OSCE Cases Flashcards
(120 cards)
1
Q
What are the most common histological types of oesophageal cancer?
A
Squamous cell carcinoma of the upper oesophagus
Adenocarcinoma of the distal oesophagus - junction of the oesophagus and stomach
2
Q
What are the risk factors for SCC of the oesophageal?
A
Low socioeconomic groups
Smoking
Alcohol
Males
Age +60
HPV infection
3
Q
What are the risk factors for adenocarcinoma of the oesophagus?
A
Smoking
Barrett’s oesophagus
GERD
Obesity
History of Breast Ca
4
Q
What are the symptoms of oesophageal cancer?
A
Dysphagia
Pain
Hoarseness
Cough with swallowing - oesophageal-tracheal fistula
Weight loss
Neck mass
5
Q
What are the signs of oesophageal cancer?
A
Cervical lymph nodes
Hypercalcaemia - parathyroid hormone production
Dehydration, weight loss and muscle wasting
6
Q
How is oesophageal cancer diagnosed?
A
History - Risk factors, symptoms
Examination - signs
Barium swallow
Endoscopy - direct visualization
FNA our Biopsy - histology
CT scan - Staging of disease
7
Q
What are the findings on barium swallow for oesophageal Ca?
A
Irregular concentric narrowing - Stricture formation
Typical shouldering at the upper end of the lesion
8
Q
Why is endoscopy performed for oesophageal Ca?
A
Direct visualisation of lesion
Biopsy of lesion for histology
9
Q
What is the management of oesophageal cancer?
A
Surgical resection - oesophagectomy
- If lesion is limited to the oesophagus
- Done via transhiatal or thoracotomy
Neoadjuvant Chemotherapy with/without neoadjuvant Radiotherapy
* For downstaging of locally advanced tumours
Expandable stents insertions
- For lesions that cannot be resected
- With neoadjuvant chemo-/radiotherapy
Laser / cryotherapy
- For intraluminal lesions that cannot be resected
- Restores patency of oesophagus
10
Q
How is oesophageal cancer staged?
A
TNM Staging…
Barium swallow
- Position
- length/size
- oesophageal tracheal fistula
- axis deviation and angulation
Endoscopic ultrasound
CT scan
11
Q
What are the contraindications for surgery in oesophageal cancer?
A
Metastasis
Invasion of adjacent structures
Severe associated co-morbid diseases
12
Q
What are the risk factors for gastric cancer?
A
Diet - low fat, low protein, high salt, alcohol
Environmental - poor food prep and drinking water, smoking
Poor socioeconomic status
Genetic predisposition
H. Pylori infection
Prior gastric surgery
Gastric ulcer
Atrophic gastritis
Polyps
Males
13
Q
Describe the Borrmann classification of the endoscopic finding of a gastric adenocarcinoma
A
Type 1: Polypoid or fungating lesion
Type 2: Ulcerating lesions surrounded by an elevated border
Type 3: Ulcerating lesion with infiltration into the gastric wall
Type 4: Diffusely infiltrating lesion
Type 5: Lesions that do not fit any of the above
14
Q
Describe Lauren’s classification for intestinal gastric adenocarcinoma
A
Ulcerative
Usually in the Antrum of the stomach
Pre-existing gastric atrophy and intestinal metaplasia
Any blood type
More common in males
Older age
Gland formation
Haematogenous spread
Better prognosis
15
Q
Describe Lauren’s classification for diffuse gastric cancer
A
No gastric atrophy or intestinal metaplasia usually
Blood group A
More common in females
Younger
Poorly differentiated, signet ring cells
Transmural or lymphatic spread
Poor prognosis
16
Q
How would a patient with a gastric adenocarcinoma present?
A
Dyspepsia - GERD
Epigastric discomfort / indigestion
Weight loss, vomiting, anorexia
Dysphasia
Gastric outlet obstruction
Early satiety
Anaemia
17
Q
What are the signs of advanced gastric adenocarcinoma?
A
Palpable abdominal mass
Palpable supraclavicular lymph-node’s (virchows LN / troisiers sign)
Sister Mary Joseph nodule
Irregular hepatomegaly
Ascites
18
Q
How is gastric adenocarcinoma diagnosed?
A
FBC
* Aneamia due to bleeding cancer
U&E
* Lookiing for electrolyte abnormalities due to weight loss, vomiting and anorexia
LFTs - To assess liver function in case of mets
CEA tumour marker
Blood gas
- If the patient has gastric outlet obstruction
- To rule out metabolic acidosis
Gastroscopy with biopsy for histological classification
CXR
* To look for/rule out lung and liver mets
CT scan
* * To look for/rule out metastases
19
Q
How do you stage a gastric adenocarcinoma?
A
TNM staging
20
Q
What is the management of a gastric carcinoma?
A
Subtotal gastrectomy- distal third tumors
Total gastrectomy - middle and proximal third tumors
Lymph nodes in close proximity are always removed
21
Q
What are the complications of a gastrectomy?
A
Bleeding
Anastomoses leakage
Obstruction
Ulcer recurrence
Gastro-jejuno-colic fistula
Alkaline reflux gastritis
Dumping syndrome
Chronic gastroparesis
Malabsorption - anaemia
22
Q
Describe the pathophysiology of bowel obstruction
A
- Complete obstruction
- Intestine proximal to obstruction contracts vigorously trying to overcome obstruction
- colicky pain + increased bowel sounds
- abdominal distension
- proliferation of gas producing bacteria
- Further abdominal distension
- vomiting (feaculant oudor)
- dehydration
- constipation/obstipation
23
Q
What are the causes of large bowel obstruction?
A
Colorectal Cancer
Faecal Impaction
Sigmoid Volvulus
Diverticular stricture
Adhesions
Foreign body
Hernia
24
Q
What are the four cardinal features of mechanical intestinal obstruction?
A
Pain
Abdominal distension
Vomiting
Constipation/Obstipation
25
How would you diagnose bowel obstruction?
History - Previous surgery, symptoms
Examination- especial abdominal and rectal examination
Bloods - FBC, U&E
AXR - supine or erect
Single contrast barium enema
26
List the risk factors / pre-malignant factors for colorectal carcinoma
Western diet - high fat, low fiber
Genetic factors:
* Family history
* FAP
* Lynch syndrome type I/II
Ulcerative colitis
Previous irradiation
Implantation of ureters in colon
Colorectal schistosomiasis
27
How did you diagnose colorectal carcinoma?
History and examination - NB PR Exam
Sigmoidoscopy
Barium enema of colonoscopy
CT abdo
28
Discuss a fungating colorectal adenocarcinoma
Usually in the right colon
Few symptoms
Early: peri umbilical/epigastric discomfort 30mins after a meal
29
Discuss a annular stenosing colorectal adenocarcinoma
Typically left colon/sigmoid
GERD
Increasing Constipation or alternating episodes of constipation and diarrhea
30
Discuss a malignant ulcer colorectal adenocarcinoma
Typically in the rectum
Blood/Mucus per rectum
Tenesmus
Spurious diarrhea
Do NOT diagnose this radiologically
31
Discuss your approach to a patient with colorectal carcinoma
History - suggestive symptoms
Examination - all especially PR exam; looking for signs
```
Special investigations -
Colonoscopy/Sigmoidoscopy and biopsy
Barium enema
Tumour markers CEA
FBC for Fe anaemia
CT abdo
```
```
Staging
TNM
CXR
LFTs
Abdo US
```
Surgical resection - colectomy/hemicolectomy with removal of regional lymph nodes
Adjuvant Chemo/radiotherapy
6 monthly follow-ups - Exam, LFTs, CXR, US abdo, CEA levels
2 yearly colonoscopies
32
Discuss your special investigation findings of colorectal carcinoma
Colonoscopy/Sigmoidoscopy and biopsy
*
Barium enema
*
Tumour markers CEA
*
FBC
* Fe deficiency anaemia - occult bleeding per rectum
CT abdo
* Staging and metastases
33
List the 2 most common causes of obstructive jaundice
Gallstones
Head of pancreas carcinoma
34
Provide a DDx for obstructive jaundice due to luminal obstruction
Gallstones
Parasites
* Ascaris Lumbricoides
* Daughter cyst of Enchinococcus cyst
35
What are the signs of obstructive jaundice?
Yellow skin and sclera
Dark Urine
Pale stools
Itching
RUQ pain and tenderness
36
How would you investigate Obstructive jaundice?
Urine dipstick
* + bilirubin
* - urobilinogen
FBC
* Increased WCC with cholangitis
LFTs
* Low albumin
* Increased Alkaline phosphate and GGT
Ultrasound
* Visualization of obstruction - cystic/solid
* Billiary Dilatation above the obstruction
* Level of obstruction
* Hyperechoic mass > gallstone
* Distended gallbladder + thickened wall > acute cholecystitis
AXR
* Radio-opaque gallstones (10-20%) - Brown and black stones coz' it contains calcium
ERCP
* Filling defect
37
What are the consequences of gallstones in the gallbladder?
Mostly asymptomatic
Gallstone dyspepsia
* Upper abdominal discomfort
* Aversion of fatty foods
* Flatulence
Biliary colic
* Colic-like pain in RUQ - radiates to right scapula
* Nausea and vomiting
* Tenderness over gallbladder
Acute cholocystitis
Carcinoma of the gallbladder
38
What is the management of symptomatic gallstones?
Laproscopic cholecystectomy
Open cholecystectomy if...
* Evidence of severe/perforated acute cholecystitis
* Exploration of bile duct required
39
What are the symptoms and signs of acute cholecystitis?
BIliary colic > constant pain in RUQ
Pyrexia
Murphy's sign (+)
Raised WCC
Paralytic ileus
*Constipation
40
How is Acute cholecystitis diagnosed?
Ultrasound
* Distended gallbladder
* Thickened gallbladder wall
* Sonographic Murphy's sign - Localised tenderness
Tc-99m HIDA scintigram
* Done under sonar
* Isotope reaches bowel but no activity seen in gallbladder
41
How would you manage acute cholecystitis due to gallstones?
Admit
IV fluids
NPO
Analgesia - Pethidine
Broad spectrum antibiotics - Cephzol / Amoxicillin + Gentamicin
Cholecystectomy within 3-4 days
42
What are the clinical features of an adenocarcinoma of the pancreas?
Painless obstructive jaundice
* Preceded by vague, deep-seated abdominal pain + bachache (poor prognostic indicator)
Anorexia, weight loss
Palpable gallbladder
Liver palpable - congestion
43
How would you diagnose a tumour of the pancreas?
LFTs
* Total bilirubin >10x normal favours malignant obstructive jaundice
Tumour Markers
* Elevated CA19-9
Ultrasound
* Biliary/pancreatic duct dilatation
* Cystic neoplasn
Abdominal CT scan
* Visualize tumour
* Biliary/pancreatic duct dilatation
* Local infiltration
* LN/Liver metastases
ERCP
* Site and form of biliary obstruction
* Displacement/obstruction of pancreas
44
What is the treatment for pancreatic tumours?
Surgical resection (whenever possible)
Islet cell tumours / cystadenoma
* Simple enucleation
Head of pancreas / peri-ampullary tumors
* Whipple operation (Pancreaticduodectomy)
Body/tail pancreatic tumour
* Distal pancreaticduodectomy + excision of spleen and splenic vessels
Unresectable tumour
* Palliative - Gallbladder/bileduct anastomosis to small bowel
45
What is the prognosis of adenocarcinoma of the pancreas?
Poor :(
Without resection 1 year survival <10%
With resection 1 year survival ± 12%
46
When would you perform surgery for portal hypertension?
(When there's complications)
Bleeding Oesophageal Varices
* Who failed other treatment modalities
* Good operative risk
Ascites
Hypersplenism
47
What are the endoscopic treatment interventions for oesophageal varices?
Sclerotherapy
Rubber band ligation
48
What are the invasive radiological treatment procedures for oesophageal varices?
Embolisation
Transjugular intrahepatic portosystemic shunt (TIPSS)
49
What are the surgical treatment procedures for oesophageal varices?
Porto-caval / Meso-caval shunt
* Creation of a communication between the hypertensive portal venous system and low pressure systemic system
* Normalises pressure in portal venous system
* Manages ascites and hypersplenism as well
50
What are the complications of the surgical treatment for oesophageal varices?
Hepatic encephalopathy
51
What are the risk factors for hepatocellular carcinoma?
Hep B/C infection
Cirrhosis
Aflatoxin contaminated foods
Alcoholic
52
How would you diagnose a hepatocellular carcinoma?
History - suggestive symptoms and risk factors
* RUQ pain
* Abdominal mass
* Loss of appetite and weight loss
* Jaundice
Examination: Palpable mass / jaundice
Macroscopic features
* Large - single well-circumscribed
* Nodular - multiple nodules
* Diffuse - ill-defined, wide infiltration, most common in SA
Alpha - Fetoprotein will be raised
U/S - visualise mass
CT scan - Staging
53
What is the management of an organ-confined hepatocellular carcinoma?
Tumour resection (where possible)
* Most effective
* Not done if there's cirrhosis coz' of bleeding risk and decreased liver function
Liver transplant
* Cirrhotic patients
54
What is the management of a non-resectable (not organ-confined) hepatocellular carcinoma?
Intralesional injections with 95% ethanol
Chemotherapy via the hepatic artery
Radiofrequency ablation
55
List the non-hereditary risk factors for breast cancer
Older patient >50 years
Females
Alcohol and smoking
Early menarche
Late menopause
Late first pregnancy/few or no pregnancy
Obesity
56
List the hereditary risk factors for breast cancer
BRCA 1 or BRCA 2 mutation
* BRCA 1 mutation - 85% chance of developing breast ca
Family history of breast cancer
Family history of ovarian cancer
Personal history of breast cancer
57
What patients are considered high risk for breast cancer?
> 1 first line relative with unilateral breast ca
1 first line relative with bilateral breast ca
1 male relative with breast ca
1 relative with breast or ovarian ca
Previous biopsy showing
* CIS
* Proliferative disease with atypia
* complex fibroadenoma
58
How is breast cancer diagnosed?
Triple Test!!
1. Clinically
* History - Risk factors
* Exam - Lump/mass and LN
* Metastases
2. Mammogram
* 2 views - CC and MLO
* Suspicious lesion
3. FNA and Cytology
* ER/PR status
* Pathological type
* Inconclusive > Core biopsy
59
What is the importance of ER/PR status of a breast carcinoma
ER/PR (+) must NOT get hormone Replacement therapy because it feeds the tumour
60
What are the features of a suspicious lesion on mammogram?
Hyperdense
Spiculated
Pleomorphic microcalcifications
61
What are the most common pathological types of breast cancer?
Infiltrating ductal (75%)
Infiltrating lobular (10%)
62
What are the management guidelines for a Stage I-II breast cancer?
Breast conservtaion therapy with adjuvant radiotherapy
* Tunour excision with axillary dissection
Adjuvant radiotherapy
* 5 days a week for 5-6 weeks
Systemic therapy depending on prognostic factors of the tumor
63
What are the indications for Neo-adjuvant chemotherapy in breast cancer?
All locally advanced disease - Stage IIb; IIIa and IIIb
>4cm mass
To downstage a tumor
If increased risk of micrometastases
To decrease tumour size
HER (+)/(-)
Triple negative - ER/PR/HER (-)
64
What are the indications for Adjuvant chemotherapy in breast cancer?
Age <40 years
ER / PR (-)
> 3 LN involvement
High grade tumours
65
What are the indications for hormone therapy in breast cancer?
ER (+)
Soft tissue metastases
Bone metastases
Pleural effusion (lung metastases)
Local reccurrance
66
What are the indications for a mastectomy (contraindications for BCT) in breast cancer?
High breast : tumour ratio
Previous irradiation to the breast
Multifocal/multicentric tumour
Wide spread microcalcifications on mammography
Tumor > 4cm
BRCA (+)
Patient preference
Collagen vascular disease - coz' radiotherapy C/I
* SLE
* Scleroderma
2 Recurrence of carcinoma
Males
Poor socio-economic circumstances
Pregnancy / Lactation
67
What hormone therapy would you use in a post-menapausal woman with breast cancer?
Tomoxifen
* Inhibits oestrodiol binding
* Especially effective in ER/PR (+) patients
Anastrozole (Arimidex)
* Aromatase inhibitor - inhibits the conversion of androgens to oestrogen
68
What are the side-effects of tomoxifen?
Menopausal symptoms:
* Hot flushes
* Mood changes
* Altered menses / amenorrhoea
* Dry vagina
* Thrush
Thromboembolism
* Stroke
* DVT
Fatty liver changes
Increased risk of endometrial cancer
Vaginal atrophy and bleeding
69
What are the side-effects of Arimidex?
MSK pain
Bone pain
70
What hormone therapy would you use in a pre-menapausal woman with breast cancer?
Ovarian ablation
* Surgical
* GnRH antagonist - Temporary, better for younger patients
Tomoxifen
71
What receives biological therapy in breast cancer and biologic would they receive?
HER-2 (+) patient
Herceptin - monoclonal antibody against HER-2
72
Discuss regional therapy in breast cancer
Palpable Axillary LN
* Axillary dissection via Modified radical mastectomy
Impalpable Axillary LN
* Sentinal LN biopsy
73
Discuss BRCA
Autosomal dominant inheritance
Associated with breast, ovarian, fallopian tube, colon and prostate carcinoma
74
What stage breast cancers would you do a CT scan and bone scan for?
Stage IIb and up
To look for Metastases
75
What are the histological indications for axillary dissection in breast cancer?
Large tumour
Soft tissue invasion
3 or more LN had tumour in it
Extranodal extension of disease
Micrometastases
76
What is the clinical presentation of a nontoxic multinodular goitre?
Euthyroid
Dysphagia and respiratory distress due to tracheal compression
Plethora (venous congestion)
* Ask patient to lift arms above head then cervical veins will dilate
77
What is the management of a nontoxic multinodular goitre?
Medical:
* Thyroid hormone replacement therapy
* Radio-active iodine (RAI) uptake to reduce goitre size
Surgical:
* Sub-total thyroidectomy - if poor RAI uptake
78
What are the risk factors for a toxic multinodular goitre (plummers disease)?
Older women
Iodine deficiency
Genetic predisposition
History of nontoxic multinodular goitre
79
What is the management of a toxic multinodular goitre?
Medical:
* Antithyroids with beta-blockers
* Radio-active iodine (RAI) uptake to reduce goitre size
Surgical:
* Sub-total thyroidectomy - if poor RAI uptake
80
What special investigations would you do in a patient with thyroid pathology and why?
Serum TSH
* Raised in hypothyroidism
* Decreased in hyperthyroidism and euthyroidism
Total T4, free T4 and free T3
* Function of the thyroid
Serum Calcitonin
* Increased in MEN 2 syndrome
Thyroid Antibodies
* Increased in autoimmune thyroiditis
81
Discuss Radioactive Iodine (RAI) Uptake testing
Provides a function-anatomical correlation of thyroid lesion
Provides information on risk of malignancy
Cold nodule = High risk of malignancy (20%)
Hot nodule = Lower risk of malignancy (5%)
* Hot nodule + hyperthyroidism = benign
82
What imaging would you do in a patient with thyroid pathology and why?
RAI uptake
* Provides information of risk of malignancy
FNA
* Diagnoses/excludes malignancy
Ultrasound
* Evaluation of thyroid nodules for suspicious signs of malignancy
CT scan
* Metastases
83
What are the suspicous signs of thyroid cancer on ultrasound?
Calcification
Increased vascularity
Irregular borders
Absent halo sign
84
What is the most common thyroid malignancy?
Papillary cell adenocarcinoma
85
What is the origin of a Papillary cell adenocarcinoma of the thyroid?
Arises from follicular epithelial cells
86
What are the risk factors for a Papillary cell adenocarcinoma of the thyroid?
Genetic mutation of BRAF gene
Previous irradiation
Family history of thyroid cancer
Familial syndromes:
* Familial papillary carcinoma
* Familial non-medullary thyroid carcinoma
* Familial adenomatous polyposis coli (FAP)
* Gardner syndrome (Familial colorectal polyposis)
* Turcot syndorme (multiple adenomatous polyps in the colon)
87
What is the clinical presentation of a Papillary cell adenocarcinoma of the thyroid?
Most common (80%)
2:1 female:male ratio
20-30 years
Solitary nodule
* Firm on palpation
* Solid on ultrasound
* Cold on RAI
Dysphagia (invasive)
Dyspnoea (invasive)
Dysphonia (invasive)
Palpable LN
88
What is the route of spread of a Papillary cell adenocarcinoma of the thyroid?
Lymphatic
89
Where does a a Papillary cell adenocarcinoma of the thyroid metastasize to?
Lungs
Bone
90
What investigations would you do for a papillary cell adenocarcinoma of the thyroid??
Thyroid function tests
* Increased TSH
* Normal FT3 and FT4
Ultrasound
* Look for suspicious signs
* Solid
FNA and cytology
* Papillary projections of columnar epithelium
* Psammoma bodies (60%)
RAI
* Cold
91
What is the management of a Papillary cell adenocarcinoma of the thyroid?
Surgical
<1 cm - Lobectomy/Isthmustectomy (Younger patients)
>1 cm - Total thyroidectomy with central node dissection
Adjuvant
* Thyroid hormone suppression and radioiodine therapy
* External beam radiotherapy for >45 years and had locally invasive disease.
Post-Total thyroidectomy
Life-long thyroid hormone replacement therapy
92
What are the indications for a Total thyroidectomy?
(Also contraindications to RAI)
Large/Multinodular goitre with poor RAI uptake
Compression symptoms
Suspicious malignant nodule/ confirmed thyroid cancer
Pregnancy/children
Patients who wish to fall pregnant
Amioderone induced hyperthyroidism
Adverse effects of antithryoids
Unable to follow long term follow-up
93
What are the complications of thyroidectomy?
Thyroid storm
Neck haematoma
Recurrent laryngeal nerve injury
Injury to the external branch of the superior laryngeal nerve
Injury to the oesophagus
Injury to to the great vessels/cervical sympathetic trunk
Hypoparathyroidism
94
Provide a DDx for a solitary nodule of the thyroid
Cyst
Colloid nodule
Papillary cell adenocarcinoma
Follicular cell adenocarcinoma
95
What are the risk factors for chronic arterial disease (critical limb ischaemia)
Smoking
DM
HPT
Hyperlipidaemia
Older age
Obesity
Males and post menapausal women
Family history
Chronic renal failure
96
What are the symptoms of chronic arterial disease?
Usually asymptomatic
Intermittent Claudication - ischaemic muscle pain induced by exercise and relieved by rest
Critical limb ischaemia:
Rest pain - severe burning pain in the forefoot or toes that’s worse at night and improves with walking or hanging the limb off the bed
Gangrene
Ischaemic ulcer
Impotence - aortic-iliac/bilateral iliac disease
Acute on chronic vascular occlusion
97
Provide a DDx for claudication
Osteoarthritis of the hip/knee
Neurospinal claudication
Chronic compartment syndrome
Venous claudication
98
Provide a DDx for rest pain
Diabetic neuropathy
Gout
Plantar fasciitis
Night cramps
99
What is critical limb ischaemia (CLI)?
It implies impending limb loss
When the blood supply to a limb is critically diminished
Often a multilevel disease
100
What are the symptoms/signs of critical limb ischaemia?
Rest pain
Non-healing ischaemic ulcer
Gangrene
101
When assessing a patient the femoral pulse and all pulses below it are absent. What is anatomical level of disease?
Aorta-iliac disease
102
When assessing a patient the highest pulse palpable is the popliteal pulse. What is anatomical level of disease?
Trifurcation disease
103
When assessing a patient the highest pulse palpable is the foot pulse. What is anatomical level of disease?
Distal disease
104
When assessing a patient the highest pulse palpable is the femoral pulse. What is anatomical level of disease?
Femero-popliteal disease
105
What special investigations would you do for a patient with chronic arterial disease?
Duplex Doppler
CT angiography
Digital Subtraction Angiography
MR angiography
106
Discuss the management of claudication
Stop smoking
Manage risk factors - DM, HPT, hypercholesteraemia (ACE inhibitors is HPT)
Aspirin
Simvastatin
Supervised exercise program
Foot care in diabetes
Warn patients about symptoms of CLI and acute on chronic vascular occlusion
Refer for intervention is conservative treatment fails
107
Discuss the management of critical limb ischaemia
Need revascularization for limb salvage:
Imaging - duplex Doppler, CT angiography, DSA
Revascularization - endovascular, surgery
Amputation of gangrenous toes
Risk factor management
108
How do you manage a patient with critical limb ischaemia that is NOT a candidate for revascularization?
Amputate - Unbearable pain/progressive infection
Medical management - Stable pain
109
List the options for revascularization
Endovascular:
Balloon dilatation
Stent
```
Surgery:
Bypass
Endarterectomy
Sympatectomy
Amputation
```
110
How would you manage a patient with aorto-iliac disease?
Aortabifemoral bypass
OR
Fem-fem bypass
111
Discuss the treatment of a septic diabetic foot
Diagnose and treat diabetic ketoacidosis
IV fluids - Ringers
Correct electrolytes
Give insulin
IV antibiotics - Entrapenem/Vancomycin
Drainage and debridement of sepsis
?Amputate
?Revascularize
112
What are the indications for amputation
Non-viable limb
Critical limb ischaemia with no bypass option
Foot no longer salvageable
Immobile or contracture of limb
Patient preference
113
Classify Abdominal Aortic Aneurysms by CT measurements
Normal: 2-3cm
Small AAA: 4-5cm
Moderate AAA: 5-6cm
Large AAA: 6-7cm (50% risk of rupture in 5 years)
Very large AAA: >7cm (100% risk of rupture in 5 years)
114
What are the complications of an AAA
Rupture
Compression of surrounding structures
Embolization
115
When is surgery indicated in an asymptomatic AAA
>5.5cm
>1cm increase in size in a year
Uncontrolled HPT
Patients request
116
What are the indications for a stent placement in AAA
Neck is atleast 1cm below renal artery or normal aorta
<60% angulation of the neck
Must have adequate access
May not be too torturous or calcified
117
What are the surgical options for AAA?
Aneurysmectomy
Stent placement
118
What is the conservative management of an AAA
Smoking cessation
BP control
Simvastatin
6 monthly follow-up for US
119
What are the symptoms of an AAA
Abdominal pain that radiates to the back
Tenderness over AAA
Rapid expansion
120
What are the complications of endovascular (stent) repair?
Endoleaks
Migration
Neck dilatation
Limb occlusion
