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MSRA > Surgery > Flashcards

Surgery Flashcards

1
Q

Ascending cholangitis cause?

A

Bacterial infection, typically E.coli, of the biliary tree

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2
Q

Most common predisposing factor to ascending cholangitis?

A

Gallstones

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3
Q

Charcot’s triad for ascending cholangitis?

A
  1. Fever
  2. RUQ pain
  3. Jaundice
  4. (+ hypotension and confusion = Reynolds’ pentad)
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4
Q

Ascending cholangitis Ix?

A

US to look for bile duct dilatation and bile stones

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5
Q

Ascending cholangitis Rx?

A
  1. IV Abx
  2. ERCP after 24-48 hours to relieve any obstruction
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6
Q

Head injury, lucid interval?

A

Extradural (epidural) haematoma

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7
Q

Primary brain injury types?

A
  1. Focal = contusion/haematoma
  2. Diffuse = diffuse axonal injury
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8
Q

Contusion types?

A

Coup vs. contre-coup

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9
Q

Intracranial haematoma types?

A
  1. Extradural
  2. Subdural
  3. Intracerabral
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10
Q

Secondary brain injury?

A

When cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury. The normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia

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11
Q

Cushing’s reflex?

A

Hypertension and bradycardia in response to raised ICP, occurs late, usually a pre-terminal event

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12
Q

RFs for subdural haematoma?

A
  1. Age
  2. Alcoholism
  3. Anticoagulation
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13
Q

Head injury, fluctuating confusion?

A

Subdural haematoma

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14
Q

Medical benefits of circumcision?

A
  1. Reduces risk of penile cancer
  2. Reduces risk of UTI
  3. Reduces risk of STIs incl. HIV
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15
Q

Medical indications for circumcision?

A
  1. Phimosis
  2. Recurrent balanitis
  3. Balanitis xerotica obliterans
  4. Paraphimosis
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16
Q

First linke Ix for prostate cancer?

A

Multiparametric MRI

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17
Q

Complications of TRUS biopsy?

A
  1. Sepsis
  2. Pain
  3. Fever
  4. Haematuria and rectal bleeding
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18
Q

Multiparametric MRI for prostate cancer interpretation?

A

Reported using 5 point Likert scale
1. If >=3 then prostate biopsy is offered
2. If 1-2 then d/w pt pros and cons of having a biopsy

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19
Q

Most common malignancy in men 20-30 years?

A

Testicular cancer

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20
Q

95% of testicular cancers are?

A

Germ cell tumours

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21
Q

Germ cell types?

A
  1. Seminomas
  2. Non-seminomas
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22
Q

Non-seminoma types?

A
  1. Embryonal
  2. Yolk sack
  3. Teratoma
  4. Choriocarcinoma
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23
Q

Non-germ cell tumour types?

A
  1. Leydig cell tumours
  2. Sarcomas
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24
Q

Peak incidence of teratomas?

A

25 y/o

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25
Q

Peak incidence of seminomas?

A

35 y/o

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26
Q

RFs for testicular cancer?

A
  1. Infertility (x3)
  2. Cryptorchidism
  3. FHx
  4. Klinefelter’s
  5. Mumps orchitis
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27
Q

Testicular cancer features?

A
  1. Painless lump (most common)
  2. Pain (minority)
  3. Hydrocele
  4. Gynaecomastia (increased oestrogen:androgen ratio)
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28
Q

Seminoma marker?

A

hCG elevated in 20%

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29
Q

Non-seminoma marker?

A

AFP and/or beta-hCG elevated in 80-85%

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30
Q

Germ cell tumour marker?

A

LDH in 40%

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31
Q

Testicular cancer Dx?

A

US

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32
Q

Testicular cancer Rx?

A
  1. Depends whether seminoma or non-seminoma
  2. Orchidectomy
  3. Chemo and radio depending on staging and tumour type
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33
Q

Testicular cancer prognosis?

A
  1. 5 year survival for seminomas 95% and teratomas 85% if stage 1
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34
Q

Immediate CT Head indications?

A
  1. GCS <13 on initial assessment
  2. GCS <15 at 2 hours post-injury
  3. Suspected open or depressed skull fracture
  4. Any sign of basal skull fracture
  5. Post-traumatic seizure
  6. Focal neurological deficit
  7. More than 1 episode of vomiting
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35
Q

CT scan within 8 hours indications?

A

Have experienced some LOC or amnesia since injury:
1. >65 y/o
2. Anticoagulants or bleeding disorder
3. Dangerous MOI, >1m, <5 stairs
3. >30mins retrograde amnesia of events immediately before head injury

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36
Q

Anti-oestrogen drugs?

A
  1. Selective oestrogen receptor modulators (SERM)
  2. Aromatase inhibitors
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37
Q

SERM example?

A

Tamoxifen

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38
Q

Tamoxifen use?

A

Oestrogen-receptor positive breast cancer

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39
Q

SERM side effects?

A
  1. Menstrual disturbance = vaginal bleeding, amenorhhoea
  2. Hot flushes
  3. VTE
  4. Endometrial Cancer
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40
Q

Aromatase inhibitor examples?

A

Anastrozole and letrozole, reduce peripheral oestrogen synthesis

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41
Q

When are aromatase inhibitors used?

A

Peripheral aromatisation accounts for the majority of oestrogen production in postmenopausal women and therefore anastrozole is used for ER +ve breast cancer in this group

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42
Q

Aromatase inhibitor s/e?

A
  1. Osteoporosis (Do DEXA before)
  2. Hot flushes
  3. Arthralgia, myalgia
  4. Insomnia
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43
Q

Breast screening mushkies?

A
  1. 50-70 y/o
  2. Mammogram every 3 years
  3. > 70 make own appointments
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44
Q

Only one relative with breast cancer referral criteria?

A

age of diagnosis < 40 years
bilateral breast cancer
male breast cancer
ovarian cancer
Jewish ancestry
sarcoma in a relative younger than age 45 years
glioma or childhood adrenal cortical carcinomas
complicated patterns of multiple cancers at a young age
paternal history of breast cancer (two or more relatives on the father’s side of the family)

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45
Q

Breast cancer risk factors?

A
  1. BRCA1/BRCA2 (40% lifetime risk of breast or ovarian cancer)
  2. 1st degree relative premenopausal relative with breast cancer
  3. Nulliparity, 1st pregnancy >30 y/o
  4. Early menarche, late menopause
  5. COCP, combined HRT
  6. Previous breast cancer
  7. Not breastfeeding
  8. Ionising radiation
  9. p53 gene mutations
  10. Obesity
  11. Previous surgery for benign disease
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46
Q

Haemorrhoid location?

A

3,7,11 o clock position

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47
Q

Haemorrhoid treatment?

A

Conservative, rubber band ligation, haemorrhoidectomy

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48
Q

Anal fissure mushkies?

A
  1. Typically presents with painful rectal bleeding
  2. Location = midline 6 (posterior midline 90%) and 12 o clock position, distal to dentate line
  3. Chronic fissure > 6/52: Ulcer, sentinel pile, enlarged anal papillae
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49
Q

Proctitis causes?

A

Crohn’s, UC, C.diff

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50
Q

Anal fistula mushkies?

A
  1. Usually due to previous ano-rectal abscess
  2. Goodsalls rule determines location
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51
Q

Most common anal cancer?

A

SCC

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52
Q

Most common rectal cancer?

A

Adenocarcinoma

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53
Q

Solitary rectal ulcer?

A

Associated with chronic straining and constipation. Histology shows mucosal thickening, lamina propria replaced with collagen and smooth muscle (fibromuscular obliteration)

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54
Q

Solitary rectal ulcer management?

A

Biopsy of lesion mandatory

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55
Q

Most common cause of breast abscess in lactational women?

A

S. aureus

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56
Q

Breast abscess management?

A
  1. Either I&D or needle aspiration under US
  2. Abx should also be given
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57
Q

Femoral hernia definition?

A

When part of abdominal viscera pass into femoral canal, via the femoral ring

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58
Q

Femoral hernia features?

A

Groin lump inferolateral to the pubic tubercle, typically non-reducible, cough impulse often absent

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59
Q

Femoral hernia epidemiology?

A
  1. Less common than inguinal
  2. 3F:1M (esp. in multiparous women)
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60
Q

Femoral hernia Dx?

A

Clinical, although US is an option

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61
Q

Femoral hernia complications?

A
  1. Incarceration (cannot be reduced)
  2. Strangulation (surgical emergency, more common in femoral)
  3. Bowel obstruction
  4. Bowel ischaemia and resection due to above
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62
Q

Femoral hernia management?

A
  1. Surgical repair necessary due to risk of strangulation
  2. Support belts/trusses should not be used
  3. Laparotomy may be needed in an emergency
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63
Q

Strangulated hernia?

A

Blood supply to the herniated tissue is compromised, leading to ischaemia or necrosis

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64
Q

Most common cause of scrotal swelling in primary care?

A

Epididymal cyst

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65
Q

Epididymal cyst features?

A
  1. Separate from body of the testicle
  2. Posterior to the testicle
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66
Q

Epididymal cyst associated conditions?

A
  1. PCKD
  2. CF
  3. vHL
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67
Q

Epididymal cyst Dx and Rx?

A
  1. Dx = US
  2. Rx = Usually supportive but surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts
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68
Q

Hydrocele definition and classification?

A
  1. Accumulation of fluid within the tunica vaginalis
  2. Communicating and non-communicating
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69
Q

Communicating hydrocele?

A

Patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life

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70
Q

Non-communicating hydrocoele?

A

Caused by excessive fluid production within the tunica vaginalis

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71
Q

Hydrocoele secondary causes?

A
  1. Epididymo-orchitis
  2. Testicular torsion
  3. Testicular tumours
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72
Q

Hydrocoele features?

A
  1. Soft, non-tender swelling of the hemiscrotum usually anterior to and below the testicle
  2. Confined to scrotum, can’t get above it
  3. Transilluminates with pen torch
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73
Q

Hydrocoele Dx?

A

May be clinical but US required if doubt od testis cant be palpated

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74
Q

Hydrocoele management?

A
  1. Infants = repaired if not resolving spontaneously by 1-2 years
  2. Adults = conservative, further investigation
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75
Q

Varicocoele mushkies?

A
  1. Abnormal enlargement of testicular veins
  2. Usually asymptomatic but may be important as they are associated with subfertility
  3. 80% left hand side
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76
Q

Varicocele Dx?

A

US with Doppler studies

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77
Q

Varicocele Rx?

A
  1. Usually conservative
  2. Occasionally surgery is required if pt troubled by pain
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78
Q

Anal fissure definition?

A

Anal fissures are longitudinal or elliptical tears of the squamous lining of the distal anal canal. If present for less than 6 weeks they are defined as acute, and chronic if present for more than 6 weeks.

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79
Q

Anal fissure RFs?

A
  1. Constipation
  2. IBD
  3. STI e.g. HIV, syphilis, herpes
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80
Q

Anal fissure features?

A
  1. Painful, bright red, rectal bleeding
  2. Around 90% anal fissures occur on the posterior midline, if found elsewhere then consider underlying cause e.g. Crohn’s
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81
Q

Acute anal fissure (<1 week) management?

A
  1. Soften stool (high fibre, high fluid, bluk forming laxatives 1st, lactulose 2nd)
  2. Lubricants e.g. petroleum jelly before defecation
  3. Topical anaesthetics
  4. Analgesia
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82
Q

Chronic anal fissure management?

A
  1. As per acute
  2. Topical GTN 1st line
  3. If not effective after 8 weeks then secondary care referral for sphincterotomy or botulinum toxin
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83
Q

Inguinal hernia location?

A

Superior and medial to pubic tubercle

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84
Q

Inguinal hernia mushkies?

A
  1. 75% of abdominal wall hernia
  2. 95% male
  3. Men have 25% lifetime risk of developing an inguinal hernia
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85
Q

Inguinal hernia features?

A
  1. Groin lump superomedial to pubic tubercle that disappears on pressure or when lying down
  2. Discomfort and ache often worse with activity
  3. Strangulation is rare
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86
Q

Direct hernia?

A

Through posterior wall of the inguinal canal

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87
Q

Indirect hernia?

A

Through the inguinal canal

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88
Q

Inguinal hernia management?

A
  1. Treat medically fit pts even if asymptomatic
  2. Truss if not fit for surgery
  3. Mesh repair is associated with lowest recurrence rate (unilateral usually done open, bilateral and recurrent usually laparoscopically)
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89
Q

Open inguinal hernia repair department for work and pensions advice?

A

Return to non-manual work after 2-3 weeks and following laparoscopic rpair after 1-2 weeks

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90
Q

Spouted stoma?

A

Small bowel stomas so irritant contents not in contact with skin

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91
Q

Flush with skin stoma?

A

Colonic stoma

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92
Q

Breast cancer management x5?

A
  1. Surgery
  2. Radiotherapy
  3. Hormone therapy
  4. Biological therapy
  5. Chemotherapy
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93
Q

Breast cancer women without palpable axillary lymphadenopathy at presentation?

A
  1. Should have pre-op US before primary surgery
  2. if positive should have sentinel node biopsy to assess nodal burden
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94
Q

Breast cancer women with palpable axillary lymphadenopathy?

A

Axillary node clearance indicated at primary surgery, may lead to arm lymphoedema and functional arm impairment

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95
Q

Wide local excision indications?

A
  1. Solitary lesion
  2. Peripheral tumour
  3. Small tumour in large breast
  4. DCIS < 4cm
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96
Q

Mastectomy indications?

A
  1. Multifocal tumour
  2. Central tumour
  3. Large lesion in small breast
  4. DCIS > 4cm
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97
Q

Radiotherapy in breast cancer?

A

Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds. For women who’ve had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes

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98
Q

Hormonal therapy for breast cancer?

A

Adjuvant hormonal therapy is offered if tumours are positive for hormone receptors. For many years this was done using tamoxifen for 5 years after diagnosis. Tamoxifen is still used in pre- and peri-menopausal women. In post-menopausal women, aromatase inhibitors such as anastrozole are used for this purpose*. This is important as aromatisation accounts for the majority of oestrogen production in post-menopausal women and therefore anastrozole is used for ER +ve breast cancer in this group.

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99
Q

Biological therapy for breast cancer?

A
  1. Most commonly trastuzumab (Herceptin), only useful in 20-25% of tumours that are HER2 positive
  2. Herceptin cannot be used in pts with a history of heart disorders
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100
Q

Chemotherapy in breast cancer?

A

Cytotoxic therapy may be used either prior to surgery (‘neoadjuvanant’ chemotherapy) to downstage a primary lesion or after surgery depending on the stage of the tumour, for example, if there is axillary node disease - FEC-D is used in this situation

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101
Q

BPH RFs?

A
  1. Age = 50% of 50 year old men will have evidence of BPH and 30% will have symptoms, 80% of 80 year old men have evidence of BPH
  2. Ethnicity = Black > White > Asian
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3
4
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102
Q

LUTS?

A
  1. Voiding symptoms = SHIT
  2. Storage symptoms = FUN
  3. Post-micturition dribbling
  4. Complications = UTI, retention, obstructive uropathy
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103
Q

BPH Ix?

A
  1. Urine dipstick
  2. Bloods = U&S, PSA
  3. Urinary frequency-volume chart for 3 days
  4. IPSS
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104
Q

IPSS?

A

International Prostate Symptom Score = to classify LUTS and QoL
1. 0-7 = mildly symptomatic
2. 8-19 = moderately symptomatic
20-35 = severely symptomatic

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105
Q

BPH Rx?

A
  1. Watchful waiting
  2. A1 antagonists = Tamsulosin, alfuzosin
  3. 5a reduce inhibitor = Finasteride
  4. Combination therapy of the above
  5. If a mixture of storage and voiding symptoms that persists after treatment with alpha blocker alone, then an antimuscarinic e.g. tolterodine or darifenacin may be used
  6. TURP
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106
Q

Alpha-1 antagonist for BPH mushkies?

A
  1. Tamsulosin, alfuzosin
  2. Decrease smooth muscle tone of the prostate and bladder
  3. Considered first line if IPSS >=8
  4. Improve symptoms in 70% men
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107
Q

Alpha 1 antagonist s/e?

A
  1. Dizziness
  2. Postural hypotension
  3. Dry mouth
  4. Depression
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108
Q

5a-reductase for BPH muskies?

A
  1. Finasteride
  2. Block conversion of testosterone to DHT, which is known to induce BPH
  3. Indicated if pt has significantly enlarged prostate and is considered to be at high risk of progression
  4. Unlike a1 antagonists causes a reduction in prostate volume and hence may slow disease progression, but takes time and symptoms may not improve for 6 months
  5. May also decrease PSA concentration by up to 50%
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109
Q

5a-reductase s/e?

A
  1. Erectile dysfunction
  2. Reduced libido
  3. Ejaculation problems
  4. Gynaecomastia
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110
Q

Diabetic surgery preparations?

A
  1. Diabetic on insulin with good glycaemic control can be managed with normal regimen
  2. Long surgery/poorly controlled diabetes will need VRII
  3. Omit SGLT2is (gliflozins)
  4. Reduce once daily insulin dose by 20%
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111
Q

Thyroid surgery prep?

A

Vocal cord check

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112
Q

Thoracic duct surgery prep?

A

Cream

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113
Q

Carcinoid tumour surgery prep?

A

Octreotide

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114
Q

Thyrotoxicosis surgery prep?

A

Lugol’s iodine/medical therapy

115
Q

Pt on steroids having surgery?

A
  1. Minor procedure under local = no supplementation required
  2. Moderate procedure = 50mg hydrocortisone before induction and 25mg every 8h for 24h
  3. Major surgery = 100mg hydrocortisone before induction and 50mg every 8h for 24h, thereafter halving dose every 24h until maintenance dose reached
116
Q

Sudden onset sensorineural hearing loss?

A

Refer within 24h to ENT for urgent assessment and consideration of steroids

117
Q

Most common cancer in adult males?

A

Prostate Ca

118
Q

Most common cause of death due to cancer in men?

A
  1. Lung
  2. Prostate
119
Q

Prostate cancer RFs?

A
  1. Increasing age
  2. Obesity
  3. Afro-Caribbean
  4. FHx
120
Q

Prostate cancer features?

A
  1. Bladder outlet obstruction = hesitancy, urinary retention
  2. Haematuria, haematospermia
  3. Pain: back, perineal or testicular
  4. DRE = asymmetrical, hard nodular enlargement with loss of median sulcus
121
Q

Acute pancreatitis causes?

A

GET SMASHED
G = Gallstones
E = Ethanol
T = Trauma
S = Steroids
M = Mumps
A = Autoimmune e.g. PAN, Ascaris
S = Scorpion Venom
H = Hypertriglyceridaemia/calcaemia, hypothermia
E = ERCP
D = Azathioprine, bendroflumethiazide, furosemide, mesalazine, pentamidine, steroids, sodium valproate

122
Q

Haemorrhoids features?

A
  1. Painless rectal bleeding most common
  2. Pruritis
  3. Pain, not significant unless thrombosed
  4. Soiling may occur with 3rd/4th degree
123
Q

Haemorrhoid external vs. internal?

A
  1. External = originates below dentate line, prone to thrombosis, may be painful
  2. Internal = originates above dentate line, do not generally cause pain
124
Q

Haemorrhoid Grading?

A
  1. Grade I = dont prolapse out of anal canal
  2. Grade II = prolapse on defecation but reduce spontaneously
  3. Grade III = can be manually reduced
  4. Grade IV = cannot be reduced
125
Q

Haemorrhoid management?

A
  1. Soften stools = increase dietary fibre and fluid intake
  2. Topical LA and steroid cream for symptoms
  3. OP treatments = Rubber band ligation superior to injection sclerotherapy
  4. Surgery reserved for large symptomatic haemorrhoids which do not respond to OP treatments
  5. Newer treatment = Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy
126
Q

Acute thrombosed external haemorrhoid Rx?

A
  1. Typically present with significant pain
  2. Examination reveals a purplish, oedematous, tender subcutaneous perianal mass
  3. If pt presents within 72 hours then referral to be be considered for excision. Otherwise patients can usually be managed with stool softeners, ice packs and analgesia. Symptoms usually settle within 10 days
127
Q

PSA referral threshold?

A

Men aged 50-69 years should be referred if the PSA is >= 3.0 ng/ml OR there is an abnormal DRE

128
Q

PSA levels may be raised by?

A
  1. BPH
  2. Prostatitis and UTI (PSA 1m after Rx)
  3. Ejaculation (wait 48h)
  4. Vigorous exercise (wait 48h)
  5. Urinary retention
  6. Instrumentation of urinary tract
  7. After DRE (1 week)
  8. Prostate biopsy (wait 6w)
129
Q

PSA sensitivity and specificity?

A
  1. 20% with prostate cancer have normal PSA
  2. 33% of men with a PSA of 4-10 ng/ml will be found to have prostate cancer. With a PSA of 10-20 ng/ml this rises to 60% of men
130
Q

General anaesthetic classification?

A
  1. Inhaled
  2. IV
131
Q

Inhaled anaesthetics?

A
  1. Volatile liquid = isoflurane, desflurane, sevoflurane –> myocardial depression, malignant hyperthermia –> used for induction and maintenance of anaesthesia
  2. Nitrous oxide –> avoided in pneumothorax as can diffuse into gas filled body compartments –> used for maintenance of anaesthesia and analgesia
132
Q

IV Anaesthetics?

A
  1. Propofol
  2. Thiopental
  3. Etomidate
  4. Ketamine
133
Q

Propofol mushkies?

A
  1. Potentiates GABA
  2. Pain on injection due to activation of pain receptor TRPA1, hypotension
  3. Anti-emetic effect
  4. Induction agent for GA, also used in ICU for ventilated pts
134
Q

Thiopental mushkies?

A
  1. A babriburate, so potentiates GABA
  2. Laryngospasm
  3. High lipid soluble so quickly affects brain
135
Q

Etomidate mushkies?

A
  1. Potentiates GABA
  2. Primary adrenal suppression (secondary to reversibly inhibiting 11β-hydroxylase), myoclonus
  3. Causes less hypotension than propofol and thiopental during induction and is therefore often used in cases of haemodynamic instability
136
Q

Ketamine mushkies?

A
  1. Blocks NMDA receptors
  2. Disorientation, hallucinations
  3. Acts as dissociative anaesthetic, doesnt cause drop in BP so useful in trauma
137
Q

Vasectomy failure rate?

A

1 in 2000

138
Q

Vasectomy mushkies?

A
  1. Simple operation, can be done under LA, go home after a few hours
  2. Doesn’t work immediately
  3. Semen analysis needs to be performed twice following before unprotected sex (usually at 16 and 20 weeks)
  4. Complications = bruising, haematoma, infection, sperm granuloma, chronic testicular pain (5-30% men)
  5. Success rate of reversal is 55% if done within 10 years, 25% after more than 10 years
139
Q

Most common type of breast cancer?

A

Invasive ductal cancer (AKA No Special Type)

140
Q

Breast cancer types?

A
  1. Invasive ductal carcinoma
  2. Invasive lobular carcinoma
  3. DCIS
  4. LCIS
141
Q

Paget’s disease of the nipple?

A

An eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer. In half of these patients, it is associated with an underlying mass lesion and 90% of such patients will have an invasive carcinoma. 30% of patients without a mass lesion will still be found to have an underlying carcinoma, usually intraductal. The remainder will have carcinoma in situ.

142
Q

Inflammatory breast cancer?

A

Cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast. This accounts for around 1 in 10,000 cases of breast cancer

143
Q

Breast cancer 2ww referral?

A
  1. Aged 30 or over and have an unexplained breast lump with or without pain
  2. Aged 50 and over with one of in one nipple: discharge, retraction, or other changes of concern
  3. CONSIDER if skin changes that suggest breast cancer or over 30 and unexplained lump in axilla
144
Q

Faecal Immunochemical Test (FIT) screening?

A
  1. Every 2 years for 60-74 y/o, and 50 to 74 y/o in Scotland. Pts aged over 74 may request screening
  2. Eligible pts sent FIT via post
  3. Pts with abnormal results are offered colonoscopy
145
Q

Colonoscopy after FIT screening?

A
  1. 50% normal exam
  2. 40% polyps
  3. 10% Malignancy
146
Q

Inguinal hernias more common on which side?

A

Right

147
Q

Paraumbilical hernia?

A

Asymmetrical bulge - half the sac is covered by skin of the abdomen directly above or below the umbilicus

148
Q

Spigelian hernia?

A
  1. Also known as lateral ventral hernia
  2. Rare and seen in older patients
  3. A hernia through the spigelian fascia (the aponeurotic layer between the rectus abdominis muscle medially and the semilunar line laterally)
149
Q

Obturator hernia?

A

A hernia which passes through the obturator foramen. More common in females and typical presents with bowel obstruction

150
Q

Richter hernia?

A
  1. A rare type of hernia where only the antimesenteric border of the bowel herniates through the fascial defect
  2. Richter’s hernia can present with strangulation without symptoms of obstruction
151
Q

Congenital inguinal hernia mushkies?

A
  1. Indirect hernias resulting from a PPV
  2. 1% of term babies
  3. More common in premature and boys
  4. 60% right, 10% bilateral
  5. Should be surgically repaired soon after diagnosis as at risk of incaceration
152
Q

Infantile umbilical hernia?

A
  1. Symmetrical bulge under umbilicus
  2. More common in premature and Afro-Caribbean
  3. Vast majority resolve without intervention before 4-5 y/o
  4. Complications are rare
153
Q

Chronic pancreatitis causes?

A
  1. 80% alcohol
  2. Genetic = CF, haemochromatosis
  3. Ductal obstruction = tumours, stones, structural (pancreas divisum + annular pancreas)
154
Q

Chronic pancreatitis features?

A
  1. Pain worse 15-30 minutes after meal
  2. Steatorrhoea (symptoms of pancreatic insufficiency usually develops 5-25 years after onset of pain)
  3. DM develops in majority, typically occurs more than 20 years after symptoms begin
155
Q

Chronic pancreatitis Ix?

A
  1. AXR = Pancreatic calcification in 30%
  2. CT = pancreatic calcification, sensitivity 80%, specificity 85%
  3. Functional test = faecal elastase
156
Q

Chronic pancreatitis management?

A
  1. Pancreatic enzyme supplements
  2. Analgesia
  3. Antioxidants
157
Q

Assessment of pancreatic exocrine function?

A

Faecal elastase

158
Q

Fibroadenoma features?

A
  1. Mobile, firm breast lumps
  2. 12% of all breast masses
  3. Over a 2 year period 30% will get smaller
  4. No increased risk of malignancy
159
Q

Fibroadenoma Rx?

A
  1. If >3cm surgical excision is usual
  2. Phyllodes tumours should be widely excised (mastectomy if lesion is large)
160
Q

Breast cyst features?

A
  1. 7% of all Western females
  2. Smooth discrete lump (may be fluctuant)
  3. Small increased risk of breast cancer (esp. if younger)
161
Q

Breast cyst Rx?

A
  1. Aspiration
  2. Those which are bloodstained or persistently refill should be biopsied or excised
162
Q

Sclerosing adenosis features?

A
  1. AKA Radial scars and complex sclerosing lesions
  2. Usually presents as breast lump or pain
  3. Mammographic changes mimic carcinoma
  4. Local distortion of lobular unit without hyperplasia
  5. No increased risk of malignancy
163
Q

Sclerosing adenosis Rx?

A

Should be biopsied, excision not mandatory

164
Q

Epithelial hyperplasia features?

A
  1. Generalised lumpiness/discrete lump
  2. Increased cellularity of terminal lobular unit, atypical features may be present
  3. Atypical features and FHx Breast Ca increases risk of malignancy
165
Q

Epithelial hyperplasia Rx?

A
  1. No atypical features –> conservative
  2. Atypical features –> close monitoring or surgical resection
166
Q

Fat necrosis features?

A
  1. 40% have traumatic aetiology
  2. Physical features mimic carcinoma
  3. Mass may increase in size initially
167
Q

Fat necrosis Rx?

A

Imaging and core biopsy

168
Q

Duct papilloma features?

A
  1. Usually present with blood stained nipple discharge
  2. Large papillomas may present as mass
  3. Discharge originates from single duct usually
  4. No increased risk of malignancy, are hyperplastic lesions
169
Q

Duct papilloma Rx?

A

Microdochectomy

170
Q

Renal colic initial management?

A
  1. NSAID e.g. IM diclofenac
  2. Alpha adrenergic blocker to aid ureteric stone management
171
Q

Renal colic Bloods?

A
  1. Urine dip and culture
  2. FBC, U&E, CRP, Calcium/urate
  3. Clotting if percutaneous intervention planned, cultures if pyrexial
172
Q

Renal colic imaging?

A
  1. Non-contrast CT KUB within 14 hours
  2. If fever/solitary kidney/uncertain diagnosis then immediate CT KUB (to exclude ruptured AAA)
  3. CT KUB has sensitivity of 97% and specificity of 95% for stones
173
Q

Renal stones Initial Rx?

A

Stones < 5 mm will usually pass spontaneously. Lithotripsy and nephrolithotomy may be for severe cases.

Most renal stones measuring less than 5mm in maximum diameter will typically pass within 4 weeks of symptom onset. More intensive and urgent treatment is indicated in the presence of ureteric obstruction, renal developmental abnormality such as horseshoe kidney and previous renal transplant. Ureteric obstruction due to stones together with infection is a surgical emergency and the system must be decompressed. Options include nephrostomy tube placement, insertion of ureteric catheters and ureteric stent placement.

174
Q

Therapeutic selection for renal stones?

A
  1. Ureteric calculi <5mm = manage expectantly
  2. Complex renal calculi and staghorn calculi = percutaneous nephrolithotomy
  3. Stone burden of less than 2cm in aggregate = lithotripsy
  4. Stone burden of less than 2cm in pregnant females = ureteroscopy
175
Q

ESWL process?

A

A shock wave is generated external to the patient, internally cavitation bubbles and mechanical stress lead to stone fragmentation. The passage of shock waves can result in the development of solid organ injury. Fragmentation of larger stones may result in the development of ureteric obstruction. The procedure is uncomfortable for patients and analgesia is required during the procedure and afterwards.

176
Q

Ureteroscopy process?

A

A ureteroscope is passed retrograde through the ureter and into the renal pelvis. It is indicated in individuals (e.g. pregnant females) where lithotripsy is contraindicated and in complex stone disease. In most cases a stent is left in situ for 4 weeks after the procedure.

177
Q

Percutaneous nephrolithotomy procedure?

A

In this procedure, access is gained to the renal collecting system. Once access is achieved, intra corporeal lithotripsy or stone fragmentation is performed and stone fragments removed.

178
Q

Prevention of calcium stones?

A
  1. High fluid intake
  2. Low animal protein, low salt diet
  3. Thiazide diuretics (increase distal tubular calcium reabsorption)
179
Q

Prevention of oxalate stones?

A
  1. Cholestyramine reduces urinary oxalate secretion
  2. Pyridoxine reduces urinary oxalate secretion
180
Q

Prevention of uric acid stones?

A
  1. Allopurinol
  2. Urinary alkalization e.g. oral bicarbonate
181
Q

Fibroadenosis mushkies?

A
  1. AKA Fibrocystic diease, benign mammary dysplasia
  2. More common in middle aged women
  3. Lumpy breasts which may be painful, symptoms may worsen prior to menstruation
182
Q

Mammary duct ectasia mushkies?

A
  1. Dilatation of the large breast ducts
  2. Most common around the menopause
  3. May present with a tender lump around the areola +/- green nipple discharge
  4. If ruptures may cause local inflammation, sometimes referred to as plasma cell mastitis
183
Q

Mammary duct ectasia mushkies?

A
  1. Dilatation of the large breast ducts
  2. Most common around the menopause
  3. May present with a tender lump around the areola +/- green nipple discharge
  4. If ruptures may cause local inflammation, sometimes referred to as plasma cell mastitis
184
Q

Penile cancer usual type?

A

SCC

185
Q

Penile cancer risk factors?

A
  1. HIV
  2. HPV
  3. Genital warts
  4. Poor hygeine
  5. Phimosis
  6. Paraphimosis
  7. Balanitis
  8. Age >50
186
Q

Penile cancer Rx?

A
  1. Radiotherapy
  2. Chemotherapy
  3. Surgery
187
Q

Penile cancer prognosis?

A

50% at 5 years

188
Q

Chancroid cause?

A

Haemophlus ducreyi

189
Q

Most common cause of SAH?

A

Traumatic SAH

190
Q

Causes of spontaneous SAH?

A
  1. Berry aneurysm = 85%, ass. ADPKD, EDS, CoA
  2. AVM
  3. Pituitary apoplexy
  4. Arterial dissection
  5. Mycotic aneurysms
  6. Perimesencephalic (idiopathic venous bleed)
191
Q

SAH features?

A
  1. Thunderclap headache
  2. N&V
  3. Meningism
  4. Coma
  5. Seizures
  6. Sudden death
  7. ECG changes including ST elevation
192
Q

Confirmation of SAH?

A
  1. CT head = negative for SAH in 7%
  2. LP = performed at least 12 hours following symptom onset
  3. Referral to NSX ASAP after SAH confirmed
193
Q

After spontaneous SAH confirmed, what to do?

A

Identify causative pathology that needs urgent treatment
1. CT intracranial angiogram to identify vascular lesion e.g. aneurysm or AVM
2. +/- digital subtraction angiogram (catheter angiogram)

194
Q

SAH Rx?

A

Depends on causative pathology
1. Intracranial aneurysms are at risk of rebleeding and therefore require prompt intervention, preferably within 24 hours
2. Coiling by interventional radiologist
3. Craniotomy and clipping by BSX
4. Until the aneurysm is treated, the patient should be kept on strict bed rest, well-controlled blood pressure and should avoid straining in order to prevent a re-bleed of the aneurysm
5. Vasospasm is prevented using a 21-day course of nimodipine (a calcium channel inhibitor targeting the brain vasculature) and treated with hypervolaemia, induced-hypertension and haemodilution
6. Hydrocephalus is temporarily treated with an external ventricular drain (CSF diverted into a bag at the bedside) or, if required, a long-term ventriculo-peritoneal shunt

195
Q

Complications of aneurysmal SAH?

A
  1. Re-bleeding (10%, most common in first 12 hours), if suspected then repeat CT, associated with 70% mortality
  2. Vasospasm, 7-14 days after onset
  3. Hyponatraemia due to SIADH
  4. Seizures
  5. Hydrocephalus
  6. Death
196
Q

Important predictive factors in SAH?

A
  1. Conscious level on admission
  2. Age
  3. Amount of blood visible on CT head
197
Q

When is clipping of SAH used instead of coiling?

A

More evidence of raised ICP e.g. haemodynamic instability or change in GCS

198
Q

Abdominal wound dehiscence Rx?

A
  1. Coverage of wound with saline impregnated gauze
  2. IV broad spectrum Abx
  3. Analgesia, IVF, arrangements made for return to theatre
199
Q

Abdominal wound dehiscence types?

A
  1. Superficial = skin wound alone fails
  2. Complete = failure of all layers
200
Q

Overactive bladder Rx?

A

Antimuscarinic e.g. oxybutynin, tolterodine and darifenacin

201
Q

What is urinary frequency-volume chart helpful for?

A

Distinguishing between urinary frequency, polyuria, nocturia and nocturnal polyuria

202
Q

Predominantly voiding symptoms Rx?

A
  1. Conservative = muscle training, bladder training, prudent fluid intake
  2. Moderate/severe = alpha blocker
  3. Big prostate/high risk of progression = 5a reductase inhibitor
  4. Mixed symptoms of voiding and storage not responding to alpha blocker = add antimuscarinic
203
Q

Overactive bladder Rx?

A
  1. Conservative = fluid intake, bladder retraining
  2. Antimuscarinic = oxybutynin, tolterodine, darifenacin
  3. Mirabegron considered if first line drugs fail
204
Q

Nocturia Rx?

A
  1. Advise about moderating fluid intake at night
  2. Furosemide 40mg in late afternoon
  3. Desmopressin
205
Q

Epididymo-orchitis causes?

A
  1. Young = chlamydia and gonorrhoea
  2. Older = E> coli
206
Q

Epididymo-orchitis features?

A
  1. Unilateral testicular pain and swelling
  2. Urethral discharge may be present, but urethritis is often asymptomatic
  3. Factors suggesting testicular torsion including patients <20 years, severe pain and an acute onset
207
Q

Most important DDx of epididymo-orchitis?

A

Testicular torsion

208
Q

Epididymo-orchitis Ix?

A

Guided by age
1. Young = assess for STIs
2. Older = MSU for culture

209
Q

Epididymo-orchitis Rx?

A

If organism unknown = Ceftriaxone 500mg IM single dose + doxycycline 100mg BD 10-14 days

210
Q

Fluctuating confusion/consciousness?

A

Subdural haematoma

211
Q

Normal infrarenal aorta diameter after 50 years?

A

1.5cm in females, 1.7cm in males

212
Q

AAA diameter?

A

> 3cm considered aneurysmal

213
Q

AAA Rfs?

A
  1. Smoking and HTN
  2. Syphilis and CTD e.g. ED1, Marfans
214
Q

AAA screening?

A

In the UK, all men aged 65 years are offered aneurysm screening with a single abdominal ultrasound. Screening has shown to decrease death from abdominal aortic aneurysm by 44% over 4 years.

215
Q

Superficial thrombophlebitis mushkies?

A

Superficial thrombophlebitis, as the name suggests describes the inflammation associated with thrombosis of one of the superficial veins, usually the long saphenous vein of the leg. This process is usually non-infective in nature but secondary bacterial infection may rarely occur resulting in septic thrombophlebitis.

Around 20% with superficial thrombophlebitis will have an underlying deep vein thrombosis (DVT) at presentation and 3-4% of patients will progress to a DVT if untreated. The risk of DVT is partly linked to the length of vein affected - an inflammed vein > 5 cm is more likely to have an associated DVT.

216
Q

Superficial thrombophlebitis Rx?

A
  1. LMWH for 30 days or fondaparinux for 45 days
  2. If LMWH C/I, 8-12 days oral NSAID
  3. Compression stocking (ABPI first)
  4. US to exclude concurrent DVT
  5. Pts with superficial thrombophlebitis at, or extending towards, the sapheno-femoral junction can be considered for therapeutic anticoagulation for 6-12 weeks
217
Q

Criteria for brainstem death testing?

A
  1. Deep coma of known aetiology
  2. Reversible causes excluded
  3. No sedation
  4. Normal electrolytes
218
Q

Testing for brain death?

A
  1. Fixed pupils, no corneal reflex, absent oculo-vestibular reflexes, no response to supra-orbital pressure
  2. No cough reflex to bronchial stimulation or gagging response to pharyngeal stimulation
  3. No observed respiratory effort in response to disconnection of the ventilator for long enough (typically 5 minutes) to ensure elevation of the arterial partial pressure of carbon dioxide to at least 6.0 kPa (6.5 kPa in patients with chronic carbon dioxide retention). Adequate oxygenation is ensured by pre-oxygenation and diffusion oxygenation during the disconnection (so the brain stem respiratory centre is not challenged by the ultimate, anoxic, drive stimulus)
219
Q

Brainstem death testing done by?

A

Two appropriately experienced doctors on two separate occasions. Both should be experienced in performing brain stem death testing and have at least 5 years post-graduate experience. One of them must be a consultant. Neither can be a member of the transplant team (if organ donation contemplated)

220
Q

Small bowel obstruction amylase levels?

A

Amylase elevated

221
Q

Most common cause of SBO?

A
  1. Adhesions
  2. Hernias
222
Q

SBO features?

A
  1. Diffuse, central abdominal pain
  2. N&V, typically bilious
  3. Constipation with complete obstruction and lack of flatulence
  4. Tinkling bowel sounds
223
Q

SBO Ix?

A
  1. AXR = distended small bowel loops with fluid level, considered dilated if small bowel is >3cm in diameter
  2. CT is definitive and more sensitive, particularly in early obstruction
224
Q

SBO Rx?

A
  1. NBM, IVF, NG Tube
  2. Some patients settle with conservative but will otherwise require surgery
225
Q

Raised ICP Rx?

A
  1. IV mannitol/furosemide whilst a/w theatre
  2. Difffuse cerebral oedema may require decompressive craniotomy
  3. Open depressed skull fractures may require formal surgical reduction
226
Q

Raised ICP monitoring?

A
  1. Appropriate in GCS 3-8 with normal CT scan
  2. Mandatory in GCS 3-8 with abnormal CT scan
  3. Minimum of cerebral perfusion pressure of 70mmHg in adults
  4. Minimal cerebral perfusion pressure of 40-70mmHg in children
227
Q

Unilaterally dilated pupil, sluggish/fixed?

A

3rd nerve compression secondary to tentorial herniation

228
Q

Bilaterally dilated pupils, sluggish/fixed?

A

Poor CNS perfusion or bilateral 3rd nerve palsy

229
Q

Unilateral dilated or equal pupils, cross reactive (Marcus-Gunn)?

A

Optic nerve injury

230
Q

Bilaterally constricted pupils?

A
  1. Opiates
  2. Pontine lesions
  3. Metabolic encephalopathy
231
Q

Unilateral constricted pupil, light response preseved?

A

Sympathetic pathway disruption

232
Q

Pts whose colorectal tumours lie below peritoneal reflection?

A

Should have mesorectum evaluated with MRI

233
Q

Why are most colorectal cancer surgeries tailored around resection of particular lymphatic chains?

A

Lymphatic drainage of the colon follows the arterial supply

234
Q

Common colonic cancer chemo?

A

5FU and oxaliplatin

235
Q

Rectal cancer surgeries?

A
  1. Anterior resection
  2. AP resection (very low tumours)
236
Q

Caecal, ascending or proximal transverse colon cancer –> resection and anastomosis?

A
  1. Right hemicolectomy
  2. Ileo-colic anastomosis
237
Q

Distal transverse, descending colon cancer –> resection and anastomosis?

A
  1. Left hemicolectomy
  2. Colo-colon anastomosis
238
Q

Sigmoid colon cancer –> resection and anastomosis?

A
  1. High anterior resection
  2. Colo-rectal
239
Q

Upper rectum cancer –> resection and anastomosis?

A
  1. Anterior resection
  2. Colo-rectal
240
Q

Low rectum cancer –> resection and anastomosis?

A
  1. Low anterior resection
  2. Colo-rectal +/- defunctioning stoma
241
Q

Anal verge cancer –> resection and anastomosis?

A

Abdomino-perineal excision of the rectum, no anastomosis

242
Q

TME?

A

In surgery of rectal cancer, in addition to excision of the rectal tube an integral part of the procedure is a meticulous dissection of the mesorectal fat and lymph nodes (total mesorectal excision/ TME)

243
Q

When are AP resections used?

A

Involve the removal of the anus, rectum and section of sigmoid colon, are used for tumours located in the distal one third of the rectum.

244
Q

Bilious vomiting in neonates?

A
  1. Duodenal atresia
  2. Malrotation with volvulus
  3. Jejunal/ileal atresia
  4. Meconium ileus
  5. NEC
245
Q

Duodenal atresia mushkies?

A
  1. 1/5000, higher in Down’s
  2. A few hours after birth
  3. AXR = double bubble study, contrast study may confirm
  4. Duodenoduodenostomy
246
Q

Malrotation with volvulus mushkies?

A
  1. Incomplete rotation during embryogenesis
  2. 3-7 days after birth, volvulus with compromised circulation may result in peritoneal signs and haemodynamic instability
  3. Upper GI contrast study may show DJ flexure is more medially placed, USS may show abnormal orientation of SMA and SMV
  4. Ladd’s procedure
247
Q

Jejunal/ileal atresia mushkies?

A
  1. 1/3000, vascular insiffuciency in utero
  2. Usually within 24 hours of birth
  3. AXR = air fluid level
  4. Laparotomy with primary resection and anastomosis
248
Q

Meconium ileus mushkies?

A
  1. 1/5000, 20% with CF
  2. 24-48 hours of life with abdominal distension and bilious vomiting
  3. AXR = air-fluid levels, sweat test for CF
  4. Surgical decompression, serosal damage may require segmental resection
249
Q

What size fibroadenoma should be excised?

A

> 3cm

250
Q

Volvulus definition?

A

Torsion of the colon around its mesenteric axis resulting in compromised blood flow and closed loop obstruction

251
Q

Most common volvulus?

A

Sigmoid

252
Q

Sigmoid volvulus associations?

A
  1. Older patients
  2. Chronic constipation
  3. Chagas disease
  4. Neurological = Parkinsons, DMD
  5. Psychiatric = Schizophrenia
253
Q

Caecal volvulus associations?

A
  1. All ages
  2. Adhesions
  3. Pregnancy
254
Q

Sigmoid volvulus Dx?

A

AXR = Coffee bean sign, air-fluid level

255
Q

Caecal volvulus Dx?

A

SBO on AXR

256
Q

Sigmoid volvulus Rx?

A

Rigid sigmoidoscopy with rectal tube insertion

257
Q

Caecal volvulus Rx?

A

Usually operative, right hemicolectomy often needed

258
Q

Colorectal cancer 2ww referral indications?

A
  1. Patients >= 40 years with unexplained weight loss AND abdominal pain
  2. Patients >= 50 years with unexplained rectal bleeding
  3. Patients >= 60 years with iron deficiency anaemia OR change in bowel habit
  4. Tests show occult blood in their faeces (see below)
259
Q

Urgent 2ww ‘consideration’?

A
  1. Rectal or abdominal mass
  2. Unexplained anal mass or anal ulceration
  3. Patients < 50 years with rectal bleeding AND any of the following unexplained symptoms/findings: abdominal pain, change in bowel habit, weight loss, iron deficiency anaemia
260
Q

FIT test recommendations for pts with new symptoms who do not meet the 2 week criteria?

A
  1. Patients >= 50 years with unexplained abdominal pain OR weight loss
  2. Patients < 60 years with changes in their bowel habit OR iron deficiency anaemia
  3. Patients >= 60 years who have anaemia even in the absence of iron deficiency
261
Q

Bladder cancer (transitional cell) risk factors?

A
  1. Smoking (most important)
  2. Exposure to aniline dyes
  3. Rubber manufacture
  4. Cyclophopshamide
262
Q

Bladder SCC RFs?

A
  1. Schistosomiasis
  2. Smoking
263
Q

Priapism definition?

A

Persistent penile erection >4 hours and not associated wiht sexual stimulation

264
Q

Priapism classification?

A
  1. Ischaemic = impaired vasorelaxation resulting in trapping of de-oxygenatedblood within the corpus cavernosa
  2. Non-ischaemic = high arterial inflow, typically due to fistula formation often either as the result of congenital or traumatic mechanisms
265
Q

Priapism epidemiology?

A
  1. Bimodal, 5-10 and 20-50 y/o
266
Q

Priapism causes?

A
  1. Idiopathic
  2. Sickle cell/other haemoglobinopathies
  3. ED medication e.g. Sildafenil
  4. Trauma
  5. Medication = Prescribed (antis), recreational (cocaine, cannabis, ecstasy)
267
Q

Priapism features?

A
  1. Erection >4 hours
  2. Pain localised to penis
  3. Non-painful/not fully rigid suggests non-ischaemic priapism
  4. History of trauma to genital or perineal region = suggestive of non-ischaemic priapism
268
Q

Priapism Ix?

A
  1. Cavernosal blood gas analysis to differentiate between ischaemic and non-ischaemic: in ischaemic priapism pO2 and pH would be reduced whilst pCO2 would be increased
  2. Doppler or duplex ultrasonography: this can be used as an alternative to blood gas analysis to assess for blood flow within the penis.
  3. A full blood count and toxicology screen can be used to assess for an underlying cause of the priapism.
  4. Diagnosis of priapism is largely clinical, with investigations helping to categorise into ischaemic and non-ischaemic as well as assessing for the underlying cause.
269
Q

Priapism Rx?

A
  1. Non-ischaemic = not a medical emergency and is normally suitable for observation as a 1st line option
  2. Ischaemic = medical emergency. If the priapism has lasted longer than 4 hours, the first-line treatment is aspiration of blood from the cavernosa, this is often combined with injection of a saline flush to help clear viscous blood that has pooled. If aspiration and injection fails, then intracavernosal injection of a vasoconstrictive agent such as phenylephrine is used and repeated at 5 minute intervals. If medical therapy fails then surgical options can be considered
270
Q

Once daily insulin dose on day of and day before surgery?

A

Reduce dose by 20%

271
Q

Colorectal cancer tumour marker?

A

CEA

272
Q

Treatment of testicular torsion?

A

If a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral

273
Q

When should COCP/HRT be stopped before surgery?

A

4 weeks before

274
Q

Elective hip replacement VTE prophylaxis?

A

LMWH for 10 days followed by aspirin (75 or 150 mg) for a further 28 days

or

LMWH for 28 days combined with anti-embolism stockings until discharge

or

Rivaroxaban

275
Q

Elective knee replacement VTE prophylaxis?

A

Aspirin (75 or 150 mg) for 14 days

or

LMWH for 14 days combined with anti-embolism stockings until discharge

or

Rivaroxaban

276
Q

Fragility fracture sof pelvis/hip/proximal femur VTE prophylaxis?

A

1 month

277
Q

Sulfonylureas on day of surgery?

A
  1. Omit on day of surgery
  2. If they take BD, can have afternoon dose if operation is in morning
278
Q

Malignant hyperthermia?

A

A rare, serious side effect of volatile liquid anaesthetics (isoflurane, desflurane, sevoflurane), which cause all skeletal muscle to rapidly contract, including during a neuromuscular blockade. MH is a genetic disorder, manifesting due to calcium overload in the skeletal muscle causing sustained muscular contraction and rhabdomyolysis, resulting in excess anaerobic metabolism causing acidosis. End-tidal CO2 increases as a result, along with body temperature which causes diaphoresis (excess sweating)

279
Q

Peripheral arterial disease comorbidity treatment

A
  1. HTN
  2. DM
  3. Obesity
280
Q

Initial Peripheral arterial disease management?

A
  1. Atorvastatin 80mg and Clopidogrel 75mg
  2. Exercise training
281
Q

Severe PAD/Critical limb ischaemia treatment?

A
  1. Endovascular revascularisation (short segments of stenosis (<10cm), aortic iiac disease and high risk patients)
  2. Surgical revascularisation (long segment lesions >10cm, multifocal lesions, lesions of common femoral artery and purely infrapopliteal disease)
282
Q

When do you amputate for PAD?

A

Pts with critical limb ischaemia who are not suitable for other interventions e.g. angioplasty or bypass surgery

283
Q

Drugs licenses for PAD?

A
  1. Naftidrofuryl oxalate: vasodilator, sometimes used for patients with a poor quality of life
  2. Cilostazol: phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects - not recommended by NICE

MSRA (25 decks)

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