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General Surgery > OSCE Cases > Flashcards

OSCE Cases Flashcards

1
Q

What are the most common histological types of oesophageal cancer?

A

Squamous cell carcinoma of the upper oesophagus

Adenocarcinoma of the distal oesophagus - junction of the oesophagus and stomach

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2
Q

What are the risk factors for SCC of the oesophageal?

A

Low socioeconomic groups

Smoking

Alcohol

Males

Age +60

HPV infection

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3
Q

What are the risk factors for adenocarcinoma of the oesophagus?

A

Smoking

Barrett’s oesophagus

GERD

Obesity

History of Breast Ca

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4
Q

What are the symptoms of oesophageal cancer?

A

Dysphagia

Pain

Hoarseness

Cough with swallowing - oesophageal-tracheal fistula

Weight loss

Neck mass

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5
Q

What are the signs of oesophageal cancer?

A

Cervical lymph nodes

Hypercalcaemia - parathyroid hormone production

Dehydration, weight loss and muscle wasting

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6
Q

How is oesophageal cancer diagnosed?

A

History - Risk factors, symptoms

Examination - signs

Barium swallow

Endoscopy - direct visualization

FNA our Biopsy - histology

CT scan - Staging of disease

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7
Q

What are the findings on barium swallow for oesophageal Ca?

A

Irregular concentric narrowing - Stricture formation

Typical shouldering at the upper end of the lesion

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8
Q

Why is endoscopy performed for oesophageal Ca?

A

Direct visualisation of lesion

Biopsy of lesion for histology

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9
Q

What is the management of oesophageal cancer?

A

Surgical resection - oesophagectomy

  • If lesion is limited to the oesophagus
  • Done via transhiatal or thoracotomy

Neoadjuvant Chemotherapy with/without neoadjuvant Radiotherapy
* For downstaging of locally advanced tumours

Expandable stents insertions

  • For lesions that cannot be resected
  • With neoadjuvant chemo-/radiotherapy

Laser / cryotherapy

  • For intraluminal lesions that cannot be resected
  • Restores patency of oesophagus
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10
Q

How is oesophageal cancer staged?

A

TNM Staging…

Barium swallow

  • Position
  • length/size
  • oesophageal tracheal fistula
  • axis deviation and angulation

Endoscopic ultrasound

CT scan

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11
Q

What are the contraindications for surgery in oesophageal cancer?

A

Metastasis

Invasion of adjacent structures

Severe associated co-morbid diseases

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12
Q

What are the risk factors for gastric cancer?

A

Diet - low fat, low protein, high salt, alcohol

Environmental - poor food prep and drinking water, smoking

Poor socioeconomic status

Genetic predisposition

H. Pylori infection

Prior gastric surgery

Gastric ulcer

Atrophic gastritis

Polyps

Males

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13
Q

Describe the Borrmann classification of the endoscopic finding of a gastric adenocarcinoma

A

Type 1: Polypoid or fungating lesion

Type 2: Ulcerating lesions surrounded by an elevated border

Type 3: Ulcerating lesion with infiltration into the gastric wall

Type 4: Diffusely infiltrating lesion

Type 5: Lesions that do not fit any of the above

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14
Q

Describe Lauren’s classification for intestinal gastric adenocarcinoma

A

Ulcerative

Usually in the Antrum of the stomach

Pre-existing gastric atrophy and intestinal metaplasia

Any blood type

More common in males

Older age

Gland formation

Haematogenous spread

Better prognosis

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15
Q

Describe Lauren’s classification for diffuse gastric cancer

A

No gastric atrophy or intestinal metaplasia usually

Blood group A

More common in females

Younger

Poorly differentiated, signet ring cells

Transmural or lymphatic spread

Poor prognosis

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16
Q

How would a patient with a gastric adenocarcinoma present?

A

Dyspepsia - GERD

Epigastric discomfort / indigestion

Weight loss, vomiting, anorexia

Dysphasia

Gastric outlet obstruction

Early satiety

Anaemia

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17
Q

What are the signs of advanced gastric adenocarcinoma?

A

Palpable abdominal mass

Palpable supraclavicular lymph-node’s (virchows LN / troisiers sign)

Sister Mary Joseph nodule

Irregular hepatomegaly

Ascites

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18
Q

How is gastric adenocarcinoma diagnosed?

A

FBC
* Aneamia due to bleeding cancer

U&E
* Lookiing for electrolyte abnormalities due to weight loss, vomiting and anorexia

LFTs - To assess liver function in case of mets

CEA tumour marker

Blood gas

  • If the patient has gastric outlet obstruction
  • To rule out metabolic acidosis

Gastroscopy with biopsy for histological classification

CXR
* To look for/rule out lung and liver mets

CT scan
* * To look for/rule out metastases

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19
Q

How do you stage a gastric adenocarcinoma?

A

TNM staging

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20
Q

What is the management of a gastric carcinoma?

A

Subtotal gastrectomy- distal third tumors

Total gastrectomy - middle and proximal third tumors

Lymph nodes in close proximity are always removed

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21
Q

What are the complications of a gastrectomy?

A

Bleeding

Anastomoses leakage

Obstruction

Ulcer recurrence

Gastro-jejuno-colic fistula

Alkaline reflux gastritis

Dumping syndrome

Chronic gastroparesis

Malabsorption - anaemia

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22
Q

Describe the pathophysiology of bowel obstruction

A
  1. Complete obstruction
  2. Intestine proximal to obstruction contracts vigorously trying to overcome obstruction
  3. colicky pain + increased bowel sounds
  4. abdominal distension
  5. proliferation of gas producing bacteria
  6. Further abdominal distension
  7. vomiting (feaculant oudor)
  8. dehydration
  9. constipation/obstipation
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23
Q

What are the causes of large bowel obstruction?

A

Colorectal Cancer

Faecal Impaction

Sigmoid Volvulus

Diverticular stricture

Adhesions

Foreign body

Hernia

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24
Q

What are the four cardinal features of mechanical intestinal obstruction?

A

Pain

Abdominal distension

Vomiting

Constipation/Obstipation

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25
Q

How would you diagnose bowel obstruction?

A

History - Previous surgery, symptoms

Examination- especial abdominal and rectal examination

Bloods - FBC, U&E

AXR - supine or erect

Single contrast barium enema

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26
Q

List the risk factors / pre-malignant factors for colorectal carcinoma

A

Western diet - high fat, low fiber

Genetic factors:

  • Family history
  • FAP
  • Lynch syndrome type I/II

Ulcerative colitis

Previous irradiation

Implantation of ureters in colon

Colorectal schistosomiasis

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27
Q

How did you diagnose colorectal carcinoma?

A

History and examination - NB PR Exam

Sigmoidoscopy

Barium enema of colonoscopy

CT abdo

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28
Q

Discuss a fungating colorectal adenocarcinoma

A

Usually in the right colon

Few symptoms
Early: peri umbilical/epigastric discomfort 30mins after a meal

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29
Q

Discuss a annular stenosing colorectal adenocarcinoma

A

Typically left colon/sigmoid

GERD

Increasing Constipation or alternating episodes of constipation and diarrhea

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30
Q

Discuss a malignant ulcer colorectal adenocarcinoma

A

Typically in the rectum

Blood/Mucus per rectum

Tenesmus

Spurious diarrhea

Do NOT diagnose this radiologically

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31
Q

Discuss your approach to a patient with colorectal carcinoma

A

History - suggestive symptoms

Examination - all especially PR exam; looking for signs

Special investigations -
Colonoscopy/Sigmoidoscopy and biopsy
Barium enema
Tumour markers CEA
FBC for Fe anaemia
CT abdo
Staging
TNM
CXR
LFTs
Abdo US

Surgical resection - colectomy/hemicolectomy with removal of regional lymph nodes

Adjuvant Chemo/radiotherapy

6 monthly follow-ups - Exam, LFTs, CXR, US abdo, CEA levels

2 yearly colonoscopies

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32
Q

Discuss your special investigation findings of colorectal carcinoma

A

Colonoscopy/Sigmoidoscopy and biopsy
*

Barium enema
*

Tumour markers CEA
*

FBC
* Fe deficiency anaemia - occult bleeding per rectum

CT abdo
* Staging and metastases

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33
Q

List the 2 most common causes of obstructive jaundice

A

Gallstones

Head of pancreas carcinoma

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34
Q

Provide a DDx for obstructive jaundice due to luminal obstruction

A

Gallstones

Parasites

  • Ascaris Lumbricoides
  • Daughter cyst of Enchinococcus cyst
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35
Q

What are the signs of obstructive jaundice?

A

Yellow skin and sclera

Dark Urine

Pale stools

Itching

RUQ pain and tenderness

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36
Q

How would you investigate Obstructive jaundice?

A

Urine dipstick

    • bilirubin
    • urobilinogen

FBC
* Increased WCC with cholangitis

LFTs

  • Low albumin
  • Increased Alkaline phosphate and GGT

Ultrasound

  • Visualization of obstruction - cystic/solid
  • Billiary Dilatation above the obstruction
  • Level of obstruction
  • Hyperechoic mass > gallstone
  • Distended gallbladder + thickened wall > acute cholecystitis

AXR
* Radio-opaque gallstones (10-20%) - Brown and black stones coz’ it contains calcium

ERCP
* Filling defect

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37
Q

What are the consequences of gallstones in the gallbladder?

A

Mostly asymptomatic

Gallstone dyspepsia

  • Upper abdominal discomfort
  • Aversion of fatty foods
  • Flatulence

Biliary colic

  • Colic-like pain in RUQ - radiates to right scapula
  • Nausea and vomiting
  • Tenderness over gallbladder

Acute cholocystitis

Carcinoma of the gallbladder

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38
Q

What is the management of symptomatic gallstones?

A

Laproscopic cholecystectomy

Open cholecystectomy if…

  • Evidence of severe/perforated acute cholecystitis
  • Exploration of bile duct required
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39
Q

What are the symptoms and signs of acute cholecystitis?

A

BIliary colic > constant pain in RUQ

Pyrexia

Murphy’s sign (+)

Raised WCC

Paralytic ileus
*Constipation

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40
Q

How is Acute cholecystitis diagnosed?

A

Ultrasound

  • Distended gallbladder
  • Thickened gallbladder wall
  • Sonographic Murphy’s sign - Localised tenderness

Tc-99m HIDA scintigram

  • Done under sonar
  • Isotope reaches bowel but no activity seen in gallbladder
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41
Q

How would you manage acute cholecystitis due to gallstones?

A

Admit

IV fluids

NPO

Analgesia - Pethidine

Broad spectrum antibiotics - Cephzol / Amoxicillin + Gentamicin

Cholecystectomy within 3-4 days

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42
Q

What are the clinical features of an adenocarcinoma of the pancreas?

A

Painless obstructive jaundice
* Preceded by vague, deep-seated abdominal pain + bachache (poor prognostic indicator)

Anorexia, weight loss

Palpable gallbladder

Liver palpable - congestion

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43
Q

How would you diagnose a tumour of the pancreas?

A

LFTs
* Total bilirubin >10x normal favours malignant obstructive jaundice

Tumour Markers
* Elevated CA19-9

Ultrasound

  • Biliary/pancreatic duct dilatation
  • Cystic neoplasn

Abdominal CT scan

  • Visualize tumour
  • Biliary/pancreatic duct dilatation
  • Local infiltration
  • LN/Liver metastases

ERCP

  • Site and form of biliary obstruction
  • Displacement/obstruction of pancreas
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44
Q

What is the treatment for pancreatic tumours?

A

Surgical resection (whenever possible)

Islet cell tumours / cystadenoma
* Simple enucleation

Head of pancreas / peri-ampullary tumors
* Whipple operation (Pancreaticduodectomy)

Body/tail pancreatic tumour
* Distal pancreaticduodectomy + excision of spleen and splenic vessels

Unresectable tumour
* Palliative - Gallbladder/bileduct anastomosis to small bowel

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45
Q

What is the prognosis of adenocarcinoma of the pancreas?

A

Poor :(

Without resection 1 year survival <10%

With resection 1 year survival ± 12%

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46
Q

When would you perform surgery for portal hypertension?

A

(When there’s complications)

Bleeding Oesophageal Varices

  • Who failed other treatment modalities
  • Good operative risk

Ascites

Hypersplenism

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47
Q

What are the endoscopic treatment interventions for oesophageal varices?

A

Sclerotherapy

Rubber band ligation

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48
Q

What are the invasive radiological treatment procedures for oesophageal varices?

A

Embolisation

Transjugular intrahepatic portosystemic shunt (TIPSS)

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49
Q

What are the surgical treatment procedures for oesophageal varices?

A

Porto-caval / Meso-caval shunt

  • Creation of a communication between the hypertensive portal venous system and low pressure systemic system
  • Normalises pressure in portal venous system
  • Manages ascites and hypersplenism as well
50
Q

What are the complications of the surgical treatment for oesophageal varices?

A

Hepatic encephalopathy

51
Q

What are the risk factors for hepatocellular carcinoma?

A

Hep B/C infection

Cirrhosis

Aflatoxin contaminated foods

Alcoholic

52
Q

How would you diagnose a hepatocellular carcinoma?

A

History - suggestive symptoms and risk factors

  • RUQ pain
  • Abdominal mass
  • Loss of appetite and weight loss
  • Jaundice

Examination: Palpable mass / jaundice

Macroscopic features

  • Large - single well-circumscribed
  • Nodular - multiple nodules
  • Diffuse - ill-defined, wide infiltration, most common in SA

Alpha - Fetoprotein will be raised

U/S - visualise mass

CT scan - Staging

53
Q

What is the management of an organ-confined hepatocellular carcinoma?

A

Tumour resection (where possible)

  • Most effective
  • Not done if there’s cirrhosis coz’ of bleeding risk and decreased liver function

Liver transplant
* Cirrhotic patients

54
Q

What is the management of a non-resectable (not organ-confined) hepatocellular carcinoma?

A

Intralesional injections with 95% ethanol

Chemotherapy via the hepatic artery

Radiofrequency ablation

55
Q

List the non-hereditary risk factors for breast cancer

A

Older patient >50 years

Females

Alcohol and smoking

Early menarche

Late menopause

Late first pregnancy/few or no pregnancy

Obesity

56
Q

List the hereditary risk factors for breast cancer

A

BRCA 1 or BRCA 2 mutation
* BRCA 1 mutation - 85% chance of developing breast ca

Family history of breast cancer

Family history of ovarian cancer

Personal history of breast cancer

57
Q

What patients are considered high risk for breast cancer?

A

> 1 first line relative with unilateral breast ca

1 first line relative with bilateral breast ca

1 male relative with breast ca

1 relative with breast or ovarian ca

Previous biopsy showing

  • CIS
  • Proliferative disease with atypia
  • complex fibroadenoma
58
Q

How is breast cancer diagnosed?

A

Triple Test!!

  1. Clinically
    * History - Risk factors
    * Exam - Lump/mass and LN
    * Metastases
  2. Mammogram
    * 2 views - CC and MLO
    * Suspicious lesion
  3. FNA and Cytology
    * ER/PR status
    * Pathological type
    * Inconclusive > Core biopsy
59
Q

What is the importance of ER/PR status of a breast carcinoma

A

ER/PR (+) must NOT get hormone Replacement therapy because it feeds the tumour

60
Q

What are the features of a suspicious lesion on mammogram?

A

Hyperdense

Spiculated

Pleomorphic microcalcifications

61
Q

What are the most common pathological types of breast cancer?

A

Infiltrating ductal (75%)

Infiltrating lobular (10%)

62
Q

What are the management guidelines for a Stage I-II breast cancer?

A

Breast conservtaion therapy with adjuvant radiotherapy
* Tunour excision with axillary dissection

Adjuvant radiotherapy
* 5 days a week for 5-6 weeks

Systemic therapy depending on prognostic factors of the tumor

63
Q

What are the indications for Neo-adjuvant chemotherapy in breast cancer?

A

All locally advanced disease - Stage IIb; IIIa and IIIb

> 4cm mass

To downstage a tumor

If increased risk of micrometastases

To decrease tumour size

HER (+)/(-)

Triple negative - ER/PR/HER (-)

64
Q

What are the indications for Adjuvant chemotherapy in breast cancer?

A

Age <40 years

ER / PR (-)

> 3 LN involvement

High grade tumours

65
Q

What are the indications for hormone therapy in breast cancer?

A

ER (+)

Soft tissue metastases

Bone metastases

Pleural effusion (lung metastases)

Local reccurrance

66
Q

What are the indications for a mastectomy (contraindications for BCT) in breast cancer?

A

High breast : tumour ratio

Previous irradiation to the breast

Multifocal/multicentric tumour

Wide spread microcalcifications on mammography

Tumor > 4cm

BRCA (+)

Patient preference

Collagen vascular disease - coz’ radiotherapy C/I

  • SLE
  • Scleroderma

2 Recurrence of carcinoma

Males

Poor socio-economic circumstances

Pregnancy / Lactation

67
Q

What hormone therapy would you use in a post-menapausal woman with breast cancer?

A

Tomoxifen

  • Inhibits oestrodiol binding
  • Especially effective in ER/PR (+) patients

Anastrozole (Arimidex)
* Aromatase inhibitor - inhibits the conversion of androgens to oestrogen

68
Q

What are the side-effects of tomoxifen?

A

Menopausal symptoms:

  • Hot flushes
  • Mood changes
  • Altered menses / amenorrhoea
  • Dry vagina
  • Thrush

Thromboembolism

  • Stroke
  • DVT

Fatty liver changes

Increased risk of endometrial cancer

Vaginal atrophy and bleeding

69
Q

What are the side-effects of Arimidex?

A

MSK pain

Bone pain

70
Q

What hormone therapy would you use in a pre-menapausal woman with breast cancer?

A

Ovarian ablation

  • Surgical
  • GnRH antagonist - Temporary, better for younger patients

Tomoxifen

71
Q

What receives biological therapy in breast cancer and biologic would they receive?

A

HER-2 (+) patient

Herceptin - monoclonal antibody against HER-2

72
Q

Discuss regional therapy in breast cancer

A

Palpable Axillary LN
* Axillary dissection via Modified radical mastectomy

Impalpable Axillary LN
* Sentinal LN biopsy

73
Q

Discuss BRCA

A

Autosomal dominant inheritance

Associated with breast, ovarian, fallopian tube, colon and prostate carcinoma

74
Q

What stage breast cancers would you do a CT scan and bone scan for?

A

Stage IIb and up

To look for Metastases

75
Q

What are the histological indications for axillary dissection in breast cancer?

A

Large tumour

Soft tissue invasion

3 or more LN had tumour in it

Extranodal extension of disease

Micrometastases

76
Q

What is the clinical presentation of a nontoxic multinodular goitre?

A

Euthyroid

Dysphagia and respiratory distress due to tracheal compression

Plethora (venous congestion)
* Ask patient to lift arms above head then cervical veins will dilate

77
Q

What is the management of a nontoxic multinodular goitre?

A

Medical:

  • Thyroid hormone replacement therapy
  • Radio-active iodine (RAI) uptake to reduce goitre size

Surgical:
* Sub-total thyroidectomy - if poor RAI uptake

78
Q

What are the risk factors for a toxic multinodular goitre (plummers disease)?

A

Older women

Iodine deficiency

Genetic predisposition

History of nontoxic multinodular goitre

79
Q

What is the management of a toxic multinodular goitre?

A

Medical:

  • Antithyroids with beta-blockers
  • Radio-active iodine (RAI) uptake to reduce goitre size

Surgical:
* Sub-total thyroidectomy - if poor RAI uptake

80
Q

What special investigations would you do in a patient with thyroid pathology and why?

A

Serum TSH

  • Raised in hypothyroidism
  • Decreased in hyperthyroidism and euthyroidism

Total T4, free T4 and free T3
* Function of the thyroid

Serum Calcitonin
* Increased in MEN 2 syndrome

Thyroid Antibodies
* Increased in autoimmune thyroiditis

81
Q

Discuss Radioactive Iodine (RAI) Uptake testing

A

Provides a function-anatomical correlation of thyroid lesion

Provides information on risk of malignancy

Cold nodule = High risk of malignancy (20%)

Hot nodule = Lower risk of malignancy (5%)
* Hot nodule + hyperthyroidism = benign

82
Q

What imaging would you do in a patient with thyroid pathology and why?

A

RAI uptake
* Provides information of risk of malignancy

FNA
* Diagnoses/excludes malignancy

Ultrasound
* Evaluation of thyroid nodules for suspicious signs of malignancy

CT scan
* Metastases

83
Q

What are the suspicous signs of thyroid cancer on ultrasound?

A

Calcification

Increased vascularity

Irregular borders

Absent halo sign

84
Q

What is the most common thyroid malignancy?

A

Papillary cell adenocarcinoma

85
Q

What is the origin of a Papillary cell adenocarcinoma of the thyroid?

A

Arises from follicular epithelial cells

86
Q

What are the risk factors for a Papillary cell adenocarcinoma of the thyroid?

A

Genetic mutation of BRAF gene

Previous irradiation

Family history of thyroid cancer

Familial syndromes:

  • Familial papillary carcinoma
  • Familial non-medullary thyroid carcinoma
  • Familial adenomatous polyposis coli (FAP)
  • Gardner syndrome (Familial colorectal polyposis)
  • Turcot syndorme (multiple adenomatous polyps in the colon)
87
Q

What is the clinical presentation of a Papillary cell adenocarcinoma of the thyroid?

A

Most common (80%)
2:1 female:male ratio
20-30 years

Solitary nodule

  • Firm on palpation
  • Solid on ultrasound
  • Cold on RAI

Dysphagia (invasive)

Dyspnoea (invasive)

Dysphonia (invasive)

Palpable LN

88
Q

What is the route of spread of a Papillary cell adenocarcinoma of the thyroid?

A

Lymphatic

89
Q

Where does a a Papillary cell adenocarcinoma of the thyroid metastasize to?

A

Lungs

Bone

90
Q

What investigations would you do for a papillary cell adenocarcinoma of the thyroid??

A

Thyroid function tests

  • Increased TSH
  • Normal FT3 and FT4

Ultrasound

  • Look for suspicious signs
  • Solid

FNA and cytology

  • Papillary projections of columnar epithelium
  • Psammoma bodies (60%)

RAI
* Cold

91
Q

What is the management of a Papillary cell adenocarcinoma of the thyroid?

A

Surgical
<1 cm - Lobectomy/Isthmustectomy (Younger patients)
>1 cm - Total thyroidectomy with central node dissection

Adjuvant

  • Thyroid hormone suppression and radioiodine therapy
  • External beam radiotherapy for >45 years and had locally invasive disease.

Post-Total thyroidectomy
Life-long thyroid hormone replacement therapy

92
Q

What are the indications for a Total thyroidectomy?

A

(Also contraindications to RAI)

Large/Multinodular goitre with poor RAI uptake

Compression symptoms

Suspicious malignant nodule/ confirmed thyroid cancer

Pregnancy/children

Patients who wish to fall pregnant

Amioderone induced hyperthyroidism

Adverse effects of antithryoids

Unable to follow long term follow-up

93
Q

What are the complications of thyroidectomy?

A

Thyroid storm

Neck haematoma

Recurrent laryngeal nerve injury

Injury to the external branch of the superior laryngeal nerve

Injury to the oesophagus

Injury to to the great vessels/cervical sympathetic trunk

Hypoparathyroidism

94
Q

Provide a DDx for a solitary nodule of the thyroid

A

Cyst

Colloid nodule

Papillary cell adenocarcinoma

Follicular cell adenocarcinoma

95
Q

What are the risk factors for chronic arterial disease (critical limb ischaemia)

A

Smoking

DM

HPT

Hyperlipidaemia

Older age

Obesity

Males and post menapausal women

Family history

Chronic renal failure

96
Q

What are the symptoms of chronic arterial disease?

A

Usually asymptomatic

Intermittent Claudication - ischaemic muscle pain induced by exercise and relieved by rest

Critical limb ischaemia:
Rest pain - severe burning pain in the forefoot or toes that’s worse at night and improves with walking or hanging the limb off the bed
Gangrene
Ischaemic ulcer

Impotence - aortic-iliac/bilateral iliac disease

Acute on chronic vascular occlusion

97
Q

Provide a DDx for claudication

A

Osteoarthritis of the hip/knee

Neurospinal claudication

Chronic compartment syndrome

Venous claudication

98
Q

Provide a DDx for rest pain

A

Diabetic neuropathy

Gout

Plantar fasciitis

Night cramps

99
Q

What is critical limb ischaemia (CLI)?

A

It implies impending limb loss

When the blood supply to a limb is critically diminished

Often a multilevel disease

100
Q

What are the symptoms/signs of critical limb ischaemia?

A

Rest pain

Non-healing ischaemic ulcer

Gangrene

101
Q

When assessing a patient the femoral pulse and all pulses below it are absent. What is anatomical level of disease?

A

Aorta-iliac disease

102
Q

When assessing a patient the highest pulse palpable is the popliteal pulse. What is anatomical level of disease?

A

Trifurcation disease

103
Q

When assessing a patient the highest pulse palpable is the foot pulse. What is anatomical level of disease?

A

Distal disease

104
Q

When assessing a patient the highest pulse palpable is the femoral pulse. What is anatomical level of disease?

A

Femero-popliteal disease

105
Q

What special investigations would you do for a patient with chronic arterial disease?

A

Duplex Doppler

CT angiography

Digital Subtraction Angiography

MR angiography

106
Q

Discuss the management of claudication

A

Stop smoking

Manage risk factors - DM, HPT, hypercholesteraemia (ACE inhibitors is HPT)

Aspirin

Simvastatin

Supervised exercise program

Foot care in diabetes

Warn patients about symptoms of CLI and acute on chronic vascular occlusion

Refer for intervention is conservative treatment fails

107
Q

Discuss the management of critical limb ischaemia

A

Need revascularization for limb salvage:
Imaging - duplex Doppler, CT angiography, DSA
Revascularization - endovascular, surgery
Amputation of gangrenous toes

Risk factor management

108
Q

How do you manage a patient with critical limb ischaemia that is NOT a candidate for revascularization?

A

Amputate - Unbearable pain/progressive infection

Medical management - Stable pain

109
Q

List the options for revascularization

A

Endovascular:
Balloon dilatation
Stent

Surgery:
Bypass
Endarterectomy
Sympatectomy
Amputation
110
Q

How would you manage a patient with aorto-iliac disease?

A

Aortabifemoral bypass

OR

Fem-fem bypass

111
Q

Discuss the treatment of a septic diabetic foot

A

Diagnose and treat diabetic ketoacidosis

IV fluids - Ringers

Correct electrolytes

Give insulin

IV antibiotics - Entrapenem/Vancomycin

Drainage and debridement of sepsis

?Amputate

?Revascularize

112
Q

What are the indications for amputation

A

Non-viable limb

Critical limb ischaemia with no bypass option

Foot no longer salvageable

Immobile or contracture of limb

Patient preference

113
Q

Classify Abdominal Aortic Aneurysms by CT measurements

A

Normal: 2-3cm

Small AAA: 4-5cm

Moderate AAA: 5-6cm

Large AAA: 6-7cm (50% risk of rupture in 5 years)

Very large AAA: >7cm (100% risk of rupture in 5 years)

114
Q

What are the complications of an AAA

A

Rupture

Compression of surrounding structures

Embolization

115
Q

When is surgery indicated in an asymptomatic AAA

A

> 5.5cm

> 1cm increase in size in a year

Uncontrolled HPT

Patients request

116
Q

What are the indications for a stent placement in AAA

A

Neck is atleast 1cm below renal artery or normal aorta

<60% angulation of the neck

Must have adequate access

May not be too torturous or calcified

117
Q

What are the surgical options for AAA?

A

Aneurysmectomy

Stent placement

118
Q

What is the conservative management of an AAA

A

Smoking cessation

BP control

Simvastatin

6 monthly follow-up for US

119
Q

What are the symptoms of an AAA

A

Abdominal pain that radiates to the back

Tenderness over AAA

Rapid expansion

120
Q

What are the complications of endovascular (stent) repair?

A

Endoleaks

Migration

Neck dilatation

Limb occlusion

General Surgery (7 decks)

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