Wrong answers Flashcards
1
Q
How to distinguish if an AAA has a high rupture risk?
A
Symptomatic - back pain
Diameter > 5.5cm
Rapidly enlarging (>1cm/yr)
2
Q
What to do if AAA has high rupture risk?
A
Refer to vascular surgery within 2 weeks
Elective endovascular repair (EVAR) - stent put in via femoral artery
2
Q
What is a possible complication for EVAR?
A
Endo-leak where the stent fails to exclude blood from the aneurysm
Found on follow-up - often asymptomatic
3
Q
Initial management for acute limb ischaemia?
A
A-E assessment
Analgesia - often IV opioids
IV unfractionated heparin
Vascular review
4
Q
What is Marjolin’s ulcer?
A
Squamous cell carcinoma occurring at sites of chronic inflammation/previous injury
Grows in size and doesn’t usually respond to creams
5
Q
How do we confirm that pulses are absent?
A
Handheld doppler examination
6
Q
How do we tell with a Doppler machine that there is an arterial block upstream?
A
Triphasic sound = normal (whooshing)
Monophasic sound = blockage
7
Q
What is screening programme for AAA?
A
Single abdominal US for men at 65 years of age
8
Q
ABPI analysis
A
> 1.2 = may indicate calcified stiff arteries - advance PAD
1 - 1.2 = normal
0.9 -1 = acceptable
0.9 = likely PAD
0.5 = severe disease - urgent referral
9
Q
PAD drug management
A
Statin + clopidogrel
10
Q
Non-pharmacological and non-surgical management of PAD
A
Smoking cessation
Optimisation of co-morbidities e.g. HTN, diabetes
Exercise training
10
Q
Initial management for chronic venous insufficiency
A
Emolient for lipodermatosclerosis
Compression stockings
11
Q
AAA screening outcome
A
< 3cm = no further action
3 - 4.5cm = repeat US every 12 months
4.5 - 5.4 = repeat US every 3 months
5.5 or above or if growth (>1cm/year) = refer within 2 weeks for intervention
12
Q
Surgical management for severe PAD/critical limb ischaemia
A
percutaneous transluminal angioplasty +/- stent placement (opens up vessel with a balloon)
surgical bypass with an autologous vein or prosthetic material
endarterectomy - removes fatty material from affected vessels
13
Q
What does cross-matching blood indicate?
What does group and save indicate?
A
Cross-matching implies that you are giving blood in that scenario
Group and save only saves the patient’s blood type for future reference and future blood transfusions
14
Q
What is prothrombin complex concentrate used for?
A
Reversal of warfarin to help manage bleeding
15
Q
Blood product management for AAA
A
Cross-match 6 units of blood
16
Q
How can diabetes affect ABPI
A
Sometimes it can cause calcification of vessels giving a raised ABPI reading
17
Q
First-line imaging for PAD
A
Duplex US
17
Q
Indications for open bypass surgery
A
Low-risk patients
Long segmental obstruction/multifocal lesions
18
Q
Acute anal fissure (<1week) management
A
High fibre diet
Bulk-forming laxatives
Lubricants
Topical anaesthetics
Analgesia
19
Q
Anal fissure risk factors
A
IBD
Constipation
STIs
20
Q
Presentation of thrombosed haemarrhoids
A
Pain and tender lump
Purple, oedematous perianal mass
21
Q
Management of thrombosed haemarrhoids
A
If within 72 hours then referral should be considered for excision
If longer than 72 hours - analgesia, stool softeners and ice packs
22
Why is gastrogafin used over barium as an enema?
Less toxic if it leaks into the abdomen
23
Perianal abscess presentation
Extreme perianal pain
Spiking temperatures
24
What type of stoma is used for colorectal cancer?
Loop ileostomy
25
What type of stoma is used for distal colon cancer?
Loop colostomy
26
Large bowel obstruction causes
Tumour - most common
Volvulus
Diverticular disease
27
Presentation of large bowel obstruction
absence of passing flatus or stool
abdominal pain
abdominal distention
peritonism if perforation
28
What type of cancer are the majority of colorectal cancers?
Adenocarcinoma
29
Management of anal fissure that don't respond to conservative management
Sphincterectomy
30
Treatment for majority of rectal tumours (not distal ones)
Anterior resection - colon and remaining rectum are brought together
31
Criteria for urgent referral to colorectal cancer pathway
patients >= 40 years with unexplained weight loss AND abdominal pain
patients >= 50 years with unexplained rectal bleeding
patients >= 60 years with iron deficiency anaemia OR change in bowel habit
32
When to suspect gastric volvulus
Borchardt's triad - severe epigastric pain, retching, inability to pass an NG tube
32
How to grade internal haemorrhoids
Grade I - Does not prolapse out of the anal canal
Grade II - Prolapse on defecation but spontaneously reduce
Grade III - Can be manually reduced
Grade IV - Cannot be reduced
33
What can topical glyceryl trinitrate be used for?
Chronic anal fissures
34
Causes of chronic pancreatitis
Excessive alcohol abuse
Genetic - cystic fibrosis, hemochromatosis
Obstruction - tumours, stones
35
Presentation of chronic pancreatitis
Pain post-meal
Steatorrhea
Commonly in diabetics
36
Investigations for chronic pancreatitis
Abdo X-Ray and CT - Pancreatic calcifications
Faecal elastase test if inconclusive imaging
37
Management for chronic pancreatitis
Pancreatic enzyme supplements
Analgesia
38
Acute cholecystitis treatment
IV Antibiotics
Laparoscopic cholecystectomy within a week
39
What is the GET SMASHED pnemonic?
Causes for acute pancreatitis
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom
Hypercalcaemia
ERCP (Endoscopic retrograde cholangiopancreatography)
Drugs (mesalazine, azathioprine, furosemide, bendroflumethiazide, steroids, sodium valproate)
40
What is Charcot's triad and what is it seen in?
RUQ pain, fever, jaundice
Ascending cholangitis
41
What is Reynold's pentad?
Charcot's triad + confusion + hypotension
Severe cases of ascending cholangitis
42
Factors that indicate severe pancreatitis?
age > 55
hypocalcaemia
hyperglycaemia
hypoxia
neutrophilia
elevated LDH and AST
43
Investigations for acute pancreatitis?
Serum amylase
Serum lipase
Ultrasound
CT
44
When would you opt for serum lipase over serum amylase for investigating acute pancreatitis?
if the presentation is over 24 hours since sx started
45
First-line imaging for acute cholecystitis
Abdominal ultrasound
46
Management for stress incontinence
Pelvic floor exercises
Surgery
Duloxetine (if no response, or decline surgery)
47
How does duloxetine help stress incontinence?
SNRI + SSRI
Increased activity of pudendal nerve, by increasing noradrenaline and serotonin synaptic concentration increases sphincter muscle contraction
48
What classification can be used for colorectal cancer?
Duke's
A - Confined to mucosa
B - Invades bowel wall - including muscular layer
C - Lymph node metastases
D - Distant metastases
49
What type of drugs are used in oestrogen receptor +ve breast cancer in postmenopausal women?
Aromatase inhibitors - a type of anti-oestrogen therapy
50
Examples of Aromatase inhibitors
Anastrozole
Letrozole
51
How do Aromatase inhibitors work?
Reduce peripheral oestrogen synthesis - main source of oestrogen in postmenopausal women
52
First line management of mastitis
Continue with breastfeeding
53
Second line management of mastitis
If systemically unwell or if symptoms do not improve within 12-24 hours of effective milk removal then prescribe oral flucoxacillin OD 10-14 days
54
When to do a sentinel node biopsy?
In women with breast cancer with no palpable lymphadenopathy but pre-op axillary US is positive.
55
What to do if sentinel node biopsy shows large numbers of nodes involved
Axillary nodal clearance
56
Typical appearance of inflammatory breast cancer
Progressive erythema and oedema
No pain
No signs of fever
Elevated CA 15-3
57
What are HER2 receptor positive breast cancers treated with?
Herceptin (Trastuzumab)
58
Commonest cause of blood stained discharge in younger women? How to investigate?
Intraductal papilloma - US is required
59
How does a fibroadenoma present?
Very mobile, non-tender, smooth lump, not tethered to skin
Breast mouse
60
Adverse effects of aromatase inhibitors
Osteoporosis
Hot flushes
Arthralgia, myalgia
Insomnia
Similar to menopause symptoms and complications
61
When should you surgically excise a breast fibroadenoma?
> 3cm
62
What treatment is given for node +ve breast cancer but is HER2 and ER -ve?
FEC D chemotherapy
63
What is FEC D chemotherapy?
Combination of drugs
Fluorouracil
Epirubicin
Cyclophosphamide
Docetaxel (not used if node -ve)
64
What is Paget's disease of the breast?
Eczematoid changes (erythema and thickening) of the nipple with underlying breast malignancy - requires urgent referral to breast clinic
65
How is Paget's disease of the breast diagnosed?
Punch biopsy
Mammogram
US Breast
66
Criteria for suspected breast cancer pathway - 2 week referral?
Aged 30 or over + unexplained breast lump
Aged 50 or over + unilateral nipple discharge or retraction
67
What treatment is best at preventing recurrence of breast cancer?
Whole breast radiotherapy
68
When to do a wide local excision vs mastectomy?
Wide local excision is a breast conserving surgery preferred whent the tumour is under 4cm
69
What is duct ectasia?
Shortening and dilatation of the terminal breast ducts. Presents with nipple retraction and creamy nipple discharge. Incidence increases with age.
70
Treatment for duct ectasia
Reassurance
No specific treatment
71
What does a halo sign indicate on a mammogram?
Benign breast growth - typically a cyst
72
What is the snowstorm sign on breast ultrasound?
Sign seen when silicone from an implant rupture is drained into the lymph nodes
73
Complication of axillary node clearance?
Lymphoedema and functional arm impairment
74
What is comedo necrosis on biopsy a sign of?
DCIS
75
Breast cancer screening programme
Mammogram every 3 years for women aged 50-70
76
What Abx are given for someone who doesn't respond to oral Abx for treatment of diverticulitis flare up?
IV ceftriaxone and metronidazole
77
Presentation of epidydimal cyst?
Scrotal swelling felt separate from the testes
Found posterior to the testicle
78
How to differentiate between testicular torsion and epididymitis?
See if elevation of the testes eases the pain.
If not, then likely to be testicular torsion
79
When to suspect renal cell cancer with a varicocoele?
If it is only right sided
If it doesn't disappear when lying down - suggests renal vein compression
80
Management for testicular torsion
BILATERAL urgent orchidopexy
81
What is balanitis?
Inflammation of the glans penis
82
Management for recurrent balanitis
Circumcision
83
Adverse effects of tamsulosin
dizziness, postural hypotension, dry mouth, depression
84
How long should a PSA test be delayed after prostatitis?
1 month
85
Additional management for acute prostatitis other than 14-day course of quinolone?
Consider STI screening in younger men
86
What is the most effective analgesia to use in acute renal colic?
IM diclofenac
87
What is the ASA classification?
A classification used to identify the risk of general anaesthesia for a particular patient
88
What is an ASA 1 patient?
Healthy patient
Normally fit and well
Non-smoker
No/minimal alcohol
89
What is an ASA 2 patient?
Mild systemic disease
Current smoker
Social drinker
Pregnant
Obesity (BMI 30-40)
Well controlled diabetes and/or HTN
Mild lung disease
90
What is an ASA 3 patient?
Severe systemic disease
Poorly controlled diabetes and/or HTN
BMI > 40
COPD
Alcohol abuse
Active hepatitis
Pacemaker
Moderate HF
previous MI/TIA/stroke (>3 months)
End stage renal failure (undergoing dialysis)
91
What is an ASA 4 patient?
Severe systemic disease - threat to life
Recent (<3 months) MI/TIA/Stroke
Ongoing cardiac ischaemia
Severe HF
Sepsis
DIC
Acute respiratory distress
End stage renal failure (no dialysis)
92
What is an ASA 5 patient?
Not expected to survive without surgery
AAA rupture
Intracranial bleed with mass effect
Ischaemic bowel
Multiple organ dysfunction
93
What is an ASA 6 patient?
Brain dead patient
94
What anaesthetic agents can cause malignant hyperthermia?
Suxamethonium and halothane
95
How does malignant hyperthermia present and why?
Hyperpyrexia and muscle rigidity due to excessive calcium release by sarcoplasmic reticulum in skeletal muscle.
96
Treatment for malignant hyperthermia?
Dantrolene - prevents Calcium release
97
What is a risk factor for malignant hyperthermia?
Genetic defect - inherited in autosomal dominant fashion
98
How to identify cause of post-operative fever?
Day 1-2: 'Wind' - Pneumonia, aspiration, pulmonary embolism
Day 3-5: 'Water' - Urinary tract infection (especially if the patient was catheterised)
Day 5-7: 'Wound' - Infection at the surgical site or abscess formation
Day 5+: 'Walking' - Deep vein thrombosis or pulmonary embolism
Any time: Drugs, transfusion reactions, sepsis, line contamination.
99
When to stop COCP prior to elective surgery?
4 weeks prior
100
How should insulin be reduced before surgery?
Once-daily dose of insulin should be reduced by 20% on the day prior and day of surgery.
101
Adverse effect of etomidate
Adrenal suppression - may require steroid treatment as it suppresses cortisol release from zona fasciculata
102
Adverse effect of etomidate
Adrenal suppression - may require steroid treatment as it suppresses cortisol release from zona fasciculata
103
How to take sulfonylureas (e.g. gliclazide) on the day of surgery?
Omit if OD
If BD + morning surgery, omit morning dose but have afternoon dose
104
When to give a variable rate intravenous insulin infusion (VRIII)
For diabetic patients who are undergoing a major surgery (where there will be a long fasting period or more than one missed meal) or who hae very poor control of their diabetes
105
Complication of long term mechanical ventilation
Tracheo-oesophageal fistula
106
Contraindications for suxamethonium
Penetrating eye injuries
Acute narrow angle glaucoma
Suxamethonium increases intra-ocular pressure
107
Most common causative organism for ascending cholangitis
E. coli
108
5 local complications of acute pancreatitis
Peripancreatic fluid collections (25% of cases)
Pseudocysts
Pancreatic necrosis
Pancreatic abscess
Haemorrhage
109
What do peripancreatic fluid collections not have and how are they managed?
They don’t have a fibrous capsule or wall of granulation
Most resolves but can develop into pseudocysts or abscesses
110
Where do pseudocysts come from and how do they present?
Come from peripancreatic fluid collection - now formed a fibrous capsule
Occurs >4 weeks after acute pancreatitis and most are retro gastric and associated with amylase elevation
111
How to investigate pseudocysts?
CT
ERCP
MRI
Endoscopic US
112
How to manage pseudocysts?
Observation for 12 weeks as 50% resolve
Aspiration
Endoscopic/surgical cystogastrostomy
113
What is a pancreatic abscess and how does it form?
Intra-abdominal collection of pus associated with pancreas (no necrosis)
Occurs as a result of an infected pseudocyst
114
Management of pancreatic abscess.
Transgastric drainage
Endoscopic drainage
115
Signs of pancreatic haemorrhage
Grey Turner’s if bleed is retroperitoneal
Cullen’s
