PasTest Surgery Flashcards
What is pneumatosis intestinalis?
Cystic colllections of gas localised to wall of colon
Causes of pneumatosis intestinalis?
Bowel necrosis, immunosuppression, severe obstructive pulmonary disease
Significance of pneumatosis intestinalis?
A radiographic finding and not a diagnosis; aetiology varies from benign to fulminant disease. Considered an ominous finding in bowel ischaemia, particularly if associated with portomesenteric venous gas. Prognosis excellent if primary (15%) and poor if associated with obstructive and necrotic GI disease
Management of pneumatosis intestinalis?
If primary, usually no treatment needed. If have bowel ischaemia or perforation, may need surgery (especially if not responding to non-operative treatment, or have signs of perforation, peritonitis, abdominal sepsis)
Patients with terminal ileal resection at greatest risk of what anaemia?
Macrocytic, normochromic anaemia (B12 absorption). See megaloblasts in BM.
Where does iron absorption occur in gut?
Jejunum and duodenum
Where is vitamin D absorbed in the gut?
Jejunum, as a free vitamin.
Causes of angular stomatitis?
Candida infection, staphyloccal infection. Can be iron/B12 deficiency or dermatitis (atopic, contact, seborrhoeic).
Centor criteria for tonsillitis?
One point for tonsillar exudate, tender anterior cervical lymph nodes, history of fever, absence of cough. Treat with Abx for 3 or 4.
Treating tonsillitis?
Protect airway, adequate analgesia, antibiotics if indicated. Specific criteria for surgical intervention.
DD tonsillitis and infectious mononucleosis?
Lower grade fever in mono, minimal exudate, more likely to have palpable spleen and be adolescent.
Clinical findings in infantile hydrocephalus?
Tense anterior fontanelle, ‘cracked pot’ sound on percussion, transillumination of cranial cavity, ‘setting sun’ appearance of the eyes, thin scalp with dilated veins, abnormally large skull on growth charts
Investigation for infantile hydrocephalus?
CT or MRI head
Common cause of infantile hydrocephalus and two associated CNS malformations?
Stenosis of the aqueduct of Sylvius. Associated with spina bifida and meningomyelocoele
Definitive treatment for infantile hydrocephalus?
CSF shunt with one-way valve between lateral ventricle and right atrium or peritoneum. After shunting can monitor ventricular size by ultrasonography through the open anterior fontanelle.
Causes of acute limb ischaemia following femoral arteriogram and balloon angioplasty?
Thrombosis, dislodgement of atheromatous plaque, internal dissection during/after angioplasty
Management of acute limb ischaemia following femoral artery procedures?
Analgesia and anti-coagulation with IV heparin, infusion of tPA (prostaglandin-derived thrombolytic agent), thromboembolectomy, repair or removal of intimal flap (varies according to cause)
Cystic artery is usually a branch of what artery?
Right hepatic!
Cardinal features of bowel obstruction?
Absolute constipation, colicky abdominal pain, distension, vomiting. High-pitched or tinkling bowel sounds suggestive of mechanical bowel obstruction; functional obstruction (pseudo-obstruction) has similar clinical picture with absent bowel sounds
DD large bowel and small bowel obstruction?
In SBO, constipation appears after the onset of vomiting; reverse in LBO
How does anal fissure cause constipation?
Often follows constipation; hard stool causes tear, anal spasm and further constipation. May not tolerate PR. Get vicious cycle.
Treating constipation cause by anal fissures?
Stool softeners, local anaesthetic, topical nitrates or diltiazem. Severe cases may require anal stretch or lateral sphincterotomy under anaesthetic. Also increase fibre.
Pregnancy and GI symptoms?
Causes constipation due to pelvic mass and reduced GI motility; later get indigestion as SM relaxation reduces tone of LOS therefore get reflux
Tenesmus?
Associated with IBS and rectal tumours (either malignant or polyps); if older and have anorexia, weight loss less likely to be IBS
Causes of SBO?
Most common is adhesions (70%), then hernia, then malignancy, then foreign body.
Management of SBO?
Fluid resuscitation, diagnosis and correction. Then “drip and suck” (IVT and regular aspiration through large-bore NG tube). Surgery is suspected strangulation.
Dividing causes of SBO?
Intraluminal (gallstone ileus, food bolus, bezoars, parasites), intramural (tumour inc. carcinoma, lymphoma, sarcoma, and stricture inc. Crohns, radiation enteritis, post-operative), extramural (hernia inc. inguinal, diaphragmatic, incisional, femoral)
Transpyloric plane?
Located at L1. Aka Addison’s plane. Halfway between jugular notch and superior border of pubic symphysis. Pylorus of stomach, first part of duodenum, duodenal-jejunal flexure, hepatic and splenic flexures of colon, fundus of GB, neck of pancreas, hila of kidneys and spleen, ninth costal cartilage, spinal cord termination, origin of SMA and confluence of SMV and splenic vein to form portal vein.
Management of urinary stones?
Most commonly extracorporeal shock wave lithotripsy (contraindicated in pregnancy and coagulopathy). Surgery for larger stones. Endoscopic retrograde procedures if lithotripsy fails. Can wait for spontaneous passage if ~3mm or so but if has got stuck at the pelvi-ureteric junction it has yet to reach the narrowest point so very unlikely to happen
First-line treatment for osteoporosis?
Bisphosphonate (daily or weekly, either risedronate or alendronate) + calcium/vit D)
Where do most gastric cancers arise from?
Cardia
History of trauma followed by fluctuating confusion and conscious level in elderly patient?
Likely to be subdural haematoma
Why are elderly more at risk of subdural?
Thinner cortical bridging veins, increased subdural space, increased probability of falls, use of medications that alter clotting
Which cerebral bleeds are more likely in the context of coagulopathy?
Subdural, usually. SAH associated with significant trauma or aneurysm, extradural with significant trauma. Mild trauma + bleed = subdural.
Chronic subdural vs acute?
Acute = headache, impaired GCS, focal signs, over-coagulated. Chronic is more insidious.
Damage to common peroneal nerve?
Not uncommon during varicose vein surgery. Get inability to dorsiflex (foot drop) and evert. Foot slaps floor. May also occur in fibular fractures or their treatments e.g. pressure from plaster back-slab
Triad in normal pressure hydrocephalus?
Gait disturbance, urinary incontinence, fluctuating confusion
MRI findings in normal pressure hydrocephalus?
Ventricular enlargement and increased signal intensity around ventricles (suggesting increased CSF production). Sulci well-preserved. Can also diagnose with serial lumbar punctures.
Treatment of normal pressure hydrocephalus?
LP and therapeutic drainage of CSF. Can consider CSF catheter or shunt to avoid repeated LPs (ventriculo-peritoneal shunt)
Why do trauma patients get hyperkalaemia?
Massive transfusion, acidaemia (buffering of H+ causes K+ efflux). Get tented T waves, then PR and QRS widen and slow and get ventricular arrhythmias. If doing massive transfusion, must do regular blood gases. Regular calcium gluconate/chloride and insulin/50% dextrose should be given.
ECG changes in hypocalcaemia?
Prolongation of QTc (due to lengthening of ST)
Hypokalaemia ECG changes?
Prominent U waves, ST depression, prolonged PR interval, T wave flattening, long QT, torsades
Hyperkalaemia ECG changes?
First get peaked T waves, then get atria paralysis above 6.5 (P wave widens and flattens, PR segment lengthens, P waves eventually disappear), above 7 get prolonged QRS, high-grade AV block, any kind of conduction block e.g BBB, sinus bradycardia or slow AF, development of sine wave (pre-terminal), then asystole/PEA/VF
Acute osteomyelitis of radius/ulna in children?
Fever, severe pain, malaise, forearm inflamed and swollen
Investigating acute osteomyelitis in children?
Aspirate from area of maximal inflammation, send fluid for gram staining and culture and sensitivity. May see raised WBC, ESR and anti-staphylococcal Ab titres
Plain radiographs in acute osteomyelitis?
Limited value during first few days. By the end of the second week get periosteal new bone formation and metaphyseal mottling (classic signs of pyogenic osteomyelitis). Should not delay treatment waiting for these signs.
Differentials for acute osteomyelitis (of forearm)?
Cellulitis, acute suppurative arthritis, sickle cell crisis, Gaucher’s (pseudo-osteitis), pyomyositis in tropical climates (same organisms)
Which investigation is indicated for determining whether a patient is a good candidate for bypass surgery?
Digital subtraction arteriography (compare images before and after IV iodinated contrast; after-image has adjacent bones and soft tissues removed to show clear picture of arteries). Assess patients “run-off” (if good, then distal arteries are well supplied by collaterals and therefore a good candidate for bypass surgery). Can use contrast arteriography if digital not available.
Usual cause of mechanical back pain?
Sedentary lifestyle!
Pain radiating down leg, paraesthesiae over lateral aspect of left lower leg and foot, SLR limited?
Sciatica caused by compression of L5 nerve root (usually caused by L4/5 prolapse)
Spinal stenosis presentation?
Get claudication, relieved within minutes of sitting down. Surgical treatment is by spinal decompression. Must exclude vascular causes as PVD presents very similarly (so must assess peripheral circulation)
28-year-old with severe lower back pain, incontinent of urine, loss of perineal sensation and SLR limited bilaterally?
Central disc prolapse; emergency requiring urgent decompression.
Managing sudden sensorineural hearing loss (SSNHL)?
ENT emergency. Often no cause found. Causes include trauma, drugs, SoL, acoustic neuroma, Lyme disease, syphilis, sarcoid, multiple sclerosis, AI inner disease, hyperviscosity, rare metabolic and mitochondrial disorders..
Must confirm hearing loss is SN with Hx, Ex, audiometry. Start steroids immediately (14 days oral pred), MR brain or audiometry to exclude retrocochlear pathology. Consider ‘salvage therapy’ with intratympanic steroids, hyperbaric oxygen therapy. In well patient, with no PMH or other features on examination, most commonly idiopathic
Mechanism of Cushing’s reflex?
Raised ICP, tonsillar herniation and subsequent compression of brainstem. Get severe hypertension, bradycardia, irregular, decreased respiration
Nutrition guidance for surgery?
No food for six hours before, clear fluids up to two hours before
Ludwig’s angina?
Painful, symmetrical swelling of the floor of the mouth and upper neck due to dental infection; life-threatening and need urgent input from surgical/critical care teams
TGN and MS?
More common in MS, and may be bilateral
Parotid swelling and symptoms?
Most parotid swellings leave facial nerve intact. Most common is benign pleomorphic adenoma. Involvement of facial nerve associated with malignant tumours so should test this in all patients with parotid swelling
Frontal sinusitis vs herpes zoster?
Both can present with forehead pain. Sinusitis worse with leaning forward. Pain may precede rash in shingles.
Score for severity of pancreatitis?
Modified Glasgow Score. Done on admission. One point for each of the following criteria (spelling PANCREAS). PaO2 <8, Age >55 Neutrophilia (WCC>15) Calcium <2 Renal (urea >16) Enzymes (AST/ALT>200 or LDH>600) Albumin <32 Sugar >10
Interpreting Modified Glasgow Score?
3 or more = severe attack and need ITU
AXR for ?gallstones?
Not indicated as many stones are radiolucent (so sensitivity low) and other modalities e.g. USS, MRCP and ERCP are effective
Some indications for AXR?
Suspected foreign body, clinical suspicion of obstruction, abdominal foreign body, constipation
Recurrent laryngeal nerve innervates?
Sensory innervation to the trachea and larynx below vocal cords, and innervates all muscles of the larynx except the cricothyroid (external laryngeal nerve, a branch of the superior laryngeal, which also gives off the internal laryngeal to provide sensation to larynx above vocal cords
Thoracic duct?
Starts at T12 from cysterna chyli, drains all the lymph from below the diaphragm, left thorax and left head and neck; starts at the right of the aorta, ascends to the right of the aorta and oesophagus as it passes through the diaphragm, then crosses midline on the left, posterior to oesophagus, at T5, drains into confluence of left subclavian and IJV. Has valves. Injury can cause chylothorax
Role of the cricothyroid muscle?
Innervated by external laryngeal nerve (branch of superior laryngeal); elongates vocal cords; injury means one vocal cord cannot be tensed so cannot produce notes of high frequency
Management of acute limb ischaemia caused by embolus?
Urgent embolectomy with a Fogarty catheter. Post-embolectomy, anticoagulate with IV heparin and switch to warfarin.
Testicular tumour resembling glomeruli?
Yolk sac tumour (endodermal sinus carcinoma). Mucinous tumour containing Schiller-Duval bodies which resemble primitive glomeruli. AFP secreted. Most common testicular tumour in under 4s.
Most common testicular tumour?
Seminoma. Large cells with fluid-filled cytoplasm that stain CD117 positive. AFP usually normal, HCG elevated in minority. LDH often elevated.
Clinical picture in MG?
Ptosis, neck weakness, dysphonia and (predominantly) proximal limb weakness in variable pattern over day. Tensilon (edrophonium) can be used to confirm diagnosis.
Antibodies positive in MG?
ACh receptor antibodies
Management of MG?
Pyridostigmine for symptomatic control, immunosuppression for control of disease. May be associated with benign mediastinal thyroid tumours and in such cases surgery to tumour can improve myasthenia control. Other AID may be associated
What are anti-smooth muscle antibodies and anti-mitochondrial antibodes associated with?
AIH and PBC respectively
Lateral blow to upper leg causing fractured neck of fibula may damage which structure?
Common peroneal nerve
Choosing between IV morphine and SC pethidine?
Morphine favoured in acute, severe pain because acts quicker, dose can be titrated more readily, has safer side effect profile and lower risk of toxicity. Both have depressive effects on CVS so not used if shocked
Why are NSAIDs bad in acute trauma?
If have acute trauma and may need surgery etc., NSAIDs create very high risk of stress ulcer.
Monitoring AAA?
Done with USS or CT. If 3-4.4cm, done yearly. If 4.5-5.4cm, 3 monthly. >5.5cm = vascular surgery referral. Initial screening done by US. Women not routinely screened. Men may be invited at 65.
What size AAA is indicated for surgery?
> 5.5cm
Managing suspected AAA leak?
Most patients should have CT before theatres to assess extent of leak
Repairing AAA?
Most commonly open surgery with insertion of synthetic graft, or endovascular repair. Can do aortic aneurysmorrhaphy (suturing sac)
Where is ampulla of Vater?
Where common bile duct and pancreatic duct enter second part (descending) duodenum. Cannulated during ERCP to allow access to biliary tree.
GIST?
Gastrointestinal stromal tumour. Can occur anywhere in GI tract, but 50-70% in stomach. Most common tumours of mesenchymal origin in GI tract. Have spindle cells (70%), epitheloid-like cells or mixed types. Tend to occur over 40, equal in men and women. Stain for DOG1. Treat with resection. Can use imatinib and systemic chemotherapy if complete resection not possible.
Managing acute pancreatitis?
Resuscitate: oxygen, IV fluids, pain relief, NG aspiration, IV broad spec Abx. Monitor lung function and oxygenation (RR and ABG), BP, HR, CVP, U&E, LFT, urine output, pancreatic function (BG, serum and urinary calcium). Surgery to manage complications of haemorrhage/necrosis in fulminant disease, or pseudocyst/abscess formation in subacute
Complications of acute pancreatitis?
Hypovolaemic shock, respiratory failure, renal failure, secondary infection, pseudocyst/abscess formation, hypocalcaemia.
Where is ampulla of Vater?
Where common bile duct and pancreatic duct enter second part (descending) duodenum. Cannulated during ERCP to allow access to biliary tree.
GIST?
Gastrointestinal stromal tumour. Can occur anywhere in GI tract, but 50-70% in stomach. Most common tumours of mesenchymal origin in GI tract. Have spindle cells (70%), epitheloid-like cells or mixed types. Tend to occur over 40, equal in men and women. Stain for DOG1. Treat with resection. Can use imatinib and systemic chemotherapy if complete resection not possible.
Managing acute pancreatitis?
Resuscitate: oxygen, IV fluids, pain relief, NG aspiration, IV broad spec Abx. Monitor lung function and oxygenation (RR and ABG), BP, HR, CVP, U&E, LFT, urine output, pancreatic function (BG, serum and urinary calcium). Surgery to manage complications of haemorrhage/necrosis in fulminant disease, or pseudocyst/abscess formation in subacute
Complications of acute pancreatitis?
Hypovolaemic shock, respiratory failure, renal failure, secondary infection, pseudocyst/abscess formation, hypocalcaemia.
Lymphatic drainage of breast?
Axillary nodes, supraclavicular nodes, internal mammary chain and inferior epigastric chain
Work-up for breast lump?
Clinical exam, then core needle biopsy, FNAC and US/mammogram findings are graded. Do sentinel LN biopsy if malignant to determine axillary nodal status.
Three causes of widened mediastinum in trauma?
Cardiac tamponade, aortic dissection/rupture, oesophageal rupture
Danger with small, missed pneumothorax?
Exacerbated by mechanical ventilation (get tachycardia, hypotension, rise in ventilation pressure)
Causes of pneumomediastinum?
Rupture oesophagus or bronchus; if have pneumothorax and lung collapse too then bronchus is likely culprit
Peutz-Jeghers?
AD condition characterised by the development of numerous GI hamartomatous polyps and mucocutaneous hyperpigmentation (macules). Risk of colorectal, breast, liver and lung cancer very high (15-fold gen pop risk for GI cancer). May get abdo pain, GI bleeding, intussusception.
Serrated polyposis syndrome?
Aka hyperplastic polyposis syndrome. Characterised by numerous serrated and or hyperplastic polyps in the colon and rectum. Not associated with any one genetic defect and not inherited in simple Mendelian fashion. Increases CRC risk.
Direct and indirect inguinal hernias?
Direct inguinal hernias is a protrusion through a weakness in the posterior wall of inguinal canal through transversalis fascia, medial to the epigastric vessels; indirect go straight through the deep inguinal ring and therefore are lateral to the inferior epigastrics
Lynch syndrome?
AD inherited. Aka HNPCC. Relatively fewer polyps than other inherited disorders, but have high malignant potential. Most common inherited CRC. Also associated with malignancies of breast, stomach, endometrium and urinary tract.
Peutz-Jeghers?
AD condition characterised by the development of numerous GI hamartomatous polyps and mucocutaneous hyperpigmentation. Risk of colorectal, breast, liver and lung cancer.
Gardner syndrome?
Subtype of FAP; AD inheritance. Hundreds of colorectal polyps and extra colonic manifestations (intestinal polyps, desmoids, osteomas, epidermoid cysts). Will inevitably develop CRC and therefore prophylactic surgery is the mainstay
Where do femoral hernias emerge?
Lateral to pubic tubercle
Diverticulitis?
Fever, LLQ tenderness, PR bleeding, vomiting. Associated with increasing age and low fibre diet. Mostly LHS. Management is generally conservative with Abx (cef and met). 15% patients require surgery. Complications include obstruction, perforation, fistula, abscess. Do erect CXR and AXR (perf/ob)
Inguinal hernias or femoral more likely to be become strangulated?
Femoral much more likely
Should all groin hernias be repaired?
Most should be repaired, especially when become symptomatic. However, if unfit for surgery can be treated conservatively e.g. using a truss
Diverticulitis?
Fever, LLQ tenderness, PR bleeding. Associated with increasing age and low fibre diet. Mostly LHS. Management is generally conservative with Abx. 15% patients require surgery. Complications include obstruction, perforation, fistula, abscess.
Diameters of small and large bowel?
Small normally maximum of 3cm; large bowel is max 6cm and 9cm at the caecum.
Appearance of air-fluid levels in small bowel?
Characteristic of small bowel obstruction
Appearance of the three broad categories of burns?
Superficial (red, moist in appearance, very painful); partial thickness (superficial dermal are drier and whiter, painful, slow return of blood with blanching; deep dermal are mottled red (capillary staining) with reduced sensation and do not blanch; may have blisters); full thickness (insensate, with white and waxy/leathery appearance; do not bleed with pinprick)
Where do the biceps heads attach?
Short head to coracoid process; long head to supraglenoid tubercle.
What does the talus articulate with at the subtalar joint?
The calcaneus. Also they articulate at the talocalcaneonavicular joint
Most common surgical diagnosis in children who present to hospital with acute abdominal pain?
Appendicitis (most commonly second decade of life)
Most common surgical diagnosis in acute abdomen under the age of two?
Intussusception
Antidote for local anaesthetic toxicity?
Intralipid, a 20% lipid emulsion
What is a peri-mortem Caesarean delivery and what is the timescale?
Delivery per abdomen in woman dying from maternal collapse or cardiopulmonary arrest; if resuscitation has not improved maternal situation in 4 minutes then do emergency C section (within five minutes) to increase chances of maternal and fetal survival (relieve aortocaval compression, increase venous return)
When to suspect that patient may have a breast abscess?
Recent mastitis, a painful, swollen lump in the breast with redness, heat and swelling of the overlying skin; fever and/or general malaise; need urgent referral to general surgeon who can confirm diagnosis with ultrasound and drain abscess
Can you have blisters in a first-degree burn?
No!
Clinical manifestations of pinealoma?
Slow-growing tumour of pineal gland; might compress midbrain cerebral aqueduct, causing non-communicating hydrocephalus (CSF cannot reach IV ventricle); midbrain tumour can also compress E-W nucleus (in grey matter near aqueduct) and therefore get no parasympathetic input to oculomotor nucleus so get mydriasis.
What symptoms will lesions in lateral geniculate nucleus cause?
Visual symptoms!
Gold standard test for bladder cancer?
Cystoscopy
Failure of proliferation of which pharyngeal arch causes branchial cleft cyst?
Second pharyngeal arch; cyst may have fistulous opening on the lateral neck
What is an isograft?
Transplant of tissue or organ from two genetically identical individuals e.g. identical twins; this is the best option as risk of reaction is almost non-existent
What is an allograft?
Transplant between two individuals of same species who are not twins
Orthotopic graft?
A graft that is transplanted in its normal anatomical position e.g. skin; kidney transplant is non-orthotopic
Xenograft?
Graft of tissue from one species to another e.g. porcine heart valves
Managing oliguria in patients who are hypovolaemic and vasoplegic?
Give fluid challenge and infusion of vasopressor e.g. noradrenaline
What is a Swan-Ganz catheter?
Specialised catheter inserted into the pulmonary artery to measure pressure; useful if have poor cardiac performance
Why could abdominal surgery cause vasoplegia?
Faecal soiling of peritoneum can cause release of inflammatory mediators particularly inducible nitric oxide synthetase
Injury to thoracodorsal nerve?
Leads to paralysis of the latissimus dorsi
Injury to medial pectoral nerve?
Innervates pectoralis major and minor; damage to the nerve paralyses these so shoulder will be abducted, laterally rotated, retracted and elevated
Which arteries supply lesser curvature of the stomach?
Left and right gastric; left gastric is one of the three branches of the coeliac trunk
Which arteries supply the greater curvature of the stomach?
Left and right gastroepiploic arteries
Which arteries supply the fundus of the stomach?
Short gastric arteries, which branch from the splenic artery
Management of ABPI 0.6-0.9?
First line is management of risk factors and clopidogrel, second line is enrolment on exercise programme, third line is surgical consideration including arterial duplex USS
When is revascularisation indicated in PVD?
Critical limb ischaemia (ABPI<0.4); do arterial duplex USS then possible contrast enhanced MRI
What is the management when emergency surgery is required and INR is raised?
Need urgent reversal of anticoagulation; give Beriplex (prothrombinex) IV before theatre. Vit K IV would be appropriate if theatre is the following day. FFP would be second-line to Beriplex
Back pain after coughing fit in elderly woman?
Mild trauma such as this can be sufficient to induce osteoporotic wedge fractures
Painless, fluctuant swelling in right groin with kyphotic angulation of dorsal spine?
TB of the dorsal spine (Pott’s disease of the spine); destruction of adjacent vertebral bodies by caseation leads to collapse, get spinal angulation; paravertebral abscess tracks down to the deep psoas fascia and points in the groin. Long history of poor health, may present with parasthesiae and leg weakness
Confirming TB of the dorsal spine?
Mantoux/Heaf skin test (+ve), raised ESR, chest radiograph showing primary lesion, radiograph of entire spine to detect distant occult lesions and assess angulation and number of vertebrae/disc spaces involves, CT or MRI for evidence of impending cord compression, needle aspiration of groin abscess
Treating Pott’s disease of the spine?
Eradicate TB, correct deformity by draining abscess and evacuating infected material, correction of angulation with strut grafts and spinal fusion, physiotherapy, high protein diet
Serious complication of Pott’s disease of the spine?
Pott’s paraplegia
Differentiating between spinal TB and tumour metastases?
Both can cause vertebral body collapse, but disc space usually preserved in metastasis
34 year old woman with known UC, intermittent jaundice, itching, right hypochondriac pain, weight loss, raised ALP?
PSC
Hyperbilirubinaemia in Gilbert’s?
Mild unconjugated
Fistula in ano?
Abnormal connection between anal canal and perianal skin, may form after an abscess/IBD/surgery; often visible lesion O/E. Presnet with discharge, pruritus, pain and swelling.
Topiramate and bone disease?
Used as anti-epileptic and for migraine prophylaxis. Causes chronic metabolic acidosis by RTA (normal anion gap); causes defective bone mineralisation (osteomalacia-like state) and can get pathological fractures. Diagnosis is topiramate-induced osteopathy
Pathophysiology and presentation of anal fissure?
Tear in lower anal canal distal to dentate line; get acute pain on defecation that can last for hours, often ‘stinging’; sphincter in spasm on DRE and may have tender, indurated and fibrotic ridge
Fistula in ano?
Abnormal connection between anal canal and perianal skin, may form after an abscess; often visible lesion O/E
Haemorrhoids and pain?
Vascular cushions in anal canal; usually asymptomatic or painless PR bleeding; may cause discomfort if external and thrombosed. If in significant pain, unlikely to be haemorrhoids
Four classical radiological signs for osteoarthritis?
Joint space narrowing, subchondral cysts, subchondral sclerosis and ostephytes
What is a Colles’ fracture?
Dorsally displaced, dorsally angulated fracture of the distal radius (dinner fork). FOOSH. Get transverse fracture of distal radius, 1 inch proximal to radiocarpal joint, radial shortening. Distal fragment dorsally angulated. Loss of radial inclination, ulnar angulation of wrist. Dorsal displacement of distal fragment. >60% have associated fracture of ulnar styloid
Patient with head injury, no symptoms and bruise behind R ear?
Need urgent CT head (as has Battle’s sign).
Signs of basal skull #?
Battle’s sign, panda eyes, rhinorrhoea (CSF from nose), otorrhoea
What is a Colles’ fracture?
Dorsally displaced, dorsally angulated fracture of the distal radius (dinner fork)
Normal management of Colles’ fracture and considerations?
Normally can be managed with closed reduction (following haematoma block) and below-elbow backslab. Open reduction and internal fixation provides most anatomical reduction but has risks (e.g. if osteoporotic, anaesthetic risks) then conservative (closed and backslab) better. After swelling has reduced, use full cast
Using fixation (e.g. plate and screws) in osteoporotic bone?
Much weaker hold and more likely to loosen
Why do you not use full casts immediately in fractures?
Fails to allow for swelling so may get compartment syndrome
? infertility, with low sperm count and mobile mass in left scrotum. US shows dilated veins in pampiniform plexus?
Varicocoele. Spermatogenesis inhibited at higher temperatures so get lower sperm count
Layers of the testes?
Some Doctors Exaggerate Conditions, Increasing Patients V(w)orry Tremendously Skin Dartos Layer External spermatic fascia Cremaster muscle Internal spermatic fascia Parietal tunica vaginalis Visceral tunica vaginalis Tunica albuginea
Varicocoele pathophysiology and treatment?
Pampiniform plexus encircles afferent testicular artery (cool blood to promote spermatogenesis); varicosities in these veins = varicocoele. More common on LHS because left gondal vein drains into left renal vein. Treat with varicocelectomy or embolisation
Two causes of cryptorchidism?
Premature infants or XXY
What renal calculi are associated with Crohns?
Calcium oxalate stones
Calcium oxalate stones?
Increased urinary oxalate can be genetic (primary oxaluria), idiopathic or enteric (severe bowel inflammation and malabsorption or extensive small bowel resection); treat with dietary calcium citrate. Give analgesia during colic and ensure no concomitant infection. May need lithotripsy
What causes calcium carcbonate stones?
High amounts of calcium in the body (either dietary or conditions such as hyperparathyroidism)
What causes magnesium carbonate stones?
UTIs; also known as struvite stones (made from Mg, ammonia and phosphate)
PCL tear?
Most commonly presents as part of damage in other ligaments. Mechanism = hyperextension or hyperflexion. Knee swollen, flexion mildly restricted. Instability when walking down stairs. Positive posterior drawer
Meniscal tears?
Most common knee injury; two peaks (young athletes and elderly); acutely are the result of rotational injury to the knee. Get knee locking. Do McMurray’s test. MRI most sensitive to diagnose.
McMurray’s test?
Knee flexed, one hand over side of knee, other on sole of foot. Then externally rotate knee while forced to extension, then IR with forced extension. If former causes pain/pop = medial meniscus; if latter = lateral meniscus
PCL tear?
Most commonly presents as part of damage in other ligaments. Mechanism = hyperextension or hyperflexion. Knee swollen, flexion mildly restricted. Positive posterior drawer
Collateral ligament tear?
Follows sudden forced twist, or direct blow to the side of the knee; presents with pain on medial or lateral side, swelling and feeling of giving way
Patella tendon rupture?
Men aged 30-40, high tensile forces applied during knee extension, on a weakened tendon. RFs include chronic tendonitis, chronic corticosteroid use, CKD, overuse or previous injury, DM. Present with infrapatellar pain or swelling, pain on weight bearing and difficulty straightening the leg. May have pop or feel knee give way. Xray shows displacement of patella.
Achilles tendon rupture?
Present with history of audible snap associated with sudden onset of pain. Do Simmond’s test.
What is Simmonds’ test?
Used to diagnose Achilles tendon rupture. Patient kneeling on chair/couch with both feet and ankles free to hang off the edge. Normally, squeezing calf muscles causes plantarflexion of foot; if Achilles is partially or completely ruptured this will not occur.
Cancrum oris (noma) presentation, causes and treatment?
Presents as ulcerating lesion in cheeks that exposes buccal cavity and alveolar margin. A necrotising stomatitis or severe ulcerative gingivitis from gums spreading to mandible and cheek. May get
trismus, overwhelming sepsis. Caused by protein-calorie malnutrition, chronic anaemia (e.g. hookworms), measles, poor oral hygiene. Treat with parenteral broad spectrum Abx, NG feeding of high protein-calorie diet, antiseptic mouthwash and wound irrigation, close of defect after healing with cutaneous pedicled flap transfer.
When should potassium be added in DKA management?
When K+ falls below 5.5mmol/L
What can diagnostic peritoneal lavage show?
Intraperitoneal bleeding or bowel contents
Possible intra-abdominal visceral injuries from fall?
Liver, spleen, pancreas, duodenum, diaphragm, kidneys, urinary bladder
Clinical/other findings that would require an emergency surgical exploration of the abdomen?
Signs of peritonism and increase in abdominal girth signify intraperitoneal haemorrhage or rupture of a hollow viscus. Imaging or diagnostic peritoneal lavage would detect bleeding and/or visceral injuries before the onset of lethal complications (oligaemia and/or toxic shock)
Risk factors for haemorrhoids?
Age, constipation, pregnancy and vaginal delivery, (any cause of increased intraabdominal pressure e.g. protracted vomiting, lifting heavy weights, low-fibre diet, obesity)
Clinical features of haemorrhoids?
Itching, painless PR bleeding, may have rectal fullness, discomfort or soiling. May describe fleshy lump protruding from anus.
Criteria for admission referral in haemorrhoids?
Acutely thrombosed haemorrhoids, perianal haematoma, associated perianal sepsis, large, permanently prolapsed haemorrhoids (may need haemorrhoidectomy)
Managing haemorrhoids?
Fluid and fibre, manage constipation, anal hygeine, analgesia. If does not respond, may need secondary care treatment e.g. rubber band ligation, injection sclerotherapy, photocoagulation, diathermy, haemorrhoidectomy, haemorrhoid artery ligation
Sentinel pile?
External lump on anus which is associated with chronic anal fissures
Grades of pressure sores?
1 = non-blanching erythema with no break in skin 2 = shallow open ulcer with pink wound bed 3 = full thickness tissue loss with exposed subcutaneous fat, but not muscle or tendon. May be shallow or deep, may have undermined wound edges 4 = exposed bone, muscle, tendon 5 = ?
When is anterior resection used and when is AP resection used?
Anterior resection for non-obstructed tumours of the distal sigmoid, middle or upper rectum; AP (abdomino-perineal) for operable low rectal and anorectal tumours; anus, rectum and sigmoid colon removed and end-colostomy fashioned.
Swelling, pain and inflammation of bunions? What causes symptoms? What causes deformity?
Hallux valgus deformity with inflammatory arthritis of first MTP; symptoms caused by pressure/friction on the medial aspect of the first metatarsal head, producing joint deviation, exostosis formation and arthritis; deformity by habitual wearing of narrow, unyielding, raised heel shoes producing progressive lateral deviation of the big toe
Treating hallux valgus?
Conserviative measures by changing shoes to wide fronts and low heels are unsatisfactory (poor compliance); surgery indicated instead
Best material for mass closure of abdominal wall at laparotomy?
1-0 nylon; non-absorbable, good tensile strength, synthetic, monofilament suture
Best material for 2cm lipoma excised from forearm?
3-0 monocryl; dissolvable, non-absorbable, monofilament, synthetic. Can be used to close clean wounds as subcuticular continuous stitch. Good here as little tension on small clean wound
Best material for emergency laparotomy for perforated duodenal ulcer?
Skin clips; likely to be contamination, so do thorough washout and drainage, but still high chance of wound infection so do clips. Quick to apply so good when unstable or end of long operation, but are interrupted and can be easily removed to release any purulent fluid if wound infection suspected
Best closure for emergency laparotomy for intra-abdominal compartment syndrome?
Laparostomy (leave ‘open abdomen’) with temporary covering over abdominal contents (transparent to visualise bowel and monitor ischaemia); good for compartment syndrome because intrabdominal pressures rise over perfusion pressure causing multiorgan failure. Close at 72 hours once shown signs of recovery
Closure for 36 y/o lady with dog bite on right forearm?
Leave superficial wound open; animal bites should be irrigated to clean and left open to heal by secondary intention (‘dirty’ wounds) as easily become infected. Patient should have oral Abx (co-amox typically) and ensure tetanus up-to-date; if not then consider IM human tetanus immunoglobulin
Closure for 54 y/o man, 7 days post-op with a superficial wound dehiscence throughout the full length of his midline abdominal wound?
Wound infection has caused the skin and SC fat to part or dehisce; this is superficial, because the underlying fascia is intact and the intra-abdominal contents protected. Can either give topical dressing and allow to heal by secondary infection (takes weeks) or do vacuum-assisted closure (VAC) using negative pressure to promote healing. Either done initially in theatre or on ward with advice from tissue viability
How does deep dehiscence present?
Pink serous discharge, haematoma or complete bowel protrusion. Likely need re-operation.
Clinical features of cribiform plate fracture?
Panda eyes, rhinorrhoea. NG tube or nasopharyngeal airway contraindicated
Clinical features of middle cranial fossa fracture or occiput fracture?
Battle sign, haemotympanum, otorrhoea
Best initial first aid for minor scald?
Run under cool or tepid water for 10-30 minutes, then apply cling film. Immediate cooling (within 20 minutes) helps, Iced water can cause vasoconstriction so is bad. Elevate burn if oedema present. Cling film protects wound, allows water loss, allows further assessment; do not wrap circumferentially around limb as may impair perfusion. Run under water for longer in chemical burns.
When is butter indicated for burns?
Burns caused by hot tar; helps remove it and therefore stop burning
What is the Salter Harris classification used for?
Physeal feactures (i.e. involve growth plate); can only occur in children before fusion of the physis
Most common finding in patients with Salter-Harris fracture?
Fracture through the metaphysis sparing the epiphysis
Salter-Harris classification?
S I - slipped A II - above L III - lower T IV - through or traverse or together 4 V - ruined or rammed
Three main types of post-operative bleeding (in patient undergoing elective splenectomy)?
Primary haemorrhage (during surgery, from uncontrolled bleeding points); reactionary haemorrhage (after return to normal BP); secondary haemorrhage (a few days later as result of infection)
Managing immediate post-operative haemorrhage?
Quarter-hourly BP, pulse and RR; examination of wound and abdominal girth measurement; resuscitation if required, blood volume replacement, emergency surgical re-exploration and haemostasis
Preventing infections in patients post-splenectomy?
Increased susceptibility to pneumococcal infections (decreased CMI); give vaccine (pneumovaccine) and antibiotic (phenoxymethylpenicillin) for future invasive procedures
Preserving immunity in splenectomy?
Re-implant small portion of the spleen during splenectomy for splenic trauma; in children, salvage spleen by repairing if possible
Management of SCFE?
In situ screw fixation (usually percutaneously)
Management of DDH?
Hip spica casts
Normal AAA screening result?
<3cm
Features of sebaceous cyst?
Small, smooth lumps closed by hair follicle blocked; have central punctum. Attached to the skin so skin does not move over them. Mobile above deep structures so will not move on swallowing etc. Can become infected, and become tender, erythematous, hot. May be excised if unsightly or infected.
Features of lipoma?
Deep to the skin, so skin moves over them. Soft, doughy, mobile on palpation. May need USS to rule out sarcoma/liposarcoma.
Sternocleidomastoid tumour?
Congenital lump, appears in first few weeks and may grow or recede; beneath SCM to deep to the skin. Typically restricts contralateral head movement.
Blood supply to sigmoid colon?
Sigmoid arteries which branch directly from the IMA
What does the ileocolic artery branch from and supply?
Terminal artery of SMA; supplies ileum, caecum and ascending colon
How does herpes encephalitis present?
Severe headache, confusion or reduced GCS with no obvious cause
