surgical exam Qs i get wrong Flashcards
A 78-year-old man complains of a long history of shoulder pain and more recently weakness. On examination active attempts at abduction are impaired. Passive movements are normal.
Rotator cuff tears- common in elderly, may occur after minor trauma or long standing impingement
A 63-year-old lady undergoes an axillary clearance for breast cancer. She makes steady progress. However, 8 weeks post operatively she still suffers from severe shoulder pain. On examination she has reduced active movements in all planes and loss of passive external rotation.
Adhesive capsulitis- initial painful stage folloed by joint stiffness
Carpal tunnel syndrome- hx
pain/pins and needles in thumb, index, middle finger
unusually the symptoms may ‘ascend’ proximally
patient shakes his hand to obtain relief, classically at night
Carpal tunnel syndrome- examination
weakness of thumb abduction (abductor pollicis brevis)
wasting of thenar eminence (NOT hypothenar)
Tinel’s sign: tapping causes paraesthesia
Phalen’s sign: flexion of wrist causes symptoms
What infection are pts with rib fracture prone to & why? How to prevent this?
Patients with rib fractures can find their deep breathing limited by pain. This causes susceptibility to chest infections as they cannot cough adequately to clear secretions.
Adequate analgesia is vital in rib fractures to ensure breathing is not affected by pain; inadequate ventilation may predispose to chest infections
Chest physiotherapy with breathing exercises helps
Iliopsoas abscess most common causative organism
Staph aureus
Initial imaging for Achilles tendon rupture?
USS
What is morton’s neuroma?
Benign neuroma affecting intermetatarsal plantar nerve
Commonly 3rd inter-metatarsophalangeal space
More common females
Forefoot pain
worse on walking
shooting or burning
Lateral knee pain in runners, no trauma…
Iliotibial band syndrome
Most common site of stress fractures
2nd metatarsal- longest metatarsal bone, thin and vulnerable to stress fracturesq
Adhesive capsulitis- which movement is classically impaired
External rotation
Fat embolism- triad of symptoms
Respiratory
Neurological
petechial rash (after the first two)
Signs of fluid depletion
- Dry mucous membranes and reduced skin turgor
- Decreasing urine output (should target >0.5 ml/kg/hr)
- Orthostatic hypotension
In worsening stages:
- Increased capillary refill time
- Tachycardia
- Low blood pressure
Signs of fluid overload
- Raised JVP
- Peripheral or sacral oedema
- Pulmonary oedema
Ix when there’s fluid problems in a pt
Fluid input/output chart
Daily weight chart
U&Es - dehydration, renal hypoperfusion, electrolyte abnormalities
NICE daily requirements
Water: 25 mL/kg/day
Na+: 1.0 mmol/kg/day
K+: 1.0 mmol/kg/day
Glucose: 50g/day
Gold standard diagnosis osteomyelitis
Bone biopsy at debridement
Which movements are most affected in frozen shoulder
All active and passive movements
external rotation more than internal rotation or abduction
What happens if u give anticoagulation in compartment syndrome
Worsens it
Red, hot swollen joint in diabetic patient- what you considering?
Charcot’s foot
Treatment for Dupuytren’s contracture
Consider surgery when pt cannot lay hand flat on table- metacarpophalangeal joints can’t be straightened
Other mx options include injectable enzyme therapy
Causes of Dupuytren’s contracture
manual labour phenytoin treatment alcoholic liver disease diabetes mellitus trauma to the hand
What is epicondylitis
Epicondylitis is caused by repeated strain leading to inflammation of the common extensor tendon at the epicondyle.
Golfers- medial epicondyle- pain on resisted pronation
Tennis- lateral epicondyle- pain on resisted wrist extension
First line ix for suspected osteoporotic vertebral fracture
X-ray of whole spine
How to diagnose De Quervains tenosynovitis
Clinical diagnosis
Finkelstein’s test: the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus
Mx undisplaced scaphoid fracture
Cast 6-8 weeks
Groin lump differentials
Hernia Saphena varix Femoral artery aneurysm Lymphaedenopathy Lipoma
Scrotal lump differentials
Hydrocoele Varicocoele Epididymal cyst Epididymitis Testicular tumour- malignant or benign Testicular torsion Inguinal hernia
Foot drop- causes
Weakness of foot dorsiflexors
Possible causes- common peroneal nerve lesion (most common)- often compression @ neck of fibula
L5 radiculopathy
Sciatic nerve lesion
Superficial or deep pernoeal nerve lesion
CNS lesions (with other features)- stroke
Mx of foot drop
Conservative if due to peroneal nerve
Avoid crossing legs, squatting, kneeling
~2-3mnths to heal
Sensory supply of anterolateral thigh
Lateral femoral cutaneous nerve (lateral cutaneous nerve of thigh)
Nerve roots L2,L3
Sensory function of obturator nerve
Middle part of medial thigh
Femoral nerve divisions + sensory functions
Anterior- anterior cutaneous branches- anteromedial and posteromedial thigh
Posterior- saphenous nerve -skin of medial leg and foot
and branches to quad fem
What supplies the posterior thigh
Posterior cutaneous nerve of the thigh/ posterior femoral cutaneous nerve
Extends to posterior leg, about 1/3 the way
Sensory supply posterolateral leg
Sural nerve (from tibial and common fib) Also supplies lateral foot
What muscles make up the Achilles tendon
Gastrocnemius
Soleus
Plantaris
Following radiotherapy for prostate cancer, what can pts develop
Patients are at increased risk of bladder, colon, and rectal cancer following radiotherapy for prostate cancer
Analgesia in acute mx of renal colic
IM diclofenac
First line ix in suspected prostate cancer
Multiparametric MRI
First line ix of testicular mass
USS
Gold standard ix renal stones
non contrast CT KUB
Criteria for inpatient admission for renal stones
Post-obstructive acute kidney injury
Uncontrollable pain from simple analgesics
Evidence of an infected stone(s)
Large stones (>5mm)
Renal calculi mx- obstructed, or infected
Stent insertion-
Retrograde stent insertion, via ureter
Or percutaenous nephrostomy is a tube into renal pelvis (antegrade stent)
When to consider extra corporeal shock wave lithotripsy in renal stones mx
<2cm
If impacted in upper ureter may consider ureteroscopy
Staghorn calculus mx
Large, proximal stones- percutaneous nephrolithototomy
Complications of TURP
TURP syndrome (hypoNa, fluid overload, glycine toxicity)
Urethral stricture/ UTI
Retrograde ejac
Prostate perforation
Schistosoma infection is closely linked to risk of developing what cancer
squamous cell carcinoma bladder
How long to delay a PSA test after prostatitis
1 month
Periureteric fat stranding indicates what…
Recent stone passage if no ureteric calculus passage
Ix for erectile dysfunction
10yr CVS risk (lipid and fasting glucose serum levels)
Free testosterone in the morning between9 and 11
If low or borderline, repeat with FSH, LH and prolactin. If abnormal, endo referral
Which artery is compromised in scaphoid fracture
Dorsal carpal branch radial artery
Causes of hip AVN
long-term steroid use
chemotherapy
alcohol excess
trauma
How does cauda equina present (early and late signs)
Cauda equina syndrome classically presents with lower back pain, sciatica, reduced perianal sensation. Late signs include urinary incontinence
Suspected psoas abscess- imaging?
CT scan
Compartment syndrome is commonly associated with which fractures?
Supracondular
TIbial
Symptoms of compartment syndrome
Pain, especially on movement (even passive)
excessive use of breakthrough analgesia should raise suspicion for compartment syndrome
Parasthesiae
Pallor may be present
Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise
Paralysis of the muscle group may occur
Will X-ray help with compartment syndrome diagnosis?
No
What is bennetts fracture
Intra-articular fracture of the first carpometacarpal joint
Impact on flexed metacarpal, caused by fist fights
X-ray: triangular fragment at ulnar base of metacarpal
What is potts fracture
Bimalleolar ankle fracture
Forced foot eversion
What is cubital tunnel syndrome
Cubital tunnel syndrome is caused by compression of the ulnar nerve @ elbow
and can present with tingling/numbness of the 4th and 5th finger
Undisplaced patella fracture mx
Conservative- brace or cast
Subluxation of radial head (pulled elbow) mx
analgesia and passively supination of the elbow joint whilst the elbow is flexed to 90 degrees
Which movement is most affected in frozen shoulder
External Rotation
Clinical features of acute limb ischaemia
6 Ps
pale, pulseless, perishingly cold, paraesthesia, paralysis, pain
Gold standard ix for acute limb ischaemia
CT angiography
Acute PR bleeds, haemodynamically stable, mx?
Supportive mx
Most common cause of small bowel obstruction
Adhesions
What is angiodysplasia
Features- rectal bleeding and anaemia
Most common vascular abnormality of GIT
Responsible for 6% lower GI bleeding and up to 8% upper GI bleed
Causes of serum amlyase rise
Infections- mumps
Intra-abdominal pathology- peptic ulcer or bowel perforation, intestinal obstruction, pancreatitis
Drugs- morphine
Renal failure
Which artery is at risk with duodenal ulcers
Gastroduodenal artery
Imaging for fistula in ano
MRI to see its course
Congenital hernias mx
inguinal: repair ASAP
umbilical: manage conservatively
