Surgery Flashcards
(185 cards)
1
Q
what layers are cut through in a midline laparotomy
A
skin campes fascia (subcutaneous fat) scarpa's fascia (membraneous) linea alba transversalis fascia pre-peritoneal fat peritoneum
2
Q
what is a midline laparotomy used for?
A
emergency: perforated DU
trauma
ruptured AAA
hartmann’s
elective:
colectomy
AAA
Vascular bypass
3
Q
pros and cons of midline laparotomy?
A
good access
bloodless line
minimal nerve and muscle injury
long scar
increased pain
4
Q
how is midline laparotomy closed?
A
PDS
blunt J suture
Jenkins rule: length of suture = 4x length of incision
1cm bite, 1cm apart
5
Q
what is a Kocher’s (subcostal) incision used for?
A
open cholecystectomy
L Kocher’s used for splenectomy
6
Q
What is a rooftop incision used for?
A
hepatobiliary surgery liver whipples liver resection gastric surgery
7
Q
what is a pfannenstiel incision used for?
A
gynaecologist surgery
lower urinary tract
8
Q
what layers do a mcburneys/lanz incision go through?
A
skin campers fascia scarpas fascia external oblique internal oblique transversus transversalis fascia pre-peritoneal fat peritoneum
9
Q
indications for mcburneys/lanz incision?
A
appendicectomy
10
Q
features mcburneys/lanz?
A
mcburneys: oblique
lanz: transverse (favoured)
risk of injury to ilioinguinal and iliohypogastric nerves may predispose to inguinal hernia
11
Q
indications thoracoabdominal incision?
A
oesophagogastrectomy
12
Q
indications transverse muscle splitting?
A
right hemicolectomy
13
Q
features of transverse muscle splitting
A
limited access cf midline incision
decreased damage to recuts
segmental nerve supply means the muscle can be cut transversely without weakening
14
Q
indications for inguinal hernia incision?
A
open inguinal hernia repair
orchidectomy
15
Q
features of inguinal hernia incision?
A
inions over the inguinal ligament
follows Langer’s lines
high rates of chronic neuropathic pain
16
Q
indications for McEvedy modified incision?
A
emergency femoral hernia
17
Q
features of McEvedy modified incision?
A
allows inspection of peritoneal cavity
easy conversion to laparotomy if necessary
‘half pfannenstiel’
18
Q
indications for loin incision?
A
nephrectomy
19
Q
indications for vascular access?
A
bypass embolectomy EVAR/TEVAR stent inserion femoral endarterectomy angioplasty
20
Q
Where do laparoscopic cholecystectomy port scars go?
A
x4 periumbilical subxiphoid medial subcostal lateral subxiphoid
21
Q
indications for median sternotomy?
A
mainly open heart surgery transplant valve surgery congenital cardiac defect corrections CABG
22
Q
where is anterolateral thoracotomy and what for?
A
under breast
left = open chest massage
23
Q
what is axillary thoracotomy used for?
A
pneumothorax
pleurectomy
pulmonary resections
24
Q
what is posterolateral thoracotomy used for ?
A
most common
pulmonary resections
oesophageal surgery chest wall resection
cut through intercostal speech beginning inferomedially to tip of scapula
25
what is Benz modification and wha tis it used for
chevron + incision and break through xiphisternum
```
diaphragmatic hernia
gastrectomy
oesophagectomy
bilateral adrenalectomy
hepatic resections
liver transplant
```
26
Indications for rutherford morrison incision?
```
extension of lanz
kidney transplant
colonic resection
caecostomy
sigmoid colostomy
```
27
What are the ASA grades?
ASA I: normal healthy patient
ASA II: patient with mild systemic disease (smoker/more than minimal drinking, controlled HTN etc), obesity
ASA III: severe systemic disease (diabetes, HTN etc)
ASA IV: severe systemic disease that is constant threat to life (recent hx of MI, CVA, TIA)
ASA V: moribund patient who is not expected to survive without the operation (ruptured abdominal or thoracic aneurysm, bleed with mass effect)
ASA VI: patient already declared brain dead/transplant removal
N.B. BMI >40 = ASA III
addition of E means emergency surgery
28
types of LA?
Lidocaine
Cocaine
Bupivicaine
Prilocaine
29
indications for lidocaine?
LA
| anti arrhythmic
30
effects of lidocaine od?
CNS overactivity -> depression
| arrhythmias
31
antidote to lidocaine OD?
IV 20% lipid emulsion
32
lidocaine drug interactions?
beta blockers
ciprofloxacin
phenytoin
33
dose of lidocaine plain and with adrenaline?
3mg/kg
| 7mg/kg
34
dose of bupivacane plain and with adrenaline?
2mg/kg
| 2mg/kg
35
dose of prilocaine plain and with adrenaline?
6mg/kg
| 9mg/kg
36
when can people eat and drink up to before surgery?
no food <6 hours before surgery
no drink <2 hours before surgery
[same rules for diabetes & pregnant]
37
how to ensure correct endotracheal tube placement?
clinically - equal and symmetrical chest expansion and air entry, fogging mask
observations - spO2 maintained, CO2 reading
radiological - CXR shows ET tube just above carina
38
what are some contraindications of neuromuscular blockers [suxamethonium]?
hyperkalaemia in burns/trauma patients
spinal cord trauma causing paraplegia, and previous suxamethonium allergy.
increased IOP
39
Complications of suxamethonium?
```
suxamethonium apnoea (pseudocholinesterase deficiency)[AD]
malignant hyperthermia (>40)
```
40
Mx suxamethonium apnoea?
re-intubate and wean off
41
Mx malignant hyperthermia?
dantrolene
42
Suxamethonium CI?
Increases IOP
| CI in patients with penetrating eye injuries or acute narrow angle glaucoma
43
Common post-op complications?
day 1: atelectasis
day 3: UTI
day 5: SSI [s.aureus most common], anastomotic leak
day 7: DVT/PE
44
S/S and Mx of atelectasis?
pyrexia
reduced o2 sats
reduced breath sounds at bases
Mx: sit up, chest physio
45
Classification of post-op haemorrhage?
primary: continued bleeding starting during surgery
reactive: bleeding <= 48 hours of surgery
secondary: bleeding >= 48 hours of surgery (7-10 days, usually due to infection)
46
Absorbable sutures and indications?
catgut MVP
catgut
monocryl - subcuticular skin closure
vicryl [braided]- subcuticular skin closure, bowel anastomosis
PDS - abdominal wall closure
47
Non absorbable sutures and indications?
SEE Prolene
Silk [braided] - secure drains
Ethibond [braided]- soft tissue approximation
Ethilon - skin wounds
Prolene - skin wounds, arterial anastomosis
48
exceptions form MRSA screening before surgery?
TOP patients
ophthalmic surgery
psychiatric inpatients
49
management MRSA prophylaxis?
nose - mupirocin 2% in white soft paraffin TDS for 5 days
| Skin - chlorhexidine gluconate OD for 5 days all over body
50
ileostomy location, appearance, output?
RIF
spouted
liquid
51
colostomy location, appearance, output?
left side but varies
flushed
solid
52
stoma indications?
```
faecal
- perforation
- permanent
- diversion
- decompression
feeding
bladder
```
53
examination of stoma?
site inspection
lumens (1= end ileostomy/colostomy, 2= loop)
spout (spouted = small bowel, flush = large bowel)
stoma output/bag contents
surrounding skin
digitation
abdomen
perineum
54
complications of stoma?
```
early:
haemorrhage
ischemia
high output -> vol depletion, electrolyte and acid base disturbance (metabolic acidosis)
parastomal abscess
stoma retraction
```
```
delayed:
parastomal hernia
obstruction (adhesion, herniation)
dermatitis
stoma prolapse
stenosis, stricture
fistula
psychosexual dysfunction
```
55
Type of resection and anastomosis for caecal, ascending or proximal transverse colon?
right hemicolectomy
| ileocolic
56
Type of resection and anastomosis for distal transverse, descending colon?
left hemicolectomy
| colo-colon
57
Type of resection and anastomosis for sigmoid colon?
high anterior resection
| colo-rectal
58
Type of resection and anastomosis for upper rectum?
```
anterior resection (TME)
colo-rectal
```
59
Type of resection and anastomosis for low rectum?
```
anterior resection (low TME)
Colorectal +/- defunctioning stoma
```
60
Type of resection and anastomosis for anal verge?
abdomino-perineal excision of rectum
| none
61
what are the types of urostomy?
```
ileal conduit (incontinent diversion)
ileal pouch (continent diversion)
```
62
types of ileal pouch?
```
KIMI
Kock
Indiana
Mitrofanoff
Ileal neobladder
```
63
which structures are on the transpyloric plane?
```
end of spinal cord
L1 body
SMA origin
origin portal vein
neck of pancreas
stomach pylorus
2nd part duodenum
sphincter of oddi
hilum of each kidney
duodenojejunal flexure
funds of gall bladder
tips of 9th costal cartilages
```
64
what is found at L1, L2 and L3?
L1: SMA, coeliac trunk
L2: renal, gonadal arteries
L3: IMA
65
What are the horizontal planes for the 9 regions of the abdomen?
trans-pyloric - end of 9th costal cartilage
| intertubecular - tubercle of crest of ilium
66
scars for right hemicolectomy?
midline laparotomy
transverse muscle splitting
laparoscopic ports
67
scars for left hemicolectomy?
midline laparotomy
| laparoscopic ports
68
What is a hartmann's procedure?
emergency procedure
sigmoid coletomy
proximal bowel exteriorised as an end colostomy
distal bowel oversewn to form rectal stump
may be reversed after 3-6m
69
indication for hartmann's?
obstruction or perforation secondary to singled tumour or diverticulitis
70
scars for hartmann's?
midline laparotomy
| previous stoma scar in LIF if it has been reversed
71
stoma for hartmanns?
single lumen colostomy in LIF
72
MOA nitrous oxide?
May act via a combination of NDMA, nACh, 5-HT3, GABAA and glycine receptors
73
Adverse effects of nitrous oxide?
May diffuse into gas-filled body compartments → increase in pressure. Should therefore be avoided in certain conditions e.g. pneumothorax
74
what is nitrous oxide used for?
Used for maintenance of anaesthesia and analgesia (e.g. during labour)
75
What is the MOA of volatile liquid anaesthetics
| (isoflurane, desflurane, sevoflurane)?
Exact mechanism of action unknown. May act via a combination of GABAA, glycine and NDMA receptors
76
Adverse effects for volatile liquid anaesthetics?
Myocardial depression
• Malignant hyperthermia
• Halothane (not commonly used now) is hepatotoxic
77
What are volatile liquid anaesthetics used for?
Used for induction and maintenance of anaesthesia
78
What are the features of abdominal wall hernias?
obesity
ascites
increasing age
surgical wounds
79
Inguinal hernia epidemiology?
Inguinal hernias account for 75% of abdominal wall hernias. Around 95% of patients are male; men have around a 25% lifetime risk of developing an inguinal hernia
80
where are inguinal hernias found?
above and medial to the pubic tubercle
81
where are femoral hernias found?
below and lateral to the pubic tubercle
82
epidemiology of femoral hernias?
More common in women, particularly multiparous ones
High risk of obstruction and strangulation
Surgical repair is required
83
what is a paraumbilical hernia?
Asymmetrical bulge - half the sac is covered by skin of the abdomen directly above or below the umbilicus
84
what is an epigastric hernia?
Lump in the midline between umbilicus and the xiphisternum
| Risk factors include extensive physical training or coughing (from lung diseases), obesity
85
What is a spingelian hernia?
Also known as lateral ventral hernia
Rare and seen in older patients
A hernia through the spigelian fascia (the aponeurotic layer between the rectus abdominis muscle medially and the semilunar line laterally)
86
What is an obturator hernia?
A hernia which passes through the obturator foramen. More common in females and typical presents with bowel obstruction
87
What is a Richter hernia?
A rare type of hernia where only the antimesenteric border of the bowel herniates through the fascial defect
Richter's hernia can present with strangulation without symptoms of obstruction
88
Management of inguinal hernia?
the clinical consensus is currently to treat medically fit patients even if they are asymptomatic
a hernia truss may be an option for patients not fit for surgery but probably has little role in other patients
mesh repair is associated with the lowest recurrence rate
unilateral inguinal hernias are generally repaired with an open approach
bilateral and recurrent inguinal hernias are generally repaired laparoscopically
89
time to return to work after inguinal hernia repair?
return to non-manual work after 2-3 weeks and following laparoscopic repair after 1-2 weeks
90
what syndromes may occurs following gastrectomy?
```
Small capacity (early satiety)
Dumping syndrome
Bile gastritis
Afferent loop syndrome
Efferent loop syndrome
Anaemia (B12 deficiency)
Metabolic bone disease
```
91
what is dumping syndrome and the S/S?
result of a hyperosmolar load rapidly entering the proximal jejunum. Osmosis drags water into the lumen
- pain
- diarrhoea
- dizziness
- hypoglycaemic symptoms
N&V
92
What are the signs of basal skull fracture?
periorbital ecchymosis
CSF rhinorrhoea
haemotypanum & mastoid process bruising (Battle sign)
93
Early causes of post-operative pyrexia? (0-5days)
Blood transfusion
Cellulitis
Urinary tract infection
Physiological systemic inflammatory reaction (usually within a day following the operation)
Pulmonary atelectasis - this if often listed but the evidence base to support this link is limited
94
Late causes of post-operative pyrexia? (>5 days)
Venous thromboembolism
Pneumonia
Wound infection
Anastomotic leak
95
what is the parkland formula?
4ml * % body surface area * weight (kg) = ml of Hartmann's to be given in first 24 hours
4 * 25 * 70 = 7000ml. Half of this should be given in the first 8 hours
96
which antibodies are found in Graves?
anti TSH
| anti TPO
97
which antibodies are found in hashimoto?
anti TPO
98
features of post-operative ileus?
```
abdominal distention/bloating
abdominal pain
nausea/vomiting
inability to pass flatus
inability to tolerate an oral diet
```
99
Ix post-operative ileus?
U&Es
| check potassium, magnesium and phosphate as these can contribute to the development of post-operative ileus
100
Mx post-operative ileus?
nil-by-mouth initially, may progress to small sips of clear fluids
nasogastric tube if vomiting
IV fludis to maintain normovolaemia
additives to correct any electrolyte disturbances
total parenteral nutrition
occasionally required for prolonged/severe cases
101
What are some causes of widened mediastinum?
```
Thoracic aortic aneurysm
Aortic dissection
Traumatic aortic rupture
Hilar lymphadenopathy either infectious or malignant
Mediastinal masses like lymphoma, seminoma, thymoma
Mediastinitis
Cardiac tamponade
Fractured ribs or thoracic vertebrae
```
102
what is the management of haemothorax?
Haemothoraces large enough to appear on CXR are treated with large bore chest drain
Surgical exploration is warranted if >1500ml blood drained immediately
103
what are the features of aortic disruption?
Deceleration injuries
Contained haematoma
Widened mediastinum
104
features of diaphragmatic disruption?
Most due to motor vehicle accidents and blunt trauma causing large radial tears (laceration injuries result in small tears)
More common on left side
Insert gastric tube, which will pass into the thoracic cavity
105
what is a mediastinal traversing wound?
Entrance wound in one hemithorax and exit wound/foreign body in opposite hemithorax
Mediastinal haematoma or pleural cap suggests great vessel injury
Mortality is 20%
106
what are some complications of poorly managed diabetes during surgery?
increased risk of wound & respiratory infections
increased risk of post-operative acute kidney injury
increased length of hospital stay
107
when should diabetic patients on oral hypoglycaemics NOT take their meds as normal?
if more than one meal is to be missed
patients with poor glycaemic control
risk of renal injury (e.g. low eGFR, contrast being used)
in such cases a VRIII should be used
108
how should once daily insulins such as lantus or levemir be altered for surgery?
Reduce dose
by 20%
(day of and day before)
109
how should twice daily Biphasic or ultra-long acting insulins (e.g. Novomix 30, Humulin M3) be altered for surgery? (day of)
Halve the usual morning dose. Leave evening dose unchanged
110
which diabetic drugs should be omitted on day of surgery
SGLT2 inhibitors
| sulphonylureas : morning op - take evening dose/evening op - omit
111
differentials for a groin mass?
```
Herniae
Lipomas
Lymph nodes
Undescended testis
Femoral aneurysm
Saphena varix (more a swelling than a mass!)
```
112
What are the four types of fistula?
1. enterocutaneous
2. Enteroenteric or Enterocolic
3. Enterovaginal
4. Enterovesicular
113
when to consider admission for lower gI bleed?
Over 60 years
Haemodynamically unstable/profuse PR bleeding
On aspirin or NSAID
Significant co morbidity
114
incarcerated hernia vs strangulated hernia?
Incarcerated hernia is unable to be reduced
strangulated hernia occurs when the hernia contents are ischemic due to a compromised blood supply
Strangulation is a surgical emergency where the blood supply to the herniated tissue is compromised, leading to ischemia or necrosis
115
what are some symptoms of a strangulated hernia?
Pain
Fever
Increase in the size of a hernia or erythema of the overlying skin
Peritonitic features such as guarding and localised tenderness
Bowel obstruction e.g. distension, nausea, vomiting
Bowel ischemia e.g. bloody stools
116
Ix strangulated hernia?
leukocytosis
| raised lactate
117
what is the indication for fluid resuscitation for burns?
>15% total body area burns in adults (>10% children)
The main aim of resuscitation is to prevent the burn deepening
Most fluid is lost 24h after injury
118
after initial 24h fluid resuscitation in burns, what should be administered?
After 24 hours
Colloid infusion is begun at a rate of 0.5 ml x(total burn surface area (%))x(body weight (kg))
Maintenance crystalloid (usually dextrose-saline) is continued at a rate of 1.5 ml x(burn area)x(body weight)
Colloids used include albumin and FFP
Antioxidants, such as vitamin C, can be used to minimize oxidant-mediated contributions to the inflammatory cascade in burns
119
what are the causes of bowel obstruction?
```
HAT CVS
Hernia
adhesions
tumour
cancer (MOST COMMON)
volvulus
strictures
```
120
Ix bowel obstruction?
1st line : AXR
| definitive: CT
121
Duke's staging for CRC?
A: tumour confined to mucosa
B: tumour invading bowel wall
C: lymph node metastasis
D: distant metastasis
122
Ix for bowel Ca
```
sigmoidoscopy - colonsocopy
screening:
55yo- flexi sig (colonoscopy if +VE)
once
male and female
```
```
60-74yo
faecal immunochemical test/FIT
every 2 years
male and female
colonoscopy if +ve
```
patients >74 may request screening
123
Mx bowel Ca?
resection (need entire Ima FOR all lymph supply)
| +/- pre-operative chemoradiotherapy (pelvic LN spread)
124
Ix sigmoid and caecal volvulus?
AXR:
Sigmoid: LBO + coffee bean sign (often air fluid levels)
Caecal: SBO (valvule conniventes, entire width of bowel wall)
125
Management of sigmoid volvulus?
therapeutic sigmoidoscopy with rectal tube insertion (if peritoneum -> laparotomy)
126
Management of caecal volvulus?
laparotomy [right hemicolectomy often needed]
127
RF for hernias?
obesity
ascites
increasing age
surgical wounds
128
types of hernia surgery?
```
herniotomy = ligation and excision of hernial sack
herniorrhaphy = repair of abdominal wall defect
hernioplasty = mesh implant
```
129
risks of using a mcburney/Lanz approach ?
risk of damage iliohypogastic/ilioinguinal nerve
130
Management of breast cancer?
```
surgery [mastectomy or WLE]
radiotherapy
biological therapy [if HER2 +ve]
hormone therapy [if ER+ve]
chemotherapy
```
131
what is the nottingham prognostic index?
NPI = tumour size x 0.2 + LN score + grade score
| axillary LN spread is the most important prognostic factor
132
when should PSA testing be avoided?
within 6w of prostate biosy
1w of DRE
4 weeks following proven UTI/prostatitis
48h of vigorous exercise AND/OR ejaculation
133
Mx of localised prostate Ca (t2/t2)?
depends on life expectancy/patient choie
C: active monitoring and watchful waiting
Radical prostatectomy
Radiotherapy (external beam and brachytherapy)
134
Mx of locally advanced prostate cancer (t3/t4)?
hormonal therapy
radical prostatectomy
radiotherapy (external beam and brachytherapy)
135
Mx of metastatic prostate cancer disease?
hormonal therapy:
- GnRH agonist (goserelin) + 3w cover of anti-androgen (flumetanide/cyproterone acetate)
- anti-androgen
- orchidectomy
136
what are the 3 types of benign renal neoplasms?
1. papillary adenoma
2. renal oncoctyoma
3. angiomyolipoma
137
what are the features of VHL?
pheochromocytoma
neuroendocrine pancreatic tumour
clear cell renal carcinoma
138
what are the subtypes of renal cell carcinoma?
clear cell renal carcinoma (70%)
papillary renal cell carcinoma (15%)
chromophobe renal cell carcinoma (5%)
remaining 10 % are rare subtypes
139
Ix RCC?
1ST: cystoscopy, renal tract USS
| Gold standard/definitive: CT urogram
140
what is the risk of progression index used clear cell renal carcinoma?
Leibovich risk model
141
what are the types of urothelial carcinomas
1. non invasive papillary urothelial carcinoma
2. infiltrating urothelial carcinoma
3. flat urothelial carcinoma in situ
142
Ix/mx for urethral injury?
ascending urethrogram
| suprapubic catheter
143
Ix/mx for bladder injury?
IVU or cystogram
| Mx: laparotomy if intraperitoneal, conservative if extraperitoneal
144
RF for testicular cancer?
```
cryptorchidism
infertility
FHx
Klinefelters
Mumps orchitis
```
145
Differentials for sterile pyuria?
```
prior treatment with Abx (MOST COMMON)
Catheterisation
TB
Calculi
Bladder neoplasm
STI
```
146
Risk factors for stress incontinence?
```
age
children
traumatic delivery
pelvic surgery
obesity
```
147
Risk factors for urge incontinence?
```
age
obesity
smoking
FHx
DM
```
148
Why are varicoceles more common on the left?
1. left testicular vein drain into renal vein at 90 degree angle
2. left testicular vein is longer than the right
3. left testicular vein often lacks a terminal valve to prevent back flow
4. left testicular vein can be compressed by renal and bowel pathology
149
Mx of varicocele?
conservative: scrotal support
surgery: radiological embolisation, palomo operation (vein exposed and ligated)
150
Medical indications for circumcision?
phimosis
recurrent balanitis
balanitis xerotica obliterans
paraphimosis
It is important to exclude hypospadias prior to circumcision as the foreskin may be used in surgical repair.
151
epididymal cyst associated conditions?
polycystic kidney disease
cystic fibrosis
von Hippel-Lindau syndrome
152
Features of testicular cancer?
a painless lump is the most common presenting symptom
pain may also be present in a minority of men
hydrocele
gynaecomastia
- this occurs due to an increased oestrogen:androgen ratio
153
What are the types of chronic urinary retention?
High pressure retention:
impaired renal function and bilateral hydronephrosis
typically due to bladder outflow obstruction
Low pressure retention:
normal renal function and no hydronephrosis
154
what are the main causes of acute tubular necrosis?
ischaemia:
shock
sepsis
```
nephrotoxins:
aminoglycosides
myoglobin secondary to rhabdomyolysis
radiocontrast agents
lead
```
155
what are the phases of ATN?
oliguric phase
polyuric phase
recovery phase
156
What are the main LUTS symptoms?
```
Voiding:
Hesitancy
Poor or intermittent stream
Straining
Incomplete emptying
Terminal dribbling
```
```
Storage:
Urgency
Frequency
Nocturia
Urinary incontinence
```
Post-micturition:
Post-micturition dribbling
Sensation of incomplete emptying
157
ABPI interpretation?
```
>1.2 abnormal calcification (stiff arteries) in PAD with advanced age
1 normal (cannot exclude DM)
0.9-0.6 claudication
0.6-0.3 rest pain
<0.3 impending
```
<0.8 or >1.3 refer to vascular surgeons
158
indications for amputation?
```
dead dangerous damaged damn nuisance
dead: PVD/PAD severe, thrombangiitis obliterans
dangerous: sepsis, NF, malignancy
damaged: trauma, burns,frostbite
pain, neurological damage
```
159
complications of EVAR?
```
poor perfusion (MI, spinal/mesenteric ischaemia, renal failure)
graft migration,stenosis, infection
leakage
distant thromboembolism (trash foot)
aorta-enteric fistula
death
```
160
when to refer someone to vascular?
significant/troublesome lower limb symptoms e.g. pain, discomfort or swelling
previous bleeding from varicose veins
skin changes secondary to chronic venous insufficiency (e.g. pigmentation and eczema)
superficial thrombophlebitis
an active or healed venous leg ulcer
161
Indications for surgical management of AAA?
Symptomatic (back pain = imminent rupture)
diameter >5.5 cm
rapidly expanding >1cm/y
causing complications e.g. emboli
162
what is subclavian steal syndrome?
Subclavian steal syndrome is associated with a stenosis or occlusion of the subclavian artery, proximal to the origin of the vertebral artery
163
S/S subclavian steal?
increased metabolic needs of the arm then cause retrograde flow and symptoms of CNS vascular insufficiency [vertigo, diplopia, dysphagia, dysarthria, visual loss, or syncope]
arm claudication
164
What is a Marjolin's ulcer?
Squamous cell carcinoma
Occurring at sites of chronic inflammation e.g; burns, osteomyelitis after 10-20 years
Mainly occur on the lower limb
165
Pyoderma gangrenosum associations?
Associated with inflammatory bowel disease/RA
Can occur at stoma sites
Erythematous nodules or pustules which ulcerate
166
Causes of tinnitus?
```
Specific: (HOMAN)
Hearing loss/head injury
otosclerosis
Menieres disease
Acoustic neuroma
Noise induced
```
Drugs: (ALE)
Aspirin/aminoglycosides
Loop diuretics
Ethanol
General:
high/low BP
167
Peripheral causes of vertigo?
Menieres
BPPV
Labyrinthitis
168
Central causes of vertigo?
```
Vestibular schwannoma
Multiple sclerosis
Stroke
Head injury
Inner ear syphilis
```
169
Drug causes of vertigo?
Gentamicin
Loop diuretics
Metronidazole
Co-trimoxazole
170
What is conductive hearing loss?
Defect between the auricle and round window
171
Causes of conductive hearing loss?
```
External canal obstruction (i.e. wax, pus)
Tympanic membrane perforation (i.e. infection, trauma)
Ossicle defects (i.e. otosclerosis, infection)
```
172
What is sensorineural hearing loss?
Defect of cochlea, cochlear nerve or brain
173
Causes of conductive hearing loss?
Drugs: aminoglycosides, vancomycine
Infective: meningitis, measles, mumps, herpes
Misc. Menieres, trauma, MS, CPA lesion, low B12
174
Give some ototoxic drugs?
```
aminoglycosides
vancomycin
aspirin
furosemide
quinine
chemotherapy
```
175
Causes of acquired hearing loss in child?
OM/OME
Infection (measles, meningitis)
head injury
176
Causes of congenital conductive hearing loss in child?
congenital abnormalities of the pinna, EAC, TM, ossicles
congenital cholesteatoma
Pierre-Robin sequence
177
Causes of congenital SNHL?
```
waardenburgs
alports (snhl, haematuria)
jervell-lange-nielson
infection
ototoxic drugs
perinatal (kernicterus, hypoxia, cerebral palsy, meningitis)
```
178
Indications for thoracotomy in haemothorax?
>1.5L blood initially or losses of >200ml per hour for >2 hours
179
What is the glasgow score for pancreatitis?
```
Predictor of prognosis:
P - PaO2 (< 7.9 kPa).
A - age (>55).
N - neutrophils (white cell count > 15x 109/L).
C - calcium (calcium < 2 mmol/L).
R - renal function (urea > 16 mmol/L).
E - enzymes (lactate dehydrogenase > 600 IU/L).
A - albumin (albumin < 32 g/L).
S - sugar (blood glucose > 10 mmol/L).
```
3 points and above suggests a high risk for severe pancreatitis.
180
In a patient with hypercalciuria and renal stones what can be given?
bendroflumethiazide (thiazidediuritec)
| reduces calcium excretion and so stone formation
181
what are the initial investigations for renal colic?
urine dipstick and culture
serum creatinine and electrolytes: check renal function
FBC / CRP: look for associated infection
calcium/urate: look for underlying causes
also: clotting if percutaneous intervention planned and blood cultures if pyrexial or other signs of sepsis
non-contrast CT KUB should be performed on all patients, within 14 hours of admission
182
prevention/management of calcium renal stones?
```
high fluid intake
low animal protein, low salt diet (a low calcium diet has not been shown to be superior to a normocalcaemic diet)
thiazides diuretics (increase distal tubular calcium resorption)
```
183
prevention/management of oxalate renal stones?
cholestyramine reduces urinary oxalate secretion
| pyridoxine reduces urinary oxalate secretion
184
prevention/management of uric acid stones?
allopurinol
| urinary alkalinization e.g. oral bicarbonate
185
what are the normal post-void volumes for >65 and <65 ?
<65 = 50 ml
| >65 =100 ml
