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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)

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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

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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

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3
Q

Initial management for acute limb ischaemia?

A

A-E assessment
Analgesia - often IV opioids
IV unfractionated heparin
Vascular review

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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

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5
Q

How do we confirm that pulses are absent?

A

Handheld doppler examination

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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

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7
Q

What is screening programme for AAA?

A

Single abdominal US for men at 65 years of age

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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

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9
Q

PAD drug management

A

Statin + clopidogrel

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10
Q

Non-pharmacological and non-surgical management of PAD

A

Smoking cessation
Optimisation of co-morbidities e.g. HTN, diabetes
Exercise training

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10
Q

Initial management for chronic venous insufficiency

A

Emolient for lipodermatosclerosis
Compression stockings

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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

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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

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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

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14
Q

What is prothrombin complex concentrate used for?

A

Reversal of warfarin to help manage bleeding

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15
Q

Blood product management for AAA

A

Cross-match 6 units of blood

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16
Q

How can diabetes affect ABPI

A

Sometimes it can cause calcification of vessels giving a raised ABPI reading

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17
Q

First-line imaging for PAD

A

Duplex US

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17
Q

Indications for open bypass surgery

A

Low-risk patients
Long segmental obstruction/multifocal lesions

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18
Q

Acute anal fissure (<1week) management

A

High fibre diet
Bulk-forming laxatives
Lubricants
Topical anaesthetics
Analgesia

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19
Q

Anal fissure risk factors

A

IBD
Constipation
STIs

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20
Q

Presentation of thrombosed haemarrhoids

A

Pain and tender lump
Purple, oedematous perianal mass

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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

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22
Q

Why is gastrogafin used over barium as an enema?

A

Less toxic if it leaks into the abdomen

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23
Q

Perianal abscess presentation

A

Extreme perianal pain
Spiking temperatures

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24
Q

What type of stoma is used for colorectal cancer?

A

Loop ileostomy

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25
Q

What type of stoma is used for distal colon cancer?

A

Loop colostomy

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26
Q

Large bowel obstruction causes

A

Tumour - most common
Volvulus
Diverticular disease

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27
Q

Presentation of large bowel obstruction

A

absence of passing flatus or stool
abdominal pain
abdominal distention
peritonism if perforation

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28
Q

What type of cancer are the majority of colorectal cancers?

A

Adenocarcinoma

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29
Q

Management of anal fissure that don’t respond to conservative management

A

Sphincterectomy

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30
Q

Treatment for majority of rectal tumours (not distal ones)

A

Anterior resection - colon and remaining rectum are brought together

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31
Q

Criteria for urgent referral to colorectal cancer pathway

A

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

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32
Q

When to suspect gastric volvulus

A

Borchardt’s triad - severe epigastric pain, retching, inability to pass an NG tube

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32
Q

How to grade internal haemorrhoids

A

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

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33
Q

What can topical glyceryl trinitrate be used for?

A

Chronic anal fissures

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34
Q

Causes of chronic pancreatitis

A

Excessive alcohol abuse
Genetic - cystic fibrosis, hemochromatosis
Obstruction - tumours, stones

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35
Q

Presentation of chronic pancreatitis

A

Pain post-meal
Steatorrhea
Commonly in diabetics

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36
Q

Investigations for chronic pancreatitis

A

Abdo X-Ray and CT - Pancreatic calcifications
Faecal elastase test if inconclusive imaging

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37
Q

Management for chronic pancreatitis

A

Pancreatic enzyme supplements
Analgesia

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38
Q

Acute cholecystitis treatment

A

IV Antibiotics
Laparoscopic cholecystectomy within a week

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39
Q

What is the GET SMASHED pnemonic?

A

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)

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40
Q

What is Charcot’s triad and what is it seen in?

A

RUQ pain, fever, jaundice

Ascending cholangitis

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41
Q

What is Reynold’s pentad?

A

Charcot’s triad + confusion + hypotension
Severe cases of ascending cholangitis

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42
Q

Factors that indicate severe pancreatitis?

A

age > 55
hypocalcaemia
hyperglycaemia
hypoxia
neutrophilia
elevated LDH and AST

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43
Q

Investigations for acute pancreatitis?

A

Serum amylase
Serum lipase
Ultrasound
CT

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44
Q

When would you opt for serum lipase over serum amylase for investigating acute pancreatitis?

A

if the presentation is over 24 hours since sx started

45
Q

First-line imaging for acute cholecystitis

A

Abdominal ultrasound

46
Q

Management for stress incontinence

A

Pelvic floor exercises
Surgery
Duloxetine (if no response, or decline surgery)

47
Q

How does duloxetine help stress incontinence?

A

SNRI + SSRI
Increased activity of pudendal nerve, by increasing noradrenaline and serotonin synaptic concentration increases sphincter muscle contraction

48
Q

What classification can be used for colorectal cancer?

A

Duke’s

A - Confined to mucosa
B - Invades bowel wall - including muscular layer
C - Lymph node metastases
D - Distant metastases

49
Q

What type of drugs are used in oestrogen receptor +ve breast cancer in postmenopausal women?

A

Aromatase inhibitors - a type of anti-oestrogen therapy

50
Q

Examples of Aromatase inhibitors

A

Anastrozole
Letrozole

51
Q

How do Aromatase inhibitors work?

A

Reduce peripheral oestrogen synthesis - main source of oestrogen in postmenopausal women

52
Q

First line management of mastitis

A

Continue with breastfeeding

53
Q

Second line management of mastitis

A

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
Q

When to do a sentinel node biopsy?

A

In women with breast cancer with no palpable lymphadenopathy but pre-op axillary US is positive.

55
Q

What to do if sentinel node biopsy shows large numbers of nodes involved

A

Axillary nodal clearance

56
Q

Typical appearance of inflammatory breast cancer

A

Progressive erythema and oedema
No pain
No signs of fever
Elevated CA 15-3

57
Q

What are HER2 receptor positive breast cancers treated with?

A

Herceptin (Trastuzumab)

58
Q

Commonest cause of blood stained discharge in younger women? How to investigate?

A

Intraductal papilloma - US is required

59
Q

How does a fibroadenoma present?

A

Very mobile, non-tender, smooth lump, not tethered to skin
Breast mouse

60
Q

Adverse effects of aromatase inhibitors

A

Osteoporosis
Hot flushes
Arthralgia, myalgia
Insomnia

Similar to menopause symptoms and complications

61
Q

When should you surgically excise a breast fibroadenoma?

A

> 3cm

62
Q

What treatment is given for node +ve breast cancer but is HER2 and ER -ve?

A

FEC D chemotherapy

63
Q

What is FEC D chemotherapy?

A

Combination of drugs

Fluorouracil
Epirubicin
Cyclophosphamide
Docetaxel (not used if node -ve)

64
Q

What is Paget’s disease of the breast?

A

Eczematoid changes (erythema and thickening) of the nipple with underlying breast malignancy - requires urgent referral to breast clinic

65
Q

How is Paget’s disease of the breast diagnosed?

A

Punch biopsy
Mammogram
US Breast

66
Q

Criteria for suspected breast cancer pathway - 2 week referral?

A

Aged 30 or over + unexplained breast lump
Aged 50 or over + unilateral nipple discharge or retraction

67
Q

What treatment is best at preventing recurrence of breast cancer?

A

Whole breast radiotherapy

68
Q

When to do a wide local excision vs mastectomy?

A

Wide local excision is a breast conserving surgery preferred whent the tumour is under 4cm

69
Q

What is duct ectasia?

A

Shortening and dilatation of the terminal breast ducts. Presents with nipple retraction and creamy nipple discharge. Incidence increases with age.

70
Q

Treatment for duct ectasia

A

Reassurance
No specific treatment

71
Q

What does a halo sign indicate on a mammogram?

A

Benign breast growth - typically a cyst

72
Q

What is the snowstorm sign on breast ultrasound?

A

Sign seen when silicone from an implant rupture is drained into the lymph nodes

73
Q

Complication of axillary node clearance?

A

Lymphoedema and functional arm impairment

74
Q

What is comedo necrosis on biopsy a sign of?

A

DCIS

75
Q

Breast cancer screening programme

A

Mammogram every 3 years for women aged 50-70

76
Q

What Abx are given for someone who doesn’t respond to oral Abx for treatment of diverticulitis flare up?

A

IV ceftriaxone and metronidazole

77
Q

Presentation of epidydimal cyst?

A

Scrotal swelling felt separate from the testes
Found posterior to the testicle

78
Q

How to differentiate between testicular torsion and epididymitis?

A

See if elevation of the testes eases the pain.
If not, then likely to be testicular torsion

79
Q

When to suspect renal cell cancer with a varicocoele?

A

If it is only right sided
If it doesn’t disappear when lying down - suggests renal vein compression

80
Q

Management for testicular torsion

A

BILATERAL urgent orchidopexy

81
Q

What is balanitis?

A

Inflammation of the glans penis

82
Q

Management for recurrent balanitis

A

Circumcision

83
Q

Adverse effects of tamsulosin

A

dizziness, postural hypotension, dry mouth, depression

84
Q

How long should a PSA test be delayed after prostatitis?

A

1 month

85
Q

Additional management for acute prostatitis other than 14-day course of quinolone?

A

Consider STI screening in younger men

86
Q

What is the most effective analgesia to use in acute renal colic?

A

IM diclofenac

87
Q

What is the ASA classification?

A

A classification used to identify the risk of general anaesthesia for a particular patient

88
Q

What is an ASA 1 patient?

A

Healthy patient

Normally fit and well
Non-smoker
No/minimal alcohol

89
Q

What is an ASA 2 patient?

A

Mild systemic disease

Current smoker
Social drinker
Pregnant
Obesity (BMI 30-40)
Well controlled diabetes and/or HTN
Mild lung disease

90
Q

What is an ASA 3 patient?

A

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
Q

What is an ASA 4 patient?

A

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
Q

What is an ASA 5 patient?

A

Not expected to survive without surgery

AAA rupture
Intracranial bleed with mass effect
Ischaemic bowel
Multiple organ dysfunction

93
Q

What is an ASA 6 patient?

A

Brain dead patient

94
Q

What anaesthetic agents can cause malignant hyperthermia?

A

Suxamethonium and halothane

95
Q

How does malignant hyperthermia present and why?

A

Hyperpyrexia and muscle rigidity due to excessive calcium release by sarcoplasmic reticulum in skeletal muscle.

96
Q

Treatment for malignant hyperthermia?

A

Dantrolene - prevents Calcium release

97
Q

What is a risk factor for malignant hyperthermia?

A

Genetic defect - inherited in autosomal dominant fashion

98
Q

How to identify cause of post-operative fever?

A

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
Q

When to stop COCP prior to elective surgery?

A

4 weeks prior

100
Q

How should insulin be reduced before surgery?

A

Once-daily dose of insulin should be reduced by 20% on the day prior and day of surgery.

101
Q

Adverse effect of etomidate

A

Adrenal suppression - may require steroid treatment as it suppresses cortisol release from zona fasciculata

102
Q

Adverse effect of etomidate

A

Adrenal suppression - may require steroid treatment as it suppresses cortisol release from zona fasciculata

103
Q

How to take sulfonylureas (e.g. gliclazide) on the day of surgery?

A

Omit if OD
If BD + morning surgery, omit morning dose but have afternoon dose

104
Q

When to give a variable rate intravenous insulin infusion (VRIII)

A

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
Q

Complication of long term mechanical ventilation

A

Tracheo-oesophageal fistula

106
Q

Contraindications for suxamethonium

A

Penetrating eye injuries
Acute narrow angle glaucoma

Suxamethonium increases intra-ocular pressure

107
Q

Most common causative organism for ascending cholangitis

A

E. coli

108
Q

5 local complications of acute pancreatitis

A

Peripancreatic fluid collections (25% of cases)
Pseudocysts
Pancreatic necrosis
Pancreatic abscess
Haemorrhage

109
Q

What do peripancreatic fluid collections not have and how are they managed?

A

They don’t have a fibrous capsule or wall of granulation
Most resolves but can develop into pseudocysts or abscesses

110
Q

Where do pseudocysts come from and how do they present?

A

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
Q

How to investigate pseudocysts?

A

CT
ERCP
MRI
Endoscopic US

112
Q

How to manage pseudocysts?

A

Observation for 12 weeks as 50% resolve
Aspiration
Endoscopic/surgical cystogastrostomy

113
Q

What is a pancreatic abscess and how does it form?

A

Intra-abdominal collection of pus associated with pancreas (no necrosis)

Occurs as a result of an infected pseudocyst

114
Q

Management of pancreatic abscess.

A

Transgastric drainage
Endoscopic drainage

115
Q

Signs of pancreatic haemorrhage

A

Grey Turner’s if bleed is retroperitoneal
Cullen’s

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