Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Surgery Notes > CST Interview - Clinical Scenarios > Flashcards

CST Interview - Clinical Scenarios Flashcards

1
Q

Differential diagnosis for post-op (GI surgery) abdominal pain in unwell patient?

A

Anastamotic leak with peritonitis, septic shock, haemorrhagic shock, bowel perforation, ischaemic bowel, obstruction, wound infection, sepsis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Why can unwell patients with IBD be difficult to assess in terms of haemodynamics and clinical signs?

A

They tend to be immunosuppressed which can mask signs of peritonism. Also tend to be young with large physiological reserve

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is a stoma?

A

A therapeutic opening in the wall of a hollow viscus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

How can you differentiate an ileostomy from a colostomy? 2 ways

A

An ileostomy has a spout vs colostomy flush to skin. Contents usually greenish, loose (small bowel content)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Types of ileostomy? 2

A

End ileostomy - single barrelled with 1 lumen

Loop ileostomy - double barrelled with proximal and distal lumen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is the purpose of a loop ileostomy?

A

Divert enteral contents away from area of bowel that is e.g. healing or obstructed. Ex. j pouch in subtotal colectomy with ileorectal anastamosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Which parts of the colon can be mobilised and therefore are suitable for loop colostomy formation?

A

Transverse and sigmoid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Differences between Crohns and UC? 3 differences

A

Crohns has full thickness skip lesions on histology, cobblestoning on endoscopy and can involve any part of GI tract. UC has continuous superficial ulceration usually in rectum and colon

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Risk of multiple bowel resections for Crohns? Symptoms?

A

Short bowel syndrome - malabsorption of vitamins + minerals. Can be temporary. Diarrhoea + weight loss, malnutrition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

At what level of small bowel loss does short bowel syndrome usually occur?

A

When there is <2m left of 6.1m short bowel left

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Risk factors for anastamotic leaks? Split into 3 groups

A

Patient (smoker, diabetes, PVD, steroid use, malnutrition/anaemia). Pathology (IBD, collagen disorders, autoimmune disease). Procedural (tension across anastamosis, local infection, inadequate blood supply to cut ends, location low rectal more than right colon more than small bowel)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are POSSUM and P-POSSUM? Stand for and use?

A

Validated scoring systems used to inform on risk of operative intervention by giving 30 day morbidity + mortality estimates. Stand for Physioloical and Operative Severity Score for the enUmeration of Mortality and Morbidity, (Portsmouth). 12 physiological and 6 operative variables.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Other than emergency, how can anastamotic leak presesnt post op?

A

Indolently with prolonged ileus, vague abdo pain, low grade temp + tachy.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Management of localised minor anastamotic leak?

A

NG tube + bowel rest, CT and/or water soluble enema. Antibiotics and drainage of collections

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Cause of acidosis + deranged LFTs in patient post-op from liver resection?

A

Portal vein thrombosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Management of basal atelectasis? Role of antibiotics?

A

Oxygen titrated to saturations, chest physiotherapy, coughing/deep breathing. Antibiotics only indicated if signs and symptoms present; not prophylactically although patients are at higher risk

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

General factors implicated in development of post-op atelectasis?

A

General anaesthesia (surfactant dysfunction, poor ventilation of basal alveoli), post-op immobility (poor ventilation)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Specific incision-related contributing factor to post-op atelectasis?

A

Large incisions e.g. subcostal discourage deep breathing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

4 causes of post-op hyponatraemia?

A

Post-op SIADH, inappropriate crystalloid administration, drugs, post-op ileus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Causes of rising PT in post-op liver resection patient?

A

Vit K deficiency OR synthetic liver dysfunction e.g. post-hepatectomy liver failure or small-for-size syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Stages of haemorrhagic shock in relation to blood loss and clinical sking/symptoms?

A

Stage 1 - less 15%, normal
Stage 2 - 15-30%, tachy, narrow pulse pressure
Stage 3 - 30-40%, tachy, hypotensive
Stage 4 - more 40% (2000ml), anuric, hypotensive

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Management of hyperkalaemia?

A

Calcium gluconate 10mls 10%
Insulin dextrose 10 units 50mls 50%
Neb salbutamol
Serial measurements + cardiac monitoring

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

4 indications for dialysis in AKI?

A

Refractory hyperkalaemia
Refractory pulm oedema/overload
Severe metabolic acidosis
Uraemic encephalopathy/pericarditis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Difference between haemofiltration and haemodialysis?

A

Haemofiltration uses pressure of fluid across semipermeable membrane, hydrostatic pressure driving molecules into ultrafiltrate which is discarded + replaced. Haemodialysis used diffusion of molecules across membrane using dialysing fluid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

2 scoring systems for AKI?

A

RIFLE (Risk, injury, failure, loss, end stage), AKIN (stage 1,2,3)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Definition of oliguria?

A

<400mls urine/24 hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

5 differentials for post-op orthopaedic leg swelling?

A

DVT, post-op haemarthrosis/oedema, infection, lymphoedema, fracture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Clinical features of DVT using Wells score?

A

Active cancer; paralysis/immobilisation of lower limb; bedridden for 3 days or 12 weeks major surgery; tenderness along distribution of deep venous system; entire leg swollen; calf swelling >3cm larger than other size; pitting oedema; collateral superficial veins; prev DVT; alternative less likely

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

If DVT likely on Wells?

A

D dimer, duplex US within 4 hours (or therapeutic LMWH + scan within 24 hours), scan repeated at 1 week if d dimer pos scan neg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

If DVT unlikely on Wells

A

D dimer + scan if positive, rule out if negative

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

4 differentials for post op tonsillectomy pain + bleeding?

A

Post-tonsillectomy bleed secondary to lack of haemostasis
Not eating/drinking post op
Infection (less likely within 48 hours)
Alternative source e.g. haemoptysis/UGI bleed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

How would you stop tonsillar bleeding in first instance?

A

Examine tonsillar fossa for fleeding points. Use local anaesthetic spray with adrenaline and try to cauterise bleeding vessels with silver nitrate stick

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

What if no clear bleeding vessel in tonsillar bleed?

A

Gargle hydrogen peroxide 3% diluted 1:4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

What if a post op patient has had a small tonsillar bleed?

A

Admit for obs - can herald a larger bleed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

If more than 48 hours post op (e.g. 5-9 days), what is the most likely cause of tonsillar bleed?

A

Secondary bleed - infection, also made worse by patient not E+D post op to clear slough

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Management of paraphimosis?

A

Analgesia, attempt manual reduction, urology if unable

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

How to manually reduce paraphimosis?

A

Clean + drape, PPE. Glans and foreskin compressed to reduce swelling, thumbs on glans and fingers to reduce phimotic band

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

How does paraphimosis occur?

A

Prepuce is retracted proximal to corona of glans, causing constricting ring (phimotic band) which cuts off lymphatic and venous return. Swelling occurs and this worsens obstruction, worsening congestion and oedema.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Sequalae of paraphimosis?

A

Ischaemia necrosis and autoamputation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Regional local anaesthesia for paraphimosis?

A

Penile block to anaesthetise left and right dorsal penile nerves (10+2 o clock) or circumferential approach. DO NOT USE ADRENALINE as vasoconstrics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

2 other non-op methods for reducing paraphimosis?

A

Bathe in concentrated dextrose (osmosis); Dundee technique to puncture prepuce and allow drainage, manually reduce

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Differentials for UGI bleed?

A

Varices, Mallory Weiss tear, ulcer, cancer, vessel, gastritis/oesophagitis/duodenitis, drugs, bleeding disorders etc

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

What impact does PPI have on UGI bleed?

A

Reduces rebleeding risk and need for surgery, but not mortality in PUD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Risk stratification to predict rebleeding risk and mortality in UGI bleed? What does it involve?

A

Rockall - pre- and post-endoscopy factors incl age, pulse, BP, comorbidities, endoscopy diagnosis and signs of blood in GI tract

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Indications for surgery in UGI bleed?

A

Severe despite transfusion of 6 (over 60) or 8 (under 60) units of blood, or if uncontrollable bleeding at endoscopy, rebleeding or high rockall scores

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Where do varices most commonly occur?

A

Lower oesophagus, also greater curvature of stomach and rectum (and caput medusae)

47
Q

What medication is used in variceal bleeding to reduce death risk?

A

IV terlipressin

48
Q

Endoscopic management of varices?

A

If unable - sengstaken blakemore. If not, banding or sclerotherapy

49
Q

2 first line methods of reducing risk of variceal rebleed?

A

Beta blockers, repeat endoscopic band ligation

50
Q

For patients with UGI secondary to varices who are resistant to band therapy, what is another surgical option?

A

TIPSS (transjugular intrahepatic portosystemic shunt) - connects portal and hepatic veins in the liver

51
Q

What is the rule of 3 for dilated bowel loops on AXR?

A

More than 3cm for small bowel, 6cm for large bowel, 9cm for caecum = distended

52
Q

What is the utility of water soluble contrast in ?obstruction?

A

Mild therapeutic benefit, determining level of obstruction

53
Q

What abnormal gas patterns indicate bowel perf on erect CXR and AXR?

A

Erect chest - air under diaphragm. AXR - Riglers sign = air both sides of bowel wall

54
Q

Usual management for a sigmoid volvulus?

A

Pass rigid sigmoidoscope in lateral position to decompress, monitor for ischaemia/necrosis. Flatus tube

55
Q

Usual patients who get sigmoid volvulus?

A

Elderly patients with chronic consiptation, poor mobility and comorbidities

56
Q

Causes of large bowel obstruction?

A

Constipation, hernias, adhesions, tumours, volvulus. Less commonly intussusception (kids), gallstone ileus, Crohns, strictures (e.g. diverticular), foreign body

57
Q

Causes of small bowel obstruction?

A

Adhesions, hernias, Meckels diverticulum, ileus, strictures, Ca

58
Q

Management of suspected bowel obstruction?

A

ABCDE, NBM + NGT, IVT, analgesia/antiemetic, CT abdo/pelvis

59
Q

3 types of nec fasc?

A

1 - polymicrobial. 2 - GAS +/- staph. 3 - clotridium perfrinigens (gas gangrene)

60
Q

What may happen when area of nec fasc is incised?

A

Dishwater fluid, pus, necrotic tissue, positive finger sweep test

61
Q

Intraop findings of nec fasc?

A

Necrotic tissue, fascial oedema, vessel thrombosis, dishwater fluid/pus

62
Q

3 risk factors for developing nec fasc?

A

Immunocompromise, postsurgical, trauma e.g. IVDU/burns/lacs

63
Q

Contraindications for skin grafting?

A

Fitness for surgery, local wound factors e.g. vascularity, oxygenation, presence of necrotic tissue, positive organism growth

64
Q

3 groups of differentials for female with RIF pain?

A

Gen surg - appendix, Meckels diverticulitis, perforation. Gynae - ovarian torsion, ectopic, PID. Urological - UTI, renal stone

65
Q

3 eponymous signs in appendicitis?

A

Rosvings, obturator, psoas sign

66
Q

5 complications of appendicitis?

A

Chronic appendicitis, sepsis, abscess, perf, death

67
Q

Why is appendicitis managed surgically first line? vs acute cholecystitis?

A

Appendix supplied by appendicular branch of ileocaecal artery which is an end artery. This can thrombose and become gangrenous with perforation. Gallbladder supplied by both cystic artery and right hepatic artery so has collateral.

68
Q

Consent forms 1-4?

A

1 - adult consenting to treatment or procedure with capacity to do so.
2 - parent on behalf of child
3 - no conscious impairment e.g. under local
4 - lacks capacity - needs 2 senior clinicians, best interest, next of kin ideally

69
Q

5 differentials for loin pain in elderly person?

A 
AAA
Pyelonephritis
Renal colic
Diverticulitis
Gynae
70
Q

RFs for AAA?

A

Vascular risk factors, CTDs, male

71
Q

3 indications for AAA surgery?

A

Symptomatic (back or abdo pain), diameter over 5.5cm, growth over 0.5cm in 6 months

72
Q

Aggressive fluids in ruptured AAA? Yes or no?

A

Permissive hypotension; not necessarily

73
Q

Management for unruptured AAAs?

A

Conservative (lifestyle), medical (vasc RFs), surgical (open/endovascular)

74
Q

Difference between true and false aneurysms?

A

True = dilatation of artery that involves all 3 layers of artery wall, false e.g. pseudoaneurysm is communication of blood between layers of artery wall and lumen without dilatation of all 3 layers

75
Q

Screening for AAAs?

A

Males age 65 - USSS. Depending on size, discharge vs monitoring vs vascular surgeon

76
Q

Where are most AAAs?

A

Infrarenal (95%)

77
Q

5 differentials for acute lower limb pain?

A

DVT, acute limb ischaemia, fracture/MSK, compartment syndrome, gout

78
Q

What are the 3 components of a normal doppler waveform?

A

Multiphasic, pulsatile and regular amplitude

79
Q

Causes of acute limb ischaemia?

A

Acute thrombosis in situ (most common), embolic (AF, MI, heart valve, aneurysm, tumour, foreign body etc.) or other (trauma, popliteal aneurysm, dissection)

80
Q

Differentiating between embolic and thromotic acute limb ischaemia?

A

Timeframe, multiple sites, source of embolis, prev claudication, artery palpation (hard in throm, soft and tender in embolic), bruits (present in thromb), collateral flow

81
Q

Results of ABPI in relation to diagnosis?

A

Normal = over 0.7
Intermittent ischaemia 0.7-0.9
rest pain 0.3-0.7
critical ischaemia less than 0.3

82
Q

What does FAST scan stand for?

A

Focused Assessment with Sonography in Trauma

83
Q

Definition of massive haemothorax?

A

Drainage of over 1500mls when chest tube inserted or 200ml/hour for 2 hours

84
Q

Where do you insert a chest tube?

A

5th ICS, just ant to mid axillary line (triangle of safety)

85
Q

Bounds of triangle of safety?

A

Anterior border of latissimus dorsi posteriorly, lateral border of pectoralis major anteriorly, 5th ICSP inferiorly. Apex is axilla

86
Q

Differentials for acute groin pain and swelling in elderly patient?

A

Hernia (incarcerated/obstructed), lymphadenopathy, saphenous varix, lipoma, femoral aneurysm, psoas abscess, AAA

87
Q

Differentiating between small and large bowel loops on AXR?

A

Small - central, valvulae conniventes. Large - peripheral, haustra + taenia coli

88
Q

Most common hernias?

A

Direct inguinal

89
Q

In whom are indirect inguinal hernias most common?

A

Children

90
Q

In whom are femoral hernias most common?

A

Older women

91
Q

Definition and anatomical relations of a femoral hernia?

A

Abnormal protrusion of a peritoneal lined sac through the femoral canal, which runs medially to the femoral sheath and laterally to pubis. Contains fat and lymph node of Cloquet. Sheath contains NAV laterally

92
Q

6 differentials for acute epigastric pain?

A

AAA, pancreatitis, cholecystitis, bowel obstruction/perf, PUD, DKA

93
Q

3 major scoring systems for acute pancreatitis?

A

APACHE II, Glasgow, (modified), Ranson

94
Q

When and why would you request a CT for ?pancreatitis?

A

Not within first 48-72 hours of symptom onset unless acute severe. Prognosticate/stratify risk of necrosis. Also if older patient ?carcinoma

95
Q

5 complications of acute pancreatitis?

A

Chronic panc, necrosis (infection or sterile), ARDS, pseudocyst, haemorrhage

96
Q

When do you score for pancreatitis?

A

Admission and 48 hours with Glasgow scoring

97
Q

When do local complications of pancreatitis (necrosis, pseudocyst) generally occur?

A

Around 10-12 days of acute event

98
Q

What investigation can be useful in assessing for cause of pancreatitis?

A

Abdo USS ?gallstones

99
Q

Definitive treatment for gallstone pancreatitis and alternative if unfit for surgery?

A

Cholecystectomy; or ERCP + sphincterotomy

100
Q

8 differentials for testicular swelling?

A

Torsion, epididymo-orchitis, varicocoele, hydrocoele, testicular tumour, hernia, epididymal cyst, mumps

101
Q

Broadly different types of testicular tumour?

A

Seminoma vs non seminoma GCTs e.g. teratoma

102
Q

4 RFs for testicular cancer?

A

FHx, Klinefelters, downs, cryptorchidism

103
Q

Surgical approach to orchidectomy for cancer? Why?

A

Inguinal - vs scrotal - because allows cross clamping of spermatic cord to prevent dissemination of cancer cells along lymphatics, and allowing ligation of lymphatics as high as possible

104
Q

What is the blood supply to the femoral head?

A

Trochanteric anastamosis formed by medial and lateral circumflex arteries and superior gluteal artery. Small supply from artery of ligamentum teres and medullary canal

105
Q

Why is surgery required quickly in an intracapsular femur injury in under 65 patient?

A

Preserve blood supply to femoral head as hip replacement will likely need revision in later life

106
Q

What is the difference between a closed, intracapsular femur injury in a 45 vs 85 year old?

A

Goal in 85 year old is to restore mobility with weight bearing as tolerated and minimize associated complications. In a 45 year old goal is to preserve femoral head (avoiding osteonecrosis) and achieve union, to avoid arthroplasty.

107
Q

Surgery for closed intracapsular femur fracture in 45 y/o patient?

A

Anatomic reduction and stable internal fixation e.g. cannulated screws or DHS

108
Q

Post-op management for young patient with hip fracture?

A

Non or partial weight bear for 6 weeks to facilitate healing

109
Q

Guidelines for intracapsular fractures in elderly patients? Summary?

A

NICE/BOA - operate with aim to fully weight bear immediately post op, replacement arthroplasty if displaced intracapsular, THR sometimes, cemented hemi if not, orthogeri review

110
Q

3 conditions for giving THR for elderly intracapsular hip fracture?

A

Walk independently before, not cognitively impaired, medically fit for anaesthetic

111
Q

What is the alternative for intracapsular hip fractures to THR if patient doesnt fill criteria?

A

Cemented hemiarthroplasty

112
Q

When would you use a DHS for hip fracture?

A

Extracapsular, pertrochanteric OR young intracapsular

113
Q

When would you use an IM nail for hip fracture?

A

Extracapsular, subtrochanteric

114
Q

How long do THRs typically last prior to loosening?

A

15-20 years

Surgery Notes (1 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions