Miscellaneous Key Flashcards

Question

A 34 YO female presents complaining of heavy menstrual bleeding (menorrhagia). She has been trying to conceive for the past 2 years but has been unsuccessful. A transvaginal Ultrasound reveals a thick-walled unilocular cyst with acoustic enhancement with diffuse homogenous ground-glass echoes located on the left ovary.

Answer 1

The likely Dx → Ovarian Endometrioma

Answer 2

Ultrasound Findings (important √) ◙ Hydatidiform mole • Snowstorm appearance of mixed echogenicity • Bilateral cystic masses (Large theca lutein cysts) ◙ PCOS Multiple follicles/ cysts • Iceberg tip sign ◙ Dermoid Cyst • Flat-fluid level • Mostly, unilocular • Dermoid mesh ◙ Ovarian Endometrioma • Ground-glass appearance • Thick wall unilocular cyst • Chocolate cyst ◙ Ovarian Teratoma • Echogenic tubercle projecting into cyst lumen ◙ Tubo-ovarian abscess Multilocular, separations, irregular thick walls Echogenic debris in the pelvis

Answer 3

2 popular stems in the exam: 1) A child taking his grandparent’s medication and presented drowsy and lethargic ± with myoclonic twitches. 2) An elderly with terminal illness and wants to end his life, presented with dry skin and mouth, and dilated pupils. ◙ The most important immediate action → ECG Monitoring ◙ As the patient is in severe Metabolic Acidosis (pH far < 7.35) → Give IV fluid Bolus (0.9% NaCl) + IV Sodium Bicarbonate 50 ml of 8.4% Careful for THE DOSE! N.B. aim for pH of 7.5-7.55!

Answer 4

→ Hypophosphatemia (↓ Phosphate)

Answer 5

◙ Refeeding syndrome is a syndrome consisting of metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved, severely malnourished or metabolically stressed. ◙ When too much food and/or liquid nutrition supplement is consumed during the initial four to seven days of refeeding, this triggers synthesis of glycogen, fat and protein in cells, to the detriment of serum concentrations of potassium, magnesium and phosphorus (Consumed → ↓). ◙ Cardiac, pulmonary and neurological symptoms can be signs of refeeding syndrome. The low serum minerals, if severe enough, can be fatal! ◙ To avoid refeeding syndrome → Slow feeds + Give Supplements of Potassium, Magnesium and Phosphate.

Answer 6

• -ve HCG, the pain radiates from loin to groin ± ↑ WBCs and CRP ± vomiting (a stone at the lower part of a ureter). Ureteric pain is usually severe enough to make a patient writhing and twisting due to intense pain.

Answer 7

→ Hypophosphatemia (↓ Phosphate)

Answer 8

• In the 1b part of the death certificate, write the “Disease or condition directly leading to 1a part”.

Answer 9

→ Suspect “non-accidental injury”. Someone is abusing this old man as the bruises are in suspicious sites. If the cause was “recurrent falls” for instance, the bruises would have been over the hip, knee or shoulder joints, not in the face

Answer 10

(liTHium) → THyroid function tests.

Answer 11

Examples ◙ Write → [Small cell carcinoma of the main right bronchus] instead of just “Lung cancer”. Inferior Myocardial Infarction ◙ Write → Instead of “coronary thrombus/ Cardiac arrest/ Cardiovascular event/ Acute coronary syndrome…etc” Pneumonia of the left lower lobe ◙ Write → Instead of “lung infection/ respiratory failure” • AVOID vague terms and modes of dying such as (Respiratory distress/ Cardiac arrest/ Cardiovascular event/ Chest infections/ Cerebrovascular event). • Never use abbreviations! • Write the date of death using (Words) NOT (Figures). Example ◙ Write → the Fourth day of July (instead of 04/07).

Answer 12

√ Thyroglobulin (Tg) levels are very helpful thyroid cancer markers. They may indicate recurrent or metastasis of thyroid cancer after a successful removal of the thyroid (during follow-up). √ They can be used after thyroidectomy for a thyroid cancer. √ (But they are not helpful in the Dx of thyroid cancer)

Answer 13

√ Initial step → Insert Nasogastric Tube (NGT) “for decompression”. √ Definitive/ most palliative step → Stoma Vomiting of fecal contents → NGT.

Answer 14

Pleural effusion. He has likely suffered from pneumonia which has led to pleural effusion. √ Absent breath sounds + Dullness on percussion → Pleural effusion. √ Inspiratory crackles + Dullness on percussion → Consolidations.

Answer 15

√ Initial step → Insert Nasogastric Tube (NGT) “for decompression”. √ Definitive/ most palliative step → Stoma Vomiting of fecal contents → NGT.

Answer 16

Examples ◙ Write → [Small cell carcinoma of the main right bronchus] instead of just “Lung cancer”. Inferior Myocardial Infarction ◙ Write → Instead of “coronary thrombus/ Cardiac arrest/ Cardiovascular event/ Acute coronary syndrome…etc” Pneumonia of the left lower lobe ◙ Write → Instead of “lung infection/ respiratory failure” • AVOID vague terms and modes of dying such as (Respiratory distress/ Cardiac arrest/ Cardiovascular event/ Chest infections/ Cerebrovascular event). • Never use abbreviations! • Write the date of death using (Words) NOT (Figures). Example ◙ Write → the Fourth day of July (instead of 04/07).

Answer 17

◙ A testicular teratoma may present as a painless lump. ◙ Complications may include ovarian torsion, testicular torsion, or hydrops fetalis. ◙ In males, teratoma is always malignant, while in females, it is usually benign.

Answer 18

◙ If still there is profuse diarrhea and dehydration, Capecitabine should be stopped.

Answer 19

. ◙ Hypercalcemia can present with: depression, lethargy, constipation, polyuria, polydipsia. ◙ In a patient with cancer “particularly prostate and breast cancer” who develops such features → Serum calcium should be requested.

Answer 20

→ Clopidogrel + Atorvastatin

Answer 21

√ Control Blood Pressure. (The patient in stem has normal BP so he does not need a medication for BP). √ Statins (for All patients regardless of their cholesterol baseline level). “Atorvastatin 80 mg”. √ Ani-platelets (or) Anti-coagulation: (Based on presence or absence of AF): • If there is Atrial Fibrillation → Anticoagulants: Warfarin [or] DOAC (Dabigatran/ Apixaban/ Rivaroxaban/ Edoxaban). The man is stem does not have AF as his ECG shows sinus rhythm. Thus, we do not use warfarin nor DOAC). • If No Atrial Fibrillation → Antiplatelets: Clopidogrel 75 mg OD. “remember that in “acute” ischemic stroke, aspirin 300 mg is given for 2 weeks then clopidogrel 75 mg is given for life”.

Answer 22

The most appropriate management → Dexamethasone. (to shrink the peri-lesional oedema and thus alleviate the increased intracranial pressure symptoms). √ Dexamethasone is the preferred glucocorticoids in intracerebral edema and the symptoms tend to improve within several hours after administration. The usual dose is: 4 mg, 4 times a day, oral or IV). • If there is associated vomiting, the best anti-emetic for vomiting secondary to increased intracranial pressure is → Cyclizine

Answer 23

Diagnosis Diagnosis can be via CXR. CT is better to outline borders of air fluid levels, however, CT has a greater radiation exposure. Treatment Treatment is mostly the treatment includes ICD (intercostal drainage) of fluid and air and treatment of underlying conditions.

Answer 24

Fatigue, weight loss, high ALP and Ca++ Think → Metastatic bone cancer. Note that his thirst and polyuria are due to hypercalcemia.

Answer 25

→ Chemotherapy-induced peripheral neuropathy. Important chemotherapy drugs that can cause peripheral neuropathy to be remembered are: Vincristine, cisplatin, carboplatin, taxanes. This is not a case of diabetes-induced peripheral neuropathy for the following reason: √ Although normal HbA1c is < 48 mmol/mol, the value here (51 mmol/mol) is considered a relatively good control in a patient on metformin. A second anti-hyperglycemic drug is only needed if his HbA1c is ≥ 58 mmol/mol.

Answer 26

After abdominal surgery, adhesions can occur leading to small bowel obstruction (laparoscopic cholecystectomy in this case). See the difference between small and large bowel obstruction below:

Answer 27

The likely Dx is → Bronchiectasis. HRCT (High resolution CT scan) of bronchiectasis showing → bronchial dilatation and wall thickening with ground glass opacities.

Answer 28

Suspect → Bronchiectasis “Irreversible dilatation of small and medium sized bronchi” ◙ Other features that may present in a stem: √ Chest X-ray may show Tramlines “cysts/ ring opacities” “Chest X-ray is often normal” √ Clubbing “drumstick-shaped fingers”: not always present, not specific. To confirm the Dx High resolution CT scan (HRCT). “important”

Answer 29

The likely Dx is → Bronchiectasis. HRCT (High resolution CT scan) of bronchiectasis showing → bronchial dilatation and wall thickening with ground glass opacities.

Answer 30

√ This is because of the lymphatic system damage that occurs during the surgery. √ It can present as upper limb swelling, tightness of the hand.

Answer 31

). • This is caused by → CSF leakage → leading to ↓ intracranial pressure. • So, fluid intake is necessary to relieve this headache as it ↑ ICP. • If the patient can tolerate orally → observe and encourage oral hydration.

Answer 32

IV aminophylline: √ Only if no adequate response to nebulised bronchodilators. • Non-invasive ventilation (NIV): e.g., CPAP, BiPAP: √ If after medical treatment, there is no adequate response, and the patient develops respiratory acidosis (low pH < 7.35 and high PaCO2). √ We try to delay the need for invasive ventilation (intubate and ventilate) as it has own complications e.g., pneumonia, barotrauma, the failure to come back to the spontaneous ventilation. √ However, invasive ventilation should be used if: NIV fails, there is respiratory arrest, there is impaired mental status, or there is a high risk of aspiration. • Invasive ventilation (intubate and ventilate): √ If NIV failed. (e.g., pH is < 7.26 and PaCO2 is still rising despite NIV). OR: √ If NIV is contraindicated e.g., respiratory arrest, high aspiration risk, impaired mental status. Important notes: ◘ Low pH, High PaCO2 → NIV. ◘ Normal pH, High PaCO2 → Continue FiO2 24-28% via venturi mask.

Answer 33

→ Non-invasive ventilation. He has respiratory acidosis after the medical treatment. + There are no indications for invasive ventilation such as impaired mental status, respiratory arrest. So, we go for NIV first. If failed, intubate and ventilate.

Answer 34

His ABG shows low pH and high paCO2. What is the most appropriate next step in management? → Intubate and ventilate (invasive ventilation). His RR is 9 and his breath sounds are quiet → going to respiratory arrest. Also, his mental status is impaired. Therefor, intubation and ventilation is the correct answer.

Answer 35

→ morphine overdose.

Answer 36

◙ First Step → 2 separate doses (10-20 minutes in between) of either: √ IV Lorazepam “1st line in-hospital and if there is established IV access”. [or] √ Buccal Midazolam [or] (Rectal Diazepam) “If no IV access or in-community” If 2 separate doses of either (IV lorazepam) or (Rectal Diazepam) or (Buccal Midazolam) have been given but the seizure is still ongoing, move to step 2 ◙ Second Step → IV Phenytoin Important: Phenytoin is preferred over phenobarbital. ◙ Third Step → Refer to ICU → Intubation, IV Phenobarbital.

Answer 37

Ultrasound + FNAC

Answer 38

s: The most likely Dx → Lung cancer (Chronic cough, Hemoptysis, Chronic smoking, Solitary coin lesion on X-ray

Answer 39

most likely Dx → Pleural effusion. As there is fever → there is likely an infection caused parapneumonic effusion

Answer 40

A) Naloxone. B) Oxygen. C) IV fluids. D) Dantrolene • You may think this is a case of heroin (opioid) toxicity that needs Naloxone to be treated. However, in opioid toxicity, the pupils are constricted, not dilated like here. Also, HR would be low. • The likely Dx here is Carbon Monoxide (CO) poisoning. It needs O2. • CO poisoning → Red, pink, flushed (cherry-red) skin/ mucosa + Altered mental status.

Answer 41

The Management of CO Poisoning: - If Conscious → 100% O2 via a tight-fitting face mask with an O2 reservoir. Another valid answer → High flow oxygen. - If Unconscious → Intubate and Ventilate with IPPV (Intermittent Positive-Pressure Ventilation) on 100% O2. Note: if the patient is confused but still conscious → high flow O2 via tight-fitting mask (NOT intubation)! Careful! If the patient is hypotensive (SBP < 100) and Unconscious → Intubation + IPPV 100% O2

Answer 42

• ACE inhibitors (e.g., lisinopril) and ARBs (e.g., losartan) need to be stopped 24 hours before surgery because they can lead to severe hypotension after the induction of GA.

Answer 43

Continue the same dose preoperatively BUT double the dose for 48 hours postoperatively. “This is to avoid adrenal insufficiency -adrenal crisis- postoperatively

Answer 44

◙ If a pregnant woman is found to have breast cancer and needed surgery: → Proceed with mastectomy. The only condition where pregnancy termination is considered is when chemotherapy is indicated.

Answer 45

Think → Angiosarcoma.

Answer 46

The first step to be done if these complications occur is to (to reverse the effect).

Answer 47

→ Gout (gouty arthritis). Alcohol is a RF for Gout. The x-ray features are consisting with gout.

Answer 48

◙ Around 70% of first presentations affect: → The first metatarsophalangeal joint (of the big toe). Other commonly affected joints include: ankle, wrist, knee. ◙ Important Exam Hints: ○ An antihypertensive and diuretic medication “Thiazide Like Diuretic” such as bendroflumethiazide can cause Gout. ○ A diuretic used in Heart Failure → Loop diuretic (Furosemide) can cause Gout. ○ Also, Drinking Too Much Alcohol can cause Gout! ○ X-ray of the painful red swollen joint → Well-defined ‘punched-out’ erosions with sclerotic margins

Answer 49

◙ Management of gout: √ If the patient is presenting with → First line → acute attack NSAIDs (eg, Ibuprofen, Naproxen) “important”: ▐ 2nd → Colchicine. √ For long-term management of gout (after 2 weeks of acute attack) → Allopurinol “with NSAIDs and Colchicine coverage” ◙ Radiological features of gout: • Joint effusion is (early sign). • Well-defined ‘punched-out’ erosions with sclerotic margins in a juxta-articular distribution, often with overhanging edges

Answer 50

• Relative preservation of joint space until late disease • Eccentric erosions • No periarticular osteopenia (in contrast to rheumatoid arthritis) • Soft tissue tophi may be seen ◙ Caution: Gout does not only affect the big toe; it can also affect Knee and others. Whenever you see “bendroflumethiazide” or another RF as heavy alcohol along with painful, tender, swollen joint: Think → Gout → Synovial fluid aspiration → NSAIDs or Colchicine for acute attack.

Answer 51

√ Administering fluids at a high rate → ↑ IV pressure → Leakage (extravasation). • Management: √ If the administered fluid is not vesicant (eg, normal saline, Hartmann solution) (to help reabsorption). → Stop the IV fluid, remove the cannula, and lift the arm Re-insert the cannula in a different vein, a different limb. √ If the administered fluid is vesicant (eg, chemotherapy), they may cause tissue damage (in the form of blistering and ulceration). It could also lead to tissue necrosis. This might need specialized clinical intervention.

Answer 52

This is an emergency which requires → Removal of the endotracheal tube, insertion of a laryngeal mask or re-intubation. Otherwise, remove tube, initiate face mask ventilation (to preserve ventilation).

Answer 53

Tamoxifen Important Notes on Tamoxifen √ It is a [Selective estrogen receptor modulator -SERM-] √ It is used in the treatment of Breast cancer. √ It is helpful after breast cancer in men who have positive estrogen receptors (around 90% of men with breast cancer). √ It increases the risk of Endometrial carcinoma. √ It prevents bone loss (guards against osteoporosis).

Answer 54

Some studies support that when giving tamoxifen to a breast cancer patient, giving (Bisphosphonates) helps reduce the risk of bone metastasis. ♦ In patients who take Tamoxifen, the most important alarming symptom would be (as it ↑ risk of endometrial carcinoma). → Vaginal bleeding NOTE: Post-menopausal women with breast cancer who have high risk of recurrence OR those with Lymph Node metastasise are given → Bisphosphonates as an adjunctive therapy after surgery.

Answer 55

This is an emergency which requires → Removal of the endotracheal tube, insertion of a laryngeal mask or re-intubation. Otherwise, remove tube, initiate face mask ventilation (to preserve ventilation).

Answer 56

Tamoxifen Important Notes on Tamoxifen √ It is a [Selective estrogen receptor modulator -SERM-] √ It is used in the treatment of Breast cancer. √ It is helpful after breast cancer in men who have positive estrogen receptors (around 90% of men with breast cancer). √ It increases the risk of Endometrial carcinoma. √ It prevents bone loss (guards against osteoporosis).

Answer 57

It occurs in 1% of patients following spinal anaesthesia but it is the most common serious complication after spinal anaesthesia. • It usually starts to appear within the first 48 hours after a meningeal puncture (eg, after spinal anaesthesia eg, epidural block). • The criteria of the post-dural puncture headache: √ Severe, throbbing, tension. √ Frontal and occipital. √ Extends to neck (stiffness/ tension in neck). √ (↑) with upright position and when elevate the neck from a supine position. √ (↓) with supine position (lying flat). √ Sometimes associated with nausea and photophobia. ◙ No imaging or investigations are needed unless there are other symptoms that suggest a different diagnosis. (PDPH is a diagnosis of exclusion).

Answer 58

• Reassure and observe. • Simple measures: √ Simple analgesia (paracetamol, NSAIDs, Codeine). √ Good hydration. √ Drinking caffeinated drinks. √ Avoid triggering positions. √ Epidural patch (if the headache is very severe and persistent despite all measures).

Answer 59

‘ • Therefore → • Also → Stope ARBs (eg, losartan, candesartan) 24 hours before surgery. stope ACE inhibitors (eg, lisinopril, candesartan) 24 hours before surgery.

Answer 60

If they have very low respiratory rate ± high paCO2 with low pH (resp. acidosis): √ The first step is → attached to supplemental oxygen. √ Followed by → Bag mask ventilation IV Naloxone.

Answer 61

First step → Bag mask ventilation. Followed and accompanied by → IV naloxone.

Answer 62

What is the most likely diagnosis? → Subarachnoid hemorrhage (SAH). • Severe “worst” headache, vomiting, photophobia, neck stiffness are features commonly seen in SAH. The patient would benefit from nimodipine (a CCB). • In SAH: CT scan show hyperdense areas (white color = blood) in the basal cisterns.

Answer 63

→ High flow oxygen (via tight-fitting mask). • The likely Dx here is carbon monoxide poisoning (was found unconscious in a burning building, tachypnic, tachycardic). • He is now confused, not unconscious. If he is unconscious, then intubate).

Answer 64

- If Conscious → 100% O2 via a tight-fitting face mask with an O2 reservoir. Another valid answer → High flow oxygen. - If Unconscious → Intubate and Ventilate with IPPV (Intermittent Positive-Pressure Ventilation) on 100% O2. Note: if the patient is confused but still conscious → high flow O2 via tight-fitting mask (NOT intubation)! Careful! If the patient is hypotensive (SBP < 100) and Unconscious → Intubation + IPPV 100% O2

Answer 65

fasting: Example: A woman is scheduled to undergo surgical removal of suspicious breast lump at 10 am. The last time she ate was at 6 am as she had her breakfast with a cup of coffee. She then continued to have clear fluids until 9 am. → Postpone the surgery until 12 pm in the same day. This way, the last time she ate was 6 hours before the surgery, and the last time she drank was more than 2 hours before the surgery.

Answer 66

Patient is unwell + Recent chemotherapy → Start IV Antibiotics IMMEDIATELY -IV Tazocin is started empirically-! Still unwell after 4-5 days? → fungal infection investigation + Add IV Antifungals Febrile Neutropenia “Neutropenic Sepsis” From its name: Febrile → Fever ▐ Neutropenia → Low Neutrophils. ≤ 0.5 √ Absolute Neutrophil count X 109/L (Normal: 2-7.5 X 109/L) (≥ 38.5°C) or 2 consecutive temperatures of (≥ 38.0°C) √ Fever • It occurs mainly after initiating chemotherapy in malignancy patients. (Chemotherapy → BM suppression → ↓ Blood Cells Production). • Another cause → within 1-year of Bone Marrow transplantation.

Answer 67

• Start empirical IV antibiotics IMMEDIATELY! • Start empirical → IV Tazocin (Tazobactam + Piperacillin). • After 48 hours, if the patient is still febrile and/or neutropenic

Answer 68

Alternative antibiotic: Meropenem ± Vancomycin. • After 4-6 days, if the patient is still unwell → Investigate for fungal infection (Sometimes, the answer would be: Add IV Antifungal).

Answer 69

Tumor Lysis Syndrome → UK Pc HyperUricemia (↑ Uric Acid “Also called serum Urate) → Gout. HyperKalemia (↑ K+ “Potassium”) HyperPhosphatemia (↑ Phosphate) Hypocalcemia. (↓ Calcium). √ It occurs mainly in Leukemia (Especially ALL) and Lymphoma (Particularly Burkitt’s Lymphoma) after initiating Chemotherapy. √ Chemotherapy, Radiotherapy, Surgery → Rapid Lysis of Tumour Cells → Excessive amounts of Uric acid “Urate”, Potassium and Phosphate are released into the blood.

Answer 70

→ Start empirical broad-spectrum IV antibiotics • Suspected neutropenic sepsis after recent chemotherapy • Unwell + Fever after recent chemotherapy → Immediate empirical IV antibiotics while waiting for blood reports.

Answer 71

Example: A man with bilateral sensorineural hearing loss + Vertigo + Tinnitus + Hx of neurofibromatosis type 2 → Acoustic neuroma → do MRI cerebellopontine angle (or MRI brain).

Answer 72

This is a rare case of: → Malpositioned NGT into the right bronchus and lung instead of stomach. → Remove this NGT and insert a new one as this one is not in the stomach.

Answer 73

The likely Dx based on this X-ray → As there is fever → there is likely an infection caused parapneumonic effusion. In other words, this is a pleural effusion caused by pneumon

Answer 74

Pneumonia → Pleural effusion, and when inflammatory response occurs in this effusion → Empyema develops. (Look at the X -ray to differentiate ).

Answer 75

First step → Bag mask ventilation. Followed and accompanied by → IV naloxone.

Answer 76

The likely Dx based on this X-ray → As there is fever → there is likely an infection caused parapneumonic effusion. In other words, this is a pleural effusion caused by pneumon

Answer 77

This is most likely a case of → Venous thromboembolism (VTE). In Short: After femur fracture, Immobility, if a patient develops dyspnea (breathlessness), tachypnea, tachycardia, hypoxemia: √ 24-72 hours after femur fracture → more likely Fat Embolism. √ Weeks after femur fracture (ie, prolonged immobility) → more likely VTE.

Answer 78

◙ Diagnosis → Punch Biopsy. Paget’s disease of breast and nipple may mimic eczema in skin appearance. However, you should consider paget disease first.

Answer 79

Management of acute pulmonary edema? (important). 1) Sit the patient up → Give O2 (airm for ≥ 95%, or > 90% if he has COPD). 2) Give glyceryl trinitrates (GTN) 2 sublingual puffs. 3) Give 40 mg of IV -slowly-

Answer 80

). ◙ Forgetful elderly (forget to lock doors, forget birthdays, forget names of people and places), easily getting lost (Disorientation), unable to do simple tasks (eg, cooking). If CT/MRI is done, it would show enlarged ventricles mostly WITH cortical atrophy. → Alzheimer’s disease.

Answer 81

(post-dural puncture headache PDPH)

Answer 82

However, if there is → in the options, pick it as it is superior to FNAC. Core Needle Biopsy is the preferred diagnostic tool for breast lumps, whether benign or suspicious. It provides a larger tissue sample for histological examination, preserving the architecture of the tissue, which is crucial for an accurate diagnosis. • If the breast lump is suspicious → Urgent 2-week wait referral to a breast clinic

Answer 83

5 ◙ Bleeding discharge per nipple in an Old woman with eczema-like changes in the nipple ± areola ± Ulcers → Paget’s disease (Malignant) → Punch Biopsy 6 ◙ Firm, non-tender, mobile mass in a breast of a young ♀ (15-30 YO) → Fibroadenoma → Clinical + Ultrasound + FNA 7 ◙ Breast pain (Mastalgia), ↑ breast size, lumpiness (nodularity) of the breast, ♀ in the reproductive age ± tend to appear just before or during menstrual cycle and disappear after it → Fibroadenosis.

Answer 84

8 ◙ Fixed, irregular, hard, painless lump ± nipple retraction ± fixed to skin (Peau d’orange) or muscle (+) Local fixed, firm axillary LNs. → Breast Cancer → Core biopsy 9 ◙ Offensive yellow discharge from an area near the nipple + Hx of Abscess near this area → Ductal Fistula (Mamillary Fistula). 10 ◙ Prolonged Redness around the areola. Hx of using antibiotics which improved symptoms slightly. Greenish discharge per nipple. ± nipple retraction ± small lump around the nipple is felt. → Periductal mastitis. (Commonly young age, smoking is a risk factor, treated with antibiotics, if left untreated it may develop into an abscess that needs drainage by fine needle). 11 ◙ Persistent nipple discharge that is non-bloody and occasionally milky or serous fluid. It is spontaneous. No breast masses. No Nipple retraction. No skin changes. → Mamillary duct fistula (abnormal connection between lactiferous ducts of the breast and skin surface → leads to spontaneous nipple discharge that is not purulent nor bloody. It can appear as a milky or serous fluid)

Answer 85

Anticoagulation may be resumed on the same evening of the surgery day or in the following day. Heparing bridging is subject to local guidleines

Answer 86

Before surgery, what is the mostly recommended investigation? • For any patient, for the fear of significant bleeding during major surgery (eg, in hip arthroplasty), haemoglobin (full blood count FBC) should be known preoperatively.

Answer 87

→ Implement sustainable changes and then re-audit.

Answer 88

Look at this image for a patient with congestive heart failure (that has led to a small pleural effusion) and presents with bilateral basal crepitions and shortness of breath:

Answer 89

◙ For healthy individuals, < 65 YO, who are undergoing a low-risk operation (eg, herniorrhaphy) → routine pre-operative investigations are NOT indicated.

Answer 90

Before surgery: Request the following if the patient is > 65 YO or has any systemic diseases: √ ECG. √ Full blood count (FBC). √ Renal profile

Answer 91

Sudden onset of: Fever, Drooling of Saliva, Stridor, Muffled voice, Cough √ Suspect → Acute epiglottitis. √ Manage → Airway maintenance: Call anaesthetist (for potential intubation /tracheostomy) and immediate ICU admission (for the fear of airway compromise) √ Then → Start IV broad spectrum antibiotics initially (there are bacterial causes for acute epiglottitis; however, remember that it is also caused by H. Influenza type B).

Answer 92

• Spinal cord metastasis (eg, from breast cancer). • Spinal cord compression. • Causa equina syndrome. Some symptoms for these cases → Hx of breast/ prostate cancer, progressive lower limb weakness, urinary retention or incontinence, bowel incontinence, diminished sensation below the level of umbilicus, low back pain. → MRI of the whole spine with contrast.

Answer 93

• As his respiratory functions are impaired (due to severe COPD), general anaesthesia should be avoided as it can cause respiratory complications eg, depression. • Spinal anaesthesia is a form of regional anaesthesia that involves injecting anaesthetics near the spinal nerves in the lower back. Therefore, it provides effective pain control for the surgeries that involve the lower abdomen and pelvis.

Answer 94

→ Spinal anaesthesia. • As his respiratory functions are impaired (due to severe COPD), general anaesthesia should be avoided as it can cause respiratory complications eg, depression. • Spinal anaesthesia is a form of regional anaesthesia that involves injecting anaesthetics near the spinal nerves in the lower back. Therefore, it provides effective pain control for the surgeries that involve the lower abdomen and pelvis.

Answer 95

√ Sharp, burning, or aching pain that radiates from axilla to the medial aspect of the upper arm. √ It usually results from surgery (eg, breast surgery, axillary nodes dissection), trauma, or other pathologies (eg, herpes zoster, thoracic outlet syndrome) that affect the nerves. √ The usually involved dermatome is → (T2). Intercostal brachial nerve

Answer 96

→ Intercostalbrachial neuralgia.

Answer 97

• A rare and aggressive cancer that arises from the endothelial cells lining the blood vessels. • It can occur in any part of the body but commonly associated with breast tissues especially following exposure to radiation therapy. • It starts as a blue/purple bruise like lesion with irregular borders. • It can arise on top of the scar following mastectomy.

Answer 98

Ovarian Endometrioma. Think → (It is a subtype of endometriosis where endometrial-like tissues grow within the ovaries forming cysts filled with dark old blood).

Answer 99

Think → Bronchial carcinoma

Answer 100

Cricothyroidotomy. B. Escharotomy of the chest wall. C. Tracheal intubation. D. Fluid resuscitation with Hartmann's solution. E. High-flow oxygen via a non-rebreather mask. Answer: The most appropriate immediate management for this patient is → C. Tracheal intubation.

Answer 101

Respiratory Support: Tracheal intubation ensures that the patient can receive adequate ventilation and oxygenation. High-flow oxygen via a non-rebreather mask (option E) is beneficial but not sufficient in this scenario due to the risk of airway obstruction and the patient’s unresponsiveness. Prevention of Further Complications: Early intubation can prevent the worsening of airway edema, which can complicate intubation if delayed. Why Not the Other Options? A. Cricothyroidotomy: This is an emergency procedure for severe airway obstruction when intubation is not possible. In this case, early tracheal intubation is preferable if feasible. B. Escharotomy of the chest wall: This is indicated for circumferential burns causing restrictive chest wall movement, which is not described here. D. Fluid resuscitation with Hartmann's solution: This is important for burn patients but is secondary to securing the airway in immediate management. E. High-flow oxygen via a non-rebreather mask: While providing oxygen is crucial, intubation is required to secure the airway and provide effective ventilation in this critical scenario. Thus, tracheal intubation is the immediate priority to manage the airway and ensure adequate oxygenation.

Answer 102

Option E (High-flow oxygen via a non-rebreather mask) would be a valid option in scenarios where the patient is experiencing respiratory distress but does not have signs of significant airway obstruction or compromise. Here are specific conditions when this option would be appropriate: Conscious and Responsive Patients: If the patient is conscious, alert, and able to maintain their airway but is experiencing respiratory distress due to smoke inhalation or other causes. No Signs of Severe Airway Obstruction: When there is no evidence of severe airway obstruction (e.g., no significant soot in the oropharynx, no stridor, and no signs of airway edema). Initial Management: In the early stages of assessment and management of a patient with suspected inhalation injury, high-flow oxygen via a non-rebreather mask can provide adequate oxygenation while preparing for further evaluation and potential intubation if the situation worsens. Mild to Moderate Respiratory Distress: Patients with mild to moderate respiratory distress, where oxygenation can be adequately maintained with non-invasive methods, and there is no immediate threat of airway compromise.

Answer 103

Most appropriate immediate management: → High-flow oxygen via a non-rebreather mask. Rationale: • Adequate Oxygenation: High-flow oxygen via a non-rebreather mask can quickly improve her oxygen saturation. • Maintaining Airway: Since she is conscious and able to maintain her airway, intubation is not immediately necessary. • Monitoring: This allows for continuous monitoring and assessment. If her condition deteriorates or signs of airway compromise develop, then escalation to intubation can be promptly performed. • This approach ensures that the patient receives the necessary oxygen while keeping invasive procedures reserved for when they become absolutely necessary.

Answer 104

In Short: The Management of Carbon Monoxide Poisoning: - If Conscious/ Dizzy→ 100% O2 via a tight-fitting face mask with an O2 reservoir. √ Another valid answer → High flow oxygen. √ - If Unconscious → Intubate and Ventilate with IPPV (Intermittent Positive-Pressure Ventilation) on 100% O2.

Answer 105

In Short: The Management of Carbon Monoxide Poisoning: - If Conscious/ Dizzy→ 100% O2 via a tight-fitting face mask with an O2 reservoir. √ Another valid answer → High flow oxygen. √ - If Unconscious → Intubate and Ventilate with IPPV (Intermittent Positive-Pressure Ventilation) on 100% O2.

Answer 106

◙ Scenario: Patient: 71-year-old woman Condition: Tonic-clonic seizure Treatment: Intravenous lorazepam ◙ Key Monitoring Focus: Most Likely Side Effect: Respiratory depression. ◙ Summary: Lorazepam is effective for controlling seizures but can cause respiratory depression. Continuous monitoring of respiratory function is crucial, especially in elderly patients.

Answer 107

During surgery, patients can experience significant blood pressure fluctuations due to anesthesia and surgical stress. Continuing ACE inhibitors can exacerbate this issue, leading to severe hypotension that can be difficult to manage intraoperatively.

Answer 108

◙ Most Appropriate Immediate Management → Insert a chest drain. Secondary Pneumothorax: Occurs in the presence of underlying lung disease like COPD. Severity: Given the size of the pneumothorax and the patient’s acute distress, immediate intervention is necessary. Chest Drain: Allows for re-expansion of the lung and stabilization of the patient’s respiratory function. ◙ Why Not Other Options? • Needle Aspiration: More suited for primary pneumothorax or smaller secondary pneumothoraces (1-2 cm). • Increased Oxygen Flow/NIV: Can worsen the pneumothorax due to positive pressure. • Antibiotics: Not immediately necessary unless there is an infection. ◙ Conclusion: √ For a patient with COPD presenting with a significant secondary pneumothorax (>2cm), the insertion of a chest drain is the most appropriate immediate intervention to re-expand the lung and stabilize respiratory function. √ If it was 1-2 cm → Needle Aspiration.

Answer 109

◙ Primary Pneumothorax: • 2 cm or Less → Conservative management. • More than 2 cm → Needle aspiration (same approach as tension pneumothorax). ◙ Secondary Pneumothorax: • Less than 1 cm → Conservative management. • 1-2 cm → Needle aspiration. • More than 2 cm → Chest drain. ◙ General Guidelines: • Conservative Management: Suitable for smaller pneumothoraces without significant symptoms. • Needle Aspiration: First-line for larger primary pneumothoraces and moderate secondary pneumothoraces. • Chest Drain: Required for large secondary pneumothoraces or when needle aspiration is not sufficient.

Answer 110

Answer → E. Mammary duct fistula. Explanation: Key Points: 1. Presentation: o Recurrent Painful Swellings: The patient reports recurrent episodes of painful swellings in the breast, which are indicative of repeated infections or abscess formation. o Discharge of Pus: Spontaneous discharge of pus suggests an ongoing infection and potential development of a fistula. o Tender Mass: A tender mass in the breast is consistent with an abscess or infected area. o Puckered Opening: The presence of a small, puckered opening on the skin surface above the mass strongly suggests a fistulous tract.

Answer 111

Differential Diagnoses: • A. Breast cyst: Typically presents as a smooth, mobile, non-tender mass without recurrent infections or pus discharge. • B. Inflammatory breast cancer: Usually presents with erythema, edema (peau d'orange), and rapid onset of breast enlargement, without a history of pus discharge. • C. Mastitis: Commonly presents with localized pain, swelling, redness, and warmth, often in lactating women, but does not usually cause a persistent fistula. • D. Mammary duct ectasia: Can cause nipple discharge and a palpable mass but typically presents with greenish or blackish discharge rather than pus and without a fistula. Given the patient's symptoms of recurrent infections, pus discharge, and the physical finding of a puckered opening, a mammary duct fistula is the most likely diagnosis

Answer 112

Answer → A. A. Skip the lunch dose of short-acting insulin. 1. Rationale for Skipping the Lunch Dose: o Timing of Surgery: The surgery is planned for 2 pm, meaning the patient will likely miss lunch. Administering the lunch dose of short-acting insulin could lead to hypoglycemia since the patient will not be eating.

Answer 113

Why Other Options are Less Appropriate: o B. Administer the usual dose of short-acting insulin with breakfast and lunch: ▪ This could result in hypoglycemia since the patient will be fasting and not consuming lunch. o C. Skip the dinner dose of short-acting insulin: ▪ The dinner dose is not relevant to the perioperative period since the surgery is scheduled for 2 pm. This option does not address the management of insulin during the critical fasting period before surgery. o D. Administer half the usual dose of short-acting insulin with lunch only: ▪ Even a reduced dose of insulin at lunch could still pose a risk of hypoglycemia because the patient will not be eating lunch. o E. Stop short-acting insulin and convert to variable rate intravenous insulin infusion (VRIII): ▪ VRIII (previously known as a sliding scale) is typically reserved for more complex cases, such as major surgeries requiring prolonged fasting or for patients with poorly controlled diabetes. Since this patient has well-controlled diabetes and the surgery is relatively minor, skipping the lunch dose is a simpler and safer approach. By skipping the lunch dose of short-acting insulin, the patient minimizes the risk of hypoglycemia during the fasting period required before her afternoon surgery.

Answer 114

For patients with Addison's disease who are undergoing surgery, it is essential to boost their glucocorticoid levels to manage the increased stress from surgery and anesthesia, thus preventing an adrenal crisis. Normally, the body increases cortisol production during stressful situations eg, surgery. However, individuals with Addison's disease are unable to do this because their adrenal glands are not functioning properly. As a result, they need additional steroid supplementation from external sources. • For this man with Addison's disease undergoing elective laparoscopic appendectomy, the most appropriate management involves: √ Administering a 100 mg IV bolus of hydrocortisone at the induction of anesthesia. This ensures that the patient has adequate cortisol levels to manage the physiological stress of surgery. √ Providing continuous IV hydrocortisone at 200 mg over 24 hours until the patient can take oral hydrocortisone. This maintains adequate cortisol levels during the perioperative period. √ Doubling the dose of hydrocortisone by mouth and tapering back to the appropriate usual maintenance dose (in most cases, this occurs within 48 hours). This allows the patient to handle the ongoing stress response post-surgery. √ Keeping the fludrocortisone dose unchanged. Fludrocortisone primarily manages electrolyte balance and blood pressure, which are not significantly impacted by surgical stress.

Answer 115

Why do we keep fludrocortisone dose unchanged? Fludrocortisone primarily manages electrolyte balance and blood pressure, which are not significantly impacted by surgical stress. The focus during surgery is on ensuring adequate cortisol levels to manage the body's increased stress response. The standard fludrocortisone dose continues to effectively manage blood pressure and electrolyte balance without the need for adjustment. Therefore, the glucocorticoid (hydrocortisone) dose is increased to address the stress response, while the fludrocortisone dose remains the same.

Answer 116

• The two-week wait referral pathway is designed for cases where there is a suspicion of cancer, to ensure that patients are seen and investigated urgently. Other Options: A. Arrange for immediate hospital admission: While the patient has significant symptoms, they are hemodynamically stable. Immediate admission is not necessary at this stage. C. Prescribe antibiotics: There is no evidence of an infection (e.g., no fever, productive cough), and antibiotics would not address the underlying issue. D. Refer via the two-week wait ear, nose, and throat pathway: This is not appropriate as the symptoms and findings are respiratory in nature. E. Refer to the respiratory clinic routinely: A routine referral would delay necessary investigations and potential treatment. In summary, the most appropriate next step is to refer the patient via the two-week wait respiratory pathway to ensure timely investigation and management of a potential malignancy.

Answer 117

Answer → B. Refer via the two-week wait respiratory pathway. Explanation: The patient presents with significant symptoms and findings that raise the suspicion of a serious underlying condition, such as lung cancer. The key points in this scenario are: Clinical Symptoms: Progressive shortness of breath over two months. Persistent dry cough. Unintentional weight loss (8 kg). Risk Factors: A 50-year history of smoking one pack per day, which significantly increases the risk for lung cancer. Radiographic Findings: The X-ray shows a mass in the left upper lung field. • Given the combination of symptoms, risk factors, and radiographic findings, there is a high suspicion of lung cancer.

Answer 118

tumour. Core biopsy provides the most definitive tissue sample for diagnosis compared to FNAC. • Excisional Biopsy is typically reserved for cases where previous biopsies (e.g., core biopsy or FNAC) are inconclusive. • Breast Imaging (e.g., ultrasound, mammogram, MRI): o Ultrasound is preferred in younger women (< 40 years old) due to denser breast tissue. o Mammogram is preferred in women > 40 years old because it provides better visualisation in less dense breast tissue. • NICE guidelines stress the importance of quick and accurate assessment of breast lumps to avoid delayed diagnosis of potentially malignant conditions.

Answer 119

Key Points on Absolute Contraindications to Elective Surgery: 1. Recent Myocardial Infarction (MI): Elective surgery should be postponed for at least 6 months following an MI to reduce the risk of perioperative cardiac complications. 2. Recent Pulmonary Embolism (PE): Surgery should be delayed for at least 3 months after a pulmonary embolism to allow for adequate anticoagulation and patient stabilization. 3. Uncontrolled Heart Failure: Surgery should be delayed until heart failure is stabilized or controlled for a minimum of 4-6 weeks prior to the elective procedure. 4. Severe Aortic Stenosis: Surgery should not proceed in patients with severe symptomatic aortic stenosis until after appropriate aortic valve intervention, which should occur at least 3 months before elective surgery, unless urgent treatment is required. 5. Uncontrolled Hypertension: Surgery should be postponed if the patient has severe uncontrolled hypertension (e.g., systolic BP > 180 mmHg or diastolic BP > 110 mmHg) due to the increased risk of perioperative cardiovascular complications, such as stroke, myocardial infarction, or bleeding. 6. Active Infection: Elective surgery should be delayed in the presence of active infection (e.g., sepsis, cellulitis) until the infection is treated and controlled. Operating on a patient with an active infection increases the risk of wound infections, sepsis, and poor postoperative recovery

Answer 120

full blood count (FBC) • For healthy patients with no significant medical history, it is still standard practice to perform a for all patients before major surgery, such as knee arthroplasty, to check for any undetected anaemia or abnormalities • NICE guidelines recommend a full blood count before major surgery to evaluate for potential blood loss risks. • ECG is recommended for patients over 65 years old or those with systemic diseases to check for underlying cardiovascular conditions. • Chest X-ray is no longer routinely recommended as a preoperative test unless there are specific indications, such as chronic lung disease or recent respiratory infections.

Miscellaneous Key Flashcards

(159 cards)