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575 Cards in this Set
- Front
- Back
How long must a Pt fast for before surgery?
- solids - fluids |
solids at least 6h
clear fluids at least 2h |
|
Is colonisation with MRSA a contraindication to surgery?
|
No
|
|
Name an AB that cover MRSA
|
vancomycin
|
|
Do you usually need bowel prep for right-sided ops?
|
Not usually
|
|
Best sized sutures for skin closure? (2)
|
3-0
or 4-0 |
|
What are the four categories of classification of surgical procedures and wound infection risk and what do they mean?
|
1. Clean: incising uninfected skin w/o opening a viscus (least infection risk)
2. clean-contaminated: intraop breach of a viscus (but not colon) 3. contaminated: breach of a viscus + spillage or opening of the colon 4. Dirty: site already contaminated with pus or poo, or from exogenous contagion e.g trauma (25% risk of infection) |
|
What suture do you use for subcuticular (below epidermi) skin closure?
|
Monocryl (monofilament)
|
|
What suture do you use for closing abdo wall?
|
PDS (monofilament)
|
|
What suture do you use for typing pedicles; bowel anastamoses; subcutaneous closure?
|
Vicryl (braided mulitfilament)
|
|
Name two absorbable sutures
|
monocryl
vicryl |
|
What suture do you use to close skin wounds (non-absorbable)
|
Ethilon (monofilament)
|
|
What non-absorbable suture do you use for securing drains?
|
Mersilk (monofilament)
|
|
How many days later can you remove sutures from neck, face, back?
|
5
|
|
How many days later can you remove sutures from abdo and prox limbs?
|
10
|
|
How many days later can you remove sutures from distal extremities?
|
14
|
|
Good for control of MSK pain, and renal or biliary colic
|
NSAIDs
|
|
SEs of opioids (7)
|
1. nausea (so prescribe anti-emetic)
2. resp depression 3. constipation 4. cough suppression 5. urinary retention 6. decreased BP 7. sedation (do not use in hepatic failure or head injury) |
|
What is Buscopan? What does it do? Mechanism of action?
|
hyoscine butylbromide
antispasmodic for intestinal, renal tract colic anticholinergic |
|
Mneumonic for Fever post-op
|
WIND = Atelectasis 1st POD
WATER = UTI 3rd POD WALK = DVT 5th POD WOUND = Wound Infection 7th POD Wonder why = abscess Weird drugs = medications(last 2 after 10th POD) |
|
Rx atelectasis post-op?
|
physio (not ABx)
|
|
Is post-op confusion common?
If you need to sedate, what do you use? |
yes - 40%
midazolam or haloperidol |
|
Post-op hypotension - first steps in mgmt? (4)
|
1. tilt bed head down
2. give oxygen 3. check fluid chart and replace losses; monitor urine output 4. review wounds and abdomen for bleeding (if unstable need to go back to OT) |
|
What is the aim for urine output in adults? (2 points of reference)
|
>30mL/h
or >0.5mL/kg/h |
|
What is usually the cause of oliguria?
|
too little replacement of lost fluid => increase fluid input
(could also be due to ARF from shock, drugs, transfusion, pancreatitis or trauma) |
|
If oliguric, what 5 steps do you take?
|
1. review fluid chart and check for signs of volume depletion
2. examine for palpable bladder - is there urinary retention? 3. est. normovolaemia 4. catheterise 5. if AFR suspected, refer to renal physician |
|
Odansetron works on which receptor?
|
5HT3
|
|
Can you use metoclopramide post-op? Why?
|
No
it's a prokinetic |
|
How to best divide up post-op complications? (3)
|
for each: immediate, early or late
1. from the anaesthetic 2. from surgery in general 3. from the specific procedure |
|
What do you think of with bilateral leg oedema? ie. it implies ______ disease with ______ venous pressure (eg?) OR ______ intravascular oncotic pressure (decreased albumin)
|
systemic
increased (e.g RHF) decreased (eg liver or kidney disease) |
|
What is the warning sign of wound dehiscence?
|
pink serous discharge
|
|
What nerve can be damaged in thyroid surgery? What does it lead to?
|
recurrent laryngeal nerve
hoarseness |
|
S+S of short gut syndrome? (2)
|
diarrhoea
malabsorption (particularly of fats) --> vitamin def |
|
What is a complication of mastectomy if you have axillary node dissection?
|
arm lymphoedema
|
|
Level of axillary dissections? (3) (risk of lymphoedema increases with level)
|
Level 1: dissection remains inferior to pec minor
Level 2: goes behind pec minor Level 3: goes superior to pec minor |
|
Colostomies are most often placed in the _________
ileostomy most often placed in the ________ |
LIF
RIF |
|
What is low in refeeding syndrome?
|
phosphate
|
|
Where should the tip of a PICC (peripherally inserted central catheter) lie?
|
SVC
|
|
D/C checklist after day-case surgery (mneumonic)
|
LEAPFROG
Lucid, no vomit, easy urination Easy breathing; urination Ambulant w/o fainting Pain relief + post-op drugs F/U arranged Rhythm, pulse, BP checked Op site check GP letter |
|
What must you always check distal to any lump? (2)
|
1. circulation
2. nerve supply |
|
Physical exam for lumps (6 Ss)
+ 6 more! |
1. site
2. size 3. shape 4. smoothness (consistency) 5. surface (contour, edge, colour) 6. surroundings ------ 1. transilluminate? 2. fixed/tethered to skin or underlying structure? 3. temperature 4. tender 5. pulsatile 6. fluctuant/compressible? |
|
Which lump:
- smooth, imprecise margins - hint of fluctuance (part of it bulges out when you push on the other part) - not fixed |
Lipoma
|
|
Which lump:
- intradermal (ie. cannot draw skin over it) - punctum (spot) |
Sebaceous cyst
|
|
Which lump:
- degenerative cyst on adjacent joint or synovial sheath commonly on dorsum or wrist or hand or dorsum of food - may transilluminate - subcutaneous |
Ganglion
|
|
are LNs lumps that are subcutaneous or intradermal?
|
s/c
|
|
If lumps in neck have been there for <3wks, should you undergo extensive Ix?
Why? |
No
likely to be self-limiting infection |
|
6 causes of ascites
|
1. malignancy
2. infections - esp TB 3. decreased albumin (e.g nephrosis) 4. CCF, pericarditis 5. pancreatits 6. myxoedema |
|
How do you tell if a pelvic mass is truly a pelvic mass?
|
you cannot get below it
|
|
Four causes of pelvic mass
|
1. foetus
2. ovarian cyst/malignancy 3. bladder 4. fibroids |
|
What do you think of with swelling, swinging fever and increased WCC?
|
abscess
|
|
Workup for acute abdomen? (9)
|
1. FBC
2. EUCs 3. LFTs 4. amylase 5. CRP 6. ABGs (mesenteric ischaemia?) 7. CXR 8. CT 9. urinalysis (plus always excl ectopic in females) |
|
What are the three things that are most perfused in a normal state and so what do you check for assessing hypovolaemia from blood loss?
|
1. brain
2. skin 3. kidney => GCS => cap refill => urine output |
|
What 2 things do you see on blood tests in appendicitis?
|
1. neutrophil leucocytosis
2. elevated CRP |
|
What is Rovsing's sign?
|
pain > in RIF than LIF when LIF is pressed
= appendicitis |
|
Prophylactic ABx in abdominal surgery (3)
(Colorectal surgery, appendicectomy, upper gastrointestinal tract or biliary surgery, including laparoscopic surgery) |
metronidazole
+ gentamycin OR cephazolin |
|
ABx for Peritonitis due to perforated viscus (3)
|
1. ampicillin
plus 2. metronidazole plus 3. gentamycin |
|
4 cardinal features of intestinal obstruction
|
1. vomiting
2. colic 3. constipation 4. distension |
|
How do bowel sounds sound in obstruction?
|
tinkling
|
|
Dx of bowel obstruction?
|
ABX
|
|
How do you tell from AXR if obstruction is in small bowel?
|
no gas in colon
|
|
S+S of ileus? (2)
(functional obstruction from reduced bowel motility) |
1. absent bowel sounds
2. no pain |
|
Immediate action for suspicion of bowel obstruction (7)
|
"drip and suck"
1. IV fluids to rehydrate 2. NG tube 3. bloods - incl amylase, EUCs, FBC 4. AXR 5. CXR 6. catheter to monitor fluids 7. analgaesia |
|
Mgmt for strangulated bowel?
|
emergency surgery
|
|
3 branches of coeliac trunk (R --> L)
|
1. common hepatic
2. splenic 3. left gastric |
|
Dukes' classification for staging of colorectal cancer (4)
|
Stage:
A -- confined to beneath muscularis mucosae B -- extension through muscularis mucosae C -- involvement of regional LNs D -- distant mets |
|
How many years younger should the patient be than their relatives who've had colorectal cancer to check for colorectal cancer?
|
10 years younger than the youngest affected relative
|
|
What surgical procedure do you do for caecal, ascending or proximal Tv colon tumours?
|
right hemicolectomy
|
|
What surgical procedure do you do for tumours in distal Tv or descending colon?
|
left hemicolectomy
|
|
What surgical procedure do you do for low sigmoid or high rectal tumours?
|
anterior resection
|
|
What do you think of with:
- acute severe abdo pain, central/RIF, constant - no abdo signs - rapid hypovolaemia --> shock |
mesenteric ischaemia
|
|
The main life-threatening complications secondary to acute mesenteric ischaemia? (2)
|
1. septic peritonitis
2. progression of a systemic inflammatory response syndrome into a multi-organ dysfunction syndrome mediated by bacterial translocation across the dying gut wall |
|
Rx for mesenteric ischaemia (3)
|
1. resus with fluid
2. ABx (gent + metronidazole) 3. heparin |
|
Layers of the colon involved in UC
|
mucosa
submucosa |
|
True or false: UC always affects the rectum
|
true
|
|
UC: continuous or skip lesions?
|
continuous
|
|
2 skin manifestations in UC
|
1. erythema nodosum
2. pyoderma gangrenosum |
|
Mgmt of UC (4)
|
1. corticosteroids
2. sulphasalazxine 3. immunosuppressants e.g azathioprine 4. Surgery - proctolectomy |
|
Which 2 parts of the colon are most susceptible to ischaemia?
|
- Griffith's point at splenic flexure - watershed area at junction of SMA and IMA supplies
- Sudeck's critical point in mid-sigmoid - junction b/t IMA and hypogastric aa |
|
Ischaemia affecting full thickness of bowel wall may lead to ___________ with __________ and ___________
|
gangrene
perforation faecal peritonitis |
|
S+S of ischaemic colitis (3)
|
1. abdo pain
2. haematochezia 3. fever |
|
Surgery for ischaemic colitis is rarely necessary.
What are 3 indications for surgery |
1. peritonitis
2. perforation 3. sepsis |
|
Dx of ischaemic colitis
|
colonoscopy
|
|
Pseudomembranous colitis = colitis due to infection with __________
|
C. difficile
(two toxins: A and B) |
|
Leading cause of infectious colitis worldwide?
|
C. jejuni
|
|
Initial mgmt of anyone suspected of having IBD should include stool cultures for....? (5)
|
C. jejuni
Y. enterocolitica Salmonella Shigella C. difficile |
|
ABx for prolonged or severe C. jejuni (3)
|
azithromycin
or ciprofloxacin or nofloxacin |
|
ABx for mod/severy C. difficile
|
Mod: metronidazole
Sev: vancomycin |
|
When in infectious colitis would you do surgery?
|
if toxic megacolon results
|
|
What is a true diverticulum?
|
composed of all layers of intestinal wall
|
|
What in the Western lifestyle can lead to diverticulitis
|
lack of dietary fibre
|
|
Where in the colon do diverticula most commonly occur?
They break through the circular muscle layer at characteristic sites relating to what? |
sigmoid
penetrating vasa recta blood vessels |
|
3 types of clinical presentations for IBS
|
1. abdo pain and constipation
2. alternating constipation and diarrhoea 3. chronic painless diarrhoea |
|
Where is the obstruction:
vomit of semi-digested food ingested 1-2d prior, no bile |
gastric outlet
|
|
Where is the obstruction:
copious bile-stained vomit within hours of onset of abdo pain |
upper small bowel
|
|
Where is the obstruction:
faeculant vomit |
distal
|
|
Where is the obstruction:
no passage of faeces or flatus |
large bowel
|
|
Most common cause of small bowel obstruction
|
adhesions (post surgery)
(followed by hernias) |
|
3 most common causes of large bowel obstruction
|
1. carcinoma
2. sigmoid volvulus 3. diverticular disease |
|
What do you see on xray in proximal small bowel obstruction?
|
lack of intestinal gas
|
|
What do you see in on xray in a distal small bowel obstruction?
|
numerous dilated loops of bowel
|
|
Post-op ileus occurs when bowel has been handled.
Normally, it should not last longer than _____ days |
4-5
|
|
True or false: colicky pain in post op ileus
|
false.
distension and diffuse discomfort |
|
What signals the resolution of paralytic ileus?
|
farting
|
|
Mgmt of ileus (3)
|
1. IV fluids
2. +/- NG decompression 3. prokinetic agents: neostigmine or bethanechol (stim parasymp activity) |
|
What do you think of with redcurrant jelly stool and sausage-shaped mass across upper abdo?
|
intussesception
|
|
What is diagnostic for intussusception?
|
air enema
|
|
Mgmt of intussusception?
|
air or contast enema with carefully controlled pressure
(if fails --> laparotomy --> manipulation. if ischaemia --> resection) |
|
What do you think of with apple-core defect on barium follow through examination?
|
small bowel carcinoma
|
|
Dx of adenocarcinoma of duodenum
|
endoscope and Bx
CT staging |
|
the majority of small bowel adenocarcinoma are:
- polypoid - ulcerated - infiltrative? |
polypoid
|
|
Mgmt for cure of small bowel adenocarcinoma?
|
surgical resection
|
|
Name of surgical resection for most duodenal lesions (adenocarcinoma)?
|
pancreaticoduodenectomy (Whipple's procedure)
|
|
What is Hirschsprung's disease?
|
AKA congenital aganglionosis
- ganglion cells absent from intermyenteric (Auerbach) and submucosal (Meissner) autonomic plexuses -> deficient peristalsis and inability of internal anal sphincter to relax |
|
When newborn's fail to pass meconium and fail to thrive, what is something to think of?
|
Hischsprung's disease
= effective intestinal blockage |
|
the majority of small bowel adenocarcinoma are:
- polypoid - ulcerated - infiltrative? |
polypoid
|
|
Mgmt for cure of small bowel adenocarcinoma?
|
surgical resection
|
|
Name of surgical resection for most duodenal lesions (adenocarcinoma)?
|
pancreaticoduodenectomy (Whipple's procedure)
|
|
What is Hirschsprung's disease?
|
AKA congenital aganglionosis
- ganglion cells absent from intermyenteric (Auerbach) and submucosal (Meissner) autonomic plexuses -> deficient peristalsis and inability of internal anal sphincter to relax |
|
When newborn's fail to pass meconium and fail to thrive, what is something to think of?
|
Hischsprung's disease
= effective intestinal blockage |
|
Dx of Hirschprung's disease
|
rectal Bx
|
|
What does the twisting of the sigmoid in sigmoid volvulus lead to? (3)
|
- ischaemia
- perforation - obstruction |
|
What is the characteristic sign of sigmoid volvulus at sigmoidoscopy?
|
corkscrew sign
|
|
what do you see on plain Xray in sigmoid volvulus?
|
single grossly dilated sigmoid loop
|
|
what do you see on erect Xray in sigmoid volvulus?
|
inverted U or coffee bean sign of bowel gas in upper abdo
|
|
Mgmt of sigmoid volvulus (2)
|
1. endoscopic decompression
2. surgery |
|
Direct inguinal hernias leave the abdomen through a split in the __________ fascia and come out through the ________________ inguinal ring
|
transversalis
superficial |
|
If a hernia becomes irreducible, what might have happened to it?
Then what is at risk? |
strangulated
ischaemic bowel |
|
Organisms (2) in cellulitis of extremities
|
group A strep
S. aureus |
|
recurrent cellulitis of the leg caused by which organism?
|
non-group A beta-haemolytic strep
|
|
Facial cellulitis: which organism?
|
H. influenzae (or, if vaccinated or if there is a local lesion such as impetigo, or a sty, Staph is more likely)
|
|
True or false: there is usually a sharp demarcation from uninvolved skin in cellulitis
|
false
but there is in erysipelas (rapidly progressive cellulitis caused by s. pyogenes) |
|
What is the most common cause of arterial stenosis which causes arterial claudication?
|
atherosclerosis
|
|
DVT: calf circumference difference significant and suggestive of DVT if > ___cm
|
3
|
|
Surgical interventions for peripheral artery disease (2)
|
- bypass surgery (graft)
- amputation |
|
Most common artery for chronic limb ischaemia?
|
superficial femoral artery
(60%) - most common site at lower end of the superficial femoral a where it passes through the hiatus in the adducter magnus into the popliteal fossa |
|
Which arterial system is involved in chronic limb ischaemia involved in buttock and thigh pain and impotence?
|
aorto-iliac
|
|
What is the gold standard for Dx of arterial occlusive disease?
|
CT angiography
|
|
Dx of occlusive arterial disease that is non-invasive (2)
|
- duplex U/S
- ABI |
|
3 surgical options of occlusive arterial disease
|
1. balloon angioplasty
2. stent 3. bypass |
|
Great and small saphenous vv - deep or superficial?
|
superficial
|
|
where does the great saphenous v run on the leg?
|
medial
|
|
Where does the small saphenous v run on the leg?
|
posterior (along calf)
|
|
Where does the great saphenous vein start?
|
dorsum of foot (then anterior to medial malleolus)
|
|
What v does the great saphenous join into?
|
common femoral v
|
|
Where does the short saphenous vein start?
|
lateral malleolus (then runs along lateral and then posterior aspect of calf)
|
|
What v does the short saphenous v join into?
|
popliteal v
|
|
Perforating veins contain valves which direct blood flow from the _______ to the _____ system
|
superficial
to deep |
|
Varicose veins are a disorder of which two systems of veins?
|
superficial and perforating
|
|
3 complications of varicose vv
|
1. thrombophlebitis
2. haemorrhage 3. ulcer |
|
3 mgmt options of venous incompetence
|
1. compression stockings
2. injection-compression therapy 3. surgery - saphenofemoral ligation |
|
General ulcer mgmt principles (5)
|
1. nutrition
2. local skin care 3. ABx for assoc cellulitis 4. remove dead tissue - surgical debridement 5. dressings - best conditions for healing are moist, warm conditions |
|
S+S of critcial arterial ischaemia (3)
|
rest pain
gangrene arterial ulceration |
|
Where are arterial ulcers usually located?
|
distally and on the dorsum of the foot or toes
|
|
Venous or arterial: majority of leg ulcers?
|
venous (80%)
|
|
What else is usually present with venous ulcers?
|
varicose vv
|
|
Where are venous ulcers usually located?
|
in 'gaiter' region:
circumferentially around lower leg from mid calf to just below medial and lateral malleoli |
|
arterial ulcer --> revascularisation
venous ulcer --> ________ |
compression (stockings)
|
|
If pulses are palpable, is this indicative that the arterial ulcer will heal?
|
yes
|
|
Elevation:
reduces pain in venous or arterial ulcer? |
venous
elevation aggrevates pain in arterial |
|
Where are diabetic ulcers commonly found?
|
in weight bearing areas e.g feet, plantar metatarsal head areas, tips of most prominent toes
|
|
Most common form of melanoma
|
superficial spreading
|
|
Most aggressive form of melanoma
|
nodular
|
|
Where do lentigo maligna melanoma arise?
|
sun damaged skin of face, scalp and neck
|
|
What is the ABCD rule for melanoma Dx?
|
A: Asymmetry—one half is different to the other
B: Border—usually irregular C: Colour—variable within the lesion. For hypomelanotic melanoma, pigment is largely or completely absent D: Diameter—greater than 6 mm |
|
Nodular melanoma usually defy the ABC rule.
What is their rule? |
mnemonic EFG—standing for 'elevated', 'firm' and 'growing for more than 1 month'
|
|
Melanoma excision margins:
melanoma in situ (confined to epidermis) |
5mm
|
|
Melanoma excision margins:
depth <1mm |
1cm
|
|
Melanoma excision margins:
depth >4mm |
2cm
|
|
Most common skin cancer
|
BCC
|
|
Where do half of BCCs occur?
|
head and neck
|
|
How do you treat recurrent BCC?
|
surgery
|
|
Rx options for primary BCC? (7)
|
1. excision
2. currettage and cautery 3. cryotherapy 4. imiquimod 5. radiotherapy 6. photodynamic therapy 7. Moh's procedure |
|
What do you think of in terms of cancer with a red patch like eczema?
|
superficial BCC
|
|
A persistent, non–healing sore (bleeds with minimal trauma) is a very common sign of an early _________
|
BCC
|
|
What is it:
papule or nodule, pearly with telangiectasia |
Nodular BCC
|
|
What is it:
ulcer with a rolled border which is translucent, pearly, smooth with telangiectasia and firm |
ulcerating BCC
|
|
What is it:
superficial scar, ill-defined, skin colour, whitish |
Sclerosing BCC
|
|
What is it:
thin plaques, pink or red with fine threadlike border and considerable SCALING |
superficial mulitcentric BCC
|
|
What is it:
brown, blue, black, smooth glistening surface |
pigmented BCC
|
|
What sort of cancer is Moh's surgery used for?
|
BCCs with high risk of recurrence or on face
|
|
What is Bowen's disease?
|
SCC in situ
|
|
What sort of cancer is leukoplakia?
|
SCC
|
|
Rx for low risk SCC
|
curettage and diathermy
|
|
Rx of choice for SCC
|
surgical excision with margins 3-5mm
|
|
A persistent red-brown scaly patch that may resemble psoriasis or eczema
|
Bowen's disease
|
|
What is it:
small firm, erythematous plaque with indistinct margins initially and then becomes raised, ulcerated and larger. May crust at bleed |
SCC
|
|
Commonest form of benign soft tissue tumour
|
lipoma
|
|
What is it:
subcutaneous lump, soft, fluctuant, movable, lobulated masses, not fixed to skin or deep in tissue |
Lipoma
|
|
A lump that becomes less obvious on contraction of the muscle is deep/superficial
Is this likely to be benign or malignant? |
deep (deep to the deep fascia)
malignant |
|
If a suspected lipoma is painful, restricted in movement, is rapidly enlarging or is firm rather than soft, what is the next step in mgmt?
|
Bx
|
|
What is a sebaceous cyst?
|
sebaceous fluid built up inside a pore or hair follicle and form a lump filled with thick greasy matter
|
|
Is a sebaceous cyst freely movable?
|
yes
|
|
What is the opening of a sebaceous cyst called?
|
punctum
|
|
What are the most common cysts?
|
epidermoid cysts
|
|
What are epidermoid cysts filled with?
|
keratin
|
|
What sort of cyst:
no punctum on scalp contain keratin |
pilar
|
|
Do epidermoid cysts have a central punctum?
|
yes
|
|
What is a neuroma?
|
growth or tumour of nerve tissue
|
|
Where do ganglion cysts usually appear?
|
on or around joints and tendons in hand and foot
|
|
What are ganglion cysts derived from?
|
the lining of a synovial joint, tendon sheath or embyological remnants of synovial tissue
|
|
At which joint to the majority of ganglion cysts occur?
|
scapho-lunate joint
|
|
How can you tell the difference between a lipoma and a ganglion cyst?
|
lipoma doesn't transilluminate
|
|
What cyst:
thick, clear, jelly like fluid |
ganglion cyst
|
|
Rx options for ganglion cysts (6)
|
1st line:
observe compressive wraps +/- NSAIDs if ache during activity 2nd line: aspiration +/- corticosteroid injection 3rd line: surgical resection |
|
What is usually the causative organism of boils?
|
S. aureus
|
|
How do you treat small uncomplicated boils with no systemic symptoms
|
incision and drainage
|
|
When would you use ABx along with incision and draining of boils? (3)
|
1. Large lesions (> 5 cm)
2. Spreading cellulitis 3. Systemic symptoms |
|
What is a furuncle?
|
boil
|
|
What is a carbuncle?
|
boils with multiple heads
|
|
What is a boil an infection of?
|
hair follicle
|
|
What is it:
painful, tender, fluctuant, erythematous nodule surmounted by pustule surrounded by rim of erythematous swelling |
skin abscess
|
|
Most common site for soft tissue sarcoma?
|
thigh
|
|
Where do most soft tissue sarcomas occur in relation to fascia?
|
deep to deep fascia (more likely to be malignant)
|
|
In which tissues do soft tissue sarcomas usually develop?
|
mesodermal
|
|
Commonest site of metastasis for soft tissue sarcomas?
|
lungs
|
|
Should you Bx all soft tissue tumours?
|
No
only if clinical or radiological features of malignancy, if it is growing, if it is deep to the deep fascia or is >5cm |
|
Mainstay of treatment for soft tissue sarcoma?
|
surgical resection
(may also need radio and chemo) |
|
What might happen to hernias if they are long standing and become irreducible?
|
incarcerated
|
|
Do strangulated hernias always present with localised pain?
|
no. may pressent with abdo pain or signs of obstruction without localised pain.
so always examine for hernias in a person with acute abdomen |
|
Indirect inguinal hernias usually occur because of a persistent _____________ ___________
|
processus vaginalis
|
|
Strangulation more common in indirect or direct inguinal hernias?
|
indirect
|
|
indirect hernia: medial or lateral to epigastric vessels?
|
lateral
|
|
Where do saphena varices and femoral artery aneurisms occur in relation to inguinal lig?
|
below
|
|
Are inguinal lymph nodes above or below inguinal lig?
|
below
|
|
Direct hernia: bulging through what?
|
transversalis fascia
|
|
Is there a cough impulse in femoral hernias?
Are they reducible? |
rarely
rarely (this is for inguinal) |
|
What else might you see on ipsilateral leg in saphena varix?
|
varicose vv
|
|
What is lipoma of the spermatic cord?
|
herniations of normal extraperitoneal fat
|
|
What is a saphena varix?
What is it caused by? |
dilation of long saphenous v just proximal to the junction with the femoral v
valvular incompetence |
|
Saphena varix is often mistaken for a femoral hernia.
What are 3 signs that differentiate it? |
1. has a cough impulse
2. has a bluish tinge 3. venous hum heard on auscultation |
|
What is in the triple assessment for breast lumps (in the order that you do them)
|
1. clinical Hx/exam
2. radiology 3. histology/cytology (FNAB or core Bx) |
|
Breast lump:
radiology if... <34 35-50 >50 |
<34: #1 = U/S (mamm is U/S sus)
35-50: U/S AND mamm >50: #1 = mamm (U/S if doesn't correlate with clinical findings) |
|
Breast lump:
asymptomatic smooth, rubbery, mobile mass mamm: well circumscribed, may have coarse calcification U/S: solid, round, lobulated, width>height |
fibroadenoma
|
|
Breast lump:
breast pain that fluctuates with periods rubbery, well circumscribed, mobile mamm: sharp borders, if complex has cystic and solid components Aspiration: resolves lump |
fibrocystic
|
|
Breast lump:
prior breast trauma/surgery firm, irregular lump mamm + U/S: indistinct margins, solid |
fat necrosis
|
|
Breast lump:
Breast pain, fever, rapid enlargement Breast fluctuance, tenderness, skin erythema, mastitis U/S: fluid filled cavity + debris aspiration: purulent fluid |
breast abscess
|
|
Breast lump:
painless, slow growing well circumscribed, mobile mass mamm: round with circum margins U/S: solid |
adenoma
|
|
Breast lump:
bloody nipple discharge small mass U/S: dilated duct with oval mass |
intraductal papilloma
|
|
Breast lump:
gradual breast enlargement, PHx or FHx of BrCa Hard, fixed, nipple inversion and d/c, skin retraction, peau d'orange, lymphadenopathy |
invasive breast cancer
|
|
Breast lump:
mamm: indistinct or spiculated margins, increased density, fine calcifications U/S: irregular, ill defined borders height>width calcifications, hypoechogenicity |
invasive breast cancer
|
|
Breast lump:
Bx: cells with hyperchromatic nuclei invading into stroma |
invasive breast cancer
|
|
Breast lump:
asymptomatic +/- mass nipple d/c breast tenderness cracking of skin (Paget's) Mamm: microcalcifications |
DCIS
|
|
Breast lump:
incidental finding on Bx for something else rarely palpable mass nothing specific on U/S or mamm but malignant cells with lobular acini and BM in tact on Bx |
LCIS
|
|
do malignant cells involving the ducts in DCIS cross the BM?
|
no
|
|
Endocrine Rx for ER +/- PR positive breast cancer in PRE- AND PERI- MENOPAUSAL women
|
Tamoxifen
SEs = increased risk of VTE and endometrial cancer Benefits = +ve effect on BMD |
|
Endocrine Rx for ER +/- PR positive breast cancer in POST-MENOPAUSAL women
|
Aromatase inhibitors
SEs = osteoporosis so must have Vit D S' and DEXA yearly |
|
5 common sites for mets of Breast cancer
|
1. liver
2. bone 3. lung 4. brain 5. bone marrow |
|
Mgmt of breast fat necrosis
|
warm compress and NSAIDs
symptoms subside after a few weeks |
|
Where do fibroadenomas arise from?
|
collagenous mesenchyme in terminal duct lobular unit of the breast
|
|
Mgmt of fibroadenoma
|
observe
if sus, excise |
|
How do you tell the difference between fibrocystic and fibroadenoma on U/S?
|
fibroadenoma has some internal echoes
|
|
Mgmt of fibrocysts of the breast?
|
if asymptomatic, just supportive measures, e.g NSAIDs
if symptomatic, aspiration |
|
What are the majority of neck lumps?
|
LNs
|
|
What is the rule of 7s for neck lumps?
|
present for 7d --> inflammatory
for 7mo --> neoplastic for 7yr --> congenital |
|
What are the 6 Ss when examining a lump?
|
Site
Size Shape Smoothness Surface (contour, edge, colour) Surroundings |
|
How can you tell a thyroglossal cyst on examination?
|
moves up on tongue protrusion
|
|
What are the borders of the posterior neck triangle?
|
anteriorly = posterior portion of SCM
posteriorly = anterior portion of trapezius inferiorly = clavicle (apex at union of SCM and trapezius) /___\ |
|
What are the borders of the anterior neck triangle?
|
anteriorly = midline of neck
posteriorly = anterior border of SCM superiorly = mandible (apex at jugular notch) |
|
What are the borders of the submandicular triangle?
|
superiorly = mandible
sides = 2 bellies of digastric |
|
2 midline neck lumps
|
dermoid cyst
thyroglossal cyst |
|
3 submandibular neck lumps
|
LNs (inflamm or malignant)
salivary stone salivary gland tumour |
|
3 anterior triangle neck lumps
|
1. branchial cyst (adult)
2. parotid tumour 3. carotid body tumour |
|
3 posterior triangle neck lumps
|
1. LNs (inflamm or cancer)
2. cystic hygroma (children 0 transilluminate) 3. subclavian artery aneurysm |
|
Four major subtypes of thyroid carcinoma (and which is most common *)
|
1. papillary*
2. follicular 3. anaplastic (these three from endodermally derived follicular cells) 4. medullary (arise from neuroendocrine-derived calcitonin secreting C cells) |
|
What is the major risk factor for papillary thyroid cancer?
|
ionizing radiation
|
|
Dx of thyroid carcinoma
|
FNAB
|
|
Rule of 80s for salivary gland tumours
|
80% are in parotid
80% are benign 80% of these are pleomorphic adenomas 80% of these are in the superficial lobe of the gland |
|
Dx of parotid tumour
|
U/S
and FNAB |
|
Risk of removal of parotid tumour?
|
damage to facial nerve
|
|
What is it:
lump at carotid bifurcation, anterior to the upper third of SCM moves from side to side but not up and down |
carotid body tumour
|
|
Do thyroglossal duct cysts elevate on swallowing?
|
no
on tongue protrusion |
|
Branchial cysts arise from failure of obliteration of what in the development of the neck?
|
branchial cleft
|
|
Branchial cysts: which neck triangle?
|
anterior
|
|
Branchial cysts: mgmt
|
surgical excision if symptomatic
|
|
What do you think of with stony hard LNs?
|
malignancy (usually mets)
|
|
What do you think of with firm and rubbery LNs
|
lymphoma
|
|
What do you think of with soft enlarged LNs?
|
inflammation and infection
|
|
What do you think of in children with shotty nodes?
|
viral illness
|
|
Majority of bladder neoplasms
|
TCC
|
|
Majority of bladder carcinoma; superficial or invasive?
|
superficial (in lamina propria or mucosa)
|
|
Gold standard for Dx of bladder carcinoma
|
cystoscopy and biopsy
|
|
Biggest RF for renal carcinoma?
|
smoking
|
|
Most common subtype of renal cell carcinoma
|
clear cell in proximal tubule
|
|
Classic triad for RCC
|
1. haematuria
2. abdominal mass 3. flank pain |
|
Rx for RCC that is <4cm or stage I or II (confined to kidney)
|
surgical resection
|
|
Rx for RCC that is stage III
|
radical nephrectomy
|
|
Rx for RCC that is stage IV (met)
|
Tyrosine kinase inhibitors (Sorafenib)
may require debulking surgically |
|
How do renal calculi present if not asymptomatic? (2)
|
loin pain
vomiting |
|
What are the majority of renal calculi made of?
|
calcium
|
|
What sort of kidney stone:
low urine volume, hypercalciuria Radiopaque on KUB |
calcium oxalate
|
|
What sort of kidney stone:
primary hyperparathyroidism renal tubular acidosis low urine vol radiopaque on KUB |
calcium phosphate
|
|
What sort of kidney stone:
urinary pH <5.5 radiolucent on KUB |
uric acid
|
|
What sort of kidney stone:
genetic error in metabolism poor radiopaque on KUB |
Cystine
|
|
What sort of kidney stone:
infection stone, Proteus or pseudomonas |
Struvite
|
|
How do majority of patients pass kidney stones?
|
75% do it spontaneously
|
|
Medical mgmt of renal stones? (2)
|
1. NSAIDs
2. Expulsive therapy (relax ureteral smooth muscle) - alpha-1 antagonists (terazosin) and calcium channel blockers (Nifedipine) |
|
Imaging modality of choice for kidney stones?
|
non contrast CT
|
|
Work up for suspected renal calculi (6)
|
1. urinalysis
2. FBC 3. EUCs 4. pregnancy test 5. non contrast helical CT 6. stone analysis |
|
Medical Rx for uric acid stones (2)
|
allopurinol
or alkalinization of urine (cos acidic urine causes uric acid stones) - with potassium citrate |
|
First line surgical Rx for renal calculi if medical Rx fails (i.e no pain relief, failure of stone to progress or persistent obstruction) (2)
|
1. ESWL (extracorporeal shock wave lithotripsy)
2. Ureteroscopy |
|
Most common bug causing UTIs
|
E. Coli
|
|
Empirical ABx for UTI
|
Cephalexin
or Trimethoprim |
|
Who gets overflow incontinence?
|
People with neuropathies e.g DM, MS
because of hypotonic bladder |
|
What are the irritative symptoms of BPH? (mnuemonic)
|
FUND
frequency urgency nocturia dysuria (all the others are obstructive symptoms) |
|
Medical mgmt of BPH (2)
|
alpha-blockers (terazosin, tamsulosin .... anything with '-ozin') - relax smooth muscle of prostate
5-alpha-reductase inhibitors (Finasteride) - reduce prostatic volume |
|
3 main surgical options for BPH
|
1. TURP
2. prostatectomy 3. stents |
|
In which zone do CaP usually occur?
|
peripheral
|
|
Dx of prostate cancer (3)
|
PSA >4microgram/L
(or increasing at a velocity of > 0.75mcg/L/year) and Bx |
|
Mgmt CaP - low risk, medium risk, high risk
|
low risk or not expected to live >10y - watch and wait
medium risk - brachytherapy or external beam radiation high risk - prostatectomy if met - add LHRH agonist (Goserelin) |
|
How do you tell the difference between a hydrocele and a spermatocele?
|
testis is NOT separable from hydrocele
testis IS separable from spermatocele (remember it by thinking that the sperm can swim away from the ball) |
|
What is a hydrocele?
|
fluid between layers of tunica vaginalis
|
|
What is a spermatocele?
|
benign cystic accumulation of sperm that arises from the head of the epididymis
|
|
What is a varicocele?
|
abnormal dilation of internal spermatic vv and pampiniform plexus
|
|
What does a varicocele feel like when palpated?
|
bag of worms
|
|
On which side are 90% of varicoceles?
|
LHS
|
|
Dx of varicocele
|
Doppler
|
|
Do varicoceles transilluminate?
|
no
|
|
2 scrotal swellings that transilluminate
|
hydroceles
spermatoceles |
|
do haematoceles transilluminate?
|
no
|
|
What do you have to rule out in sudden onset acute scrotal pain?
|
testicular torsion
|
|
Other than pain and enlargement, what other S+S are there of testicular torsion? (4)
|
1. N+V
2. exquisitely tender 3. testis transverse lie (horizontal) 4. absence of cremasteric reflex |
|
How many hours do you have to act in testicular torsion?
|
6
|
|
Rx of testicular torsion (3)
|
1. surgical exploration + orchidopexy (stitching testis to posterior tunica vaginalis) if viable testis, or orchidectomy if testis not viable. Also fix contralat testis to posterior wall
2. supportive care: morphine, anti-emetics 3. if no surgery available w/i 6h, attempt manual de-torsion |
|
Sexual causes of epididymitis is from what?
Non-sexual causes are from enteric organisms such as what? |
Chlamydia, gonorrhoea
E. Coli |
|
What do you think of with painful, indurated scrotum +/- urethral d/c
|
epididymitis
|
|
Mgmt epidiymitis (3)
|
1. analgaesia
2. bed rest and scrotal elevation 3. ABx (if probably STI give ceftriaxone + azithromycin + doxycycline) |
|
Direct force usually causes which sort of #?
|
transverse
soft tissue must also be damaged |
|
A crushing force usually causes which sort of #?
|
comminuted
|
|
A twisting force usually causes which sort of #?
|
spiral
|
|
A compression force usually causes which sort of #?
|
oblique
|
|
A bending for usually causes which sort of #?
|
triangular butterfly
|
|
A tension force (eg pulling in opposite directions) causes what sort of #?
|
transverse
|
|
What is a comminuted #?
|
>2 pieces (i.e as opposed to simple which is just 2 fragments)
|
|
5 stages of fracture healing
|
1. Haematoma formation – soon after (hours-days)
2. Inflammation/cellular proliferation around # site (can last for weeks) 3. soft Callus 4. Consolidation (formation of hard callus) 5. Remodelling (months – years) |
|
What should you suspect if there is a # with trivial injury or a # with a Hx of malignancy?
|
pathological #
|
|
4 principles of fracture healing
|
1. manipulate to improve position
2. splint 3. preserve joint 4. rehabilitate |
|
When to undergo reduction for fractures
|
when there is displacement to realign fracture surfaces
|
|
After a closed reduction and then putting on a cast, what do you have to do?
|
xray to make sure it's realigned properly
|
|
Articular #s: alway open or closed reduction?
|
open - need perfect anatomical alignment
|
|
Following reduction, the available methods of holding are...?(5)
|
1) continuous traction
2) cast splintage 3) functional bracing 4) internal fixation 5) external fixation |
|
After putting on a cast, if there is diffuse pain or paraesthesia, what do you do? (2 steps)
|
1. elevate limb
if that doesn't work 2. strip everything off down to skin |
|
Remember for lower limb casts, what position do you put ankle and tarsus/forefoot?
|
ankle usually at right angle
tarsus/forefoot neutral = plantegrade position |
|
Does internal fixation heal faster or slower than casts and traction?
|
slower
|
|
Following reduction, what method of holding is used for pathological #s?
|
internal fixation
|
|
If there is severe soft tissue damage or nerve/BV damage along with fracture, what method do you use for holding?
|
external fixation
|
|
What are compound fractures?
|
open fractures
|
|
What immunological status do you need to check with compound fractures?
|
tetanus
|
|
4 principles of Rx with compound fractures
|
- Wound debridement
- Antibiotic prophylaxis - Stabilisation of fracture - Early wound cover |
|
What nerve can be damaged in....
shoulder dislocation How can you tell? |
axilla
weak deltoid and decreased sensation around lateral shoulder |
|
What nerve can be damaged in....
Humerus shaft fracture |
radial
|
|
What nerve can be damaged in...
humerus supracondylar fracture |
median or radial
|
|
What nerve can be damaged in....
hip dislocation |
sciatic
|
|
What nerve can be damaged in....
knee dislocation |
peroneal
|
|
5 early complications of fracture
|
- Vascular injury
- Nerve injury - Compartment syndrome - Infection - Fracture blisters (elevation of superficial layers of skin by oedema) |
|
5 late complications of fracture
|
- Delayed/Non-union
- Malunion - Avascular necrosis - Growth disturbance - Stiffness, CRPS (chronic regional pain syndrome), post traumatic osteoarthritis, etc |
|
What's wrong with the muscle if there is pain on passive stretch?
|
ischaemic
|
|
3 fractures that are notorious for leading to avascular necrosis
|
1. NOF or hip dislocation
2. scaphoid 3. talus (particularly proximal fractures with the 2nd 2 cos blood supply runs distal - proximal) |
|
Most common direction for shoulder dislocation
|
anteroinferior
(ie forward and down) |
|
What is a Smith's fracture?
Where is it? |
Reverse Colle's
ie. it's a flexion fracture distal radius |
|
What sort of fracture (ie direction) is a Colle's?
|
extension fracture
|
|
Where is a Boxer's fracture?
|
4th and/or 5th transverse neck of the metacarpal bone secondary to an indirect force such as striking an object with a closed fist
|
|
True or false:
you get avascular necrosis in intertrochanteric # |
False
NOF you do though |
|
Clinical presentation of hip fracture (both NOF and intertrochanteric)
|
leg is shortened and externally rotated
|
|
What artery is often damaged in knee dislocation?
|
popliteal
=> check foot circulation |
|
Mgmt of knee dislocation
|
urgent reduction
|
|
What is a Jone's fracture?
|
5th metatarsal #
|
|
What must you think of if there is a child <2 with a fractured femur?
|
child abuse
|
|
What should you think of in an Asian with a neck lump?
|
nasopharynx SCC
|
|
Swallowing elevates ______________ ____________
|
thyroid nodules
|
|
Poking tongue out elevates ____________ ____________
|
thyroglossal cysts
|
|
Where do malignancies of head and neck first spread to?
|
parotid gland
|
|
What do you worry about with firm, non tender LNs in male >40
|
malignancy
|
|
ulcer in medial aspect of leg, it is a _____________ ____________ ulcer until proven otherwise.
|
chronic venous
|
|
What is characteristic about the margins of venous ulcer?
|
sloped
|
|
Are venous ulcers painful?
|
no
(unless infection - look for cellulitis) |
|
6 Grades of venous ulcer
|
(0 = valvular incompetence with no signs)
1 = telangiectasiae (spider vv - at surface) 2 = varicosities (knotty) 3 = leg swelling 4 = lipodermatosclerosis (chronic skin changes) 5 = healed ulceration 6 = chronic venous ulcer |
|
If a venous ulcer has been present for ages and the edges become raised and everted, what do you think of?
|
transformation to SCC
|
|
Most common site of valve incompetence?
|
saphenofemoral junction
(reflex back into great saphenous) |
|
True or false:
DVT can lead to secondary varicose veins? |
true
valves destroyed/obstruction |
|
At which junction is there reflux back into small saphenous v?
|
saphenopopliteal junction
|
|
Pathophysiology of valvular incompetence (3)
|
1. reflux
2. obstruction (e.g DVT) 3. reflux + obstruction |
|
Mainstay Ix for venous disease
|
Duplex U/S
|
|
Venous or arterial disease:
noctural pain when leg elevated |
arterial
|
|
Venous disease Rx
|
- Regular walking for calf muscle pump
- Weight reduction - Avoid prolonged standing, sitting - Frequent leg elevation - Compression stockings (athoxysclerol = sclerotherapy for Grade 1-2) (Grade 2-6 = Surgery) |
|
Surgical Rx of venous disease
|
high ligation and stripping
|
|
Don’t strip great saphenous from below _______ even if incompetent since _______ nerve can leave Pt with parasthesia if damage
|
knee
saphenous |
|
Effectiveness of prophylaxis in General surgery (5)
|
IPC > LMWH > unfrac Heparin > GCS > aspirin
|
|
Pt should receive pharmacological DVT prophylaxis if having major surgery and are >___ years old
What is considered major surgery? |
40
Abdo surgery Surgery >45min Hip or knee athroplasty hip surgery #3 surgery w/ previous DVT active cancer |
|
VTE prophylaxis:
Total hip replacement |
LMWH or fondaparinux or rivaroxaban
PLUS GCS or IPC til fully mobile |
|
VTE prophylaxis:
total knee replacement |
LMWH or fondaparinux or rivaroxaban
PLUS IPC |
|
VTE prophylaxis:
lower leg immobilisation due to injury |
consider LMWH til fully mobile
|
|
VTE prophylaxis:
Hip fracture surgery |
LMWH or fondaparinux
|
|
VTE prophylaxis:
major general surgery, eg abdominal, gynaecological, cardiac, thoracic or vascular surgery |
LMWH or unfractionated heparin
PLUS GCS |
|
VTE prophylaxis:
Neurosurgery |
consider with caution, LMWH or UFH
PLUS IPC |
|
VTE prophylaxis:
Cancer patients having surgery |
LMWH or UFH
|
|
Physiological or pathological:
unilateral nipple discharge |
pathological
|
|
Physiological or pathological:
green brownish thick nipple discharge |
physiological
|
|
Physiological or pathological:
serious, bloody, clear discharge |
pathological
|
|
Most common form of invasive breast cancer?
|
ductal NST (no special type)
|
|
What are the two most common invasive breast cancers of 'special type'?
|
Lobular
Tubular |
|
Do special or non special types of breast cancer have a better prognosis?
|
special
|
|
With complete local excision of a breast lump, what margins do you need to get?
|
5-10mm
|
|
Lymphoscintigraphy: What does it show up?
What does it mean? |
sentinel LN
doesn't mean it's spread there but it means you have to take it out |
|
Problems associated with axillary dissection
|
- Seroma formation
- Numbness and paraesthesia - Damage to motor nerves - Reduced shoulder mobility and stiffness - Chronic lymphoedema |
|
Verification of Dx of hernia if unsure by which Ix? (3)
|
1. U/S
2. herniography (inject dye into peritoneal cavity – see dye coming through hernia orifice OR use air) 3. CT |
|
3 principles of surgical repair of hernia
|
1) reduce contents
2) excise peritoneal sac (herniotomy) 3) repair the muscular defect (if acquired) (unnecessary if congenital) with prosthetic mesh |
|
Most common hernia
|
inguinal
|
|
During hernia repair, which nerve do you have to protect?
What does it innervate? |
ilioinguinal nerve
scrotum, penis, inner thigh |
|
Direct or indirect: into scrotum
|
indirect
|
|
Other than observe, what other conservative hernia management is there?
|
'Truss' belt
|
|
Borders of femoral ring
|
anteriorly inguinal ligament, medially by lacunar ligament which is a rounded ligament of external oblique, posteriorly by iliopectineal ligament, laterally by femoral v
|
|
Femoral hernia, more common in women or men?
|
women
|
|
Epigastric hernia: defect in what?
|
linea alba
|
|
What sort of hernia is Divarication of the recti?
|
epigastric
|
|
What sort of fluid comes out before abdominal wound dehissence?
|
serosangionous - like pink champagne
|
|
Small breast lumps (<5mm): use which sort of Bx?
|
FNAB
|
|
Multicentric disease (i.e more than one cancer in the chest) - lumpectomy or mastectomy?
|
mastectomy
|
|
Large tumour / breast ratio - lumpectomy or mastectomy?
|
mastectomy
|
|
Doing a mastectomy avoids radiotherapy unless... (2)?
|
tumour >5cm
>4 LNs involved |
|
What's the point of doing sentinel LN Bx?
|
if sentinel LN is negative for Ca, then the assumption is made that the rest of the LNs will be negative and are left in situ. If sentinel nodes +ve for Ca, recommend that clear remaining LNs
|
|
How soon before surgery are smokers recommended to quit?
|
8 weeks
|
|
What is the most common 'complication' when undergoing GA?
|
dental damage
|
|
Cut off line for GA is at ___ METs – i.e cardioresp reserve is adequate
(Measure of Exercise Tolerance) |
4
(1 = dress yourself, 4 = climb flight of stairs, 10 = strenuous exercise) |
|
What reflex do you test if suspect testicular torsion?
Absent or present? |
cremasteric
absent |
|
What is patent in a communicating hydrocele?
|
processus vaginalis
|
|
Mgmt of hydrocele
|
do not aspirate
adults: if no discomfort, no Rx necessary children: ligate processus vaginalis + excision, or drainage of hydrocele (inguinal approach if <12, scrotal approach if >12) |
|
What is cryptorchidism?
What is it a risk factor for? What is the name of the procedure that fixes cryptorchidism? |
undescended testis
testicular cancer orchidopexy (permanently fix it to tunica vaginalis) |
|
What sort of tumour is the majority of testicular cancer?
|
germ cell tumours
- seminomas or non-seminomas |
|
3 tumour markers for testicular cancer
|
AFP
beta-hCG LDH |
|
Rx testicular cancer
|
medical: chemo
surgical: radical inguinal orchidectomy |
|
A sliding inguinal hernia is a portion of viscera which slides behind the peritoneal sac into the inguinal canal with the wall of the organ forming part of the hernial sac. If it's on the RHS, what is it likely to be? On LHS?
|
R: caecum
L: sigmoid colon |
|
Which inguinal hernia is lateral and which medial to inferior epigastric vessels?
|
lateral: indirect
medial: direct |
|
If you suspect intracerebral haemorrhage, which imaging do you get? What would it look like?
|
non-contrast CT
blood shows up brightly |
|
Extradural haematoma- often from temporofacial skull fracture that disrupts which artery?
|
middle meningeal artery
|
|
Presentation of extradural haematoma? (3)
|
1. brief post-traumatic loss of consciousness
2. lucid interval for several hours 3. then obtundation, contralateral hemiparesis, ipsilateral pupillary dilatation |
|
Shape of extradural haematoma on non-contrast CT?
|
convex
|
|
Rx of extradural haematoma if large?
|
surgical evacuation
(clot removal through craniotomy) |
|
Of all traumatic brain injuries, which has the highest mortality?
|
subdural haematomas
|
|
What does subdural haematoma look like on CT?
|
crescent shaped
("Cubdural") |
|
Most common cause of SAH?
|
trauma
|
|
What do you think of with SUDDEN onset, severe (worst ever) headache?
|
SAH
|
|
True or false: neck stiffness in SAH
|
true
|
|
First Ix for suspected SAH is non-contrast CT.
If that's -ve but you're still suspicious, what would you do? Once diagnosed, what is the gold standard for finding the source? |
LP
cerebral angiogram |
|
Vasospam is sequelae of which sort of head bleed?
How do you treat it? |
SAH
CCB |
|
non-contast CT - blood found within sulci. What is it?
|
SAH
|
|
True or false: having a first degree relative with a family history of cerebral aneurysms is a risk factor for cerebral aneurysms
|
true
|
|
Cerebral aneurysms: fusiform or saccular (berry):
congenital predisposition (defect in muscular layer of arterial wall) |
fusiform
|
|
Cerebral aneurysms: fusiform or saccular (berry):
HTN or atherosclerosis |
saccular
|
|
Main cause of berry aneurysms?
|
HTN or atherosclerosis
|
|
Most common location for saccular (berry) aneurysms
|
anterior communicating artery
|
|
Most common location for fusiform aneurysms
|
vertebrobasilar system
|
|
Gold standard mgmt for aneurysms?
|
surgical clipping
(medical mgmt: control RFs eg HTN) |
|
What Glascow coma scale score means coma?
|
> or = 8
|
|
GCS:
what are the three categories to test? |
eye opening
verbal response motor response |
|
GCS:
eye opening points |
4 = spont
3 = to speech 2 = to pain 1 = 0 |
|
GCS: verbal response scoring
|
5 = orientated
4 = confused 3 = inappropriate 2 = incomprehensible 1 = none |
|
GCS: motor response scoring
|
6 = obeys
5 = localises to pain 4 = withdraws to pain 3 = decorticate (flexion of upper limb) 2 = decerebrate (extension of upper limb) 1 = none |
|
Highest possible GCS score?
Lowest? |
15
3 |
|
Any person with a (minor) head injury should be observed in hospital for at least how many hours?
|
4
(longer than 4 if drowsy, unconscious >10min, focal neuro deficits, skull #, persistent N+V) |
|
three types of cerebral oedema (can occur within ours of head injury)
|
1. cytotoxic - head injury, cells die and swell and then shrink: BBB in tact
2: vasogenic: BBB disrupted, protein leaks out and gets extravasation, responds to corticosteroids (dexamethasone) 3: ischaemic : combo of other two |
|
What does cerebral oedema look like on non-contrast CT?
|
low density (darker)
|
|
Which CNs can be damaged in temporal bone fracture?
What would the signs be? |
VII: loss of facial movement
VIII: hearing loss/tinnitus |
|
A fracture where in the skull might lead to anosmia?
|
anterior fossa
(damaged olfactory) |
|
3 symptoms of raised ICP
|
1. headache- frontal and in the morning
2. vomiting 3. blurred vision |
|
5 signs of raised ICP
|
1. depressed consciousness
2. Cushing's Triad: HTN, bradycardia, abno respiration 3. VI nerve palsy 4. papilloedema 5. pupillary dilation (compression of III) |
|
MGMT OF RAISED ICP in order that you'd do them (5)
|
1. elevate head of bed
2. mannitol or lasix 3. hyperventilate (ventilate to a PaCO2 or 30mmHg) - INTUBATE IF GCS <8 OR ANY PUPIL DILATION 4. avoid hypotension (MAP should be > normal to maintain cerebral perfusion) 5. Dexamethasone in vasogenic cerebral oedema (eg CNS tumours) |
|
If Patient is unconscious and has undergone trauma and has raised ICP, what can you do?
|
external ventricular drain (in OT)
|
|
What is the most common brain tumour?
|
metastasis
(but most common primary is GLIOMA) |
|
Three most common presentations of brain tumour
|
1. focal neurological deficit (usually motor weakness)
2. headache 3. seizure |
|
If Patient is unconscious and has undergone trauma and has raised ICP, what can you do?
|
external ventricular drain (in OT)
|
|
What is the most common brain tumour?
|
metastasis
(but most common primary is GLIOMA) |
|
Three most common presentations of brain tumour
|
1. focal neurological deficit (usually motor weakness)
2. headache 3. seizure |
|
Brain tumours can be split up into which two categories based on location?
|
Supratentorial (may have Sz)
Infratentorial (may have cerebellar signs, brain stem signs) Both have raised ICP from effect of tumour and/or associated oedema or blockage of CSF drainage leading to hydrocephalus |
|
Ionizing radiation is a risk factor for which brain tumour?
|
glioblastoma multiforme
|
|
Meningioma:
- grow fast or slow? - malignant or benign? - arises from which cells? - most common location? - mgmt? - prognosis |
- slow growing
- usually benign - arise from arachnoid cap cells - parasagittal - mgmt: watch and wait. If symptomatic or growing, surgically resect - good prognosis |
|
Glioma:
- arises from which cells? - most common location? - mgmt? - prognosis |
- glial cells
- anywhere in the brain - mgmt: surgical resection + radiotherapy or surg + chemo (Temozolomide) - prognosis : low grade = a few years, high grade (Glioblastoma multiforme) <1yr |
|
General mgmt of brain tumours
|
medical: decrease raised ICP with dexamethasone
surgical: excision if possible |
|
What sort of glioma is glioblastoma multiforme?
|
astrocytoma
|
|
Oligodendroglioma is a type of glioma.
- most common presentation - arise from which cells - most common location - mgmt - prognosis |
- seizures
- oligodendrocytes - frontal lobes (affect personality) - surg and chemo - 5-8 years |
|
What are the three types of glioma
|
1. ependymoma
2. astrocytoma (think GBM) 3. oligodendroglioma |
|
What is the most common primary source of cerebral mets?
|
lung
|
|
Mean survival for brain mets, even with Rx?
|
8mo
|
|
Initial mgmt for brain mets (2)
|
anticonvulsants
corticosteroids |
|
Modes of Rx for brain mets
|
depends on origin...
Surgical resection - usually for solitary lesions Radiotherapy - for radiosensitive tumours eg. small cell lung Ca, lymphoma/MM/leukaemia, breast Chemo - depends on cancer |
|
What do meningiomas look like on MRI?
|
White dense masses near meninges - so either at the edge or near the falx
|
|
What do glioblastoma multiforme look like on MRI?
|
blotchy mass with ring enhancement around tumour (= blood from angiogenesis) with a central hypodensity (darker) and oedema around the tumour
|
|
What do cerebral mets look like on MRI?
|
smallish white round masses - usually MANY
|
|
What location are paediatric tumours usually?
|
infratentorial
- most in posterior fossa (adults usually supratentorial) |
|
Most common paeds brain tumours (4)
|
1. cerebellar astrocytoma (pilocytic astrocytoma)
2. medulloblastoma 3. brainstem glioma 4. ependymoma |
|
Most commonly, pituitary tumours secrete which hormone
|
prolactin
|
|
Hydrocephalus: most common mgmt in the form of shunting
|
ventriculoperitoneal shunt
|
|
Medical therapies for hydrocephalus (3)
|
1. acetazolamide
2. diuretics 3. spinal tap (serial LPs) - use with caution so as not to cause herniation |
|
Triad of presentation in normal pressure hydrocephalus (not pathognomonic)
|
1. gait disturbance
then 2. dementia then 3. urinary incontinence |
|
Where in the spine is the most common location for epidural abscess?
|
thoracic
|
|
Most common organism in epidural abscess?
|
staph aureus
|
|
Contents of carpal tunnel
|
flexor digitorum profundus tendons
flexor digitorum superficialis tendons flexor pollicis longus tendon (ie. FLEXORS) and median nerve |
|
Which fingers/part of hand affected in carpal tunnel?
|
thumb, index finger, middle finger and half of ring finger
|
|
Which muscle might be wasted in carpal tunnel?
|
thenar eminence
|
|
Rx of carpal tunnel (conservative and surgery)
|
conservative: wrist splint, NSAIDs
surg: flexor retinaculum division |
|
Ulnar neuropathy: paraesthesia and flexion of which fingers?
|
ring and little
|
|
What is Chiari II malformation most commonly associated with?
|
myelomeningocele
|
|
What is the difference between Chiari I and Chiari II in terms of displacement?
|
I: cerebellar tonsils go into cervical canal but not medulla
II: medulla, vermis and 4th V do into cervical canal |
|
What is the difference between meningocele and myelomeningocele?
|
Both: defect of vertebral arches with cystic dilation of meninges
meningocele: no abnormality of neural tissues myelomeningocele: structural or functional abnormality of spinal cord or cauda equina |
|
What is Hirschrpung's disease?
How does it present? Ix Rx |
lack of ganglion cells in distal colon (Auerbach's and Meissner's plexus) => uncoordinated peristalsis and decreased motility
Failure to pass meconium, bilious vomiting, later constipation Barium enema then plain Xray (distended loops) Rx: diverting colostomy |
|
Most common type of RCC
|
clear cell carcinoma
|
|
Large bowel obstruction:
4 categories of causes |
1. within the wall:
tumours inflamm stricutres (e.g crohn's, diverticular) drug induced strictures (NSAIDs) lymphoma intussusception 2. outside the wall adhesions tumours hernias volvulus 3) within in the lumen impacted poo gallstones foreign body 4) pseudo-obstruction - eg motility disordere.g disturbance of nerves |
|
Imaging of choice for diverticular disease
|
CT
|
|
Can diverticula lead to obstruction?
|
yes by poo - faecolith obstruction
|
|
Dx of colonic perforation
|
xray shows air in peritoneal cavity
CT shows location of perforation |
|
Gold standard to Dx PID
|
direct visualisation with laparoscope
|
|
Mgmt of PID
|
ABx
|
|
What is Rovsing sign
Psoas sign obturator sign |
Rovsing - tenderness in RIF when palpating LIF
Psoas - pain on hip extension Obturator - pain when hip flexed and externally rotated |
|
Dx of appendicitis
|
clinical Dx
Ultrasound has good PPV WCC high |
|
High or low grade fever in appendicitis
|
low
|
|
Mgmt of appendicitis (7)
|
1. NBM
2. pain relief 3. crystalloid fluids 4. anti-emetics 5. prophylacic ABx (metronidazole + cephazolin OR gentamycin) 6. surgery |
|
Most common ovarian cyst
|
follicular
|
|
What do you think of with severe unilateral abdo and pelvic pain with extremely tender unilateral adnexal mass (pregnancy can predispose to it)
What is the Rx? |
ovarian torsion
Surgery: untwisting of pedicle, stabilisation of the ovary through sutures |
|
How long prior to surgery do you stop aspirin?
|
1 week
|
|
5 organisms in wound infection
|
S. aureus
E. coli Enterococcus Step spp. Clostridium spp |
|
Perforated duodenal ulcer:
which wall if see free air under diaphragm on CXR? |
anterior
|
|
Perforated duodenal ulcer:
Which wall if goes into pancreas or haemorrhage (and which artery) |
posterior
gastroduodenal |
|
Perforated duodenal ulcer:
Rx? |
omental patch
|
|
Which has a greater risk of bleeding: gastric or duodenal ulcer?
|
gastric
|
|
What is Meckel's diverticulum?
|
remnant of embryonic vitelline duct on antimesenteric border of ileum
|
|
Rx of strangulated hernia
|
emergency repair
|
|
What does an incarcerated hernia mean?
Strangulated? |
irreducible
irreducible with ischaemia |
|
Which hernias are most likely to strangulate?
|
femoral
|
|
How can bowel obstruction lead to electrolyte disturbances?
|
bowel wall oedema and disruption of normal bowel absorptive function --> increased intraluminal fluid --> transudative fluid loss into peritoneal cavity and electrolyte disturbances
|
|
on AXR, what do you see in SBO and LBO?
|
SBO: air-fluid levels; 'ladder pattern', proximal distension
LBO: air fluid levels; 'picture frame' of colon around periphery of abdomen, proximal distension and distal decompression |
|
Bowel sounds in SBO and LBO vs paralytic ileus
|
normal or increased
decreased or absent in paralytic |
|
Top 3 causes of SBO
|
ABC
1. adhesions 2. 'bulge': hernia 3: carcinoma |
|
Rx of bowel obstruction
|
stabilize vitals, fluid and electrolyte resus (normal saline then add potassium after fluid deficits corrected [hypokalaemia due to metabolic alkalosis due to vomiting]), NG tube to prevent aspirate and decompress, foley catheter to monitor UO
|
|
Top 3 causes of LBO
|
1. cancer
2. diverticulitis 3. volvulus |
|
Paralytic ileus: post op, when does gastric and small bowel motility return?
And colonic? |
24-48h
3-5d |
|
An acute abdomen (with pain out of keeping with physical findings) + metabolic acidosis = ____________________ until proven otherwise
|
bowel ischaemia
|
|
What do you see on bloods in intestinal ischaemia?
|
leukocytosis
(late) lactic acidosis |
|
What is the Dx:
xray: portal venous gas, intestinal pneumatosis (gas in bowel wall) CT: thickened bowel wall, SMA or SMV thrombus.. |
intestinal ischaemia
|
|
How long in appendicitis til perforation?
|
can be around 24h
|
|
Indications for surgery of Crohn's
|
1. medical mgmt failed
2. SBO due to stricture/inflammation 3. abscess, fistula, QOL, perforation, haemorrhage, chronic disability, perianal disease |
|
Surgical procedures in Crohn's
|
resection and anastomosis/stoma if inflammation
stricutroplasty - widens lumen in chronically scarred bowel (can't do if active inflammation) |
|
What's the difference between right and left sided diverticuli?
|
right - contains all three layers (congenital)
left - contains only mucosal and submucosal layers (acquired) |
|
Most common location for diverticula? Why?
|
sigmoid colon
highest pressure at site of penetrating vessels at antimesenteric tenia (greatest weakness) |
|
Bowel movements in diverticulitis?
|
alternating constipation and diarrhoea
|
|
Best imaging for diverticulitis?
|
CT
|
|
Hinchey Staging and Rx for diverticulitis:
1: Phlegmon/small pericolic abscess 2. large abscess/fistula 3. purulent peritonitis (ruptured abscess) 4. faeculent peritonitis |
1. medical mgmt (IV ABx covering B.fragilis [metronidazole])
2. abscess drainage, resection 3. hartmann procedure 4. hartmann procedure |
|
Two types of adenoma colorectal polyps
Which has higher malignancy potential |
tubular - pedunculated - low malignant potential
villous - sessile - high malignant potential |
|
FAP has mutation in which gene?
|
APC
|
|
Most common site of colorectal carcinoma met
|
liver
|
|
What tumour marker do you check before surgery for a baseline in colorectal cancer?
|
CEA
|
|
TNM staging for colorectal cancer
|
I: T1,2 N0M0
II: T3,4 N0M0 III: Tx N+ M0 IV: Tx Nx + M1 |
|
If colorectal cancer is low in rectum, they will require an abdominal perineal resection and need a permanent what?
|
colostomy
|
|
What does sigmoid volvulus look like on AXR?
|
coffee bean sign that points to LLQ
|
|
Mgmt of sigmoid volvulus
|
decompression by flexible sigmoidoscopy and insertion of rectal tube past obstruction
then elective surgery later recommended |
|
What line is the cut off line between internal and external haemorrhoids?
Which circulation involved in which? |
internal: above dentate line, portal circulation
external: below dentate line, systemic circulation |
|
internal haemorrhoids
4 degrees and their Rx |
1st: bleed but not prolapse - high fibre diet, sitz bath, steroid cream, Anusol
2nd: prolapse with straining but spontaneous reduction - rubber band ligation 3rd: prolapse requiring manual reduction - rubber band ligation 4th: permanently prolapsed, cannot be manually reduced - closed haemorrhoidectomy |
|
Rx of external haemorrhoids
|
(assoc with poor hygeine)
if symptomatic - fibre, stool softeners, steroid cream, Anusol |
|
What do you get perianal skin tags from?
|
resolved thrombosed haemorrhoids
|
|
Anal fissures are a tear below what?
|
dentate line
|
|
Rx of anal chronic anal fissures
|
stool softeners, sitz baths
topical nitroglycerin or nifedipine to increase local blood flow and promote healing surgery is most effective - lateral internal sphincterotomy Botox injection |
|
Imaging modality of choice for biliary tract
|
U/S
|
|
Cholelithiasis: what is it?
S+S? Rx? |
stones in gall bladder
asymptomatic most do not need Rx |
|
Biliary Colic: what is it?
S+S? Rx? |
gall stone transiently impacted in cystic duct - constant pain, no infection
Rx: analgaesia and rehydration during colic episode; elective cholecystectomy |
|
Acute cholecystitis: what is it?
S+S Rx |
inflammation/infection of gallblader resulting from sustained gallstone impaction in cystic duct
severe constant epigastric/RUQ pain, Murphy's sign, fever Rx: analgaeia and ABx + cholecystectomy |
|
What 4 organisms usually involved in cholecystitis?
|
E. coli
Klebsiella Enterococcus Clostridium ABx = ampicillin or gentamycin |
|
What is choledocolithiasis?
S+S? Rx? |
stones in common bile duct
usually asymptomatic or RUQ tenderness can have jaundice Rx: ERCP and later elective cholecystectomy |
|
What happen to LFTs in choledocolithiasis?
|
increased Br and ALP
|
|
Acute cholangitis
What is it? S+S? Rx? |
obstruction of common bile duct leading to biliary stasis, bacterial overgrowth, suppuration and biliary sepsis
Charcot's triad: fever, RUQ pain, jaundice Rx: initial: NBM, fluid and electrolyte resus, NG tube, IV ABx Decompression - ERCP and sphincterotomy and cholecystectomy |
|
Common bacteria in biliary tract (in cholangitis) (hint: mneumonic)
|
KEEPS
Klebsiella E. coli Enterococcus Pseudomonas Serratia |
|
What do you think of with vague abdominal pain with weight loss +/- jaundice in Pt > 50?
|
pancreatic cancer
|
|
Levels of axillary LNs
|
I: lateral to pec minor
II: deep to pec minor III: medial to pec minor |
|
Most common benign breast tumour in women <30
|
fibroadenoma
|
|
Where is breast cancer most likely to met to?
|
bone > lungs > liver > brain
|
|
Amylase/lipase in chronic pancreatitis?
|
normal or near normal
|
|
Amylase/lipase elevated by ___x the upper limit of normal
|
3
(800-1000) |
|
What imaging confirms Dx of pancreatitis?
|
CT - Pancreatic swelling with peri-pancreatic stranding, necrosis or hypo-perfusion of the pancreas
|
|
What can happen to calcium in pancreatits?
|
decrease
|