NEW Flashcards
1
Q
Breast mass evaluation and management
A
Overall
- Triple assessment
- > hx + exam
- > imaging (mammo or US)
- > histology (CNB/FNA)
- Performed in sequence
- > each component has risk score
- > positive if any component suspicious/confirmed
Hx
- Mass
- > onset and evolution
- > fluctuating size or progressive
- > relation to menstrual cycle
- Associated symptoms
- > nipple discharge (unilateral/bilateral/colour)
- > pain (mastitis)
- > trauma (fat necrosis)
- OnG
- > menarche/menopause
- > parity
- > pil
- Family hx
- > first degree + premenopausal
- > BRCA mutations
- Meds
- > HRT
- > COCP
- Social
- > alcohol
Exam
- Inspect
- > nipple or breast asymmetry
- > eczema (pagets)
- > peu d’orange
- > obvious mass
- > dimpling/retraction/inversion
- Nipple
- > discharge (serous/sanguinous/serosanguinous)
- > uni-lobular or multi-lobular
- > unilateral or bi-lateral
- Palpate
- > mobile (fibrocystic change)
- > fixed + firm (cancer)
- Lymphadenopathy
- > axilla
- > cervical
- > supra/infraclavicular
Investigations
- Mammography
- > women over 30 years
- > spiculated mass + microcalcifications
- US
- > women under 30 years
- > simple cyst = anechoic + smooth + round (bengin)
- > complex cyst = septa or debris (risk of malignancy)
- > axillary lymphadenopathy
- FNA
- > fast/low pain/in rooms
- > no architecture/DCIS vs invasive
- CNB
- > preferred method
- > larger needle but fast/low pain/in rooms
- > assesses architecture/hormone receptor status
- EB
- > only performed to out concurrent malignancy with ADH
Management
- TA positive
- > surgical referral + MDT meeting
- > further investigations
- > patient age/comorbidities/functional status
- > tumour type/stage/receptor status
- TA negative
- > false negative rate <1%
- > no further investigations
- Definitive treatment
- > lumpectomy or mastectomy
- > sentinel node biopsy or axillary node dissection
- > HER2 +ive = tamoxifen +- letrazol
- > consider radiotherapy
2
Q
Hoarseness evaluation and management
A
Hx
- PC
- > hoarseness
- > dysphagia
- > odynophagia
- > otalgia
- > weight loss
- Past
- > GORD
- > radiation
- > immunosuppression
- Family
- > laryngeal cancer
- Sexual
- > men who have sex with men (HPV)
- Social
- > smoking
- > alcohol
- > asbestos
Exam
- Inspect
- > quality of voice
- > cachexia
- Ear
- > middle ear effusion
- > otitis externa
- Mouth
- > leukoplakia
- Neck
- > lymphadenopathy
- > thyroid mass
- Lungs
- > respiratory effort (worse while supine)
- > stridor
Investigations
- CT neck + chest with contrast
- > local spread
- > lymph node involvement
- FNA
- > if positive imaging
- > low negative predictive value
Management
- ENT referral
- > flexible laryngoscopy
- > rigid laryngoscopy + biopsy
- > videostroboscopy
- > whole body PET
- Early glottic/supraglottic
- > larynx sparing surgery or radiation
- > 5 year survival over 75%
- Advanced
- > partial or total laryngectomy
- > 5 year survival under 50%
- > chemoradiation
- Subglottic
- > total laryngectomy + neck dissection (thyroidectomy)
3
Q
Post thyroidectomy haematoma management
A
Issues
- Expanding haematoma
- > subglottic lesion
- > supra-glottic adjuncts useless
- Anaphylaxis
- Inhaled foreign body
Initial response
- Call for help
- Vitals
- > saturation
- Primary survey
- Empirical management
- > cut stitches
Primary survey
- A
- > lip/tongue swelling
- > ability to speak/change in voice
- B
- > respiratory distress
- > air entry
- > monitor saturations
- C
- > evidence of shock
- D
- > altered mental state
- E
- > urticarial rash
- > cyanosis
Management
- Stay with patient
- > press code button/call for help
- > surgeon or registra on call
- A
- > jaw thrust/chin lift
- B
- > cut superficial and deep sutures
- > inflammation due to haematoma (secure airway)
- > intubation or tacheostomy in arrest
- > supplement oxygen
- Definitive
- > return to OR
- > evacuation of haematoma
- > then intubation
- > haemostasis
- > drain placement
- > overnight intubation
4
Q
Subphrenic abscess evaluation and management
A
Hx
- Timing
- > persistent for many days
- > asymptomatic prior
- PC
- > worsening pain
- > nausea/vomiting
- > obstipation/diarrhoea
- > fevers/rigors/malaise
- Review
- > surgical complications
- > drains or catheters
- > immunosuppression
- > comorbidities
Exam
- Vitals
- > fever
- > review between the flags
- Sepsis
- > evidence of shock
- Wound
- > erythema
- > oedema
- > tenderness
- > fistula
- Canula
- > infection
- Abdo
- > generalised or focal tenderness
- > may have peritonism
- Chest
- > new murmur/friction rub
- > wheeze/crackles
- Calves
- > soft non tender
Investigations
- Blood cultures
- VBG
- > lactate
- FBC
- > leukocytosis (not always)
- ESR/CRP
- EUCs
- CT abdo with contrast
- > free air in collection
- > rim enhancement with debris
Management
- Supportive
- > fluids
- > analgesia
- > closer monitoring
- Call surgeon
- Consult radiologist
- > review images to see if amenable to drainage
- Percutaneous drain
- > CT or US guided
- Microbio
- > gram stain + culture
- > targeted antibiotics
- Empirical antibiotics
- > amoxicillin + gentamicin + metronidazole IV
- > consider MRSA risk
5
Q
Pre-op coagulopathy evaluation and management
A
Hx
- Characterise bleeds
- > menorrhagia
- > mucosal
- > epistaxis
- > GI
- > haemoarthrosis
- > dental procedures
- Associated symptoms
- > fatigue/SOB
- > fevers/night sweats
- Past
- > immunosuppression
- > malignancy
- > liver disease
- > crohns
- > autoimmune
- > connective tissue disorder
- Family
- > vWF = autosomal dominant
- > haemophilia = X linked
- Medications
- > anti-platelet/anti-coagulant
- > methotrexate
- Social
- > vegan (folate/B12)
Exam
- Inspect
- > pallor
- > purpura/petechiae/ecchymoses
- Lymphadenopathy
- Hepatosplenomegaly
- Mouth
- > glossitis
- > angular stomatitis
Investigations
- FBC
- > anaemia
- > thrombocytopenia
- > pancytopenia
- Smear
- > blasts
- Coags
- > aPTT (corrects with mixing in vWD and haemophilia)
- > PT (normal in vWD and haemophilia)
- > fibrinogen
- vWF
- > antigen
- > ristocetin activity
- > factor VIII activity
- Factor VIII and IX levels
- > low in haemophilia
- Blood group
Management
- Consult
- > haematologist
- > surgeon
- Delay surgery
- > test desmopressin response 1 week before
- Optimise for surgery
- > tranexamic acid IV immediately before procedure
- > desmopressin IV 30 mins before procedure
- > consider vWF concentrate
- > consider platelets
6
Q
Non operative management large bowel obstruction
A
Aetiology
- malignancy
- volvulus
- pseudo-obstruction
- impaction
- strictures
- > diverticulitis
- abscess
- hernia
- bezoars
- retroperitoneal fibrosis
Management
- Overall
- > 75% require surgery
- Sigmoid volvulus
- > flexible sigmoidoscopy for decompression
- Malignancy
- > stenting as bridge to surgery or palliation
- Impaction
- > manual disimpaction
- > enema
- > laxatives
- Pseudo-obstruction
- > reverse underlying cause
- > flatus tube
- > flexible sigmoidoscopy decompression
- > neostigmine
- Abscess
- > percutaneous drainage
- Advanced care directive
- > no interventions
7
Q
Post op nausea and vomiting management
A
Vitals
- Febrile
- Sepsis
Primary survey
- B
- > wheeze or crackles (aspiration)
- > respiratory rate (opioids)
- C
- > evidence of shock
- > irregular pulse
- > volume status
- D
- > change in mental status
- E
- > evidence of peritonism
- > rash
- > lines and drains
Hx
- PC
- > increasing pain
- > obstipation
- > fevers/rigors
- Review
- > PONV risk
- > PONV prophylaxis and timing
- > current analgesia
- Check
- > comorbidities
- > allergies
- > regular medications
- > kidney and liver function
Management
- Call for help
- > evidence of infection
- Multimodal
- > ensure adequate analgesia
- > maintain hydration
- > address any anxiety or concern
- > supplement electrolyte deficiencies
- No prophylaxis given
- > ondansetron IV 1-4mg
- > gransetron IV 1mg
- Prophylaxis given
- > droperidol IV
- > dexamethasone IV
8
Q
Post op fluid management
A
Assess
- Fluid input
- > fluid type
- > rate
- > electrolytes given
- Fluid loss
- > vomiting/diarrhoea
- > bleeding
- > drains
- > third spacing
- Volume status
- > urine output + fluid chart
- > weight
- > clinical assessment
Review
- Demographic
- > weight
- > age
- Comorbidities
- > HF
- > CKD
- > diabetes
- Check
- > Na/K/Ca/Mg
- > urea/creatinine
- > glucose
Consider
- Water
- > 25mL/kg/day
- Na
- > 1mmol/kg/day
- K
- > 1mmol/kg/day
Manage
- Resuss
- > urine output <0.5mL/kg/hr
- Maintenance
- > 4:2:1 per hr rule
- > hartmanns unless hyperkalaemia/drug incompatibility
- > hartmanns = K + Ca/normal saline = metabolic acidosis
- > can give normal saline + 30mL K combination
- > glucose given with feeds not fluid
- Replacement
- > assess quantity
- > electrolyte rich (vomiting/diarrhoea)
9
Q
Consent cholecystectomy
A
Competence and capacity
- Assumed unless clear evidence to the contrary
- Guardianship
Indication
- symptomatic cholelithiasis
- cholecystitis
- cholecystitis complications
- > porcelain
- gallstone pancreatitis
Procedure
- Usually laparoscopic
- > open if concerns for cancer
- General anaesthesia
- Entry
- > umbilical port
- > 2 more on right + one on left
- Inside
- > remove adhesions and exposure critical view of safety
- > intraoperative cholangiogram or preop MRCP
- Getting out
- > remove gallbladder with endocatch
- > absorbable stitches
- > local anaesthetic at port sites
Risks and Benefits
- Benefit
- > reduce pain
- > prevent recurrence
- > prevent complications (cholecystitis/perforation)
- Intra-operative
- > anaesthetic (teeth/throat/larynx/PONV/heart/lungs)
- > haemorrhage (dissection from vascular liver)
- > surrounding structures (bladder/bowel/liver)
- > common bile duct (1/300 to 1/500)
- > subtotal + ERCP + drain (unclear anatomy/adhesions)
- > conversion to open (stones in duct/unclear anatomy)
- Post-operative
- > pain/bleeding/infection
- > DVT/PE/MI/CVA
- > adhesions/hernias
- > bile leak (clip slip)
- > bile duct stricture (jaundice requiring stenting)
- > steatorrhoea
Alternatives
- Expectant management
- > approx 1/4 asymptomatic stones will develop symptoms
- > approx 1/3 symptomatic stones develop symptoms yearly
- Supportive management
- > analgesia
- > bile acid dissolution + US follow up at 6 and 12 months
- Interventions
- > cholecystostomy + delayed percutaneous extraction
- > extracorporeal shock wave lithotripsy (recurrence)
Concerns
-??
10
Q
Consent for ERCP
A
Competence and capacity
- Assumed unless clear evidence to the contrary
- Guardianship
Indication
- suspected obstructive jaundice or LFTs
- equivocal imaging for suspected pancreatic cancer
- gall stone pancreatitis or pancreatitis unknown aetiology
- cholangitis
- sphincter of oddi dysfunction
- biopsy of duct or pancreatic mass
- placement of stents
Procedure
- general anaesthesia
- endoscope down to duodenum
- cannula insert into sphincter of oddi
- fluroscopy
- > injection of dye
- > evidence of blockages
- sphincterotomy
- > removal of stones
- common bile duct trawling
- > basket or ballon
- > removal of stones
- stent placement
- biopsies
Risks and Benefits
- Intraoperative
- > anaesthetic (teeth/throat/larynx/PONV/heart/lungs)
- > haemorrhage (sphincterotomy/biopsies)
- > surrounding structures (bowel perforation)
- > pancreatitis (5-15%)
- Post operative
- > pain/bleeding/infection
- > DVT/PE/MI/CVA
- > infection (biliary obstruction)
- > papillary stenosis requires ballooning stenting (1%)
Alternatives
- MRCP
- > non invasive MRI with specific T2 weighted images
- > comparable sensitivity/specificity
- > cannot intervene
- Endoscopic ultrasonography
- > minimally invasive + heavy sedation or general
- > comparable sensitivity/specificity
- > biopsies possible
Concerns
-???
