Vascular, Breast & Thyroid Surgery

Question 1

Surgical sieve

Answer 1

Vasc

Inf

Trauma

AI

Metabolic

Idiopathic/iatrogenic

Neoplasia

Congenital

Degenerative/drugs

Question 2

General inspection signs & assoc Dx

Answer 2

Question 3

Vascular legs DDx?

Answer 3

Question 4

Acute limb ischaemia - Def? Presentation? Ix? Mx?

Answer 4

• Def: a sudden decrease in limb perfusion that threatens the viability of limb
  
  • AF = major RF for acute limb ischemia
• Presentation - 6Ps:
  
  • Pale
  • Pulseless
  • Painful
  • Perishingly cold
  • NOTE: need immediate vascularisation (<6hrs) if:
    
    • Paralysis
    • Paraesthesia (esp worrying)
• Ix (after initial Mx):
  
  • Bedside: ABPI (PAD), ECG (AF)
  • Bloods: FBC, U&E, clotting, HbA1c, lipid profile
  • Imaging: duplex USS, CT/MR angiography
• Mx:
  
  • Initial:
    
    • A-E, IV access, analgesia
    • IV heparin infusion - reduces the chance of the clot getting worse
  • Limb viability:
    
    • Immediate - tender muscles, loss of power, loss of sensation
    • Urgent - pale, pulseless, painful, cold
    • Irreversible - fixed, mottled skin, woody, hard muscles
  • Refer to vascular surgery:
    
    • Thrombotic - local intra-arterial thrombolysis, angioplasty, bypass
    • Embolic - embolectomy/local intra-arterial thrombolysis/bypass

Question 5

Peripheral vascular (arterial) disease - Def? RFs? Spectrum? Ix? Special test?

Answer 5

Def: limb ischemia (chronic) from atherosclerosis in lower limb vasculature

RFs: male, older, smoker, HTN, DM

Spectrum:

• Intermittent claudication (mild) - cramping leg pain after walking (& have to stop) + relieved by rest
  
  • NOTE: the equivalent of stable angina (worse on exertion)
  • Worse going uphill/upstairs
• Critical limb ischemia (severe) - ulcers, gangrene, night pain & rest pain
  
  • ​NOTE: the equivalent of unstable angina (present at rest)

Ix:

• Bedside:
  
  • Exam special test = Buerger’s angle - elevation pallor –> sudden drop feet down = sunset sign
  • exercise-treadmill ABPI (ankle-brachial pressure index) - <0.8 (<0.3 = CLI)
• Bloods - FBC, U&E, LFTs, CRP, clotting
• Imaging:
  
  • Arterial duplex USS
  • CT/MR angiography

Mx: dealt with by vascular surgeons –> optimise meds + surgery (bypass)

• Conservative: smoking cessation
• Medical: ACEi, clopidogrel, statin, DM control
• Surgery: angioplasty/stent/bypass graft/amputation

Question 6

Arterial vs venous insufficiency in legs signs

Answer 6

Question 7

Peripheral vascular disease localisation & type of bypass graft?

Answer 7

• Both sides all reduced pulse = aorta-iliac –> aorto-bifemoral
• One side reduced pulse from the popliteal down = femoro-popliteal
• One side reduced pulse distally in anterior tibial = femoro-distal
• One side reduced pulse distally in posterior tibial = femoro-distal

Question 8

PAD Mx?

Answer 8

Conservative: smoking cessation

Medical: ACEi, clopidogrel, statin, DM control

Surgery: angioplasty/stent/bypass graft/amputation

Question 9

Neck lump DDx?

What can I add to a differential for a neck lump (or a lump anywhere else) if stuck?

Non-functional thyroid nodule Ix?

Answer 9

Neck lump ddx:

• GOITRE –> midline, firm, thyroid status
• LNs –> reactive/malignant
• Thyroglossal cyst –> midline, moves with tongue
• Branchial cyst –> fluctuant, anterior triangle

Everywhere lumps = sebaceous cysts, lipoma or lymphadenopathy

US of neck ± FNA

Question 10

Graves’ Mx?

Answer 10

Question 11

Thyroid neck exam process? Goitre complications? Further Ix?

Answer 11

Thyroid status exam:

• Hands - hands out straight
  
  • Hyperthyroidism - sweating, onycholysis, palmar erythema, peripheral tremor, thyroid acropatchy (looks like clubbing, only in Graves’)
  • Hypothyroidism - thin/dry skin
• Arms - pulse (rate, rhythm - low HR in hypo; high HR in hyper; AF in hyper)
  
  • Pemberton’s sign - hands above head (SVC obstruction)
• Face:
  
  • Inspection:
    
    • Hyperthyroidism - sweating
    • Hypothyroidism - outer 1/3 eyebrow loss, dry skin
  • Eyes - in thyrotoxicosis (e.g. Graves):
    
    • Look at eyes from front, side & above:
      
      • Lid retraction
      • Exophthalmos (proptosis)
      • Eye inflammation
    • H-test (head still):
      
      • ​Diplopia & pain during eye mov
      • Hold finger high and bring down –> Lid lag (upper lid does not move down with downgaze)
  • Neck:
    
    • Lymph nodes assessment - for LN mets
    • Tracheal deviation (in large goitre)
  • Thyroid:
    
    • Inspect neck from front & side (goitre, prev thyroidectomy scar):
      
      • Swallow water:
        
        • Thyroid & thyroglossal cysts move up
        • LNs move little
        • Invasive thyroid malignancy may not move if tethered to underlying tissue
      • Stick out tongue:
        
        • Thyroglossal cysts move up
        • All others stay still
    • Palpation:
      
      • Stand behind and place 3 fingers of each hand along the middle neck - locate thyroid cartilage (adam’s apple) and then cricoid cartilage - below this is the thyroid - feel the isthmus in the middle & lobes on either side
      • Swallow water while palpating - if not symmetrical elevation = unilateral mass
      • Stick out tongue while palpating - if thyroglossal cyst will rise
      • NOTE:
        
        • Size
        • Symmetry
        • Consistency
        • Masses (position, shape, mobility, consistency)
        • Palpable thrill (increased vascularity in Graves)
    • Percussion from sternal notch - retroperitoneal extension
    • Auscultate thyroid with bell - bruit (increased vascularity in Graves
  • Further tests:
    
    • Knee jerk reflex (hyporeflexia in hypothyroidism)
    • Pretibial myxoedema (waxy induration of skin on anterior lower leg) - Graves
    • Proximal myopathy (hands crossed over chest, stand up) - multinodular goitre/Graves

Local goitre complications:

• SVC obstruction
• Dysphagia, upper airway obstruction
• Recurrent laryngeal nerve compression (hoarse)

Further Ix:

• Bedside: ECG - AF
• Bloods: TFTs
• Imaging: thyroid USS
• Invasive: thyroid biopsy - FNA

Question 12

Diabetic foot - what are they secondary to? presentation? How to identify neuropathic ulcer? Mx?

Answer 12

Secondary to: PVD, small vessel disease, neuropathy, infection

Presentation:

• Callus, deep ulcers
• Single toe amputation due to osteomyelitis
• ± features of peripheral vascular disease
• Finger marks from BM monitoring
• Lipoatrophy/lipohypertrophy from insulin injection sites

Neuropathic ulcer = insensate + punched out

Question 13

Chronic venous insufficiency & varicose veins - presentation? Ix? Mx? Complications of varicose veins?

Answer 13

Presentation:

• Oedema, haemosiderin deposition, lipodermatosclerosis (inverted-champagne bottle), eczema, venous ulcers
• Varicose veins - dilated tortuous, superficial veins
  
  • Pain, swelling, itching, restless legs, cramps
  • Feel for thrombosis (hard = thrombophlebitis)
  • Cough impulse at SFJ (for Saphena Varix - dilation of saphenous vein @junction w/ femoral vein)
  • Trendelenburg test
    
    • Lying flat, lift up leg & empty veins
    • Compression over SFJ –> stand up (maintain pressure) - if do not fill = competent valves below SFJ
    • If do fill = incompetent valves below SFJ (blood flow from deep to superficial vein via perforating veins)
    • Repeat with pressure lower down until filling stops
  • Perthe’s test - apply tourniquet to mid-thigh + walk for 5-mins –> compresses superficial vein
    
    • Less distended - normal deep veins as calf compression pushes blood into deep venous system
    • Remain distended - impaired deep veins
  • Doppler US for reflux
• Warfarin - previous DVT
• Abdo mass with compression

Ix: duplex USS (allow DVT to be ruled out)

Venous insufficiency Mx:

• ABPI > 0.8 –> Compression bandaging
• Varicose veins:
  
  • Conservative - weight loss, avoid standing for prolonged periods
  • Minimally invasive procedures - injection sclerotherapy, endovenous radiofrequency ablation
  • Surgical - vein ligation

Varicose Veins complications:

• thrombophlebitis - Tx for superficial: NSAIDs
• Eczema
• Bleeding
• Haemosiderin deposition
• Lipodermatosclerosis (champagne bottle)
• Ulceration

Question 14

Surgery - observations & assoc Dx

Answer 14

• Groin lump above inguinal ligament –> inguinal hernia
• Reduced pulses –> PVD
• Midline neck lump –> Graves’ disease, Multinodular goitre
• Abdominal scar + lump –> incisional hernia
• Toe amputation –> diabetic foot disease
• Oedematous legs –> venous insufficiency

Question 15

AAA key Sx & ruptured Sx? Ix? Mx?

Answer 15

Sx:

• Central abdo pain
• Radiates to back
• Bloating
• Pulsatile mass on palpation (expansile - moves to sides)
• NOTE: always consider if abdo pain + RFs (male, >65yrs, HTN, smoking etc.)

Ruptured AAA Sx:

• Severe pain radiating to back
• Visible pulsating abdo mass
• Shock (circulatory compromise)

Ix:

• Abdo duplex USS if part of national screening - male age 65yrs
• CT angiography if stable but suspicious of rupture

Mx:

• <5.5cm –> Conservative: monitor w/ USS + RF modification
  
  • <4.5cm –> yearly USS
  • 4.5≤x<5.5com –> 3 monthly USS
• Medical: optimise BP control, statin, aspirin
• Sx/>5.5cm/expanding >1cm/yr –> Surgical: endovascular (catheter into aorta to insert stent)/open repair

Question 16

Chest pain through to scapula & connective tissue disorder (e.g. Marfan’s) - Dx?

Answer 16

Aortic dissection

Question 17

Aneurysmal sac enlargement post-EVAR (endovascular aneurysm repair) - what should you think?

Answer 17

Endoleak

Question 18

IVC collapse/”Halo sign” on CT - what should you think?

Answer 18

Hypovolaemic shock

Question 19

How to calculate ABPI? ABPI value range?

Answer 19

• BP cuff above ankle with leads upwards – find dorsalis pedis pulse with doppler
• Inflate cuff until signal disappears – let down cuff until signal reappears = ankle pressure
• Repeat procedure in arm using brachial artery signal to record the brachial pressure
• ABPI = ankle pressure/brachial pressure

Range:

• 0.8-1 = normal
• 0.6-0.8 = claudication (may only drop to this with exercise)
• Below 0.6 = critical limb ischaemia

Question 20

Vascular exam - upper, abdo & lower? Arterial & venous anatomy?

Answer 20

NOTE: if press harder and it is there = my own pulse; if press weaker and it is there = their pulse

• If can’t feel pulses can use doppler USS: triphasic signal
  
  • 1st phase - forward rush of blood
  • 2nd phase - reverse flow from elastic recoil (in arterial wall)
    
    • Lost in arterial disease = biphasic/monophasic signal
  • 3rd phase - forward flow on vessel relaxing

EXAMINATION:

General inspection – smoking, inhalers, diabetic meds, fistula, dressings, walking stick

Upper:

• Hands – splinter haemorrhages, nicotine stains, missing digits (more common in trauma, Buerger’s disease), temperature + CRT
• Supra-aortic pulses:
  
  • Radial – rate, rhythm, radio-radial delay
  • Brachial pulse – character
  • Subclavian pulse, in supraclavicular fossa
  • Carotid pulse
• BP
• Listen for bruits in neck, breathe in and out slowly

Abdo:

• Inspect for scars, look around sides
• Palpate for aneurysms - abdominal aortic pulse
• Listen for aortic and renal bruits (above umbilicus and to either side)

Lower:

• Inspect (colour, swelling, scars, varicose veins)
• Palpate:
  
  • Temp in feet, calves, thighs (run back of hand along)
  • Tenderness - squeeze ankles/calves (DVT)
  • CRT, pitting oedema
  • Measure leg diameter 10cm below tibial tuberosity (If <3cm between = not significant)
• Femoral arteries (ASIS & pubic symphysis midpoint):
  
  • Feel simultaneously as weak femoral pulse difficult to determine
  • Radio-femoral delay
  • Auscultate femoral pulse for bruits (can also listen to iliacs - below umbilicus on either side) –> sometimes only picked up on exercise
• Popliteal arteries – reach around back of knee, behind the knee, slightly lateral, lift leg up to 30 degrees so weight resting on fingers
• Pedal arteries – anterior (dorsalis pedis) & posterior tibial (behind medial malleolus)
• BUERGER’S TEST (for peripheral vascular disease)
  
  • Both feet held up – angle foot goes white is Buerger’s angle –> when foot blanches swing legs over side of bed and let them hand down –> ischaemic foot will go brick red = severe peripheral vascular disease of lower limb = SUNSET SIGN
  • Ideally, I should hold feet for 1 minute but still say -ve test if no blanching
• ABPI:
  
  • BP cuff above ankle with leads upwards – find dorsalis pedis pulse with doppler USS
  • Inflate cuff until signal disappears – let down cuff until signal reappears = ankle pressure
  • Repeat procedure in arm using brachial artery signal to record the brachial pressure
  • ABPI = ankle pressure/brachial pressure
  • 0.5-0.8 = claudication (mild-moderate disease); <0.5 = rest pain (severe disease); <0.2 = gangrene

Finally - complete relevant neuro exam, vascular exam where not been done in exam, CV & abdo exams

• Bloods - FBC, U&E, coag
• D-dimer, duplex USS (venous - DVT/arterial - perfussion) –> CTPA (PE)
• Tx: DOAC/Warfarin if high-risk DVT

Leg Anatomy:

• Arterial:
  
  • External iliac artery > femoral artery (pulse):
    
    • Profunda artery (minor branch)
    • Superficial femora artery (main branch) > Popliteal artery (pulse):
      
      • Anterior tibial artery - form dorsalis pedis artery (pulse)
      • Posterior tibial artery - goes around medial malleolus (pulse)
        
        • Peroneal artery (branch of PTA)
• Venous:
  
  • Great-saphenous vein (medial) - meets deep femoral vein in medial upper thigh (as goes into groin)
  • Small-saphenous vein (lateral)
  • Connected via perforating vein

Question 21

Breast Diagnostics

Answer 21

Screening MMG

• ≥50yrs - 3yrly
• >40yrs - attending clinics

USS focused:

• <40yrs USS only
• ≥40yrs USS + MMG

Biopsy:

• all breast lumps in women >25yrs
• USS-guided

Question 22

Benign breast diseases - types? presentation? Dx? Mx?

Answer 22

Breast pain

• Presentation:
  
  • Benign breast pain, cyclic/non-cyclic (fibrocystic breast)
  • Other causes - inf, trauma (fat necrosis), haematoma (on anti-coag)
• Dx: nothing if no masses/concerning features on exam
• Mx:
  
  • Reassurance, supportive bra
  • Ibuprofen/voltarol gel
  • Evening primrose oil

Breast Cyst

• Presentation:
  
  • Sudden tender, small, smooth lump –> disappears after a period
  • Multiple w/ previous similar episodes
  • Younger
• Dx:
  
  • USS only <35ys; USS + MMG ≥35yrs
  • USS - fluid-filled, well-circumscribed collection
    
    • Disappears after aspiration, biopsy if solid posterior residual lesion
• Mx: USS-guided aspiration only if large + painful

Fibroadenoma - common benign breast tumours of both glandular and stromal tissue

• Presentation:
  
  • Mobile, easily palpable, can be lobulated
  • Young women
• Dx:
  
  • Age-dependent
  • Biopsy >25yrs/very large/concerns over phyllodes tumour
  • Re-scan small FAD again in 3-6 months to monitor for rapid enlargement
• Mx:
  
  • Surgical excision - if rapid enlargement/>4cm
  • Reassurance otherwise

Mammary duct ectasia (periductal mastitis)

• Presentation:
  
  • Milk ducts dilate and fill with fluid –> breast pain + green-white nipple discharge
  • Assoc w/ smoking, menopause
• Dx: can mimic breast cancer –> need triple assessment
• Mx: conservative ± abx ± surgery for complications

Breast abscess

• Presentation:
  
  • breast-feeding, DM, post-op, smokers
  • Red, hot, tender fluctuant mass, systemic (febrile, unwell)
  • Acute Hx
• Dx:
  
  • Too painful to tolerate MMG - USS only initially
  • MMG on resolution if ≥35yrs
• Mx:
  
  • USS-guided aspiration + Abx
  • Clinical review in 48hrs –> possible repeat aspiration
  • Incision & drainage under GA if overlying necrotic skin

Question 23

Nipple discharge - causes? presentation? Dx? Mx?

Answer 23

Causes:

• Physiological (90%)
• Duct ectasia - benign, normal in post-menopausal, multi-duct
• Intraductal papilloma - papilloma growth in single duct
• Epithelial hyperplasia
• Galactorrhoea - pregnancy/prolactinoma

Presentation:

• Smokers - green multi-duct
• Duct ectasia (dilated ducts) - yellow multi duct –> cheesy watery discharge ± bloodstained
• Prolactinoma/pregnancy - b/l milky, multi duct
• Underlying pathology (cancer, PCIS, papilloma) - bloody discharge from a single duct (can be watery/serous)
  
  • Epithelial hyperplasia has a similar but less severe presentation

Dx:

• Age-related ± MRI
• USS retro-areolar w/ biopsy of visible lesions

Mx:

• Treat cancer incl. excision of NAC
• Papilloma - single/total duct excision

Question 24

Gynaecomastia - causes? presentation? Dx? Mx?

Answer 24

Causes:

• Failures:
  
  • Liver cirrhosis due to alcoholism (failure of liver to metabolise oestrogens)
  • Renal failure
• Neoplasm:
  
  • Bronchial carcinoma
  • Pituitary tumours (hyperprolactinaemia)
  • Testicular tumours
• Hyperthyroidism, Hypogonadism
• Drug-related (spironolatone)

Presentation: elderly/puberty

Dx: bilateral USS

Mx:

• Cause
• Tamoxifen
• Surgery
• NOTE: do not stop meds just because they are causing gynecomastia

Question 25

Breast carcinoma - RFs? types (incl. receptors, axilla involvement)? Presentation? Dx? Mx?

Answer 25

RFs:

• Increase:
  
  • FHx (breast, ovarian, colon)
  • Genetic mutations (BRCA1/2 - sign increase risk of breast/ovarian cancer)
  • Post-menopausal, ≥40yrs, early menopause/late menarche
  • OCP (decreases risk of endometrial/ovarian/colorectal)
• Decrease: pregnancy, breastfeeding

Types:

• Invasive ductal carcinoma - 70%, firm/hard
• Lobular carcinoma - 10%, bilateral in 20%, multicentric
• Tubular - 10%, small stellate lesions, picked up on screening
• Other: medullary (soft/fleshy, good prog), mucoid (rare, good prog), Paget’s (nipple excoriation, underly intraductal tumour, poor prog)

Receptor involvement: ER (oestrogen), PR (progesterone), HER2 (Herceptin)

• ER/PR-receptive = good prognostic signs
• HER2 = bad prognostic sign (but now Tx for it)

Presentation:

• Post-menopausal
• Firm mass ± skin tethering/dimpling
• LNs in axilla

Ix:

• Triple assessment:
  
  • ≥35yrs - MMG + USS + biopsy (FNA/core biopsy)
  • <35yrs - USS + biopsy –if proven cancer–> MMG + MRI
• Axilla - USS + biopsy if any abnormal LNs
• Staging CT & bone scan if >3cm/LNs involved - TNM
  
  • T1-4 (size, 4= invasive), N0/1 (no/yes), MO/1 (no/yes)
  • Mets - bone, lung, liver
  • Nottingham prognostic index - size & grade of tumour & LNs
• MRI if lobular cancer

Mx:

• ALWAYS - Surgery:
  
  • _​_Mastectomy/wide local excision - depends on tumour size vs breast size
• ALWAYS - SLNB/ALNC
  
  • ​Sentinel LN biopsy vs axillary LN clearance = remove all
• Chemo - if involve LNs/large cancer/young patient/HER2 +ve/Triple -ve disease
• Radio - >4cm, LN involvement, skin/muscle involvement
• Endo: ONLY if ER +ve
  
  • Tamoxifen pre-menopausal
  • Letrozole if post-menopausal
  • Herceptin (Trastuzumab) for HER2+
• MDT approach (incl psychological support)

Question 26

Aortic dissection - def? Sx? Ix? Mx?

Answer 26

Def: tear in tunica intima (inner layer of BV) –> blood collection between tunica intima and tunica media –> false lumen (can occlude blood flows through aorta) –> AR, myocardial ischaemia, stroke

Sx: sudden onset, central tearing chest pain –> radiating to between shoulder blades

• Hx of intermittent claudication
• Haemodynamic instability (high HR, low BP)
• Before left subclavian artery - left arm smaller than right arm
• After left subclavian artery - lower body less developed than upper body

Ix:

• BP in both arms - radio-radial delay
• ECG, CXR (widened mediastinum)
• Gold-standard: CT-aortogram w/ contrast

Mx:

• Stanford A (ascending aorta) - more WORRYING (compromise blood to brain, cause aortic regurg):
  
  • BP control - B-blockers & CCB (aim 100-120mmHg)
  • Immediate referral for vascular surgery
• Stanford B (descending aorta)
  
  • BP control - B-blockers & CCB (aim 100-120mmHg)
  • Urgent referral to vascular surgery (repair likely if complicated)

Question 27

What profile group do Phyllodes commonly affect? What are they?

Answer 27

Older women

Fibroepithelial breast tumour - epithelial & stromal elements (similar histologically to fibroadenoma)

Can become malignant, normally require surgical resection

Question 28

Breast anatomy? Breast exam? Triple assessment?

Answer 28

Breast anatomy - Lobules > ducts > nipple

• Ligaments suspending breast = Cooper’s ligaments
• Most lymphatic drainage to axilla (& intercostal, interthoracic LNs)
• Blood supply - perforating intercostal arteries

Intro - WIPE + chaperone

Inspection:

• SITTING Positions:
  
  • Relaxed arms
  • Hands rested on thighs
  • Hands-on hips - tense pectoralis
  • Hands behind head - accentuate dimpling/asymmetry
  • Lift breasts - submammary fold (ask patient)
• Look for:
  
  • Asymmetry, local swelling, scars (look under breasts)
  • Skin changes:
    
    • Dimpling/puckering - tethering due to cancer
    • Peau d’orange - lymphatic oedema due to cancer
  • Nipple changes:
    
    • Paget’s disease of breast - unilateral nipple = cancer
    • Eczema - areola (rarely nipple), bilateral
    • Inversion - normal variant/cancer

Palpation: LYING DOWN + hand on the side being examined behind head + check for pain (start on normal side)

• Use palmar surface of middle 3 fingers to feel for any lumps starting in centre and going round in concentric circles
• Pinch along axillary tail (first 2 fingers & thumb)
• Ask patient to squeeze each nipple to check for discharge
• Localise + describe lump: 3Ss, 3Cs, 3Ts
  
  • Site, Size, Shape
  • Consistency, Contours, Colour
  • Tenderness, Temperature, Tethering/Transillumination
• Lymph nodes:
  
  • Axillary - ask patient to hold bicep:
    
    • Palpate apical, lateral, medial, anterior, posterior aspects
  • Cervical LN exam
• Offer to examine lungs and liver for mets

Triple assessment:

• Examination
• Imaging (USS <35yrs; MMG + USS ≥35yrs)
• Biopsy (FNA if cystic, core biopsy if solid)

Question 29

Comparing different types of vascular ulcers:

• Hx
• Location
• Characteristics - ulcer & surrounding skin
• Tx

Answer 29

Venous:

• Hx: varicose veins, previous DVT, obesity, preg, recurrent phlebitis
• Location: lower calf-medial malleolus
• Characteristics: mild pain
  
  • Ulcer - shallow/flat margins, exudate, sloughing @base, granulation tissue
  • Surrounding skin - haemosiderin staining, eczematous, oedematous, thickening skin, (normal CRT)
• Tx: compression bandaging, leg elevation, surgical Mx

Arterial:

• Hx: HTN, DM, smoking, prev vascular disease
• Location: pressure points, toes/feet, lateral malleolus, tibia
• Characteristics: painful
  
  • Ulcer - punched-out/deep, irreg shape, necrosis, no exudate (unless inf)
  • Surrounding skin: thin, shiny, reduced hair, 6Ps (pallor, pain, perishingly cold, pulselessness, paraesthesia, paralysis)
• Tx: revascularization (e.g. bypass), anti-platelet, manage RFs

Neuropathic:

• Hx: DM (peripheral neuropathy), trauma, prolonged pressure
• Location: plantar foot, tip of toe, lateral-fifth metatarsal
• Characteristics: no pain
  
  • Ulcer - deep, surrounded by callus, insensate (no feeling)
  • Surrounding skin - dry, cracked, callus, insensate
• Tx: off-loading pressure, topical GF

Pressure:

• Hx: limited mobility
• Location: bony prominence, heel
• Characteristics:
  
  • Ulcer - deep, macerated (moist, wrinkly)
  • Surrounding skin - atrophic skin, lost muscle mass
• Tx: off-loading pressure, reduced moisture, increased nutrition

Question 30

Hypertension BP targets? Ix? Mx?

Answer 30

BP targets:

• <140/90
• <150/95 for over 80yrs
• Causes of hypertensive crisis ≥180/120: pregnancy, scleroderma, vasculitis, renovascular, endo, cocaine –> reduce BP slowly

Ix:

• Bedside - ECG, urine dip
• Bloods - FBC, U&E, lipids, BM, TFTs

Drug treatment:

• Conservative management - diet (low salt), exercise, reduce alcohol
• 1. a) <55yrs/DM –> ACEi (ramipril)/ANG-II receptor antagonist (Losartan)
• 1. b) ≥55yrs/black –> CCB (amlodipine)/thiazide diuretic (bendroflumethiazide)
• 2. ACEi + CCB OR ACEi + thiazide diuretic
• 3. ACEi + CCB + thiazide diuretic
• 4. Add:
     * Spironolactone (or other diuretic)
     * Alpha-blocker
     * Beta-blocker
     * Specialist advice

Question 31

Breast triple assessment?

Answer 31

Clinical examination

Breast imaging (MMG, USS)

Breast biopsy

Question 32

DVT - def? RFs? Presentation? Scoring & Ix? Mx?

Answer 32

Def: occlusion of deep vein in lower limb

RFs: SICC - Surgery, Immobility, Cancer, COCP

Presentation: pain, swelling (if extends proximally to iliacs –> bilateral swelling), pitting oedema, warmth, erythema

Scoring & Ix: Well’s score

• 0-1= D-Dimer –sign raised–> as below
• ≥2 = proximal leg vein USS + D-Dimer
• Obtain baseline before starting anti-coag: FBC, U&E, LFTs, clotting screen

Mx:

• Ongoing anticoagulation - DOAC/Warfarin
• Provoked - 3 months (SICC)
• Unprovoked - >6 months + thrombophilia testing

Question 33

• Itchy after showers, abdo pain & distension, prev DVT
• Exam - dilated veins on abdo, ascites, hepatomegaly
• Bloods - hepatitis picture

Dx? Assoc condition(s)? Ix? Mx?

Answer 33

NOTE: hot water –> histamine release from basophils

Dx: Budd-Chiari syndrome = hepatic vein thrombosis

• 50% associated with JAK2 myeloproliferative disorders e.g. Polycythaemia Rubra Vera (and essential thrombocythaemia) - this is what causes itching after showers
• NOTE: any portal vein thrombosis (different to hepatic vein thrombosis) is related to cirrhosis and may be painless/asymptomatic

Ix: urgent doppler USS of hepatic veins

Mx: tx as any DVT - DOAC (e.g. apixaban)

Question 34

Thyroglossal duct cyst - def? presentation? Tx?

Answer 34

Most common congenital neck mass

• Thyroglossal duct - embryological duct connecting back of tongue & thyroid gland
• Cyst results from failure of thyroglossal duct closing before birth

Presentation: painless fluctuant midline mass

• Often presents in childhood following inf (painful red)
• On exam moves upwards when sticking out tongue due to attachment of duct

Tx: surgical resection of cyst & duct

Question 35

Thyroid function hormonal axis?

Answer 35

Hypothalamus releases thyrotrophin-releasing hormone (TRH)

TRH stimulates ant. pituitary gland to release thyroid-stimulating hormone (TSH)

Stimulates thyroid to release triiodothyronine (T3) & thyroxine (T4) –> -ve feedback

Outcomes:

• Hyperthyroidism - low TSH, high T3/4
• Primary hypothyroidism - high TSH, low T3/4
• Secondary hypothyroidism - low TSH, low T3/4

Question 36

Case:

• 40yrs woman had a thyroidectomy 12hrs ago
• Developed neck pain & swelling, complaining of difficulty breathing
• Exam: raised RR, stridor, bandage overwound is soaked with blood & swollen

What do you do?

Answer 36

1. Take off the bandage, take out sutures
2. Open skin to expose strap muscles
3. Open strap muscles to expose trachea
4. Pack overwound

Question 37

Describing a lump?

Answer 37

Localise + describe lump: 3Ss, 3Cs, 3Ts

• Site, Size, Shape
• Consistency, Contours, Colour
• Tenderness, Temperature, Tethering

Question 38

Pre-cancerous breast masses

Answer 38

Ductal carcinoma in-situ

• Def:
  
  • Limited to mammary ducts by basement membrane –> can’t metastasise
  • Can transform into invasive (ductal) malignancy
• Presentation: often not palpable, picked up on screening
• Mx: breast-conserving surgery - wide local excision

Lobular carcinoma in-situ

Question 39

Allen’s test - process? When do you do this test?

Answer 39

Process:

• Find radial & ulnar pulse - patient makes tight fist
• Occlude both vessels –> ask to open hand –> release radial side –> observe for re-perfusion
• Repeat & release on ulnar side

NOTE: ulnar artery is dominant artery in the hand

When do you do this in daily practice - before doing ABG

Question 40

What is the cervical rib? What can it cause?

Answer 40

Cervical rib is an abnormal rib at C7

• Compression of subclavian artery when raising arms/neck flexion (thoracic outlet obstruction syndrome)
• Obliteration of radial pulse

Can cause - Subclavian Steal Syndrome

• Proximal obstruction in subclavian artery
• Retrograde flow through vertebral/internal thoracic artery
• Reduces cerebral blood flow –> syncopal Sx

Question 41

Types of obstructive vasculitis?

Answer 41

• Takayasu’s arteritis = occlusive large-vessel vasculitis (aorta & main branches)
  
  • Upper limb claudication, diminished/absent pulse
• Thromboangitis obliterans (Buerger’s disease) - affects small & medium vessels in lower limb
  
  • Segmental occlusion, young male smokers, tortuous corkscrew collateral vessels on angiography