Finals Medicine Surgery

Question 0

Managing hyper kalmia

Answer 0

10ml 10% calcium chloride/gluconate over 5-10 min
Insulin/glucose infusion
Salbutamol
Calcium resinous
Identify and manage underlying cause

Question 1

Hyperkalemia on ECG

4 features

Answer 1

Tall tented T wave
QRS a complex broaden
PR prolonged
P wave flattened

Question 2

Wolf Parkinson white syndrome

Answer 2

Delta wave (characteristic slurred up slope)
(Pre-excited AF sometimes)
PR short
(Accessory pathway: bundle of Kent)

Question 3

ECG changes of ACS (chronological)

Answer 3

Normal
Peaked T wave
ST segment elevation 
Q wave formation and loss of R wave (anterior chest leads)
T wave inversion

Question 4

4 criteria for STEMI/Emergency re perfusion

Answer 4

2 mm ST elevation in 2 or more contiguous chest leads
1 mm ST elevation in 2 or more limb leads of same territory
New LBBB or LBBB in clinical MI
True posterior MI

Question 5

RV hypertrophy on ECG

Answer 5

R axis deviation
Dominant R wave in lead V1
Inverted T waves spreading from right side of the heart

Question 6

Axis deviation

Answer 6

Look at I and avF
If away from each other then L axis deviation
If towards each other then R axis deviation if both positive then normal

Question 7

IE bacteria

Answer 7

Strep
Staph
HACEK
The HACEK organisms are a group of fastidious Gram-negative bacteria that are an unusual cause infective endocarditis (IE), which is an inflammation of the heart due to bacterial infection.[1] HACEK is an abbreviation of the initials of the genera of this group of bacteria: Haemophilus, Aggregatibacter (previously Actinobacillus), Cardiobacterium, Eikenella corrodens, Kingella.[1] The HACEK organisms are a normal part of the human flora, living in the oral-pharyngeal region.[2]

Question 8

Causes of dominant R wave in V1/V2

Answer 8

Posterior MI
PE
RBBB
RVH

DUchenne muscular dystrophy
Dectrocardia
WPW

Question 9

Why is it important to diagnose posterior MI?

Answer 9

Posterior MI can cause back pressure and raise JVP.
Usually when we see JVP elevation, we tend to give diuretics because we think it’s R heart failure. However diuretics can be fatal for posterior MI as we’re decreasing the preload, ie stretching… (Sterling law)

Question 10

Mesenteric ischemia (classic triad)

Answer 10

GI emptying
Abdo pain
Underlying cardiac disease

Question 11

JVP waves

Answer 11

http://youtu.be/cLETr8qmXPQ

Question 12

How to differentiate a jugular venous pulse from the carotid pulse

Answer 12

JVP:
Not palpable.
Obliterated by pressure.
Characterised by a double waveform.
Variable with respiration - it decreases with inspiration.
Enhanced by the hepatojugular reflux

Question 13

Waveforms of JVP

Answer 13

Waves[2][3][4]
a - presystolic; produced by right atrial contraction.
c - bulging of the tricuspid valve into the right atrium during ventricular systole (isovolumic phase).
v - occurs in late systole; increased blood in the right atrium from venous return.
Descents
x - a combination of atrial relaxation, downward movement of the tricuspid valve and ventricular systole.
y - the tricuspid valve opens and blood flows into the right ventricle.
The a and v waves can be identified by timing the double waveform with the opposite carotid pulse. The a wave will occur just before the pulse and the v wave occurs towards the end of the pulse. Distinguishing the c wave, x and y descents is an almost impossible task.

Question 14

Causes of raised jugular venous pressure

Answer 14

Heart failure.
Constrictive pericarditis (JVP increases on inspiration - called Kussmaul’s sign).
Cardiac tamponade.
Fluid overload, eg renal disease.
Superior vena cava obstruction (no pulsation).

Question 15

Abnormalities of jugular venous pressure

Answer 15

Abnormalities of the a wave: disappears in atrial fibrillation.

Large a waves occur in any cause of right ventricular hypertrophy (pulmonary hypertension and pulmonary stenosis) and tricuspid stenosis.

Extra large a waves (called cannon waves) in complete heart block and ventricular tachycardia.

Prominent v waves

Tricuspid regurgitation - called cv or v waves and occurring at the same time as systole (a combination of v wave and loss of x descent); there may be earlobe movement.

Slow y descent
Tricuspid stenosis.
Right atrial myxoma.

Steep y descent
Right ventricular failure.
Constrictive pericarditis.
Tricuspid regurgitation.
(The last two conditions have a rapid rise and fall of the JVP - called Friedreich's sign.)

Question 16

Austin-flint murmur

Answer 16

soft mid-diastolic rumble heard at the apical area. It appears when regurgitant jet from the severe aortic insufficiency renders partial closure of the anterior mitral leaflet.(in similar way to MS)

Question 17

AR signs

Answer 17

large-volume, ‘collapsing’ pulse also known as: Watson’s water hammer pulse

Corrigan’s pulse (rapid upstroke and collapse of the carotid artery pulse)
low diastolic and increased pulse pressure

de Musset’s sign (head nodding in time with the heart beat)

Quincke’s sign (pulsation of the capillary bed in the nail; named for Heinrich Quincke)

Traube’s sign (a ‘pistol shot’ systolic sound heard over the femoral artery; named for Ludwig Traube)

Duroziez’s sign (systolic and diastolic murmurs heard over the femoral artery when it is gradually compressed with the stethoscope)

Question 18

Drugs not to be used in severe AS

Answer 18

Nitrates (risk of syncope)

Question 19

TAVI

Answer 19

Transcatheter aortic valve implantation

Question 20

AF definition

Answer 20

Uncoordinated and disordered contraction of atria at fast rate which leads to initiation of ventricular contraction through the AV node at varying intervals… Thus leading to an irregularly irregular pulse

Question 21

NY Heart Association classification of HF

Answer 21

I Cardiac disease, but no symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc.

II Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.

III Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20–100 m).
Comfortable only at rest.

IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.

Question 22

What sign is pathognomic of HF?

Answer 22

3rd heart sound

Question 23

Most common causes of HF in UK

Answer 23

CAD
HTN
Alcohol
Valvular disease

Question 24

Lifestyle modifications in HF?

Answer 24

Smoking Alcohol Salt intake Limit fluid intake (<2L)

Question 25

TTT of HF

Answer 25

ACEI/ARB Betablockers Spironolactone/eplerenone Diuretics for fluid overload but don't impact prognosis

Question 26

Other ttt for HF

Answer 26

Revascularisation if CAD Bi ventricular pacemaker /defibrillator if dysynchrony Transplantation LVAD

Question 27

Symptoms of IE

Answer 27

Lethargy Fever Night sweats Less common: New heart failure Embolic phenomena (stroke)

Question 28

IE on examination

Answer 28

New murmur Splenomegaly Embolic phenomena (splinter hges, osler's nodes, janeway lesions, petechiae Evidence of aetiology: IVDA, infected cannula, recent surgery

Question 29

Ix in IE

Answer 29

``` 3 blood cultures (different sites / different times) Echo (find vegetation) Baseline blood test (CRP) ECG Urine (hematuria) ```

Question 30

Transoesophageal Echo (TOE) vs TTE in IE

Answer 30

TTE (60% sensitive) vs TOE (90% sensitive)

Question 31

Dx of IE

Answer 31

Modified Duke criteria 2 major 1 major + 3 minor 5 minor Major criteria: 1) evidence of endocardial involvement with either vegetarians/abscess on echo or new murmur 2) typical microorganism from 2 separate blood cultures Minor criteria 1) predisposition (cardiac lesion/IVDU/line) 2) fever (>38) 3) vascular phenomena (arterial emboli) 4) immunological phenomena (glomerulonephritis) 5) echo abnormalities but no vegetation/abscess

Question 32

Surgical replacement of infected valve in IE: when?

Answer 32

Evidence of HF (caused by infected valve, abscess or collection) Heart block (caused by infection with virulent organisms unlikely to be cleared with antibiotics) Large vegetation at risk of embolisation Prosthetic valve endocarditis (always almost requires surgical Mx)

Question 33

Prognosis of IE

Answer 33

Mortality 20% Worse prognosis: prosthetic valve Embolic phenomena Staph aureus

Question 34

Causes of MR

Answer 34

Acute MR: from papillary muscule rupture or dysfct following MIA, perforation or valve leaflet during IE Chronic MR: Causes: Rh fever, mitral heart disease prolapse. Functional MR in HF

Question 35

Examination findings of MR

Answer 35

Pansystolic murmur ?third heart sound Apex beat displaced Basal creps + peripheral edema (HF)

Question 36

MS finding on ECG

Answer 36

Bifid P wave = P mitrale | Due to LA enlargement

Question 37

Surgical Mx of MS

Answer 37

PBMV: percutaneous balloon mitral valvotomy Mitral valve repair Mitral valve replacement

Question 38

Causes of TR

Answer 38

Rh heart disease Endocarditis (mainly IVDA) Carcinoid heart disease Most common: Dilation of RV (usually due to L heart failure, PHTN or RV infarct)

Question 39

Carcinoid heart disease

Answer 39

Carcinoid heart disease is common in patients with carcinoid syndrome, and occurs in up to 50% of these patients.iiiIt is characterised by right sided cardiac involvement, caused by plaque-like deposits of fibrous tissue which are thought to be caused by serotonin, via action on the 5HT2b receptoriv.These deposits are most commonly seen on valve cusps and leaflets, but can be anywhere in the cardiac chambers, and even in the pulmonary arteries or aorta. The left side of the heart is relatively protected, with the pulmonary circulation filtering out the majority of the serotonin produced by the tumour. Overt left sided disease has been described in patients with a patent foramen ovale, bronchial carcinoid and patients with very high levels of serotonin

Question 40

Signs in TR

Answer 40

Pansystolic murmur at L sternal edge Prominent systolic wave in JVP Pulsatile hepatomegaly (pathognomic)

Question 41

Carcinoid syndrome

Answer 41

Carcinoid tumour in GI tract or bronchi that secrete 5-HT. | 5-HT leads to flushing wheezing and diarrhea

Question 42

Cardiac causes of syncope

Answer 42

``` HAPE HOCM AS PE Atrial Myxoma ``` AF Heart block

Question 43

Patients who don't get classical chest pain

Answer 43

Elderly | DM

Question 44

Atypical presentation of MI (in DM and elderly)

Answer 44

SOB Syncope Sweating N&V

Question 45

Complications of MI

Answer 45

FAM Failure Arrhythmias (commonest VT/VF... DC cardioversion) Murmur (MR or VSD)

Question 46

Approach to systolic murmurs Chest pain...? Chest pain + palpitations...? Dizziness + chest pain...?

Answer 46

Chest pain...? AS Chest pain + palpitations...? Mitral Dizziness + chest pain...? AS

Question 47

Symptoms of AS

Answer 47

Syncope Angina Dyspnea

Question 48

Stenosis vs Sclerosis

Answer 48

Sclerosis: No radiation Normal pulse Normal in elderly

Question 49

Causes of malar flush

Answer 49

``` MS Pregnancy SLE Parvovirus Any hyperdynamic state (thyrotoxicosis) ```

Question 50

Graham steel murmur

Answer 50

Leakage of pulmonary valve... Pulmonary regurgitation... Early diastolic murmur

Question 51

Increased JVP a

Answer 51

``` R sided heart failure TR/TS SVC obstruction Heart block CCF ```

Question 52

When JVP elevated, how to differentiate between TR/TS and SVC obstruction

Answer 52

SVC obstruction is non pulsatile while TR/TS is

Question 53

VSD murmur

Answer 53

Usually asymptomatic in finals Very loud pansystolic murmur throughout precordium + thrill Murmur louder at sternal edge compared to apex Machinery like murmur

Question 54

Signs of previous CABG in exams

Answer 54

Midline sternotomy scar LIMA Legs (saphenous) Arms (radial artery)

Question 55

Prosthetic valve signs

Answer 55

Median sternotomy scar (no leg scar) Bruised skin (on warfarin) Audible clicks from end of bed Prosthetic first heart sound

Question 56

Complications of prosthetic valve

Answer 56

``` Failure (valve dehiscence) Infection Bleeding Anaemia (from anticoagulant, hemolytic anemia, secondary to IE) Theomboembolic ```

Question 57

CHA2DS2VASC

Answer 57

C Congestive heart failure (or Left ventricular systolic dysfunction) 1 H Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication) 1 A2 Age ≥75 years 2 D Diabetes Mellitus 1 S2 Prior Stroke or TIA or thromboembolism 2 V Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic plaque) 1 A Age 65–74 years 1 Sc Sex category (i.e. female sex) 1

Question 58

Electrolytes disturbance causingbTdP

Answer 58

Hypokalemia | Hypomagnesemia

Question 59

Bifascicular block

Answer 59

RBBB + LAD

Question 60

Trifascicular block

Answer 60

RBBB + LAD + 1st degree heat block

Question 61

WPW

Answer 61

AVRT (1% mortality vs 0% mortality in AVNRT)

Question 62

Definition of MI

Answer 62

Detection of rise or fall of cardiac biomarker (trop) + at least 1 of the following: - symptoms of ischemia - ST changes or new LBBB - pathological q waves - imaging evidence of new loss of viable myocardium or new regional wall motion abnormality

Question 63

Cardiac sounding chest pain

Answer 63

- constricting discomfort in front of chest, neck shoulders jaw or arms - precipitated by physical exertion - relieved by rest or GTN within about 5 min

Question 64

DD of chest pain

Answer 64

``` MS chest pain Pneumonic/pleuritic chest pain Pericarditic chest pain GORD/Gastric/Upper abdo Aortic dissection/AAA ```

Question 65

STEMI Definition & Management

Answer 65

Def: - ST elevation > 2 mm in anterior leads in 2 consecutive leads - or ST elevation 1 mm in 2 consecutive limb leads, - or new onset of LBBB Mx: - PAMI and CP<12h or pt still complaining of CP - far from PAMI then thrombolysis (streptokinase, alteplase, tinctplase) Post-reperfusion: - beta blockers - DAPT (dual antiplatelet therapy) 12 months - Statin high intensity - ACEI/ARB

Question 66

Mx of NSTEMI

Answer 66

``` MONAC (initially) Assess risk (GRACE score for risk of death/MIA) Start beta blockers, anti-coagulation, high intensity statin, ACEI/ARB ```

Question 67

Definition of HF

Answer 67

Abnormality of cardiac structure and or function leading to failure of the heart to deliver xylem at a rate equivalent to the requirement of the metabolising tissues. Clinically, typical symptoms are (SOB, swelling and oedema, fatigue) and signs (raised JVP, pulmonary crackles) resulting from abnormality of cardiac structure / fct

Question 68

HF types

Answer 68

- HFREF vs HFPEF (reduced vs preserved ejection fraction) - Acute vs chronic - left vs right - severity (NYHA grade I to IV)

Question 69

Causes of HF

Answer 69

- Myocardial disease: CAD, cardiomyopathy - Valvular heart disease - Pericardial disease - Endocardial disease - Arrhythmia - conduction disorder - high output status / volume overload / congenital HD

Question 70

Pathophysiology of HF

Answer 70

Pathological re-modelling of the ventricle with dilation and impaired contractility

Question 71

Signs of HF

Answer 71

``` SOB exertion Raised JVP Pulse abnormalities (irregular/ tachycardia) Murmur S3 gallop Displaced apex Pulmonary creps Hepatomegaly Oedema Ascites ```

Question 72

Digoxin ttt effects on ECG

Answer 72

Reduced wave amplitude ST segment depression Increased u wave amplitude Shortened QT interval

Question 73

Pleural tap Ix

Answer 73

Protein Glucose LDH Cell count, culture and microscopy cytology AAFB and culture if suspecting TB

Question 74

Ligth's criteria | Used when protein 25-35g/l or patients with abnormal serum protein Transudate < 30g/L Exudate > 30 g/L

Answer 74

Simultaneous measurement of pleural fluid and serum - pleural fluid protein/serum protein > 0.5 - pleural fluid LDH/serum LDH>0.6 - pleural fluid LDH>2/3 upper limit of normal Any criteria met... Effusion=exudate

Question 75

Causes of transudates

Answer 75

``` CCF Cirrhosis Hypoalbuminemia Nephrotic syndrome Hypothyroidism ```

Question 76

Causes of exudate

Answer 76

``` Infection (pneumonia) Empyema (pleural pH of <7.2 is highly suspicious) TB Neoplastic RA Trauma Sarcoidosis Pancreatitis Esophageal rupture ```

Question 77

CAP: typical and atypical bacteria

Answer 77

``` Typical: Strep pneumoniae H influenzae S aureus G- organisms ``` ``` Atypical: Mycoplasma pneumoniae Legionella Pneumophilia Chlamydia pneumoniae/psittaci ```

Question 78

CURB 65

Answer 78

Confusion +1 Blood Urea Nitrogen (BUN) > 19 mg/dL (> 7 mmol/L) +1 Respiratory Rate ≥ 30 +1 Systolic BP < 90 mmHg or Diastolic BP ≤ 60 mmHg +1 Age ≥ 65 +1 0-1: Treat as an outpatient 2-3: Consider a short stay in hospital or watch very closely as an outpatient 4-5: Requires hospitalization with consideration as to whether they need to be in the intensive care unit

Question 79

HAP causative organisms

Answer 79

G- Enterobacteria S Aureus Klebsiella

Question 80

Risk factors for aspiration pneumonia

Answer 80

Reduced GCS | Neurological conditions: stroke , bulbar palsies, MG, drug alcohol misuse

Question 81

Signs of CF

Answer 81

``` Underweight Cyanotic Finger clubbing Coarse crackles throughout both lung fields Wheeze ```

Question 82

Mx of CF

Answer 82

``` MDT approach Dietitian (malnutrition) Physio (postural drainage) Pancreatic enzymes supplements IV/nebulised antibiotics Bronchodilators Inhaled recombinant DNAase (improve FEV1) Lung transplant ```

Question 83

Causes of bronchioecstasis

Answer 83

Genetic (CF, Karatgener's, primary ciliary dyskinesia) Post-infective (pneumonia, TB) Post childhood infection (measles, pertussis) Bronchial obstruction (foreign body, tumour) Hypogammaglobulinemia Allergic bronchopulmonary aspergillosis AI disorders (RA)

Question 84

Risk factors for PE

Answer 84

``` Recent surgery (hip/knee, pelvic/abdo) Recent lower limb fracture Malignancy Recent hospitalisation Previous Hx of VTE Pregnancy Prolonged immobility Long-haul travel OCP ```

Question 85

Signs of PE

Answer 85

``` Breathlessness Pleuritic chest pain Cough Haemoptysis Clinical evidence of DVT Tachypnea Tachycardia Raised JVP Hypotension Raised JVP Pleural rub on auscultation ```

Question 86

ECG pattern in PE

Answer 86

Tachycardia Right heart strain/RBBB S1Q3T3 (large S wave in lead I, a large Q wave in lead III, and an inverted T wave in lead III)

Question 87

Definition of sarcoidosis

Answer 87

Multi-system disorder characterised by non-caseating granulomas. Aetiology unknown

Question 88

Sarcoidosis: Respiratory signs and symptoms

Answer 88

``` Breathlessness Chest pain Malaise / reduced exercise tolerance Cough - usually dry Low grade Pyrexia Bilateral hilar lymphadenopathy on CXR Lung fibrosis ```

Question 89

Sarcoidosis: non pulmonary manifestation

Answer 89

``` Erythema nodosum Lymphadenopathy Hypercalcemia Hepatosplenomegaly Lupus pernio Posterior or anterior uveitis Keratoconjunctivitis sicca Enlargement of parotid glands Neurosarcoidosis Cardiomyopathy/Arrhythmia Arthralgia ```

Question 90

Causes of interstitial lung disease

Answer 90

``` Idiopathic pulmonary fibrosis Hypersensitivity pneumonitis Sarcoidosis Pulmonary eosinophilia Coal workers pneumoconiosis Malignancy Previous infection Cryptogenic organising pneumonia Langerhans cell histiocytosis Drugs (amiodarone, cyclophosphamide, bleomycin) ```

Question 91

Treatment of Idiopathic pulmonary fibrosis

Answer 91

Triple therapy: steroids + azathioprine + n-acetylcysteine | Lung transplant

Question 92

Hypersensitivity pneumonitis

Answer 92

= extrinsic allergic alveolitis | Farmer's lung most common

Question 93

Horner's syndrome

Answer 93

Ptosis Miosis Anhydrosis Caused by Pancoast tumour

Question 94

SVC obstruction s&s

Answer 94

Facial suffusion Upper limb swelling Distended jugular veins

Question 95

Para neoplasticism drone

Answer 95

PTH-RP: hypercalcemia (SCC) SiADH: hyponatremia Eaton-Lambert syndrome (Lambert-Eaton myasthenic syndrome (LEMS) is a disorder of neuromuscular transmission caused by impaired presynaptic release of acetylcholine). Ectopic ACTH production - Cushing (SCLC)

Question 96

TB extrapulmonary manifestations

Answer 96

``` CNS: meningeal TB Genitourinary TB Bone TB (Potts disease) Skin TB (lupus vulgaris) Peritoneal TB Pericarditis (active or constrictive) GI TB ```

Question 97

TB Ix

Answer 97

``` Sputum samples (AAFB smear and culture) Early morning krone for AAFB if renal disease suspected CXR Mantoux Bronchial washing or biopsy ```

Question 98

TB Drug side effects

Answer 98

Rifampicin: liver function, urine orange Isoniazid: peripheral neuropathy (give pyridoxine) Ethambutol: retrobullar neuritis Pyrazinamide: abnormal liver enzymes

Question 99

Wegener granulomatosis TTT

Answer 99

Steroids Cyclophosphamide Infliximab

Question 100

Aspergillosis six

Answer 100

Serum precipitins

Question 101

Acute exacerbation of asthma: Mx

Answer 101

``` Oxygen Nebs Salbutamol 5 mg Nebs Ipratropium 0.5 mg IV hydrocortisone 200 mg Back to back Nebs Theophylline (check they're not already on it) Magnesium (1.2-2g IV) ```

Question 102

If treating a patient that looks like acute exacerbation of asthma... And after giving all treatment no improvements, what can it be?

Answer 102

Pneumothorax (do Xray): asthmatic at higher risk of developing pneumothorax Super added Infection

Question 103

S&s in PE not usually asked

Answer 103

Syncope PE Coma due to resp failure Cardiac arrest

Question 104

Na and K daily requirements:

Answer 104

Na 100mmol/24h (1.5-2 mmol /kg/24h) K 60 mmol/24h (1 mmol/kg/24h)

Question 105

Fever and fluid requirement

Answer 105

Give 1 extra litre of fluid saline per degree rise every 24h

Question 106

Adequate urine output

Answer 106

0.5 ml/kg/h

Question 107

Wells score for PE diagnosis

Answer 107

clinically suspected DVT — 3.0 points alternative diagnosis is less likely than PE — 3.0 points tachycardia (heart rate > 100) — 1.5 points immobilization (≥ 3d)/surgery in previous four weeks — 1.5 points history of DVT or PE — 1.5 points hemoptysis — 1.0 points malignancy (with treatment within 6 months) or palliative — 1.0 points Traditional interpretation[9][10][15] Score >6.0 — High (probability 59% based on pooled data[16]) Score 2.0 to 6.0 — Moderate (probability 29% based on pooled data[16]) Score 4 — PE likely. Consider diagnostic imaging. Score 4 or less — PE unlikely. Consider D-dimer to rule out PE.

Question 108

BTS pre-test probability score for PE

Answer 108

Pt has clinical features compatible with PE: raised RR, hemoptysis, pleuritic chest pain Plus 2 other factors: 1- absence of another reasonable clinical explanation 2- presence of a major risk factor If 1 and 2 high probability If 1 or 2: intermediate probability If none: low probability

Question 109

In what circumstances do u use thrombolysis in PE?

Answer 109

In Massive PE with cardiac instability

Question 110

Signs of PE

Answer 110

``` Tachycardia Tachypnea RV strain / pulmonary hypertension - high JVP - RV heave - loud P2 - TR Systemic hypotension (SBP<100) Cyanosis ``` ``` On ECG: - Sinus tachy (commonest) - R sided strain - AF/atrial flutter/atrial tachycardia - RAD - partial or complete RBBB - TWI anteriorly +- laterally +- inferiority - S1Q3T3 - ST depression - P pulomonale - ST elevation (V1-V3) 1 reported case ECG can be completely normal ```

Question 111

JVP anatomical position

Answer 111

The Jugular Venous Pressure (JVP) is found between the sternal and clavicular heads of the Sternoclavicular Muscle (SCM); usually just above the clavicle.

Question 112

Coronary arteries and MI

Answer 112

RCA infarct: - inferior MI (leads II, III and aVF) - posterior MI (prominent R wave in V1/V2) LAD infarct: - anteroseptal (V1/V2) - anterior (V3/V4) - anterolateral (I, aVL, V3-6) - excessive anterior (I, aVL, V1-6) Circumflex infarct: - lateral (I, aVL, V5-6) - isolated posterior (prominent R wave in V1-2)

Question 113

ST elevation in aVR?

Answer 113

Left stem occlusion (very dangerous)... ST elevation probably in All leads then

Question 114

How is a fluid challenge done?

Answer 114

250 ml bolus of colloid administered as quickly as possible. Response in CVP or urine output should be seen within min. (Importance of size and duration of CVP response rather than the actual values recorded)

Question 115

Shock: definition and types

Answer 115

Abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation (ie cardiac output is unable to meet the tissues metabolic requirements) Hypovolemic (most common: hemorrhagic shock after injury) Septic Cardiogenic (from blunt injury, tamponade, air embolus, infarct). Anaphylactic Neurogenic (spinal injury causes shock because of loss of sympathetic tone (presenting as hypotension and bradycardia) which may compound and present hypovolemia) Addisonian (withdrawal from steroids)

Question 116

Quantifying Hypovolemic Shock

Answer 116

Class I: 0-15% blood loss (750ml) Class II: 15-30% blood loss (750-1500ml) Class III: 30-40% blood loss (1.5-2l) Class IVA: >40% >2l BP starts falling at >30%

Question 117

Hypernatremia and urine osmolality

Answer 117

If urine osmolality is high: hyponatremia due to dehydration If urine osmolality is low: diabetes insipidus

Question 118

Causes of cardiogenic pulmonary oedema

Answer 118

Remember acronym HAVM 1- hypertension 2- arrhythmia 3- valve disease (aortic/mitral) 4- MI/IHD ``` 5- failure of prosthetic heart valve 6- cardiomyopathy 7- VSD 8- negatively inotropic drugs 9- pericardial disease ```

Question 119

T wave morphology

Answer 119

Normal Inverted (new old MI) Biphasic (ischemia) Tented peak (in hyperkalemia, hyperacute in ischemia)

Question 120

VT vs SVT (with aberrancy)

Answer 120

``` More likely VT if Concordance Very wide qrs > 150 msec Captured beats Fusion beats ```

Question 121

LVH on ECG

Answer 121

S1R6 > 35 mm

Question 122

RVH on ECG

Answer 122

Prominent R V1 > 10 mm

Question 123

Shock definition

Answer 123

Inadequate tissue perfusion and oxygenation

Question 124

Definition/Dx of cardiac arrest

Answer 124

2 things - unresponsive - no major pulse

Question 125

Diagnosis of tamponade clinically

Answer 125

Beck's triad: low arterial blood pressure, distended neck veins, and distant, muffled heart sounds

Question 126

Causes of PEA (pulseless electrical activity)

Answer 126

These possible causes are remembered as the 6 Hs and the 6 Ts ``` Hypovolemia Hypoxia Hydrogen ions (Acidosis) Hyperkalemia or Hypokalemia Hypoglycemia Hypothermia Tablets or Toxins (Drug overdose) Cardiac Tamponade Tension pneumothorax Thrombosis (Myocardial infarction)(Pulmonary embolism) Tachycardia Trauma (Hypovolemia from blood loss) ```

Question 127

Signs of cerebellar disease

Answer 127

DANISH T - Dysdiadochokinesis - impairement of rapid alternating movements - Ataxia-broad based gait, falling to side of lesion - Nystagmus - horizontal nystagmus with fast beat towards side of lesion - Intention tremor (finger to nose and heel to shin testing) - Stoccato speech-usually with bilateral lesions (cerebellar dysarthria) - hypotonia - titubation (rhythmic tremor of head)

Question 128

Causes of cerebellar disease

Answer 128

Demyelination (MS) Space-occupying lesion in posterior fossa Brainstem vascular disease Infection - HIV abscesses Toxicity (alcohol, anticonvulants, CO, lead) Inherited (friedrich's ataxia, sca (spinocerebellar ataxias) Degenerative

Question 129

Charcot-Marie tooth disease (peroneal muscular dystrophy)

Answer 129

``` Distal limb weakness : pes cavus Wasting of small muscles (hands, arms...) Hyporeflexia Absent ankle jerks High stepping gait ```

Question 130

Azathioprine: what test before starting?

Answer 130

Test TPMT Thiopurine methyltransferase (TPMT) is the main enzyme responsible for inactivating toxic products of azathioprine ...

Question 131

Adrenaline dose for cardiac arrest

Answer 131

1 mg IV | 1/10000 concentration

Question 132

Speed of anaphylactic reactions

Answer 132

Food reaction=Resp arrest in 30-35 min Insect stings: shock 15 min IV meds: within 5 min

Question 133

Anaphylaxis : adrenaline dose?

Answer 133

0.5 mg IM 1/1000

Question 134

Mix of UMN and LMN degeneration symptoms and no sensory abnormalities...?

Answer 134

Think Motor neurone disease

Question 135

Heart failure – Chest X ray signs | ABCDE

Answer 135

Heart failure – Chest X ray signs ABCDE ``` Alveolar oedema (bat’s wings) kerley B lines (interstitial oedema) Cardiomegaly Dilated prominent upper lobe vessels Effusion (pleural) ```

Question 136

Causes of blackout

Answer 136

CRASH Cardiac (stokes Adams) Reflexes (vagal overactivity, postural hypotension) Arterial (migraine, Tia, shock...) Systemic (glucose drop, resp(hypoxia), blood (anemia) Head (epilepsy...)

Question 137

Chorea (definition and causes)

Answer 137

``` Non rhythmic purposeless jerky flitting movements Causes Huntington Sydenhan Wilson L-dopa ```

Question 138

Sparing of forehead wrinkling and blink

Answer 138

Frontales and orbicularis muscle have bilateral UMN representation (LMN lesion: the final common pathway is destroyed)

Question 139

Drug induced SLE

Answer 139

``` CHIMP Carabamazepube Hydralazine Isoniazidr Minocycline Procaibamide, pyrazinamide ```

Question 140

Causes of fractured neck of femur

Answer 140

Osteoporosis Trauma Combination

Question 141

What to know in Hx of fractured neck of femur

Answer 141

Age Comorbidity Preinjury mobility Social hx

Question 142

Describing a fracture radiograph

Answer 142

``` Location: (which bone and part) Pieces: simple/multifragmentory Pattern: transverse/oblique/spiral Displaced/undisplaced Transverse/angulated ```

Question 143

Red flag for bone pain

Answer 143

Malignancy Infection severity pain

Question 144

Hx to ask about in OA

Answer 144

Pain (exertional, rest, night) Disability (walking distance /stairs...) Deformity Previous history (trauma and infection) Treatment given (physio injection operation) Other joints affected Problem as a child (development dysplasia of the hip)

Question 145

OA management

Answer 145

Conservative : analgesics, physio, walking aids, avoidance of exacerbating activity, injections (steroid, viscosupplementation) ``` Operative : 1- replace (knee/hip) 2- realign (knee/big toe) 3- excise (toe) 4- fuse (big toe) 5- synovectomy (rheumatoid) 6- denervate (wrist) ```

Question 146

Most common causes of large bowel obstruction

Answer 146

Cancer Diverticular disease Volvulus

Question 147

Bird's beak sign on barium swallow

Answer 147

Achalasia

Question 148

Fourth heart sound

Answer 148

Long standing aortic stenosis or hypertension

Question 149

Third heart sound

Answer 149

Heart failure: rapid ventricular filing

Question 150

Signs of chronic liver disease

Answer 150

- General: cachexia, icterus, excoriation, bruising - Hands: leuconychia, clubbing, dupuytren, Palmar erythema - Face: xanthelasma, parotid swelling, fetor hepaticus - Chest and abdomen: spider naevi, caput medusa, reduced body hair, gynecomastia, testicular atrophy

Question 151

Signs of hepatomegaly

Answer 151

palpation and percussion: - mass in r upper quadrant, moves with respiration, not able to get above, dull to percussion - estimate size: finger breaths below diaphragm - Smooth our craggy/nodular (malignancy cirrhosis) - Pulsatile (TR in CCF) Auscultation - Bruit over liver (hepatocellular carcinoma)

Question 152

Evidence of an underlying cause of hepatomegaly

Answer 152

``` Tattoos and needle marks Pigmentation Cachexia Midline sternotomy scar Infectious hepatitis / alcohol Haemochromatosis Malignancy CCF ```

Question 153

Evidence of DECOMPENSATED chronic liver disease

Answer 153

AAA Ascites (shifting dullness) Asterixis (liver flap) Altered consciousness (encephalopathy)

Question 154

Causes of hepatomegaly

Answer 154

- Big 3 Cirrhosis (alcoholic) Carcinoma (secondaries) CCF - Other Infectious (hep b c) Immune (pbc, psc, autoimmune hepatitis) Infiltrative (amyloid and myeloproliferative disorders)

Question 155

What do patients with portal hypertension die of

Answer 155

Variceal bleeding which would be a medical emergency

Question 156

What it's major hemorrhage protocol

Answer 156

Hh

Question 157

Urobilinogen in obstruction

Answer 157

Is negative (we all have a tiny amount)

Question 158

What happen to bile salts in obstruction

Answer 158

They leak into bloodstream

Question 159

What are true liver enzymes

Answer 159

Albumin Bilirubin Alkaline phosphatase ALT (alanine amino transferase) In addition need to measure AST and GGT

Question 160

What does polio do

Answer 160

Old polio which damages the nucleus of the lower motor neuron

Question 161

Mixed upper and lower motor neurone disease

Answer 161

ALS

Question 162

Child pugh score

Answer 162

Classification score for cirrhosis Based on ``` Bilirubin Albumin INR Ascites Encephalopathy ```

Question 163

Felty's syndrome

Answer 163

is characterized by the combination of rheumatoid arthritis, splenomegaly and neutropenia.

Question 164

Causes of unilateral kidney engagement

Answer 164

Polycystic kidney disease Renal Cell carcinoma Simple cysts Hydronephrosis (due to ureteric obstruction)

Question 165

Causes of bilateral kidney enlargement

Answer 165

``` Polycystic kidney disease Bilateral renal Cell carcinoma Bilateral Hydronephrosis Tuberous sclerosis Amyloidosis ```

Question 166

Evidence of immunosuppressive

Answer 166

Ciclosporin: gum hypertrophy and hypertension Steroids: cushingoid appearance, thin skin ecchymoses...

Question 167

Top 3 causes for renal transplantation

Answer 167

Glomerulonephritis Diabetic nephropathy Polycystic Kidney disease

Question 168

Top 3 causes for liver transplantation

Answer 168

Cirrhosis Acute hepatic failure (hepatitis a b, paracetamol overdose) Hepatic malignancy

Question 169

Causes of gum hypertrophy

Answer 169

``` Drugs: ciclosporin, phenytoin, nifedipine Scurvy Aml Pregnancy Familial ```

Question 170

Dorsal columns

Answer 170

Vibration | Proprioception

Question 171

Spinothalamic tract

Answer 171

Pain | Temperature

Question 172

Tabes dorsalis

Answer 172

Tabes dorsalis, also known as syphilitic myelopathy, is a slow degeneration (specifically, demyelination) of the nerves primarily in the dorsal columns (posterior columns) of the spinal cord (the portion closest to the back of the body). They help maintain a person's sense of position (proprioception), vibration, and discriminative touch.

Question 173

Horner's syndrome causes

Answer 173

Causes of Horner syndrome may also be classified as involving first-order, second-order, or third-order neuron lesions. First-order neuron lesions that may give rise to the syndrome include the following: Arnold-Chiari malformation Basal meningitis (eg, syphilis) Basal skull tumors Cerebral vascular accident (CVA)/Wallenberg syndrome (lateral medullary syndrome) Demyelinating disease (eg, multiple sclerosis) Lesions in the hypothalamus or medulla Intrapontine hemorrhage Neck trauma (eg, traumatic dislocation of cervical vertebrae or traumatic dissection of the vertebral artery) - Horner syndrome occurring in association with spinal cord trauma suggests a high cervical cord lesion because it does not occur with lesions below T2 or T3 Pituitary tumor Syringomyelia Second-order neuron lesions that may give rise to Horner syndrome include the following: Pancoast tumor (tumor in the apex of the lung, most commonly squamous cell carcinoma) Birth trauma with injury to lower brachial plexus[6] Cervical rib Aneurysm or dissection of the aorta Lesions of the subclavian or common carotid artery Central venous catheterization Trauma or surgical injury (eg, from radical neck dissection, thyroidectomy, carotid angiography, or coronary artery bypass grafting)[7] Chest tubes Lymphadenopathy (eg, Hodgkin disease, leukemia, tuberculosis, or mediastinal tumors) Mandibular tooth abscess Lesions of the middle ear (eg, acute otitis media) Neuroblastoma[8]

Question 174

Austin flint murmur

Answer 174

In cardiology, an Austin Flint murmur is a low-pitched rumbling heart murmur which is best heard at the cardiac apex.[1] It can be a mid-diastolic[2] or presystolic murmur[3] It is associated with severe aortic regurgitation, although the role of this sign in clinical practice has been questioned.[4]

Question 175

Pericardiris on ECG

Answer 175

``` St elevation (,notchz,) Pr deression ```

Question 176

Meeran eye slide

Answer 176

Micro aneurysm Hard exudate Blot hemorrhages Background diabetic nephropathy Patient needs good diabetic control: diet exercise maybe metformin (add gliclazide if needed)

Question 177

Pros and cons ctpa vs vq scan

Answer 177

``` Ctpa: More radiation (not pregnant,) More available in hospitals Vq scan can be done only if xrays normal Ctpa can give more info (pleural effusion...) If pe wrong diagnosis ```

Question 178

Commonest bacteria in teeth that might cause problems

Answer 178

Strep viridans

Question 179

Pleurisy in paces

Answer 179

Pleural rub heard... Crunch... Walking on snow Usually from: Primary infarction, or following pneumonia or following pulmonary embolus.

Question 180

Horner syndrome

Answer 180

Horner syndrome is due to a deficiency of sympathetic activity. The site of lesion to the sympathetic outflow is on the ipsilateral side of the symptoms. The following are examples of conditions that cause the clinical appearance of Horner's syndrome: First-order neuron disorder: Central lesions that involve the hypothalamospinal tract (e.g. transection of the cervical spinal cord). Second-order neuron disorder: Preganglionic lesions (e.g. compression of the sympathetic chain by a lung tumor). Third-order neuron disorder: Postganglionic lesions at the level of the internal carotid artery (e.g. a tumor in the cavernous sinus or a carotid artery dissection). Partial Horner's syndrome In case of a third-neuron disorder, anhidrosis is limited to the middle part of the forehead or can be absent, resulting in a partial Horner's syndrome.[3]

Question 181

Eye out and down

Answer 181

Third nerve palsy Surgical or medical Look at pupil size Surgery: posterior aneurysm...

Question 182

In a squint

Answer 182

The outside image is from the weak eye By doing cover test Probably 6th nerve palsy or 3rd or complex ophtalmoplegia

Question 183

Cause of complex opthalmoplegia

Answer 183

Graves disease (commonest) MG Retro-orbital tumour Miller-Fisher syndrome (orbital guillain Barre syndrome) (one patient is usually in exams)

Question 184

Eye slide Number 2

Answer 184

NOrmal fundus

Question 185

What to see in background retinopathy

Answer 185

Hard exudates,(cholesterol) Micraneyrysms,z(dots Blot hemorrhages

Question 186

Third slide eye Meeran

Answer 186

Cotton wool spots (used to be called soft exudates)

Question 187

What are cotton wool spots

Answer 187

Retinal ischemia

Question 188

Slide 4 Meeran eye

Answer 188

New vessels Silver wiring Diabetes They present wiyh hyperosmolar... Weren't diagnosed before

Question 189

Slide 5 eye Meeran

Answer 189

Hdhdhd

Question 190

Management of diabetic retinopathy

Answer 190

Background Pre-proliferative: cotton wool spots. Suggests General ischemia. If left alone New vessels will grow. Needs Pan retinal phosphorylation Proliferative: visible New vessels (this is an emergency weight be seen in exam) Needs Pan retinal photocoagulation

Question 191

Eye slide 6

Answer 191

See laser spots Can ask if they have diabetes but might be shouted at Pan retinal photocoagulation... Older laser black burns Newer lasers are paler

Question 192

Pan retinal photocoagulation

Answer 192

Carefully avoid burning the macula | So we are sacrificing some peripheral vision tip maintain central vision

Question 193

Eye slide 7

Answer 193

Retinitis pigmentosa

Question 194

Retinitis pigmentosa

Answer 194

Retinitis pigmentosa (RP) is an inherited, degenerative eye disease that causes severe vision impairment and often blindness.[1] The progress of RP is not consistent. Some people will exhibit symptoms from infancy, others may not notice symptoms until later in life.[2] Generally, the later the onset, the more rapid is the deterioration in sight.[citation needed] Those who do not have RP have 90 degree peripheral vision, while some people who have RP have less than 90 degrees.

Question 195

Retinitis pigmentosa with photonic acid

Answer 195

Chelsea and westminster site Heritable Many genetic syndromes example usher syndrome (Deafness) Refsum's disease (failure to metabolize phytanic acid) Can lead to blindness and would like to take Family history

Question 196

Causes for hirner syndrome

Answer 196

Damage to sympathetic chain Trauma to carotid sheeth (central line) Apical lung tumour

Question 197

Stages of hypertensive retinopathy

Answer 197

1- Silver wiring 2- av nipping 3- cotton wool and flame shaped hemorrhages 4- Papilloedema

Question 198

Visits fields

Answer 198

Homonymous hemianopia (Cva (stroke), braintumour middle cerebral or occipital cortex) Bitemporal hemianopia (pituitary tumour) Unilateral hemianopia (Surgery): optic nerve... Check slide

Question 199

Why right side perceived with left side brain

Answer 199

Check

Question 200

How to present an acromegaly patient

Answer 200

Inspect hands... Check slide Meeran Photos Gtt with gh check igf1 Examine visual fields

Question 201

How to present graves disease patient

Answer 201

How to tell if active or not What investigations Management Check Meeran slide

Question 202

Mechanism of lid lag

Answer 202

Sympathetic activation with high t3 Opposite of Horner Eyelids don't relax as quickly Caused by adrenal activation

Question 203

Cushing syndrome patient viva

Answer 203

If not on steroids Active disease down by proximal myopathy, red Syria's and thin skin Investigations include urine free... Check slide

Question 204

Rheumatology short case

Answer 204

Put hands on pillow and minimise discomfort Subluxation (displacement without dislocation) Mcp and pip joints Is it active ) unlikely to be tender warm) Any problems with adl (kettle button) Proceed to viva Ulnar derision of mcp joints Swan neck deformity of fingers Boutonniere deformity of the thumb Management Ix DMard

Question 205

Describe hands you see pic Meeran

Answer 205

Young patient Pip involvement Another case of ra Had ra for 3 Months only... Needs biologics asap Pip and mcp is ra Urgent referral for specialist opinion Needs pain control

Question 206

Other oa

Answer 206

``` Dip Older patient No inflammation Wear and tear No autoimmune Aging of joint ``` Treatment is pain relief No dmard MENTION KNEES AND HIPS... heberdens nodes

Question 207

Care 4 hands Meeran pic | Describe

Answer 207

Thin shiny skin hard (sclerosis=hard) Scleroderma Autoimmune Mixed connective tissue disease Crest syndrome possible Immunopharmacology therapy

Question 208

Image 5 hands

Answer 208

Tophaceous gout Management Pain relief Nsaid (just ndomethacin) Aspirate joint Negatively birefringent crystals Acid uric metabolism Ttt: indomethacin or colchicin Interval glut: either xo inhibitor allopurinol or uricosuric =probenicid

Question 209

Case 6: AS see pic

Answer 209

Vertebrae are ankylosed and fixed Measure occiout to wall to decide how severe it is Corrective Surgery to the back Refer to specialist

Question 210

Dermatology

Answer 210

Describe the skin lesions Describe distribution: extensor area on less Complications Management

Question 211

Describe Meeran first dermatology pic

Answer 211

Erythematous, scaly...well defined lesion Onycholysis If artritis, think of psoriatic arthropathy

Question 212

Management of psoriasis

Answer 212

Moisturizer and creams | Cost tar... Check slide

Question 213

Complications of fractures

Answer 213

``` - Local Nerve injuries (sensory motor autonomic conseQuences) LigameNts Local infection Compartment syndrome ``` Nonunion malunion causing deformity Long term autonomic: reflex sympathetic dystrophy General/systemic Infection/sepsis uti DVT PE Shock hemorrhagic Immediate Early late

Question 214

Fractured NOF | Causes

Answer 214

Osteoporosis (older) Trauma (younger) Combination

Question 215

In the context of c diff, what are pseudomembranes

Answer 215

Consist of neutrophils fibrin mucus and debris

Question 216

Fractured nof history

Answer 216

Age Comirbidity (Resp cardio diabetes cancer) Pre injury mobility Social history

Question 217

Severe osteoarthritis

Answer 217

Wakes you up at night

Question 218

Night pain in ortho

Answer 218

Osteoarthritis malignancy Infection

Question 219

Slide on face and noise

Answer 219

Describe our: This is oral candidiasis Immunosuppressed, on steroids, bruising noise On nose this is kaposi sarcoma

Question 220

Erythema ab ignae

Answer 220

Erythema ab igne (EAI, also known as hot water bottle rash,[1] fire stains,[2] laptop thigh, granny's tartan and toasted skin syndrome[2]) is a skin condition caused by long-term exposure to heat (infrared radiation).[3] Prolonged thermal radiation exposure to the skin can lead to the development of reticulated erythema, hyperpigmentation, scaling and telangiectasias in the affected area. Some people may complain of mild itchiness and a burning sensation, but often, unless a change in pigmentation is seen, it can go unnoticed.

Question 221

Definition of Respiratory failure | Type 1 and 2

Answer 221

Po2 < 8 Type 1: only hypoxic Type 2: hypoxic and hupercapnic

Question 222

Complications of pseudomembranous colitis

Answer 222

``` Hypovolemic shock Electrolyte imbalance Hypoalbuminemia Perforation of bowel Toxic megacolon ```

Question 223

Management of toxic megacolon

Answer 223

Subtotal colectomy | Appears as dilated colon with featureless wall on xray

Question 224

What characterises neurogenic shock

Answer 224

``` Bradycardia Warm peripheries (pooling of blood) ```

Question 225

Asa grading

Answer 225

American society of anesthesiologists grading system used to predict patient pre operative morbidity outside of Surgery type 1- normal healthy 2- mild systemic disease 3- severe systemic disease that limits activity 4- incapacitating systemic disease and life threatening 5- not expected to survive more than 24h

Question 226

Features of portal hypertension

Answer 226

Ascites Splenomegaly Esophageal varies

Question 227

Causes of foot drop

Answer 227

Common peroneal nerve lesion

Question 228

Buerger disease

Answer 228

Vasculitis of medium sized vessels Like intermittent claudication in young patients less than 45. Gangrene...

Question 229

Glasgow modified score to predict prognosis of pancreatitis

Answer 229

``` PANCREAS PO2 < 8 AGE > 55 NEUTROPHILS ACC > 15 CALCIUM < 2 RENAL (UREA) > 16 ENZYMES (LDH, AST) > 600 ALBUMIN < 32 SUGAR (GLUCOSE) > 10 ```

Question 230

Volkmann ischemic contracture

Answer 230

Complication of suprscondylar fracture Due to brachial artery injury Described add flexion contracture of hand and wrist caused by circulatory compromise and ischemia leading to fibrosis of forearm compartment. Secondary to untreated compartment syndrome.

Question 231

Brown sequard syndrome

Answer 231

Described features of unilateral transaction (hemisection) of the spinal cord. Ipsilatetal loss of motor function with impaired joint posit ion and vibration sense (dorsal column dysfunction) Contralateral sensory loss for pain and temperature.

Question 232

Gastrochisis

Answer 232

Congenital defect in anterior abdominal wall next to umbilicus in newborn

Question 233

Morton neuroma

Answer 233

Neuroma of the digital nerve of the foot that is most common between third and fourth metatarsals. Common cause of foot pain.

Question 234

Frozen shoulder called

Answer 234

Adhesive capsulitis

Question 235

Most common causes of small bowel obstruction

Answer 235

Adhesions Hernias Tumours

Question 236

Most common causes of small bowel obstruction

Answer 236

Adhesions Hernias Tumours

Question 237

Most common cause of large bowel obstruction

Answer 237

Tumour

Question 238

Four cardinal symptoms of intestinal obstruction

Answer 238

Colicky abdominal pain Distension Vomiting Obstipation (inability to pass fluids our feces)

Question 239

Normal pressure hydrocephalus

Answer 239

Elderly commonly Saturation of the ventricles without any signs of raised intracranial pressure Triad of dementia, urinary incontinence and ataxia

Question 240

What ate the vertebral levels of different organs in abdomen

Answer 240

Check...

Question 241

Causes of high alkaline phosphatase

Answer 241

``` ALKPHOS any fracture Liver damage (posthepatic) Kancer Pagets disease of bone Pregnancy Hyperparathyroidism Osteomalacia Surgery ```

Question 242

Peutz-Jeghers syndrome

Answer 242

Peutz-Jeghers syndrome, also known as hereditary intestinal polyposis syndrome, is an autosomal dominant genetic disease characterized by the development of benign hamartomatous polyps in the gastrointestinal tract and hyperpigmented macules on the lips and oral mucosa (melanosis).[1] Peutz–Jeghers syndrome has an incidence of approximately 1 in 25,000 to 300,000 births.[2]

Question 243

Causes of clauducation

Answer 243

Spinal stenosis

Question 244

Ambulatory blood pressure monitoring

Answer 244

Check cutoff for positive results

Question 245

Causes of proteinuria and nephrotic syndrome

Answer 245

Glomerular Pathology: - Minimal change - Membranous - Diabetes - Amyloid - SLE

Question 247

Aneurysm: definition

Answer 247

This is the pathological localised permanent dilatation of an artery to more than 1.5 times its original diameter involving all 3 layers of its parent wall.PSEUDOANEURYSM DOESN'T INVOLVE ALL THREE LAYERS OF THE ARTERIAL WALL.

Question 248

Causes of bowel obstruction

Answer 248

Small bowel obstruction is more common than large bowel. The most common causes of small bowel obstruction are - adhesions- hernias- cancersThe most common causes for large bowel obstruction are:- cancers- diverticular disease- volvulusThe causes of bowel obstruction can be divided into mechanical and non-mechanical causes.Mechanical causes can be classified according to their relation to the bowel wall:- luminal: gallstones, meconium, impacted faces, ...- extramural: adhesions, cancers, hernia, volvulus- in the wall: congenital stenosis, strictures, IBD, diverticulitis, cancer...Non-mechanical causes, known as paralytic ileus, are due to - postop abdo surgery, - mesenteric ischemic- metabolic causes (hypokalemia, uremia, hypoglycemia and hypothyroidism)

Question 249

Causes of clubbing

Answer 249

The most common cause of digital clubbing is idiopathic. However, there are many causes of clubbing and they can be classified into:- GI causes: IBD, PBC, coeliac- Resp causes: Lung Ca, bronchiecstasis (suppurating lung disease), CF, Mesothelioma, fibrosing alveolitis - cardiac causes: congenital cyanotic heart disease, endocarditis- other causes: familial, idiopathic, graves' diseaseShamroth's test

Question 250

Ix for acute abdomen

Answer 250

!!! simple bedside tests:- ECG (to rule out ischemic/MI)- urinalysis (hematuria in renal calculi, UTI, or pregnancy test)- BM: blood sugar levels, if suspected DM presenting as abdo pain!!! Blood tests:--- Simple tests- FBC (raised WCC in infection or anemia if GI bleed)- U&E: look for dehydration, renal failure, raised urea in case of acute GI bleed, electrolyte imbalance secondary to massive fluid shifts in pancreatitis or cases of bowel obstruction- LFT: for acute cholecystitis, or obstructive jaundice- Amylase: compulsory in acute abdomen. Raised in acute pancreatitis to at least greater than 3 times the upper limit of normal - G&S: if expecting an operation or if there is blood loss- Cross-match: if expect pt will need operation and will require blood transfusion (eg upper GI bleed taken to theatre)- ABG: if pt particularly sick, will help to gauge how sick he is. Lactate and pH are helpful indicators of level of shock and can help unmask conditions like mesenteric ischemia.--- specialist tests (for pancreatitis for example: do BM, Ca levels, liver transaminases and CRP to score severity).!!! Imaging--- plain films- erect CXR: if suspecting perforated intra-abdominal viscous...then looking for air under diaphragm. Film taken while patient sitting upright for at least 20 min prior to film taken, because air will need time to rise and demonstrate a pneumoperitomeum. Sign only present in 80% of cases- AXR: if bowel obstruction thought- Contrast films: gastrograffin enema if bowel obstruction or IVU for ureteric colic.--- Ultrasound- USS liver: to scan biliary tree for evidence of gallstones or to measure size of common bile duct in suspected obstructive jaundice--- CT scans:- CT KUB: first line Ix for renal calculi- CT abdo/pelvis: depends on the case but useful in pts not responding to ttt and in whom urgent Sx exploration is not mandated.

Question 251

Question about discussing the management

Answer 251

Start with stating Hx, examination, Ix, differential diagnosis and ttt options.Ttt options can be either:- conservative: includes anything non-surgical. May be in the forms of IV fluids, NG tube for drainage of stomach contents and urinary catheterisation. Includes as well MDT approach (OT, PT, clinical nurse specialists) in chronic debilitating conditions such as OA or cancers- medical: any drugs (eg analgesia, antibiotics...). May also take form of more invasive but non-surgical ttt options, such as injection sclerotherapy in varicose veins or injecting Hemorrhoids. Some surgeons argue that endoscopic ttt options fall under this category.- surgical: any surgical procedure performed

Question 252

Discussing surgical complications

Answer 252

2 main categories1- complications from anaesthetics: 1.1 damage to local structures (mouth, pharynx, teeth) 1.2 allergic reactions to agents (minor vs major) 1.3 slow recovery (due to poor cardiac, hepatic renal function...) 1.4 malignant hyperpyrexia (caused by anesthetic gas or suxamethonium) 1.5 awareness (pt paralysed but without effective anaesthetic)2. Complications due to surgery 2.1 related to any surgical operation: pain, infection, bleeding, DVt/PE 2.2 specific to the surgical procedure 2.2.1 immediate 2.2.2 early 2.2.3 late

Question 253

Postop complications of total thyroidectomy

Answer 253

1. Cpx from anaesthetics2. Cpx from surgery 2.1- general to any surgical operation 2.2- specific to thyroidectomy A- immediate (3 weeks): hypothyroidism, keloid scar formation, recurrence.FYI: primary hge or laryngeal edema compromising the airway is a surgical emergency. Surgical clips should be removed to facilitate evacuation and help relieve the immediate airway compromise (buys time before definitive surgical evacuation). Surgical clip removers always by the bedside of post-thyroidectomy pts.

Question 254

Testicular pain age groups

Answer 254

- prepubertal: mumps orchitis, idiopathic scrotal oedema, testicular torsion- adolescent (10-21): testicular torsion (most likely), epididymo-orchitis, torsion of the Hydatid of Morgagni (7-14)- adult (>21): epididymo-orchitis (most likely), testicular torsion- all age groups: trauma

Question 255

Focused Hx for Testicular pain

Answer 255

- patient age- testicular pain: bilateral (mumps orchitis), unilateral (testicular torsion or epididymo-orchitis), acute onset (torsion) vs gradual onset / hours (epididymo-orchitis), sharp pain (torsion) vs dull heavy (epididymo-orchitis), pain relieved by standing up or wearing scrotal support (epididymo-orchitis), radiation to thigh groin or abdomen (t10 dermatome) implies testicle, if to penile shaft or perineum implies idiopathic scrotal edema.- Urinary symptoms: dysuria, urinary frequency and urethral discharge commonly seen in epididymis-orchitis. Nothing in torsion.- sexual HX; relevant for epididymo-orchitis- swelling: + erythema = scrotal edema or mumps orchitis / just after trauma = hemToma / swelling can occur with torsion.- previous HX: torsion (usually intermittent torsion previously) - fever/vomiting: with epididymo-orchitis, torsion or mumps. Vomit from pain in torsion.

Question 256

How to describe a scar

Answer 256

1- Identify scar: name with eponymous name or anatomically ((eg 2cm scar in R groin). Comment on whether scar recent (raised and pink/red) or old (flat and same colour as surrounding skin)2- check for incisional hernia: ask pt to cough or raise head off the bed3- suggest possible operations

Question 257

Possible operations for Midline laparotomy scarWhat about Upper midline scar and lower midline scar

Answer 257

Exploratory laparotomyHemicolectomy Hartmann'sAAA repairUpper midline scar: splenectomy (massive)Lower midline scar: para-umbilical hernia repair, colectomy

Question 258

Possible operations for Kocher's or right subcostal scar

Answer 258

Open cholecystectomyPartial liver resectionAny biliary surgery

Question 259

Reversed Kocher's (left subcostal)

Answer 259

Open splenectomy

Question 260

Possible operations for Double Kocher's or rooftop scar (=R and L subcostal)

Answer 260

Ivor Lewis (Oesophagectomy)Complex pancreatic/gastric surgery

Question 261

Possible operations for Mercedes scar or extended rooftop

Answer 261

Complex upper GI surgery (eg McKeown Oesophagectomy, gastrectomy, liver transplant

Question 262

Possible operations for left nephrectomy scar or loin incision

Answer 262

NephrectomySpecialist renal surgery

Question 263

Possible operations for Gridiron or McBurney's scar

Answer 263

Appendicectomy

Question 264

Possible operations for Pfannestiel scar

Answer 264

- pelvic surgery: bladder resection, prostatectomy, bilateral hernia repairs- gynae: C-section, cystectomy, hysterectomy

Question 265

Possible operations for Rutherford Morrison or hockey stick scar

Answer 265

Renal transplant

Question 266

(When seeing a renal transplant scar, what else would u like to examine/look for?

Answer 266

I would like to look for associated scars:eg - AV fistula at wrist, - median sternotomy scar, - CAPD (Tenckhoff) scar on abdominal wall or - infraclavicular scars from previous dialysis access (Vas Cath insertions)

Question 267

Gridiron scar vs Lanz scar

Answer 267

Gridiron scar perpendicular to McBurney's line at McBurney's pointLanz is a transverse muscle splitting incision better for cosmetic result (incision follows Langers's lines)

Question 268

What structures would you go through in 1- an Appendicectomy scar?2- a midline laparotomy scar?

Answer 268

Appendicectomy scar: From superficial to deep:1- skin, subcutaneous tissue2- scarpa's fascia, Linea alba3- muscle layers: external oblique, internal oblique than transfers us abdominis4- transversalis fascia5- extra peritoneal fat then parietal peritoneumMidline laparotomy scar: From superficial to deep:1- skin, subcutaneous tissue2- scarpa's fascia, Linea alba3- transversalis fascia4- extra peritoneal fat then parietal peritoneum

Question 269

What's a peritoneum?

Answer 269

It's a serous membrane that forms the lining of the abdominal cavity. It covers most of the intra-abdominal organs, and is composed of a layer of mesothelium supported by a thin layer of connective tissue. The peritoneum supports the abdo organs and serves as a conduit for their blood vessels, lymph vessels and nerves.

Question 270

Pros and cons of midline laparotomy scar

Answer 270

Pros: - good access- can be easily extended- speed of closure and opening- relatively avascular (Linea alba)Cons:- incision more painful than transverse incision- scar crosses Langer's lines (poor cosmetic appearance)- Narrow Linea alba below umbilicus (therefore can damage bladder)

Question 271

What features determine the placement of laparoscopic ports?

Answer 271

In general, ports should be placed away from areas of high risk, such as:- previous scars, adhesions and known organomegaly- the vessels of the anterior abdominal wall should be avoided , particularly the inferior epigastric arteryThe minimum number of ports should be used (typically 3)The positioning of these ports should then allow for the target organ to be at an apex of an imaginary diamond formed by the various ports as well as the target organ itself.The 10 mm port is the camera and is useful for the removal of organs such as the gallbladder in a cholecystectomy. All other ports are typically 5mm in size.

Question 272

Pros and cons of laparoscopic surgery

Answer 272

Pros:- shorter hospital stay and rehabilitation- less post-op pain- better cosmetic result- less wound complications- decreased handling of organs (eg bowel)- less trauma to tissues- later reduced incidence of postop adhesionsCons:- lack of tactile feedback to the operating surgeon- longer operation times- more technical expertise required, prolonged training- expensive equipment- difficulty in controlling massive bleed- increased risk of iatrogenic injury to surrounding organs- not always feasible due to CI (eg adhesions)

Question 273

Nine regions of abdomen

Answer 273

From R to L:- Upper: R hypochondrial, Epigastric, L hypochondrial- Middle: R lumbar, umbilical, L lumbar- lower: R iliac fossa, suprapubic, L iliac fossa

Question 274

Underlying organs behind the 9 abdominal regions

Answer 274

- R hypochondrial: liver, gallbladder, R kidney, hepatic flexure of colon- R lumbar: ascending colon, small bowel, R urinary tract- R iliac: caecum, appendix, terminal ileum, R ovary and R Fallopian tube- Epigastric: Liver (left lobe), pylorus, duodenum, transverse colon, head and body of the pancreas- Umbilical: Duodenum, small bowel, abdominal aorta- Suprapubic: Bladder, uterus- L hypochondrial: spleen, stomach, splenic flexure of colon, tail of the pancreas, L kidney- L lumbar: descending colon, small bowel- L iliac: sigmoid colon, L ovary and L Fallopian tube

Question 275

Umbilical vs paraumbilical hernias

Answer 275

Central umbilical hernia-Clinical featuresOccurs following failed fusion of the anterior abdominal wall after birth.Often evident a few days after delivery.The hernias are usually small.The underlying defect is usually smaller than the visible hernia.A cough reflex is present. - Management:Most settle spontaneously and parents can be reassured.Surgeons are usually unhappy to operate before one year old.Strangulation never occurs in central hernias.Paraumbilical hernia- Clinical featuresOccur as a central swelling usually above or below the umbilicus.These hernias may become very large.More common in adults (especially women), than children.May be associated with obesity and weak abdominal muscles.The sac may contain both bowel and omentum.This is a true defect in the linea alba close to the umbilicus. - ManagementThese hernias will not resolve without surgical intervention.The patient should be advised to lose weight.Surgical repair is recommended because of strangulation risk.

Question 276

Striae: causes and types

Answer 276

Due to rupture of the reticular dermisSilver striae: signifiant changes in weightBluish striae: present in hyoercortisolism

Question 277

Abdominal signs in acute pancreatitis

Answer 277

Discolouration / bruising in haemoperitomeum, secondary to haemorrhagic pancreatitis or ruptured ectopic.Cullen's sign: bluish discolouration around umbilicusGrey turner's : bluish discolouration at the flanks

Question 278

Interpretation of bowel sounds: absent, increased, tinkling

Answer 278

- Absent bowel sounds: paralytic ileus, peritonitis, obstruction, mesenteric ischemia/infarction- increased sounds: diarrhoea, obstruction- tinkling: ileus (disruptions caused by failure of peristalsis), a later phase of obstruction

Question 279

Special tests for acute abdomen examination- McBurney's point tenderness- Psoas sign- Obturator sign- rovsing's sign- cough test- carnett' sign- succussion splash- boas' sign

Answer 279

- McBurney's point tenderness: acute appendicitis. Found 1/3 of the way from ASIS to umbilicus- Psoas sign: hand above R knee and apply resistance and ask pt to flex hip. If this increases abdo pain, then positive sign for appendicitis.- Obturator sign: R knee flexed, and internal rotation of hip, if increased abdo pain, then positive sign for appendicitis.- rovsing's sign: palpate in LIF. On releasing the pressure, if pt experiences pain in RIF, test positive for appendicitis.- cough test: pain experienced by pt when asked to cough in peritonitis, as this moves the peritoneum and causes pain when there is peritoneal irritation. This is another way to elicit rebound tenderness.- carnett' sign: to differentiate abdo wall pathology (eg rectal sheath hematoma) vs pain caused by intra-abdo pathology. Ask pt to lift the head and shoulders off the couch or to straight leg raise both legs.- boas' sign: pain that radiates from inflamed gallbladder in acute cholecystitis to the tip of R scapula. Leads to an area of skin just below scapula to become extremely sensitive to touch, resulting in pain (hyperesthesia)

Question 280

What is the significance of palpating a tender gallbladder?

Answer 280

- this elicits Murphy's sign, seen in cholecystitis. Pain on inspiration- if able to palpate a gallbladder, this is always pathological. If no coexisting jaundice, then this has resulted from obstruction of the cystic duct, resulting in mucocele or empyema- if co-existing jaundice, it implies obstruction of CBD and is thought to be caused by other causes besides gallstones. With gallstones, the gallbladder wall can become thickened and fibrosed after recurrent episodes of inflammation; but gallbladder enlargment typically arises as a result of carcinoma of the head of the pancreas, or another cause as stated in Courvoisier's law

Question 281

Courvoisier's law

Answer 281

in the presence of an enlarged gallbladder which is nontender and accompanied with mild jaundice, the cause is unlikely to be gallstones.

Question 282

Causes of abdominal ascites

Answer 282

Causes of ascites can be divided into those that can cause an exudate or a transudate exudate (>30g/l of protein)-- peritoneal malignancy-- infection (eg TB)-- obstruction of IVC-- obstruction of hepatic portal vein-- acute pancreatitisTransudate (<30 g/l)-- heart failure due to hydrostatic increase in venous return-- cirrhosis of liver as a result of increased portal hypertension-- hypoalbuminemia due to nephrotic syndrome

Question 283

Key features to look for in hepatomegaly

Answer 283

- site: R hypochondrium: can extend into epigastrium if very large- palpation: can't get above it- moves with respiration- not ballotable- dull to percussion- can be associated with splenomegaly

Question 284

Key features for splenomegaly

Answer 284

- site: L hypochondrium- can't get above it- moves down toward RIF with respiration- not ballotable- dull to percussion- palpable notch: enlarges towards the umbilicus/RIF

Question 285

Key features in kiney organomegaly

Answer 285

- site: L or R flank (if very large, may involve the ipsilatera Hypochondria)- L1/L2 level- can get above it- moves vertically down on inspiration- ballotable- usually resonant due to overlying bowel- if bilateral, consider polycystic kidney disease

Question 286

Causes of hepatomegaly

Answer 286

- jaundiced, smoothly enlarged: viral hepatitis, biliary tree obstruction, cholangitis- jaundiced, knobbly enlargment: malignancy (primary or secondary), cirrhosis, liver abscess, Hydatid cyst- no jaundice, smooth enlargment: CCF, cirrhosis, Budd-Chiari syndrome, amyloidosis - no jaundice, knobbly enlargment: primary hepatocellular Ca, cirrhosis

Question 287

Causes of splenomegaly

Answer 287

- infection: malaria, EBV, CMV, TB- congestion: portal hypertension, CCF- infarction: subacute endocarditis- malignancy: leukaemia, lymphoma, myeloproliferative disorders- others: felty' syndrome (RA, neutropenia, splenomegaly)

Question 288

Causes of hepatosplenomegaly

Answer 288

- infection: infectious mononucleosis- cellular proliferation: polycythemia rubra Vera, myelofibrosis- malignancy: lymphoma, leukemia- others: amyloidosis, sarcoidosis, cirrhosis

Question 289

What is portal hypertension

Answer 289

This is increased portal venous pressures to > 10 mm HgThe most common cause worldwide is post viral hepatitis, and in the UK it is alcoholic liver cirrhosis

Question 290

What is Budd-Chiari syndrome

Answer 290

It's a condition caused by occlusion of the hepatic veins that drain the liver. It presents with the classical triad of- abdo pain- ascites- hepatomegaly

Question 291

Causes of RIF mass

Answer 291

- skin and subcutaneous tissues, muscle: lipoma, sebaceous cyst, Psoas abscess, Psoas bursa- bowel: caecal carcinoma, crohn's mass, TB mass, appendix abscess or mass- urological: transplanted kidney (common in exam), ectopic kidney, bladder carcinoma- reproductive system: males (ectopic testes, u descended testes) females (fibroids, ovarian tumours)- blood vessels: iliac artery aneurysms, lymphadenopathy, sachems varix, ruptured epigastric artery, femoral aneurysm.On L side, same + diverticular abscess or carcinoma of colon.

Question 292

What are the indications for performing a DRE?

Answer 292

- acute abdomen assessment (appendicitis, peritonitis, lower abdo pain- prostate assessment: prostate hypertrophy or prostatic Ca- pre-procedure: before doing proctoscopy, sigmoidoscopy, colonoscopy- Dx purposes: constipation, change in bowel habit, anorectal pain or tenesmus...

Question 293

What are haemorrhoids?How are they managed?

Answer 293

Surgical definition: Hemorrhoids are enlarged anal cushions (dilated veins)(Typical HX of painless bright red rectal bleeding... Can be painful if thrombosed)Management: conservatively: 1- sitz bath, analgesia and dietary advice2- injection sclerotherapy: Gabriel syringe containing 5% phenol in almond oil injected above the dentate line (beware not to inject in prostate gland and cause prostatitis)3- banding: rubber band placed around pile, which causes ischemia and shrinkageSurgical1- hemorrhoidectomy

Question 294

What is dentate line (=pectinate line)?

Answer 294

It's an anatomical landmark that divides the sensory part of the anal canal.Above it there is no sensation, but below there is, that's why injection sclerotherapy is done above this lineThis line divides the upper 2/3 and lower 1/3 of the anal canal. Above it, we have columnar epithelium and below it's stratified squamous epithelium.

Question 295

Abdominal stoma examination

Answer 295

Do not remove the stoma bag in the examination unless you have been specifically directed to do so//Introduction//Inspection1- describe the site of stoma: LIF (colostomy) RIF (ileostomy) R lumbar (urostomy) (on the right because ureter is slightly shorter on R side), epigastric (gastrostomy/jejunostomy, or even loop colostomy), suprapubic (mucous fistula)2- estimate the size of lumen (large=colostomy/small=ileostomy or urostomy). Beware that if lumen is small, then this may have occurred from complications related to stomas, like stenosis or retraction. A prolapsed stoma will make the lumen look bigger.3- count number of lumens: single lumen (most cases: eg end stoma), double lumen (either looped or double stoma)4- examine for a spout: absence of spout (if lumen is flush with skin, it is probably a colostomy (unless prolapsed) vs spout present (ileostomies usually to keep irritant effluent off the skin. Urostomies as well).5- bag content: dark-green fluid and odourless (ileostomy), solid faeces and faeculent (colostomy), urine (urostomy)6- look for abdo scars: give a clue to what surgery they had (eg midline laparotomy scar in conjunction with colostomy, which can be from an abdominoperitoneal resection or Hartmann's procedure)//Complete the examination: to complete my examination I would like to examine the perineum to look for the presence of a patent anal canal and anal stump (pouch left behind after colon is diverted surgically).Differentiation of a colostomy between AP resection (abdominoperineal) (in low-lying rectal Ca or severe UC) vs Hartmann's (done as emergency for diverticulitis or bowel obstruction, secondary to colorectal Ca): Closed perineum vs patent anal canal.

Question 296

Differentiation of a colostomy between AP and Hartmann's

Answer 296

AP resection (abdominoperineal) (in low-lying rectal Ca or severe UC) Closed perineumHartmann's (done as emergency for diverticulitis or bowel obstruction, secondary to colorectal Ca): patent anal canal.

Question 297

What is a stoma

Answer 297

This is a surgically created connection between the GI or urinary tract and the skin. It can be temporary (reversible) or permanent.

Question 298

How to distinguish between ileostomy and colostomy?

Answer 298

1- Site: RIFT (ileostomy) vs LIF (colostomy)2- Spout : present (ileostomy) vs Flush (colostomy)3- bag effluent: odourless dark-green liquid (ileostomy) vs solid faeces (colostomy)4- effluent volume: 500 ml (low output) to 1L (high output) (ileostomy)/ day vs 300 ml/day (colostomy)

Question 299

What are the complications of a stoma?

Answer 299

These can be divided into general complications and complications specific to the stoma itself:- general cpx: nutritional disorders (eg vit b deficiency), renal stones, short gut syndrome, stoma diarrhea, psychological- specific complications: technical problems (such as ischemia, prolapse, parastomal hernia, stenosis or retraction). Practical problems (include malodour, skin irritation due to spillage of bag effluent).

Question 300

Causes of abdominal pain?

Answer 300

Localisation of pain:- R hypochondrial: biliary colic, acute cholecystitis, ascending cholangitis, empyema, hepatitis, sub phrenic abscess- Epigastric: peptic ulcer disease, leaking AAA, acute pancreatitis, perforated duodenal ulcer- L hypochondrial: splenic infarct/rupture- R lumbar: renal and ureteric colic, pyelonephritis- Umbilical: leaking AAA, small bowel obstruction- L lumbar: renal and ureteric colic, pyelonephritis- R iliac fossa: appendicitis, ureteric colic, inguinal hernia, terminal ileitis, gynae pathology- suprapubic: distended bladder, large bowel obstruction, UTI, pelvic inflammatory disease- L iliac fossa: diverticulitis, ureteric colic, gynae pathology, inguinal hernia

Question 301

How can pain be categorised?

Answer 301

Pain can be categorised depending on its aetiology:- visceral pain: diffuse pain that is poorly localised; usually described as being dull and aching in character---- foregut pain (described as being epigastric in site)---- mid-gut pain (usually felt in para-umbilical region)---- hindgut pain described as pain in lower abdo- parietal / somatic pain: well localised and sharp in nature, arising from peritoneal inflammation- referred pain: aching in nature and perceived as being near the surface of the body.

Question 302

Indications for various types of stomas?

Answer 302

- feeding: jejunostomy, gastrostomy- decompression: caecostomy, gastrostomy- diversion: urostomy (ileal conduit), ileostomy (temporary or permanent), loop colostomy (currently performed using the sigmoid colon, 2 openings, 1 functioning to release stool and gas, 1 non-functioning), double-barrelled colostomy: both ends of the colon are brought to the surface next to each other and are sutured together along the anti-mesenteric border- exteriorisation: double barrelled colostomy, end colostomy (AP resection), end colostomy and rectal stump (Hartmann's), end colostomy and mucous fistula

Question 303

Typical structure of an orthopedic examination

Answer 303

LookFeelMoveSpecial testsNeurovascular examinationX-Rays

Question 304

Phases of the gait cycle

Answer 304

1- Heel strike (heel touches the ground)2- stance phase (entire period where foot is on ground) (represents 60% of gait cycle)3- toe off4- swing phase (foot in the air for limb advancement)

Question 305

Gait examination

Answer 305

////Look- check for walking aids or appliances (in presentation "this patient is walking unaided" or "the patient walks aided by a Zimmer fame"). Appliances include shoe raises, orthotics or calipers- ask for pt to walk: symmetry of arm swing, presence of pelvic tilt and stride length - carefully observe the gait: looking for 1- limp (gait smooth or halted (due to abductor weakness in Trendelenburg, or leg shortening or antalgic gait)) 2- distinctive pattern of the gait, 3- arm swing, 4- how the patient turns around////Special tests- Heel-to-shin pathology- Romberg's test: if positive... Indicative of vestibular or proprioceptive problem

Question 306

Patterns of gait

Answer 306

-- antalgic gait: decreased stance phase and increased swing phase... Pathology=pain-- Trendelenburg lurch: shoulders and trunk lurch sideways in order to bring the body weight over the affected limb. Pathology=weak abductors-- drop foot: foot drops in swing phase, and the foot is lifted higher than normal so that the toes don't drag along the ground. The foot may slap the ground prematurely. Pathology=peripheral neuropathy or injury to the nerves L5 supplying the ankle dorsidlexors (common peroneal or sciatic nerve palsy)-- high stepping: compared to drop foot, both feet are raised here. Pathology=bilateral foot drop, proprioception or cerebellar disease-- short leg: ipsilatera hip falls when pt weight bears on short leg. Pathology: congenital shortening, previous fracture-- waddling: pt trunk moves from side to side with each step they take. Pathology=dislocation of hips, weakness of abductor muscles

Question 307

What is antalgic gait?

Answer 307

It's a gait with a decreased stance phase and increased swing phase, usually due to pain

Question 308

What types of walking aids are there?

Answer 308

Walking aids can be broadly classified into sticks, crutches and frames.Various types in each group, eg Zimmer frame, elbow crutches, or a wooden stick with crook handles

Question 309

Can u tell which side has the pathology from the position of the stick?

Answer 309

When using one stick, stick should be held in the opposite hand to the side of pathologyIf hip pathology, in opposite hand to reduce the weight bearing loadIf kmee pathology, usually held in ipsilateral hand

Question 310

What is the Trendelenberg sign

Answer 310

Sign found in people with weak or paralysed abductors of the hip, namely gluteus medius and gluteus minimus

Question 311

What to expect in examining a hip with osteoarthritis

Answer 311

!!! Look- Patient usually older than 50- Functional aids: walking aid, especially walking stick (held in the hands opposite to the affected hip)- Gait: obvious limp, angelic gait or Trendelenberg positive- From front: hip scar often seen in opposite hip (Patient often awaiting arthroplasty for the other hip), muscle wasting, leg length discrepancy- From the back: lumbar lordosis may be increased in those with fixed flexion deformity, scoliosis, scars from posterior approach!!! Closer inspection: affected leg will appear short, fixed flexion deformity!!! Feel: tenderness!!! Move: movements are generally restricted!!! Special tests: Thomas demonstrates a fixed flexion deformity

Question 312

What does Trendelenberg test indicate?

Answer 312

Weakness of the hip abductorsMore specifically, - This could be a false positive, usually due to pain or poor balance on the patients part as a result of generalised weakness- Gluteal muscle inhibition due to pain from the hip joint- Gluteal muscle inefficiency due to congenital hip dislocation or coxa vara - Gluteal muscle paralysis from polio

Question 313

How you investigate a patient with an osteoarthritic hip?

Answer 313

- simple blood tests such as renal function tests, because the patient is likely to be on long-term NSAID which may lead to interstitial nephritis- Specialist blood tests, particularly rheumatoid factor and ANA , to exclude a systemic cause- Imaging, which would include plain film radiographs of the affected hip with two views, AP and lateral, and views of the joint above and below

Question 314

What radiological features to find in osteoarthritic hip?

Answer 314

Loss of joint spaceOsteophytesSclerosisSubchondral cysts

Question 315

Radiological features of rheumatoid arthritis

Answer 315

Periarticular osteoporosisLoss of joint spaceMarginal erosionsAbsence of osteophytes

Question 316

Management of osteoarthritis

Answer 316

MDT approach with input from orthopedic surgeon, gp, physiotherapist and occupational therapistDivided in:!!! Conservative measures:- Lifestyle changes ( Functional aids to help with daily living activities)- Walking stick held in the opposite hand- Weight loss and regular physiotherapy!!! Medical treatments involve:- Pain relief ( who analgesic ladder)!!! Surgical interventions- Vary according to age: if patient>50, total joint replacement is procedure of choice- For younger patients, they will have at least one revision in their lifetime, therefore benefit from other procedures such as repositioning osteotomy until an arthroplastybecomes a viable option

Question 317

Features suggesting a total joint replacement be suitable

Answer 317

Intractable pain (with failure of conservative and Medical measures)Rest pain, instability or loss of mobility

Question 318

What to find in hip affected by rheumatoid arthritis

Answer 318

- Patient has usually an established pattern of multiple joint involvement that is typically symmetrical- There is a marked Gluteal muscle and calf wasting- Affected limb is held in fixed fixation in external rotation- All movements are generally restricted and painful, whereas in osteoarthritis the movements may be restricted but often painless with a limited range

Question 319

Hip examination... Main steps

Answer 319

//// Look- walking aids or appliances - observe from front: 1- level of hips and knees: symmetrical? 2- valgus/varus deformities of the knees 3- surgical scars 4- obvious leg length discrepancy?- observe from back : 1- surgical scars (don't forget posterior approach to hip), 2- any gluten muscle wasting? 3- any scoliosis? (compensory scoliosis can be seen in true shortening)- examine gait- perform trendelenburg's test//// closer inspection - measure leg length: apparent leg length (umbilicus to medial malleolus) and true leg length (ASIS to medial malleolus). If discrepancy do Galeazzi test//// Feel- palpate over bony landmarks for tenderness : (over ASIS, PSIS and greater trochanter for trochanter bursitis)//// Move- Thomas' test: for fixed flexion deformity. And assess flexion (130o) extension (10o) at same time - check abduction (45o) and adduction (30o)- check rotation internal (35o) and external (45o)//// complete examination " to complete my examination I would like to assess the neurovascular status of the lower limbs and examine the knees and back"- could ask for x-ray in 2 positions and for joint above and below

Question 320

Pes cavus and pes planus

Answer 320

Pes cavus: arched feetPes planus: flat feet

Question 321

Swelling in knee

Answer 321

- could be local effusion that may be reactive or secondary to osteoarthritis, haemarthrosis, (in tibial plateau fractures), septic arthritis (Dx with joint aspiration of the fluid and tested for MC&S and gram stain)- Prepatellar bursitis (housemaid's knee), infrapatellar bursitis (clergyman's knee- Popliteal fossa swellings (baker's cyst)

Question 322

What provides stability to the knee joint

Answer 322

The following ligaments:- ACL and PCL (intracapsular) stop the tibia moving anteriorly and posteriorly respectively in relation to the femur- Medial and collateral ligaments (extracapsular) provide support for the capsule of the knee.- Medial collateral attached to the medial tibial condyle and protects against a valgus force- Lateral collateral attached to the head of the fibula and protects against a varus force- Quadriceps and hamstrings are massive providers of stability to the knee joint

Question 323

What is the purpose of the fibula

Answer 323

Acts as a support for the tibia, so in lower limb fractures if only the tibia is fractured it can be treated in plaster alone, as it is considered to be a relatively stable injuryWhen both tibia and fibula fractured, most centres treat with an intramedullary nail of the tibia, because this is classified as a unstable fracture

Question 324

What to expect in examination of an osteoarthritic knee

Answer 324

!!! Look- Walking stick- Varus deformity, fixed flexion deformity- Opposite knee having a midline scar, indicating previous total knee replacement- Quadriceps muscle wasting- Antalgic gait !!! Feel- Joint line tenderness- Effusion may be present!!! Move- Crepitus on movement- Decreased range of flexion- Fixed flexion deformity of the knee may become apparent- Generalised tenderness on active and passive movement !!! Special tests- Positive McMurray's test

Question 325

What features would you look for in an X-ray of an osteoarthritic knee?

Answer 325

I would request a weight bearing X-ray of the knee, with AP and lateral views looking specifically for:- Loss of joint space- Osteophytes - sclerosis- Subchondral cysts Mnemonic LOSS

Question 326

How would you manage osteoarthritis of the knee

Answer 326

Essentially managed in a similar fashion using an MDT management approach. Details specific to the knee include:- Physiotherapy to improve quadriceps muscle strength- Simple analgesia in the form of paracetamol or co-codamol - Walking aid in form of stick or framesIntra-articular steroid injection for temporary pain relief- Partial or total knee arthroplasty

Question 327

How do you initially assess a Surgical Emergency?

Answer 327

It is important to state initially:"this is a surgical emergency. I will resuscitate the patient by:!!! Assessing the airways:- Give supplemental oxygen (high flow oxygen via a non rebreathable bag- Assess potency: 1)ask patient a question. If no answer, then 2) assess for evidence of airway compromise (anything blocking, blood vomits, suction using a Yankauer suction. Listen for stridor. 3) establish a patent airway by a) simple manoeuvres ( jaw thrust, chin lift, removing foreign bodies) b) airways adjuncts (oropharyngeal (guedel) or nasopharyngeal) c) secure or definitive airway (orotracheal intubation).!!! Checking the breathing- Monitoring: saturation probe or ABG - Inspection: cyanosis, check Respiratory rate, chest wall expansion, distended neck veins (pneumothorax), paradoxical chest wall movement (flail chest)- Palpation: tracheal deviation? Percussion for hyperresonance in pneumothorax or dullness in postoperative basal atelectasis or haemothorax.- Auscultate: !!! Assess circulation- Assess level of shock: cool? Clammy? Capillary refill time?- Monitoring: attach to monitor and check vital signs (HR, BP)- obtain IV access (2 large bore cannulae (grey or brown)- Resuscitation fluids: (crystalloids, colloids or blood)- Additional monitoring: urinary catheter, central line...!!! Assess disability- Neurological status: GCS, AVPU (alert, verbal response, response to pain, unresponsive)- Pupils: opiates (bilateral pinpoint pupils) or blown pupil (unilateral dilated pupil) in space occupying lesion (subdural or extradural hematoma)- BM glucose: !!! Assess environment/exposure- Exposure for bleeding..- Assess abdomen (pulsatile / expantile mass)!!! Reassess Always say that you will go back and reassess a b and c to check there is anything you have missed!!! Emergency investigations!!! Call for Senior help and advice!!! Definitive treatment (conservative, medical or surgical)Say that you will book an emergency theatre slot

Question 328

What is a definitive airway:

Answer 328

Is one where a cuffed tube is secured in the trachea, ensuring patency

Question 329

Atelectasis definition

Answer 329

Defined as the collapse or closure of the lung resulting I reduced or absent gas exchange. Alveoli are deflated. Acute onset may occur as a post operative complication or resultant of surfactant deficiency

Question 330

What emergency investigations would you confident in a surgical patient?

Answer 330

- simple bedside tests: EGG, pregnancy test, BM glucose- Blood tests: FBC, U&E ... ABG if critically ill- Imaging: erect chest X-ray, CT abdomen- Specialist investigations: depends on differentials (eg serum amylase in acute abdomen)- Exploratory laparotomy

Question 331

How to manage a 35 year old woman complaining of right upper quadrant pain. Serum amylase is 3500.

Answer 331

This is acute pancreatitis.This is a surgical emergency1- initial resuscitation: I would resuscitate the patient, ensuring the patient's airway is patent with access to high flow oxygen. I would then ensure the patient is breathing adequately. I will address the circulation by inserting 2 large bore cannulae whilst taking blood for pancreatic severity assessment at the same time. I would begin the patient on aggressive fluid resuscitation as thepatient is likely to have suffered significant third space loss.2- additional monitoring: to accurately guide fluid replacement I would like to assess the patient volume status through Clinical examination, the patient vital signs and urine output. Need for urinary catheter and a strict fluid balance chart documented in order to maintain positive balance3- call for help: at this point I would call for senior help and advice. After discussion with a senior colleague, I would like to consider the need for a central line to accurately guide fluid replacement4- assess severity: I would then like to assess the severity of this pancreatitis attack as this will help determine the level of Care the patient requires, particularly the need for an HDU bed. Using the modified Glasgow severity score, I would perform a arterial blood gas analysis on air to check for type over respiratory failure with pO2 less than 8 as this would suggest acute respiratory distress syndrome. I would also check for a Metabolic acidosis and serum lactate levels as this gives an indication of the level of shock. Other specific tests I would request include glucose levels to check for hyperglycemia as the patient may need an insulin sliding scale plus serum calcium levels and particularly a CRP as this helps to monitor and guide treatment. Other investigations include a plain abdominal radiography to check for calcified gallstones as a possible cause and a chest X-ray to check for signs of ARDS5- Definitive treatment- I would keep the patient NBM consider nutritional support (enteral or parenteral if severe) + good pain relief (PCA through a dedicated line)- I would request an USS to check for stones in the biliary

Question 332

Causes of pancreatitis

Answer 332

GET SMASHED- Gallstones (most common cause in the UK)- Ethanol (second most common)- Trauma- Steroids - Mumps- Autoimmune disease- Scorpion bites- Hyperlipidemia , hyperacalcemia- ERCP- Drugs (thiazide diuretics)

Question 333

What fluids to give in acute pancreatitis (surgical emergency)

Answer 333

The constituents ions of Hartmann's solution are very similar to the ECF compartment. As pancreatitis leads to fluid loss, which is mainly ECF , replacing with an isotonic crystalloid seems the logical choice

Question 334

How much fluid to give as resuscitation of acute pancreatitis

Answer 334

Patients should receive maintenance fluids plus additional losses. As this patient is likely to have suffered significant third space loss, it would not be unusual to give 6l or more in one dayHowever I would firstly need to assess the patient volume status and guide fluid replacement according to thatEmpirically I would give 1l stat followed by another 1l over the first hour, then another 1l over the subsequent 2 hours, another over the next 3 hours and then 6 hourly thereafter. This would be guided by the fluid balance chart which should be strictly kept

Question 335

How would you assess the severity of the pancreatitis attack?

Answer 335

Using the Glasgow prognostic score (in the first 48 hours)- P: Arterial pO2 < 8 KAps- A: Age > 55- N: Neutrophiles > 15- C: Calcium < 2- R: Raised urea > 16- E: elevated enzymes AST> 125 or LDH > 600- A: Albumin < 32- A: Sugar > 10Score of 1: mildScore of 2: moderateScore of =>3: severe and is an indication for HDU Independent from the other variables, a CRP > 150 constitutes a severe attack

Question 336

What are the different types of pancreatitis

Answer 336

- Oedematous (most common)- Haemorrhagic (look for Cullen's sign or Grey Turner sign)- Necrotising pancreatitis

Question 337

Would you start antibiotics in a acute pancreatitis

Answer 337

Use of antibiotics is controversial. Important to:- Follow trust protocol- In case of infected pancreatic necrosis, discuss with on call microbiologist and my seniors...

Question 338

What diagnosis would you consider if a patient had a persistent raised amylase?

Answer 338

- pancreatic pseudocyst is the likely causeIt commonly occurs in pancreatitis due to alcohol and is conformed on CT scanThose< 6 cm in size resolve within 6 weeksLarger ones may need to be percutaneously drained under radiological guidance

Question 339

How to manage a man with hematemesis?

Answer 339

- recognise its an emergency- Initial resuscitation: mainly assess level of hypovolemic shock- Emergency investigation: FBC, U&E (IF raised urea then recent GI bleeding), LFT, Amylase, clotting, cross match at least 4 units of blood- Additional monitoring: CVP line and catheter to accurately guide resuscitation- Call for help: "after Discussion with a senior colleague I would like to consider the need for an emergency OGD In the unstable patient.- Assess severity: rockall score (prognostic scoring system for acute GI bleeds based on the patient's medical history, current clinical Condition and endoscopic findings)- Definitive treatment: 1- consider resuscitation with blood if still hypertensive 2- PPI (if known peptic ulcer disease) 3- emergency OGD for diagnosis and treatment 3- Sengstaken-Blakemore tube if massive bleeding and the patient is still awaiting definitive treatment 4- Surgery if uncontrolled bleeding, re-bleeding, recurrent hypotension or the bleeding site is not identified as OGD.NEVER FORGET TO CROSS MATCH BLOODAND PUT TWO LARGE BORE CANNULA IN ANTECUBITAL FOSSA

Question 340

How to manage a man with hematemesis?

Answer 340

- recognise its an emergency- Initial resuscitation: mainly assess level of hypovolemic shock- Emergency investigation: FBC, U&E (IF raised urea then recent GI bleeding), LFT, Amylase, clotting, cross match at least 4 units of blood- Additional monitoring: CVP line and catheter to accurately guide resuscitation- Call for help: "after Discussion with a senior colleague I would like to consider the need for an emergency OGD In the unstable patient.- Assess severity: rockall score (prognostic scoring system for acute GI bleeds based on the patient's medical history, current clinical Condition and endoscopic findings)- Definitive treatment: 1- consider resuscitation with blood if still hypertensive 2- PPI (if known peptic ulcer disease) 3- emergency OGD for diagnosis and treatment 3- Sengstaken-Blakemore tube if massive bleeding and the patient is still awaiting definitive treatment 4- Surgery if uncontrolled bleeding, re-bleeding, recurrent hypotension or the bleeding site is not identified as OGD.NEVER FORGET TO CROSS MATCH BLOODAND PUT TWO LARGE BORE CANNULA IN ANTECUBITAL FOSSA

Question 341

What are the causes of an upper GI bleed

Answer 341

- duodenal ulcer (most common)- Gastritis, esophageal varices- Mallory-weiss tears - Malignancy

Question 342

What ate the surgical options if bleeding is due to bleeding peptic ulcer

Answer 342

- under-running of the bleeding vessel- Excision of the ulcer- Gastrectomy

Question 343

What are the causes of an upper GI bleed

Answer 343

- duodenal ulcer (most common)- Gastritis, esophageal varices- Mallory-weiss tears - Malignancy

Question 344

What ate the surgical options if bleeding is due to bleeding peptic ulcer

Answer 344

- under-running of the bleeding vessel- Excision of the ulcer- Gastrectomy

Question 345

What is the rockall score?

Answer 345

This is a prognostic scoring system for acute GI bleeding baSed on patients Medical history, current Clinical condition and endoscopic findings(Age, shock, co-morbidity, diagnosis, endoscopy)Score>8: high risk of deathSour<3: excellent prognosis

Question 346

How to manage an acutely painful pulseless leg

Answer 346

Key features to mention:- Recognise that this is an emergency- Initial resuscitation: include iv fluids and opiate analgesia- Emergency investigations: angiogram in incomplete ischemia, DO NOT DELAY DEFINITIVE TREATMENT IF COMPLETE ISCHEMIA- additional monitoring: CVP line and catheter to accurately guide resuscitation- Call for help: call early as time is

Question 347

What are the signs of acute limb ischemia

Answer 347

This is known as the 6 Ps- Pain: usually severe- Pallor: occurs in progressive stages (1- white appearance progressing to mottled but blanching 2- non blanching mottled skin 3- fixed staining and liquefaction- Perishingly cold- Pulseless (confirm with Doppler)- Paresthesiae (Assess sensation)- Paralysis (Assess motor function)PARESTHESIAE AND PARALYSIS ARE LATE SIGNS (USUALLY IRREVERSIBLE)

Question 348

what specific post Op complications to look for

Answer 348

- Reperfusion injury: when arterial oxygen is reintroduced, leads to oxygen free radicals causing endothelial damage- Can lead to metabolic complications such as acidosis ARDS and myoglobinemia or it can lead to a compartment syndrome which requires emergency fasciotomy

Question 349

This man was found collapsed in the street. He has a plausible expansile mass on abdominal examination. How would you manage him?

Answer 349

- recognise urgency- Initial resuscitation: includes blood (do not wait for cross match, give O-), maintain BP < 90, as it may destabilise a tamponading clot (permissive hypotension), two large bore cannula...- Emergency investigations: none required. Straight to theatre. 10 units needed...- Additional monitoring: CVP line and urinary catheter- Call for help- Definitive treatment: immediate Surgery to cross clamp the aorta proximal to the rupture and control the bleeding ITU care post operativelyA 60 YEAR OLD MAN WHO PRESENTS WITH RENAL COLIC CAN BE A LEAKING AAA.NEVER SEND AN UNSTABLE PATIENT TO CT SCAN. THEY MIGHT ATTEST

Question 350

5 days Post hemicolectomy (for sigmoid ca). The nurses have called you as she has spiked temperature. How to manage Post operative fever?

Answer 350

- Recognise urgency- initial resuscitation: involves a quick systematic examination to look for a cause (listen to chest for basal atelectasis, examine the abdomen for peritonitis, look at wounds for signs of infections and examine the legs for DVT. Assess for SIRS (systematic inflammatory response syndrome)- Emergency investigations: do septic screen (FBC, urine dipstick, CXR, and blood culture before starting antibiotics. Consider water soluble contrast study of the rectum to rule out an anastomotic leak- Call for help- Definitive treatment: depends on cause/// NBM /// If urine or chest infection: give empirical antibiotics iv and chest physiotherapy for basal atelectasis. If patient in septic shock then give fluid challenge and consider HDU/// Anastomotic leak (occur between day 3 and d 5): if patient stable and leak is small them conservative management preferred. If peritonitic, then laparotomy for wash out and plug the leak

Question 351

What is the most common cause of postoperative fever in abdominal surgery

Answer 351

Basal atelectasis. It can be prevented with good chest physiotherapy an nd airway adequate analgesia. That's why some patients are kept on epidural analgesia to be able to take good deep breaths.

Question 352

What are the causes of postoperative fever

Answer 352

- immediate < 24 hours: physiological stress response to Surgery- Early: /// < 3 days: basal atelectasis (pneumonia)/// > 3 days: pneumonia, wound infection, anastomotic leaks, subphrenic or pelvic abscess, UTI, line infection/// > 5 days: PE or DVT

Question 353

What is SIRS?

Answer 353

systemic inflammatory response syndrome with at least 2 of the following features:- Temperature>38 or 90 minutes- Respiratory rate: > 20 / minute- White Cell count: > 12 or < 4

Question 354

Woman returning to the Ward after having a laparotomy for acute abdominal pain. Hourly urine output<30 ml. How to manage postoperative oliguria?

Answer 354

- Recognise urgency- Initial resuscitation: quick systematic examination to assess volume status:/// Mental status (confusion)/// Hands (skin turgor, prolonged CRT, patient cool and clammy,?/// Vital signs: tachycardia, hypotension/// JVP: if low/// Examine: chest for signs of fluid overload, abdomen for distended bladder (in obstruction)/// Fluid balance chart assessment- Emergency investigations: renal function urea creatinine...- Additional monitoring: CVP monitoring if not responding to fluid challenges + urinary catheter...- Call for help- Definitive treatment: depends on cause/// Post renal: obstruction by large stove or BPH causing acute urinary retention/// intrinsic renal: call for expert (may need dialysis)/// Pre-renal: give fluid challenge and reassess. This is the most common cause of postoperative oliguria and is most likely due to hypovolemia secondary to dehydration.

Question 355

Man involved in rta. No obvious sites of injury.

Answer 355

- Recognise urgency: manage according to ATLS principles- Initial resuscitation: intubation because gcs low (endotracheal tube)... Fluids... Anesthetits- Emergency investigations: CXR, pelvic x Ray c-spine. FAST scan to look for source of bleeding. CT head chest abdo pelvis if stable.- Additional monitoring: urinary catheter- Call for help- Definitive treatment: /// Identify source of bleeding by looking in 5 places: abdomen, chest, long bones/pelvis, head and floor/// If intra abdominal bleeding this will require immediate laparotomy to diagnose and treat

Question 356

How do you assess hypovolemic shock?

Answer 356

Through Clinical examination and Assessment:- Stages of hypovolemia1- blood loss up to 15%2- 15-303- 30-404- > 40...Bp will only drop in phase 3

Question 357

What is a FAST scan

Answer 357

Focused Assessment sonogram in traumaRapid because ultrasound examination of various parts of the body where blood is likely to have collected Post trauma. Looking at: abdomen, thorax...

Question 358

Peripheral vascular examination

Answer 358

- General inspection: paraphernalia of disease: 1- does patient have an amputation? Describe level. Any associated walking/mobility aids or prosthesis? 2- is patient on oxygen, iv infusion of heparin, GTN spray and our cigarettes?- Upper limb vascular examination:1- examine hands: skin changes (tar staining, tendon Palmar xanthoma, purple discoloration of fingers (atheroembolism), muscle wasting (thoracic outlet syndrome), temperature, pulses, CRT, BP (less than 15 mmHg between 2 sides in absence of arterial disease)2- examine neck and face: eyes (corneal arcus, xanthelasma, conjunctivital pallor), mouth (central cyanosis & angular stomatitis), neck (prominent veins on neck, chest wall and over shoulders (indicates subclavian vein occlusion)), pulses (feel carotid pulse), bruits (auscultate for carotid bruits using bell of stethoscope).- Abdominal examination: Check for AS A- Lower limb vascular examination:1- General inspection: asymmetry (amputation, edema, muscle wasting), Surgical scars (indicative of previous varicose vein removal, or suggestive of vein harvesting for CABG, any varicosities present), skin changes (discoloration (erythema, pallor, Brown/hemosiderin deposits, purple/black from haemostasis), venous guttering, trophic changes(no hair, shiny skin, gangrene), ulcers2- closer inspection: detailed inspection of toes (amputation, purple discoloration (AAA trash foot), ulcers), focus on pressure areas where ischemic ulcers can develop (sole, lateral, heels...)3- palpation: Check skin temperature, CRT (if prolonged do a Buerger's test, Buerger's test (lift leg...). If PAD, then legs turn bluish from deoxygenated blood as it travels over ischemic tissues and then turns red from reactive hyperuremia from Post-hypoxic vasodilation. Check peripheral pulses (femoral (mid-inguinal point= halfway between ASIS and the pubic tubercle), popliteal pulse, posterior tibial pulse (posterior and 2 cm inferior to medial malleolus of tibia), dorsalis pedis pulse (lateral to extensor hallucis longus tendon, absent in 10%)4- auscultation: listen for bruits over femoral artery and over aorta and iliac barrels5- special tests: measure ABPI on both sides (>0.9 normal, 1.2 can suggest hardening of the arteries from calcification, resulting in arteries being stiffer or less compressible. Seen in patients with DM and renal failure.

Question 359

How to investigate a peripheral artery disease patient?

Answer 359

Investigations can be divided into bedside tests, blood tests and imaging.1- simple bedside tests: BM (see if diabetic), ECG (for evidence of coexisting heart disease because patient likely arteriopath)2- simple blood tests: FBC (anemia, polycythemia), U&E (renal function, important if undergoing contrast studies, especially in diabetics (contrast-induced nephropathy), lipid profile, clotting, esr (vasculititdes), G&S (if operative management)3- imaging: ///"cxr to look for coexisting cardio Respiratory disease, particularly as part of a pre oPerative Assessment". "I would like to request specialist imaging to assess the extent of disease and help plan operative management: duplex scan to check for the degree of stenosis. ///Spiral CT to reconstruct 3d images of vessels noninvasively. /// in some patients a digital subtraction angiogram (DSA) to demonstrate the level of blockage, runoff and presence of collateral blood supply.Management: those who undergo invasive imaging such as angiography have a catheter introduced (seldinger technique) into femoral artery and guided to site of lesion, where radio dense contrast is injected and imaged using x rays. Stenosis can be treated at same time by balloon angioplasty.

Question 360

Can you estimate the extent of stenosis from a hand held Doppler probe

Answer 360

- Simple hand held Doppler probe detects arterial pulsation add an audible signal.- Degree of stenosis causes turbulent blood flow which results in bruits heard on auscultation with a stethoscope- Characteristic waveforms seen:/// Normal vessels: triphasic waveforms/// Mild stenosis: biphasic waveform/// Severe stenosis: monophasic waveform

Question 361

Why are lower limbs more commonly affected by PAD compared to lower limbs

Answer 361

Arterial supply to legs is noir as well developed as the arterial supply to upper limbsTherefore th re lower limb arterial supply is also more susceptible to atherosclerosis than the upper limbs. So PAD is 8 times more common in lower limbs than in upper limbs

Question 362

How to treat a patient with lower limb occlusive arterial disease?

Answer 362

This involves an MDT management approach. Conservative and Medical management focus around modification of risk factors and Surgical measures1- Conservative measures include: stopping

Question 363

Benefits of a below-knee amputation (BKA) over an above knee amputation (AKA)

Answer 363

BKA are preferred:- Better mobility for patients and less likely to be ♿ bound- Physical benefits (reducing energy to mobilise)- Life expectancy better for BKA - Patients with AKA more likely to develop critical ischemia in other leg

Question 364

Reasons for amputation?

Answer 364

Three Ds - Dead limb (vascular (PAD)- Dangerous limb (infection (osteomyelitis)- Debilitating limb (trauma (frostbite))

Question 365

Please examine this man's abdomen as part of your vascular examination

Answer 365

Key features to look for:-inspection: look for abdo scars, mainly over femorals (from previous bypass surgery), obvious mass in epigastrium, visible pulsations (kneel from side to see them)- Palpation/auscultation: /// Palpate above and slightly to left of the umbilicus (before aorta bifurcates at L4 level)/// See if pulsatile and expansile (one ✋ moves laterally with each pulse)/// Estimate transverse diameter of the mass in centimeters/// Try to feel the upper border of the mass, if felt it would suggest aneurysm is infrarenal (only 1% suprarenal)/// Auscultate aneurysm for bruits/// Examine femoral and popliteal pulses

Question 366

Please examine this man's abdomen as part of your vascular examination

Answer 366

Key features to look for:-inspection: look for abdo scars, mainly over femorals (from previous bypass surgery), obvious mass in epigastrium, visible pulsations (kneel from side to see them)- Palpation/auscultation: /// Palpate above and slightly to left of the umbilicus (before aorta bifurcates at L4 level)/// See if pulsatile and expansile (one ✋ moves laterally with each pulse)/// Estimate transverse diameter of the mass in centimeters/// Try to feel the upper border of the mass, if felt it would suggest aneurysm is infrarenal (only 1% suprarenal)/// Auscultate aneurysm for bruits/// Examine femoral and popliteal pulses

Question 367

Please examine this man's abdomen as part of your vascular examination

Answer 367

Key features to look for:-inspection: look for abdo scars, mainly over femorals (from previous bypass surgery), obvious mass in epigastrium, visible pulsations (kneel from side to see them)- Palpation/auscultation: /// Palpate above and slightly to left of the umbilicus (before aorta bifurcates at L4 level)/// See if pulsatile and expansile (one ✋ moves laterally with each pulse)/// Estimate transverse diameter of the mass in centimeters/// Try to feel the upper border of the mass, if felt it would suggest aneurysm is infrarenal (only 1% suprarenal)/// Auscultate aneurysm for bruits/// Examine femoral and popliteal pulses

Question 368

potential complications of AAA

Answer 368

- rupture, dissection, thrombosis and embolisation from the thrombosis leading to trash foot- Fistula formation into adjacent organs, such as the colon (mainly duodenum) our vena cava

Question 369

What is a fistula?

Answer 369

It's an abnormal connection between two epithelial surfaces lined by granulation tissue

Question 370

What factors to make you consider elective operative treatment of an aneurysm

Answer 370

Depends on two features: symptomatic or not/// Asymptomatic: recommendation for repair when aneurysm diameter is >5.5 cm or if expanding at rate of > 1 cm a year/// Symptomatic patients should have their aneurysm repairedTypes of AAA repair:- Endovascular repair (can be done by interventional radiologist- Open repair

Question 371

What do you know about the NHS AAA screening programme

Answer 371

If you are a man aged over 65 you are more likely to have an abdominal aortic aneurysm. That is why the NHS AAA Screening Programme invites men for screening during the year (1 April to 31 March) that they turn 65.Men over 65 who have not previously been screened or diagnosed with an aneurysm can request a scan by contacting their local programme directly.Good screening programme needs to meet the Modified Wilson's criteria for screening programmes (the condition should be an important health problemthe natural history of the condition should be understoodthere should be a recognisable latent or early symptomatic stagethere should be a test that is easy to perform and interpret, acceptable, accurate, reliable, sensitive and specificthere should be an accepted treatment recognised for the diseasetreatment should be more effective if started earlythere should be a policy on who should be treateddiagnosis and treatment should be cost-effectivecase-finding should be a continuous process)

Question 372

Draw the arterial vessels of the body

Answer 372

....

Question 373

Draw the venous system of the body

Answer 373

Lower limbs: 1- superficial system: long and short saphenous veins. Responsible for draining the skin and subcutaneous tissues of the leg2- deep venous system: exists within the muscles of the leg and is covered by fascia. Receives blood from superficial venous system through the connecting perforation veins. When muscle contracts, blood pushed towards the ❤ and valves in veins are responsible for preventing backflow of blood. If valves incompetent, blood is forced from deep system to superficial system, causing veins to dilate.

Question 374

Definition of varicose veins

Answer 374

Dilated tortuous and prominent veins of the superficial venous system of the lower limb seen in the distribution of the short and long saphenous veins

Question 375

Risk factors for Development of varicose veins

Answer 375

History of dvt/pe Increasing ageObesityPositive family historyPregnancy and pelvic masses (cause increase pressure on the ivc and iliac veins)Any previous treatment to the legOCP use (needs to be stopped at least 4 weeks before any Surgical intervention due to risks of DVTAsk in history about aching legs and swellings, legs feeling heavy, pruritus, restless legs and skin changes (venous eczema, ulcers). Symptoms usually worse at night, and in occupation that requires standing o

Question 376

Clinical examination of varicose veins

Answer 376

ALWAYS REMEMBER TO EXAMINE PATIENT ERECT AAD VARICOSITIES MIGHT BE COLLAPSED IF SUPINE 1- introduction: patient spine initially then patient required to stand up2- inspection:/// Observe patIent lying spine: - General inspection (any obvious asymmetry, scars from previous varicose veins removal or vein harvesting for CABG, any varicosities), - signs for chronic venous insufficiency (1- swelling and brown discoloration/hemosiderin deposition, 2- telangiectasia and venous eczema, 3- lipodermatosclerosis from chronic venous hypertension causing sclerosis of skin and subcutaneous tissues from fibrin deposition 4- erythema seen in thrombophlebitis.- Look in gaiter area around medial malleolus (where venous ulcers are typically seen)- Look at groin for hernias, saphena varus or prominent lymph node/// Observe patient standing: look for tortuous varicosities (anteriorly for long saphenous and posteriorly for short saphenous). "Posteriorly I can see that there are multiple dilated and elongated veins in the distribution of the short saphenous vein". PATIENT REMAINS STANDING UNTIL TOURNIQUET TEST3- Palpation /// Palpate for a saphena varix (locate SFJ which is 2 cm inferior and 2 cm medial to femoral pulse (at mid-inguinal point). If lump found, might be a saphena varix which will be smooth with a palpable thrill and will empty on minimal pressure and refill once fingers are removed/// Cough test: place 2 fingers on SFJ while patient standing, if thrill felt then incompetence of valve. DO COUGH TEST AFTER CHECKING FOR SAPHENA VARIX./// Palpate varicosities: press and release and see refill. If pain then phlebitis. If vein feels hard, then thrombosis./// Palpate to check temperature4- special tests: to determine site of incompetence/// Tap test: find prominent varicosity. One hand over SFJ and other over varicosity. Tap over SFJ. If thrill transmitted to varicosity... Suggests incompetence at SFJ./// Trendelenberg / tourniquet test: in supine position, raise leg to comfortable angle for patient and you. Milk leg. Then tourniquet as high as possible. Patient stands. If veins refill immediately: level of incompetence below SFJ (repeat with tourniquet lower, mid-thigh, calf)). If veins do not fill: level of incompetence above tourniquet i.e. at SFJ./// Doppler probe: most reliable of the special tests. Place Doppler over SFJ. With other hand squeeze calf. And listen to the"whoosh" sound coming from probe. In normal leg: only hear noise once as blood forced proximal. In SFJ incompetence, double whoosh (second heard because blood flows backwards through valve when stop squeezing the calf). Repeat at saphenopopliteal junction.5- Auscultate: listen for bruits over varicositiesTo compete my examination, I would like to Palpate for peripheral pulses and examine the abdomen as well as perform a DRE to exclude an abdominal or rectal mass.IT'S IMPORTANT TO CONSIDER SECONDARY CAUSES OF VARICOSE VEINS, PARTICULARLY MALIGNANCIES.

Question 377

Where to locate the SFJ (saphenofemoral junction)

Answer 377

4 cm below and 4 cm lateral to public tubercle

Question 378

describe the course of great and short saphenous vein?

Answer 378

- great saphenous vein: passes anterior to medial malleolus, travels proximal in medial aspect of the calf to the popliteal fossa and then travels along medial aspect of thigh to join the common femoral vein at SFJ - Short saphenous vein: arises posterior to lateral malleolus and ascends along the midline of the calf to join the popliteal vein in SFJ in popliteal fossaDON'T SAY VEINS START AT SFJ. STAY DISTALLY

Question 379

how to investigate a varicose veins patient

Answer 379

- rule or secondary causes, ie abdominal/pelvic malignancies, DVT- Color duplex scanning with mating of perforators

Question 380

How do you manage a varicose veins patient

Answer 380

Management involves- Taking a focused history to rule or secondary causes of varicose veins- Thorough clinical examination- Tailoring of investigations depending on findings before mentioning treatment options.Treatment can be conservative, medical or surgical- Conservative: treaty underlying cause if any (e.g. weight loss in obese, constipation...), Graduated compression stockings for symptomatic relief (TED stocking: thromboembolic disease)- Surgical measures/// Injection chemotherapy for small varicosities/// Multiple stab avulsions with vein stripping and ligation of the incompetent junction/// Subfacial endoscopic perforator Surgery (SEPS)/// radiofrequency or foam ablation

Question 381

Possible differential diagnosis for varicose veins

Answer 381

- cellulitis, DVT - Phlebitis: inflammation of superficial veins, secondary to intraluminal thrombosis. If migratory, then raise suspicions about underlying malignancy- Osler-weber-rendu syndrome (telangiectasia, recurrent epsitaxis)

Question 382

Tell me about DVT prophylaxis for surgical patients

Answer 382

I will take a history to assess for the presence of risk factors such as age, ocp use, smoking, previous history of DVT/PE and high risk surgical procedures associated with DVT (eg TKR (incidence=50%)).Main DVT prophylaxis:- TED stockings- Low Molecular weight heparin

Question 383

Why is it important to check for history of DVT in patients undergoing varicose vein surgery?

Answer 383

- varicose veins may be secondary to thrombosis of the deep or superficial veins- If deep venous system not functioning, particularly after a DVT, patient is relying on the superficial system for venous return- Patients should have Doppler ultrasound scanning of their deep veins to confirm patency and check valve competence prior to Surgery- Clinically could perform a perthes test (put elastic bandage from toes to upper third of thigh to obliterate superficial veins. Ask patient to walk for 5 min. If deep system ok, nothing will happen. If incompetent, then pain in leg.

Question 384

If the patient with varicose veins has an unusual rash on his face, what diagnosis to consider

Answer 384

Varicose veins associated with a port wine stain and limb hypertrophy are signs seem in the rare Klippel-Trenaunay syndrome.

Question 385

Different types/causes of ulcers

Answer 385

Most common:- Arterial disease- Venous insufficiencyOther:- peripheral neuropathy- Trauma- Neoplastic causes: eg marjolin's ulcer (an scc in long standing Non healing ulcer) eg in previous trauma or wound- Systemic disease (uc, ra), leading to pyoderma gangrenosum

Question 386

Clinical examination of an ulcer

Answer 386

1- introduction: it's acceptable to ask the patient at this point whether the ulcer is painful (helps in diagnosis)2- inspection/// General inspection of lower limbs: ? Signs of chronic venous insufficiency, varicose veins, trophic changes, amputations or surgical scars/// Describe site of ulcers- Arterial: pressure areas, tips of toes- Venous: gaiter area- Neuropathic: heel, on the sole under the metatarsal heads/// Describe size and shape of ulcer: estimate size in cm. Check shape to see if margins well defined or irregular- Arterial: small (few cm)- shape: well defined margins with regular outline- Venous: variable in size (can be very large). Shape: irregular outline and variable shape- Neuropathic: size: variable (several cm). Shape: regular outline/// Describe edge of ulcer- Arterial: punched out- Venous: sloping or flat- Neuropathic: punched out /// Describe base of ulcer: resonate depth of ulcer (sometimes can see underlying bone and tendons). Base can be from healthy to completely avascular.- healthy: pink granulation tissue, areas of epithelialisation- Sloughy: offensive, exudative discharge, usually green or yellow in color- Necrotic: black dead tissue- Avascular : shiny paleIF YOU SEE DISCHARGE, SAY TO EXAMINER THAT YOU WOULD TAKE SWABS FOR MC&S (MICROSCOPY CULTURE AND SENSITIVITY)AND START TOPICAL ANTIBIOTICS3- Palpation/// Check if painful (Neuropathic: no pain/ arterial and venous painful, but usually arterial more painful and require opiate analgesia)/// Check temperature of surrounding skin: Arterial: if colder than rest of leg. Venous: if warmer than rest of leg/// Check CRT: Arterial: prolonged crt /// Check peripheral pulses (mainly distal pulses)To complete my examination I would like to perform a complete peripheral vascular examination, looking particularly at sensation.

Question 387

Definition of gaiter area

Answer 387

It's the distal one third of the leg along the medial aspect, above the medial malleolus

Question 388

What is granulation tissue (in the vascular context)

Answer 388

Granulation tissue is a heterogeneous structure that forms within the extracellular matrix at the end of the proliferative phase of wound healing. It consists of fibroblasts, macrophages and endothelial cells with a rich capillary network

Question 389

What is a sloughy tissue (in vascular context)

Answer 389

This is most necrotic tissue

Question 390

Please examine the lesion on this patient's leg (Venous ulcer on gaiter area)

Answer 390

Key features to look for:- Inspection:/// Associated paraphernalia: treatment on table (topical antibiotic), for of bed raised (part of ulcer treatment), patient's last bandage next to bedside/// General inspection of leg: patient usually an arteriopath, look for signs of chronic venous insufficiency or varicose veins. "On general inspection, the lower limbs are Oedematous with loss of hair, areas of hemosiderin deposition and lipodermatosclerosis. Site: gaiter area, size/shape: variable in size, can be extremely large, irregular margins. Edge: sloping. Base: shallow and sloughy with underlying pink granulation tissue./// Palpation: temperature: skin surrounding ulcer is warmer than the rest of the leg. Usually painless./// Completion: offer to examine for varicose veins as an associated feature. Offer ABPI. An index of >0.8 is prerequisite top compression bandaging. "I would like to check the patient's ABPI to ensure the index is greater than 0.8 as the patient is likely to require four layer compression bandaging as part of his treatment".i

Question 391

What is lipodermatosclerosis and hemosiderin ?

Answer 391

It's a skin and connective tissue disease. Known as chronic panniculitis with lipomembranous changes. An inflammation of the layer of fat under the epidermis.Hemosiderin deposition: common late complication of untreated superficial venous insufficiency or venous reflux resulting in chronic venous hypertension. Buildup of venous pressure in the superficial dilated veins leads too leakage of red blood cells from the capillaries into the surrounding tissues under the skin. Over time, breakdown of haemoglobin content of the red blood cells in these tissues lead to accumulation of hemosiderin, resulting in long term and potentially permanent brown pigmentation of the overlying skin. (Potential treatment: intense pulse light (IPL) and tattoo removal lasers)

Question 392

What is compression bandaging

Answer 392

This is part of the treatment for venous ulcers and most ulcers heal within a year with this treatmentEvidence based medicine proves that compression bandaging works, it should be offered to all patients with an ABPI>0.8 (because they could otherwise compromise arterial flow to the limb. It's a four layer bandaging technique (Non adherent dressing over the ulcer, followed by crepe bandage, blue lien bandage and finally an adhesive bandage).

Question 393

What to consider if venous ulcer fails to heal

Answer 393

"The great majority of ulcers heal by 12 weeks and most heal by a year. So if an ulcer fails to heal, I would need to consider the possibility of malignant transformation of a long-standing ulcer and arrange for a biopsy to exclude a marjolin's ulcer.Always say MDT management (including wound Care Nurse, OT, district Nurse Care...)In conservative management: patient advised to rest and keep limb elevated to reduce venous hypertension. Once ulcers are healed, patient advised to wear graduated elastic compression stockings.Surgical: skin graft may be used with excitation of the underlying dead skin.

Question 394

Please examine the lesion on this patient's foot (Arterial ulcer)

Answer 394

Key features to look forInspection://// Associated paraphernalia: patient may be on prostaglandin infusion/// General inspection of the leg: patient usually arteriopath. If amputation on opposite limb them mention it./// Site: usually on pressure areas of feet, around the toes)/// Size/shape: well defined regular margins, size no more than several cm/// Edge: classically punched out/// Base: no granulation tissue due to poor blood supply. May be necrotic or Avascular. Can be deep. Even potentially see tendons and bone. "The ulcer appears deep and I cam see the underlying bone"- Palpation: temperature (surrounding skin cold and grayish blue discoloration), painful ulcer (may be masked by peripheral neuropathy in diabetics. Peripheral pulses absent (offer to use a Doppler probe, loss of triphasic waveform seen in arteriopath).Completion/management:Management similar to those for peripheral vascular disease. PAIN RELIEF IS KEY (WHO pain ladder). Use of vasodilators such as prostaglandins or surgical techniques such as lumbar sympathectomy.

Question 395

How to distinguish ivc obstruction from portal hypertension

Answer 395

, look at veins below umbilicus

Question 396

When to consider pleuridesis

Answer 396

2 or more spontaneous pneumothorax

Question 397

Tell me about bone scan

Answer 397

Radioisotopes caught by more metabolically active...

Question 398

Definition of laparotomy

Answer 398

Inspection of.... Check

Question 399

Difference between arterial claudication and neurological claudication (spinal stenosis)

Answer 399

Other types of claudicationNeurological: spinal stenosis (numbness, worse on bending forward),

Question 400

What do claudication patients die of

Answer 400

Mi cva renal failureMortality 5y 60%Give antiplatelets and statin

Question 401

Definition of critical ischemia

Answer 401

3 parts Greater than 2 weeks Rest pain unremittingTissue lossAbpi less than 0,5

Question 402

Acute ischemia

Answer 402

PalePulselessPerishing coldPainfulParasthesiaParalysis

Question 403

How do aneurysms present

Answer 403

Incidental findingNerve compression/painVein compression/dvt (popliteal aneurysm)Embolisation or thrombosisFistula (aorta enteric fistula, aorta cutaneous fistula, aorto cava fistula)

Question 404

Screening for aaa

Answer 404

> 65One of uss of abdomen

Question 405

Complications of aneurysms

Answer 405

RuptureEmbolisation (trash footThrombosis (acutely ischemi, leg)Pressure DVTFistularion acutely unstable usually

Question 406

Thoracic outlet syndrome

Answer 406

Venous: upper limb dvt and long term swellingArterial: raynaud, claudication embolisationNeurological: pain radiculipathyIx: mri, mra MarcDuplex in abductionNerve conduction studies

Question 407

Why do diabetics get ulcer

Answer 407

Pvd Small vessel diseaseNeuropathyInfection

Question 408

What is a charcot joint

Answer 408

Painless... Check definition

Question 409

Causes of raynaud

Answer 409

CrestThoracic outlet syndromeIdiopathic (Primary) most common white blue redLarge vessel diseaseVasculiticOccupational: vibrating toolIatrogenic: anthocyaninsHaematological: polycythemia, cold affliction.

Question 410

How to estimate area of body surface burntWhy is it important to know

Answer 410

Rule of 9If more than 15% them start fluid resuscitationManagement with split-skin graft taken from thigh

Question 411

Common nerve lesions in carotid artery Surgery

Answer 411

Hypoglossal nerve palsy (tongue towards lesion)Recurrent laryngeal 9 (cough)...8710

Question 412

Describing fracture radiograph

Answer 412

See photo

Question 413

Management of fractures

Answer 413

ResussReduce restrict/hold Rehabilitate

Question 414

Smith and colles fracture

Answer 414

Smith's fracture, also sometimes known as a reverse Colles' fracture or Goyrand-Smith's, is a fracture of the distal radius.[1] It is caused by a direct blow to the dorsal forearm[2] or falling onto flexed wrists, as opposed to a Colles' fracture which occurs as a result of falling onto wrists in extension. Smith's fractures are less common than Colles' fractures.The distal fracture fragment is displaced volarly (ventrally), as opposed to a Colles' fracture which the fragment is displaced dorsally. Depending on the severity of the impact, there may be one or many fragments and it may or may not involve the articular surface of the wrist joint.

Question 415

Most likely cause of postoperative pyrexia, tachycardia and dyspnea

Answer 415

Postoperative pulmonary collapse. Extremely common following thoracic abdominal or groin Surgery.Pyrexia unlikely from wound infection our PE so soon after surgery.Cause: retention of plugs of mucus in bronchial tree.Managed Physio, vigorous breathing exercises, coughing in upright position, passion management pca, antibiotic

Question 416

Burst abdomen = abdominal wall dehiscenceFactors- causes

Answer 416

FolloWing colectomy...Usually preceded by pink fluid sign, serous peritoneal exudate from wound several days before complete dehiscence.Factors:Preoperative factors: vit c deficiency, protein deficiency, jaundice, uremia, anemia, chronic cough, abdominal distensionOperative factors: faulty techniquePostoperative factors: cough abdominal dissension, wound sepsis

Question 417

Managing burst abdomen

Answer 417

Reassure patient or relativesIv morphine as sedation and pre anesthetic medication and antiemeticCover exposed viscera and transfer to theatre with General anesthesia

Question 418

What happens with incisionsal hernia

Answer 418

Deep layers of abdominal wound give eau but skin sutures hold

Question 419

Definition of fistula

Answer 419

Pathological communication between two epithelial surfaces

Question 420

Fistulogram

Answer 420

Injection of radioopaque contrast fluid gastrograffin through fine catheter into the fistula

Question 421

Definition of cellulitis

Answer 421

Spreading infection of cellular tissues. May involve superficial fascia, overlying skin...Symptoms: heat pain redness swellingComplications: abscess + homogeneous ,+ systemic features like Pyrexia ill Management: swab blOod culture antibiotics

Question 422

Definition of abscess

Answer 422

It's a localised collection of pus. Pus is defined as living and dead phagocytes usually containing living and dead bacteria.

Question 423

General manifestations of an abscess

Answer 423

Swinging PyrexiaTachycardiaMalaiseAnorexiaSweating Polynorph leucocytosisSometimes pus seen around a piece of suture: stitch abscess

Question 424

Carbuncle

Answer 424

Area of subcutaneous necrosis that discharges onto the surface through multiple sinuses. Most commonly neck from collar excoriatingUsually staph aureus Common in diabetics

Question 425

Indications of renal transplant

Answer 425

Check

Question 426

Sister Marie Joseph nodule

Answer 426

Intra abdominal and ovarian cancer

Question 427

Recti

Answer 427

Lines alba

Question 428

Hydrocele

Answer 428

Fluid in tunica vaginalis

Question 429

Hematuria causes

Answer 429

Check

Question 430

Bladder cancer

Answer 430

Majority transitional Cell cancerScc: shistosomiasis

Question 431

JJ stent

Answer 431

A ureteral stent, sometimes as well called ureteric stent, is a thin tube inserted into the ureter to prevent or treat obstruction of the urine flow from the kidney. The length of the stents used in adult patients varies between 24 to 30 cm. Additionally, stents come in differing diameters or gauges, to fit different size ureters. The stent is usually inserted with the aid of a cystoscope. One or both ends of the stent may be coiled to prevent it from moving out of place, this is called a JJ stent, double J stent or pig-tail stent.

Question 432

Definition of urinary retention

Answer 432

Painful palpable our percussavle bladder when the patient us unable to pass any urine Inability of passing urine

Question 433

Contents of spermatic cord

Answer 433

Arteries: testicular artery, deferential artery, cremasteric arteryNerves: nerve to cremaster (genital branch of the genitofemoral nerve), testicular nerves (sympathetic nerves) and the ilio-inguinal nerve- Ilio-inguinal nerve not inside spermatic cord, but runs along the outside.Vas deferens (ductus deferens)Pampiniform plexusLymphatic vesselsTunica vaginalis (remains of the processus vaginalis)

Question 434

Borders of inguinal canal

Answer 434

Superior wall (roof): 2 Muscles:internal oblique Muscletransverse abdominus MuscleAnterior wall: 2 Aponeuroses:Aponeurosis of external obliqueAponeurosis of internal obliqueLower wall (floor): 2 Ligaments:inguinal Ligament·lacunar LigamentPosterior wall: 2Ts:Transversalis fasciaconjoint Tendon

Question 435

Hesselbach triangle

Answer 435

RIPMedial border: Lateral margin of the rectus sheath, also called linea semilunarisSuperolateral border: Inferior epigastric vesselsInferior border: Inguinal ligament, sometimes referred to as Poupart's ligament

Question 436

Midline laparotomy

Answer 436

Skin, fat, linea alba and peritoneum

Question 437

Femoral triangle

Answer 437

The femoral triangle is bounded:superiorly by the inguinal ligament.medially by the medial border of the adductor longus muscle.laterally by the medial border of the sartorius muscle.[2]

Question 438

Focused Hx in skin presentation

Answer 438

- duration: how long it's been present- changing lesion: changed, increased, decreased, disappeared then reappeared? Seasonal? Bleeding? Itching?- inheritance: FH?- environmental influence: occupation and hobbies. Sun? Sun Beds?- Drug side effect: patient taking any meds?- hypersensitivity: any known allergies- pt HX: anything like this before? How was it treated?

Question 439

What are the muscles of the eyelids

Answer 439

Orbicularis oculi (facial nerve 7): closes eyeLevator palpebrae: (CN3): opens eye

Question 440

CN in medulla

Answer 440

9 10 11 12

Question 441

CN in pons

Answer 441

5 6 7 8

Question 442

Swinging light test

Answer 442

RAPD relative afferent pupillary defectAka Marcus Gunn pupil

Question 443

Eye muscles

Answer 443

Superior rectus: 45 lateralInferior rectus: 135 lateral Medical rectus: 90 medialLateral rectus: 90 lateralSuperior oblique: 135 medial Inferior oblique: 45 medial

Question 444

Cranial nerve 4 palsy

Answer 444

Muscle involved: trochlear / superior obliqueEffect: head tilt away, hypertropia (up tilt and away from lesion... Very subtle. Eye moves up when horizontal H examination). Double vision when reading book or walking down stairsCauses: vasculitic (diabetes hypertension), trauma, congenital, tumour

Question 445

Cranial nerve 3 palsy

Answer 445

Lateral rectus muscle and levator muscleEffect: down and out+ pupil dilationCauses: vasculitic ( diabetes, hypertension) aneurysms

Question 446

Cranial nerve 6 palsy

Answer 446

Abducens muscleEffect: crossed eyes (double vision when looking towards affected eye)Causes: vasculitic (diabetes, hypertension), increased intracranial pressure

Question 447

Patient with horizontal diplopia and lots of hearing. Where is the lesion

Answer 447

If CN3, then down and out which is not the case hereSo probably CN6 (loss of hearing 7) so probably in pons

Question 448

No eye movement at all+ good vision+ loss of sensation in cheek and brow. Where is the lesion?

Answer 448

Cavernous sinus lesion causing problems with CN 3 4 and 6 and V1 and V2 of CN5

Question 449

Definition of angina and how to differentiate it from MI

Answer 449

Angina is a term used to describe cardiac chest pain resulting from myocardial infarctionAngina usually lasts less than 20 min, is relieved by rest and by GTNvsMI tends to be longer, lasting more than 20 min and can last several hoursELDERLY AND DIABETICS CAN HAVE SILENT MI

Question 450

Apart from chest pain, how can cardiac patients present

Answer 450

Symptoms of cardiac failure such as: * SOB * Orthopnea * Paroxysmal Nocturnal Dyspnoea (PND) * Ankle swelling

Question 451

What is PND

Answer 451

Paroxysmal nocturnal dyspnea (or PND) refers to attacks of severe shortness of breath and coughing that generally occur at night. It usually awakens the person from sleep, and may be quite frightening. Though simple orthopnea may be relieved by sitting upright at the side of the bed with legs dependent (legs dangling), in a patient with paroxysmal nocturnal dyspnea, coughing and wheezing often persist even in this position.

Question 452

How might cardiac conduction abnormalities manifest in symptoms?

Answer 452

* Palpitations * Chest pain * Syncope

Question 453

Possible causes of palpitations?

Answer 453

* AF * VT * SVT

Question 454

Define syncope

Answer 454

Syncope is a transient loss of consciousness usually due to inadequate cerebral perfusion

Question 455

What are the cardiac causes of syncope? And the other important but sometimes overlooked causes of cardiac syncope?

Answer 455

Cardiac causes include: * AF * Paroxysmal tachycardias * Ventricular tachycardias * Heart block (I, II, III) * slow arrhythmia (sinus brady)Other: HAPE mnemonic * HOCM (hypertrophic obstructive cardiomyopathy) * Aortic stenosis * PE (important prognostic factor in PE) * Atrial myxomaSlow arrhythmia

Question 456

What to ask for in the FH section in the CV history taking?

Answer 456

Non-modifiable risk factor:  * Early death * FH of peripheral vascular disease * FH of ischemic heart disease * FH of stroke * FH of hypertension * FH of hyperlipidemia * FH of sudden death !!!!!!!!

Question 457

What to ask about in the Drug history section in CV history taking?

Answer 457

* OTC drugs * Recreational drugs such as cocaine (cause chest pain)  * Check if asthmatic cause relative CI to beta blockers * Check if there is Hx of peptic ulcer disease... It's an important negative. might be prescribing aspirin. 

Question 458

What are splinter hemorrhages?

Answer 458

these are vasculitic lesions under the nail. Seen in endocarditis.

Question 459

What are osler's nodes and Janeway lesions?

Answer 459

* Osler's node: finger pulp - Tender | * Janeway lesions: Palms - PainlessBoth seen in Endocarditis

Question 460

Causes of raised JVP?

Answer 460

* CCF * Cor pulmonale * Tricuspid regurgitation * Pulmonary hypertension * Complete heart block

Question 461

Describe the different waves in the JVP

Answer 461

* a wave: atrial contraction. Dissapears in AF * c: tricuspid contraction * x: atrium relaxes * v wave: atrial venous filling (in tricuspid regurgitation) * y: atrial emptying

Question 462

What are the different eponymous signs of Aortic regurgitation?

Answer 462

* Watson's water hammer pulse (collapsing pulse) * Corrigan's pulse (rapid upstroke and collapse of the carotid artery pulse) * low diastolic and increased pulse pressure * de Musset's sign (head nodding in time with the heart beat) * Quincke's sign (pulsation of the capillary bed in the nail; named for Heinrich Quincke) * Traube's sign (a 'pistol shot' systolic sound heard over the femoral artery; named for Ludwig Traube) * Duroziez's sign (systolic and diastolic murmurs heard over the femoral artery when it is gradually compressed with the stethoscope)

Question 463

What signs can be elicited in the eyes in a CV examination?

Answer 463

* Corneal arcus Argyll Robertson pupil (syphillis) (not reactive/no constriction to light = prostitute pupil) (small, irregular pupils, the size of the pupils may be unequal, absence of the light reflex, a prompt accomodation reflex) * Xanthelasma * Conjunctival pallor

Question 464

What are Thrills and Heaves

Answer 464

* Thrills: palpable murmurs | * Heaves: palpable beats (usually right ventricle hypertrophy)

Question 465

What else to mention in a CV examination as other things to do/examine?

Answer 465

* lungs (for crackles), sacrum and ankle oedema Abdomen: * for tender pulsatile liver (cardiac failure or tricuspid regurgitation) * spleen for splenomegaly (infective endocarditis) * Tender pulsatile mass indicative of AAA * Auscultate for renal artery stenosis bruit * Palpate for peripheral pulses * Look for radiofemoral delay and auscultate over femoral arteries (aortic regurg) * Examine the fundi for diabetic and hypertensive retinopathy, + look for Roth spots (IE) Dipstick urine for: * Proteinuria (hypertensive retinopathy) * Glycosuria (DM) * Haematuria (IE)

Question 466

Causes of heart murmurs

Answer 466

DR PECCS (mnemonic): * Degenrative * Rheumatic fever * Prosthetic * Endocarditis * Congenital * Connective tissue disease * Syphillis (aortic regurg)

Question 467

What are the non-modifiable risk factors for coronary artery disease?

Answer 467

* age * sex * family history

Question 468

Name some modifiable risk factors for coronary artery disease

Answer 468

* smoking * DM * Dyslipidemia * HTN * Obesity * Sedentary lifestyle

Question 469

Symptoms of MI

Answer 469

* Chest pain at rest (rather on exertion) (often radiating to jaw, neck or L arm) * Nausea * Vomiting * Sweating * Collapse or SOB (if reduction of CO)DM sometimes no pain and N&V are the prominent symptom

Question 470

Differentiate between the different acute coronary syndromes

Answer 470

* ACS: ischemic chest pain at rest or on rapidly reducing levels of exertion * Unstable angina is pain without an enzyme rise (without evidence of necrosis) * NSTEMI: chest pain with positive markers of necrosis (ie troponin) but without ST elevation * STEMI: chest pain with ST elevation on ECG

Question 471

Reliable examination findings in ACS?

Answer 471

Possible "autonomic features": * clamminess * sweating * Evidence of cardiogenic shock (shut down peripherally, hypotensive) * Heart failure: crepitations, raised JVPSometimes not much is found on examination

Question 472

What do ECG changes indicate in ACS?

Answer 472

ST elevation on ECG indicate full-thickness ischemia (STEMI). * Usually due to thrombosis of an unstable plaque in a coronary artery leading to total occlusion * Subtotal or transient occlusion generates partial thickness ischemia and this is represented on an ECG with ST depression or T wave abnormalities.Management: * STEMI: Emergency reperfusion therapy (PAMI: Primary angioplasty in acute MI) * NSTEMI: require angiography as well but pt can be stabilised medically.

Question 473

Complications of ACS

Answer 473

Depending on the damage to the heart, there may be: * evidence of shock = poor prognosis structural complications: * infarction of mitral valve papillary muscles leading to acute mitral regurgitation * rupture of the intraventricular septum causing VSD * rhythm disturbances common. heart failure (serious and long term complication)  * function of ventricle impaired by presence of non contracting scar

Question 474

What Rx to give on presentation of ACS?

Answer 474

* Aspirin (usually long-term) * Clopidogrel (usually for 1 year) * Enoxaparin (clexane) * statin * ACEI * beta-blocker (if no CI)

Question 475

Characteristics of unstable angina

Answer 475

* Chest pain at rest * chest pain getting worse with exertion (reduced exercise tolerance) * new onset chest pain

Question 476

When is troponin measured?

Answer 476

12 hours from peak of pain (in practice on admission and 12h after).Troponin is used in risk stratification

Question 477

What are the different cardiac biomarkers?

Answer 477

* Myoglobin (quickly) * CK-MB * LDH * BNP 

Question 478

Complications of MI?

Answer 478

Mnemonic FAM * Failure * Arrhythmias (commonest VT & VF... require cardioversion * Murmur: MR or VSD

Question 479

Approach to systolic murmurs

Answer 479

* Chest pain... Likely AS * Chest pain + Palipitations... Likely Mitral * Chest pain + Dizziness... Likely AS

Question 480

What are the main causes of Aortic stenosis?

Answer 480

* Calcific / degenerative AS : common with aging population (associated with atherosclerotic RF). Elderly >70 * Rheumatic heart disease (fusion of the commissures)

Question 481

Most common symptoms of AS?

Answer 481

* Angina (often first symptom) * Syncope * Heart failure (breathlessness, oedema)

Question 482

Signs of AS?

Answer 482

* Ejection systolic murmur in aortic region (R sternal edge) heard in carotids * Apex hyperdynamic * Slow rising pulse * Low volume

Question 483

Typical ECG findings of AS?

Answer 483

Resistance to outflow through the left ventricular outflow tract caused LVH.

Question 484

Treatment options for AS?

Answer 484

* Medical: no evidence Surgical: * Symptomatic AS: Valve replacement (gold standard) * Asyptomatic AS: regular annual fup with serial echo * IN OLDER PATIENTS, DO ANGIOGRAPHY BEFORE VALVE REPLACEMENT

Question 485

What drug class not to use in patients with severe AS?

Answer 485

Never give NITRATES in severe AS as they reduce preload which will impact the cardiac output

Question 486

What is valvuloplasty?

Answer 486

It involves inserting a balloon across the valve and inflating it to increase the size of the stenosed valve orifice. Doesn;t increase survival and risk of complications

Question 487

What is a TAVI?

Answer 487

* Transcatheter aortic valve implantation * Under GA, catheter inserted accross stenosed aortic valve (through apex of the heart or from femoral arteries). * In catheter, there is expandable valve opens in the old stenosed valve, crushing the calcified old leaflets.  * Used for patients with unacceptably high risks of open valve replacement.

Question 488

Prognosis of AS if untreated?

Answer 488

* Asymptomatic patients: very good Px Symptomatic patients: median survival of 2 years if untreated * clinical features of HF are a late sign and carry worse prognosis.

Question 489

What is the difference between aortic stenosis and sclerosis (classical final Q)

Answer 489

Sclerosis: * No radiation * Normal pulse * Normally elderly  

Question 490

What advice to give when discharging a patient with AS?

Answer 490

Advice on: * Symptoms: chest pain, syncope, cardiac failure * Complications: HF

Question 491

What is cardiogenic shock?

Answer 491

The clinical definition of cardiogenic shock is decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. Cardiogenic shock is the leading cause of death in acute MI, with mortality rates of up to 70-90% in the absence of aggressive, highly experienced technical care. Signs and symptoms: The diagnosis of cardiogenic shock can sometimes be made at the bedside by observing the following: * Hypotension * Absence of hypovolemia * Clinical signs of poor tissue perfusion (ie, oliguria, cyanosis, cool extremities, altered mentation)

Question 492

Features of Pancoast syndrome?

Answer 492

Pancoast syndrome is characterized by a malignant neoplasm of the superior sulcus of the lung (lung cancer) with destructive lesions of the thoracic inlet and involvement of the brachial plexus and cervical sympathetic nerves (stellate ganglion). This is accompanied by the following: * Severe pain in the shoulder region radiating toward the axilla and scapula along the ulnar aspect of the muscles of the hand * Atrophy of hand and arm muscles * Horner syndrome (ptosis, miosis, hemianhidrosis, enophthalmos) * Compression of the blood vessels with edema

Question 493

Signs of portal hypertension

Answer 493

* Ascites * Hepatic encephalopathy. * Increased risk of spontaneous bacterial peritonitis. * Increased risk of hepatorenal syndrome. * Splenomegaly (enlargement of the spleen) with a consequent accumulation of red blood cells, white blood cells, and platelets together leading to mild pancytopenia. * Portacaval anastomoses: Esophageal varices, gastric varices, anorectal varices and caput medusae. Esophageal and gastric varices pose an ongoing risk of life-threatening hemorrhage, with hematemesis or melena.

Question 494

Causes of ascites

Answer 494

Causes of high SAAG ("transudate") are * Cirrhosis - 81% (alcoholic in 65%, viral in 10%, cryptogenic in 6%) * Heart failure - 3% * Hepatic venous occlusion: Budd-Chiari syndrome or veno-occlusive disease * Constrictive pericarditis * Kwashiorkor (childhood protein-energy malnutrition) Causes of low SAAG ("exudate") are: * Cancer (primary peritoneal carcinomatosis and metastasis) - 10% * Infection: Tuberculosis - 2% or Spontaneous bacterial peritonitis * Pancreatitis - 1% * Serositis * Nephrotic syndrome * Hereditary angioedema Other Rare causes: * Meigs syndrome * Vasculitis * Hypothyroidism * Renal dialysis * Peritoneum mesothelioma

Question 495

Stages of diabetic retinopathy

Answer 495

Diabetic retinopathy has four stages: * Mild Nonproliferative Retinopathy. At this earliest stage, microaneurysms occur. They are small areas of balloon-like swelling in the retina’s tiny blood vessels. * Moderate Nonproliferative Retinopathy. As the disease progresses, some blood vessels that nourish the retina are blocked. * Severe Nonproliferative Retinopathy. Many more blood vessels are blocked, depriving several areas of the retina with their blood supply. These areas of the retina send signals to the body to grow new blood vessels for nourishment. * Proliferative Retinopathy. At this advanced stage, the signals sent by the retina for nourishment trigger the growth of new blood vessels. This condition is called proliferative retinopathy. These new blood vessels are abnormal and fragile. They grow along the retina and along the surface of the clear, vitreous gel that fills the inside of the eye. By themselves, these blood vessels do not cause symptoms or vision loss. However, they have thin, fragile walls. If they leak blood, severe vision loss and even blindness can result.

Question 496

Grades of hypertensive retinopathy

Answer 496

Grade 1: Arteriolar constriction/attenuation/sclerosis -`silver wiring` and vascular tortuosities Grade 2: As grade 1 + Irregularly located, tight constrictions - Known as `AV nicking` or `AV nipping` Grade 3: As grade 2 + Retinal edema, cotton wool spots and flame-hemorrhages Grade 4: As grade 3 + swelling of the optic disk (papilloedema) + macular star