Surgery Flashcards
(116 cards)
1
Q
When do we use tamoxifen?
A
Tamoxifen is used in the management of oestrogen receptor-positive breast cancer in pre or peri-menopausal women
2
Q
A 42 yr old F presents worried due to a FH of breast ca and ovarian ca. What is the management?
A
Referral to secondary care
3
Q
How do we treat oestrogen positive breast cancer?
A
Oestrogen positive means it has hormone receptor and that’s when you use anastrozole or letrozole in post-menopausal women, or tamoxifen in pre- or peri-menopausal women.
4
Q
How do we treat HER receptor positive cancer?
A
Her2 positive is positive for human epifermal growth receptor 2 (HER2) and indicates treatment with herceptin
5
Q
What is the most common type of breast cancer?
A
Invasive ductal carcinoma (no special type)
6
Q
How does an epidydimal cyst present?
A
These are common in middle-aged men and feature a swelling posterior and separate from the body of the testicle. They are benign, and the diagnosis can be confirmed by ultrasound. Management is generally conservative.
7
Q
How do germ-cell tumours present?
A
Germ-cell tumour presents as a firm and typically painless lump on the testicle. They are the most common malignancy in younger males, but the incidence then decreases with age. Other risk factors include infertility, cryptorchidism, mumps orchitis, and Klinefelter syndrome. There may be associated hydrocele and gynaecomastia due to an increased oestrogen to androgen ratio.
8
Q
What is varicocele?
A
Varicocele is an abnormal enlargement of the testicular veins that is classically felt as a ‘bag of worms’ within the scrotum. It is more common on the left side and can be associated with subfertility.
9
Q
How do we diagnose varicocele?
A
Diagnosis can be confirmed on ultrasound with Doppler studies.
10
Q
How do we manage varicocele?
A
Management is generally conservative unless the patient is having issues with pain or subfertility.
11
Q
How do we manage chronic anal fissures?
A
Topical glyceryl trinitrate
12
Q
When should you stop the COCP prior to surgery?
A
1/12
13
Q
When do we perform abdominoperineal resections?
A
abdominoperineal resections, which involve the removal of the anus, rectum and section of sigmoid colon, are used for tumours located in the distal one third of the rectum.
14
Q
How do we manage obstructive urinary caliculi?
A
Patients with obstructive urinary calculi and signs of infection require urgent renal decompression and IV antibiotics due to the risk of sepsis
15
Q
Why can we give alpha blockers in renal colic?
A
Alpha blockers like tamsulosin can help the stone pass
16
Q
What is fibroadenosis?
A
Most common in middle-aged women
‘Lumpy’ breasts which may be painful. Symptoms may worsen prior to menstruation
17
Q
What is Stellwag’s sign?
A
Stellwag sign is reduced blinking seen in Grave’s disease (from exophthalmos)
18
Q
What is the blood loss like with haemorrhoids?
A
Post defecatory rectal bleeding that is noted in the toilet pan and on toilet paper is often haemorroidal in nature
19
Q
What can increase the risk of breast cancer?
A
HRT, early menarche, late menopause and COCP all increase the risk of breast cancer whereas multiple pregnancy and breastfeeding reduce the risk
20
Q
Which antigen do we use to monitor patients with colorectal ca?
A
Carcinoembryonic antigen
21
Q
What is administered in most cases of SAH?
A
Nimodipine
22
Q
How do we manage hernias in babies?
A
Congenital hernias
inguinal: repair ASAP
umbilical: manage conservatively
23
Q
Which type of resection is used for a Caecal, ascending or proximal transverse colon malignancy?
A
R hemicolectomy
24
Q
Which type of resection is used for a distal transverse/descending colon malignancy?
A
L hemicolectomy
25
Which type of resection is used for a sigmoid colon malignancy?
High anterior resection
26
Which type of resection is used for a upper rectum malignancy?
Anterior resection (TME)
27
Which type of resection is used for a low rectum malignancy?
Anterior resection (Low TME)
28
Which type of resection is used for an anal verge malignancy?
Abdomino-perineal excision of rectum
29
Which operation: known sigmoid colon tumour that was graded as T3N0M0. Surgeons recommended surgery as the first line treatment for this and it was scheduled for next week. However, he has just been brought to the emergency department with intense abdominal pain, which was found to be due to a perforation.
Hartmann's - leads to end colostomy
30
What is diffuse axonal injury?
Diffuse axonal injury occurs when the head is rapidly accelerated or decelerated. There are 2 components:
1. Multiple haemorrhages
2. Diffuse axonal damage in the white matter
Up to 2/3 occur at the junction of grey/white matter due to the different densities of the tissue. The changes are mainly histological and axonal damage is secondary to biochemical cascades. Often there are no signs of a fracture or contusion.
31
How do we manage metformin prior to surgery?
Surgery / metformin on day of surgery:
OD or BD: take as normal
TDS: miss lunchtime dose
assumes only one meal will be missed during surgery, eGFR > 60 and no contrast during procedure
32
What is the key side effect of aromatase inhibitors?
Aromatase inhibitors (e.g. anastrozole) may cause osteoporosis
DEXA scan prior to initiation
33
How does duodenal ulcer present?
episodic epigastric pain that is relieved by eating.
34
How do we manage sulfonylureas prior to surgery?
Surgery / sulfonylureas on day of surgery:
omit on the day of surgery
exception is morning surgery in patients who take BD - they can have the afternoon dose
35
How do we manage asymptomatic inguinal hernia?
Studies looking at conservative management tend to find that many patients become symptomatic and eventually have surgery anyway. As this patient is medically fit most clinicians would refer for surgical repair
36
How does extradural haematoma present?
This is due to the classic presentation of a 'lucid interval' following head trauma, where the patient initially loses consciousness, regains it and appears well for a period of time before deteriorating again.
37
What is the pathophysiology in extradural haematoma?
Extradural haematomas typically occur when there is a tear in the middle meningeal artery, often following a skull fracture. The bleeding accumulates between the dura mater and the skull, leading to increased intracranial pressure and neurological deficits.
38
What is cerebral contusion?
A cerebral contusion is less likely in this case as it refers to bruising of brain tissue following blunt force trauma. While cerebral contusions can cause loss of consciousness and neurological deficits, they do not typically present with a lucid interval. Cerebral contusions are more commonly associated with diffuse axonal injury or coup-contrecoup injuries.
39
How do we manage hiatus hernia?
Majority do not need surgical repair
40
How does duct papilloma present?
This patient is presenting with a unilateral bloody discharge and a small lumpy mass. This is most likely to be a duct papilloma. These occur in middle-aged women and develop in the lactiferous ducts just below the nipple. They form a lumpy mass and are associated with a bloody discharge.
41
What is mammary duct ectasia?
Mammary duct ectasia is a benign breast condition in which the milk ducts beneath the nipple become inflamed and dilated. Patients usually present with an angry, erythematous breast with a creamy or green discharge. It occurs most often in women during or after menopause.
42
What is the most common cause of epididymo-orchitis?
Chlamydia
43
How do we manage hydroceles in infants?
Communicating hydroceles are common in newborn males and often resolve spontaneously
44
How do we manage fibroadenoma?
Current guidance states that, for a young female with small fibroadenomas - less than 3cm on imaging - a biopsy is not required if a straightforward diagnosis. The most appropriate step is to reassure and monitor. Over the next 2 years, 30% will get smaller. There is no increase in the risk of breast cancer.
45
How do we grade haemorrhoids?
Grade I haemorrhoids are those which do not prolapse outside the anal canal. They may bleed but are only visible via proctoscopy, therefore this grade does not match with the patient's symptoms of prolapsing piles which need manual reduction.
Grade II haemorrhoids are those that prolapse during defecation but reduce spontaneously afterwards. As our patient has to manually reduce his piles following defecation, his condition cannot be categorised as Grade II.
The correct answer is Grade III. In the classification of internal haemorrhoids, Grade III refers to haemorrhoids that prolapse during bowel movements and require manual reduction. This grading system is based on the extent of prolapse and the requirement for manual reduction.
Grade IV is wrong as well. These are haemorrhoids that are permanently prolapsed and cannot be manually reduced back into the anal canal. In this scenario, the man can still manually reduce his piles after defecation so he would not be classified as having Grade IV haemorrhoids.
46
What are sitz baths used for?
Sitz baths are a form of hydrotherapy where the patient sits in warm water up to their hips. While they can provide temporary relief from symptoms such as itching, burning or discomfort associated with haemorrhoids, they do not address the underlying issue of increased pressure on the anal cushions due to hard stools and straining.
47
In which population is prostate ca more common?
Afro-caribbean
48
How does ascending cholangitis present?
Fever, jaundice, RUQ pain
49
How do we treat torsion?
When correcting a torsion in the presence of a bell clapper deformity both testes (if still viable) should be fixed to prevent the other testicle from rotating at a later date.
50
What is Prehn's sign?
elevation of the testis does not ease the pain (seen in torsion)
51
How do we manage abdominal wound dishience?
Abdominal wound dehiscence should initially be managed with coverage of the wound with saline impregnated gauze + IV broad-spectrum antibiotics
The initial management is treating with intravenous antibiotics, covering the wound with sterile gauze soaked in sterile saline to ensure the abdominal contents do not dry out and arranging for the patient to be taken to theatre for a wound repair.
52
How do we treat local anaesthetic toxicity?
Local anesthetic toxicity can be treated with IV 20% lipid emulsion
53
How does femoral vessel and iliac vessel stenosis differ in presentation?
Claudication affecting the femoral vessels is likely to present with calf pain rather than iliac claudication which causes buttock pain
54
What is the difference between and inguinal and a femoral hernia?
Inguinal hernias and superior and medial to the pubic tubercle
A femoral hernia is located laterally and inferiorly to the pubic tubercle.
55
What is first line mx for varicose veins?
Graduated compression stockings
56
What are pseudocysts?
In acute pancreatitis result from organisation of peripancreatic fluid collection. They may or may not communicate with the ductal system.
The collection is walled by fibrous or granulation tissue and typically occurs 4 weeks or more after an attack of acute pancreatitis
57
What are pseudocysts associated with?
Mild persistent elevation of amylase
58
How do we investigate pseudocysts?
Investigation is with CT, ERCP and MRI or endoscopic USS
59
How do we treat pseudocysts?
Treatment is either with endoscopic or surgical cystogastrostomy or aspiration
60
How does Wernicke's syndrome present?
Wernicke's COAT
Confusion
Oculomotor dysfunction
Ataxia
Thiamine is treatment
61
How does Korsakoff's syndrome present?
Korsakoff's CART (Cart them off - because it's incurable at this stage)
Confabulation
Anterograde and
Retrograde amnesia
Temperament altered
62
How does subdural haematoma present?
Fluctuating confusion/consciousness? - subdural haematoma
63
How does fibroadenosis present?
Most common in middle-aged women
'Lumpy' breasts which may be painful. Symptoms may worsen prior to menstruation
64
How does fibroadenoma present?
Common in women under the age of 30 years
Often described as 'breast mice' due as they are discrete, non-tender, highly mobile lumps
65
What is Paget's disease of the breast?
Paget's disease of the breast - intraductal carcinoma associated with a reddening and thickening (may resemble eczematous changes) of the nipple/areola
66
What is mammary duct ectasia?
Dilatation of the large breast ducts
Most common around the menopause
May present with a tender lump around the areola +/- a green nipple discharge
If ruptures may cause local inflammation, sometimes referred to as 'plasma cell mastitis'
67
What is duct papilloma?
Local areas of epithelial proliferation in large mammary ducts
Hyperplastic lesions rather than malignant or premalignant
May present with blood stained discharge
68
Which test do we use for exocrine function in pancreatitis?
Faecal elastase is a useful test of exocrine function in chronic pancreatits
69
Nigel is a 53-year-old gentleman with a background of prostate cancer who underwent a complete prostatectomy 3 months ago. You have been asked to perform a PSA level after 3 months for routine surveillance. The result shows a PSA level of 2 ng/ml (normal upper range for his age group is 3.9 ng/ml). How would you manage this result?
Urgent referral to oncology
Following a complete prostatectomy, the PSA level should be 'undetectable' which is defined usually as a value less than 0.2ng/ml. Therefore following 3 months a value of 2 (albeit within the normal range for patients who have not had treatment) would be considered a significantly elevated value and would, therefore, warrant urgent referral to oncology for further investigation.
70
How do we investigate priaprism?
An important first step is to confirm if the priapism is cavernosal blood gas analysis which will indicate if it is ischaemic or non-ischaemic. This will aid management as ischaemic priapism is a medical emergency warranting aspiration of blood from the cavernosa, whereas non-ischaemic priapism can be managed with observation initially. In Paediatric patients, a doppler ultrasound is an alternative option to consider (if there are radiologists who are able to perform this scan) due to the potentially traumatic nature to a child of cavernosal blood gases.
71
How do we treat peripheral arterial disease?
Atorvastatin and clopidogrel
72
How do we manage free air in the abdomen?
Urgent surgical referral to determine cause
73
Describe the abdominal aortic aneurysm screening programme in the UK
In the UK, all men aged 65 years are offered aneurysm screening with a single abdominal ultrasound. Screening has shown to decrease death from abdominal aortic aneurysm by 44% over 4 years
74
What are the NICE guidelines for cut-off for breast lump referral?
NICE guidelines suggest a cut-off age of 30 years when a woman has an unexplained breast lump with or without pain
| Non-urgent referral otherwise
75
How do we reduce incidence of calcium urinary stones?
In a patient with hypercalciuria and renal stones, calcium excretion and stone formation can be decreased by the use of thiazide diuretics
76
When do we excise fibroadenomas?
If >3cm
77
Which infection is penile cancer associated with?
HIV
78
Give a side effect of excessive infusions of saline.
Excessive administration of sodium chloride is a recognised cause of hyperchloraemic acidosis and therefore Hartmans solution may be preferred where large volumes of fluid are to be administered.
79
When do we CT head within 8hrs?
Within 8hrs: ABCD
- Age over 65
- Bleeding risk: anti-coagulation, clotting disorder
- Concussion: retrograde amnesia before head injury
- Dangerous mechanism of injury: e.g. hit by car / fall from height / from 1m height or >5 stairs
80
When do we CT head after 1hr?
Within 1hr: BANGSS
- Basal skull fracture signs
- Any suspected open / depressed skull fracture
- Neurological deficit focal
- GCS <13 on initial assessment or <15 2hrs after injury
- Sick more than x1 post injury
- Seizure post injury
81
How does chronic venous insufficiency present?
This patient has evidence of chronic venous insufficiency (CVI) given their history of obesity and lower limb swelling that is worse at the end of the day. Lipodermatosclerosis (tightened, hardened skin), venous ulcers (shallow and irregular ulcers), and haemosiderin deposition (skin hyperpigmentation) support a diagnosis of CVI.
82
How do we investigate CVI? What is seen?
The investigation of choice of CVI is a venous duplex ultrasound scan
| Shows retrograde venous flow due to incompetent venous valves.
83
What is the most common cause of SBO?
Adhesions
84
How does malrotation present?
Malrotation is most common in babies <30 days of age. It tends to present with bilious vomiting. The abdomen is typically soft and non-tender initially, but if not treated, it leads to strangulation of the gut. This is suggested in this scenario by the presence of a distended and firm abdomen, and the lack of stool.
85
How do we manage medium aneurysms?
3-monthly ultrasound assessment is currently recommended for medium aneurysms (4.5-5.4cm). These aneurysms have a higher chance of rupture, and so should be monitored on a 3-monthly basis to make sure that there is no rapid diameter increase.
86
How do we manage small aneurysms?
12-monthly ultrasound assessment should be considered for small AAAs (<4.5cm). These aneurysms have a low risk of rupture, and so should be monitored infrequently to make sure there is no growth.
87
How do we manage severe aneurysms?
Urgent surgical referral to vascular surgery should be considered for any patient with a large aneurysm (>5.4cm) or a rapidly enlarging aneurysm. These aneurysms have a very high chance of rupture, and so should be referred urgently for endovascular or open repair.
88
Why are bulk-forming laxatives stool softeners?
Bulk-forming laxatives are stool softeners - they draw water into the poo making it softer and preventing it from drying out therefore whilst nominally larger will pass out very easily as opposed to a dry one which may require you to strain.
89
Where do you see the coffee-bean sign on XR?
Sigmoid volvulus
90
Give the iatrogenic causes of pancreatitis
Big = Bendroflumethiaide
Fish = Furosemide
Swim = Sodium valproate
Deeply = Didanosine
Across = Azathioprine
Many = Mesalazine
Ponds = Pentamidine
91
At which age would you be worried that breast cancers are familial?
<40
92
How can we differentiate between ileostomy and colostomies?
To differentiate between a colostomy and a small intestine stoma you can use multiple hints. Usually, an ileostomy is on the right iliac fossa whilst a colostomy is on the left iliac fossa.
If it is spouted, it means that you are looking at an ileostomy because the small bowel's contents are irritant to the skin, hence the spouting protects it. If it is flush to the skin, you are looking at a colostomy, because the large bowel contents are not irritant. Additionally, the faecal material will be liquid in an ileostomy, whilst a colostomy would contain more solid contents.
93
How do we manage breast cysts?
Aspirate them - they carry a small risk of breast ca
94
How do we manage OD long-acting insulin prior to surgery?
Reduce by 80%
95
What is the difference between class I and class IV haemorrhagic shock?
Class I shock would be completely compensated for.
Class II shock would cause tachycardia.
Class III shock causes tachycardia and hypotension as well as confusion.
Class IV shock causes loss of consciousness as well as severe hypotension.
96
How do we give TPN
Total parenteral nutrition should be administered via a central vein as it is strongly phlebitic
97
What is first-line ix for prostate ca?
Multiparametric MRI has replaced TRUS biopsy as the first-line investigation in suspected prostate cancer
98
What is the Parkland formula?
The Parkland formula for fluid resuscitation in burns is:
Volume of fluid = total body surface area of the burn % x weight (Kg) x 4ml
99
What is first-line for BPH?
In the UK, the first-line management for BPH with bothersome lower urinary tract symptoms is an alpha-1 antagonist such as tamsulosin or alfuzosin. These drugs work by relaxing the smooth muscle in the prostate and bladder neck, thereby improving urinary flow.
100
What is a normal PSA?
It's age-related
40-49 = 2.5
Add 1 for every ten year range up to 79
101
Which have a better prognosis: seminomas or teratomas?
'Seminomas have a better prognosis than teratomas'. This is because seminomas are a type of germ cell tumour that are generally more sensitive to radiation and chemotherapy compared to non-seminomatous germ cell tumours such as teratomas.
Testicular cancer
102
How do we investigate DVT w/ long saphenous vein superficial thrombophlebitis ?
Straight to US doppler
103
How do we manage acute limb ischaemia ?
analgesia, IV heparin and vascular review
104
A 29-year-old man is referred to the colorectal surgeons with recurrent episodes of bright red rectal bleeding that have been occurring for the past 4 months. On examination, there is a muco-epithelial defect in the posterior midline of the anus. Dx?
Anal fissure
105
What is last line for anal fissures?
Anal fissures - sphincterotomy may be considered for cases that do not respond to conservative management
106
During counselling for colonoscopy he asks what percentage of patients with a positive faecal occult blood test have colorectal cancer. What is the most accurate answer?
5-15%
107
What is a loop ileostomy used for?
This procedure involves taking a loop of ileum, performing a horizontal incision and bring it up to the skin. It is indicated to defunction the colon, for example, after rectal cancer surgery. Eventually, it can be reversed.
108
Which side are congenital inguinal hernias more common on?
they are more common on the right side. Congenital inguinal hernias occur when the processus vaginalis, a structure that normally closes before birth, fails to close properly. This results in a weak spot in the groin area, through which abdominal contents can protrude and form a hernia. They are more commonly seen on the right side due to delayed closure of the processus vaginalis compared to the left side.
109
Give three RFs for transitional cell carcinoma
Risk factors for urothelial (transitional cell) carcinoma of the bladder include:
Smoking
most important risk factor in western countries
hazard ratio is around 4
Exposure to aniline dyes
for example working in the printing and textile industry
examples are 2-naphthylamine and benzidine
Rubber manufacture
Cyclophosphamide
110
Give two RFs for squamous cell carcinoma
Risk factors for squamous cell carcinoma of the bladder include:
Schistosomiasis
Smoking
111
From when can't you eat before surgery?
6 hours before
112
Name the causes of acute pancreatitis
Popular mnemonic is GET SMASHED
Gallstones
Ethanol
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
ERCP
Drugs (Big Fish Swim Across Many Ponds)
113
What might cause malignant hyperthermia during surgery?
Volatile liquid anaesthetics
(isoflurane, desflurane, sevoflurane) may cause malignant hyperthermia
114
A 65-year-old woman presents to the breast clinic with complaints of a palpable mass in her right breast. The diagnostic mammogram shows a spiculated mass measuring 1.9 cm. Ultrasound detects a hypoechoic mass measuring 1.9 cm x 1.1 cm x 0.9 cm. Incisional biopsy reveals a well-differentiated mucinous carcinoma which is negative for oestrogen (ER) and human epidermal growth factor receptor 2 (HER2). Lumpectomy is performed with 5 mm normal tissue margins.
Which of the following is the recommended course of treatment to prevent recurrence in this patient?
Whole breast radiotherapy
'a lumpectomy without radiotherapy is an unfinished job'
115
What is the first-line ix for suspected prostate cancer?
Multiparametric MRI has replaced TRUS biopsy as the first-line investigation in suspected prostate cancer
116
What is Cushing's triad?
hypertension, bradycardia, and irregular breathing) seen in raised intracranial pressure (ICP)
