Surgery General

Front 1

what is the most common cause of fever POD# 1

Back 1

atelectasis

Front 2

What are the anorectal causes of rectal bleeding

Back 2

Haemorrhoids
anal fissure
rectal ulcer
rectal varices

Front 3

patient reports bright red blood in toilet bowel, pain, and pruritis
Examination reveals a submucosal swelling at the 3 oclock position

Back 3

Haemorrhoid
Rx
- mild = high fibre diet
- prolapsing = band ligation or sclerotherapy (injection)

low rates of recurrance post Rx

Front 4

Patient reports difficulty passing stool, painful with small amount of bright red blood on the paper
examination reveals skin tag in posterior midline

Back 4

Anal fissure

90% are posterior midline
Rx= stool softeners, topical nitroglycerin or nifedipine..
surgery - relieves sphincter spasm

Front 5

what are 3 perioperative considerations for any patients undergoing Bowel resection

Back 5

1. bowel prep -reduces both wound and anastamotic sepsis
2. antibiotic prophylaxis
3. VTE prophylaxis

Front 6

when should someone be advised to stop smoking before surgery to maximise benefits

Back 6

6 weeks before

Front 7

what is the infection rate fir a dirty procedure with and without prophylactive Abx

Back 7

10% and 40-50%

Front 8

what is the definition of a 'clean' procedure

Back 8

no contamination - GIT, GUT, respiratory tracts not breached

Front 9

what is a 'clean contaminated' procedure

Back 9

GIT, GUT, resp tracts opened but elective and no spillage

Front 10

what is a contaminated procedure

Back 10

acute inflammation, infected urine, bile, gross spillage from GIT tract

Front 11

what is a dirty procedure

Back 11

established infection prior to procedure

Front 12

what are the aims of fluid management

Back 12

correct abnormality (resuss)
provide daily requirement
replace loss

Front 13

what is the minimum urine output you expect to see

Back 13

.5ml/kg/hr

Front 14

patient presents day 2 post op with confusion, cramps, and deteriorating LOC
IDC in situ - urine output over prev two days = 30 and 25ml

Back 14

Dx- dilutional Hyponatraemia in immediate post op period ADH is increased, therefore fluid should be restricted to 2L/day until diuresis has occured

Front 15

patient with pre existing renal failure presents day 3 post op with palpitations and muscle weakness. ECG shows broad QRS complex with peaked T waves

Back 15

Hyperkalaemia
- Rx = Insulin, HCO3, salbutamol (calcium gluconate to stabolise myocardium)

Front 16

Patient presents with BP 90/60
8 days post op with mild fever; Hb 80 ; WCC = 12

Back 16

secondary haemorrhage due to erosion of vessel wall by local infection

Often seen when contaminated wounds are closed primarily - in this case should have delayed wound closure

Front 17

what are the 2 most common causes of vomitting post op

Back 17

Drug induced (GA)- generally in the first 24 hrs

Atony - presents days after post op.

Front 18

when are central venous lines used

Back 18

prolonged IV access
total parenteral nutrition
haemodyalysis
chemotherapy
monitoring central venous pressure

Front 19

what is the definition of severe malnutrition?

Back 19

20% weight loss

Front 20

what are the 6 components of nutrition

Back 20

protein
water
energy (fat, CHO)
electrolytes
minerals
vitamins

Front 21

why is dead tissue debrided?

Back 21

because it is a nidus for bacterial growth

Front 22

what organisms are most frequently implicated in nosocomial infection?

Back 22

Staph aureus
Gram -ve bacilli (e.coli)

Front 23

what are the basic principles of wound infection management

Back 23

- debride dead tissue
- remove foreign bodies
- drain puss
- targetted antibiotiucs

Front 24

how long are wound dressings left on post operatively

Back 24

at least 24 hours

Front 25

how is phlebitis avoided in post operative period

Back 25

change IV cannulae every 72 hrs

Front 26

how often should IV cannulae be changed?

Back 26

every 72 hours

Front 27

a patient presents with watery diarrhea after being on antibiotics for 6 days. what is your management

Back 27

1. take stool for culture
2. treat empirically for C.difficile pseudomembranous colitis
Metronidazole

Front 28

what is the most common cause of post operative confusion?

Back 28

hypoxia due to
- chest infection
- opiate OD
- cardiac failure
- sepsis
- ETOH withdrawal.

Front 29

what is the most common cause of post op oliguria

Back 29

first few days can be due to body increasing ADH then most likely due to inadequate fluid replacement

Front 30

what are the important causes of post operative shock

Back 30

pump failure (cardiogenic)
haemorrhage (hypovolaemic)
Sepsis (septicaemia)
Anaphylaxis (drug reaction)

Front 31

in a patient with shock, once cardiogenic shock has been ruled out what are the first treatment steps you would take

Back 31

oxygen, 500ml bolus of isotonic saline.

Front 32

what is falling blood pressure and rising HR a sign of

Back 32

haemorrhage

Front 33

what is the empirical management in patients with assumed gram negative septic shock

Back 33

MAG
metronidazole, amoxycillin, gentamycin

Front 34

In a V/Q perfusion scan a pulmonary embolus would likely show

Back 34

normal ventilation and poor perfusion in a certain area

- if there is poor both it is likely another pathology
- consolidation on Xray with good perfusion and poor ventilation in an area suggests lobar pneumonia.

Front 35

a 70 year old man presents with post operative confusion - what is the most appropriate first management

Back 35

- give oxygen - Hypoxia is most common cause of post op confusion.

Front 36

what are the causes of fever 0-2 days post op?

Back 36

atelectasis #1
early wound infection - clostridium, group A strep.
aspiration pneumonitis

Front 37

a patient presents with fever on day 3 post op

Back 37

infection likely from day 3 on
day 3-5 = UTI, wound infection, IV line

Front 38

what are the causes of fever POD#5 -

Back 38

intra-abdominal abscess (spiking)
DVT/PE (usually POD# 7-10)
drug fever

Front 39

when does epitheliazation of a wound occur

Back 39

48 hours after wound closure

Front 40

when should drains be removed?

Back 40

once drainage is minimal (<30-50cc in 24hr)

Front 41

what patient characteristics make wound infection more likely

Back 41

Age, DM, steroids, obese, burns, other infections, traumatic wound, malnutrition (IVDU)

Front 42

when do wound infections commonly present

Back 42

POD #3-6 with
- pain
- blanchable wound erythema
- induration
- pus
- warmth

Front 43

When should post op antibiotics be given

Back 43

contaminated and dirty procedures, or RF for infection (steroids, DM etc.)

give for 24 hrs

Front 44

how are wound infections treated

Back 44

1. reopen affected part and drain/debride dead tissue
2. culture, pack, heal by secondary intention
3. antibiotics.

Front 45

patient presents post op with pain, swelling, discolouration around wound edges and leakage at wound

Back 45

wound haemorrhage
- due to inadequate haemostasis if before day 7, could be due to erosion 2ndary to infection after that

Front 46

what is the treatment of pulmonary oedema

Back 46

Lasix
Morphine
Nitrates
Oxygen
position - sit up

Front 47

what are the earliest manifestations of impending respiratory failure

Back 47

RR>25
pO2<60

Front 48

when do most MIs occur post op and who is most at risk?

Back 48

most occur on the day of the operation or day 1-4
those with a previous MI are most at risk

Front 49

patient is observed to have a spiking fever at POD #3 after having laparotomy for bowel resection.

Back 49

-most likely intra abdominal abscess - presents with spiking fever ~ day 3.

Rx = IR percutaneous drainage + debridement of dead/infected tissue +ampicillin, gentamycin, metronidazole.

Front 50

what are the two types of hiatus hernia and which is more common?

Back 50

sliding and rolling
- sliding =90%

Front 51

what is the Ix of choice for Dx of dysphagia?

Back 51

Barium swallow

Front 52

what are the non pharmacological treatments of GORD

Back 52

stop smoking, weight loss, elevate head of bed, don't eat 3 hrs before bed, small frequent meals, avoid ETOH, avoid coffee and fatty foods.

Front 53

patient with Hx of smoking, reflux, gets sudden onset RLQ pain which develops into diffuse pain. CXR shows gas under the diaphragm.

Back 53

perforated duodenal ulcer - fluid can track down the right paracolic gutter.

Front 54

what are the complications of duodenal ulcers?

Back 54

perforation
bleeding
obstruction
penetration into pancreas

Front 55

what are the common complications of peptic ulcer disease

Back 55

gastroduodenal bleeding
perforation

Front 56

what % of peptic ulcers involve H.pylori?

Back 56

duodenal = 90%
Gastric = 60%

Front 57

what % of people presenting with dyspepsia have peptic ulcer

Back 57

20%

Front 58

what is the most accurate investigation for Dx of peptic ulcer disease

Back 58

Endoscopy + biopsy

Front 59

what red flags call for urgent endoscopy relating to peptic ulcer disease

Back 59

weight loss, age>55, bleeding, anaemia, vomitting, early satiety, dysphagia

Front 60

40 year old presents with sporadic epigastric pain that is worse after meals and at night with associated dyspepsia, what tests would you order?

Back 60

- see if dyspepsia/ pain is relieved by antacids
- H.pylori - urea breath test and stool Ag test (beware false -ve on PPIs)
- FOBT and FBC (screen for Ca but unlikely)

NB. this man does not have any red flags therefore invasive endoscopy is not indicated.

Front 61

patient is haemodynamically unstable, abdominal pain radiating to back w pulsatile mass

Back 61

AAA

Front 62

patient has abdo pain disproportionate to the signs on physical examination with a Hx of smoking and AF

Back 62

mesenteric ischaemia

Front 63

what are three top causes of small bowel obstruction

Back 63

1. adhesions
2. hernias
3. cancer

Front 64

what are the top 3 causes of large bowel obstruction

Back 64

1. cancer
2. diverticulitis
3. volvulus

Front 65

what are the DDx of RUQ pain

Back 65

Biliary colic
cholecystitis
cholangitis
hepatitis

Front 66

what are the 2 main GIT causes of RLQ pain

Back 66

Acute appendicitis
Crohn's disease

Front 67

how is choledocolithiasis managed

Back 67

ERCP with biliary sphincterectomy and stone extraction

Front 68

fever, RUQ pain, jaundice

Back 68

ascending cholangitis
Rx - ERCP + abx

- amoxycillin + gentamycin

(most common cause is e.coli)

Front 69

what sequence of presentation is present in 95% of acute addendcitis?

Back 69

Anorexia --> abdo pain --> vomitting

Front 70

what is mcburneys sign
what is rovsigs sign
what is psoas and obturator sign

Back 70

RLQ tenderness -
RLQ tenderness wen LLQ palpated
Pain on thigh extension
pain on internal hip rotation

Front 71

what tests should be ordered if acute appendicitis is suspected

Back 71

FBC - raised WCC w left shift high discriminatory power when combined with Hx
bHCG
Urine dipstick - UTI and renal colic

Front 72

30 year old female with acute severe lower abdominal pain and nausea. FBC is normal, bHCG is -ve, urine dipstick is normal. What is the likely Dx

Back 72

Ovarian torsion

Rx = surgical tetorsion or salpingo-oopherectomy if non viable.

Front 73

what is the most common cause of acute ischaemic bowel

Back 73

Embolism - 50%
But take Hx of IHD or PVD into account as 15-20% are from thrombus at origin of SMA.
also 20-30% are due to hypoperfusion - at watershed areas (splenic flexure and recto sigmoid Jn

Front 74

what are the upper limits for colonic dilatation on abdo Xray

Back 74

caecum = 10-12 cm
ascending colon = 8cm
recto-sigmoid = 6.5 cm

Front 75

what are the 3 aims when confronted with acute pancreatitis

Back 75

1. confirm Dx and rule out severe DDx
2. assess severity/ complications
3. determine cause

(serum amylase/lipase; CT scan - is most useful ithin 48 hrs of presentation; XRAY - AAA, ruptured PU)

Front 76

patient presents 10 days after episode of acute pancreatitis with spiking fever, BP90/60, HR 120

Back 76

Infection post pancreatitis. abscess in necrotic tissue

Rx - surgical debridement of necrotic tissue, Abx, drian

Front 77

what is the treatment for uncomlicated acute inflammatory pancreatitis

Back 77

IV fluids, analgesia, O2, gut rest for 48 hrs

Front 78

what is the initial treatment for severe dehydration

Back 78

IV n.saline 10ml/kg bolus infused over 30 minutes. Then normal maintenance (2-3 litres/day one salt 2 sugar; KCl every 1-2 days)

Front 79

patient with Hx of recurrent heartburn undergoes endoscopy - linear ulceration is seen

Back 79

reflux oesophagitis - mucosal ulceration and breakdown due to persistant reflux (GORD). can lead to Barret's oesophagus or peptic stricture.

Front 80

Patient with long standing GORD presents with worsening dysphagia and globus sensation. Barium swallow shows area of narrowing

Back 80

Peptic stricture 2ndary to GORD, oesophagitis.

Rx - baloon dilatation

Front 81

what % of patients with GORD get Barrett's oesophagus and what does it increase you RR of

Back 81

- 10%
increases RR of adenocarcinoma of Oesophagus by 40x

Rx = PPIs, endoscopy + biopsy every 2-3 years to look for dysplasia

Front 82

patient with Hx of asthma and eczema presents with worsening heartburn and dysphagia. Serum IgE is raised. Endoscopy shows multiple exudative rings in proximal oesophagus.

Back 82

Eosinophilic oesophagitis

Rx = flucticasone (seretide - swallow)
elimination diet, montelukast.

Front 83

what is the 5 year survival of oesophageal Carcinoma

Back 83

<10%

SCC = alcohol and smoking
Adenocarcinoma = Barret's

Front 84

what is achalasia?

Back 84

an oesophageal dysmotility disorder
- failure of the LOS to relax - causes 'pseudo heart burn'; dysphagia.
regurgitation of undigested food.

characteristic barium swallow = 'birds beak'

Rx. = surgery - cut sphincter
dilate with baloon
botox injection

Beware 'pseudoachalasia' which is 2ndary to malignancy

Front 85

patient presents with dysphagia and chest pain. Dysphagia is with both liquids and solids. Barium swallow shows - corkscrew oesophagus

Back 85

Diffuse oesophageal spasm

Front 86

corkscrew oesophagus

Back 86

diffuse oesophageal spasm

Front 87

birds beak oesophagus

Back 87

achalasia

Front 88

patient presents with drooling, food spillage, inability to swallow, dysarthria

Back 88

Oral dysphagia ==> most likely neuro cause

Front 89

how does pharyngeal dysphagia present

Back 89

globus sensation
cough
dyphonia
repetitive swallowing

Front 90

patient who has been vomitting profusely presents with chest pain, dyspnoea, subcutaneous empyhsema. CXR shows widening of the mediastinum

Back 90

Boerhaave's syndrome - oesophageal rupture causing pneumomediastinum

Rx= fluid resuss, abx
if <24 hrs - surgical repair
if >24 hrs diversion followed by delayed reconstruction

Front 91

What tests should be ordered in someone who presents with oesophageal candidiasis

Back 91

HIV elisa
OGTT.

Front 92

what drugs are given to patients presenting with an acute oesophageal varices bleed

Back 92

Beta blockers - lowers systemic pressure .

Rx - band ligation, tube tamponade.

Front 93

How is ascending cholangitis managed

Back 93

1. IV Abx - most likely gram -ve (e. coli) but need gram +ve and anaerobe cover as well
- cefepime (4* C)+ Metronidazole

2. Biliary decompression with ERCP

3. Opiod analgesia.

Front 94

what are the most common bacterial agents in infective colitis

Back 94

E. coli; shigella; salmonella; campylobacter; yersinia

Front 95

first step in treatment of an acute abdomen

Back 95

1.NBM, antiemetics, analgesia
2. IV fluid resuss
3. order tests

Abx if suspect risk of perforation - MAG or 3rd gen ceph with metronidazole

Front 96

Fever, lower abdominal/back pain with radiation to the hip and knee.

Back 96

Psoas abscess
- 1st test - plain Xray will show bulge or gas in sheath (CT more sensitive)

management ==> Abx + surgical drainage

cause - 2ndary to diverticulitis, appendicitis, perforation

Front 97

30yo female presents with sudden intense lower abdo and pelvic pain which radiates down right thigh, w assoc. N & V. bHCG is negative. she has had similar pain in preceding weeks but not this severe.
What is your next examination

Back 97

TVUS

Ovarian torsion - doppler will determine whether there is blood flow

Nb. all women presenting with abdo/pelvic pain should have
bHCG, FBC, U/A

Rx = surgery
cystectomy if viable
- salpingooopherectomy if non viable

Front 98

Mark Fryer, a chronic alcoholic presents with epigastric abdominal pain radiating to the back, steatorrhoea, malnutrition, and diabetes mellitus. What do you think he has? what tests would confirm this?

Back 98

Chronic pancreatitis

confirm with US, CT or Xray looking for calcifications in pancreas

Front 99

what are the clinical features of Biliary obstruction

Back 99

pale stools, dark urine, itch

Front 100

what needs to be considered pre operatively in a jaundiced patient

Back 100

jaundiced patients have
- increased VTE risk
- increased infection risk
- increased risk of renal failure

Front 101

what are the ranson criteria for pancreatitis severity

Back 101

Age>55
BSL >11
AST>250
LDH>350

after 24 hr
fall in HCT
rise in BUN
PO2<60
serum Ca<2
Fluid sequestration>6L
Base deficit >4