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Final Year - ICSM > Vascular, Breast & Thyroid Surgery > Flashcards

Vascular, Breast & Thyroid Surgery Flashcards

1
Q

Surgical sieve

A

Vasc

Inf

Trauma

AI

Metabolic

Idiopathic/iatrogenic

Neoplasia

Congenital

Degenerative/drugs

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2
Q

General inspection signs & assoc Dx

A
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3
Q

Vascular legs DDx?

A
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4
Q

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

A
  • 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
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5
Q

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

A

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
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6
Q

Arterial vs venous insufficiency in legs signs

A
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7
Q

Peripheral vascular disease localisation & type of bypass graft?

A
  • 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
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8
Q

PAD Mx?

A

Conservative: smoking cessation

Medical: ACEi, clopidogrel, statin, DM control

Surgery: angioplasty/stent/bypass graft/amputation

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9
Q

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?

A

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

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10
Q

Graves’ Mx?

A
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11
Q

Thyroid neck exam process? Goitre complications? Further Ix?

A

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
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12
Q

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

A

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

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13
Q

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

A

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
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14
Q

Surgery - observations & assoc Dx

A
  • 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
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15
Q

AAA key Sx & ruptured Sx? Ix? Mx?

A

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
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16
Q

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

A

Aortic dissection

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17
Q

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

18
Q

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

A

Hypovolaemic shock

19
Q

How to calculate ABPI? ABPI value range?

A
  • 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
20
Q

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

A

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
21
Q

Breast Diagnostics

A

Screening MMG

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

USS focused:

  • <40yrs USS only
  • ≥40yrs USS + MMG

Biopsy:

  • all breast lumps in women >25yrs
  • USS-guided
22
Q

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

A

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
23
Q

Nipple discharge - causes? presentation? Dx? Mx?

A

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
24
Q

Gynaecomastia - causes? presentation? Dx? Mx?

A

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
25
Q

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

A

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)
26
Q

Aortic dissection - def? Sx? Ix? Mx?

A

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)
27
Q

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

A

Older women

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

Can become malignant, normally require surgical resection

28
Q

Breast anatomy? Breast exam? Triple assessment?

A

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)
29
Q

Comparing different types of vascular ulcers:

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

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
30
Q

Hypertension BP targets? Ix? Mx?

A

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)
    1. ACEi + CCB OR ACEi + thiazide diuretic
    1. ACEi + CCB + thiazide diuretic
    1. Add:
      * Spironolactone (or other diuretic)
      * Alpha-blocker
      * Beta-blocker
      * Specialist advice
31
Q

Breast triple assessment?

A

Clinical examination

Breast imaging (MMG, USS)

Breast biopsy

32
Q

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

A

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
33
Q
  • Itchy after showers, abdo pain & distension, prev DVT
  • Exam - dilated veins on abdo, ascites, hepatomegaly
  • Bloods - hepatitis picture

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

A

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)

34
Q

Thyroglossal duct cyst - def? presentation? Tx?

A

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

35
Q

Thyroid function hormonal axis?

A

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
36
Q

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?

A
  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
37
Q

Describing a lump?

A

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

  • Site, Size, Shape
  • Consistency, Contours, Colour
  • Tenderness, Temperature, Tethering
38
Q

Pre-cancerous breast masses

A

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

39
Q

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

A

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

40
Q

What is the cervical rib? What can it cause?

A

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
41
Q

Types of obstructive vasculitis?

A
  • 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

Final Year - ICSM (20 decks)

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