Essential Examination 2nd Edition: SURGERY Flashcards
(92 cards)
1
Q
Differential Diagnosis for Palmar Erythema
A
- Rheumatoid Arthritis
- Chronic Liver Disease
- Hyperthyroidism
- Pregnancy
2
Q
DDx of Fixed Flexion deformity in fingers seen in prayer position
A
- RA
- Scleroderma
- Dupuytren’s Contracture
- Osteoarthritis
3
Q
DDx of Dupuytren’s Contracture
A
- CLD
- Diabetes
- Heavy Labour
- Phenytoin
- Trauma
- Familial
4
Q
Where to test median nerve sensation on hand?
A
Lateral aspect of index finger
5
Q
Where to test ulnar nerve sensation on hand?
A
Medial aspect of little finger
6
Q
Where to test radial nerve sensation on hand?
A
Anatomical snuff box
7
Q
How to test median nerve motor power on hand?
A
Thumb ABduction
8
Q
How to test ulnar nerve motor power on hand?
A
Index finger ABduction
9
Q
How to test radial nerve motor power on hand?
A
Finger Extension
10
Q
Present a classic RA hand examination
A
There is a symmetrical deforming polyarthropathy affecting the small joints of the hands in a rheumatoid pattern.
The most common differentials for this clinical picture are rheumatoid arthritis and psoriatic arthropathy.
11
Q
What does Deltoid muscle wasting indicate?
A
Axillary Nerve Palsy
12
Q
What does winging of the scapular indicate?
A
Long thoracic nerve palsy
13
Q
Normal Shoulder Flexion
A
180
14
Q
Normal Shoulder Extension
A
60
15
Q
Normal Shoulder External rotation with arms flexed to 90
A
70
16
Q
Normal Shoulder ABduction
A
180
17
Q
Possible Procedure for End Colostomy
A
Abdominal-Perineal (AP) Resection
Hartmann’s procedure with rectum oversewn
Ask pt if still have a back passage
No= AP resection for low rectal tumour
Yes= Hartmann’s procedure for higher tumour
18
Q
Possible Procedure for End Ileostomy
A
Panprotocolectomy (e.g. UC, FAP)
Emergency subtotal colectomy
19
Q
Possible Procedure for Loop Ileostomy
A
To defunction
20
Q
Possible Procedure for Loop Colostomy
A
(Now rarely performed)
To defunction the bowel
21
Q
Possible Procedure for End Colostomy and mucous fistula
A
Hartmann’s procedure with rectum brought to the skin
22
Q
Possible Procedure for Urostomy
A
Cystetomy
23
Q
What is the ideal site for a stoma?
A
- Healthy Skin
- Away from umbilicus and belt line
- Avoiding- Boney prominances, scars and skin creases
24
Q
What are the complications of a Stoma
A
- Haemorrhage
- Necrosis
- Prolapse
- Retraction
- Obstruction
- Peristomal skin inflammation
- Parastomal hernia
- High Output
25
What is the triple assessment of a breast lump?
1. Clinical Examination
2. Imagine (Mammography/USS)
3. Fine Needle Aspiration
26
What is the implication of breast dimpling?
Can imply invasion of cancer into underlying musculature
But an intra-mammary tumour can pull on a 'ligament of astley cooper' causing dimpling of the skin- the action of raising your arms above your head accentuates this.
27
Why are varicoceles more common on the left hand side?
The right spermatic vein drain into the inferior vena cava. It has a short, direct course so there is a lower incidence of vascular pathology.
The left spermatic vein drains into the left renal vein. iT is a long and torturous course. Valves are often absent or incompetent.
Rarely, the Left spermatic vein can be obstructed by a renal ca which is why a new diagnosis left varioceoele requires an abdominal USS to exclude.
28
Causes of Chronic Venous Insufficiency
1. Valvular incompetance of deep veins (90%)
- Primary (seem RF as varicose veins)
- Secondary (damaged by DVT)
2. Obstruction of Deep veins by DVT (10%)
N.B Chronic venous insufficiency secondary to DVT is POST THROMBOTIC SYNDROME
29
What is Superficial Thrombophlebitis?
Inflammation and Thrombosis almost invariably occuring in varicose veins.
Redness and tenderness follow line of vein
Thrombosis may spread to deep system and cause DVT
Mx
Analgesia, Support Stockings and active exercise and underlying vein often removed as recurrence is common.
Propagation towards deep veins is an indictio for IV heparin
30
Features of a Diabetic Foot
Peripheral Neuropathy
- Loss of ankle jerk and vibration sense
- Accidental injury/ tissue damage
- Charcot's joints (neuropathic arthropathy)
Large Vessel Arterial Disease
Small Vessel arterial disease
Autonomic neuropathy
- Reduced sweating
- Dry Cracked Skin
- Infection
31
Typical Features of an Arterial Ulcer
```
Classically on feet/ between the toes and the ankle (lateral maleolus)
Punched out edges
Painful
May have trophic changes/ gangrene
Not very much exudate.
```
MANAGEMENT
32
What is Leirche's Syndrome?
Bilateral buttock pain and erectile impotance due to common iliac disease
33
Definition of a Hernia
The protrusion of all or, more commonly part of a viscus through an opening in its containing cavity into a place where it is not normally found.
34
Features of Active Inflammed Joints
Red
Hot
Swollen
Tender
35
Features of active Rheumatoid Arthritis
Inflammed Joints (Red, Hot, Swollen, Tender)
Pain on passive movement
Increased duration on morning stiffness
Raised ESR
Anaemia (of Chronic Disease/ Iron deficiency due to NSAID gastritis or peptic ulcers/ aplastic anamia due to DMARDs/ macrocytic anaemia due to methotrexate)
36
Extra-articular features of RA
General: Malaise, Lethargy, Low Grade Fever, Wt Loss
Eyes: Episcleritis, Scleritis, Sjogrens, Keratoconjunctivitis sicca
Cardiac: Pericarditis/ Pericardial Effusions
Respiratory: Pleural effusions, Rheumatoid Nodules, Pulmonary Fibrosis, Pneumoconiosis (Caplan's Syndrome)
Urinary: Renal Amyloid
Neurology: Carpal Tunnel, polyneuropathy, atlanto-axial subluxation
Blood: Anaemia, Decreased WCC (+ Splenomegaly= Feltys)
37
RA X Ray
```
Loss of Joint Space
Bony Erosions
Periarticular osteoporosis
Deformity (e.g Subluxation)
Soft Tissue Swelling
```
38
OA X Ray
```
Loss of Joint Space
Osteophyte Formation
Subchondral Cysts
Subchondral Sclerosis
Deformity
```
39
Presentation of Psoriatic Arthritis
```
Asymmetrical Oligoarthritis
Lone DIP disease
Rheumatoid Pattern
Arthritis Mutilans
Sacroilitis
```
40
What is Sjogrens Syndrome?
```
Dry eyes (Keratoconjunctivitis sicca), dry mouth (xerostomia) and parotid gland enlargement.
May occur independently or associated with RA, SLE or Scleroderma
```
41
Side Effects of all DMARDS
Marrow Suppression
Hepatotoxicity
Rash
GI upset
42
Side Effects of Methotrexate
Pneumonitis and Pulmonary Fibrosis
Megaloblastic Anaemia
Marrow Suppression
Hepatotoxicity
Rash
GI upset
43
SE of Hydroxychloroquine
Retinopathy
Marrow Suppression
Hepatotoxicity
Rash
GI upset
44
SE of Sulfasalazine
Oligospermia
Marrow Suppression
Hepatotoxicity
Rash
GI upset
45
SE of IM Gold
Nephrotic Syndrome
Marrow Suppression
Hepatotoxicity
Rash
GI upset
46
SE of Penicillamine
Nephrotic Syndrome
Altered Taste
Myasthenia Gravis Like Syndrome
Marrow Suppression
Hepatotoxicity
Rash
GI upset
47
SE Ciclosporin
Renal Impairment
HTN
Gum Hypertrophy
Marrow Suppression
Hepatotoxicity
Rash
GI upset
48
Shoulder Apprehension Test
Testing for Shoulder Instability
Young Pts with Previous Dislocation
(How for now position. Stabalise pts elbow with one hand,, force external rotation by pushing downwards and back on hand)
Apprehensive reaction = positive test
If positive apply posterior pressure at front to see if relieves apprehension (realignment test)
49
Hawkins Test
Testing for Impingement Syndrome
Middle Aged Patients
Flex shoulder and elbow to 90, internally rotate shoulder
Pain in shoulder is a positive test
50
Jobes Test
Rotator Cuff Injury: Supraspinatus
Straight arm ABducted to 90 thumb pointed at floor.
"Keep your arm up, don't let me push it down"
Pain/ Difficulty= Positive Test (DDx Impingement may also give pain)
51
Gerbers Test
Lift off Test
Rotator Cuff Injury: Subscapularis
52
How to test Teres Minor and Infraspinatus
Resisted external rotation (Apply inwards pressure to hands)
Rotator Cuff Injury Teres Minor and Infraspinatus
53
Shoulder Instability
Usually Young Patient
Previous Dislocations
SHOULDER APPREHENSION TEST
54
Inpingement Syndrome
Usually Middle Aged
HAWKINS TEST
55
Rotator Cuff Tear
Usually Older Pt "Grey Hair Cuff Tear"
Supraspinatus: Anteriorsuperior cuff: Jobe's Test
Subscapularis: Anteriorinferior cuff: Gerbers Lift off test
Teres Minor and Infraspinatous: Inferior Cuff: Resisted External Shoulder Rotation
56
Underlying Pathology of Impingement Syndrome
Also Known as Painful Arc Syndrome
Underlying pathology is Supraspinatous Tendoitis
57
Painful Arc
Classical sign of Supraspinatous tendonitis
Pain during abduction: 60-120
Due to impingement of the underside of the acromion on the inflamed tendon
58
Complications of Anterior Dislocations of Shoulder
Axillary Nerve Damage
Brachial Plexus/ Other Nerve Damage
Axillary Artery Damage
Associated Fracture (30% of cases- humeral head, clavicle, acromion)
Recurrent Shoulder dislocation
Anatomical Lesion (Bankart or Hill-Sachs)
Rotator Cuff Injury
59
Definition of a Hernia
Protrusion of whole or part of a viscus through an opening in the wall of its containing cavity into a place where it is not normally found.
60
What does para umbilical Hernia go through?
Linea Alba (Usually just above umbilicus)
| It should always be repaired as high risk of incarceration
61
What does true umbilical Hernia go through?
Umbilicus. Usually resolve later in life- should repair if persists at 3yrs
62
What does Epigastric Hernia go through?
Linea Alba in epigastrium
| More common in thin people
Usually repaired as medium risk of incarceration
63
What does Spigelian Hernia go through?
Through linea semilunaris at outer border of rectus sheath
| It should always be repaired as high risk of incarceration
64
What is Divarication of the Rectus?
Not actually a hernia
| Weakness of Linea Alba leads to bulge in epigastrium.
65
Differential Diagnosis of In Intradermal Lump
Unable to move skin above it
Sebaceous Cyst
Abcess
Dermoid Cyst
Granuloma
66
DDx of a subcutaneous Lump
Skin can slide above
Lipoma
Ganglion
Neurofibroma
Lymph Node
67
Signs of Infection
```
Heat
Pain
Redness
Swelling
Loss of Function
```
68
Ganglion
Degerative cyst from synovium of joint/ tendon
Dorsum of Hand/ Wrist or Dorsum of Foot
Subcutaneous
Moves with the tendon
May tranilluminate
69
Mx of Ganglion
50% disappear on own.
Aspirate
Excision
70
Sebaceous Cyst
Epidermal proliferation within dermis
can occur anywhere on body. (Common: Trunk, Neck, Face and Scalp)
Intradermal
Central Punctum
Commonly gets infected
71
Mx of Sebaceous Cyst
Incision and Drainage if infected
Occasionally Abx needed
Non-infected cysts can be shelled out under LA
72
Lipoma
Benign fatty tumour
occurs anywhere fat can expand (NOT PALMS OR SOLES)
Subcutaneous
Smooth, fluctuant
May cause symptoms secondary to pressure affects.
73
Mx of Lipoma
Conservative
| May excise for cosmetic reasons or local pressure effects.
74
DDx Erythema Nodosum
Pg 103
75
DDx of scrotal Swelling
Tumour
Hydrocele
Epididymal Cyst
Varicocele
76
Ix Scrotal Swelling
USS
Aspiration of Fluid
Tumour Markers (AlphaFetoprotein, Beta HCG)
77
Lymphatic Spread of Testicular tumours
Lungs and Liver
78
Tx Testicular Tumours
Seminoma: Highly RADIOSENSITIVE: 95% 5 year survival
Teratoma: Chemotherapy: 75% 5 Year Survival
79
Management of Varicose Veins
Conservative:
Elastic supposrt hose, wt loss, exercise, avoid prolonged standing
Medical: Injection Scleroterapy
Suitable for small varices below the knee. Not SFJ incompetance.
Surgery:
Junction ligated. If LSV then can strip vein but not if Short due to risk of damaging Sural Nerve
Do stab avulsions of remaining varices.
Can also do US guided foam sclerotherapy
Radiofrequency or laser obliteration of LSV/SSV
80
What is a Saphena varix?
Bluish lump in groin at SFJ secondary to incompetance.
81
Signs of Progessive Chronic Venous Insufficiency
In order of progression
1. Oedema
2. Venous Eczema
3. Haemosiderosis
4. Lipodermatosclerosis
5. Atrophie Blanche
6. Ulceration
82
What is Haemosiderosis?
Brown, Speckled discolouration "Cayenne Pepper Petechiae"
| Especially in medial gaiter area
83
What is lipodermatosclerosis?
Scarring of SC fat
| Skin tight and indurated- hard and woody feeling
84
Perthes Test
Patient stands
Examiner applies a Tourniquet below the knee
Patient completes 10 heel raises
Varicose Veins empty: Reflux site is above the Tourniquet
Varicose Veins remain distended: Reflux site is below the Tourniquet
85
Trendelenberg Test (Venous) Interpretation
No filling on standing and rapid filling on release of tournique: Isolated SFJ incompetence
Slow filling on standing and rapid filling on release: Mixed SFJ and perforating vein incompetance
86
Causes of claudication in presence of normal peripheral pulses
1. Neurogenic
2. Beta Blockers
3. Anaemia
87
Critically Ischaemic Limb
6 Ps
```
Pale
Pallor
Pulseless
Perishingly Cold
Parasthesia
Paralysis
```
88
ABPI measurements
1 Normal
0.5-1: Intermittant claudication
0.3-0.5: Critical limb ischamia/ rest pain
<0.3: Gangrene and ulcers
89
Arterial Supply to lower limbs
Common Iliac branches to internal and external iliac
External iliac passes inguinal ligament and becomes common femoral
Common femoral branches into deep and superficial femoral
Superficial femoral becomes popliteal artery and then trifercates into the anterior tibial (--> dorsalis pedis), the posterior tibal and the peroneal arteries.
90
What is Leriches syndrome
Bilateral buttock pain and errectile impotence due to common iliac disease
91
Venous vs Arterial Ulcers
page 91
92
DO PAGE 88-89
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