Misc 5 Flashcards
1
Q
What is a breast fibroadenoma?
A
Proliferation of epithelium and stromal tissue of duct lobules
Round/oval well defined, rubbery mobile less than 5cm
2
Q
Where are fibroadenomas commonly found?
A
Upper outer
Bilateral/multiepl
3
Q
Outline breast triple assessment?
A
Physical exam
Imaging - USS for patients under 35-40 or male, mammography for older
Tissue = FNA/core
4
Q
What imaging is suitable for women of different ages investigating breast Ca?
A
US for under 35-40 as denser breast tissue
Mammogrphy for older women
5
Q
What gradings are the components of the triple assessment for breast given?
A
1-5 where 1 is normal/insufficient, 2 is benign, 3 is uncertain, 4 is suspcious and 5 is malginant
6
Q
Give 2 examples of biphasic breast lesions? Differences between them?
A
Phylloides tumour
Fibroadenoma
Phylloides usually larger, present later in life and grow rapidly
7
Q
Management of phylloides tumour?
A
Depends on behaviour, from WLE to mastectomy
8
Q
What are breast cysts?
A
Fluid filled inverted lobules presenting in peri-menopausal females - smooth discrete painful lumps
9
Q
Management of breast cysts?
A
Confirm diagnosis with mammography/USS
Can aspirate if persistent; if aspirate blood stained or lesion persistent then needs triple assessment
10
Q
Different types of mastalgia?
A
Cylical - usually both breasts
Non cyclical - may be medications e.g. contraceptives, antidepressants or antipsychotics
Extarmmary - chest wall/shoulder
11
Q
What is ‘true mastalgia’ and what causes it?
A
Exaggerated response of breast tissue to hormaonl changes during menstrual cycle causing enlrgement, pain and nodularity
12
Q
Management f cylclical mastalgia?
A
Reassurance, pain relief
Soft/support or well fitting bra
Specialists options include danazol
13
Q
What is an abscess?
A
Colelction of pus surrounded by granulation/fibrous tissue
14
Q
How can breast abscesses be divided?
A
Lactational or non-lactational
15
Q
Common bacteria in lactational abscesses?
A
S aureus, epidermidis
Strep species
16
Q
Management of lactational abscesses?
A
Refer to gen surgery for US, drainage of abscess and fluid culture
Continue breast feeding if poss or express if not
17
Q
What is a common type of non-lactational mastitis and what are its features? Who does it occur in?
A
Peri-ductal mastitis
Painful, red, tender with nipple retration lump and discharge
Can form abscesses
Occurs in young female smokers
18
Q
What is Mondor’s disease? Management?
A
Sclerosing thrombophlebitis of superficial veins of breast and chest wall
Conservative management with NSAIDs
19
Q
Give 7 causes of nipple discharge?
A
Physiological Cancer Duct ectasia - creamy +/- bloodstained Intra-ductal papilloma Epithelial hyperplasia Galactorrhoea - bilateral milk production Gestational
20
Q
Features of duct ectasia? Management?
A
Involutional change in perimenopausal women causing shortening and dilatation of subareolar ducts
Can have discharge, nipple retraction or mass
Discharge can be creamy or bloodstained
Management requires duct excision to exclude malignancy
21
Q
Features of intraductal papilloma? Is there an increase risk of cancer?
A
Serous or bloodstained discharge plus or minus palpable lump
Yes if multi-ductal
22
Q
Features of epithelial hyperplasia? Is there an increased risk of cancer?
A
Increase in number of epithelial cells lining terminal ducto-lobular units
Bloody nipplie discharge
May be increased risk if widespread
23
Q
Differentials for haematuria and difficulty passing urine from prox to distal?
A
Kidneyts - cancer, pyelonephritis
Ureter - calculus, tumour
Bladder - cancer, calculus, cystitis
Urethra - stricture
24
Q
Why can difficulty passing urine occur in bladder cancer?
A
2 reasons - clot retention if bleeds heavily
Or cancer itself obstructs passage into urethra - less likely
25
Describe how to do bladder washout and irrigation?
Pass a 3 way catheter
Instill 50ml boluses to disperse any large clots and suction out, monitoring in/output
Attach irrigation and monitor volume
26
Most common type of bladder cancer in western world?
Transitional cell
27
4 RFs for transitional cell bladder cancer?
Smkoing
Males
Dyes e.g. hairdresseers
Ruber.leather
28
Most common type of bladder cancer in developing world? Why?
Squamous cell - due to schistosoma haematobium causing chronic inflalmmation
29
2 most common causes of squamous cell bladder cancer in western world?
Bladder calculi
Indewlling catheters
Due to chronic inflammation and metaplsai
30
Gold standard investigations for visible haematuria? Alternatives?
Flexible cystoscopy with biopsy
Ct urogram or US if poor renal function
MRI / staging CT to look for local invasion or metastasis
31
Surgical options for bladder cancer?
If early - transurethral resection with resectoscope
| Radical cystectyom for muscle invasive cancer
32
What does a radical cystectomy entail in men?
Removal of bladder, lymph nodes, uretrha, seminal vesicles, prostate and part of vas
33
What does a radical cystectomy entail in women?
Removal of bladder, lymph nodes, urethra, cervix, uterus, fallopian tubes +/- ovary and vagina
34
Reconstruction post radical cystectomy?
Urinary diversion - incontinent e.g. ileal conduit into urostomy bag
- continent e.g. kock, indian or mitrofanoff pouch
35
Treatments to prevent recurrence of bladder cancer?
Intravesical chemo - mitomycin C
| BCG immunotherapy
36
RFs for thyroid cancer?
```
Female
Radiation in early years
Family history or cancer syndrome
Obseity
Goitre or thyroiditis
Acromegaly
```
37
Discuss utility of US in thyroid nodules?
Numeber, size and location - useful for interval scanning
Sonographic features - solid appearance, absence of halo, microcalcification, vascularity and irregular margins = cancer
Look for lymph nodes
38
3 indications for removal of nodular goitre?
?cancer
Pressure symptoms e.g. stridor, venous obstruction, dysphagia
Hyperthyroidism refractory to medical treatment
39
Usual causes of primary hyper PTH?
Usually adenoma
| Sometimes hyperplasia or carcinoma
40
Differentiating from secondary and tertiary hyperPTH?
```
Secondary = low calcium due to renal disease or malabsoprtion - high PTH due to neg feedback
Tertiary = autonomous hyperplastic parathyroids in patients with secondary PTH resulting in profound hyperCa
```
41
Causes of hypoPTH?
```
Post thyroidectomy - iartrogenic
Autommune such as Addionsis, percinious anaemai
Post radiotherapy
Low Mg
DiGoerge
```
42
What happens to aldosterone and renin in secondary hyperaldosternoism? Causes?
Both high
| E.g. renal vascular disease, renin secreting tumours or liver cirrhosis
43
Which cells secrete PTH?
Chief cells
44
Mechanism of secondary hyperPTH?
Renal failure - less conversion of 25-1,25 hydroxyvit D in kidneys, so reduced uptake of Ca from GI tract, reduced release from bone and inreased renal excretion
Results in hypocalcaemia and hyper PTH due to neg feedback
45
2 main uses of frozen section in surgery?
Guide if lesions malignant or benign
| Guide if resction margins clear
46
Which 2 cells are seen in normal parathyroid tissue?
Chief
| Oxyphil
47
Indications cor anaesthetic rv in burns?
```
Hx of fire in enclosed space
Soot around nostrils, in nose or mouth or singeing of nasal hairs
Carbonaceous sputum
Hoarseness
Stridor/wheeze
Drooling
COHb over 10%
```
48
Differentiation of burn thickness?
Superficial = epidermis only
Partial thickness = superficial (epidermis and upper dermis) and deep (epidermis and whole dermis but not underlying tissue) dermal burns
Full thcikness= through epidermis, dermis and into subcutaenous tissue
49
Features of spuerficial dermal burns?
Pinks skin that blanches with slow cap refill
Painful
Feels normal to touch
Often moist with blisters
50
3 ways of estimating burns surface area?
Wallace's rule of 9 - head, arm = 9 each, torso front and back = 18 each, leg = 18 each, genitals 1%
Lund and Browder charts
Patients hand = 1%
51
Indications for fluid replacement in burns?
Over 15% TBSA in any thickness, or 10% in children give 4xBWxTBSA
ATLS states over 20% in deep partial or full thickness give 2xBWxTBSA (so half)
Doesn't include maintenance
52
Indications for referrral to speicalist burns unit?
```
Over 5% in children or 10% in adults
Under 5 or over 60 year old
High pressure steam, electricity or chemical
Circumferential burns
Inhalation injuries
Serious comorbidity
NAI suspected
```
53
Mount Vernon formula?
Used to caclulate burn fluid resus - weight x % divided by 2, given 6 times over 36 hours
54
Features of epidermal burns?
e.g. sunburn, red, painflu, doesnt blister, dry, blanches and refils
55
Features of deep derpmal burns?
red, blotchy mottled skin that doesnt blanch. may be blistersed but less painful than superficial dermal
56
Features of full thickness burns?
leathery charred skin, pale non blanching
| Painless
57
What is sedation?
Alteration in consciousness +/- analgesia +/- decreased anxiety
58
Difference between light, deep and GA sedation?
```
Light = conscious - own airway with intact reflex mechanism, response to stimuli, anxiolytic
Deep = airway may need support, repeated painful stimuli for response
GA = unrousable, airway unprotected
```
59
Contraindications to sedation?
```
Neuromuscular insufficiency
Clinically unstable
Long lasting procedure
Not appropirately starved
Lack of approrpirate monitoring
Patient refusal
```
60
Describe how to sedate e.g. for shoulder relocation?
Move to resus with monitoring - 3 lead ECG, sats, BP, HR
Appropriately trained staff
Good IV access
ACcess to reversal agents
Multidrug approach e.g. morhpine, midaz, NO2
61
Describe how morphine and midaz might be used for sedation?
Morphine 0.1mg/kg IV for loading
| Midaz 1-2mg per dose IV
62
5 discharge criteria from ED following proceduarl sedation?
```
Normal obs
Normal mental status
Managing PO intake
Pain controlled
Someone at home to supervise
```
63
4 SIRS criteria?
```
pulse over 90
RR over 20 or low PACO2
WCC over 12 or under 4
temp over 38 or udner 36
Need 2 or more
```
64
Clinical features of nec fasc?
```
POOP
Possble skin break
Swelling, disolouration
Blister formation with dark fluid and necrosis
Subctaneous oedema and crepituus
Systemic symptoms
```
65
4 types of nec fasc?
1 - polymicrobial e.g. s aureus, haemophilus, pseudomanos and coliforms
2 - monomicrobial - GAS e.g. pyogenes, MRSA
3 - monomicrobial e.g. clostridium
4 - fungal e.g. candida
66
Score system for nec fasc?
LRINEC - Laboratory risk indicator for nec fasc
67
Ratinoale behind second look surgery e.g. for nec fasc?
Returning to theatre after planned period of time to examine affected regions under GA - often to look for need for further debridement
68
Differentials for nec fasc of groin?
Groin abscess/cellulitis
Pseudoaneurysm of groin
Simple perianal abscess
69
Immobilising c spine straight away?
Rigid collar on firm surface, supplemented with blocks and tape
70
Most common level of c spine fracture?
C5
71
What is a hangmans fraccutre? Typical mechanism?
Fracture through both pedicles of C2
| Usually flexion-extension injury
72
What si a jefferson fracutre? Typical mechanism?
Burst fracture of C1 with double fractures thorugh ant and post arches
Head on injury with axial loading e.g. diving headfirst into pool
73
Spinal vs neurogenic shock?
```
Spinal = flaccid paralysis, arreflexia and sensory loss followign spinal cord trauma
Neurogenic = actual shock due to loss of symp tone
```
74
What is the bulbocavernosus reflex and why is it used?
S2-4 nerve roots, sphincter contraction following tug on cath/glans squeeze/clitoral pressure. suggests spinal shock if absent with supportive sensorimotor signs
75
Anaesthetic issues with untreated aortic stenosis?
Limited coronary blood supply as cardiac output fixed, can't ersponse to decreased afterload that may occur in anaesthesia or blood loss
Also with spinal anaehetsics, drop in BP can't be compensated for
76
Coronary perfusion pressure is equal to?
Systemic diastolic arterial pressure - left ventricular end diastolic pressure
77
Normal coronary axis?
-30 to +90 degrees in frontal plane
| Leads 1 and 2 normamlly both positive
78
Voltage criteria for LVH?
S in V1 plus R in V5/6 over 35mm (7 large suwares)
79
Mechanism of action of mannitol?
Osmotic diuretic - filtered in glomerulsus but not reabsorbed, so increased osmolality of filtrate nd increased water excretion in urine
80
How and where do thiazides work?
Proximal part of CT, prevents reabsorption of Na via Na/Cl symporter
81
How and where do potassium sparing diuretics work? work?
Aldosterone antagonists - distal part of DCT
| Prevents activation of Na/K exchange which normally swaps Na in urine for K, preventing concentration of urine
82
Outline equipment required for chest drain insertion?
```
Sterile gloves and gown, drapes
Local anaesthetic, syringe + needles
Scalpel and blade
Clips, large haemostat
Dissecting scissors
Chest tube - 30Fr
Silk 1/0 suture
Gauze/swabs
Underwater drainage system
Occlusive dressing
```
83
5 indications for chest drain insertion?
```
Tension pneumo
Traumatic pneumo
Haemothorax
Large secondary pneumo
Large spont pneumo not resolved by needle decompression
```
84
Inidications for cardiothoracics team in pnuemothorax?
Spontaneous haemothorax
Bilateral pneumo
Second ipsilateral pnuemo
Persistent air leak after a week or failure to re-expand
At risk profrsesionals e.g. driver, pilot
Pneumothorax in pregnancy
85
Excision margins for excsiion of small skin lesion? How would this change if you suspected SCC? How to site lesion?
2mm
4mm if SCC
Elliptical incision 3:1 lenght:width
86
Time for suture removal at different sites?
Face = 5 days
Scalp = 7 days
Trunk or limb s= 10-14 days
87
What kind of dressing might you use for a contaiminated open wound?
Alginate packing/dressing
88
What features of tissue during wound debridement separates non-viable from viable tissue?
Bleeding
89
What other prophylactics should patients who have contaminated wound washout and debridement receive?
Antibiotis
| Tetanus
90
4 steps of wound debridement?
Removal of obvious contaminants
Irrigation/washout
Excision of dead or devitalised tissue
Wound management
91
What is NCEPOD and what are the classifications of surgical timing?
National Confidential Inquiry into Patient Outcome and Death
1 - immediate - resus and intervention for life saving
1a - immediate - resus prior to surgery, limb or organ saving
2 - urgent - wwithin hours
3 - expedited - within days
4 - elective - all else
92
ASA grades and examples?
1 - fit and well
2 - mild sysetmic disease - well controlled asthma
3 - severe systemic disease well controled e.g. angina
4 - severe systemic disease poorly controlled e.g. advanced COPD, unstable angina
5 - life threatening e.g. multi organ failure
93
Layers passed through in midline laparotomy?
```
Skin
Campers fascia - subcut fat
Scarpas fascia
Linea alba
Transversalis fascia
Extraperitoneal fat
Peritoneum
```
94
What might a left paramedian incision be used to access?
Spleen
95
How may wounds be classified?
Mechanism - incised, lacerated, abrasion, de-gloving, burns
Contamination - Clean, Clean contaminated, Contaminated, Dirty
Depth - Superficial deep
96
What are the contaminated wound types?
Clean e.g. skin lesion excision
Clean contaminated e.g. cholecystectomy with no leak
Contaminated e.g. cholecystectomy with bile leak
Dirty e.g. perforated bowel
97
Give the 5 absorbable sutures and how long they take to resorb?
```
Vicryl rapide - 42d
Vicryl 56-70d
Cat gut 70-90d
Monocryl 91-119 d
PDS 180-210 d
```
98
Appropriate suture for facial closure, superficial?
Ethilon, prolene
99
Appropriate suture for facial closure, deep tissue?
Vicryl
100
Appropriate suture for abdominal mass closure?
PDS
101
Appropriate suture for bowel anastomosis?
Vicryl
| Staples
102
Apprpirate suture for vascular anastomoses?
Prolene
103
Apprporiate suture for forming a stoma?
Vicryl
104
Define diathermy?
Use of high frequency electrical current to generate heat to cut or coagulate tissue
105
Minimum plate size for monopolar?
70 square cms
106
Define cutting, coagulation, blend and spray?
Cutting - continuous, high heat, cells explode. sinus wave form
Coagulation - square wave form, pulsing current, cells dehydrate
Blend - mix of coag and cutting
Spray - coagulation over wide area
107
What is rheumatic fever? What type of reaction is it?
Systemic post-GAS pharyngeal infection affecting heart, skin, joints and brain
Type 2 hypersensitivity
108
What heart problems may follow rheumatic fever?
60% of post carditis patients will have chronic rheumatic heart disease - most commonly mitral or aortic, and usually regurge that may preced stenosis over years
109
General differentials for infections in post op patients?
```
Wound
Lines
Chest
Urine
Relative to site of surgery e.g. intra abdominal
```
110
Criteria for diagnosing infective endocarditis?
Dukes criteria - 2 major, 1 major 3 minor, or 5 minor
111
What are the major Dukes criteria for IE?
Causative organisns in blood cultures - s viridans, strep bovis, HACEK, s aureus, enterococci
Lesions on endocardium on echo - valve vegeitation, asbcess etc
112
Criteria for diagnosing rheumatic fever?
Modified Jones
| Requires evidence of strep infection and associated post-strep features
113
Why is IE so hard to treat?
Valves do not receive specific blood supply so neither immune mechanisms nor Abx can reach valves
114
Are prophylactic antibiotics used to prevent endocarditis?
Not routinely
115
What is a neoplasm? 3 features
Abnormal growth of tissue displaying uncoordinated growth which exceeds that of normal tissue and continue despite removal of original stumulus
116
Discuss neoplasms division by cell type?
Unicellular - epithelial, mesenchymal or lymphoma
More than one cell type from one germ layer - pleomorphic adenoma, fibroadenoma
More than one cell type from more than one germ layer - teratoma
117
Types of epithetlial neoplasa?
Papilloma, adenoma, carcinoma
118
Types of mesenchymal neoplasia?
Fibroma, lipoma, sarcoma
119
Differences between benign and mlaignant neoplasia?
Benign = non invasive, no mets, well differentiated, slow growing, normal nuclei, well cicrumscribed with pseudocapsule and rarely necrose
Vs malignant which is invasive through BM, can met, may be poorly differentiated, rapidly growing, abnormal nuclear morophology with irregular border and necrosis common
120
2 physiological and 2 pathological examples of hyperplasia?
```
Physiological = breast during puberty, thyroid during pregnancy
Pathological = BPH, Adrenals in cushings
```
121
2 physiological and 2 pathological examples of hypertrophy?
```
Physiological = muscle enlargment with exercise, uterus in pregnancy
Pathological = LVH/cardiomyopathy, thyroid in graves
```
122
What is a hamartoma? examples?
Tumour like malforamation composed of disogranised arrangment of different amounts of tissue normally found at that site, which grows under normal growth controls
E.g. peutz jeghers, haemangiomas, lipoma. bronchial hamartoma, CNS hamartoma, melanocytic naevus
123
What is metaplasia? 2 pathological examples?
Reversible replacement of one fully developed cell type with another differentiated cell type
E.g. barrets oesophagus - squamous to adeno/columnar epithelium
Trasnformation zone of cervix due to HPV - columnar to squamous epithelium
124
What is dysplasia?
Disordered cellular development charactersied by increased mitosis and pleomorphism without ability to invade basement membrane or metastasis
125
Hisotological features of dysplasia?
Increased mitosis
Pleomorphism
Aneuploidy
Hyperchromatism
126
Mechanisms by which tumours spread?
```
Haematogoenous
Local invasion
Lymph
Transcoelomic
CSF for CNS
Iatrogenic e.g. seeding during biopsy
```
127
What is a polyp?
Abnormal growth of tissue projecting from a mucous membrane or epithleial surface
128
Classifications/types of polyps?
Non-neoplastic - metaplastic, hamartomatous, inflammatory pesudeopolyps
Neoplastic - tubular, tubulovillous and villous in order of most to least common
129
Which type of neoplastic polyp has highest malignant potential?
Villous
| Then tubulovillous, then tubular
130
Complcaitions of GI polyps?
```
Malgiant transformation
Ulceration
Bleeding
Infection
Intussusception
Protein or potassium loss
```
131
Where are the polyps seen in FAP?
Intestinal
| Also duodenal periampullary adenomas, gastric polyps
132
What syndromes are associated with FAP and additional tumour sites?
Gardner - oestoma (mandible), mesenteric fibroma, thyroid, epidermoid cysts
Turcot - CNS e.g. medulloblastoma
133
Recommended surveillance for FAP?
Colonoscopy from age 12-14, then every 1-3 years depending on phenotype
Gastroscopy and duodenoscopy at 25
134
At what age are patients usually offered surgery for FAP?
Around 25
135
Options of surgery for FAP?
Total colectomy and ileorectal anastamosis, with regular stump surveillance via sigmoid/pouchoscopy
Total panproctocolectomy with end ileostomy or ileoanal pouch
136
What surveillance is required for FAP post surgery?
UGI endoscopy every 6 months to 4 years
| Sigmoid/pouchoscopy every 1-3 years if joined up
137
Medications decreasing number of polyps in FAP?
Celecoxib
| Sulindac
138
Features of Peutz Jehgers?
Multiple hamartomatous polyps (AD inheritance)
Increased risk of breast, lung, uterus and panc cancer
Pigmentation around lips/perioral skin
139
Any surgery prophylactically needed in Peutz Jehgers?
No - low malignant potential for intestinal hamartomas
140
How might colorectal polyps progress to adenocarcinoma in someone without a genetic predispoisiotn?
Acculmulation of genetic defects causing progression from normal cells to dysplasia to malignant cells that can invade through BM
141
Carcinomas typically spread by which route?
Lymph (exvcept follicular thyroid Ca - blood)
142
Sarcomas typiaclly spread by which route?
Blood
143
Define diverticulum?
Abnormal outpouching of a hollow viscus into surrounding tissues
