• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

Card Range To Study

through

image

Play button

image

Play button

image

Progress

1/575

Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

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