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MRCS Part B - Paul Edit > Miscellaneous 2 > Flashcards

Miscellaneous 2 Flashcards

1
Q

What is gynaecomastia and what causes it? What is the difference between this and galactorrhoea?

A

Gynaecomastia is abnormal amount of breast tissue in males usually due to increased oestrogen:androgen ratio Galactorrhoea is different and due to actions of prolactin on breast tissue

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2
Q

Key questions in gynaecomastia history?

A

Duration, progression Systemic symptoms - visual disturbance? Any new medications PMH - liver disease, testicular issues Family history Drug/alcohol use

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3
Q

Which testicular issues are associated with gynaecomastia?

A

Previous orchidopexy for cryptorchidism could predispose to hormone-secreting testicular tumours

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4
Q

Investigation of gynaecomastia?

A

Clinical exam - breast and testicular Testicular US if indicated Bloods - inlc BHcG and prolactin

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5
Q

9 causes of gynaecomastia?

A

Physiological e.g. in puberty
Androgen deficiency -
Klinefelters
Testicular failure e.g. mumps
Testicular cancer e.g. HcG secreting seminoma
Liver disease
Ectopic tumour secreting HcG Hyperthyroidism
Haemodialysis
Drugs e.g. spironolactone, digoxin, cannabis, cmietidine, finasteride, steroids and oestrogens

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6
Q

Management options for idiopathic gynaecomastia?

A

Conservative Medical - tamoxifen

Surgical - liposuction (better than subareolar incision and excision of tissue)

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7
Q

What is acute pancreatitis? Underlying mechanism of damage?

A

Acute inflammation of the pancreas gland causing interstitial oedema, cellular destruction and release of pancreatic enzymes Presumed mechanism is premature activation of enzymes within the gland itself

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8
Q

Investigating/diagnosing pancreatitis?

A

Largely clinical Amylase can be acutely raised up to around 48 hours before falling again, if over 3x greater than normal = suggestive. Lipase less prone to false negative as elevated for longer CT not routinely done unless delayed, severe or uncertain diagnosis All patients need CXR and US to look for stones

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9
Q

How to identify severity of pancreatitis?

A

Clinical factors including obesity, hypoxia, haemodynamic compromise and signs of haemorrhage Biochemical factors including age, liver enzymes, urea, glucose, LDH, albumin, O2 sats, WCC

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10
Q

What scoring systems are there for acute pancreatitis? What is the difference? What constitutes a severe attack?

A

Glasgow Ranson Difference is when parameters are measured - on admission or at 48 hours Severe attack = derangement of 3 or more parameters, or CRP over 150 at 48 hours

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11
Q

What is the mortality of a severe attack of pancreatitis?

A

20-50%

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12
Q

Complications of acute severe pancreatitis?

A

Early - ARDS, renal failure, haemodynamic instability and shock Mid (1 week) - local complications e.g. necrosis, fluid collections, peripancreatic abscesses, haemorrhage, effusion, splenic vein thrombosis Later (over 4 weeks) - pseudocyst, chronic pancreatitis

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13
Q

When and why would you CT an acute severe pancreatitis routinely?

A

Around 1 week - to look for necrosis

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14
Q

Management of pancreatic necrosis?

A

Conservative - enteral nutrition, monitoring If infected - radiologically aspirate for MC+S and start antibiotics, usually minimal invasive

Surgical necrosectomy as rescue procedure

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15
Q

Management of pancreatitis associated with gallstones?

A

US - if stones do MRCP
Do ERCP or cholecystectomy when well in same admission or soon after
Alternative would be cholecystectomy an on table cholangiogram +/- transcystic CBD exploration

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16
Q

Management of fluid collections in pancreatitis?

A

Generally percutaneous - drain if exerting significant pressure or if infected

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17
Q

Manage of haemorrhagic pancreatitis? Where does the blood come from?

A

May be managed with IR if bleeding from retroperitoneal vessels

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18
Q

What clot complication may occur in severe pancreatitis?

A

Portal or splenic vein thrombosis, which may cause portal hypertension

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19
Q

Managing pancreatitic pseudocyst?

A

If over 6cm, persists over 12 weeks and symptomatic can either do cystogastrostomy or minimally invasive alternative

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20
Q

What is the most common extra-intestinal complication of Crohn’s in GI tract? Why?

A

Gallstones - because of impaired bile salt resorption in terminal ileum

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21
Q

4 reasons why diarrhoea may occur in Crohn’s disease?

A

Inflammation in acute phase causing wall inflammation and secretion of mucous into bowel lumen Terminal ileal disease and bile acid malabsorption Patients with extensive resection or extensive disease causing short gut syndrome due to decreased absorption Entero-colic fistulas - small bowel contents straight into distal colon

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22
Q

What is this?

A

Erythema nodusm

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23
Q

What is this and where may it be found in IBD patients?

A

Pyoderma gangrenosum - around stoma sites

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24
Q

What is this? What is it made of and how is it managed?

A

Ganglion cyst - soft mobile compressible lesion usually on dorsal aspect of wrist- cyst wall of epithelial cells containing fluid from underlying tendon or joint - may occur due to ligaementous strain or embryological remnant of synovial tissue

Usually conservative - usually resolve spontaneously

If excise, risk of recurrence

Usually excise volar ganglia but consider where radial artery is

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25
From what do dorsal ganglia arise? What about volar?
Scapholunate articulation Volar more from radiocarpal joint and adhere to radial artery
26
What is a Maisonneueve injury?
spiral fracture of fibula extending inferiorly to inveolve syndesmosis with injury to malleolus
27
2 mechanisms of traumatic pneumothorax?
Penetrating trauma - flap of lung issue creating one-way valve Blunt injury cauing rib fracture which may pierce pleura
28
What should you do for lung penetrating trauma with even very small pneumothorax? Why?
Chest drain May progress to tension
29
30
How are flat feet typically managed?
Conservatively, with insoles/shoe inserts
31
How is ankle arthritis managed?
Symptomatically, can consider arthoplasty or arthrodesis
32
What are the 3 main ankle ligaments that you can assess clinically? How?
Deltoid - felt at medial malleolus - evert foot Lateral - felt at lateral malleolus - invert foot Tibiofibular (inferior) ligament - anteriorly around joint - dorsiflex and move talus laterally, if disrupted talus moves
33
What is pes planus and what causes it in adults?
Flattening of arches - in adults degenerative, obesity
34
What is plantar fasciitis?
Tearing of calcaneal attachment of plantar fascia - thick and tender on examination
35
What is hallux valgus?
Lateral deviation of great toe where first metatarsal head moves off sesamoids to increase intermetatarsal angle, causing corns and calluses
36
What is Charcot foot?
Markedly deformed foot with lack of sensation and hyperaemia, stigmata of arterial insufficiency. Secondary to diabetes, neuropathy
37
What is a Morton's neuroma?
Plantar digital neuroma of plantar nerve between 3rd and 4th metatarsal heads, causing burning pain and paraesthesia of affected toes.
38
Examinatino findings for Morton's neuroma?
Palptaing between and just distal to metatarsal heads is painful Metatarsal comperssion may cause Mulder click
39
What deformities and exam findings may be seen in CMT?
Symmetrical elevation of arches with plantar flexed first ray, hindfoot varus, claw toes and flat foot Heel-toe walking (Marionette gait) and absent ankle jerks
40
What is anterior metatarsalgia and what is on exam?
pain under metatarsal heads with associated widening of foot, flattened medial arch, claw toes and calloses
41
Describe this? How would you manage?
Distal radial transverse fracture of left wrist with dorsal angulation of fracture fracgment, associated ulnar styloid fracture Manage with reduction and casting with haematoma block, or consider fixing given styloid fracture
42
What would make you surgically manage a fracture?
Young person, high energy mechanism of injury Suggestive of instability: Dorsal tilt of more than 20 degrees Communited fractures Ulnar styloid injury, neck of femur injury etc. Intra-articular disruption
43
Why are cardiac myocytes able to generate own action potentials?
Electrochemically unstable membrane - in SA node gradually depolasrises from -70 to -50mV and then fully depolarises generating electrical impulse
44
Why do transplants with denervated hearts have high resting HR? What is it?
100 - no vagal tone so spontaneous discharge of 100/min
45
Why do cardiac cells have refractory period? What can happen in pathological instances?
To allow for adequate ventricular filling In prolonged pathological tachycardia, inadequate ventricular filling can lead to fall in CO
46
What are the sympathetic and parasympathetic innervations to the heart?
PNS - Vagus nerve, ACh Symp - cardiac plexus - NA (beta1 in SA node), adrenaline
47
How much of the cardiac cycle is normally made up of diastole?
2/3
48
Why can air embolus occur e.g. if neck veins exposed to air?
Atrial pressures can be negative, so can entrain air - make sure good positioning
49
What is the usual cardiac output in L/min?
5-6L/min
50
What is cardiac output affected by?
Anything which affects HR and SV - preload, EF, drugs, nervous system Afterload - aortic resting pressure - particularly important as determines perfusion pressure of myocardium
51
What is Starling's Law of the heart?
If all other factors remain constant, increase in EDV (preload) triggers stretching of ventricles and subsequent increase in SV and therefore CO. True up to a point, when EDV exceeds ventricular capacity to contract effectively CO can decline
52
What is Laplace's law? What heart things does it explain?
For hollow organs with a circular cross section, total circumferential wall tension depends upon circumference of wall x thickness of wall and on wall tension Explains why ventricular pressure rises due to physical change in heart size during ejection phase, and why dilated diseased heart will have impaired function
53
Where are peripheral baroreceptors located and what do they do? How do they work?
Aortic arch and carotid sinus Stimulated by stretch (pressure) and trigger vagus (aortic) and glossopharyngeal (carotid) nerve firing Increase PNS discharge to SA node Decrease SNS discharge to ventricular muscle via cardiac plexus Decrease SNS to venous system causing reduced VR Decrease PVR
54
Where are atrial stretch receptors found? What is the Bainbridge reflex?
In atria between pulmonary veins and vena cava Bainbridge reflexes results in increase of heart rate due to stretch of atria
55
What is the rate of HIV transmission following needlestick injury from an infected person? Hep B/ Hep C?
0.3% for HIV (0.2-0.5) 30% for unvaccinated Hep B, 1.8% for Hep C
56
Blood testing regime post needlestick?
At time from donor and recipient 6 weeks and 3 months
57
Differentials/management of catheter not draining?
Anuric - renal failure Catheter blocked/malfunctioned/malpositioned Examine abdomen, bladder scan / US renal tract, bladder washout/irrigation + urine dip
58
What is the usual size of urinary catheter?
14 or 16 Fr
59
Discuss diathermy and pacemakers?
Contraindicated in ICDs If not, need to ensure electrode placement so that electricity doesn't pass through pacemaker
60
Management of pacemakers in elective surgery?
Ensure patient has passport with them, type known etc. and ideally had recent check up Ensure theatre has CPR and temporary pacing equipment available Continuous ECG monitoring Judicious use of monopolar (with plate far away from pacemaker, in short bursts) and bipolar
61
Safe bipolar plate placement?
Large contact area, dry shaved area, away from bony prominences
62
In which settings is bipolar better than monopolar?
Patients with pacemakers Extremities with end arteries Structures with narrow pedicle
63
Difference between antiseptic and disinfectant?
Antiseptic = on living tissue Disinfectant = on inanimate object
64
Discuss differences between chlorhexidine, betadine and isopropyl alcohol?
Chlorhex has broadest spectrum and lasts for \>4 hours after application, but is poor against spores and fungi. Bacterostatic at low concentration, bacterocidal at higher concentrations Betadine can irritate skin and is shorter lasting, but has some activity against spores. Works via oxidization Isopropyl is fast acting with good broad spectrum, but no activity against spores
65
Important characteristics of surgical drapes?
Strong and withstand wet/dry stresses Non-irritant Flame retardant Barrier for microorganisms or fluids Breathable Electrostatic properties
66
Differences between cleaning, disinfection and sterilization?
Clearning = removing visible debris Disinfection = reducing number of organisms Sterilization = removing all microorganisms including spores
67
How are surgical trays sterilized? What about heat-sensitve things e.g. endoscopes?
Usually steam autoclaved using moist heat Heat senstive things can be either irradiated or ethylene oxided
68
Management of warfarin for elective surgery?
If low risk - stop 5 days pre op, check day before and ensure INR less than 1.5 before surgery If high risk - stop 4-5 days pre op, consider treatment dose LMWH which is stopped 12 hours pre op, check INR before surgery and ensure less than 1.5 Restart as soon as happy with haemostasis - keep treatment dose LMWH going until INR in range if high risk
69
What is C Diff?
Gram positive anaerobic bacilus often commensal in GI tract but commonly associated with nosocomial infection particularly in instances of broad spec Abx use Normal gut flora disturbed and allows C Diff to proliferate and start producing toxins
70
4 antibiotics at particularly high risk for C Diff?
Co-amoxiclav Cephalosporins Clindamycin Ciprofloxacin Also vanc
71
What is betadine better than chlorhex against? Other advantage?
Fungi, mycobacterium, viruses Less flamable
72
Does any sterilization destroy prions?
No
73
4 different methods for sterilisation?
Steam/heat - autoclave for surgical equipment Cold/chemical - plastics/endoscopes Gas sterilisation - sutures and electrical equipment Ionising radiation - catheters, syringes
74
4 chemicals used in sterilisation?
Ethylene oxide Formalderhyde Gluteraldehyde Hydrogen peroxide
75
What is actinic keratosis?
Premalignant (for SCC) condition brought about by UV light
76
What histological features suggest skin SCC?
Atypical keratinocyte proliferation Invasion of dermis Keratin pearls
77
How long would you keep a clean dressing on for generally?
1 week, clean and dry
78
Times for suture removal depending on site?
Face - 5 days Scalp - 7 days Trunk or limbs - 10-14 days
79
Signs and symptoms of LA toxicity?
Peroral tingling/numbness Drowsiness, Seizures Coma Apnoea, paralysis Arrhythmias Shock (negative inotropes and vasodilators)
80
Risks of surgery-related MI in terms of time post MI? How long would you wait?
Within 30 days = 30% 1-3 months = 8-19% 3-6 months = 6% Less after 6 months so wait til then if poss
81
Why are metallic heart valves highest risk for thrombosis?
Low-flow vs aortic
82
Duration of onset of oral vs IV vit K?
Oral = 12-24 hours IV = 6 hours
83
When would you hold the COCP surrounding surgery?
4 weeks before if major, involving limbs or significant reduction in mobilisation Restart 2 weeks after full mobilisation
84
What FEV1/FVC ratio is associated with higher risk of surgery?
Less than 50%
85
Describe Glasgow score for pancreatitis?
PaO2 less than 8 Age over 55 Neuts over 15 Calcium less than 2 Renal (urea) Enzymes - LDH/AST Albumin less than 32 Sugar - glucose over 10 Score of 3 or above = severe
86
Alternative scoring systems for pancreatits?
APACHE 2 Ranson Balthazar - CT ststem
87
How would you manage stridor?
Crash trolley, call anaesthetics/ENT If obtunded - examine airway/suction, use adjuncts, head tilt chin lift/jaw thrust and 15L O2 If ok - sit upright Consider dex 8mg IV and adrenaline 1mg neb
88
Inidications for surgical airway?
Failed intubation Laryngeal trauma/fracture Upper airway obstruction due to laryngeal oedema, burns, facial trauma, haemorrhage, bilat vocal cord palsy etc.
89
Tracheostomy vs cricothyroidotomy?
Tracheostomy is between 2nd-5th tracheal rings vs cricothyroidotomy in cricothyroid membrane between cricoid and thyroid cartilages
90
Layers when doing tracheostomy?
Skin Subcutaneous fat Superficial fascia incl platysma Investing layer deep cervical fascia Strap muscles (usually retracted) Pretracheal fascia Thyroid isthmus Trachea
91
Define a fistula?
Abnormal communication between two epithelial or endothelial lined surfaces, lined with granulation tissue
92
What is a sinus?
Blind-end tract lined by granulation tissue
93
What is an abscess?
Pus filled cavity surrounded by granulation tissue
94
5 risk factors for enterocutaneous fistula?
Surgery Cancer Irradiation Infection Inflammation e.g Crohns
95
Classification of fistula by output?
Low = less than 200ml per day Moderate = 200-500ml per day High = over 500ml per day
96
SNAP of managing fistulas?
Sepsis control Nutritional support Adequate fluid/electyolte and anatomical assessment Plan and protect skin
97
What kind of nutrition is recommended for high output fistula and why?
TPN - because reduces output and can manage electrolyte disturbance/prevent further high output due to oral intake
98
Complications of TPN?
Metabolic - high or low BM, hypoK, hypoPho, hypoMg Related to venous access- throbmoembolism if peripheral, infection, complications of central lien insertion
99
Complications of central line insertion?
Immediate - haematoma, haemorrhage, haemo/pneumo/chylothorax, right atrial perf and tamponade, air embolism, arrhythmia Early - blocakage, pseudoaneurysm Late - infection, thrombosis, vascular stenosis or erosion, catheter fracture
100
Indications for central line insertion?
Monitoring - CVP, Swan Ganz - cardiac output Interventional - TPN, inortopes/pressors, haemodialysis, transcutaneous pacign wires (Swann sheath)
101
Preferred sites for central lines?
Right IJV Then left IJV Subclavian veins Femoral veins
102
What is the obturator sign?
Flexion and internal rotation of right hip causes pain due to irritation of obturator internus - due to appendicitis
103
Initial pain of appendicitis travels through which general visceral afferent nerev?
Lesser splanchnic
104
Scoring systems for appendicitis?
Alvarado Appendicits Infallamtory Response (AIR)
105
Advantages of lap approach over open for e.g. appendix, chole?
Better cosmesis Quicker recovery Less post op pain Lower rate of post op wound infection Easier visualisation of other intra-abdominal structures
106

MRCS Part B - Paul Edit (29 decks)

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