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589 Cards in this Set
- Front
- Back
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Murphy's sign
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inspiratory arrest on deep palpation of RUQ
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Camper's fascia is continuous with...
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dartos muscle
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Scarpa's fascia
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Blends with the fascia lata of thigh, helps to form dartos/ Fascia of Colles
Deep to Camper fascia Superficial to external oblique More fibrous, membranous than camper fascia |
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External oblique is continuous with
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inguinal ligament
external spermatic fascia fascia lata |
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Internal oblique is continuous with
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cremasteric muscle
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Transversalis fascia
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thin aponeurotic membrane, liews between transversus abdominis and extraperitoneal fascia
continuous with internal spermatic fascia |
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Rectus abdominus is divided centrally by
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linea alba
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List 3 types of thrombosis prophylaxis?
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graduated compression stockings
heparin mechanical calf compressors |
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What are 4 aims of anaesthesia
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analgesia
still surgical field Anxiolysis, sedation, hypnosis Cardioresp stability |
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What are 7 A's of anaesthesia
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allergies
aspiration risk airways assessment aortic stenosis apnoea activity level (exercise tolerance) Access (IV or invasive) |
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Why are patients fasted pre-op?
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reduce risk of aspiration
reduce volume of GIT fluid/activity |
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During GA, aortic stenosis increases risk of
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myocardial ischaemia
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Define MAC50
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minimum alveolar concentration required for lack of responses to surgical incision in 50% of patients; highly reproducible for given agent
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During surgery, BP should be maintained....
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within 20% of resting values
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Which ECG leads are continuously monitored during surgery?
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Limb lead I
Unipolar lead V5 |
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What is BIS
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bispectural index form of processed EEG; number between deep 0- awake100
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What is incidence of awareness during surgery
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0.1%
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Why is pethidine not used for prolonged post-op analgesia?
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toxic metabolite norpethidine accumulates
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Describe mechanism of tramadol
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opioid activity
noradrenaline uptake serotonin uptake |
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What is fluid maintenance for 70kg man?
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2-3L/day
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What are daily requirements of Na and K
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100-150mmol
60-90mmol |
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What hormone causes fluid retention in post-op period?
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increased ADH (vasopressin) secretion by posterior pituitary
increases water absorption in collecting ducts synthesized in hypothalamus reduces/concentrates urine |
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List 3 functions of surgical drains?
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assessment of fluid loss
allow lung re-expansion diverts secretions/decompression |
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What is advantage of closed drain systems?
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decreased risk of infection
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What is gastric dilatation
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rare; associated with upper GI surgery. 2-3 days post-op. Sudden onset. Massive fluid secretion into stomach- aspiration
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Define AAA
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permanent pathological dilation of aorta >2x expected diameter
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Normal aortic valve diameter
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21.4mm male
18.7 mm female |
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True aneurysm
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involves ALL layer (intima, media, adventitia)
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False aneuysm
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part of wall is fibrous tissue; secondary to trauma
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Is AAA more common above or below renal arteries
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90% below
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Which arterial aneurysms are commonly bilateral
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femoral
popliteal |
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Which aneurysm is associated with AAA in 50% of cases
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popliteal
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What % of aneurysms are inflammatory
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5%
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What is incidence of AAA in >65
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6-9%
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Is AAA more common in males or females
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males (4-6x); but females more likely to rupture
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What is the 10th most common cause of death in Australia
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AAA
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Indication for AAA surgical repair
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Rupture
>5cm Symptomatic (pain, tenderness) Rapid growth |
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Average AAA growth rate
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3-4mm/year
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What is strongest risk factor for AAA
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smoking (each year of smoking increases RR by 4%)
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What is a negative predictor of AAA
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diabetes (arterial calcification is protective)
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What is the most common presentation of AAA?
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75% asymptomatic
Pulsatile abdominal mass |
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What is classic triad of Ruptured AAA?
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1. severe abdominal/back pain
2. pulsatile mass 3. shock |
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What is best diagnostic/surveillance tool for AAA
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Duplex US
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Which has higher mortality: intra or retro peritoneal AAA rupture?
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intraperitoneal (retro bleed may be more contained; more likely to make it to theatre)
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How often is surveillance of AAA recommended
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<4cm annual
>4cm 6-monthly |
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What are most common complications of endoscopic AAA repair
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lymphocele, haematoma, wound infection, endoleak
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Mortality rate of AAA rupture
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~50% if patient survives till surgery; >90% without
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What is mortality of AAA open repair (not ruptured)
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3-5%
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Does LMWH affect APTT and/or INR?
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No (unless in overdose)
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What lab value should be monitored while patient on LMWH
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renal function
serum creatinine |
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Dabigatran
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direct thrombin inhibitor
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Rivaroxaban
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anti-factor Xa
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When are compression stockings contraindicated
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peripheral vascular disease
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what VTE prophylaxis is appropriate with creatinine clearance <30ml/min
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enoxaparin 20mg daily
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What are contraindicaitons for LMWH
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HIT
platelet<50,000/ul acute bacterial endocarditis high bleeding risk e.g. haemorrhagic stroke, major bleeding disorder, active PUD |
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List features of SIRS (2 or more meet criteria)
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temperature >38 or <36
HR >90 RR >20 MAP <54 WBC >12 |
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Most common cause of chronic limb ischaemia
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atherosclerosis 90%
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List causes of chronic limb ischaemia
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atherosclerosis 90%
aortic coarctation, arterial fibrodysplasia, arterial tumour, arterial dissection, arterial embolism, thrombosis, vasospasm, trauma |
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Most common peripheral site of artherosclerotic arterial occlusion/stenosis
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distal superficial femoral artery 60% at hiatus in adductor magnus muscle
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Le riche syndrome
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buttock/thigh claudication + impotence due to aortic iliac arterial stenosis
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What is ankle brachial index (ABI)
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highest ankle systolic/ arm systolic
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What is normal ABI?
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normal >0.95
intermittent claudication 0.4-0.9 Rest pain 0.15-0.4 Gangrene <0.15 |
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Which is associated with greater bleeding, incomplete or complete arterial transection?
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incomplete (vasospasm and thrombosis limits bleeding in complete transection
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What is most common vascular trauma in australia?
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blunt trauma from MVA
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List clinical features of vascular trauma
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pulsatile bleeding
signs of distal ischaemia expanding haematoma thrill or bruit at injury site |
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Describe sizes of varicose veins, telangectasias, reticular veins
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varicose veins >3mm
reticular veins 1-3mm telangiectasias <1mm |
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risk factors for varicose veins
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age, FHx, female, multiparity, Dx DVT, occupation with prolonged standing, obesity
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What is CEAP for chronic venous disease
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Clnical
Etiology Anatomical Site Pathology |
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List primary and secondary causes of chronic venous disease
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Primary- incompentent valves, familial
Secondary- previous DVT |
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What is most common site of venous incompetence
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saphenofemoral junction (2/3)
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What pressure is provided by compression stockings for chronic venous disease?
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20-40mmHg
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Incidence of VTE
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1:1000
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A temperature rising and falling several times is suggestive of...
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collection of pus and intermittent pyaemia
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Homan's sign
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pain on dorsiflexion of foot
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Define primary, reactionary and secondary haemorrhage
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primary= intraoperative
reactionary = within 24 hrs secondary = 7-10 days |
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What is meant by universal precautions
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behave as if every patient harbours dangerous pathogens
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Limb torniquet pressures
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arm 50mmHg
leg 100mmHg |
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Limb torniquet complications
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thrombosis, distal ischaemia, nerve compression, skin traction
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monofilament vs multifilament sutures
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mono glide easily, lower infection risk but less knot security
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define sepsis
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SIRS as a result of infection
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the presence of viable bacteria in the blood
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bacteraemia
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define severe sepsis
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sepsis associated with organ dysfunction e.g. coagulation derangement, altered mental status, oliguria
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Define shock
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hypotension (systolic <90mmHg or reduction >40mmHg from baseline) in absence of other cause
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Define MODS
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multiple organ dysfunction syndrome; affects lungs>liver>kidney>heart>gut>brain>pancreas>adrenals
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Describe clinical manifestations of MODS
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SIRS, hyperdynamic ciculatory state, hypermetabolic state, respiratory dysfunction (48hrs), liver and kidney dysfunction etc.
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Richter's hernia
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only part of circumference of bowel; ischaemia, perforation not obstruction
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Little's hernia
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Meckel's diverticulum in hernal sac. Most common in inguinal hernia
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Maydl's hernia
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contains 2 loops of bowel
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Secondary hernias
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incisional
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widest part of hernia
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body
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most common hernia
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80% inguinal
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most common hernia in females
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inguinal
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T/F epigastric should be promptly treated surgically
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NO, rarely need treatment
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Femoral hernias should be promptly treated surgically
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yes, narrow neck due to muscular walls, risk of incarceration, obstruction, strangulation
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List lifestyle approaches to managing a hernia
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stopping smoking (cough), treat constipation, weight reduction, manage ascites, change occupation/activities
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What mechanism underlies irreducibility of hernias
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Adhesions between sac and contents
Fibrosis leading to narrowing of neck Incarceration due to sudden IAP |
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hernial strangulation
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blood supply to contents has ceased. Preceded by lymphatic and venous occlusion, swelling.
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Direct inguinal hernia
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Medial to inferior epigastric artery
Through Hesselbach's triangle Acquired (not congenital) |
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Direct inguinal hernia pathology
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muscular defect; tranversalis fascia is not supported by conjoint ligament
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Indirect inguinal hernia
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sac comes out with cord through deep inguinal ring. Patent processus vaginalis. Congenital.
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Location indirect inguinal hernia
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Lateral to internal epigastric artery
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which is more common: indirect or direct hernia?
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indirect 4x
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indirect inguinal hernia confined to inguinal canal is called...
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bubonocele
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indirect inguinal hernia extending entire length of inguinal canal is called...
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funicular
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indirect inguinal hernia extending through the superficial inguinal ring into scrotum/labium is called...
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complete, scrotal or inguinoscrotal
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Sliding inguinal hernia
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part of viscus (usually colon) is adherent to outside of peritoneum forming the hernial sac beyond the hernial orifice (imagine 2 sacs)
more common on left side (where contain part of sigmoid) usually only found in males |
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Spermatic cord contents
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testicular arteries, cremasteric artery, genital branch of the genitofemoral, testicular nerve, vas deferens, pampiniform plexus, lymphatic vessels, tunica vaginalis
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Recurrence rate of mesh repair of inguinal hernia
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2%
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What nerve may be damaged in surgical repair of inguinal hernia
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ilioinguinal nerve
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borders of femoral canal
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anterior: inguinal ligament
posterior: ligament of cooper medially: lacunar ligament lateral: femoral vein |
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Are femoral hernias congenital?
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no
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Which hernia is likely to be found in multiparous women in her 60s who has recently lost 50kg
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femoral
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congenital umbilical hernia
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exomphalos
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What % of caucasian infants have umbilical hernia?
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5-10%
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Should umbilical hernias be treated promptly with surgery?
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No, will usually resolve by 2yrs. If remain, may need surgery
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ventral hernia
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incisional hernia
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Poor surgical techniques predisposing to incisional hernias
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angulated/parallel incision, devitalised tissue in wound, absorbable sutures of short duration (e.g. cat gut)
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Aetiology of incision hernias
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poor surgical technique
local wound factors (infection, haematoma, foreign body) Impaired wound healing Raised IAP |
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Should incisional hernias be treated promptly with surgery?
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Yes, will increase in size over time, are at risk of incarceration etc. Often requested by patient
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Umbilical herna in adults is more correctly termed
|
para-umbilical
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Para-umbilical hernia
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protrudes from SIDE of umbilical ring, umbilicus still retains its fibrous character withing the linea alba
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What % of neck lumps presenting in adults are malignant
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80%
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LN levels of the neck
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I submental, submandibular
II upper jugular, jugilodigastric III middle jugular IV lower jugular Vposterior triangle |
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Development of branchial arches
|
wks 2-7
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1st Branchial arch
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Ectoderm: EAC, TM
Mesoderm: mandible, maxilla, malleus, incus Mastication muscles CN IV |
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painless swelling below the hyoid bone which elevates on tongue protrusion
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thryoglossal cyst
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painless swelling at anterior border of SCM muscle below jaw (level II)
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branchial cyst
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cystic submandibular swelling due to extravasation through mylohyoid muscle of saliva from disrupted saliva gland
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plunging ranula
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Nasopharynx SCC is more common in
|
Asians
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Normal anatomy causing neck 'lumps'
|
C1 lateral process
hyoid bone thryoid cartilage Ptosed submandibular gland carotid bifurcation |
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what is most common parotid swelling in Australia?
|
skin cancer metastasis
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What proportion of women >50 have thryoid nodules?
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50%
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What is most commonly used biopsy method for neck lumps
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fine need aspirational biopsy
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When must excisional biopsy be performed?
|
to confirm Dx of lymphoma
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Which is better: incisional or excisional biopsy?
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excisional; incisional no recommened due to risk of border disruption
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where only one cortex of bone is fractured; periosteum intact
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green stick
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march fracture
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stress fracture
2nd metatarsal |
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direct force most likely gives rise to what type of fracture
|
transverse fracture
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twisting force
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spiral fracture
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compression force gives rise to what type of fracture
|
short oblique
crush if cancellous bone |
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triangular butterfly fracture is caused by what force
|
bending
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tension
|
transverse
|
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What % of # in children involve growth plate?
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>10%
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What is most common salter-harris fracture?
|
type II: through physis and metaphysis (sparing epiphysis)
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SALTR pneumonic
|
straight, above, lower, through, rammed
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pain in anatomical snuff box
|
scaphoid fracture
|
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off-ended
|
100% translation (shift)
|
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translation %
|
described with reference to DISTAL fragment
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Rule of 2s for ortho xrays
|
2 planes (AP and lateral)
2 joints above and below 2 limbs compare sides 2 injuires keep looking 2 occasions some fractures take a while to manifest on xray |
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'cold' bone scan
|
false negative if performed withi 48-72hrs of injury; may also have lower sensitivity in geriatrics
|
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what imaging mode is excellent for delineating cortical and trabecullar bone?
|
CT
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What imaging mode is good for soft tissue injury
|
MRI T2
|
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Indications for external fixation
|
severe soft tissue damage
nerve/vessel injury comminuted/unstable pelvic # infected severe multiple injuries |
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indications for internal fixation
|
failed treatment by closed means
inherently unstable known to unite poorly pathological fractures multiple fractures |
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management of open fracture
|
cleaning, irrigation, debridement, stabilisation, reduction, closure of exposed bone
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managment of simple closed fracture
|
reduction, immobilisation, rehabilitation
|
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5 stages of indirect fracture healing
|
haematoma formation
inflammation/proliferative callus formation consolidation remodelling |
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direct healing
|
if fracture is IMMOBILE e.g. fixed with plate, or impacted cancellous bone (e.g. crush).
NO CALLOUS |
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Healing with no callous formation
|
DIRECT healing
|
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Fracture union
|
has occurred when no mobility occurs at fracture site
|
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non-weight bearing duration
|
6-8wks lower limb
4-6 wks upper limb |
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5 Ps of compartment syndrome
|
Pain, parasthaesia, pallor, paralysis, pulselessness
|
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Key clinical features of compartment syndrome
|
Pain out of proportion
Pain on passive stretch |
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Excessive pain on passive stretch following fracture
|
compartment syndrome
|
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muscle total ischemia time
|
4-6hrs
|
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nerve damage shoulder dislocation
|
axillary nerve
|
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nerve damage humeral shaft
|
radial nerve
|
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humerus supracondylar fracture
|
posterior or anterior interosseous nerve
|
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hip dislocation nerve injury
|
sciatic nerve
|
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knee dislocation nerve injury
|
peroneal nerve
|
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delayed union
|
when fracture not united in period of time >25% expected
|
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causes of delayed union
|
inadequate immobilisation, infection, avascular necrosis of bone, soft tissue interposition between fracture ends, smoking
|
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hypertrophic non-union
|
callus formed but does not bridge defect
|
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non union
|
no evidence of union > 6mnths
|
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hypotrophic non-union
(atrophic) |
no callus formed
|
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malunion
|
union results in loss of anatomical alignment
|
|
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causes of malunion
|
poor initial reduction, failure to hold, gradual collapse of comminuted or osteoporotic bone
|
|
|
which bones are particularly susceptible to avascular necrosis?
|
femoral head
scaphoid talus |
|
|
what is most commonly fractured bone?
|
clavicle; medial 2/3
|
|
|
most common type of shoulder dislocation
|
anterioinferior
|
|
|
Low impact fracture of distal radius with radial angulation and backward displacement
|
Colle's fracture
|
|
|
Reverse colles?
|
Smith fracture
|
|
|
Fracture of distal radius with anterior displacement of distal fragament
|
Smith (reverse colles)
|
|
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Fracture of radial shaft with dislocation of inferior radio-ulnar joint
|
Galeazzi fracture
|
|
|
Fracture of proximal ulna with anterior dislocation of radial head
|
Monteggia
|
|
|
1st metacarpal avulsion fracture; often intraarticular
|
Bennet's
|
|
|
Distal 5th metacarpal fracture
|
Boxer's fracture
|
|
|
Boxer's fracture
|
Distal 5th metacarpal fracture
|
|
|
avulsion of distal phalanx
|
mallet finger
|
|
|
Pilon fracture
|
distal tibia fracture. Talus is driven certically into tibial plafond
|
|
|
What ligament divides breasts into lobes?
|
suspensory ligament of cooper
|
|
|
Level I axillary LN are located
|
inferior/below pectoralis minor
(closer to arm pit) |
|
|
Level 2 axillary LN are found
|
under pectoralis minor
|
|
|
Level 3 axillary LN are found
|
above/superior pectoralis minor
closest to clavicle |
|
|
breast fibroadenomas are most common at what age?
|
15-25
|
|
|
What is a locally invasive variant of breast fibroadenoma?
|
Phyllodes tumor
|
|
|
Duct ectasia
|
accumulation of secretions in the duct +/- inflammation and infection
|
|
|
what proportion of women experience nipple discharge
|
25% if nipple compressed
50% if suction applied |
|
|
Clinical signs of physiological niplpe discharge
|
bilateral
multiple ducts milk-like/green/brownish/thick |
|
|
Clinical signs of pathological nipple discharge
|
single duct
spontaneous unilateral blood stained/serous/clear |
|
|
Screening for breast cancer criteria
|
targets asymptomatic women 50-69 for biannual mammography
|
|
|
What views are taken on screening mammography
|
Mediolateral oblique view (MLO)
Craniocaudal (CC) |
|
|
Category 1 risk of breast cancer
|
no or weak FHx
95% of female population Life time risk 8-12% |
|
|
Category 2 (mod) risk of breast cancer
|
1-2 1st degree relatives Dx OR
2 or more distant relatives on same side Lifetime risk: 12-25% |
|
|
Category 3 (high) risk of breast cancer
|
3 or more close relatives with young age; multifocal or bilateral BCa or ovarian Ca.
Lifetime risk: 40-80% <1% of population |
|
|
Triple Assessment for Breast Cancer
|
Clinical fidings
Imaging (mammography, US) Non-surgical biopsy |
|
|
What imaging mode is good for DDx solid from cystic mass?
|
US
|
|
|
If all components of Triple Assessment are concordant what is accuracy
|
>99%
|
|
|
What is required for appropriate reporting of FNAB for breast cancer
|
>6 clusters of cells
Minimal blood |
|
|
Advantages of FNAB for breast cancer
|
Can be performed under local anaesthetic, rapid results, wide sampling (multiple needle insertions at same site), can be used with small lesions (<5mm)
|
|
|
What are advantages of Core needle biopsy for breast cancer
|
gives histological Dx
Allows immunohistochemistry for biological markers |
|
|
What are disadvantages of Core needle biopsy for breast cancer
|
Selection biopsy (only one tract of tissue); takes longer than FNAB, undereestimates invasion in 10-20%
|
|
|
BRCA1
|
tumor suppressor gene chromosome 17
AD inheritance |
|
|
BRCA2
|
tumor suppressor gene
chromosome 13 AD inheritance |
|
|
Genetic conditions associated with increase breast cancer risk
|
BRCA1/2
Li Fraumeni Lynch Peutz-Jeghers |
|
|
Most breast cancers are derived from...
|
epithelial cells that line the terminal duct lobular unit (TDLU)
|
|
|
Lobular carcinoma in situ
|
marker of increase risk of disease in either breast. Appropriate to monitor over time.
|
|
|
Ductal carcinoma in situ
|
pre-malignant, pre-invasive; increased risk of invasive disease at site biopsied. Variable, unpredicatble time to progression. Treat, not monitor.
Microcalcification on mammography |
|
|
What margins are goal of complete local excision of breast lump
|
5-10mm (sometimes accepted down to 1mm)
|
|
|
What is the most significant prognostic factor in breast cancer?
|
nodal status
|
|
|
Trastuzumab
|
monoclonal antibody against Her2/Neu (Herceptin)
|
|
|
What is major risk of sentinal node biopsy?
|
false negative mapping of axilla (5-8%)
|
|
|
What are complication of axillary dissection
|
Chronic lymphodema
Seroma formation Numbness and parasthesia (damage to intercobrachial nerve) Stiffness of shoulder joint |
|
|
What proportion of women experience chronic lymphoedema following axillary dissection
|
5-7% severe
25% mild-mod |
|
|
What features suggest a women requires radiotherapy post mastectomy
|
tumour >5cm
>4 LN positive |
|
|
Prevalence of acute appendicitis
|
1:7
|
|
|
Movement of pain to right iliac fossa in appendicitis suggests
|
transmural involvement. Serosa +/- parietal peritoneum now involved, somatic pain fibres stimulated
|
|
|
Right loin pain in setting of appendicitis suggests
|
retrocaecal appendix
|
|
|
McBurney's point
|
1/3 of way from ASIS to umbilicus
|
|
|
Rovsing sign
|
palpation of LLQ results in pain in RLQ- indicates local peritonitis
|
|
|
Psoas sign
|
used to elicit tenderness in retrocaecal appendicitis. Pain on extension of right hip (stretches psoas)
|
|
|
Appendicitis US findings
|
thick walled appendix; dilated lumen. Sensitivity 75%; Specificity 95%
|
|
|
Mesenteric adenitis
|
Most common in children. Recent Hx of sore throat + fever. Self-limiting disease, spontaneous improvement 24-36hrs. No muscle rigidity.
|
|
|
Barrett's esophagus
|
normal squamous mucosa is replaced by columnar; pre-malignant (adenocarcinoma)
|
|
|
Rolling hernia also known as
|
para-oesophageal hiatus hernia
|
|
|
What proportion of oesophageal tumours are benign?
|
1%
|
|
|
What is most common benign esophageal tumour?
|
leiomyoma
|
|
|
what is the most common oesophageal cancer?
|
SCC
|
|
|
Murphy's sign
|
inspiratory arrest on deep palpation of RUQ (cholecystitis)
|
|
|
What is the most common type of hiatus hernia?
|
sliding
|
|
|
Name some H2 antagonists
|
cimetidine, ranitidine
|
|
|
Nissen fundoplication
|
fundus of stomach is wrapped around LES and sutured
|
|
|
Define paraesophageal hiatus hernia
|
part of stomach herniated through esophageal hiatus into thorax with undisplaced gastroesophageal junction
|
|
|
Plummer vinison syndrome
|
chronic iron deficiency secondary to esophageal cancer
|
|
|
Is the risk of haemorrhage higher for gastric or duodenal ulcers?
|
3x higher in gastric
|
|
|
Most duodenal ulcers are within what distance of pylorus?
|
2cm (in duodenal bulb)
|
|
|
Posterior perforation of duodenal ulcer might involve
|
gastroduodenal arteral
pancreas; elevated amylase |
|
|
What xray sign is present in 70% of patients with perforated duodenal ulcer?
|
free air under diaphragm
|
|
|
Risk factors for gastric carcinoma
|
smoking, alcohol, nitrosamines, chronic H. pylori, pernicious anaemia, previous partial gastrectomy, HNPCC, gastric adenomatous polyps
|
|
|
What is most common gastric cancer
|
adenocarcinoma >90%
|
|
|
Virchow's nodes
|
left supraclavicular
|
|
|
Krukenberg tumour
|
metastasis to ovary
|
|
|
Blumer's shelf
|
mass in pouch of douglas
|
|
|
extrinsic causes of small bowel obstruction
|
adhesions
hernia volvulus annular pancreas neoplasm |
|
|
intrinsic causes of small bowel obstruction
|
neoplasm (15%)
inflammatory lesions/strictures congenital malformations cystic fibrosis superior mesenteric artery syndrome |
|
|
list Intraluminal causes of small bowel obstruction
|
gallstone ileus
faeces/bezoar foreign body (barium, worms) intramural haematoma |
|
|
describe pathogenesis of abdominal distension in setting of small bowel obstruction
|
bowel wall edema, loss of absorptive function, increased fluid in lumen, transudative fluid loss into peritoneum + swallowed air + gas from bacteria cause distension
|
|
|
Colon emptying time
|
12-24hrs
|
|
|
profuse vomiting followed by onset of colicky abdo pain with minimal abdominal distension suggests
|
proximal small bowel obstruction
|
|
|
late feculent vomiting, obstipation and abdominal distension with peristaltic rushes suggests
|
distal small bowel obstruction
|
|
|
what proportion of small bowel obstructions becomes strangulating
|
10%
|
|
|
Abdominal xray signs for small bowel obstruction
|
air-fluid levels, dllated edematous loop of bowel (ladder pattern- plica cicularae)
|
|
|
Signs ischemic bowel
|
free air, pneumatosis, thickened bowel wall, air in portal vein
|
|
|
proximal small bowel obstruction with frequent emesis causes what metabolic derangement?
|
alkalosis
|
|
|
initial management of small bowel obstruction
|
NG tube to relieve vomtiting and abdominal distention, fluid resus, catheter to monitor in/outs
|
|
|
carcinoid tumors of GIT
|
originate from enterochromaffin cell type in crypts
most common 60cm from ileocecal valve + appendix. May be associated with MEN |
|
|
carcinoid sydnrome
|
<10% of carcinoid tumors; secretion serotonin, kinins, vasoactive peptides. Hot flushes, hypotension, diarrhoea, bronchoconstriction, right heart failure
|
|
|
What is the most common type and site of small intestine lymphoma?
|
non-hodgkin's; >70yrs
distal ileum coeliac: proximal jejunum |
|
|
Meckel's diverticulum
|
remnant of embryonic vitelline duct; 10-90cm from IC valve on ileum
|
|
|
Rule of 2s for meckel's diverticulum
|
2% of pop
2% symptomatic Most present within 2 yrs 2ft from IC valve (10-90cm) |
|
|
fistula
|
abnormal communication between 2 epithelialized surfaces
|
|
|
why fistulas stay open
(FRIENDO) |
foreign body
radiation infection epithelialisation neoplasm distal obstruction (most common) Other: steroids, increased flow |
|
|
what is the most common tumor found in the appendix
|
carcinoid (90% benign)
|
|
|
what is the most common indication for surgery in Crohn's disease
|
SBO due to stricture/inflammation
|
|
|
short gut syndrome
|
diarrhoea, steatorrhoea, malnutrition
|
|
|
what is most common site of large bowel obstruction
|
sigmoid colon
|
|
|
what is most common cause of large bowel obstruction
|
colorectal adenocarcinoma 65%
|
|
|
list causes of large bowel obstruction
|
colorectal cancer
diverticulitis + scarring Volvulus other: IBD, benign tumours, fecal impaction, |
|
|
which is slower in onset with less vomiting, small or large bowel obstruction?
|
large
|
|
|
which part of the large bowel is at greatest risk of perforation
|
cecum
|
|
|
Ogilvie's syndrome
|
pseudoobstruction, distention of colon without mechanical obstruction.
|
|
|
diverticulum
|
abnormal sac or pouch protruding from the wall of a hollow organ
|
|
|
diverticulosis
|
presence of a divertulum (an abnormal sac or pouch protruding from the wall of a hollow organ)
|
|
|
true diverticula
|
contain all layers, congenital (right sided)
|
|
|
fasle diverticula
|
contain only mucosal and submucosal, acquired, left sided
|
|
|
Where is most common site of a diverticula?
|
sigmoid colon
|
|
|
What proportion of diverticula are asymptomatic
|
90%
|
|
|
what is the most common fistula associated with diverticulitis
|
colovesicular (pneumaturia, fecaluria, recurrent UTIs)
|
|
|
toxic megacolin
|
a type of ileus that can occur in patients with UC in which there is transmural inflammation and colonic dilatation
|
|
|
adynamic ileus is associated with what chemotherapy agent?
|
vincristine; co-prescribe with metoclopramide.
|
|
|
a vascular anomaly most common in right colon of patients >60 is called
|
angiodysplasia
|
|
|
histology of angiodysplasia
|
dilated thin-walled vessels in the mucosa and submucosa covered by single layer of epithelium
|
|
|
ischaemic colitis
|
reduced blood to colon due to occlusion, vasospasm, hypoperfusional states.
|
|
|
What location is most commonly affected in ischaemic colitis
|
'watershed' (splenic flexure, right colon)
|
|
|
colonoscopy findings of ischaemic colitis
|
petechial haemorrhage
friability ulceration |
|
|
Volvulus
|
rotation of segment of bowel about its mesentery
|
|
|
a volvulus becomes symptomatic if
|
bowel obstruction or bowel ischaemia develops
|
|
|
what is most common site of volvulus
|
sigmoid (70%)
|
|
|
risk factors for volvulus
|
Age (>70), elongated colon, low fibre/high residue diets, chronic constipation, laxative abuse, pregnancy, elderly, bedridden
|
|
|
omega or bent inner tube signs on abdo Xray suggests
|
sigmoid volvulus
|
|
|
ace of spades finding on barium enema
|
sigmoid volvulus (contrast filled lumen tapers)
|
|
|
polyp
|
small mucosal outgrowth with grows into the lumen of the colon or rectum
|
|
|
sessile
|
flat
|
|
|
what is prevalence of polyps
|
50s 30%
60s 40% 70s 50% |
|
|
what polyps are premalignant
|
adenoma (tubular, villous)
|
|
|
which has higher risk of malignancy: villous or tubular adenomatous polyps
|
villous (35%)
tubular (5%) |
|
|
Familial adenomatous polyposis (FAP)
|
Autosomal dominant
Mutation in APC multiple colonic adenomas from age 40. Colon Ca in 90% at 45 if untreated |
|
|
Hereditary non-polyposis colorectal carcinoma (HNPCC)
|
AD inheritance, mutation in DNA mismatch repair gene resulting in genomic instability and subsequent mutations.
Usually RIGHT colon |
|
|
Risk factors for colorectal carcinoma
|
FAP, HNPCC, adenomatous polyps (esp >1cm), age >50, IBD, FHx colon Ca (also gonadal, breast), smoking, DM, dietary factors
|
|
|
List Amsterdam Criteria for HNPCC
|
1. >3 relatives with colon Ca
2. Over 2 or more generations 3. >1 Dx <50yrs 4. exclude FAP |
|
|
Which is associated with higher risk of colon ca, UC or crohns?
|
UC
1-2%/year after 10 years |
|
|
What is the most common metastasis site of colorectal cancers?
|
liver (haematogenous)
|
|
|
Name of criteria for staging colorectal Ca
|
Dukes (A-D)
|
|
|
What % of recurrences of colorectal Ca occur within 2 years
|
80%
|
|
|
Is diverticular disease more common in males or females?
|
females
|
|
|
haemorrhoids
|
a plexus of dilated veins (cushion) arising from the superior or inferior haemorrhoidal veins
|
|
|
List causes of haemorrhoids
|
increased intra-abdominal pressire
chronic constipation pregnancy obesity portal HTN |
|
|
internal haemorrhoids
|
above dentate line; plexus of superior haemorrhoid veins
portal circulation 3, 7, 11 o'clock PAINLESS rectal bleeding |
|
|
external haemorrhoids
|
below dentate line
inferior haemorrhoid veins systemic circulation PAINFUL |
|
|
inferior haemorrhoid veins
|
systemic circulation
external PAINFUL |
|
|
superior haemorrhoidal veins
|
portal circulation
internal; 3, 7, 11 PAINLESS |
|
|
How long do thrombosed haemorrhoid take to resolve
|
usually 2wks
|
|
|
Anal fissures
|
tear of anal canal below dentate line
|
|
|
Most common position of anal fissures
|
90% posterior midline
10% anterior midline |
|
|
What are causes of anal fissures off midline
|
IBD, STD, TB, leukaemia
|
|
|
chronic fissure triad
|
fissure, sentinel skin tags, hypertrophied papillae
|
|
|
lateral subcutaneous internal sphincterotomy is performed at what position?
|
3 oclock
|
|
|
Anorectal abscess
|
infection in anal spaces; usually bacterial infection of blocked anal gland at the dentate line
|
|
|
What organisms are implicated in anorectal abscess
|
E.coli, Proteus, Strept, anaerobes
|
|
|
what is Rx of anorectal abscess
|
incision + drainage + Abx
|
|
|
Perianal abscess
|
travels distally in the intersphincteric groove; unremmiting pain, indurated swelling
|
|
|
Ischiorectal abscess
|
penetrate through the external anal sphincter
|
|
|
Intersphincteric abscess
|
between the internal and external sphincters; fluctuant mass palpated in DRE
|
|
|
List 4 types of anorectal abscess
|
Perianal
Ischiorectal Intersphincteric Supralevator |
|
|
pilonidal disease
|
acute abscess or chronic draining sinus in sacrococcygeal area secondary to obstruction of hair follicles
|
|
|
Rectal prolapse
|
protrusion of full thickness of rectum through anus
|
|
|
what is the most common tumour of the anal canal?
|
epidermoid (75%) squamous or transition cell
|
|
|
polyp-to-cancer sequence takes how long
|
5-10yrs
|
|
|
what is most common benign hepatic tumour
|
hemangioma (malformation of angioblastic fetal tissue)
|
|
|
are benign liver hemangiomas more common in males of females
|
females 6:1
|
|
|
What factors promote the growth of liver hemangiomas
|
steroids, estrogen, pregnancy
|
|
|
what happens if you attempt to biopsy liver haemangioma?
|
haemorrhage
|
|
|
list types of benign liver tumours
|
hemangioma, adenoma, focal nodular hyperplasia
|
|
|
In what patients is an liver adenoma most common
|
young women 30-50 on OCP for many years presenting with RUQ pain or mass
|
|
|
What is the most common primary liver malignancy?
|
hepatocellular adenocarcinoma
|
|
|
list types of liver malignancies
|
hepatocellular adenocarcinoma (most common)
cholangiocarcinoma, angiosarcoma, hepatoblastoma |
|
|
Are malignant liver tumours more common in males or females
|
males 2:1
|
|
|
List risk factors for primaruy liver cancer
|
chronic Hep B/C
cirrhosis (esp macronodular) OCPs steroids smoking, alcohol chemical carcinogens haemochromatosis |
|
|
What proportion of patients presenting with liver cancer have resectable disease
|
10% (70% have mets to nodes and lungs); cirrhosis is relative contraindication due to decreased hepatic reserve
|
|
|
What is the most common liver cancer
|
secondary (metastatic)
bronchogenic, GI, pancreas, breast, ovary |
|
|
List factors involved in Child's classification for TIPS
|
serum bilirubin
serum albumin presence of ascites encephalopathy malnutrition |
|
|
TIPS
|
transjugular intravascular portasystemic shunt- shunt between portal and hepatic vein via catheter placed in liver
|
|
|
cholelithiasis
|
imbalance of cholesterol and its solubilizaing agents, bile salts and concentrations
|
|
|
4 Fs of cholelithiasis
|
female, fat, fertile, forties
|
|
|
What is the most common component of gallstones
|
Mixed type >70% cholesterol by weight; radioluscent
|
|
|
what proportion of gallstones are pigment stones?
|
20%
|
|
|
Are pigment stones likely to be radioopaque or -luscuent?
|
radioopaque
|
|
|
What is composition of pigment stones
|
unconjugated bilirubin, calcium, bile acids
|
|
|
can most gallstones be seen on xray
|
no, most are cholesterol which are radioluscent
|
|
|
black pigment gallstones are associated with
|
cirrhosis
chronic haemolytic states |
|
|
what proportion of gallstones are symptomatic
|
20% develop symptoms over 15years
|
|
|
surgical indications for gallstones
|
recurrent symptoms
cholecystitis calcified 'porcelain' gallbladder sick cell disease DM Hx of biliary pancreatitis |
|
|
Acute cholecystitis
|
inflammation of gallbladder resulting from sustained obstruction of cystic duct by gallstone (80%)
|
|
|
DDx of acute cholecystitis
|
PUD, MI, pancreatitis, hiatus hernia, right lower lobe pneumonia, appendicitis, hepatitis, herpes zoster
|
|
|
US findings in acute cholecystitis
|
distended, edematous gallbladder, pericholecystic fluid, stones, sonographic Murphy's sign.
|
|
|
Complications of acute cholecystitis
|
hydrops (mucus accumulation)
gangrene, perforation empyema cholecystoenteric fistula gallstone ileus choledocholithiasis (15%) |
|
|
What are most common infective cause of acute cholecystitis?
|
E.coli
Klebsiella Enterococcus Enterobacter |
|
|
Complications of cholecystectomy
|
anaesthetic risk/post-op risks
bile duct injury (0.2-1%) |
|
|
choledocholithiasis
|
stones in common bile duct
|
|
|
What clinical features suggest choledocholithiasis (compaied to cholelithiasis)
|
increased bilirubin >10
US hepatic duct dilation |
|
|
ERCP
|
endoscopic retrograde cholangiopancreatography
|
|
|
acute cholangitis
|
obstruction of common bile duct leading to biliary stasis, bacterial overgrowth, suppuration, inflammation
|
|
|
Does US reliably detect common bile duct stones?
|
NO
|
|
|
Etiology of acute cholangitis
|
choledocholithiasis (60%)
post-op stricture pancreatic or biliary tumour |
|
|
Charcot's triad
|
fever, jaundice, RUQ
|
|
|
Reynold's triad of acute cholangitis
|
Charcot triad (fever, jaundice, RUQ pain) + mental confusion + hypotension (risk of renal failure)
|
|
|
gallstone ileus
|
cholecystoenteric fistula (usually duodenal) with large gallstone impacting most commonly at ileocecal valve
|
|
|
Abdominal xray findings of gallstone ileus
|
dilated small intestine, gallstone in RLQ, air in biliary tress
|
|
|
risk factors for pancreatic cancer
|
age, smoking (2-5x increased risk), low fibre/high fat diet, chronic pancreatitis, diabetes, alcohol
|
|
|
what is the most common location of pancreatic cancer
|
haed of pancreas 70%
|
|
|
what symptoms are associated with head of pancreas cancer
|
weight loss, obstructive jaundice, adominal pain
|
|
|
which is more likely to present at late state: head or tail of pancreas cancer?
|
tail
|
|
|
what proportion of patients with body or tail of pancreas tumours will have jaundice?
|
<10%
|
|
|
what is most common type of pancreatic cancer
|
ductal adenocarcinoma
|
|
|
Whipple's procedure
|
pancreatoduodenectomy
|
|
|
Hasselbach's triangle
|
lateral edge of rectus sheath
inguinal ligament inferior epigastric artery |
|
|
What are most commonly Dx cancers
|
prostate, bowel, breast
|
|
|
what are most common causes of cancer death?
|
lung, bowel, prostate
|
|
|
what is the most common cancer in Australian women
|
breast (1/9 by 85yrs)
|
|
|
what are risk factors for prostate cancer
|
Age, 1or more 1st degree relative <65yrs, 1st degree relative with BRAC1/2
|
|
|
Do men experiencing LUTS have increased risk of prostate cancer
|
No, usually caused by benign prostatic hypertrophy
|
|
|
42yo man presents with right testicular swelling. AFP 42, BHCG 0, LD 399. What is Dx?
|
testicular cancer
Non-seminomatous germ cell tumour |
|
|
Layers of scrotum (outside to inside)
|
skin, dartos, tunica vaginalis, tunical albuginea, testis/epidiymis/vas deferens
|
|
|
Cremaster muscle originates from
|
internal oblique
|
|
|
What scrotal layer is formed of peritoneum
|
tunica vaginalis (obliterated processus vaginalis)
|
|
|
What tumor markers are tested in testicular cancer
|
alpha feto protein
beta HCG lactate dehyrdogenase |
|
|
what is the imaging study of choice for testicular masses
|
doppler US
|
|
|
what increases risk of testicular cancer by 7-10%
|
cryptoorchidism
|
|
|
incidence of testicular cancer in Aust
|
2-3 per 100,000
|
|
|
what is life time risk of testicular cancer
|
.2%
|
|
|
what is most common type of testicular cancer
|
germ cell 95% of which seminomatous most common
|
|
|
Should a fine needle biopsy be performed in the evaluation of a testicular mass?
|
NO, risk of spreading malignant tumour
|
|
|
what is the management of testicular cancer
|
Inguinal orchidectomy + staging (lymph node dissection if indicated)
|
|
|
Freely mobile, painless, discrete mass in dermal layer of scrotum
|
sebaceous cyst
|
|
|
an enlarging, firm papule on the scrotal skin
|
SCC
|
|
|
a unilateral scrotal swelling which is fluctuant and tranilluminating
|
hydrocele
|
|
|
"bag of worms"
|
varicocele
|
|
|
a tall, thin man presents with scrotal mass on left side which disappears when lying down
|
variocele
|
|
|
DDx of testicular torsion and appendix testis torsion
|
'blue dot sign'
|
|
|
A chronic, painless soft nodule in head of epididymis which does not transillluminate
|
spermatocele
|
|
|
Sudden onset of painful testicular swelling while sleeping suggests
|
testicular torsion
|
|
|
Clinical signs of testicular torsion
|
swelling, tenderness
testis high in scrotum absent cremesteric reflex elevation aggrevates pain |
|
|
In what age group is testicular torsion most common
|
10-25yrs
|
|
|
Raised beta HCG in the setting of firm, heterogenous testicular mass suggests
|
germ cell tumour (seminoma or non-seminoma)
|
|
|
Scrotal swelling spreading up the spermatic cord with cough impulse
|
indirect inguinal hernia
|
|
|
Thrombosis at origin of SMA results in...
|
ischaema from ligament of Treitz to splenic flexture
|
|
|
Which has poorer prognosis, thrombosis or embolism of SMA
|
Thrombosis (tends to form at origin)
Emboli tend to lodge distal to middle colic artery, sparing proximal jejunum |
|
|
Sparing of proximal jejunum in setting of SMA embolism suggests
|
emboli has lodged DISTAL to middle colic artery
|
|
|
Which is more common: thrombosis of mesenteric vein or artery?
|
artery; venous accounts for <10%
Dx usually at surgery |
|
|
Length of normal small bowel
|
350cm
|
|
|
Short bowel syndrome occurs when how much bowel is lost?
|
>50-70% or less than 100cm
|
|
|
Which would you rather lose: jejunum or ileum?
|
jejunum. Ilieum is important for bile salt and intrinsic factor-bound B12 reabsorption. Loss of jejunum often causes lactose intolerance
|
|
|
Griffith's point
|
at splenic flexure at junction of SMA and IMA regions
|
|
|
Sudeck's ciritical point
|
midportion of sigmoid colon at junction of IMA and hypogastric arteries
|
|
|
midline shift on axial CT following MVA
|
subfalcine cerebral herniation
|
|
|
subfalcine herniation
|
singulate gyrus under falx cerebri- midline shift
|
|
|
what cranial nerve may be compressed in uncal (transtentorial) herniation
|
occulomotor III
|
|
|
what CN injury is associated with fracture of petrous temporal bone
|
V, VII
|
|
|
minimum criteria for obligatory admission to hospital after head injury
|
LOC >10mins
persistent drowsiness focal neuro deficits skull fracture persisting nausea/vomiting lack of adequate care at home |
|
|
extradural haematoma
|
accumulation of blood between the inner table of skull and stripped off dural membrane
|
|
|
are extradural haematomas more common in young or old?
|
young (60% <20)
Dura easier to strip off underlying bone |
|
|
what is most common vessel involved in extradural haematomas?
|
middle meningeal artery
(venous sinuses 30%) |
|
|
Do extradural haemorrhages cross suture lines?
|
No, dura more strongly adhered along sutures
|
|
|
CT findings of extradural haematoma
|
lenticular/biconvex homogeneous hyperdensity with compression of underlying brain, distortion of lateral ventricle, not crossing suture line
|
|
|
air in acute extradural haematoma suggests
|
fracture of sinus or mastoid air cells
|
|
|
subdural haematoma
|
collection of blood between dural and arachnoid. Accounts for 60% of acute traumatic intracranial haematomas
|
|
|
lucid interval followed by neurological decline in young person with skull fracture
|
epidural haematoma
|
|
|
Are symptoms associated with chronic subdural haematoma usually due to decreased cerebral perfusion and ischaemia
|
no, caused by direct compression on underlying brain
|
|
|
a subdural haematoma that is heterogenous and loculated suggests
|
sub-acute (3-21 days) inflammatory reaction, neomembrane formation (or acute on chronic)
|
|
|
a subdural haematoma that is diffusely hypodense suggests
|
chronic >21 days old
|
|
|
List risk factors for subdural haematoma?
|
coagulopathy (aspirin, warfarin etc)
age >65 Hx of liver/renal diseas alcoholism brain atropy recent trauma |
|
|
otorrhoea/rhinorrhoea in setting of head injury may suggest
|
basilar skull fracture
|
|
|
When assessing a head injury, what imaging modality is most appropriate
|
NON-CONTRAST CT
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a crescentic shaped haematoma that crosses suture lines on axial non-contrast CT suggests
|
subdural haematoma
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what proportion of strokes are haemorrhagic
|
10%
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Acquired aneurysms secondary to HTN which often occur in the small penetrating vessels of brainstem and midbrain
|
charcot-bouchard
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what is the most common brain aneuyrsm
|
berry/saccular
1 in 100,000 90% of all aneurysms |
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where are berry aneurysms usually found
|
circle of willis (anterior circulation 80-90%)
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what is the most common cause of subarachnoid haemorrhage
|
rupture of berry aneurysm
70-80% |
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|
subarachnoid hemorrhage
|
extravasation of blood into the subarachnoid space between the pial and arachnoid membranes
|
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aneurysmal sac or berry aneurysms is normally composed of
|
only intima and adventitia (no media)
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intracranial aneurysms are mutliple in what %
|
10-30% (most have 2)
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Are intracranial aneurysms more common in males or females
|
females 5:1
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What is the most common age where intracranial aneuyrsms become symtptomatic
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55-60yrs
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>80% o of all intracranail aneurysms are found
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in anterior circualtion (e.g. birfucations, ACA, ICA and MCA)
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what is most common paediatric cancer (accounts for 20%)
|
brain tumours
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what is the most common brain tumor
|
neuroepithelial (52%)
most are gliomas (astrocytomas) |
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What is most common glioma
|
astrocytoma
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List types of glioma
|
astrocytoma
oligodendrocytoma ependymoma choroid plexus tumour medulloblastoma |
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medulloblastoma is a type of...
|
neuroepithelal glioma
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List types of neuronal brain tumors
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ganglioma, gangliocytoma, neuroblastoma
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List CT features suggestive of high grade glioma
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large
extensive edema enhance vividly |
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is chemotherapy recommended for Rx of gliomas
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no, poor results
radiotherapy is favoured |
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A slow growing glioma with calcium deposition that presents with epilepsy suggests
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oligodendrocytoma
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what is the most common benign brain tumour
|
meningioma
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Are acoutic neuromas considered bengin of malignant
|
benign
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acoutic neuromas
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arise from CNVIII (vestibulocochlear)
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pituitary tumours make up what % of all intracranial tumours
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10%
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what are symptoms of acoutic neuromas
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tinnitus, unilateral partial or complete sensory neural hearing loss
(eventually cerebellum compression causing ataxia) |
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CT findings of acoutic neuroma
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enhancing tumour in cerebellopontine angle + internal auditory meatus (widened)
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colloid cysts are usually found
|
anterior and roof of 3rd ventricle. May obstruct foramena of munro
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what are 3 histological cell types in pituitary
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chromophilic, acidophilic, basophilic
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A microadenoma of the pituitary is what size
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<1cm
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A macroadenoma of the pituitary is what size
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>1cm
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what is the most common pituitary adenoma
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prolactinoma 40%
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What proportion of pituitary tumours are non-secreting
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20%
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What is the second most common pituitary adenoma
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GH-secreting
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a midline neck lump that moves with protusion of tongue and on swallowing in a young child is most likely
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thyroglossal duct cyst
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Should FNAB be performed for thyroid nodule?
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Yes
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what is most common type of thyroid cancer
|
papillary thyroid cancer
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a multi-focal thryoid mass in a 30yr old man with LN spread is most likely
|
Papillary thyroid cancer
(50% of all thyroid cancers) 20-40yrs |
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A single thyroid mass in a 60yr old man with distant metastasis is most likley
|
Follicular thryoid cancer
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Medullary thryoid cancers are derived from what cell type
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C cells
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Medullary thryoid cancers may secrete what
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calcitonin
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Lymphoma of the thyroid is associated with
|
Hashimotos thyroiditis
|
|
|
Plummer's disease
|
toxic multinodular goitre
multiple autonomously functioning nodules hyperthryroidism (2nd most common after Grave's in Western World) |
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complications of thyroid surgery
|
damage to recurrent laryngeal nerve, external branch of superior laryngeal nerve, parathyroid glands
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which parathryoid glands are easiest to find?
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superior 2
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ectopic or supernumary parathyroid glands occur in what %
|
>10% of population
|
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Functions of PTH
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increase renal Ca resorption
Increase osteoclast acitivity increase vit D production in proximal tube |
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1/2 life of PTH
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5 mins
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primary hyperparathyroidism is usually caused by
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single or multiple parathyroid adenoma (90%)
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classic presentation of parathryoid adenoma
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women 40s, 50s
hypercalcaemia, osteoporosis, bone pain, fatigue MEN I or IIA |
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what is most common cause of secondary hyperparathyroidism
|
chronic renal disease
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most common cause of hypoparathyroidism
|
surgical removal (opps)
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List 4 main categories of adrenal gland tumours
|
phaeochromocytoma
cushings conns verilising/feminizing tumours |
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Sweating, palpitations and HTN in setting of adrenal mass suggests
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phaeochromocytoma
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Are most phaeochromocytomas benign/malignant
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benign
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Are most phaeochromocytomas functioning/non-functioning
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functioning
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Although rare, extension of phaeochromocytoma occurs in what direction
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along renal vein into IVC
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Secreting Adrenocortical tumours cause what syndrome
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Cushing's sydnrome
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Conn's syndrome
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aldosterone-secreting tumour
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HTN, polyuria, polydipsia and muscle weakness in the setting of adrenal mass
|
Conn's syndrome
aldosterone-secreting tumour |
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Ix for Conn's syndrome
|
plasma renin:aldosterone ratio
low plasma renin Hypokaelamia (not always) |
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Are sex-steroid secreting adrenal tumours usually benign or malignant
|
malignant (50% with mets; many with palpable mass)
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Which adrenal tumour is most likely to present as palpable mass
|
virilising/feminizing tumours
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a translucent nodule made more obvious by stretching skin located on the central face is classic presentation of
|
basal cell carcinoma
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what is the most common skin cancer
|
basal cell carcinoma
|
|
|
Major Salivary glands
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parotid
submandibular sublingual |
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Parotid gland
|
largest salivary gland
overlies the masseter Facial nerve enters posteromedially splits into 2 trunks at pes anserinus |
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submandibular salivary gland wraps around what muscle
|
mylohyoid
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|
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Duct from submandibular gland opening in floor of mouth
|
Wharton's duct
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|
|
Warthin's tumor
|
benign papillary cystadenoma of salivary glands (usually parotid)
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what is most common cause of bilateral salivary gland enlargement
|
worldwide: mumps (paramyxovirus)
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What viral infections can case sialadenitis
|
mumps, coxsackievirus, CMV, EBV, inluenza, HIV
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What is the most common neoplasm of the salivary glands
|
benign pleomorphic adenoma of parotid gland (followed by metastatic SCC)
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do most pleomorphic parotid adenomas lie superficial or deep to facial nerve
|
90% superficial
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What parotid tumour is associated with smoking, is more common in elderly males and may be bilateral 10% of the time
|
Warton's tumor (adenolymphoma)
|
|
|
what is the most common cause of malignant mass in salivary gland in Australia
|
SCC
|
|
|
what is the most common malignant primary salivary gland cancer
|
mucoepidermoid tumour
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|
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what is most common type of bladder cancer in developed countries
|
transitional cell carcinoma (>90%) followed by SCC
|
|
|
describe link between smoking and bladder cancer
|
2-4x increased risk
dose dependent interval between exposure and cancer is 15yrs |
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List risk factors of bladder cancer
|
smoking
occupational exposure e.g. dyes, aromatic amines age >55 pelvic radiation systemic chemotherapy schistomsoma infection male (4:1) chronic bladder inflammation positive FHx |
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|
increased laxity with valgus stress to knee suggests damage to
|
medial collateral ligament
|
|
|
what force is most commonly associated with medial collateral ligament knee injury
|
a lateral blow to the knee
sign elicited by applying valgus force |
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|
lateral collateral ligament injury often results from what force to knee
|
medial blow to the knee
|
|
|
what is the most common endocrine tumour of the GI tract
|
carcinoid
|
|
|
what is the most common primary malignancy of the small bowel
|
adenocarcinoma accounts for 50%
|
|
|
Primary small bowel lymphoma is more common in what setting
|
coeliac disease, regional enteritis, congenital immune disorders, organ transplant recipients, autoimmune disease, AIDS
|
|
|
What condition can cause a false-positive elevation in serum amylase
|
renal failure
|
|
|
Schillings test
|
To test for B12 absorption and DDx
pernicious anaemia, intestinal mucosal disease, malnutrition etc. |
|
|
what is the most common hereditary cause of increased serum bilirubin
|
gilberts syndrome (5% of populations)
|
|
|
Gilberts syndrome associated with conjugated or unconjugated hyperbilirubinaemia?
|
unconjugated
|
|
|
gilbert's syndrome pathogenesis
|
reduced activity of glucuronyltransferase enzyme
increased unconjugated bilirubinaemia |
|
|
peutz-jeghers syndrome
|
interstinal polyposis, dark brown spots on lips and palate, pigment around lips, nose, eyes, hands. Tumours of ovarian, breast, pancreas, endometrium
|
|
|
Long term effects of OSA
|
systemic HTN
pulmonary HTN right ventricular hypertrophy |
|
|
why are patients with OSA at increased risk during surgery
|
difficult mask ventilation
difficult intubation acute right heart dysfunction |
|
|
risk factors for obstruction
|
recent solid food intake
GIT obstruction emergency surgery difficult airway gastric fluid >25mL with pH<2.5 |
|
|
What classification system is used to assess activity level in pre-op patients
|
Metabolic equivalents (METs)
|
|
|
What METs is considered adequate for most surgery
|
4 or more METs
Equivalent to carrying shopping bags up 2 flights of stairs |
|
|
Describe ASA classification of 'fitness' for surgery
|
I fit for age
II systemic disease, not interfering with normal acitivity III systemic disease, limits normal activity IV systemic disease, constant threat to life V patient not expected to survive 24hrs |
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|
why does aortic stenosis increase risk of surgical procedure
|
fixed output through narrowed aortic valve + LV hypertrophy- precarious balance of oxygen supply-demand in heart
|
|
|
Who should have routine pre-op ECG
|
all patients >50
any patient with risk factors |
|
|
absolute contraindications for use of regional anaesthesia
|
pt refusal/uncooperation
full anticoagulation infection at injection site septicaemia hypovolaemia (with neuraxial block) allergy to local anaesthetic |
|
|
relative contraindications for use of regional anaethesia
|
partial anticoagulation, pre-exisitng neurological deficit, back pain
|
|
|
indications for use of regional anaesthesia
|
adverse reactions to GA
To reduce pulmonary complication or need for post-op positive pressure ventilation (respiratory disease, obesity) Obstetrics: avoidance of foetal depression, 'bonding' |
|
|
3 phases of anaesthesia
|
induction
maintenance recovery |
|
|
iv induction of GA
|
lipid soluble bolus that will be effectively removed from arterial blood on first pass through the brain/organs.
|
|
|
Initial distribution of induction bolus reflects
|
CO
|
|
|
What properties must a vapour/gas anaesthesia have to be used for induction of GA
|
adequate potency
avoidance of airway irritation, coughing or apnoea ability to achieve necessary partial pressure in CNS rapidly. |
|
|
list drugs used for injalational induction
|
halothane
sevoflurane (can be single breath) |
|
|
how is the end-point for LOC assessed?
|
loss of eyelash response
|
|
|
MAC50
|
minimum alveolar concentration required for lack of response to surgical incision in 50% of patients
|
|
|
why should oxygen always be given for recovery
|
respiratory depression
displacement of O2 by NO V-Q mismatch |
|
|
Complications of recovery
|
laryngospasm
PONV shivering increased oxygen consumption |
|
|
what causes slow cognitive recovery after GA
|
slow release of anaethetic drugs from skeletal muscle and fat
|
|
|
what features should be considered when viewing intracranial mass on CT
|
size, homogeneity, edema, necrosis, haemorrhage, midline shift, herniations, effacement of ventricles
|
|
|
multiple supratentorial masses at the grey-white matter junction in pt with Hx of renal cell carcinoma suggests
|
metastasis
|
|
|
what is the most common primary brain tumour
|
astrocytoma 45-50%
|
|
|
what proportion of meningiomas are malignant
|
1% (most are benign, slow-growing, non-infiltrative)
|
|
|
list common locations for intracranial meningiomas
|
parasagittal covexity
sphenoid wing falx |
|
|
what is primary treatment option for meningiomas
|
surgery (curative if complete resection)
radiotherapy is ineffective |
|
|
vestibular schwannoma also called
|
acoustic neuroma
|
|
|
progressive unilateral deafness is
|
acoustic neuroma until proven otherwise
|
|
|
are acoustic neuromas benign or malignant
|
most benign (slow growing)
|
|
|
what tumour arises from vestibular componetns of CNVIII at cerebello-pontine angle
|
acoustic neuroma
|
|
|
a contrast enhancing mass in cerebello-pontine angle on CT is most likely
|
acoustic neuroma
|
|
|
compression of cavernous sinus in pituitary adeomas may involve what cranial nerves
|
III, IV, V (1,2), VI
|
|
|
abrupt onset headache, visual disturbances, ophthalmoplegia, reduced mental status in patient with known pituitary adeoma
|
pituitary apoplexy
|
|
|
what medical treatment may be used in prolactinomas
|
bromocriptine (dopamine agonist)
|
|
|
a brain abscess caused by toxoplasmosis is characteristic of patients with what condition
|
HIV/AIDS
immunosuppressed |
|
|
Is stroke more commonly caused by infarction or haemorrhage
|
infarction 80%
haemorrhage 20% |
|
|
what are 3 categories of intracranial haemorrhage
|
subarachnoid
spontaneous intracerebral intraventricular |
|
|
Common causes of subarachnoid haemorrhoage
|
Trauma
Spontaneous= aneurysms 75%, idiopathic 15%, AVMs 5% |
|
|
what is the risk of rebleeding in SAH
|
4% on day 1
15-2-% within 2wks 50% by 6mnths |
|
|
Contraindications for lumbar puncture
|
known or suspected intracranial mass
non-communicating obstructive hydrocephalus decreased LOC, focal neurological deficits (hemiparesis) coagulopathy infection at site |
|
|
blood on LP is Dx of
|
subarachnoid haemorrhage (will become xanthochromic supernatant (yellow) by 12-24hrs)
DDx traumatic tap |
|
|
what is triple H or vasospasm following intracranial haemorrhage
|
Hypertension
Hypervolaemia Hemodilution |
|
|
Management for SAH (post-surgical evacuation)
|
bed rest, elevate bed 30
control BP:avoid hypotension, CBF autoregulation impaired Prophylactic anticonvulsant Nimodipine for vasospasm |
|
|
Which is more likely to present insidiously, stroke by infarction or spontenous intracerebral haemorrhage
|
spontaneous intracerebral haemorrhage
|
|
|
length of anal canal in adults
|
5cm
(Rectum 18cm) |
|
|
a perianal haematoma is caused by
|
a burst perianal vein
(trhrombosed external pile) |
|
|
First degree haemorrhoid
|
bleeds during defecation but does not prolapse
|
|
|
Second degree haemorrhoid
|
bleed during defecation + prolapse but reduce spontaneously after defecation
|
|
|
3rd degree haemorrhoid
|
prolapse, have to be manually reduced
|
|
|
Fourth degree haemorrhoid
|
thrombosed internal piles
permanently prolapsed and irreducible very painful requires surgical intervention |
|
|
where is sclerosant injected in the treatment of haemorrhoids
|
at the neck of haemorrhoid in PROXIMAL part of anal canal (less painful)
|
|
|
what is the most common location of an anal fissure
|
midline posteriorly
|
|
|
initial management for anal fissure
|
topical application of GTN and increasing dietary fibre intake
|
