Surgery II Flashcards
A patient sustains an injury to one of the nerves of his upper limb. He complains of weak finger abduction and adduction with reduced sensation over the ulnar border of his hand. On examination you note clawing of the 4th and 5th digits. During recovery, the patient notices worsening of this deformity before eventually resolving. What is the most likely diagnosis?
Damage to ulnar at the elbow
The ulnar paradox: proximal lesions of the ulnar nerve produce a less prominent deformity than distal lesions
special test for achilles rupture
simmonds test
simmonds test
They should also feel for a gap in the tendon and gently squeeze the calf muscles if there is an acute rupture of the Achilles tendon the injured foot will stay in the neutral position when the calf is squeezed.
Ultrasound is the initial imaging modality of choice for suspected Achilles tendon rupture
A 67-year-old man presents to the emergency department following a fall onto his right hand. He reports a fall onto an outstretched right hand while running to catch a bus. Since the incident, his right wrist has been painful and he reports it is starting to swell.
Examination reveals tenderness over his right anatomical snuffbox, pain on ulnar deviation of his right wrist and a small effusion around the right wrist.
Based on the information provided, what is the most appropriate management option?
if suspecting scaphoid fracture: apply splint and arrange xray
diagnose
salter harris type 2
ottowa ankle score
whether or not to x-ray
test for achilles tendon rupture
Thompson/Simmonds test
wont be able to plantar flex
test for achilles tendon rupture
Thompson/Simmonds test
wont be able to plantar flex
An 83-year-old female with a history of dementia presented to the emergency department with a suspected hip fracture. She received an x-ray, which diagnosed a subcapital fracture of the femur with partial displacement. What is the most likely surgical treatment option for this type of fracture?
Hemiarthroplasty- dementia
Hemiarthroplasty or total hip replacement is the treatment of choice for all patients with a displaced hip fracture
A 65 year old male patient presents to the general practitioner with a history of occasional rectal bleeding. He describes 4 episodes of fresh PR blood over the last 6 months. He also reports fatigue and shortness of breath on exertion.
On physical examination there is conjunctival pallor. Vital signs are within normal range. He is referred for colonoscopy which reveals scattered bright red lesions, with a branching appearance of vessels arising form a central vessel.
Which of the following is the most appropriate management for this patient?
angiodysplasia (AVN malformation)
Interventional endoscopy e.g. adrenaline injection
A 27 year old woman attends the emergency department with a 24 hour history of severe right sided intermittent loin pain and haematuria. She is 15 weeks pregnant with her second child. The 12 week scan was normal and her first pregnancy was uncomplicated. She is known to have recurrent renal stones. Her observations are normal. Urine dip shows Hb++. An ultrasound scan is performed which shows a 13mm right renal stone. What is the most appropriate management?
ureteroscopic stone removal
stoen over 1cm
other treatments not suitable due to pregnancy
A 65 year old male patient presents to the emergency department with a 12 hour history of inability to pass urine and suprapubic discomfort. Prior to this episode, he reports a 3 month history of weak stream, hesitancy, and nocturia. He has a past medical history of osteoarthritis affecting the knees, managed with oral paracetamol, but is otherwise well.
On physical examination there is a palpable tender mass arising from the pelvis which is dull to percussion.
Given the most likely diagnosis, which of the following is the most appropriate management?
2 way Foley catheter and doxazosin (alpha blocker)
A 60-year-old man presents to his GP. His wife has noticed that his skin has become yellowed over the preceding weeks. He has no pain. He also mentions he had lost around 5-10% of his body weight unintentionally over the same period. His past medical history is positive for medically managed ulcerative colitis (UC) and primary sclerosing cholangitis (PSC). He drinks alcohol and smokes heavily. On examination, a painless mass is noted in the right upper quadrant.
What is the most likely diagnosis?
cholangiocarcinoma
do Ca 19.9
primary sclerosing cholangitis big RF
strings of Kantour after contrast enema
Crohns disease
oesophageal cancer investigation
- OGD
- CT TAP
- PET
- Endoscopic ultrasound- staging
leaning forward helps with
pericarditis
pancreatitis
management of pancreatitis
IV fluid resus
analgesia
anti-emetic
Colorectal cancer treatment: caecal, ascending or proximal transverse
right hemicolectomy
Colorectal cancer treatment: distal transverse or descending colon
left hemicolectomy
Colorectal cancer treatment: sigmoid colon
high anterior resection
Colorectal cancer treatment: upper rectum
low anterior resection
Colorectal cancer treatment: anal verge
abdominal- perineal excision of the rectum
Crohns treatment overview: inducing remission
first line: Glucocorticoid (Prednisolone or IV hydrocortisone)
Crohns treatment overview: maintaining remission
first line: Azathioprine (inhibits purine synthesis)
second line: methotrexate
UC treatment overview : inducting remission
Mid-mod disease
- first line: Mesalazine oral/ PR (aminosaliylate)
- second line: corticosteroids e.g. prednisolone
Severe disease
- first line: IV corticosteroid (hydrocortisone)
- second line: IV ciclosporin (inhibits the transcription of interleukin 2)
UC treatment overview : maintaining remission
Mesalazine (5-ASA)
medication following renal transplant
Induction treatment in transplantation
- Methylprednisolone with any of the following:
- Basiliximab
- Thymoglobulin
Maintenance treatment in transplantation
- Tacrolimus
- Mycophenolate
- Prednisolone
Outline epidural
- Catheter inserted into the epidural space in the lower back.
- This is outside the dura mater, separate from the spinal cord and CSF.
- Local anaesthetic medications are infused through the catheter into the epidural space, where they diffuse to the surrounding tissues and through to the spinal cord, where they have an analgesic effect.
Levobupivacaine is often used, with or without fentanyl.
which layers must be passed during epidural
- skin
- fat
- supraspinous
- interspinous
- ligamentum flavum
injected into the epidural space (not past the dura which surrounds the spinal cord)
where to do epidural
L3/L4
child presents with broken wrist
PMH: 2 wrist fractures, hearing loss, short stature
diagnose
Osteogenesis imperfecta
- may also have blue sclera
signs of osteomyelitis on X-ray
- periosteal reaction
- focal cortical loss
- regional osteopenia
*
A 46 year old male presents with a two month history of arm pain. He was involved in a fall 3 months ago, which led to him needing an open reduction and internal fixation of his right arm. He presents with severe, burning pain and paraesthesia of the right upper limb. On examination, light touch causes him to cry out in pain, and the right arm is red.
What is the most likely diagnosis of this patient?
complex regional pain syndrome
tennis elbow
lateral epicondylitis
- pain on resisted extension
golfers elbow
medial epicondylitis
pain on resisted flexion
diagnose
green stick fracture of the mid ulnar and radius
A 64-year-old gentleman has suffered from debilitating arthritis of his left hip for over five years and finally undergoes a total hip replacement. However, whilst undergoing physiotherapy a week later, he feels a sharp pain whilst stepping on the affected leg and can no longer weight-bear.
On examination, his left leg is adducted, shortened and internally rotated.
What is the most-likely diagnosis?
Posterior hip dislocation
which movement is decreased in carpal tunnel syndrome
grip strength- wasting of thenar muscle
evidence of high pressure renal obstruction
hydronephrosis
action of tetanus toxin
blocks neurotransmitter relase from spinal inhibitory neurones
lignocaine same as
lidocaine
when is lignocaine used
nerve block e.g. ring block
when is bupivicaine used
epidural
