General surgery (passmed)

Question 1

What are the two ‘signs’ of appendicitis to do with discolouration?

Answer 1

Periumbilical discolouration
- Cullen’s sign

Flank discolouration
- Grey-Turner’s sign is described but rare

Question 2

What is the sign for Cholecystitis, pain in the RUQ when pressed?

Answer 2

Murphy’s

Question 3

What is Rovsing’s sign for?

Answer 3

Appendicitis

Question 4

Classic differentials for abdo swelling?

Answer 4

Pregnancy
Intestinal obstruction
Ascites
Urinary Retention
Ovarian Ca.

Question 5

Location and aetiology of inguinal hernias and femoral hernias?

What type has the highest risk of strangulation?

Answer 5

Direct Inguinal

• Above and medial to pubic tubercle
• Medial to epigastric vessels
• Weakness in transversalis fascia

Indirect Inguinal

• Above and medial to pubic tubercle
• Lateral to epigastric vessels
• Failure of the processus vaginalis to close

Femoral
- Below and lateral to the pubic tubercle

Femoral has the highest risk of strangulation

Question 6

Difference in an umbilical and paraumbilical hernia?

Answer 6

Paraumbilical is an asymmetric bulge - half is covered by skin

Question 7

What are the three biological therapies used in Rheumatoid arthritis and Crohns disease?

Answer 7

Adalimumab
Infliximab
Etanercept

Question 8

What is cryptorchidism?

Answer 8

A congenital undescended testis

Question 9

What is Scheuermann’s disease?

• Presentation (symptoms and signs)
• What is it

Answer 9

Epiphysitis of the vertebral joints is the main pathological process

Presentation:

• Predominantly affects adolescents
• Symptoms include back pain and stiffness
• X-ray changes include epiphyseal plate disturbance and anterior wedging
• Clinical features include progressive kyphosis (at least 3 vertebrae must be involved)

Question 10

Types of scoliosis?

Answer 10

Structural and non-structural

Non structural typically disappears upon movement

Question 11

What are the three categories of spina bifida?

Answer 11

Myelomeningocele
- The worst, may have neurological defects

Meningocele
- ?just needs to be closed

Occulta
- Fine, about 10% of babies

Question 12

What is Spondylolysis?

Answer 12

Congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/ L5.

May be asymptomatic and affects up to 5% of the population.

Spondylolysis is the commonest cause of spondylolisthesis in children.

Question 13

What is Spondylolisthesis?

Answer 13

One vertebra is displaced relative to its immediate inferior vertebral body

May occur as a result of stress fracture or spondylolysis

Question 14

Treatment for spondylolisthesis?

Answer 14

Treatment depends upon the extent of deformity and associated neurological symptoms, minor cases may be actively monitored. Individuals with radicular symptoms or signs will usually require spinal decompression and stabilisation.

Question 15

What determines whether you should gastric feed/feed elsewhere?

Answer 15

Upper GI function

If dysfunction then jejunal/duodenal

Question 16

What are the four types of fistulae, and their features?

Answer 16

Enterocutaneous

• Intestines to skin
• High or low output (>500ml is high)

Enteroenteric/enterocolic
- Small bowel or large bowel

Enterovaginal
- Bowel to vagina

Enterovesicular

• Bowel to bladder
• Pneumouria

Question 17

Management of fistulas?

Answer 17

Most will heal by themselves if not associated with underlying inflammatory condition

If enterocutaneous then need to protect skin, e.g. use stoma bag.

Can use octreotide if high volume (less pancreatic secretions)

Question 18

What is the Parkland formula for fluid resus in burns?

Answer 18

4 x (total burn surface are x weight (kg))

Half given in first 8 hours

Question 19

At what percentage body surface cover should you fluid resus in kids and adults?

Answer 19

> 15% in adults

> 10% in kids

Question 20

Summary of low acute GI management?

Answer 20

Consider admission if:

• Over 60 years
• Haemodynamically unstable/profuse PR bleeding
• On aspirin or NSAID
• Significant co-morbidity

Management:

• All patients should have a history and examination, PR and proctoscopy
• Colonoscopic haemostasis aimed for in post polypectomy or diverticular bleeding

Question 21

Groin lumps key questions

Answer 21

Is there a cough impulse

Is it pulsatile AND is it expansile (to distinguish between false and true aneurysm)

Are both testes intra scrotal

Any lesions in the legs such as malignancy or infections (?lymph nodes)

Examine the ano rectum as anal cancer may metastasise to the groin

Is the lump soft, small and very superficial (?lipoma)

Question 22

Scrotal lumps key questions

Answer 22

Is the lump entirely intra scrotal

Does it transilluminate (?hydrocele)

Is there a cough impulse (?hernia)

Question 23

What are hydatid cysts?

Investigations and management?

Answer 23

Caused by the tapeworm parasite Echinococcus granulosus

Need CT and surgery

Question 24

Boundaries of hesselbachs triangle?

Answer 24

Medial: Rectus abdominis
Lateral: Inferior epigastric vessels
Inferior: Inguinal ligament

Question 25

Management of inguinal hernias?

Answer 25

If at risk, or if patient is well then surgical repair (usually mesh) Open if first time Laparoscopic if recurrence or bilateral

Question 26

Common types of liver tumours?

Answer 26

95 % are mets from another primary Primaries HCC - Normally secondary to chronic Hep B infection Cholangiocarcinoma - PSC biggest risk factor

Question 27

Management of pancreatitis?

Answer 27

Enteral nutrition Abx - Imipenem - May not be worth it if mild disease Surgery - If due to gallstones, then early cholecystectomy - If obstructed biliary system due to stones then ERCP - Maybe debridement or aspiration if necrosis - If infected necrosis then radiological drainage or necrosectomy

Question 28

Definitions of massive haemorrhage?

Answer 28

Loss of blood volume in 24 hours (7% of weight) Loss of 50% blood volume in 3 hours Loss of blood volume >150ml a minute

Question 29

What are the three main types of antigen that may give rise to rejection in organ transplant?

Answer 29

ABO HLA MHC

Question 30

Most common type of pancreatic cancer?

Answer 30

Adenocarcinoma of the head of the pancreas

Question 31

Presentation of pancreatic cancer?

Answer 31

Classically painless jaundice Patients typically present in a non-specific way with anorexia, weight loss, epigastric pain Loss of exocrine function (e.g. steatorrhoea) Atypical back pain is often seen

Question 32

Investigation choices for pancreatic cancer?

Answer 32

Ultrasound has a sensitivity of around 60-90% High resolution CT scanning is the investigation of choice if the diagnosis is suspected

Question 33

Primary malignant bone tumours?

Answer 33

Chondrosarcoma Osteosarcoma Ewing's tumour

Question 34

Where are pilonidal cysts normally located?

Answer 34

Midline of natal cleft

Question 35

What is Meckel's diverticulum

Answer 35

A Meckel's diverticulum is a congenital abnormality that is present in about 2% of the population Typically 2 feet proximal to the ileocaecal valve May be lined by ectopic gastric mucosal tissue and produce bleeding, and RIF pain

Question 36

Types of shock?

Answer 36

There are five ``` Septic Haemorrhagic Neurogenic Cardiogenic Anaphylactic ```

Question 37

What is the aetiology in neurogenic shock?

Answer 37

Spinal cord transection, usually at a high level. There is a resultant interruption of the autonomic nervous system. The result is either decreased sympathetic tone or increased parasympathetic tone

Question 38

What is the aetiology in cardiogenic shock?

Answer 38

The main cause is ischaemic heart disease

Question 39

Presentation of small bowel obstruction?

Answer 39

Central abdominal pain Nausea and vomiting 'constipation' with complete obstruction abdominal distension may be apparent, particularly with lower levels of obstruction

Question 40

What does TPN include, where should it ideally be given?

Answer 40

Bags contain combinations of glucose, lipids and essential electrolytes, the exact composition is determined by the patients nutritional requirements. Ideally given centrally (PICC line)

Question 41

What are the types of transplant?

Answer 41

Allograft Transplant of tissue from genetically non identical donor from the same species. Isograft Graft of tissue between two individuals who are genetically identical Autograft Transplantation of organs or tissues from one part of the body to another in the same individual e.g. Skin graft Xenograft Tissue transplanted from another species e.g. Porcine heart valve

Question 42

When would you perform a diagnostic peritoneal lavage?

Answer 42

Document bleeding if hypotensive

Question 43

UGIB presentation?

Answer 43

Haematemesis and/ or malaena Epigastric discomfort Sudden collapse

Question 44

After UGIB endoscopy what score do you need to do?

Answer 44

Rockwall score to determine risk of re-bleeding

Question 45

Polycythaemia occurs in which renal ca.?

Answer 45

Adenocarcinoma of the kidney

Question 46

In a pt with haemothorax at what point do you want to do a thoracotomy?

Answer 46

>1.5L of blood loss initially or >220/hour for the next two hours.

Question 47

How can you tell apart FAP and HNPCC (lynch)?

Answer 47

HNPCC does not have loads of polyps

Question 48

Most common scoring system in pancreatitis?

Answer 48

Glasgow

Question 49

Small bowel obstruction management?

Answer 49

Drip (Iv fluids) and suck (NG tube)