Surgical Specialties Flashcards
Pelvic floor exercises better for which type of incontinence?
Stress incontinence
First line medication for urge incontinence
Oxybutynin
Tolteridone
Mirabegron
Which type of incontinence is due to overactive detrusor muscle?
Urge incontinence
Which medication can be used in stress incontinence?
Duloxetine
If conservative management for removal of kidney stone fails, which surgery is most likely?
Shock wave lithotripsy
- breaks stones into smaller pieces so that they can be passed
Detrusor overactivity is diagnosed by which investigation?
Urodynamics
Which type of incontinence is due to damage to the pelvic floor or urethral function?
Stress incontinence
Stress / urge incontinence has a better role for pharmacotherapy?
Urge incontinence
Mainstay of treatment for stress incontinence?
Pelvic floor exercises
First line treatment for urge incontinence
Bladder retraining (6 weeks)
First line treatment for stress incontinence
Pelvic floor exercises (3 months)
Who should not get oxybutynin?
Frail elderly women
Ring pessaries are used as non surgical management for?
Pelvic organ prolapse
Anti-muscarinic drugs and side effects
Oxybutynin, tolteridone
SE: anti-cholinergic (dry mouth, constipation)
When are urodynamics needed?
When there is diagnostic uncertainty
When there are plans for surgery
Sympathetics dilate/constrict the pupil
Dilate
Parasympathetics dilate/constrict the pupil
Constrict
Fixed pin point pupil makes you think
Opioid toxicity
Fixed dilated pupil makes you think pathology of which CN?
CN III
Blink reflex
- afferent arm
- efferent arm
Afferent arm : CNV1
Efferent arm : CNVII
Pupillary light reflex
- afferent arm
- efferent arm
Afferent arm : CN II
Efferent arm : CN III (constriction bilaterally)
Lacrimal gland is under sympathetic/parasympathetic control and is supplied by which CN ?
Parasympathetic
CN VII
Eye in “down and out” position. Which CN is most likely to be affected?
CN III
Blurred vision when going down stairs (looking down) and double vision. Which CN is most likely to be affected?
CN IV
How do you measure intra ocular pressure?
Tanometry
- measures how much force is required to indent into a patients eye?
- patient given LA
What produces aqueous humour?
Cilliary body
if you hear “arcuate scotoma” where is the pathology?
Retina
If you have a process where you’re losing ganglion cells in the eye, you will notice the effects in the periphery/middle first?
Periphery
An enlarging cup:disc ratio is a buzzword for which ophthalmology condition?
What does it actually mean?
Glaucoma
- raised IOP causes ganglion cells around the optic nerve to die –> as they die, see fewer of them -> get a larger cup
Increased risk of open angle glaucoma if you are short / long sighted?
Short sighted
Name 5 types of medication for glaucoma
Prostaglandin analogues Beta blockers Carbonic anhydrase inhibitors (acetazolomide) Parasympathomimetics (pilocarpine) sympathomimetics (adrenaline, alphagan)
Name the 2 types of medication for glaucoma which ‘turn off the tap’ i.e. reduce aqueous humour production
Beta blockers
carbonic anhydrase inhibitors
Carbonic anhydrase inhibitors - which preparation is better: oral tablet or topical drops?
Oral tablet more effective
First line medication type for glaucoma
Prostaglandin analogues
Usual order of treatment for glaucoma
1) prostaglandin analogues
2) + B-blocker / carbonic anhydrase inhibitor
3) + B-blocker + carbonic anhydrase inhibitor
4) laser surgery?
5) sympathomimetic or parasympathomimetic
6) surgery (trabeculectomy)
Increased risk of ACUTE closed angle glaucoma if you are short sighted / long sighted?
Long sighted
What presents more in the emergency setting
- open angle glaucoma
- closed angle glaucoma
Closed angle glaucoma
Thumping headache, sick, really unwell, visual loss, often red eye. Gets CT scan everything normal. Someone looks in eye - find abnormality. What is likely diagnosis
Acute angle closure glaucoma
Management of acute angle closure glaucoma
1) decrease IOP medically with IV acetazolomide (carbonic anhydrase inhibitor)
2) peripheral iridotomy (stop it from happening again)
What is the most worrying acute cause of raised intra ocular pressure
Acute angle closure glaucoma
treatment of bacterial conjunctivitis
Topical chloramphenicol
Bacterial / viral conjunctivitis is associated with tender pre-auricular lymph nodes?
Viral
Unilateral folicular conjunctivitis in a young patient. What do you need to consider?
Chlamydial conjunctivitis
Bacterial corneal ulcer (keratitis) investigation of choice
Corneal scrape
First line management of bacterial kertatitis
Ofloxacin (hourly drops)
Why should you be cautious of using steroids in patient with red eye?
If the cause is herpetic keratitis and the patient has a dendritic ulcer, steroids will cause geographical ulcer making it much harder to treat
Which is more common: episcleritis or scleritis
Episcleritis
Which is more serious: episcleritis or scleritis
Scleritis
Red eye (limbus) Acute onset Dull achey pain Vision may be reduced Photophobia Hypopyon What do these symptoms make you think of?
Anterior uveitis
Cloudy cornea Red eye Fixed mid dilated pupil Significantly reduced visual acuity. Makes you think?
Acute angle closure glaucoma
How does aqueous humour normally drain away?
Through the trabecular meshwork
Emergency first line management of acute angle closure glaucoma
IV acetazolamide - to reduce the IOP
What does pilocarpine do to the pupil?
Shrinks the pupil
Surgical treatment for closed angle glaucoma
Peripheral iridotomy
Myopia - short sighted or long sighted
Short sighted
High myopia can increase risk of what condition?
Retinal detachment
High hypermetropia can increase risk of what condition?
Acute angle closure glaucoma
What carries 2/3rds of the ability to focus in the eye?
Lens
What is the commonest cause of blindness in the elderly population?
ARMD
Patient with gradual decrease in central visual acuity and then one day wakes up with sudden dramatic decrease in visual acuity. What is the likely diagnosis?
Dry ARMD –> wet ARMD
Describe the pathogenesis of wet ARMD
New blood vessels created to ‘repair’ the damage made by dry ARMD.
These blood vessels leak fluid / blood into the retinal tissue
Cause sudden sharp decrease in central visual acuity
What is the best way to diagnose or monitor ARMD
OCT scan
Tenting of the retinal pigment epithelium on OCT suggests
wet ARMD
What is the best investigation to confirm the diagnosis of wet ARMD
fluorescene angiography
Management of wet ARMD
Anti VEGF injection
- inhibits the growth of new vessels -> decreased leakage
Name 4 causes of gradual visual loss
Cataracts
ARMD
Diabetic retinopathy
Open angle glaucoma
Name 5 causes of PAINLESS sudden visual loss
Central retinal artery occlusion Central retinal vein occlusion Amaurosis fugax Retinal detachment Vitreous haemorrhage
Name 3 causes of PAINFUL sudden visual loss
Acute angle closure glaucoma
Optic neuritis
Giant cell arteritis
TIA in the eye
Amaurosis fugax
Pale swollen retina with cherry red spot at macula
Central retinal artery occlusion
Sudden profound visual loss + temporal headache, scalp tenderness, jaw claudication what do you think?
Giant cell arteritis
Treatment of GCA
Long term steroids
Paper bag breathing causes increased/decreased pCO2 and therefore vasodilation/vasoconstriction of the arteries
Increased pCO2
Vasodilation
Management of CRAO
If presents within 12-24 hours
- occular massage (push to a branch)
- paper bag breathing
- IV acetazolamide
Which visual loss is more severe? CRAO or CRVO ?
CRAO
Stormy sunset
Cotton wool spots
Dilated torturous veins
What do you think
CRVO
What is a cotton wool spot
Ischaemia of the retinal nerve fibre layer
Sudden onset of flashing lights in the periphery
Burst of new floaters
Dark shadow in peripheral vision, increasing in size
makes you think
Retinal detachment
Which features of examination do you focus on when assessing optic nerve function
Visual acuity
Visual fields
Colour vision
Pupil responses - RAPD (swinging light reflex)
Unilateral optic disc swelling - what condition are you thinking about
OPtic neuritis
Bilateral optic disc swelling - what condition are you thinking about
Papilloedema
MS and which ophthalmic condition go hand in hand
Optic neuritis
Patient with optic neuritis, female, young. What investigation should you consider?
MRI
Sudden unilateral loss in vision over period of a few days, dull ache pain on eye movements, decreased colour vision in affected eye
optic neuritis
Bilateral optic disc swelling and raised ICP. What is first investigation and what are you looking for
MRI / CT scan to identify if there is a space occupying lesion
Bilateral optic disc swelling and raised ICP. Ix done but no space occupying lesion found…what could be the diagnosis now and what Ix should you do?
Idiopathic intracranial hypertension
Ix - Lumbar puncture
Lesion at optic nerve would do what to vision?
Unilateral visual loss (on same side as optic nerve damage)
Lesion at optic chiasm would do what to vision?
Bitemporal hemianopia
Lesion at optic tract / radiation would do what to vision?
Homonymous hemianopia
Lesion at visual cortex would do what to vision?
Cortical blindness, macula sparing
Mild ptosis (eyelid droop) Constricted pupil which does not dilate Reduced ipsilateral sweating
Horners Syndrome
Patient with double vision -> cover one eye and double vision disappears. This is monocular/binocular diplopia?
Binocular
Patient with double vision -> cover one eye and double vision remains indicates
Problem with that eye
- ie corneal problem or cataract
Monocular/binocular diplopia is seen with problems with eye movement (ie CN pathology)
Binocular diplopia
CN III palsy clinical findings (3)
Dilated pupil
Ptosis (eyelid droop)
Eye looks down and out
Patient with sudden loss of vision. What is it important to exclude?
GCA
Goinoscopy is used for
Glaucoma
What is the leading cause of blindness in working age people?
Diabetic retinopathy
What is the management of proliferative retinopathy
Later treatment (pan-retino-photocoagulation) ablate peripheral retina to preserve the central
A child’s visual system is constantly developing from birth until the age of
6
What is amblyopia?
Reduced vision usually in one eye due to a degraded retinal period so the brain doesn’t develop the binocular visual pathways
essentially a lazy eye
Causes of amblyopia?
Squint
Unequal refractive errors
Obstruction to visual axis: cataract, ptosis
How do you treat amblyopia?
Cover the good eye
Patch
Long sighted (hypermetropic) people have a tendency for eyes to point inwards/outwards?
Inwards
4 year old boy presents with 1 week Hx convergent squint and vomiting ++. What are you worried about?
Raised intra cranial pressure
Which CN palsy (3,4, or 6) makes you most worried about raised intra cranial pressure?
CN 6 palsy (esp if bilateral)
Patient with ?papilloedema - bilateral CN VI palsy - vomiting - swollen optic discs What is your investigation of choice?
Urgent CT
- look for dilated ventricles
Why should infant with no red reflex be referred urgently?
?retinoblastoma
Retinoblastoma is most common eye cancer in childhood. True or false?
True
What would an iris coloboma look like?
Think madelline mccann
Area of iris is missing
Key hole defect
Absent red reflex but instead a yellow reflex completely filling the pupil. What does this make you think of?
Retinoblastoma
14 month toddler, normal visual development up until 12 months, then stopped walking and was becoming more distressed, couldn’t see food on plate. What does this make you think?
Congenital cataract
What are the 2 main causes of sticky eyes in infancy?
Ophthalmia neonatorum (conjunctivitis occurring in first 28 days from birth)
Blocked nasolacrimal duct
Commonest cause of ophthalmia neonatorum
Picked up from maternal STI when passing through the birth canal
- gonococcal cause presents quickest
- chlamydial cause presents 2 weeks post birth
Management of ophthalmia neonatorum
Swabs
Azithromycin
Contact tracing for mother
Sticky + watery + white uninflammed eye from 2 months. What is likely diagnosis?
Blocked nasolacrimal duct
What investigation is done if ?blocked nasolacrimal duct?
Fluorescene dye
- should be seen in nostrils
- confirms diagnosis if the dye is picked up around the eye
Management of blocked nasolacrimal duct
DO nothing
- resist prescribing topical antibiotics
How are most convergent squints treated
Glasses
What is the likely diagnosis in a 21 year old male, with a longstanding female partner who presents with conjunctivitis and urethritis?
How would you treat this patient?
Reiters syndrome likely
antibiotics
How do you treat amblyopia if patient doesn’t tolerate patch?
Atropine 1% in good eye
Latent squint always affects both eyes. True or false?
True
Management of paediatric squint
Maximise visual acuity
- correct refractive error
- treat amblyopia
THEN surgery if required
flexible/rigid uteroscope is used to get stones from the kidney?
Flexible - so it can move into the calyces
Flexible/rigid uteroscope is used to get stones from the ureter?
Rigid
What is cystoscopy used for?
Follow up bladder cancer
Investigate ?bladder cancer
Name some LUTS
Voiding AND Storage
Voiding
- difficulty initiating
- poor stream
- post micturation dribble
Storage
- frequency
- urgency
- nocturia
Patient with white patches where foreskin usually contracts and bleeding. What is the likely diagnosis and management?
Diagnosis: balantitis xerotica obliterans
Management: Circumcision
BPH usually occurs in which zone of prostate?
Transitional zone (central)
Elderly male patient with LUTS. What examination do you do?
PR exam
Name 2 medications used to manage BPH (and their MOA)
Tamsulosin (alpha blocker - better flow)
Finasteride (5-alpha reductase inhibitor - shrinks prostate)
Which surgical procedure is carried out for BPH
TURP
Name 2 possible complications of BPH
Acute urinary retention
UTI
Name 2 risk factors for bladder cancer
Dye/chemical exposure, smoking
Painless frank haematuria. No other symptoms. What are you worried about?
Bladder cancer
In which region of the bladder does bladder cancer usually occur?
Trigone
Patient with painless haematuria. Which investigations do you want to carry out?
Urinalysis
Bloods
Flexible cystoscopy
CT urogram
Patient with painless haematuria. Flexible cystoscopy reveals an area which is potentially malignant. What do you do?
Rigid cystoscopy + biopsy
Management of bladder cancer (including follow up) in LOW risk patients
Transurethral bladder resection
Follow up with cystoscopy for ?3 years
Management of bladder cancer (including follow up) in HIGH risk patients
Transurethral bladder resection
Follow up with cystoscopy for 10 years
BCG injection
Which Vaccination helps reduce the recurrence of bladder cancer?
BCG
Management of bladder cancer if patient is not fit for surgery
external beam radiotherapy
Bladder cancer has a HIGH/LOW recurrence rate?
High
Which zone of prostate is it most common to get prostate cancer?
Peripheral zone
LUTS, haematospermia, weight loss, bone pain makes you think
Prostate cancer (advanced)
Suspect prostate cancer, which examination is done?
PR exam
- hard, craggy, irregular mass
Patient with ?prostate cancer, which investigations are valuable?
PSA
Trans rectal US guided prostate biopsy
PSA is a good diagnostic test. True or false?
False
- but it is good for monitoring
Scoring system used for prostate cancer (and breakdown)
Gleason score
- score < 6 - low risk
- score 6-7 - intermediate risk
- score 8-10 - high risk
Treatment of low risk prostate cancer
radical prostatectomy + radical radiotherapy
Treatment of intermediate risk prostate cancer
Radical prostatectomy + external beam radiotherapy + hormone therapy (LHRH agonist)
Penile cancer - common in young/elderly males?
Elderly
Elderly male with phimosis, raised red area of penis, red velvety patches on glans of penis. What is the likely diagnosis?
Penile cancer (SCC)
What is the investigation of choice for penile cancer
US
Testicular cancer - common in young/elderly male?
Young
What are the 2 broad categories of testicular tumours
Seminoma
Non-seminoma (yolk sac, teratoma)
Testicular tumour with solid homogenous pale macroscopic appearance
Seminoma
Which is more likely to spread: seminoma / non-seminoma?
Non-seminoma
Investigation of choice for ?testicular cancer?
US
Which tumour marker is raised in non-seminoma but NOT seminoma? PLAP B-HCG AFP LDH
AFP
Which tumour marker is raised in yolk sac tumours (non-seminoma) ? PLAP B-HCG AFP LDH
AFP
Which lymph nodes to testicular tumours typically spread to
Para aortic / aortocaval
Which is more RADIOsensitive: seminoma / non-seminoma
Seminoma
Which is more CHEMOsensitive: seminoma / non-seminoma
Non-seminoma
Define hydronephrosis
Back pressure of urine into the kidneys due to dilatation of ureters
- urine back pressure into the calyces compresses the nephrons within the medullary pyramids resulting in renal failure
Management of hydronephrosis?
Nephrostomy
Patient develops AKI after treatment of hypertension. What is the most likely diagnosis?
Renal artery stenosis
What is the management of acute urinary retention?
Catheterise
Foetus with small break in nose, low lying ears, regressing jaw. What is the likely diagnosis?
Potter’s syndrome
Name 5 causes of frank haematuria
Tumours (Bladder cancer, renal cell cancer, prostate cancer) Infection Stones Trauma Polycystic kidneys
What are the 2 best investigations to investigate frank haematuria
Flexible cystoscopy
CT urogram
Which medications (3) can look like patient is having haematuria
Nitrofurantoin
Anticoagulation
Rifampicin
Blood clots in urine
- long and worm like VS shapeless
Long and worm like - think upper urinary tract
shapeless - think lower urinary tract
What is the first line investigation if there is frank haematuria in over 50 year olds?
CT urogram
