fissure ulcers ```

Question 140

what are the acute and chronic complications of colitis?

Answer 140

acute toxic colitis toxic dilatation/perforation bleeding malignancy

Question 141

what are the clinical features of ileitis (CD)?

Answer 141

abdominal pain (cramps, worse after eating) weight loss diarrhoea mass in RIF

Question 142

what are the clinical features of anal/perianal disease (CD)?

Answer 142

skin tags fissures fistula abscess

Question 143

what are the extraintestinal manifestations of IBD?

Answer 143

``` arthropathy sacroiliitis ankylosing spondylitis episcleritis/uveitis erythema nodosum pyoderma gangrenosum aphthous oral ulceration sclerosis cholangitis ```

Question 144

what is the management of IBD?

Answer 144

``` diet fe/B12/folate vitamins anti-diarrhoeals osteoporosis prophylaxis antibiotics aminosalicylates (sulfasalazine, olsalazine, mesalazine, balsalazide) oral/rectum administration corticosteroids (systemic; IV/oral, topical; enema/suppositories) immunomodulators (ciclosporin to induce remission, azathioprine and mercatopurine to maintain remission) anti-TNF alpha antibodies (infliximab, adalimumab) resection strictureplasty abdominal colectomy segmental resection ileorectal anastomosis proctocolectomy and ileostomy ```

Question 145

what are the causes of upper GI bleeding?

Answer 145

``` peptic ulcer oesophagitis gastritis/erosions erosive duodenitis varices portal hypertensive gastropathy malignancy mallory-weiss tear vascular malformation ```

Question 146

describe the pathology and treatment of duodenal ulcer

Answer 146

strong association with helicobacter pylori triple therapy reduces the risk of recurrent ulcers and bleeding; clarithromycin, metronidazole, PPI NSAIDs - inhibit the action of cyclooxygenase, impaired mucosal defence against acid

Question 147

describe oesophageal varices

Answer 147

chronic liver disease | portal hypertension leads to portal-systemic shunting

Question 148

describe the management of haematemesis and melaena

Answer 148

treat hypovolaemia and shock (ABC) estimate the amount of blood loss treat the underlying cause

Question 149

what are the components of the Rockall score?

Answer 149

``` age shock comorbidity diagnosis major stigmata of recent haemorrhage ```

Question 150

what is the initial treatment of GI bleeding?

Answer 150

``` ABC IV fluids urinary catheter and hourly urometer transfuse as necessary correct coagulopathy PPI (maintain pH > 6, protects ulcer clot from fibrinolysis) ```

Question 151

describe endoscopic strategies

Answer 151

injection - adrenaline or sclerosant thermal - coagulation using heater probe mechanical - endoscopic clips

Question 152

what is the treatment of rebleeding?

Answer 152

repeat endoscopy radiology surgery (laparotomy and haemorrhage control); underrunning vessel, gastrectomy

Question 153

what is the management of variceal bleeding?

Answer 153

endoscopy; variceal band ligation, injection scleropathy pharmacology; vasoactive drugs (reduction in portal blood flow), antibiotics balloon tamponade; sengstaken, temporary salvage

Question 154

what re the types of varicose veins and varicose disorders?

Answer 154

``` primary trunk varicose veins secondary trunk varicose veins reticular veins spider veins/venous flares venous malformations ```

Question 155

what is the pathophysiology of primary valve failure?

Answer 155

primary degenerative changes in the valve leaflets

Question 156

what is the pathophysiology of secondary valve failure?

Answer 156

developmental weakness in vein wall and secondary vein widening and valve incompetence

Question 157

what are the complications of varicose veins?

Answer 157

``` superficial thrombophlebitis lipodermatosclerosis and pigmentation varicose eczema ulceration haemorrhage ```

Question 158

describe the examination of varicose veins

Answer 158

``` standing and adequately exposed inspection: distribution of varicose veins (GSV/SSV) chronic venous insufficiency scars trendelenberg's test perthes test hand held doppler ```

Question 159

what is the treatment of varicose veins?

Answer 159

``` reassurance compression hoisery foam scleropathy endovenous ablation conventional surgery ```

Question 160

describe foam scleropathy

Answer 160

sodium tetra decyl sulphate mixed with air in ratio 1:4 causes phlebitis and vein occlusion injection of foam into truncal vein or varicose vein

Question 161

describe endovenous ablation

Answer 161

radio frequency ablation endovenous laser ablation both damage the vein wall causing subsequent thrombosis pass guide wire/catheter position catheter tumescent anaesthesia catheter withdrawn analgesia - NSAIDs

Question 162

describe conventional varicose vein surgery

Answer 162

gold standard saphenofemoral ligation and stripping GSV saphenopopliteal ligation phlebectomies

Question 163

what are the complications of conventional varicose vein surgery

Answer 163

``` bruising bleeding wound infection nerve injury DVT ```

Question 164

which groups are at risk of requiring a transfusion?

Answer 164

nutritional deficiencies malabsorption syndromes inflammatory bowel conditions chronic low grade bleeding conditions (haemorrhoids, haematuria, menorrhagia, bowel cancer)

Question 165

what is the treatment of anaemia?

Answer 165

oral iron if intolerant - IV iron cause unknown - refer to specialist

Question 166

what are the causes of a decreased red cell count?

Answer 166

decreased red cell production - marrow failure increased red cell destruction - haemolytic problems increased red cell loss - bleeding

Question 167

when should a patient who is <65, stable and no cerebro/cardiovascular problems be transfused?

Answer 167

<7 g/dL

Question 168

when should a patient who is >65, stable and no cerebro/cardiovascular problems be transfused?

Answer 168

<8 g/dL

Question 169

when should a patient who has cerebro/cardiovascular problems be transfused?

Answer 169

<9 g/dL

Question 170

in what circumstances should transfusion <10 g/dL be considered?

Answer 170

appropriately symptomatic (dyspnoea, angina, tachycardia, orthostatic hypotension, syncope) or bone marrow failure/receiving chemo/radiotherapy or obvious evidence of ongoing significant bleeding (>500ml/hr)

Question 171

define overtransfusion

Answer 171

transfusing to a Hb level >2g/dL above the transfusion threshold for that patient

Question 172

what are the complications of blood transfusion?

Answer 172

febrile reaction delayed haemolytic reaction wrong blood incident infection; HIV, hepatitis B

Question 173

how should a patient receiving a blood transfusion be monitored?

Answer 173

baseline HR, BP, temperature before transfusion check 15 minutes into transfusion check at the end of transfusion clinical observations during transfusion

Question 174

what are the symptoms and signs of a transfusion reaction?

Answer 174

``` fever urticaria rash pruritus pyrexia rigors hypotension loin/back pain increasing anxiety pain at infusion site dark urine respiratory distress severe tachycardia unexpected bleeding (DIC) ```

Question 175

what is the management of a mild acute transfusion reaction?

Answer 175

stop transfusion appropriate treatment (antipyretic/antihistamines) reassess patient if signs and symptoms worsen in 15 minutes, treat as severe reaction

Question 176

what is the management of a severe transfusion reaction?

Answer 176

stop transfusion IV maintained with normal saline infusion resuscitation/drugs trolley may be required monitor and reassess frequently inform the lab and return the component document in patient case notes report event to monitoring body

Question 177

what are the principles of ANTT?

Answer 177

always wash hands effectively non-touch technique take appropriate equipment precautions take steps to protect key parts at all times

Question 178

what is the treatment of a mild diabetic foot ulcer?

Answer 178

flucloxacillin 1g 6hrly PO | MRSA - doxycycline 100mg BD PO

Question 179

what is the treatment of a severe diabetic foot ulcer?

Answer 179

co-amoxiclav 625mg 8hrly MRSA - add vancomycin 1g BD IV or teicoplanin 10mg/kg IV 12hrly (3 doses) then maintenance dose 10mg/kg daily (serum levels)

Question 180

what is the treatment of a diabetic foot ulcer in osteomyelitis?

Answer 180

flucloxacillin 2g 6hrly + fusidic acid 500mg 8hrly PO | MRSA - teicoplanin or vancomycin + fusidic acid

Question 181

what are the exceptions to single dose prophylactic antibiotics?

Answer 181

duration of surgery >4hrs blood loss >1.5L emergency surgery for dirty/contaminated wounds infection already present

Question 182

describe general surgery prophylaxis

Answer 182

co-amoxiclav 1.2g IV or gentamicin 2mg/kg IV plus metronidazole 500mg MRSA - above + teicoplanin 400mg IV

Question 183

what are the consequences of overnutrition?

Answer 183

``` hypertension T2DM hyperlipidaemia coronary artery disease osteoarthritis obstructive sleep apnoea gallbladder disease cancer ```

Question 184

what are the causes of undernutrition?

Answer 184

``` reduced food intake (anorexia, fasting, pain on swallowing, handicap) malabsorption (impaired digestion, impaired absorption, excess losses from the gut) modified metabolism (trauma, burns, sepsis, surgery) ```

Question 185

what are the consequences of undernutrition?

Answer 185

organ function - reduced strength, motility, impaired respiration, apathy, impaired immunity increased peri-operative morbidity and mortality

Question 186

describe types of enteral nutrition

Answer 186

``` sip feeds tube feeds (NGT, PEG, PEG-jej, gastrostomy, jejunostomy, button) ```

Question 187

what are the indications for parenteral nutrition?

Answer 187

``` malnourished or likely to become malnourished and GI tract not functional or not accessible ```

Question 188

what are the components that decide the amount of calories require in parenteral nutrition?

Answer 188

BMI stress factor activity energy stores

Question 189

what is the amount of different substances required in parenteral feeding?

Answer 189

``` fluids - 30 ml/kg/day calories - 30 cal/kg/day fat - 30% total protein - 1 g/day Na - 1 mmol/kg/day K - 1 mmol/kg/day Cl - 1 mmol/kg/day ```

Question 190

describe the embryology of the thyroid gland

Answer 190

endodermal invagination of tongue at foramen caecum at week 4 of gestation descends anterior to hyoid and larynx thyroglossal duct degenerates secreting thyroid hormone by 12th week contribution from 5th pharyngeal pouch (ultimobranchial body - C cells)

Question 191

what questions are required from a history of a thyroid nodule?

Answer 191

``` age (50% >14yrs malignant) sex (men) growth rate pain voice changes pressure symptoms hypo/hyperthyroidism previous irradiation (20-50% malignant) FHx ```

Question 192

describe MEN 2A

Answer 192

medullary thyroid carcinoma hyperparathyroidism phaeochromocytoma

Question 193

describe MEN 2B

Answer 193

medullary thyroid carcinoma hyperparathyroidism neuroma (lips and tongue)

Question 194

what are the symptoms and signs of hypothyroidism?

Answer 194

``` tiredness moodiness slower thinking depression inability to concentration thinning hair/hair loss dry, patchy skin weight gain cold intolerance elevated cholesterol puffy eyes goitre hoarseness persistent dry/sore throat throat deepening difficulty swallowing irregular/heavy periods bradycardia infertility constipation muscle weakness/cramps ```

Question 195

what are the signs and symptoms of hyperthyroidism?

Answer 195

``` nervousness/tremor irritability difficulty sleeping eye bulging irregular/light periods frequent bowel movements first-trimester miscarriage persistent vomiting in pregnancy hoarseness/deepening of voice persistent dry/sore throat difficulty swallowing tachycardia palpitation impaired fertility weight loss/gain heat intolerance increased sweating sudden paralysis FHx of thyroid disease or diabetes ```

Question 196

what is looked for in an examination of the thyroid?

Answer 196

``` size solitary/dominant nodule in MNG consistency lymphadenopathy signs of hypo/hyperthyroidism antibodies to thyroglobulin and TPO TSH receptor autoantibodies thyroglobulin/calcitonin and CEA US FNA ```

Question 197

what is the differential diagnosis of a thyroid nodule?

Answer 197

benign; colloid nodule, simple cyst, focal thyroiditis, follicular adenoma, Hurthle cell adenoma malignant; papillary, follicular, anaplastic, medullary carcinoma, lymphoma, Hurthle cell carcinoma

Question 198

what is the treatment of a thyroid nodule?

Answer 198

surgery; hemithyroidectomy (including isthmus and pyramidal lobe), total thyroidectomy

Question 199

what are the complications of thyroid surgery?

Answer 199

``` haematoma nerve damage; external SLN (voice changes, loss of high-pitch phonation) RLN (unilateral) - hoarse, weak voice RLN (bilateral) - loss of phonation, stridor, tracheostomy hypocalcaemia scar infection recurrent hypercalcaemia ```

Question 200

what are the indications for a hemithyroidectomy?

Answer 200

recurrent cysts follicular lesions colloid nodule <1cm papillary carcinoma

Question 201

what are the indications for a total thyroidectomy?

Answer 201

papillary carcinoma (with nodes) follicular carcinoma medullary carcinoma (with nodes) multi nodular goitre with compressive symptoms

Question 202

what factors indicate the prognosis of a thyroidectomy?

Answer 202

``` metastases age completeness of resection invasion size ```

Question 203

what is the treatment/follow-up post-thyroidectomy?

Answer 203

``` T3 20mcgs TID radioactive I at 6 weeks thyroxine replacement clinical examination TFTs serial thyroglobulin (calcitonin/CEA) ```

Question 204

what are the indications for sub/total thyroidectomy for goitre?

Answer 204

cosmesis compression MNG grave's (diffuse toxic goitre); relapse on antithyroid drugs, large goitre, difficult control, high T4 conc, eye signs

Question 205

describe atherosclerosis

Answer 205

damages arterial wall by; endothelial injury, lipid deposition, inflammatory cell infiltrate, smooth muscle cell infiltration disrupts blood flow by; stenosis, complete occlusion, plaque rupture, embolisation

Question 206

what are the consequences of atherosclerosis?

Answer 206

``` ischaemic stroke TIA myocardial infarct angina (stable and unstable) peripheral arterial disease renovascular disease ```

Question 207

what are the consequences of peripheral arterial disease?

Answer 207

indicator of overall cardiovascular risk | 5 year mortality - 30% die from MI/stroke, 50% critical limb ischaemia

Question 208

what are the risk factors for developing peripheral arterial disease?

Answer 208

``` age gender smoking HTN hyperlipidaemia diabetes mellitus ```

Question 209

describe critical limb ischaemia

Answer 209

pain at rest >2 weeks at night (woken up) not relieved by simple analgesia relief from hanging foot out of bed (gravity/reduction in metabolic activity)

Question 210

describe acute limb ischaemia

Answer 210

``` sudden onset surgical emergency (6hr window) often embolism, thrombosis and trauma is the patient in AF? previous Hx of claudication? 6 P's ```

Question 211

name the 6 P's

Answer 211

``` pain pallor parasthesia paralysis pulselessness perishingly cold ```

Question 212

what are the signs of PVD that would be present on examination?

Answer 212

``` supra-aortic (rate, rhythm, character, volume) BP both arms carotid/renal bruits cardiac murmurs AAA absent/weak pulses pallor cool muscle atrophy loss of hair growth brittle crumbly nails neuropathy ```

Question 213

what are the symptoms and signs of the "critically ischaemic foot?"

Answer 213

``` tissue necrosis (dry and wet gangrene; superimposed infection, cellulitis) absent pulses venous guttering positive Buerger's test pallor increased with elevation ```

Question 214

describe a popliteal pulse

Answer 214

midline between heads of gastrocnemius press neuromuscular bundle against tibia thumbs apply counter pressure prominent - popliteal aneurysm

Question 215

what investigations are required to diagnose PVD?

Answer 215

ankle-brachial pressure index (confirms the diagnosis) duplex ultrasonography (grayscale US measures architecture and colour doppler visualises flow) MRA (no radiation, ferrous metals (pacemakers) CTA (radiation, contrast nephrotoxicity, iodine) digital subtraction angiography (DSA, gold standard, radiation, contrast allergy, nephrotoxicity, more commonly 2nd line)

Question 216

what is the treatment of PVD?

Answer 216

``` smoking cessation weight reduction total cholesterol <4.4 mmol/L LDL cholesterol <1.8 mmol/L glycaemic control BP control exercise therapy pharmacotherapy endovascular intervention (angioplasty/stents, better for proximal aorta-iliac disease) surgery - bypass/endarterectomy (invasive, better long-term results) ```

Question 217

what is the treatment of critical limb ischaemia?

Answer 217

``` endovascular intervention (angioplasty, stents) surgical (bypass, endarterectomy) amputation ```

Question 218

define pancreatic necrosis

Answer 218

focal or diffuse development of non-viable parenchyma which have become infected

Question 219

what are the causes of pancreatitis?

Answer 219

``` gallstones alcohol idiopathic trauma (ERCP, blunt abdominal) drugs (steroids, thiazide diuretics) metabolic (hyperlipidaemic, hypercalcaemia) infection (mumps, coxsackie) hereditary nutritional (anorexia, bulimia, malnutrition) hypothermia scorpion venom ```

Question 220

what are the symptoms and signs of pancreatitis?

Answer 220

``` severe epigastric pain and tenderness nausea vomiting shallow breathing flank bruising (grey-turner's sign) peri-umbilical bruising (Cullen's sign) ```

Question 221

what are the components of the Glasgow (imrie) system?

Answer 221

``` age WCC serum glucose PaO2 albumin Ca LDH AST ```

Question 222

what is the initial management of pancreatitis?

Answer 222

``` pain relief IV fluid resus anti-emetic NBM NG suction if severe vomiting) mild - treatment/removal of etiological factor severe - treatment of complications ```

Question 223

what is the management of gallstone pancreatitis?

Answer 223

US gallstones removed within 2-4 weeks of acute attack laparoscopic cholecystectomy or ERCP + sphincterotomy MRCP or intra-op cholangiogram to exclude CBD stones

Question 224

what are the complications of acute pancreatitis?

Answer 224

``` pseudocyst necrosis abscess exocrine insufficiency (steatorrhoea) endocrine insufficiency (diabetes) chronic pancreatitis ```

Question 225

describe a pancreatic pseudocyst

Answer 225

collection of fluid in lesser sac may be palpable per abdomen abdominal pain delayed gastric emptying

Question 226

what is the management of necrotic pancreatitis?

Answer 226

initially conservative ICU support for organ failure minimally invasive resection of pancreas (MIRP) open surgical debridement (necrosectomy)

Question 227

describe chronic pancreatitis

Answer 227

``` fibrosis of pancreas structuring and dilatation of pancreatic duct pseudocyst formation mainly due to chronic alcohol abuse increased risk of pancreatic cancer calcification in gland on x-ray or CT chronic abdominal pain exocrine insufficiency (steatorrhoea, managed by Creon) endocrine insufficiency (diabetes) ```

Question 228

what are the risk factors for developing breast cancer?

Answer 228

``` increasing age environment factors > genetic menstrual onset and end age at first pregnancy BMI alcohol diet previous breast disease (CIS, atypical hyperplasia) exogenous oestrogen (HRT, OCP) genetics (BRCA-1, BRCA-2) ```

Question 229

what is the presentation of breast cancer?

Answer 229

``` lump nipple discharge or retraction skin changes - rash, scaling, puckering pain mammography screening FHx ```

Question 230

what are the characteristics of a suspicious breast lump?

Answer 230

``` single lesion hard immovable irregular border skin dimpling >2cm ```

Question 231

describe a fine need aspiration of a breast lump

Answer 231

simple cyst - clear fluid aspirated and swelling cyst resolves bloody fluid - send for cytology and consider further assessment

Question 232

how is a breast lump diagnosed?

Answer 232

triple diagnosis; exam, imaging and FNA 0.7% cancer if all 3 benign, 99.4% cancer if all 3 malignant bilateral mammograms US of breast and axilla CXR routine bloods

Question 233

describe the surgical procedures available for breast cancer

Answer 233

modified radical mastectomy simple mastectomy partial mastectomy axillary clearance vs sentinel node biopsy

Question 234

how is the sentinel node detected?

Answer 234

blue dye injected around the areola and will drain into the lymph nodes (the sentinel node first)

Question 235

what is the post-operative management of breast cancer?

Answer 235

chemotherapy (best results in node positive young women) hormonal therapy (tamoxifen/aromatase inhibitor) radiotherapy monoclonal antibody (Herceptin in HER2 positive women)

Question 236

what are the complications of breast surgery?

Answer 236

``` anaesthesia complications DVT, PE, LRTI wound infections nerve damage (long thoracic) chronic wound pain cosmetic psychological lymphoedema ```

Question 237

what are the reconstructive techniques in breast surgery?

Answer 237

TRAM flap latissimus dorsi flap prosthetic implants

Question 238

what are the types of intestinal obstruction?

Answer 238

mechanical; partial/complete, simple/strangulation | function; paralytic ileus, pseudo-obstruction

Question 239

what are the causes of intestinal obstruction?

Answer 239

``` foreign object in body; food, bezoar gallstones parasites adhesions hernia (primary or secondary) tumour (primary or secondary) inflammation (IBD) diverticular disease stricture vasculitis ```

Question 240

what are the symptoms and signs of intestinal obstruction?

Answer 240

``` abdominal pain distention vomiting constipation tachycardia hypotension fever scars hernias auscultation (no bowel sounds) dilatation on scans ```

Question 241

what is the management of intestinal obstruction?

Answer 241

fluid resuscitation (saline, K) urinary catheter NG tube analgesia operative - post-resuscitation, antibiotics, DVT prophylaxis non operative - paralytic ileus, known adhesions, metastatic disease, inflammatory

Question 242

define sepsis

Answer 242

life-threatening organ dysfunction cause by a dysregulated host response

Question 243

describe septic shock

Answer 243

hypovolaemia, vasodilation, impaired cardiac function and mitochondrial dysfunction lactate >2mmol/L persistent hypotension requiring vasopressors to keep MAP above 65mmHg

Question 244

what are the non-infectious causes of sepsis?

Answer 244

``` pancreatitis tissue ischaemia trauma burns thromboembolism vasculitis drug reactions autoimmunity neoplasia ```

Question 245

what are the infectious causes of sepsis?

Answer 245

lungs intra-abdominal GU bloodstream

Question 246

what is the pathophysiology of sepsis?

Answer 246

``` CO increase systemic vascular resistance decrease serum lactate increase (hypo perfusion/hypoxia, aerobic glycolysis through enhanced adrenergic tone) increased leucocyte adhesion increased coagulation vasodilatation loss of barrier function hypercytokinaemia ```

Question 247

what are the consequences of sepsis?

Answer 247

``` DIC bacterial translocation ARDS AKI encephalopathy hepatic failure ```

Question 248

describe the sepsis cycle

Answer 248

ARDS - lung injury sedative - reduced mobility, progressive catabolism, severe neuromuscular weakness intestinal barrier dysfunction - ongoing bacterial translocation and malnutrition immune dysfunction - secondary infections

Question 249

describe sepsis pathophysiology on a cellular/molecular level

Answer 249

endotoxins, macrophage, cytokine production inflammatory signalling potent cytokine response pyroptosis - caspase mediated plasma membrane rupture early damage pathway (RO species, complement activation, immunothrombosis) metabolic dysfunction resolution pathways (anti-inflammatory pathways)

Question 250

what is the treatment of sepsis?

Answer 250

6; IVI (crystalloids), BS antibiotics, O2, urine measurement, blood cultures, serum lactate ``` early and effective antimicrobial therapy resus; colloids and crystalloids vasopressors; vasopressin, adrenaline, noradrenaline lung protective ventilation insulin therapy enteral feeding urinary catheter reduced sedation ```

Question 251

what drugs are useful in sepsis?

Answer 251

anti-cytokines; etanercept, afelimomab, anakinra anti-virulence factors; HA-1A, ES, eritoran anti-coagulopathy; activated protein C, antithrombin III, heparin immune stimulation; G-CSF, GM-CSF

Question 252

define diverticulosis

Answer 252

presence of diverticula in bowel wall

Question 253

define diverticulitis

Answer 253

inflammation of diverticula

Question 254

define diverticular disease

Answer 254

entire spectrum of clinical consequences

Question 255

what is the pathogenesis of diverticular disease?

Answer 255

mucosal herniations points of weakness - vasa recta beside taeniae false diverticula present in sigmoid column, none in rectum areas of high pressure - segmentation

Question 256

what are the signs and symptoms of diverticular disease?

Answer 256

``` asymptomatic crampy lower abdominal pain LIF discomfort, tenderness and guarding pyrexia rabbit-like stools increased WCC, CRP must exclude sinister pathology ```

Question 257

what is the treatment of diverticular disease?

Answer 257

high fibre diet (20-30g bran) fibre supplements anti-spasmodics reduces pain not complications

Question 258

what are the complications of diverticulitis?

Answer 258

phlegmon (stricture) perforation (localised abscess, generalised peritonitis) fistula (colovesical, colovaginal, coloenteric, colocutaneous) bleeding

Question 259

what is the treatment of diverticulitis?

Answer 259

oral fluids IV antibiotics (broad spectrum penicillin and metronidazole) oral antibiotics if resolving BE or colonoscopy in 4-6 weeks

Question 260

how do an abscess present?

Answer 260

failure to resolve temperature spiking obvious mass

Question 261

what is the management of an abscess?

Answer 261

broader spectrum antibiotics (tazobactam and piperacillin) CT percutaneous drainage sigmoid colectomy failure to resolve - surgery hartmann's; safe, 50% not resolved sigmoid colectomy + loop ileostomy; higher risk, easier reversible

Question 262

what are the signs and symptoms of intestinal perforation?

Answer 262

``` severe, generalised abdominal pain sudden onset shock tender, guarding, rebound seen on erect CXR ```

Question 263

what is the management of intestinal perforation?

Answer 263

``` resus IV fluid broad spectrum IV antibiotics emergency Hartmann's procedure extensive lavage; large bore drains high mortality ```

Question 264

what are the symptoms, signs and management of a colovesical fistula?

Answer 264

recurrent UTIs, pneumoturia, faecoturia BE (80%), Bournes test, cystoscopy, CT

Question 265

what are the symptoms, signs and management of a colovaginal fistula?

Answer 265

prior hysterectomy flatus, foul-smelling discharge, faeces PV BE, vaginal exam

Question 266

what are the symptoms and signs of a colocutaneous fistula?

Answer 266

cellulitis induration perforation

Question 267

what are the symptoms, signs and management of a stricture?

Answer 267

``` crampy abdominal pain constipation diarrhoea thin stools abdominal distension ``` exclude malignancy barium enema colonoscopy sigmoid colectomy

Question 268

what are the symptoms, signs and management of bleeding?

Answer 268

sudden and significant bright red/maroon haemodynamic upset anaemia ``` resuscitation (70% resolve) OGD technetium red cell scan angiography - vasopressin, embolisation surgery ```

Question 269

describe a perianal examination

Answer 269

``` inspection digital rectal examination rigid sigmoidoscopy proctoscopy flexible sigmoidoscopy colonoscopy ```

Question 270

what investigations are performed in diagnosing perianal disease?

Answer 270

``` endo-anal US barium studies ano-rectal manometry defaecating proctogram fistulogram MRI rectal muscosa biopsy ```

Question 271

describe the classification of haemorrhoids

Answer 271

1st degree; bleeding 2nd degree; prolapse and reduce spontaneously 3rd degree; remain prolapsed

Question 272

what is the management of haemorrhoids?

Answer 272

``` avoid constipation and straining adjust diet use faecal softeners rubber band ligation injection infra-red photocoagulation transfixion and excision circular stapling ```

Question 273

name other perianal diseases

Answer 273

``` anal fistula (Seton encircling) perianal CD anal fissure thrombosed external pile perianal haematoma perianal warts anal cancer rectal prolapse pruritus ani ```

Question 274

what is included on the sign-in surgical safety checklist?

Answer 274

``` correct patient correct site anaesthetic check monitoring check allergy status airway risk (including aspiration) anticipated blood loss ```

Question 275

what is included on the time-out surgical safety checklist?

Answer 275

``` team member introduction correct patient and site antibiotic prophylaxis anticipated critical events imaging displayed ```

Question 276

what is included on the sign-out surgical safety checklist?

Answer 276

``` procedure instrument/swab count specimen labelling any equipment problems any recovery concerns ```

Question 277

name some high-risk medications

Answer 277

``` anticoagulants opiates injectable sedatives insulin antibiotics chemotherapy infusion fluids antipsychotics drugs requiring monitoring of levels; digoxin, vancomycin, lithium, theophylline, warfarin ```

Question 278

define systemic inflammatory response syndrome (SIRS)

Answer 278

``` 2 or more of the following; temperature >38.3 or <36.0 HR >90 (unless AF) RR >20 WCC <4 or >12 x109/L glucose >8.3mmol/L (unless diabetic) ``` only significant if new to an individual patient

Question 279

define sepsis

Answer 279

SIRS + infection (presence bacterial, viral, fungi, parasitic in normally sterile tissue) infection has led to systemic sirs-like effects

Question 280

define severe sepsis

Answer 280

sepsis + one or more organ dysfunction | sepsis + tissue hypo perfusion

Question 281

what are the signs of respiratory dysfunction?

Answer 281

new/increased O2 requirement to maintain spO2 >90%

Question 282

what are the signs of renal dysfunction?

Answer 282

creatinine >177mmol/L or UO >0.5ml/kg/hr for 2hrs

Question 283

what are the signs of hepatic dysfunction?

Answer 283

bilirubin >34mmol/L

Question 284

what are the signs of coagulation dysfunction?

Answer 284

PLT <100 INR >1.5 aPTT >60s

Question 285

what are the causes of SIRS?

Answer 285

pancreatitis trauma burns other

Question 286

what is the management of severe sepsis?

Answer 286

medical emergency requires a fluid challenge to avoid irreversible organ damage fluid challenge should reverse the tissue hypo perfusion parameters just described

Question 287

define septic shock

Answer 287

if, following the immediate administration of fluid challenges, the patient retains signs of tissue hypoperfusion or has a repeat lactate of >4mmol/L

Question 288

what are the functions of calcium?

Answer 288

``` muscle contraction nerve impulse conduction intracellular signalling blood clotting glandular secretions preservation of bone density regulation of digestion, energy and fat metabolism regulates insulin secretion regulates PTH and calcitonin secretion ```

Question 289

describe parathyroid hormone

Answer 289

t1/2 3 minutes responds to changes in extracellular Ca parathyroid chief cells have cell surface Ca sensing receptor

Question 290

describe calcitriol (1,25-dihydroxyvitamin D)

Answer 290

vitamin D from diet/skin hydroxylated in liver | PTH controls 2nd hydroxylation in kidney

Question 291

describe Ca homeostasis

Answer 291

calcitriol controls absorption from GI tract PTH increases osteoclastic activity calcitriol and PTH control Ca excretion from kidney decreased intake/absorption - PTH increases Ca release from bone, Ca reabsorption from distal nephron and calcitriol production

Question 292

what are the signs and symptoms of hypercalcaemia?

Answer 292

``` polyuria polydipsia dyspepsia vage depressive complaints mild cognitive impairment apathy weakness nausea anorexia constipation dehydration abdominal pain seizures lethargy coma becomes more symptomatic the high the Ca levels are ```

Question 293

what are the renal symptoms (stones) of hypercalcaemia?

Answer 293

polyuria polydipsia nephrolithiasis nocturia

Question 294

what are the skeletal symptoms (bone) of hypercalcaemia?

Answer 294

joint pain bone pain increased risk of fracture gout

Question 295

what are the neurological symptoms (psychiatric overtones) of hypercalcaemia?

Answer 295

fatigue weakness depression memory loss

Question 296

what are the GI symptoms (moans) of hypercalcaemia?

Answer 296

``` anorexia constipation heartburn PUD pancreatitis ```

Question 297

describe non-parathyroid related hypercalcaemia

Answer 297

malignancy associated granulomatous (sarcoid, TB) endocrinopathies (hyperthyroidism, adrenal insufficiency) drugs (thiazides, Ca supplements, vitamin D) immobilisation

Question 298

describe parathyroid mediated hypercalcaemia

Answer 298

primary hyperparathyroidism; parathyroid adenoma, hyperplasia, carcinoma tertiary hyperparathyroidism familial hypocalcuric hypercalcaemia lithium therapy

Question 299

what investigations are required to diagnose hyperparathyroidism?

Answer 299

``` corrected Ca PTH phosphate 24hr urine Ca excretion bone densitometry sestimibi scan US ```

Question 300

what are the complications of hyperparathyroidism?

Answer 300

``` renal disease bone loss HTN neuropsychiatric disorders glucose intolerance ```

Question 301

when is surgery required for hyperparathyroidism?

Answer 301

serum Ca >0.5mmol/dL above reference range 24hr urinary Ca excretion >400mg/day 30% decreased in creatinine clearance T score

Question 302

what surgery is required in renal disease?

Answer 302

sub-total total and autotransplant total parathyroidectomy all patients with renal disease should have a thymectomy

Question 303

describe the pathophysiology of appendicitis

Answer 303

luminal obstruction with resultant inflammation increased pressure resulting in abdominal pain from visceral nerve fibres accumulation of E. coli and bacteroides

Question 304

what is the location of McBurney's point?

Answer 304

1/3 from the ASIS to the umbilicus

Question 305

describe Rovsing's sign

Answer 305

pressing on the LIF elicits pain in the RIF | present in appendicitis

Question 306

what groups of people are most likely to develop appendicitis?

Answer 306

young males women of child-bearing age older patients >30yrs

Question 307

what is the differential diagnosis of appendicitis in young males?

Answer 307

mesenteric adenitis acute appendicitis inflamed meckel's diverticulum Crohn's disease

Question 308

what is the differential diagnosis of appendicitis of women of child-bearing age?

Answer 308

``` ovarian torsion ovarian cyst rupture ectopic pregnancy UTI pyelonephritis renal colic acute appendicitis acute diverticulitis terminal ileal Crohn's disease colitis meckel's diverticulum ```

Question 309

what is the differential diagnosis of acute appendicitis in older patients?

Answer 309

``` caecal tumours terminal ileal Crohn's disease acute diverticulitis renal colic ovarian/uterine malignancy ```

Question 310

what investigations are required to diagnose acute appendicitis?

Answer 310

``` USS CTAP bloods; WCC, CRP urinalysis beta CG history and examination ```

Question 311

what are the complications of appendicitis surgery?

Answer 311

early; bleeding, visceral injury (small bowel, caecum) immediate; ileus, wound infection, intrabdominal collections late; adhesions obstruction, incisional hernia

Question 312

describe the distribution of infused fluids

Answer 312

colloids; plasma 0.9% NaCl; interstitial fluid 5% dextrose; intracellular fluid

Question 313

what are the causes of existing fluid/electrolytes deficits and excesses?

Answer 313

dehydration fluid overload hypo/hyperkalaemia

Question 314

what are the causes of ongoing fluid/electrolyte deficits and excesses?

Answer 314

``` vomiting and NG tube loss biliary drainage loss high/low volume ileal stoma loss diarrhoea/excess colostomy loss ongoing blood loss sweating, fever, dehydration pancreatic, jejunal fistula, stoma loss urinary loss; post-AKI polyuria ```

Question 315

what are the causes of fluid redistribution issues?

Answer 315

``` gross oedema severe sepsis hypo/hypernatraemia renal, liver, cardiac impairment post-operative fluid retention and redistribution malnourishment and refeeding issues ```

Question 316

what are the symptoms and signs of hypovolaemia?

Answer 316

``` sunken skin reduced turgor fluids out; drains, GI losses diuretics fever tachycardia decreased pulse pressure postural hypotension low vascular tone B-blockade autonomic neuropathy sunken eyes dry mucous membranes no JVP visible increased CRT raised creatinine (AKI) raised lactate ```

Question 317

what are the symptoms and signs of hypervolaemia?

Answer 317

``` dyspnoea increased RR oedema fluids in; IV fluids, infusions raised JVP apex beat displacement 3rd HS pulmonary oedema in lung bases ascites peripheral oedema raised BNP (HF) CXR; overload signs echocardiogram; LV function, HF signs, overload ```

Question 318

describe pre-renal AKI

Answer 318

hypovolaemia and hypotension compromised the normal perfusion mostly due to hypotension associated with sepsis and/or fluid depletion exacerbated by ACE inhibitors or NSAIDs will often respond to fluid replacement and drug withdrawal avoid nephrotoxins; radio contrast, high dose aminoglycoside

Question 319

define an established AKI

Answer 319

creatinine rise >26mmol/L in 48hrs >50% from baseline value within 7 days UO <30ml/hr for 6hrs

Question 320

what is the management of an established AKI?

Answer 320

``` bloods, urinalysis, urinary Na renal USS; if upper tract obstruction or no response to treatment resuscitation fluids optimise blood pressure stop NSAIDs, COX II, ACEi, ARBs, metformin avoid antihypertensives, diuretics correct dosing to eGFR level maintenance fluids; rate = UO + 30ml/hr avoid Hartmann's if K >5.5mmol/L ```

Question 321

what are the indications of AKI for referral to nephrology?

Answer 321

suspected intrinsic renal disease; blood and protein on urinalysis with suspected glomerulonephritis, unclear aetiology of AKI potential need for dialysis; refractory hyperkalaemia, pulmonary oedema, severe metabolic acidosis, progressive AKI AKI in; renal transplant patients, baseline GFR <30ml/min

Question 322

what questions should be asked in a hernia history?

Answer 322

``` bulging/lump pain; type, onset, site, when, where standing vs lying down previous treatment smoking diabetes occupation ```

Question 323

what are the general principles of a hernia examination?

Answer 323

``` exposure of abdomen fully including groin standing vs lying down reducibility tenderness overlying skin bowel sounds ```

Question 324

what are the risks of a hernia?

Answer 324

incarceration obstruction strangulation and necrosis

Question 325

what are the features of a primary acquired hernia?

Answer 325

weakness of muscles/fascia ``` genetic diabetes smoking obesity pregnancy occupation? ```

Question 326

describe an epigastric hernia

Answer 326

above umbilicus midline x2 in males fixed with sutures or mesh

Question 327

describe (para)umbilical hernias

Answer 327

acquired paraumbilical; associated with age, obesity, pregnancy, females x3, fix congenital umbilical; usually leave alone

Question 328

describe hesselbach's triangle

Answer 328

an area of potential weakness in the abdominal wall; herniation of abdominal contents can occur between the inguinal ligament, inferior epigastric vessel and lateral border of the rectus abdominis muscle

Question 329

describe the treatment methods of hernias

Answer 329

herniotomy division of sac (paediatric) herniorraphy repair hernioplasty repair with mesh

Question 330

what is the composition of calcium in the body?

Answer 330

1kg in average human body 99% in skeleton 60% albumin bound, or complexed with phosphate and citrate

Question 331

describe the calcium phosphate ratio

Answer 331

calcium:phosphate normally 2:1 | increase in plasma calcium causes corresponding decreased in phosphate absorption

Question 332

describe the hormonal control of calcium and phosphate metabolism

Answer 332

``` 4 integrated systems; endocrine; vitamin D, PTH, calcitonin gut bone kidney ```

Question 333

describe calcium absorption

Answer 333

derived through dietary sources as calcium phosphate, carbonate, tartrate and oxalate absorbed from the GI tract; simple diffusion, active transport, and distributed 99% is filtered in the glomerulus only a small quantity is excreted through urine calcium may be deposited or resorbed in the bone depending on the level of calcium in the plasma

Question 334

what are the actions of PTH with calcitriol?

Answer 334

bone; act on osteoclasts to promote bone resorption and increase calcium concentration small intestine; stimulates calcium reabsorption via vitamin D activation renal; PTH stimulates renal 1 alpha hydroxylase to stimulate intestinal calcium absorption

Question 335

describe calcitonin

Answer 335

released by the parafollicular or C cells actions; decreased absorption of bone by osteoclasts decreased formation of new osteoclasts and decreased in the number of osteoblasts

Question 336

what are the causes of hypercalcaemia?

Answer 336

PTH mediated; primary hyperparathyroidism, lithium FHH, tertiary hyperparathyroidism cancer; multiple myeloma, PTHrp mediated, renal cancer, bone metastases calcitriol mediated; granulomatous disease, lymphoma, milk alkali syndrome, exogenous vitamin D dialysis vitamin A toxicity, thyrotoxicosis, Paget's disease, adrenal insufficiency, thiazide use

Question 337

what are the causes of hyperparathyroidism?

Answer 337

80-85%; pituitary adenoma 5%; double adenoma carcinoma; <1% hyperplasia; more common in familial syndromes

Question 338

what are the major features of hyperparathyroidism?

Answer 338

``` progressive mild decline in renal function decreased bone density fatigue and muscle pain nausea, constipation and heartburn nocturia brain fog depression, anxiety, poor sleep neuropsychiatric features ```

Question 339

what are the symptoms and signs of osteoporosis?

Answer 339

decrease in height over time hunched or stooped posture back pain; particularly lower back secondary to a collapsed vertebra bones fracturing easily

Question 340

describe familial hypocalciuric hypercalcaemia

Answer 340

``` rare genetic disorder; calcium receptor in kidney AD mild hypercalcaemia low urinary calcium genetic testing PTH may be normal ```

Question 341

what investigations are required to diagnose hyperparathyroidism?

Answer 341

``` calcium PTH serum phosphate creatinine 24hr urinary calcium vitamin D levels; all patients should be vitamin D deplete USS; may locate adenoma sestamibi scan 4D CT scan ```

Question 342

what are the indications for thyroid surgery?

Answer 342

history of renal stones osteoporosis; lowest T score on scan <50yrs calcium >2.75 neurocognitive and neuropsychiatric symptoms considered in CVD, persistent GORD, fibromyalgia

Question 343

what are the consequences of thyroid surgery?

Answer 343

``` cure calcium normalises quickly PTH takes longer to normalise reverses osteoporosis decreases risk of hip fracture reduces renal stone risk increased life expectancy feel better; less weak, fatigue, depression, thirst ```

Question 344

what is the management of hypocalcaemia?

Answer 344

drink of milk or cheese calcium supplements start 1g elemental TID and monitor response vitamin D can be added 10ml 10% calcium gluconate IV never IM

Question 345

describe the features of post-operative neck haematoma

Answer 345

worsening wound swelling after neck surgery | respiratory distress; tachypnoea, stridor, low saturation

Question 346

what is the management of post-operative neck haematoma?

Answer 346

``` sit up start 100% O2 by mask monitor closely 100mg IV hydrocortisone open the wound and pack closely; SCOOP ```

Question 347

describe primary hyperparathyroidism

Answer 347

raised serum calcium and PTH in the setting of normal renal function measure these and calcitriol and 24hr urinary calcium consider familial hypocalciuric hypercalcaemia causing secondary hyperparathyroidism assess for end organ damage; nephrolithiasis, osteoporosis, reduced renal function surgery; only curative treatment

Question 348

what is the treatment of hypercalcaemia?

Answer 348

avoid calcium containing foods and supplements volume expansion and rehydration normal saline at 200-300ml/hr consider steroids for known malignancy loop diuretic only if fluid overloaded IV bisphosphate; zolendronic (4mg IV / 15 mins) or pamidronate (60-90mg / 2hrs) or denosumab (120mg every 4 weeks) in renal impairment

Question 349

describe the pathogenesis of gallstones

Answer 349

components of bile get out of correct concentrations | loss of gallbladder motility/excessive sphincter contraction; bile stasis, sludge/stones

Question 350

what does bile consist of?

Answer 350

bilirubin, cholesterol, fatty acids and various minerals

Question 351

what are the risk factors for developing gallstones?

Answer 351

``` FHx white european/North American, asians, black africans female pregnancy morbid obesity/rapid weight loss total parenteral nutrition drugs; fibrates diet high in fats and carbohydrates sedentary lifestyle T2DM dyslipidaemia ```

Question 352

what are the causes of black gallstones?

Answer 352

``` excess unconjugated bile/increased enterohepatic circulation of bilirubin haemolytic anaemia ineffective erythropoiesis liver cirrhosis ileal disease ```

Question 353

describe brown gallstones

Answer 353

predominate in other areas of biliary tract; intrahepatic ducts, gallbladder SE asia; parasite infestation, e. coli

Question 354

what are the clinical features of gallstones?

Answer 354

contraction of GB smooth muscle activation of visceral nerve fibres in the GB wall sensation of referred pain in the T9 dermatome poorly localised pain often associated with nausea and vomiting local cytokine release; irritation to parietal peritoneum in RUQ biliary pain; >few hours, localised to RUQ, tender RUQ, increased WBC, CRP, ESR, deranged LFTs, mucocele, empyema

Question 355

what is the pathophysiology of acute pancreatitis?

Answer 355

CBD stones pass out of the bile duct | impacted gallstone in distal bile duct obstructs Pd, increasing pancreatic pressure, damaging ductal and acinar cells

Question 356

what investigations are required to diagnose bile duct stones?

Answer 356

``` faecal sampling LFTs; GGT, ALP, transaminases, bilirubin USS MRCP ERCP; therapeutic only EUS ```

Question 357

describe Charcot's triad

Answer 357

``` jaundice high temperature (39-40) RUQ pain indicates cholangitis; E. coli, klebsiella, enterobacter, enterococcus treatment; antibiotics and ERCP ```

Question 358

describe mirizzi syndrome

Answer 358

stone impacted in hartmann's pouch produces an inflammatory process resulting in adherence of hartmann's pouch to CBD obliterates hepatocystic triangle resulting in partial obstruction of CBD and cholecysto-choedochal fistula

Question 359

what is the treatment of gallstones?

Answer 359

laparoscopic cholecystectomy cholecystostomy tube open cholecystectomy

Question 360

what is the management of CBD stones?

Answer 360

ERCP; sphincterotomy, remove stones, insert stent, take brushings of bile duct strictures complications; acute pancreatitis, haemorrhage, death laparoscopic; choledochoscope used T tube

Question 361

describe gallstone ileus

Answer 361

mechanical obstruction caused by a large gallstone typically inflamed gallbladder erodes into duodenum usually impacts the terminal ileum once the stone has passed the fistula will usually close

Question 362

describe porcelain gallbladder

Answer 362

extensive calcium deposited in the gallbladder wall | usually asymptomatic

Question 363

describe acute acalulous cholecystitis

Answer 363

often seen in sick patients in ICU; burns, trauma, post cardiac surgery gallbladder ischaemia

Question 364

describe gallstones in children

Answer 364

rare | associated with underlying disease; haemolytic anaemia, Crohn's, genetic disorders, liver disease, obesity

Question 365

describe hypovolaemic shock

Answer 365

inadequate organ perfusion caused by loss of intravascular volume usually acute drop of cardiac preload to a critical level haemorrhagic/non-haemorrhagic

Question 366

describe haemorrhagic hypovolaemic shock

Answer 366

blood loss; vasoconstriction increased HR to preserve CO endogenous catecholamines; nor/adrenaline contraction of the venous system to increase venous return cellular; conversion to anaerobic metabolism (lactic acidosis) prolonged; multi organ dysfunction

Question 367

what are the signs of hypovolaemic shock?

Answer 367

``` tachycardia reduced BP increased RR reduced UO decreased mental status increased CRT ```

Question 368

describe distributive shock

Answer 368

a state of relative hypovolaemia resulting from pathological redistribution of intravascular volume

Question 369

describe qSOFA

Answer 369

identifies patients with suspected infection who are at greater risk for a poor outcome outside ICU; SBP <100mmHg RR >22 GCS <15

Question 370

what is the treatment of septic shock?

Answer 370

``` oxygen IV fluids bloods including ABG (lactate) urinary catheter blood cultures abscess drainage sample IV antibiotics; empirical, may need micro consult HDU/ICU consult source ontrol; radiological, surgery (GI perforation) ```

Question 371

define anaphylactic shock

Answer 371

massive histamine mediated vasodilation with shift of fluid from the intra to extravascular space triggers; food products, insect venom treatment; adrenaline injection. fluids, steroids

Question 372

describe neurogenic shock

Answer 372

SBP <100mmHg HR <60 obtunded consciousness high spinal cord injury; loss of spinal reflexes

Question 373

describe cariogenic shock

Answer 373

disorder of cardiac function critical reduction of the hearts pumping capacity systolic or diastolic dysfunction; reduced ejection fraction or impaired ventricular filling

Question 374

what are the symptoms of cariogenic shock?

Answer 374

agitation disturbed consciousness cool extremities oliguria

Question 375

describe obstructive shock

Answer 375

due to extra cardiac causes of cardiac pump failure and often associated with poor RV output pulmonary vascular; RV failure from a haemodynamically significant PE or severe pulmonary hypertension mechanical; decreased preload, reduced venous return to RA, tension pneumothorax, pericardial tamponade contrastive pericarditis, cardiomyopathy

Question 376

what is the cause of cardiac tamponade

Answer 376

penetrating or blunt injuries that cause the pericardium to fill with blood from the heart, great vessels or pericardial vessels

Question 377

what is the classic clinical triad of cardiac tamponade?

Answer 377

muffled heart sounds hypotension distended veins

Question 378

what is the treatment of cardiac tamponade?

Answer 378

thoracotomy; drain the pericardial sac

Question 379

what is the treatment of an adenocarcinoma of distal sigmoid colon?

Answer 379

laparoscopic panproctocolectomy | restorative proctocolectomy ileal J-pouch

Question 380

name the inherited CRCs

Answer 380

Lynch syndrome polyposis syndrome; FAP, AFAP, MAP familial

Question 381

what cancers is Lynch syndrome associated with a greater risk?

Answer 381

colorectal endometrial ovarian stomach

Question 382

what are the treatment options of a rectal adenocarcinoma?

Answer 382

surgery; low anterior resection radiotherapy; pre-operative watch and wait; chemoradiotherapy with monitoring and follow up

Question 383

what is the treatment of a rectosigmoid adenocarcinoma?

Answer 383

surgery; hartmann's operation, colostomy | colonic stent; endoscopically placed, morbidity and mortality equal to surgery

Question 384

what are the indications for AAA surgical repair?

Answer 384

rupture; emergency symptomatic; urgent, regardless of size >5.5cm rapid expansion; >1cm over 12 months

Question 385

what are the post-operative complications of AAA surgery?

Answer 385

``` cardiac complications renal insufficiency respiratory problems lower extremity ischaemia/emboli post-operative haemorrhage colonic ischaemia paraplegia ``` late; false aneurysm graft limb thrombosis graft infection enteric fistula

Question 386

what is the classical triad of AAA rupture?

Answer 386

abdominal/back pain hypovolaemic shock elderly patient

Question 387

what are the signs, symptoms and investigations required to diagnose a leaking AAA?

Answer 387

abdominal, back or groin pain pulsatile expansile abdominal mass hypotension/shock contrast enhanced CT USS

Question 388

what is the differential diagnosis of a ruptured AAA?

Answer 388

``` MI acute pancreatitis renal/ureteric colic acute cholecystitis perforated peptic ulcers intestinal obstruction ischaemic gut ```

Question 389

what is the management of a ruptured AAA?

Answer 389

large bore cannula urgent bloods; FBC, U&E, coag, G&X 6 units analgesia, oxygen, urinary catheter, haemodynamic monitoring permissive hypotension urgent transfer to theatre for surgery

Question 390

what are the complications specific to ruptured AAA?

Answer 390

``` bowel ischaemia abdominal compartment syndrome leg ischaemia renal failure cardiac complications ```

Question 391

describe the stress response system

Answer 391

CRH is released from the hypothalamus CRH acts on the pituitary gland to release ACTH ACTH acts on the adrenal gland to produce cortisol

Question 392

what are the actions of cortisol?

Answer 392

``` promotes fat breakdown reduces bone formation increases glucose generation from the liver decreases amino acid uptake by muscle counteracts the actions of insulin ```

Question 393

what are the actions of cytokines?

Answer 393

maintain the stress response release of inflammatory mediators may be harmful response

Question 394

what is the initial management of suspected ACS (acute chest pain)?

Answer 394

``` MONA; morphine oygen nitrate aspirin 300mg ```

Question 395

what is the treatment of an NSTEMI?

Answer 395

``` morphine oxygen; only <90% nitrates aspirin clopidogrel enoxaparin ```

Question 396

what is the management of hypovolaemic shock due to haemorrhage?

Answer 396

``` permissive hypotension get help wide bore access; 2 16G cannula XIM 6 units to theatre ASAP massive transfusion protocol cardiac monitor ```

Question 397

describe the pathogenesis of sepsis

Answer 397

local infection caused by bacteria bacteria enter the bloodstream immune system responds to fight infection bacteria and immune cells spread throughout the body causing uncontrolled inflammation leads to organ damage and death if left untreated

Question 398

what are the aims or urine output?

Answer 398

adults; 0.5-1.0 ml/kg/hr | children <30kgs; 1ml/kg/hr

Question 399

what are the causes of AKI?

Answer 399

``` recent infection certain drugs severe dehydration exposure to heavy metals or toxic solvents blood loss shock parenchymal disease ```

Question 400

what is the treatment of an AKI?

Answer 400

``` low grade temperature stop DAMN drugs fluid resuscitation aim SBP >100 and UO >0.5 ml/kg/min consider sepsis and treat accordingly stop antihypertensives if hypotensive avoid contrast if possible discuss with renal team if at stage 3 ```

Question 401

what are the risk factors for developing ulcerative colitis?

Answer 401

high fat intake sleep deprivation; flare ups gastroenteritis smoking and appendectomy decrease risk

Question 402

what is the pathophysiology of ulcerative colitis?

Answer 402

mucosal ulcers and crypt abscess formation intact and oedematous mucosa projects in the bowel lumen chronic inflammation leads to loss of haustra predisposition to dysplastic change

Question 403

what are the clinical features of ulcerative colitis?

Answer 403

``` blood diarrhoea tenesmus weight and appetite loss electrolyte imbalance; hypokalaemia systemically unwell toxic megacolon extra-intestinal manifestations ```

Question 404

what are the signs of ulcerative colitis on endoscopy?

Answer 404

mucosal inflammation of colon and rectum | biopsy shows typical pathological features of UC

Question 405

what are the signs of ulcerative colitis on barium enema?

Answer 405

loss of haustra pseudopolyps lead pipe colon

Question 406

what are the signs of ulcerative colitis on CT?

Answer 406

diffusely thickened colonic walls

Question 407

what are the risk factors for Crohn's disease?

Answer 407

``` smoking high fat intake low vitamin D intake gastroenteritis physical activity and high fibre intake decreases risk ```