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613 Cards in this Set
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- Back
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How long should one wash their hands before a procedure?
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30-60 seconds
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How long should one wash their hands before the first surgery of the day?
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5 minutes
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When disgowning, should gloves be removed first or last?
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first! Otherwise you might spread contamination to face or elsewhere
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What test can one do to ensure that a duckbill mask fits properly?
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Fit test by breathing in and out, and see if mask moves with each breathe
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Is chlorhexadine an effective treatment for C difficile?
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No, it forms spores. Like all spore-forming bacteria they are protected from this and many other means of disinfection.
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Is double-gloving, in surgery, necessary?
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Yes! It is required by NSW Health Infection Control Policy
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What size must a droplet be to reach the alveolar space of the lungs?
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Less than 5uM in size
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When is it okay to wear operating scrubs outside of theatre?
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One should never wear operating scrubs outside of theatre, as this defeats the purpose and can transmit infection to those around you. The exception is when a patient must be attended to in an emergency
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Name three serious infectious agents that can be transmitted by airborne transmission
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TB; varicella; measles; pandemic influenza; SARS; haemorrhagic fever
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What is the Garling report?
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Multi-million dollar government report on adequecy of hospital infection control measures, which highlighted inadequacies in the system and determined there is a significant hospital-acquired infection rate
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What are the four trademarks of an infection?
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Redness, Swelling, Pain, Heat
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When does a fever usually occur, if associated with infection?
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2 to 5 days later, if post-surgical (otherwise attributed to something else)
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Why are razors no longer used to remove hair from a site before surgery?
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Because of the increased risk of infection. Now clippers are used, which cause less trauma
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Which is more effective of a disinfectant: povidine-iodine or chlorhexidine-alcohol?
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Chlorhexidine-alcohol has been shown to concur with half the risk of post-operative infection
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When should prophylatic antibiotics (ie. Cefazolin) be administered prior to surgery?
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1-30 minutes before the first incision, as this window confers maximum effectiveness
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Does acute pancreatitis begin with infection?
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No, this is usually sequelae
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What type of acute pancreatitis accounts for 30% of cases, but has a 10-20% mortality rate?
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Necrotizing pancreatitis
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Chronic pancreatitis is necrotic or not?
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Not necrotic
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T/F: chronic pancreatitis has elevated amylase/lipase enzymes?
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False: usually normal
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What two enzymes activate the pro-enzymes released from the pancreas?
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Enterokinase (initial activation) and Trypsin (which can then auto-activate trypsinogen)
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The three main types of acute pancreatitis are?
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Obstructive, Metabolic (ie. alcoholic), Miscellaneous (infectious, vascular, etc)
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What enzyme inhibits trypsin normally?
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Trypsin inhibitor
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The pancreatic enzyme responsible for oedema is?
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Kallikrein
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The pancreatic enzyme contributing to vascular leakage, and eventually shock, is?
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Chymotrypsin
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The pancreatic enzymes which causes fat necrosis is?
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Phospholipase and Lipase
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80% of acute pancreatitis is by which two things?
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Alcohol (40%) and Gallstones (40%)
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What haemodynamic change is often seen in pancreatitis?
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Hypovolaemia and hypotension
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The flank bruising seen in acute pancreatitis is called what?
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Cullen's sign
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Peri-umbilical bruising seen in acute pancreatitis is called what?
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Grey Turner's sign
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What DDx needs to be excluded on presentation of acute pancreatitis?
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a) perforated ulcer, b) ruptured AAA
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Investigations for acute pancreatitis should include?
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a) serum amylases/lipases, b) CT of abdomen, c) U/S for gallstones, d) IGG4 [for autoimmunity]
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How long should mod-severe cases of acute pancreatitis be monitored in hospital?
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At least 24-48 hours to see if deterioration occurs
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Using Ranson's scoring criteria for acute pancreatitis, how many points is associated with <1% mortality? 100% mortality?
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<3 points (<1% mortality); >6 points (100% mortality)
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Using the Glasgow scoring criteria for acute pancreatitis, 'severe' is determined by how many points?
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3 or more points
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Why does hypocalcaemia occurs in acute pancreatitis?
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a) calcium/fat saponification, b) hypomagnesia interferes with PTH, c) increased renal secretion
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Why is acute pancreatitis painful?
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Local compartment syndrome (from fluid sequestration) stretches pain fibres
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How is compartment syndrome, in acute pancreatitis, managed?
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a) Intubation, b) urgent laparotomy, c) dialysis, d) inotropes
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Why are antibiotics often not effective management of acute pancreatitis?
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Necrotic tissue is poorly vascularized and does not allow adequate penetration of antibiotics
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What is the best treatment of necrotic pancreatitis?
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Surgical debridement
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When is ERCP indicated for acute pancreatitis?
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Only for co-existent cholangitis or jaundice
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How much is the decrease in mortality, using a epidural/spinal vs GA?
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30%
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Where should local anaesthesia never be used?
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Extremities, such as the penis, digits, nose
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What channels are typically blocked with anaesthesia?
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Sodium channels
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Which is metabolized more rapidly: ester or amide anaesthetics?
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Esters
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Major complications due to systemic absorption of local analgesia includes?
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Seizure, Loss of Consciousness, Arrhythmias
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How common are allergic reactions to local analgesia?
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Rare!
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What are the benefits of adding a vasoconstrictor to a local analgesia?
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1) reduces blood loss, 2) reduces systemic absorption
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The major anaesthetic agent used in epidurals/spinals is?
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Bupivacaine (t1/2 of 3-10 hours)
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One must be mindful not to disrupt sympathetic reflexes at what level (due to spread), when using a spinal block?
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level T1-4
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What kind of diet should be adhered to prior to a bowel prep?
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Low fibre
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How long does bowel prep take, until effluent is clear?
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4- 6 hours
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What is the most commonly used bowel prep, currently, and what are the drawbacks?
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Polyethylene glycol (aka. Moviprep, Klean-prep). Drawbacks include: large volume (4L) and unpalatable taste.
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Sodium phosphate (Fleet Phospho-Soda) is a well-tolerated alternative bowel prep, but is contraindicated in which patients?
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Those with an electrolytes disturbance or renal complications.
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Side effects of bowel prep include?
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N/V, abdominal pain/cramping/distension, haemodynamic instability, electrolytes disturbance, dehydration
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Tolerabilitiy of bowel prep can be improved by what means?
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1) chilling solution, 2) sucking on lemon slices, 3) adding clear, sugar-free flavor enhancers (ie. Crystal Light)
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What are some contraindications to bowel prep?
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neurological impairment, gastric retention, ileus, severe colitis, toxic megacolon, GI obstruction/perforation
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Which is more effective in preventing DVT/PE: graduated compression stockings, or pharmacological agents?
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pharmacological agents. GCS is used as an adjunct
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GCS should be fitted for each patient, and the pressure at the ankle should be?
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16-20mmHg
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GCS added to thromboprophylaxis reduces the risk of VTE by how much?
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50%
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What surgeries are high risk for DVT?
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Hip/knee arthroplasty, Major trauma, Hip fractures, Active Cancers, Major surgeries on pts > 40
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Graduated compression stockings are contraindicated when?
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Deformed leg; Recent skin graft; Severe peripheral neuropathy; Severe peripheral arterial disease
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Both heparin and warfarin are effective in reducing post-op DVT/PE, but what is the advantage of heparin?
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It doesn't have to be commenced 5+ days beforehand
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How much does prophylactic LMWH reduce post-op DVT/PE by?
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70%
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What is the risk of low-dose heparin for surgical DVT/PE prophylaxis?
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Patients bleed 10% more at major surgery
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Should surgical antibiotic prophylaxis be bactericidal or bacteriostatic?
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Bactericidal
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What reduction in post-operative infection rate is seen, if prophylactic antibiotics are used in 'high risk' cases?
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75% reduction
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When are prophylactic antibiotics best administered in surgery?
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1 hour prior, OR by IV at induction
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Surgeries considered at 'high risk' (rates of 5-10%) of post-op infection include?
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Emergency abdominal surgery; Elective colonic surgery; Upper GI operations for malignancy
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Low risk operations where antibiotic prophylaxis is still indicated, include?
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Prosthetic implants; Mitral stenosis/risk of endocarditis
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How effective are post-op doses of prophylactic antibiotics?
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Of very little effectiveness, and not recommended
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Which antibiotic is used for prophylaxis in appendicectomy?
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Metronidazole
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What antibiotics are used prophylactically for vascular grafts & joint replacements?
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Flucloxacillin + Gentamycin
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What antibiotics are given prophylactically for bowel surgery?
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Cephalosporin + metronidazole
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Untreated, what percent of DVT will progress to PE within the month?
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30-50%
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With DVT, what is the sign called in which dorsiflexion of the foot elicits calf pain?
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Homan's sign
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How long should anticoagulation be continued after at DVT develops?
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3-12 months, depending on the site and risk factors (ie. recurrence)
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What management should be taken for the hypovolaemic patient, post-op?
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1) Resuscitate, 2) Give blood, 3) Pressors, 4) Stress dose steroids, 5) Intensive insulin, 6) Fix any bleeds
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Chest infection, post-op, is usually due to?
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Aspiration of gastric contents
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90% of post-op pulmonary complications are?
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Atelectasis (lung collapse)
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How does atelectasis present?
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low-grade fever, tachycardia, productive cough, crackles, dec breath sounds, bronchial breathing, tachypnoea
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How far in advance should one cease smoking, prior to an elective surgery?
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Cease 6 weeks prior, to minimize the chance of post-op chest infection
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What organism is responsible for most minor wound infections, post-op?
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Staph aureus
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Surgeries that cellulitis is associated with are?
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Abdominal and Gastrointestinal surgery
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How long does it take for cellulitis to occur, post-op?
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Usually 1-3 weeks post-op
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How is cellulitis managed?
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Swab for microbes, before commencing IV antibiotics
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How is a surgical abscess managed?
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Surgically drained, then left open to heal by secondary intention
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Gas gangrene is caused by?
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Anaerobes proliferating in necrotic tissue (usually C difficile)
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What is noted on palpation of gas gangrene?
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Crackling of the wound
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How is gas gangrene treated?
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IV penicillin, and excision of necrotic tissue
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What causes pelvic abscesses after surgery?
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contamination of surgical site, with faeces
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What clinical signs are indicative of a pelvic abscess?
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Swinging pyrexia, local peritonitis, signs of sepsis
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What is wound dehiscence and how frequently does it occur with abdominal wounds?
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It is total breakdown of the wound, and occurs in 1% of abdo wounds
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How does wound dehiscence present?
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Starts with profuse discharge of sero-sangiunous fluid, then sudden bursting open of the abdomen (usually not very painful)
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What percent of a) adults and b) infants acutely infected with HBV will develop chronic hepatitis?
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5% of adults; 90% of infants
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The risk of post-needlestick infection is what, for a) HBV, b) HCV and c) HIV?
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(HBV) 30%; (HCV) 3%; (HIV) 0.3%
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If no prophylaxis is used, what percent of infants born to HIV mothers will contract the disease?
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25%
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How is HIV screened for in adults?
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presence of HIV-1/HIV-2 Abs + HIV RNA
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How is HIV screened for in infants?
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presence of HIV RNA (Abs from mother can persist for 18 months, and are not a reliable marker)
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When should a newborn be immunized for HBV, after birth?
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Immediately, then at 2, 4 and 6 months
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What is the regimen for post-exposure HIV prophylaxis, with protease inhibitors?
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Commenced within 72 hours (preferrably within 1hr), then continued for 4 weeks
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Which blood products require compatability testing?
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Whole blood, and RBCs
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How long does whole blood last for at room temperature (eg. 20-24 degrees)
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Less than 24 hours
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When is whole blood clearly indicated for transfusion?
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There are no clear indications for whole blood
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When are Red Blood Cells clearly indicated for transfusion, by haemoglobin levels?
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If Hb < 70g/L
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How long do packed RBCs last if refridgerated?
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about 35 days
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One unit of packed RBCs should raise the recipients Hb by?
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10g/L
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Platelet transfusion is indicated for therapy when?
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Thrombocytopenia is contributing to active bleeding (platelet count < 50 x 10^9/L)
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Under what conditions is platelet transfusion not appropriate, if there is a platelet deficiency?
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1) Immune-mediated platelet destruction [ITP], 2) Thrombotic thrombocytopenic purpura [TTP], 3) drug induced thrombocytopenia [eg. HIT]
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How long can platelets be stored for at room temperature?
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5 days
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One unit of platelets should increase the platelet count of the recipient by?
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20-40x10^9/L
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When is fresh frozen plasma indicated for transfusion?
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1) replacement of single factor deficiencies, 2) immediate reversal of warfarin effects, 3) treatment of multiple coagulation defects, 4) treatment of TTP ... (others)
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How long can Fresh frozen plasma be stored, at -25C?
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12 months
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One 10-20ml bolus of Fresh Frozen Plasma should increase the recipient's coagulation factors by what percent?
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15-20%
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Cryoprecipitate is derived how?
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Thawing FFP to 4C, and removing precipitating FVIII, FXIII, vWF and fibrinogen
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T/F: cryoprecipitation is used to treat haemophilia?
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False: specific factors should be used
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What is cryoprecipitate indicated for?
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Fibrinogen deficiency
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What is the definition of dysphagia?
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Difficulty swallowing
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What is the term for the sensation of fullness or bloating in the throat?
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Globus sensation
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What is the definition of odynophagia?
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Painful swallowing
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Term for food getting stuck on swallowing?
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Food bolus impaction
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What medications can cause odynophagia?
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bisphosphonates; tetracycline; K+; aspirin; NSAIDs; iron tablets
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What is the most common cause of odynophagia?
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Infection
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If someone has dysphagia, what is garnered by determining difficulty with solids vs liquids?
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(problems with solids:) tend to be caused by Obstruction; (problems with liquids:) tend to be caused by Motility Disorders
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What is the investigation of choice in dysphagia?
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Barium swallow
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Definition: hiatus hernia? two subtypes?
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herniation of the upper stomach through the diaphragmatic hiatus. (subtypes: Sliding of junction and Rolling of stomach)
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What the clinical significance of a hiatus hernia?
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(usually) none! Only important if symptomatic (may predispose to GORD and dysphagia though)
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How is GORD usually diagnosed?
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On clinical history alone
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What timing of symptoms is associated with GORD?
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Post-prandial, bending over, or at bedtime
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T/F: excess acid is produced in GORD?
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FALSE: acid levels are usually normal (though PPIs are mainstay of treatment)
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What lifestyle factors can be addressed to manage GORD?
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Avoid excess alcohol/coffee/chocolate/tea/fatty foods/smoking; Don't eat before bed; Lose weight; elevate head of bed
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Reflux esophagitis is sequelae of?
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GORD
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What dysplastic cell type are seen in Barrett's esophagus?
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Columnar epithelia
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What is the mainstay of treatment for Barrett's esophagus?
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PPIs + 2-3 year surveillance biopsies
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What medications can be used to treat eosinophilic esophagitis?
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1) Montelukast, an LT receptor antagonist, 2) Fluticasone, swallowed
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How does eosinophilic esophagitis present?
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dysphagia, chest pain, bolus impaction, heartburn with PPIs, associated atopy
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How is esophageal cancer diagnosed?
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endoscopic biopsy and barium swallow
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What is the 5 year survival of esophageal cancer?
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< 10%
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What cancer commonly arises from Barrett's esophagus?
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esophageal adenocarcinoma
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What is the mainstay of treatment for Esophageal cancer?
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Surgery, augmented with chemo/radio
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How is achalasia diagnosed?
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Aperistalsis in esophagus, on manometry. Incomplete relaxation of LOS may be noted
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What nervous input is degenerated in achalasia?
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The inhibitory ganglion cells of the myenteric plexus
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Inability to belch is indicative of what esophageal motility disorder?
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Achalasia
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How does achalasia appear with a barium swallow?
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smoothly tapering, beak-life narrowing of esophagus
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Pseudo-achalasia is secondary to what pathology?
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Carcinoma of the gastric fundus
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If barium swallow shows a corkscrew-like pattern, what is the likely diagnosis?
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Diffuse esophageal spasm
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What clues, on history, indicate chest pain is non-cardiac in origin?
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Not predictably exertion-induced; occuring at night; related to meals
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Spontaneous esophageal rupture is known as?
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Boerhaave's syndrome (typically occuring with vomiting or raised intra-abdo pressure)
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What is a globus sensation usually related to? How is it treated?
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Related: GORD; Tx: PPIs and reassurance
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Regurgitation of old, foul-tasting food occurs with what esophageal pathology?
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Zenker's diverticulum
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What medication is used to treat esophageal varices?
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Beta-blockers, to reduce portal hypertension
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What should be measured daily, post-op, to monitor hydration status of a patient?
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Electrolytes, urea, creatinine, FBC
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Surgical patients afflicted with what problems, are at high risk of dehydration? (4 major categories)
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Abdominal infection; Sepsis; Fistulae; Extensive Burns
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What volume of one's daily 2.5L water intake comes from diet?
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2.3litres (0.2 from metabolism)
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How much water is typically lost through the skin each day?
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0.5L
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What is the daily requirement for sodium intake? (in mmol)
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150mmol
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What is the daily requirement for potassium intake? (in mmol)
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100mmol
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How many litres of fluid deficit create compensatory hypotension?
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3 litres
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Hypovolaemic shock occurs typically when there is how much fluid deficit?
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4 litres fluid deficit
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What percent of dextrose-saline solution is NaCl?
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0.18%
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What percent concentration is Normal Saline?
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0.9%
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What percent concentration is dextrose solution? What is the function of the dextrose?
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5%. The dextrose is to make the solution isotonic, not for nutrition.
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Hartmann's solution is indicated for?
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Buffering acidosis in children
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Why are potassium drips usually not necessary in the 24-48 hours post-op?
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Potassium levels will rise on their own, as it is released from damaged tissue
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Crystalloids are indicated for what volume loss?
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For small volume replacement (0.5-1.0L)
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Why does oliguria and sodium retention occur in the post-op phase?
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Body compensates by increasing ADH and RAAS activity
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What physical examination finding indicates a patient has been over hydrated?
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raised JVP
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What is thought to cause abdominal compartment syndrome?
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Retroperitoneal haemorrhage
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What complications occur with abdominal compartment syndrome?
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reduced cardiac output, oliguria and hypotension
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What are the 5 layers of the epidermis? (from superficial to deep)
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Stratum: corneum > lucidum > granulosum > spinosum > basale
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what layer of the skin contains melanocytes?
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melanocytes are located in the epidermis
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Collagen composes what percent of the dermal layer of skin (by weight)?
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70%
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Where on the body, are sebaceous glands absent?
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The palmar surface of the hands (including digits), and the soles of the feet
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How do atypical naevi differ from the common naevi?
|
They tend to appear around puberty (cf. earlier), continue developing past fourth decade (cf. cessation of growth), and appear irregardless of sun-exposure
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Benign skin lesions that commonly appear after 40, have milia-like cyts and a 'stuck on' appearance are called what?
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Seborrhoeic keratoses
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What are the two 'negative features' that exclude melanoma?
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1) presence of a single colour, 2) symmetry of pigmentation pattern
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What are some of the 'positive features' found in melanoma? (list 3)
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(only one needed in combination with negative features:) blue-white veil; multiple brown dots; pseudopods; radial streaming; scar-like depigmentation; peripheral black dots/globules; multiple (5-6) colours; multiple blue-grey dots; broadened network
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Superficial spreading melanoma typically occurs where in men? women?
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(men) torso; (women) legs
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What type of melanoma has a late stage diagnosis (hence a poor prognosis) after a rapid vertical growth?
|
Nodular melanoma
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What melanoma type typically develops on the sun-damaged skin of the face and neck?
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Lentigo maligna melanoma
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Melanoma that occurs on the palms, soles and nailbeds of (typically) darker skinned individuals is called?
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Acral lentiginous melanoma
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Which confers greater risk for melanoma: 20 atypical or typical moles?
|
Atypical moles (though >75 typical moles is also a significant risk factor)
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What size of congenital nevus confers a 15% risk of melanoma?
|
One that is >20 cm
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What part of the UV spectrum is thought to contribute to melanoma?
|
UVB
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The most important prognostic factor in assessing a melanoma is?
|
Depth of tumour invasion (Breslow thickness)
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What Breslow thickness confers a 50% 5-year survival?
|
>4mm
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If a melanoma is >2mm in depth, but has no lymph node spread it is stage as?
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Stage II
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Stage 3 melanoma is defined as?
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Draining lymph node involvement.
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Definition: sentinel lymph node?
|
first node in the lymphatic basin that drains the lesions
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When is sentinel node biopsy indicated, in melanoma?
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1) melanomas >1mm depth, 2) histologic ulceration is present, 3) Clark level >3
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What is the 5 year survival for those with Stage 4 melanoma?
|
<10%
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What is the median survival of Stage 4 melanoma?
|
6 to 9 months
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Standard chemotherapy for melanoma is what agent?
|
dacarbazine (DTIC)
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What is the only adjuvant for chemotherapy that has been shown to be effective against melanoma?
|
Interferon Alpha-2B
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|
what are the three common growth patterns of BCC?
|
1) Superficial multifocal, 2) nodular, 3) morphoeic
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Superficial BCC presents as?
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amelanocytic, pearly lesion which lack scales and may bleed with minor trauma
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A pearly skin lesion with overlying telangectasia is likely?
|
A nodular BCC
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BCCs are related to what type of sun exposure?
|
Intermittent/Recreational sun exposure
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What percent of individuals with BCC or SCC will develop a subsequent skin cancer in the next 5 years?
|
40%
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What cell type does SCC arise from?
|
keratinocytes
|
|
|
Bowen's disease is eponymous for?
|
SCC in situ
|
|
|
What skin cancer is known to have an incidence related to geographical latitude?
|
SCC
|
|
|
Amelanocytic skin lesions which enlarged over weeks to months, and are tender on palpation are likely?
|
SCC
|
|
|
How do keratocanthomas present? Are they excised?
|
Rapidly growing, dome-shaped nodule, with keratin-filled crater, which involutes after 2-3 months. Yes, they are excised.
|
|
|
What is the overall frequency of metastatic disease with SCC?
|
1-2%
|
|
|
How is cryotherapy applied to SCCs?
|
repeat freeze-thaw cycles with 5mm margins
|
|
|
Clinically favorable SCCs are excised with what margins?
|
4mm
|
|
|
Clinically unfavorable SCCs are excised with what margins?
|
10mm
|
|
|
What diameter margin is used to excise melanomas of 1mm thickness?
|
1cm
|
|
|
What diameter margin is used to excise melanomas with >2mm thickness?
|
2cm
|
|
|
How do lipomas present?
|
Soft, mobile, painless, superficial cutaneous mass, usually on the trunk.
|
|
|
What is the indication for excision of a lipoma?
|
If it is symptomatic
|
|
|
What are subaceous cysts filled with?
|
Keratin (not sebum!)
|
|
|
What are subaceous cysts caused by?
|
Blockage of the hair follicle or subaceous gland
|
|
|
What is the most common location of subaceous cysts?
|
The scalp
|
|
|
Where is the epidermal layer, in relation to a subaceous cyst?
|
Located in the centre of the growing cyst
|
|
|
How do subaceous cyts present?
|
Painless unless infected. Skin immobile above cyst. Visible punctum at site of blockage
|
|
|
How do neuromas present?
|
Small violaceous nodules, gelatinous in appearance, and may sting or itch. May be disfiguring.
|
|
|
When should neuromas be removed?
|
When a) symptomatic, or b) involving a neural plexus
|
|
|
Small, (usually) painless, compressible tumours of the wrist are usually?
|
Ganglions
|
|
|
How should ganglions be managed?
|
60% spontaneously resolved, so only excise if neurovascular compromise
|
|
|
What pathogen is usually implicated in subcutaenous abscess?
|
Staph aureus
|
|
|
How do subcutaneous abscesses arise?
|
Typically as cellulitis, which leads to walling off of liquified, necrotic tissue
|
|
|
Are antibiotics indicated in treatment of subcutaneous abscesses?
|
Not unless there is surrounding cellulitis or systemic infection
|
|
|
What does the word sarcoma mean?
|
(Gr.) 'Fleshy', as they arise from mesenchymal tissue
|
|
|
What is the most common soft tissue sarcoma in adults?
|
Malignant fibrous histiosarcoma (MFH)
|
|
|
What is the five year survival for Malignant Fibrous Histiosarcoma?
|
50%
|
|
|
A sarcoma which presents as an elevated, firm, solitary , slow growing and painless mass in the scalp/neck is likely?
|
A Dermatofibrosarcoma Protuberans
|
|
|
What is the prognosis for a dermatofibrosarcoma protuberans, once excised?
|
'excellent'
|
|
|
A sarcoma which presents as an ulcerating, nodular or diffuse dermal lesion on the head/neck is likely?
|
Angiosarcoma
|
|
|
The most common childhood sarcoma, found in the head/neck, is?
|
Rhabdomyosarcoma
|
|
|
What is the prognosis for rhabdomyosarcomas?
|
Poor, as they metastasise early
|
|
|
Sarcomas which present retroperitoneally, and carry a poor prognosis are?
|
Leiomyosarcomas
|
|
|
Sarcomas which present around deep tissue of joints, in extremities are?
|
Synovial sarcomas
|
|
|
Synovial sarcomas usually present as a deep seated mass than has been present for years. What is the 10 year survival for these?
|
33%
|
|
|
What 'grading' system is used for sarcomas?
|
the French, FNCLCC system
|
|
|
What three factors are used to grade a sarcoma?
|
1) Differentiation [1-3], 2) Mitotic Count on microscopy[1-3], 3) Tumour Necrosis [0-2]
|
|
|
A FNCLCC Grade of 2 (G2) is attained with a score of?
|
Score of 4-5
|
|
|
Sarcomas are staged as T2, if they are what diameter?
|
>5 cm
|
|
|
If a sarcoma has 3 lymph nodes involved, it is given what 'N' stage?
|
N1 (no N2 exists)
|
|
|
In 'stage grouping' of sarcoma, what is a Stage III?
|
If either: a) T2, Nx, Mx, G3 or b) Tx, N1, Mx, Gx
|
|
|
In 'stage grouping' of sarcoma, what is Stage IV?
|
If M1
|
|
|
What is the recurrence rate of a sarcoma, if treated with wide excision (2-3cm) and radiotherapy?
|
8% (so commonly used)
|
|
|
What is a radical resection of a sarcoma? What is the recurrence rate?
|
When the entire compartment is excised. Recurrence rate is 8%
|
|
|
What are important points not to forget when examining a lump in the groin?
|
a) patient should be examined both standing/supine, b) test for cough impulse/reducibility, c) determine relationship of origin to inguinal canal/pubic tubercle
|
|
|
Is a percutaneous needle biopsy safe to do for a lump in the groin region?
|
Yes, and is useful in differentiating if benign or malignant
|
|
|
What is the cause of a congenital inguinal hernia?
|
A persistant process vaginalis, after birth (almost always the cause)
|
|
|
What is the cause of an acquired inguinal hernia?
|
Due to defects in the anterior abdominal wall, usually from abnormalities of connective tissue (hence the higher rate in Marfan's and Ehlers-Danlos syndromes)
|
|
|
What is the lifetime risk for inguinal hernias in men?
|
27%
|
|
|
What is the ratio of inguinal hernias between men:women?
|
7:1
|
|
|
What is the rate of bilateral hernias in those afflicted with one?
|
20% will develop them bilaterally
|
|
|
Where does an indirect inguinal hernia arise from, in relation to the pubic tubercle?
|
Just lateral to the pubic tubercle
|
|
|
Which kind of inguinal hernia is most likely to strangulate?
|
Indirect, due to it's narrow neck (Direct rarely strangulates)
|
|
|
How should a small, asymptomatic inguinal hernia be managed?
|
Watchful waiting (educate patient)
|
|
|
When should an inguinal hernia be managed with an open surgical repair?
|
When it is a) irreducible, b) strangulated, c) obstructed
|
|
|
What is the definition of an obstructed inguinal hernia?
|
One that is irreducible, but still has an intact blood supply
|
|
|
What is a strangulated inguinal hernia?
|
One that is irreducible, and whose blood supply is compromised (surgical emergency!)
|
|
|
When are antibiotics indicated in the management of an inguinal hernia?
|
Only when treating a strangulated hernia (requiring emergency surgery)
|
|
|
What are the three complications that commonly arise from inguinal hernia repair?
|
1) haematomas, 2) seromas, 3) chronic groin pain
|
|
|
Which sex is commonly afflicted with femoral hernias more frequently?
|
Women (especially those who are multiparous)
|
|
|
How do femoral hernias present?
|
(Usually:) a) immobile, b) with no cough impulse and c) irreducible
|
|
|
What is the management of femoral hernias?
|
Open surgical repair, as 40% will strangulate
|
|
|
Regarding lymphadenopathy, what does the differential diagnosis acronym of CHICAGO stand for?
|
Cancer; Hypersensitivity (to drugs); Infection; Collagen vascular disease; Atypical lymphoproliferative disorders; Granulomatous disease; Other!
|
|
|
Why is there a need to biopsy lipomas, when they have no malignant potential?
|
To exclude Liposarcomas, which do have malignant potential
|
|
|
If a patient presents with a 'cold abscess' below the inguinal ligament, fever and a positive psoas sign (pain on flexion) they may have what rare pathology?
|
Psoas abscess
|
|
|
Psoas abscesses are related to what pathological organism?
|
Mycobacterium tuberculosis
|
|
|
What is the management of a psoas abscess?
|
Drainage and antibiotics
|
|
|
What enzymes are implicated in the pathology of aneurysms?
|
Matrix Metalloproteases (MMPs)
|
|
|
On examination of a lump on the groin, what characteristics would implicate a femoral aneurysm?
|
Lump is midpoint of inguinal ligament, with pulsatile nature
|
|
|
What characteristics of a lump in the groin implicate a Saphena Varix (dilation of great saphenous)?
|
a) Soft on palpation, b) Empties with minimal pressure, c) refills on release
|
|
|
For a breast lump in a female under age 25, what means of imaging should be employed?
|
U/S (if findings are suspicious, perform MMG)
|
|
|
How should a biopsy of a lump in the breast be performed?
|
By Fine Needle Aspiration (FNA) or Core Biopsy
|
|
|
In reference to breast lumps investigations, what is the 'triple test'? When is it considered positive?
|
1) breast exam, 2) imaging, 3) biopsy. (Positive if any component is indeterminant/suspicious/malignnant)
|
|
|
95% of breast carcinomas are of what subtype?
|
adenocarcinoma
|
|
|
What percent of breast cancers are not detectable as lumps on breast exam?
|
15-30% (DCIS and LCIS are detected on MMG and FNA, respectively)
|
|
|
Lobular Carcinoma In Situ (LCIS) accounts for what percent of breast carcinomas?
|
1-6%
|
|
|
On average, what percent of women presenting with a lump in the breast (due to carcinoma) have metastases to their axillary nodes?
|
About half
|
|
|
Carcinomas of the breast which present as lumps as of what histological type?
|
Invasive (infiltrating) Carcinoma
|
|
|
What is the standard approach for management of breast cancer?
|
Surgery with/without radiotherapy. Augmented with chemotherapy or hormone therapy if prognostic factors are poor.
|
|
|
What ages are the presentations of fibroadenomas of the breast typically at?
|
Ages 15-25
|
|
|
A 'popcorn'-like lesion on mammogram is typical of what?
|
Lobulated fibroadenomas (benign)
|
|
|
How are fibroadenomas of the breast managed?
|
Patient reassurance. Enucleate capsule if painful.
|
|
|
When, in a woman's life, to breast cysts most commonly occur?
|
In her 40s
|
|
|
How is diagnosis of a breast cyst typically made?
|
On aspiration, which typically relieves the mass and is no longer palpable
|
|
|
When should the aspirate of a breast cyst be sent for cytological examination?
|
If a) the breast lump is a recurrence, or b) there is blood present in the aspirate
|
|
|
What is the first line antibiotic for mastitis?
|
Flu/dicloxacillin (500mg PO QID for at least 5 days)
|
|
|
alcohol and smoking increase the risk of neck cancers by how much?
|
35-fold
|
|
|
what characteristics of a lump should raise suspicion of malignancy?
|
large (>1cm), hard, immobile
|
|
|
how does one determine if a lump in the neck is malignanct or not?
|
fine-need aspiration biopsy (FNAB)
|
|
|
if investigation of a neck lump reveals low TSH levels, what imaging modality should be employed for subsequent investigation?
|
Thyroid scan
|
|
|
what percent of the population will have a thyroid nodule found on U/S?
|
25%
|
|
|
non-toxic multinodular goitres are usually asyptomatic until what stage of growth?
|
70% obstruction of tracheal
|
|
|
how are non-toxic multinodular goitres (MNGs) managed?
|
If asymptomatic: monitor; if bothersome to patient (obstruction/cosmesis) I-133 can reduce goitre up to 50%
|
|
|
what requirements must a patient meet before undergoing a thyroidectomy?
|
Must be euthyroid (antithyroid drugs, such as carbimazole)
|
|
|
when investigating a toxic goitre, what antibodies should be screened for?
|
antibodies to TSH-R and thyroid peroxidase
|
|
|
what is first line treatment of a benign thyroid lump in a pregnant woman? Second line?
|
1st: antithyroid drugs [propylthiouracil, PTU]; 2nd: thyroidectomy
|
|
|
in a non-suspicious, toxic multinodular goitre, if the adult is otherwise healthy, what is first line treatment?
|
I-133
|
|
|
in a suspicious, toxic multinodular goitre, what is first line therapy?
|
thyroidectomy
|
|
|
Benign follicular adenomas of the thyroid are usually caused by what?
|
Mutations in the TSH receptor
|
|
|
what is first line treatment of a functional, benign follicular adenoma of the thyroid?
|
I-133 (take 3 months to correct 75% of all cases)
|
|
|
Thyroid cysts constitute what portion of palpable thyroid nodules?
|
1/3
|
|
|
what is an effective means of managing thyroid cysts?
|
there are none, currently; both aspiration and surgery are prone to frequent recurrence
|
|
|
most thyroid cancers are derived from what tissue type?
|
follicular epithelia
|
|
|
T/F: most thyroid cancers are well-differentiated.
|
TRUE: odd, no?
|
|
|
What two common sites are metastases of thyroid cancer found?
|
Bone and Lung
|
|
|
if a patient with papillary or follicular carcinoma of the thyroid is <45yo, with Mets, what stage are they? If they were >45yo?
|
(<45yo) Stage II; (>45yo) Stage IV
|
|
|
what form of thyroid cancer has only a 'Stage IV'? (ie. No Stage I-III, due to it's poor prognosis)
|
Anaplastic thyroid cancer, which has an average survival of a few months
|
|
|
medullary carcinoma of the thyroid with lymphatic invasion, but no mets, is Stage …?
|
Stage III
|
|
|
The mainstay of management for thyroid cancer is total thyroidectomy. What type of thyroid carcinoma is the exception, and can be managed with a thyroid lobectomy?
|
This can be used ONLY in select low-risk patients with papillary/follicular thyroid carcinoma
|
|
|
when should I-133 be commenced after total thyroidectomy for a thyroid carcinoma?
|
3-4 weeks later, when maximal TSH levels have been achieved
|
|
|
how are metastases screened for in thyroid carcinoma?
|
I-133 whole-body scans
|
|
|
what is the prognosis for stage I of papillary or follicular thyroid carcinoma?
|
10 year survival is 90%
|
|
|
what is the prognosis for medullary thyroid carcinoma?
|
5 year survival is 80%
|
|
|
what percent of parotid tumours are benign?
|
80%
|
|
|
what facial nerve palsy indicates a parotid tumour may have become malignant?
|
CN VII (facial)
|
|
|
in Australia, what is the most common malignancy involving the parotid glands?
|
metastases from SCC (usually head/neck)
|
|
|
how does one determine if a lump in the parotid gland is malignanct or not?
|
FNAB
|
|
|
how are malignant parotid tumours managed?
|
complete surgical excision, which has an excellent prognosis
|
|
|
what are the signs and symptoms associated with a carotid body tumour?
|
a) neck mass which is slow-growing, painless, smooth, firm, deep, laterally located; b) may appear pulsatile; c) may obstruct surrounding nerves
|
|
|
how are carotid body tumours managed? What is the prognosis?
|
Surgical excision, which has a 90% control rate
|
|
|
thyroglossal duct cysts arise from what structure?
|
remnants of the thyroglossal duct (usually involutes at 10w gestation)
|
|
|
what percent of thyroglossal duct cysts contain cancer?
|
1%
|
|
|
what is the typical presentation of the thyroglossal duct cyst?
|
midline, smooth lump, usually 1-4cm; resides over hyoid bone; moves with tongue protrusion/swallowing
|
|
|
where do branchial cysts occur?
|
as lateral neck lumps, below the jaw
|
|
|
Which anal sphincter does one have voluntary control over?
|
The external anal sphincter
|
|
|
what spinal nerve supplies the external anal sphincter?
|
S4, via the inferior rectal nerve
|
|
|
what muscle does the internal anal sphincter arise from?
|
The muscularis propria, of the rectum
|
|
|
which vessels do haemorrhoids arise from?
|
(the terminal branches of) the Superior Rectal Arteries and Veins
|
|
|
what nerve can be stimulated to increase sphincter tone, if it is the cause of incontinence?
|
the Sacral Nerve
|
|
|
how does a pilonidal sinus form?
|
folliculitis (hair follicle), at the natal cleft, becomes infected with Staph/Strep, leading to an abscess
|
|
|
how can the chance of recurrence of a pilonidal sinus be minimized?
|
if excised, the wound should be closed off of the midline
|
|
|
what management strategy of pilonidal sinus has the best outcome?
|
surgical drainage or excision
|
|
|
what is the most common precipitating factor of haemorrhoids?
|
constipation
|
|
|
what are the three degrees of prolapse referred to in haemorrhoids?
|
1st - piles don't prolapse; 2nd - piles prolapse during defaecation but retract spontaneously; 3rd - piles remain externally unless replaced digitally
|
|
|
using a clock-face, what are the most common locations for external haemorrhoids?
|
3, 7 & 11 o'clock
|
|
|
do haemorrhoids warrant a colonoscopy?
|
yes; if there is bleeding, bowel cancer must be investigated
|
|
|
of the patients who present with rectal bleeding, what percent have bowel cancer?
|
2%
|
|
|
how are internal haemorrhoids surgically treated?
|
banding can remove them
|
|
|
how are haemorrhoids managed medically?
|
stool bulking/softening agents, high fiber diet, water consumption
|
|
|
what is the indication for excisional haemorrhoidectomy?
|
third degree haemorrhoids, or those that have failed to respond to other treatments
|
|
|
what is the definition of a fissure-in-ano?
|
a longitudinal tear in the mucosa and skin of the anal canal (usually midline)
|
|
|
if an anal fissure is not in the midline, what disease should be suspected?
|
Crohn's
|
|
|
on history, what helps differentiate an anal fissure from a haemorrhoid?
|
pain on defaecation
|
|
|
how are anal fissures managed medically?
|
fibre/water; GTN (relax sphincter spasm & improve blood supply)
|
|
|
what are the surgical options for an anal fissure?
|
botox (every 3/12); fissurectomy; sphincterectomy
|
|
|
what is the chance of incontinence, after a sphincterectomy?
|
1%
|
|
|
how does a fistula-in-ano originate?
|
as a peri-anal abscess from the cryptoglandular area
|
|
|
what are clinical signs of anal malignancy?
|
frank blood, anal pain, discomfort, discharge
|
|
|
where in the anus do anal malignancies usually arise from?
|
commonly from the dendate line
|
|
|
what is the treatment of anal cancer?
|
radiation and chemotherapy
|
|
|
what is the cause of rectal prolapse?
|
when the rectum is not firmly attached to the sacrum
|
|
|
the surgical procedure used to correct rectal prolapse is called?
|
rectopexy
|
|
|
what major pathologies might leave one at risk for arterial occlusive disease?
|
HTN, diabetes
|
|
|
if investigating arterial occlusion, what is a positive Buerger's test?
|
(lying supine) if a limb is raised for 20-30s and pallor of the limb occurs. Normally limb should remain perfused.
|
|
|
intolerable limb pain at night, progressing to be continuous, is characteristic of what pathology?
|
arterial occlusive disease
|
|
|
what are the major risk factors for DVT?
|
recent hospitalization; recent major surgery; recent long-distance travel; lower limb trauma; OCP; pregnancy; active cancer; coagulopathies
|
|
|
if a limb is painful and cool to touch, what kind of vessel blockage is it likely?
|
arterial
|
|
|
a positive Homan's sign is?
|
calf pain on dorsiflexion of the foot
|
|
|
blood tests should be done for arterial occlusive disease to exclude?
|
polycythaemia & thrombocythaemia
|
|
|
what organism most commonly causes cellulitis?
|
beta-haemolytic streptococci (S. pyogenes)
|
|
|
what enzymes are made by infective organisms of cellulitis, which allow them to promote their spread through the tissue plane?
|
fibrinolysins & hyaluronidase
|
|
|
what is the initial management of cellulitis?
|
C&S; start tetracycline; rest, elevate and compress
|
|
|
what increases the risk of future occurence of cellulitis?
|
damage to the draining lymphatics
|
|
|
over the age of 55, what percent of men experience arterial claudication? women?
|
>15% of men; >20% of women
|
|
|
what lifestyle factors can be addressed to improve claudication?
|
1) smoking, 2) dietary fats, 3) systemaic exercise
|
|
|
what medications can be used to manage claudication?
|
anti-hypertensives (for HTN); anti-platelet agents; statin (even if cholesterol is normal); cilostazol (phophodiesterase inhibitor which improves walking distance)
|
|
|
when is thrombo-endarterectomy used to treat arterial claudication?
|
when occlusion is located at the Femoral Artery
|
|
|
what is standard surgery for claudication?
|
Angioplasty - a balloon catheter which crushes the arthroma
|
|
|
what is the major cause of death in those with arterial claudication?
|
coronary heart disease
|
|
|
what are the components of Virschow's triad?
|
change in 1) vessel wall, 2) blood flow, 3) blood constitution
|
|
|
what is the theory behind anticoagulation therapy for DVT?
|
halting coagulation allows the body to lyse thrombi naturally
|
|
|
how long does it take for IV heparin to take effect? how long do the effects last for?
|
effect is immediate, and lasts 5 days
|
|
|
how is heparin monitored? what is the ideal range?
|
monitored by PTT. therapeutic range is 2-3X normal
|
|
|
how long should oral warfarin be taken for DVT?
|
3-6 months
|
|
|
why is systemic thrombolysis not used for most cases of DVT?
|
due to the high risk of haemorrhage (22%!)
|
|
|
what percent of patients will develop recurrent DVT during the first 6 months of anticoagulation?
|
about 5%
|
|
|
what is the annual incidence of life-threatening haemorrhage if one is taking warfarin chronically?
|
1-2% per year
|
|
|
for DVT, when is warfarin usually started, in relation to heparin administration?
|
usually same day, as heparin is immediate and warfarin takes days to have effect (exceptions: high risk of bleeding, active bleeding, malignancy. then delay warfarin 1-2 days)
|
|
|
what causes of DVT indicate warfarin should be taken for 3 months?
|
DVT from surgery, immobilization, trauma
|
|
|
what causes of DVT indicated warfarin should be taken for 6 months?
|
idiopathic or unprovoked DVT
|
|
|
common thrombolytic agents, often used in PE, include?
|
alteplase, urokinase, streptokinase, reteplase
|
|
|
when should aPTT be measured if taking heparin?
|
6 hours after initiation/dose adjustment, then once/daily after that
|
|
|
when should aPTT be measured for LMWH or fondaparinux?
|
It is not necessary to measure aPTT for these therapies; just with unfractionated heparin
|
|
|
what is the most common pathology behind a leg ulcer?
|
venous insufficiency (50%)
|
|
|
what percent of leg ulcers are due to arterial insufficiency?
|
20%
|
|
|
what is the characteristic appearance and location of an arterial ulcer?
|
appearance: punched-out look; location: typically over a bony prominence
|
|
|
arterial occlusion resulting in absence of sensation and power is an emergency. how is it managed?
|
embolectomy
|
|
|
what is the prognosis for acute arterial insufficiency?
|
15% mortality; 5-40% amputation
|
|
|
in assessing the ankle-brachial index for chronic arterial insufficiency, what result is abnormal?
|
<0.9
|
|
|
what percent of chronic arterial insufficiency results in amputation?
|
<4%
|
|
|
where are the majority of pressure ulcers located?
|
over bony prominences of the lower limbs (30%) and pelvis (65%)
|
|
|
what preparation of a pressure ulcer must be undertaken before grading it?
|
debridement
|
|
|
what are the four grades of a pressure ulcer?
|
1) non-blanchable erythema (>1hr after pressure), 2) partial thickness skin loss, 3) full thickness skin loss, into subcutaneous tissue, 4) through fascia, to muscle, tendon, bone, joint
|
|
|
what investigation is done for a pressure ulcer, to determine it's stage (and detect osteomyelitis)?
|
biopsy
|
|
|
how can pressure ulcers be avoided?
|
keep skin clean/dry; frequent repositioning; proper nutrition; maintain continence; maintain activity
|
|
|
what topical can be applied to a pressure ulcer to promote healing?
|
fibroblast growth factor and platelet derived growth factor
|
|
|
how long after diagnosis do diabetics typically develop foot ulcers?
|
10 years
|
|
|
what percent of diabetics will develop foot ulcers?
|
25%
|
|
|
what percent of diabetics with foot ulcers will eventually require amputation?
|
25%
|
|
|
what is the lifetime risk of a woman developing breast cancer before age 75?
|
1 in 11
|
|
|
BreastScreen Australia targets what age group?
|
age 50-69 (women in 40s and 70s allowed to attend)
|
|
|
How often should women between 50-69 go for breast screening?
|
every 2 years
|
|
|
what the is the present participation rate of (the target age group) in BreastScreen Australia?
|
55%
|
|
|
what percent of bowel cancers are caught in the early stages?
|
< 40%
|
|
|
What is the eligible population of the national bowel screening program pilot?
|
Australians (holding Medicare/DVA gold cards) turning age 50, 55 or 65
|
|
|
what means are being used to screen adults invited for the national bowel screening program?
|
initial screen: faecal occult blood samples; subsequent investigations: colonoscopy
|
|
|
what population-based screening is performed for prostate cancer in Australia?
|
there is no national screening program for prostate cancer, as DRE/PSA are insensitive and unspecific
|
|
|
what modifiiable risk factors are known for prostate cancer?
|
at this time, there is little evidence of modifiable risk factors
|
|
|
what is the NNT to prevent one premature death from prostate cancer?
|
48
|
|
|
what are some common complications of treatment of prostate cancer?
|
erectile dysfunction, urinary incontinence, proctitis
|
|
|
what population based screening programs are in place for skin cancer, in Australia?
|
none, as of yet ('slip, slop, slap' is a ad campaign)
|
|
|
why does the Australasian College of Dermatologists not recommend pop'n based screening for melanoma?
|
Current screening practices are not optimally accurate or cost-effective, and screening has not shown effective for reducing mortality
|
|
|
in leiu of a national screening program, what does the Australasian College of Dermatologists recommend from GPs?
|
a) develop survey programs for high risk patients, b) assess patients who are concerned, c) identify risk factors of patients and educate them, d) offer full body examinations
|
|
|
what drugs should be discontinued prior to surgery?
|
oral hypoglycaemics, aspirin, warfarin
|
|
|
prior to major surgery, what investigations should be considered?
|
FBC, blood grouping, UEC, ECG, CXR, spirometry, ABGs, LFTs, serology, cultures (MRSA), CT/MRI, echo
|
|
|
when should oral hypoglycaemics be ceased prior to surgery?
|
the day of surgery (48 hours prior, for metformin in patients with renal impairment)
|
|
|
which antidepressants are associated with interactions with anaesthetic drugs?
|
MAOIs
|
|
|
how does the ASA grade someone's risk of anaesthesia if they have mild systemic disease with no functional limitation?
|
ASA II
|
|
|
how does the ASA grade someone's risk of anaesthesia if they have severe systemic disease that is a constant threat to life?
|
ASA IV
|
|
|
what is risk of post-op cardiac death or major complication, in patients over age 40 who are undergoing non-cardiac surgery?
|
<6%
|
|
|
what are MAJOR cardiac risk factors for surgery?
|
unstable angina, decompensated CCF, significant arrhythmia, severe valvular disease
|
|
|
what is the major surgical complication a patient with GORD is at risk of?
|
aspiration
|
|
|
which complications occur more commonly in surgery: cardiac or pulmonary?
|
pulmonary
|
|
|
what antiemetic is commonly used for post-operative nausea/vomiting (PONV)?
|
Maxalon
|
|
|
indications for ventilation, post-op, include?
|
GCS < 8, airway obstruction, pCO2 > 50mmHg, V/Q mismatch
|
|
|
what is the most common post-op complication?
|
Sore throat (1 in 2)
|
|
|
what percent of people experience PONV?
|
25%
|
|
|
what is the risk of thrombosis from surgery?
|
1 in 20
|
|
|
what is the risk of stroke with head and neck surgery?
|
1 in 20
|
|
|
what is the risk of death due to anaesthesia?
|
1 in 50,000
|
|
|
Using the Goldman Cardiac Risk Factors, patients with a score > 25 have what incidence of death?
|
56%
|
|
|
what three items on the Goldman Cardiac Risk scale are weighted with more than 10 pts?
|
1) S3 [11], 2) elevated JVP [11], 3) MI in past 6m [10]
|
|
|
Using the Goldman Cardiac Risk Factors, patients with a score < 25 have what incidence of death?
|
4%
|
|
|
Using the Goldman Cardiac Risk Factors, patients with a score < 6 have what incidence of death?
|
0.2%
|
|
|
what instructions are given for bowel prep before surgery?
|
1) diet is limited to fluids/low-fibre foods for a few days beforehand, 2) laxatives are given, 3) patient passes effluent until it is clear (4-6 hrs), 4) fast completely for 6 hours prior
|
|
|
why are osmotic laxatives avoided prior to bowel surgery?
|
increased risk of explosion (hydrogen gas produced by bacterial fermentation of non-absorbed carbs)
|
|
|
MoviPrep is the brand name for what bowel prep?
|
Polyethelene glycol
|
|
|
what is the most common choice for bowel prep? what are the drawbacks?
|
Polyethelene glycol. Drawbacks: unpalatable, large volume (4L)
|
|
|
what are some side effects of bowel preps to caution patients about?
|
N/V, abdominal pain/bloating, haemodynamic instability, electrolyte disturbances, dehydration
|
|
|
if patients experience N/V with bowel prep, what drug can be given to aid this?
|
metoclopramide (5-10mg orally)
|
|
|
what is the most effective means of reducing post-op DVT/PE?
|
low-dose UF-heparin or LMWH
|
|
|
how does an allergic reaction to blood transfusion commonly present?
|
pruritic urticaria, wheezing, angioedema
|
|
|
how is an allergic reaction to blood transfusion managed?
|
1) cease transfusion, 2) administer antihistamine, 3) administer corticosteroids/adrenaline if severe
|
|
|
what is the risk of HIV infection from blood transfusion?
|
1 in 5.4 million
|
|
|
What are the four Fs for history of abdominal pain?
|
Fetus, flatus, faeces, fluid
|
|
|
An abdominal mass that waxes and wanes is characteristic of?
|
A hernia
|
|
|
Cancer in the liver will present how on palpation?
|
hard, with an irregular border
|
|
|
What is a Riedel's lobe, in the liver?
|
A congenitally enlarged right lobe
|
|
|
If a left iliac fossa mass is indentable, that is characteristic of?
|
A faecal mass
|
|
|
What is a Spigelian hernia?
|
One that has developed between layers of the abdominal wall
|
|
|
How does one exclude a distended bladder, on presentation of a pelvic mass?
|
Examine after urinary catheterization
|
|
|
An asymptomatic large mass in the right iliac fossa is characteristic of?
|
Carcinoma of the caecum
|
|
|
A tender mass in the right iliac fossa should made one suspicious of?
|
Crohn's disease
|
|
|
What is the most common type of cancer of the stomach?
|
Adenocarcinoma (90%)
|
|
|
What is the differential diagnosis if kidney enlargement is unilateral?
|
Carcinoma, Solitary kidney, PCKD, kidney stone
|
|
|
what is Mittelschmertz?
|
pain on ovulation
|
|
|
what is the most common cause of small bowel obstruction?
|
post-op adhesions
|
|
|
what are the two most common causes of small bowel obstruction?
|
1) adhesions (post-op), 2) external hernias
|
|
|
in abdominal obstruction, how does distension typically compare between proximal and distal obstructions?
|
more severe distension with distal location
|
|
|
how many air fluid levels should be seen on x-ray, to diagnose small bowel obstruction?
|
3 or more
|
|
|
what width of proximal bowel distension is seen on x-ray to diagnose small bowel obstruction?
|
>3 cm
|
|
|
when is conservative, non-surgical management of a small bowel obstruction considered?
|
if associated with a history of abdo/pelvis surgery, duration of <2 days and no complications
|
|
|
what is the mortality rate from ischaemic bowel obstructions?
|
>50%
|
|
|
what is the mortality rate from a non-strangulating bowel obstruction?
|
<1%
|
|
|
what is the hallmark of acute small bowel infarction/ischaemia?
|
severe abdominal pain which is disproportionate to physical findings; vomiting; bloody diarrhoea; bloating; minimal peritoneal signs early in course
|
|
|
what are the signs associate with chronic small bowel infarction/ischaemia?
|
postprandial pain, and weight loss
|
|
|
what areas of the bowel are most commonly affected by ischaemia?
|
the watershed areas served by the SMA: splenic flexure, left colon, sigmoid colon
|
|
|
bloodwork that should be ordered for the investigation of bowel infarction/ischaemia includes?
|
FBC (leukocytosis), [progress monitors: amylase, LDH, CK], coagulation studies
|
|
|
what investigation is the gold standard for bowel ischaemia/infarction?
|
CT angiography
|
|
|
what imaging might be considered prior to CT angiography, for bowel infarction/ischaemia?
|
X-ray, or contrast CT
|
|
|
what surgical options are available for bowel infarction/ischaemia?
|
embolectomy, bypass graft, mesenteric endarterectomy, segmental resection
|
|
|
if viability of ischaemic bowel is questionable, on laparotomy, is it removed?
|
No, not yet. A subsequent laparotomy is performed 12-24 hrs later
|
|
|
in Crohn's disease, what are the indications for bowel surgery?
|
failure of medical management; small bowel obstruction; abscess; fistula, perforation; haemorrhage
|
|
|
what surgical management is used in Crohn's disease, for inflammation, perforation and fistula?
|
resection and anastamosis/stoma
|
|
|
what surgical management is preferred in Crohn's disease, for small bowel obstruction due to stricture?
|
strictoplasty - widens the lumens of chronically scarred bowel
|
|
|
what are the common complications of 'short gut syndrome' after resectioning small bowel?
|
diarrhoea, steatorrhoea, malnutrition
|
|
|
what are the common complications of resectioning the small bowel?
|
short gut syndrome, gallstones, fistulas, kidney stones
|
|
|
why are gallstones more common after a small bowel resection?
|
if terminal ileum is resected, there is reduced bile salt resorption
|
|
|
what are the two main pathological mechanisms contributing to AAAs?
|
1) atherosclerosis, and 2) disordered turnover of elastin/collagen (MMPs)
|
|
|
how are AAAs usually found?
|
incidentally on palpation or imaging
|
|
|
what means of screening can effectively be used in older men at risk of AAAs?
|
abdominal ultrasound
|
|
|
the most common symptom of a leaking aneurysm is?
|
pain
|
|
|
at what diameter of AAA should one consider surgery?
|
5.5cm
|
|
|
what growth rate of an AAA is indicative for surgery?
|
0.5cm/yr
|
|
|
what is the mortality rate from ruptured AAAs?
|
>85%
|
|
|
of the half of the patients which make it to hospital, with a ruptured AAA, what proportion of these survive?
|
less than half
|
|
|
what imaging should be used to plan an elective AAA repair?
|
CT angiography
|
|
|
what is the indication for an open repair of an AAA?
|
renal artery involvement
|
|
|
the most effective method for emergency repair of a ruptured AAA is?
|
endovascular AAA repair (EVAR)
|
|
|
does data support cost-effectiveness of emergency AAA repair, despite the high mortality rate?
|
Yes. Despite the 50% mortality rate, 60% of survivors will attain an average lifespan
|
|
|
what is the risk of over-aggressive fluid resuscitation for a leaking AAA?
|
it may be converted to a free rupture
|
|
|
what is Mittelschmertz?
|
pain on ovulation
|
|
|
what is the most common cause of small bowel obstruction?
|
post-op adhesions
|
|
|
what are the two most common causes of small bowel obstruction?
|
1) adhesions (post-op), 2) external hernias
|
|
|
in abdominal obstruction, how does distension typically compare between proximal and distal obstructions?
|
more severe distension with distal location
|
|
|
how many air fluid levels should be seen on x-ray, to diagnose small bowel obstruction?
|
3 or more
|
|
|
what width of proximal bowel distension is seen on x-ray to diagnose small bowel obstruction?
|
>3 cm
|
|
|
when is conservative, non-surgical management of a small bowel obstruction considered?
|
if associated with a history of abdo/pelvis surgery, duration of <2 days and no complications
|
|
|
what is the mortality rate from ischaemic bowel obstructions?
|
>50%
|
|
|
what is the mortality rate from a non-strangulating bowel obstruction?
|
<1%
|
|
|
what is the hallmark of acute small bowel infarction/ischaemia?
|
severe abdominal pain which is disproportionate to physical findings; vomiting; bloody diarrhoea; bloating; minimal peritoneal signs early in course
|
|
|
what are the signs associate with chronic small bowel infarction/ischaemia?
|
postprandial pain, and weight loss
|
|
|
what areas of the bowel are most commonly affected by ischaemia?
|
the watershed areas served by the SMA: splenic flexure, left colon, sigmoid colon
|
|
|
bloodwork that should be ordered for the investigation of bowel infarction/ischaemia includes?
|
FBC (leukocytosis), [progress monitors: amylase, LDH, CK], coagulation studies
|
|
|
what investigation is the gold standard for bowel ischaemia/infarction?
|
CT angiography
|
|
|
what imaging might be considered prior to CT angiography, for bowel infarction/ischaemia?
|
X-ray, or contrast CT
|
|
|
what surgical options are available for bowel infarction/ischaemia?
|
embolectomy, bypass graft, mesenteric endarterectomy, segmental resection
|
|
|
if viability of ischaemic bowel is questionable, on laparotomy, is it removed?
|
No, not yet. A subsequent laparotomy is performed 12-24 hrs later
|
|
|
in Crohn's disease, what are the indications for bowel surgery?
|
failure of medical management; small bowel obstruction; abscess; fistula, perforation; haemorrhage
|
|
|
what surgical management is used in Crohn's disease, for inflammation, perforation and fistula?
|
resection and anastamosis/stoma
|
|
|
what surgical management is preferred in Crohn's disease, for small bowel obstruction due to stricture?
|
strictoplasty - widens the lumens of chronically scarred bowel
|
|
|
what are the common complications of 'short gut syndrome' after resectioning small bowel?
|
diarrhoea, steatorrhoea, malnutrition
|
|
|
what are the common complications of resectioning the small bowel?
|
short gut syndrome, gallstones, fistulas, kidney stones
|
|
|
why are gallstones more common after a small bowel resection?
|
if terminal ileum is resected, there is reduced bile salt resorption
|
|
|
what are the two main pathological mechanisms contributing to AAAs?
|
1) atherosclerosis, and 2) disordered turnover of elastin/collagen (MMPs)
|
|
|
how are AAAs usually found?
|
incidentally on palpation or imaging
|
|
|
what means of screening can effectively be used in older men at risk of AAAs?
|
abdominal ultrasound
|
|
|
the most common symptom of a leaking aneurysm is?
|
pain
|
|
|
at what diameter of AAA should one consider surgery?
|
5.5cm
|
|
|
what growth rate of an AAA is indicative for surgery?
|
0.5cm/yr
|
|
|
what is the mortality rate from ruptured AAAs?
|
>85%
|
|
|
of the half of the patients which make it to hospital, with a ruptured AAA, what proportion of these survive?
|
less than half
|
|
|
what imaging should be used to plan an elective AAA repair?
|
CT angiography
|
|
|
what is the indication for an open repair of an AAA?
|
renal artery involvement
|
|
|
the most effective method for emergency repair of a ruptured AAA is?
|
endovascular AAA repair (EVAR)
|
|
|
does data support cost-effectiveness of emergency AAA repair, despite the high mortality rate?
|
Yes. Despite the 50% mortality rate, 60% of survivors will attain an average lifespan
|
|
|
what is the risk of over-aggressive fluid resuscitation for a leaking AAA?
|
it may be converted to a free rupture
|
|
|
combined with the clinical picture, how is a small bowel obstruction confirmed?
|
nasogastric aspiration, showing faeculent fluid
|
|
|
how does peristalsis change with time in a bowel obstruction?
|
initially causes constriction proximal to the obstruction, then ceases after a few hours
|
|
|
how do bowel obstructions differ if they are more distally located, compared to proximal ones?
|
presentation is later (2-3 days), and distension and constipation are prominent features
|
|
|
what compound can be used to determine the extent of a bowel obstruction?
|
Gastrografin, which is hyperosmolar and may stimulate peristalsis
|
|
|
what is the non-surgical management used for a small bowel obstruction for the first 48 hours?
|
a) fluid replacement, b) monitor vitals, c) NG tube, d) pain relief
|
|
|
if pain of a bowel obstruction becomes constant, what is that a hallmark of?
|
bowel ischaemia
|
|
|
what is the rate of recurrence of small bowel obstruction?
|
20%
|
|
|
what is the preferred means of management of recurrent small bowel obstruction?
|
non-surgical (supportive)
|
|
|
when are post-op adhesions most prominent after surgery?
|
10-21 days later
|
|
|
how large must a gallstone be to be able to cause a gallstone ileus? where is the most common location to obstruct?
|
it must be 2.5cm, and usually obstructs 60cm from the ileocaecal valve, the narrowest point of the intestine
|
|
|
what electrolytes disturbances are seen in small bowel obstruction, with time?
|
hyponatraemia, hypokalaemia, hypochloraemia, metabolic alkalosis
|
|
|
colonic pseudo-obstruction commonly occurs in what population(s)?
|
the elderly and debilitated
|
|
|
why is large bowel obstruction a medical emergency?
|
due to the risk of colonic perforation
|
|
|
complete left-sided large bowel obstruction is usually managed with what surgery?
|
three-staged surgery (stoma, resection, closure)
|
|
|
what are the three most common causes of large bowel obstruction?
|
1) carcinoma [over 50%], 2) sigmoid volvulus, 3) diverticular disease
|
|
|
what is the most common site of carcinoma of the colon?
|
sigmoid colon (30%), followed by the splenic flexure
|
|
|
sigmoid volvulus occurs in which population(s)?
|
the elderly and frail
|
|
|
which area of the colon is most commonly affected by diverticular disease?
|
the sigmoid colon
|
|
|
why do some patients with constipation present with faecal incontinence?
|
more proximal liquid stool pass out the sphincters, which have been relaxed by the impacted bolus
|
|
|
in large bowel obstruction, what is guarding or peritonism indicative of?
|
vascular compromise or perforation
|
|
|
peritonitis with a large bowel obstruction has what mortality rate?
|
'high', due to the faecal content
|
|
|
free intraperitoneal gas on abdominal X-ray is indicative of what?
|
perforation of the bowel
|
|
|
what is a Hartmann's procedure?
|
establishment of a sigmoid colostomy and overscrewing of the rectal stump
|
|
|
self-expandable metal stents are being used with increasing frequency in what large bowel obstructions?
|
malignant, low left-sided large bowel obstructions
|
|
|
what is the rate of recurrence of sigmoid volvulus?
|
50%
|
|
|
what is a potent parasympathemimetic that is administered by IV, for pseudo-obstructions?
|
neostigmine
|
|
|
which antibiotic is also known to have prokinetic properties on the large bowel?
|
erythromycin
|
|
|
Chronic constipation is defined as constipation in excess of?
|
6 weeks
|
|
|
Symptoms of chronic constipation are:
|
a) less than 3 bowel movements per week, or b) straining during defaecation 25%+ of the time, or c) frequent inability to completely empty the rectum
|
|
|
How long does it take, on average for the residue of a meal to be completely evacuated by stools?
|
3-4 days
|
|
|
What is the normal frequency of bowel movements on average?
|
3 times a week, to 3 times a day
|
|
|
The main region of storage in the colon is?
|
The transverse colon
|
|
|
How are transit marker studies performed?
|
Ingesting non-absorbed radio-opaque markers, and taking abdominal X-rays at standardized intervals
|
|
|
Disorders of defaecation are assessed with what type of study?
|
defaecation proctography - rectum filled with radiological contrast and defaecation monitored on radioluscent toilet seat
|
|
|
what common medications may cause constipation? (list three)
|
Iron, psychiatric (SSRIs, anticonvulsants, anti-Parkinsonian, antipsychotics), narcotics/opiates, CCBs, antacids, barium sulfate, fibre supplements w/inadequate fluid
|
|
|
What is the recommended daily intake for dietary fibre?
|
30g/day
|
|
|
what is good 'defaecation hygeine'?
|
adequate fibre/fluid, regular bowel habits, not ignoring need to pass stool, regular exercise
|
|
|
What is the preferred investigation for chronic constipation?
|
Barium enema
|
|
|
what is the most common gastro-intestinal disease?
|
Irritable Bowel Syndrome (IBS), occuring in 15% of adults
|
|
|
How is slow-transit constipation (presenting commonly in 20-30s) managed, in intractible cases?
|
Total colectomy with ileorectal anastomosis
|
|
|
Slow-transit constipation is diagnosed how?
|
Transit marker studies, showing >20% retention of marker 5 days after ingestion
|
|
|
What is a rectocoele?
|
Weakness of the anterior wall of the rectum, often producing a pouch which protrudes into the vagina, requiring digital reduction for defaecation
|
|
|
the best prophylaxis against infection in dirty wounds is achieved by ...?
|
removing foreign bodies and devitalized tissues
|
|
|
Staphylococcus has an affinity for cells with what receptor?
|
Protein A molecules
|
|
|
What two bacteria commonly cause cellulitis?
|
Streptococcus and Haemophilus
|
|
|
beta-haemolytic Streptococcus secretes what, to aid in spreading of cellulitis?
|
hyaluronidase and streptokinase
|
|
|
What component of E coli prevents activation of complement?
|
K-antigen
|
|
|
The failure of multiple organs in sepsis is called?
|
Severe sepsis
|
|
|
Should antibiotics be administered in drainage of an abscess?
|
Yes, it is advisable
|
|
|
what percent of patients admitted to the surgical ward will develop a clinically significant infection?
|
10%
|
|
|
How long should stitches remain if the wound is on the face?
|
3-5 days
|
|
|
How long should stitches remain if the wound is on the scalp?
|
7-10 days
|
|
|
how long should stitches remain if the wound is on the abdomen?
|
10 days
|
|
|
How long should stitches remain for the stump of an amputation?
|
21 days
|
|
|
How long does it take for thrombophilia and phlebitis to begin at the insertion site of a cannula
|
3 days
|
|
|
Controlled surgery of the abdomen, with no spillage is classifed as what (ie. clean)?
|
Clean-contaminated
|
|
|
What are the two most common bacteria isolated from nosocomial infection?
|
Staphylococcus aereus, and Gram-negative bacilli
|
|
|
Pyrexia of Unknown origin, post-op may be attributed to?
|
Catheter induced UTI
|
|
|
Enterocolitis post-op, when patient has received prophylactic antibiotics, is often due to which organism?
|
C difficile
|
|
|
Enterocolitis due to C difficile should be managed how?
|
Cease broad-spectrum antibiotics, and commence oral metronidazole or vancomycin
|
|
|
How should atelectasis be managed in the post-op patient, if no other complications?
|
Wait and watch, as most will be self-limiting. Antibiotics are contra-indicated unless purulence is noted!
|
|
|
What is the first step in managing an oligouric post-op patient, if there is no obvious cause?
|
Bolus infusion of 500ml isotonic saline
|
|
|
What is the most important/common cause of confusion, post-op?
|
Hypoxia
|
|
|
If a surgical wound appears to have an abscess, how should it be managed?
|
1) local incision, 2) antibiotics if evidence of systemic infection
|
|
|
If a wound is secreting a discharge, what does this indicate?
|
Wound closure may be inadequate and need to be redone. Should be probed for preliminary investigation (ensure sterile!)
|
|
|
In septic shock, what is the next best step in management, in a post-op patient?
|
O2 + bolus of 500ml saline + antibiotics
|
|
|
What three antibiotics should be given to a patient with suspected septic shock?
|
Gentamycin + Metronidazole + Amoxycillin
|
|
|
For a confirmed DVT, what dosing of heparin is to be administered?
|
5000U stat, followed by 1000U/hr
|
|
|
Jaundice can be detected clinically when plasma conjugated-bilirubin levels reach?
|
>30umol/L
|
|
|
Hyperbilirubinemia leads to malabsorption of which vitamin, and causes what sequelae?
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Vitamin K -> risk of bleeding diathesis
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How can confirmation of Acute Cholecystitis be obtained in the emergency setting?
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By ultrasound + amylase (pancreatitis) + LFTs
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what is the treatment of choice for cholecystitis?
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Cholecystectomy
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what are the two leading causes of pancreatitis, worldwide?
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gallstones and alcohol (80% of cases)
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abdominal pain which is poorly localized, but relieved by leaning forward (Ingelfinger's sign) is indicative of?
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pancreatitis
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what level of plasma amylase is indicative of pancreatitis?
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3-4x the normal level
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if gallstones are the causative factor in acute pancreatitis, how is this managed?
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ERCP within 72 hours
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how are mild attacks of pancreatitis managed?
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Fluid resuscitation and analgesia
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what is the most common portion of the pancreas to be affected by pancreatic cancer?
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the head, where 70% of the cases occur
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where does pancreatic cancer commonly metastasize to?
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the peritoneum and liver
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what age group is typically affected by pancreatic cancer?
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>50 yrs (below this is rare)
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what is the RR of pancreatic cancer, with smoking?
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2-3x
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how is pancreatic cancer managed if no metastases has occured (5% of presenting cases)
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resectioning of the pancreas (Whipple procedure)
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how is pancreatic cancer managed if metastases has occured (95% of presenting cases)
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Palliation. Stenting can relieve jaundice
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what is the DDx for multifocal tumours of the liver?
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metastases, or HCC
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the most common risk factor for HCC, in developed countries, is?
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alcoholic cirrhosis
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how is HCC diagnosed?
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imaging (US or CT) + serum AFP levels
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how is HCC managed?
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(curative resection is impossible, but) cancer is removed with 1-2cm margin
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