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classical presentation of biliary colic
pain becomes worse after eating but she is generally well, afebrile and her abdomen is soft
features of cholecystitis
In cholecystitis, you would expect evidence of infection (e.g. fever, tachycardia). You might also be able to palpate the gallbladder, and she may be Murphy’s sign positive.
Treatment of choice for biliary colic
Elective laparoscopic cholecystectomy
RF for prostate cancer
Increasing age
Obesity
Afro-carribean
FH: BRCA mutations
Next step after wide local excision of breast cancer
Whole breast radiotherapy
In women with breast cancer and no palpable lymphadenopathy, if a pre-operative axillary ultrasound is negative then they should have a:
sentinel node biopsy to assess the nodal burden
Mng of acute anal fissure
Stool softners - high fibre diet, high fluid intake, bulk forming laxatives
Lubricants such as petroleum jelly
Topical anasthetics
Analgesia
Mng of chronic anal fissure
Continue acutemng
Topical GTN —> then if not effective after 8 weeks secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin
90% of anal fissures occur in which location
Posterior midline
how many days before surgery should clopidogrel be ceased
7 days
Intact surgical wound, not discharging but tender and fever → ?
intra-abdominal abscess
when to cease PO antihyperglycemics prior to surg
The morning of surgery to prevent hypogylcemia during the fasting period
When to withold ACEi prior to surg
24hours
When to cease warfarin prior to surgery
5 days prior
WHen to cease DOACS prior to surg
stop 24 hours before low/moderate bleeding risk surgery (e.g. hernia repair).
stop 48 hours before high bleeding risk surgery (e.g. cardiothoracic surgery).
in renal impairment (e.g. CrCl <30), stop up to 72 hours before high-risk surgery.
when to cease antiplatelets prior to surg
Antiplatelets
aspirin
continue in most cases.
stop 7 days before high-risk surgeries (e.g. neurosurgery).
P2Y12 inhibitors
clopidogrel/prasugrel: Stop 7 days
ticagrelor: Stop 5 days
Dual Antiplatelet Therapy (DAPT)
discuss with cardiology if recent ACS or stent.
low-risk procedures: can proceed on DAPT.
high-risk procedures: ideally delay surgery. If not possible:
continue aspirin, stop P2Y12 inhibitor as per above.
WHne to cease ACE/ARB prior to surg
discontinued 24 hours before surgery.
Surgery / metformin on day of surgery:
OD or BD: take as normal
TDS: miss lunchtime dose
assumes only one meal will be missed during surgery, eGFR > 60 and no contrast during procedure
What is required for patients taking oral prednisolone
IV hydrocortisone is required at induction and after surgery
Isolated fever in well patient in first 24 hours following surgery?
Think physiological reaction to operation
Abdominal pain, bloating and vomiting following bowel surgery → ?
postoperative ileus
What type of anal fissure can suggest causes beyond constipation only
Lateral anal fissue
