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Flashcards in Surgery Deck (99)
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0
Q

What are the characteristics of breast cysts and what is their prognosis?

A

Flattened epithelium derived from lobular-ductal unit forming round, symmetrical lumps. Occasionally painful but almost always benign.

Often associated with fibrocystic change (fibrosis, cysts and hormone-driven breast pain)

1
Q

What are the characteristics of adenocarcinoma and what is their prognosis?

A

Women 25-35 years
Highly mobile, firm, smooth,painless
1/3 regress, 1/3 stay the same, 1/3 get bigger

2
Q

What are the benign tumours of the breast?

A

Hamartomas (disorganised growth of normal tissue)
Adenomas
Duct papillomas
Phyllodes tumours (tumour arising from periductal stroma)

3
Q

What are the most common types malignant of breast cancer?

A

Invasive adenocarcinomas arising from terminal ducts (invasive ductal carcinoma) or lobular units (invasive lobular carcinoma). These have a poor prognosis.

Rarer types (tubular carcinoma, mucinous carcinoma) have better prognosis

4
Q

What is Paget’s disease?

A

Spread of intraductal carcinoma –> nipple

Reddening, thickening and scaling of nipple and areola resembling eczema .: consider with any rash!!

5
Q

What is the spread of breast cancer?

A

Local –> adjacent breast, skin (-> tethering), pectoral muscles (deep fixation)

Lymphatic –> lymphatics of skin (peau d’orange), axillary nodes and internal mammary chain

Vascular –> bone, brain, liver, lung

6
Q

What are the risk factors for breast Ca?

A

Western culture
PMHx breast Ca
FH breast Ca (BRCA1,2 and p53 = 5% of cases)
Proliferative breast disease
Increased oestrogen exposure (early menarche, late menopause, nulliparity/1st child > 30 years, not breast feeding, HRT and COC)
Obesity and alcohol

7
Q

How sensitive is mammography and what features of cancer would you see?

A

Sensitivity 88% women >40 (worse in women <35 so not performed)

Presence of a mass
Microcalcification (benign = coarse and chunky, malignant = fine and linear)
Architectural distortion
Asymmetry

8
Q

How would you image the breast?

A

Mammography

USS (solid vs cysts)

9
Q

How would you biopsy a breast lump and what are the sensitivities and differences between techniques?

A

Fine needle aspiration cytology (FNAC) - 95% sensitivity, can detect malignancy, cannot stage

Core biopsy - 97% sensitivity, can stage

Excisional biopsy - staging and first step in controlling local disease

Punch biopsy - vs Paget’s disease of the nipple

10
Q

How would you manage fibroadenoma, fibroadenosis, and cysts?

A

Fibroadenoma - excision only if concern vs. diagnosis, cosmesis or symptoms

Fibroadenosis - reassurance, anti-inflammatories, hormone or cellular manipulation (linoleic acid, COC pill, cyst aspiration)

Cyst - repeated aspiration, hormone manipulation if multiple recurrent cysts

11
Q

What is the staging of breast cancer?

A

Stage 1 - confined to breast, mobile
Stage 2 - confined to breast, mobile, nodes in ipsilateral axilla
Stage 3 - tumour fixed to muscle, skin involvement larger than tumour
Stage 4 - complete fixation of tumour to chest wall, distant metastases

12
Q

Management of breast cancer

A

Wide local excision - breast conserving, eu combined with local radiotherapy

Simple mastectomy - vs large tumours, central location, complications (eg. ulcers). Adjuvant radiotherapy rarely required

Endocrine therapy - best vs ER +ve tumours - Anti-oestrogens (Tamoxifen), Lutenising hormone releasing hormone antagonists, aromatase inhibitors

Monoclonal antibodies - Traztuzumab (Herceptin) vs HER-2 +ve

Chemotherapy - anthracyclines, cyclophosphamide, 5-FU methotrexate vs high risk features

Radiotherapy - vs sym from bone/liver/brain mets

13
Q

Management of regional lymph nodes in breast cancer

A

Axillary node sampling = retrieve minimum 4 nodes, avoids disruption lymph drainage BUT inadequate for treatment (adjuvant radiotrX if +ve)

Axillary node clearance = treatment of axilla BUT increased risk lymphoedema

Sentinel node biopsy = ID +ve drainage nodes with radioactive tracer and then remove avoiding major axillary surgery

14
Q

What is the Nottingham Prognostic Index and what are it’s survival rates?

A

NPI = 0.2 x tumour size cm + histological grade + nodal status

10yr survival with only surgery
5.4 = 20%

15
Q

How would you investigate a breast lump?

A

1) Clinical exam
2) Radiology - USS 35
3) Histology/cytology - FNA or core biopsy

16
Q

What are the types of nipple discharge and what are their causes?

A

Milky - pregnancy, hyperprolactinaemia
Clear - physiological
Green - perimenopausal ,duct ectasia, fibroadenotic cyst
Blood stained - Carcinoma, intraduct papilloma, REFER!!!

17
Q

Describe the structure of the breast

A

The breast overlies ribs 2-6 with an axillary tail extending into the axilla. It is composed of 15-20 lobes seperated by fibrous septa which acts as suspensory ligaments and attaches the breast to the pectoral mm beneath
The retromammary space is a layer of loose areolar tissue between the deep fascia of the breast and mm

18
Q

What is the vasculature of the breast?

A

aa = Internal and intercostal aa perforating branches
Axillary –> L thoracic and thoracoacrromial branches

vv follow aa

19
Q

What are the lymphatics of the breast?

A

L quadrants –> axillary lymph nodes and pectoral

M quadrants –> internal thoracic (behind sternum so v. hard to treat)

20
Q

Which quadrant do the majority of breast cancers originate in?

A

Outer L quadrant (60%)

21
Q

What are the important urological symptoms and how would you classify them?

A

Storage sym = urgency, frequency, nocturia
Voiding sym = hesitancy, poor stream, post micturition dribble, incomplete emptying

Misc sym = haematuria, dysuria

22
Q

What is the difference between a keloid and a hypertrophic scar?

A

Hypertrophic scar = follows boundaries of wound

Keloid scar = grows over boundaries of wound

23
Q

How do you manage keloid scars?

A

Do NOT try to re-excise them!!

Corticosteroid injections

24
Q

In the presence of parotid swelling what should you check and why?

A

Facial nn function (mm of facial expression), divides into its five branches within the parotid gland

25
Q

When would you use clips instead of stitches?

A

Mainly if there is a concern about post-op bleeding. Clips can be removed rapidly whereas stitches take longer.

26
Q

How do x-rays cause damage?

A

Ionising radiation

27
Q

What is the difference between dose-dependent and dose-independent x-ray damage?

A
Dose-dependent = burns etc.
Dose-independent = cancer
28
Q

What are the fortes of CT and MRI?

A
CT = bone
MRI = soft tissue
29
Q

What is “windowing”?

A

MRI gives images in approx 2000 shades of grey. Humans can only see 15 or so. Windowing allows focusing in on a specific part of that spectrum and better images to be given.

30
Q

What are the definitions and infection rates of clean, potentially contaminated, contaminated and dirty operations?

A

Clean - Infection rate 2-5%, does not enter colonised viscus/lumen of body, eu = skin commensals

Potentially contaminated = infection rate 10%, enters colonised viscus/lumen but under controlled conditions,

Contaminated = infection rate 20%, contamination present without obvious infection eg. vs penetrating injury with intestinal spillage

Dirty = infection rate >30%, surgery when active infection already present

31
Q

What constitutes pre-op evaluation?

A
Identification & details of patient
Diagnosis & proposed op
Cardiac and respiratory exam
PMHx vs complicating factors
Relevant laboratory/diagnostic factors
Informed consent
Advise patient re. nature of procedure
Expected benefits and possible risks
Need for HDU/ICU care
32
Q

What constitutes operative records?

A

Pre-op and post-op Dx
Important anatomical and physiological observations about pt
Operative procedure performed and incision used
Name of surgeonn and anaesthetist
Anaesthetic used
Estimated blood loss and fluid given during procedure
Results of intraoperative tests
Complications
Tubes/drains/prosthesis used and location
Condition of pt at end of surgery

33
Q

What constitutes post-op assessment?

A
Dx
Pt condition
Vital signs
Analgesia assessment
Activity restrictions?
Wound care
Tube and drain care
Dietary requirements?
Fluids & meds
aB prophylaxis
34
Q

What are the indications for rigid sigmoidoscopy/proctoscopy?

A
Sigmoidoscopy = examination of rectum --> rectosigmoid junction
Proctoscopy = examination of anal canal
Any sym suggesting colonic neoplasia
Inflammatory BD
Taking biopsies of pathology within direct visualisation
Before ano-rectal ops/procedure
Proctoscopy can treat haemorrhoids
35
Q

What are the indications for flexible sgmoidoscopy?

A

Visualises up to descending colon

Screening for CRC
Pre-op eval before anorectal surgery
Surveillance of previous Dx malignancy
Removal of rectal foreign body
Endoluminal stent insertion for strictures, balloon dilatation, decompression
Haematochezia (passing fresh blood)
36
Q

What are the indications for a tube thoracostomy?

A

(Chest drain)

Anything in lungs (pneumo-, haemo-, haemopneumo-, hydro-, chylo-, empyema, plearal effusion)
Post op for thoracotomy, oesophagectomy, cardiac surgery

37
Q

Where should you insert a chest drain?

A

“Safe triangle”

A. border lat dorsi, L. border pec major, horizontal level of nipple, apex at axilla

Aim for upper border of lower rib to avoid neurovascular bundle

38
Q

What sites should you use for central venous access?

A

Internal jugular vein (right= preferred)
Lies in carotid sheath, A. to SCM in upper neck, carotid = anteromedial

Subclavian also possible

39
Q

What is a urostomy?

A

Ureters –> short length of disconnected ileum

Eu = right sided and indistinguishable from ileostomies unless looking at contents

40
Q

What are the gastrostomies/jejunostomies?

A

Narrow calibre, flush to the skin in left upper quadrant. Oft contain indwelling tubes/catheters

Primary use = direct feeding

41
Q

What are the indications for urethral catheterisation?

A

Acute/chronic urinary retention
Monitor urinary output in critically ill patient
Perioperative monitoring of urinary output
Incontinence
Aid to abdominal or pelvic surgery

42
Q

What are the alternatives to urethral catheterisation?

A

Suprapubic catheterisation - MUST have distended bladder. Mandatory if pelvic trauma and suspected urethral injury

Ultrasound guided drainage - as it says

43
Q

What are the complications of catheterisation?

A
Infections
Paraphimosis
Creation of false passages
Urethral strictures & perforation
Bleeding
44
Q

What are the different types of drains available?

A

Active drains = suction to drain collections
Passive drains = dependent on gravity or capillary action although reversal in pressures and infection is possible

Open drains = ALWAYS passive –> stoma/dressing
Closed drains = –> container with or without suction (active or passive)

45
Q

What is shortening of a drain?

A

Gradual removal of a drain to allow healing from the bottom of the wound upwards while still allowing removal of any collections

46
Q

What are the complications of drains?

A

Damage to structures
Route of infection
Do not always drain properly –> false sense of security

47
Q

Can you sample urine for analysis and culture from a catheter bag?

A

No no no no NO!

48
Q

What is a Swan-Ganz catheter?

A

Catheter used to measure pulmonary artery pressure

49
Q

What is the difference between primary, secondary and reactionary haemorrhage?

A

Primary = Immediately after surgery

Reactionary = within 24h, thought to occur as fluid volume increases and ruptures vessels

Secondary = up to 10 days post op, eu following secondary infection

50
Q

What would you use to treat secondary infection of a surgical wound?

A

Eu = skin flora .: Flucloxacillin

Consider vs. anaerobes if v. unwell = metronidazole
MRSA = vancomycin

51
Q

What are the indications for a central venous catheter?

A

Critically ill needing continuous monitoring of fluid levels

Infusion of irritating or narrow therapuetic window agents (cytotoxic/inotropic)

Long term parenteral nutrition, chemotherapy or prophylactic aB

Frequent blood sampling

Haemodialysis

52
Q

What is a Quinton catheter?

A

Non-tunneled central venous catheter

53
Q

What is a Hickman/Groshong catheter?

A

Tunneled central venous catheter

54
Q

What is a PICC line?

A

Peripherally inserted catheter, eu in arm and advanced to SVC

55
Q

What are the indications for a Swan-Ganz catheter?

A

Arterial catheter allowing for measurement of pulmonary arterial Pa

Diagnosis of shock
Dx of idiopathic pulmonary hypertension, valvular disease, PE, intracardiac shunts, cardiac tamponade
Mx of complicated AMI, multiorgan failure, severe burns, haemodynamically unstable pts

56
Q

What is Allen’s test?

A

Test to ensure collateral blood supply present to hand via radial and ulnar aa

Elevate hand and ask pt to make fist for 30s
Occlude both ulnar and radial aa
When blanched release ulnar aa Pa and colour return in 7-10s MAX

57
Q

What are the indications for arterial catheterisation?

A

Frequent ABG or blood sampling
Continuous invasive BP monitoring
If unable to measure BP (burns, morbid obesity)

58
Q

What are the complications of central venous catheterisation?

A
Haemorrhage
Arterial (subclavian/carotid) or thoracic duct puncture
Pneumothorax/air embolus
Thrombosis
Sepsis
59
Q

What are the 4 stages of wound healing and how long do they last?

A

1) Haemostasis = immediate (platelet aggregation, clotting & complement activated –> thrombus and reactive vasospasm)
2) Inflammation = 0-3 days (vasodilation and capillary permeability, neutrophils amplify inflammatory response, macrophage secrete growth factors and cytokines)
3) Proliferation = 3 days - 3 weeks (fibroblasts migrate and synthesise collagen, angiogenesis stimulated by hypoxia)
4) Remodelling = 3 weeks - 1 year (re-orientation and maturation of collagen fibres)

60
Q

What is granulation tissue?

A

Combination of capillary loops and myofibroblasts, bleeds easily. Think skin under scab which is removed to soon.

61
Q

What is the difference between primary intention and secondary intention?

A

Primary intention = wound edges can be clearly apposed and are clean (think cuts)

Secondary intention = wound edges cannot be clearly apposed and heal by granulation tissue filling in gap and being covered by epitehlium

62
Q

Should you immediately close an untidy wound?

A

NO! First need to debride it and excise dead tissue, particularly if heavily contaminated and >6 hours old. Closure should occur at 48-72h assuming granulation tissue healthy and no further complications

63
Q

When should you remove sutures from the head/face, upper limb and abdomen/lower limb?

A

Head/face = 5 days
Upper limb = days
Abdomen and lower limb = 10 days

64
Q

What is shock?

A

Acute circulatory failure of sufficient magnitude to compromise tissue perfusion

65
Q

What are the types of shock?

A
Hypovolaemic
Cardiogenic
Septic shock
Anaphylactic shock
Neurogenic shock
66
Q

What are the causes of hypovolaemic shock?

A

Revealed haemorrhage
Concealed haemorrhage
Extensive burns (fluid loss from skins)
Sepsis (fluid in interstitial tissues)
Dehydration
Bowel obstruction (fluid sequestered in bowel)
Excessive urinary fluid loss (DKA, acute tubular necrosis, diuretics)
Accumulation of fluid in peritoneal cavity (acute pancreatitis, ascites, generalised peritonitis)

67
Q

What are the causes of cardiogenic shock?

A

Reduction in cardiac output, eu = direct myocarrdial damage

Ventricular arrythmia
MI/ischaemia
Valve dysfunction

Metabolic/electrolyte disturbances
Massive PE
Tamponade
Tension pneuomthorax

68
Q

What are the causes of septic shock?

A

Overactivation of innate immune system

Infection
Trauma/surgery
Severe burns
Necrotic tissue
Toxic shock syndrome (super-absorbent tampons)
69
Q

What are the causes of anaphylactic shock?

A

Generalised type I IgE mediated hypersensitivity reaction

70
Q

What are the causes of neurogenic shock?

A

Impaired SNS outflow from spinal cord

Epidural anaesthesia,
Spinal cord injury

71
Q

What are the effects of shock on the lung, heart, brian, kidney, GI and skin?

A

Lung = tachypnoea

Heart = Reduced diastolic, increased HR, reduced cardiac output, may –> ischaemic chest pain, arrhythmias, infarction

Brain = Decreased cerebral perfusion, pt –> agitated, confused, drowsy, unresponsive

Kidney = Hypotension –> reduced urine output & impaired renal fXn

GI = reduced perfusion –> impaired motility and absorption

Skin = cool, clammy, grey peripherally (except sepsis where = opposite)

72
Q

What are the characteristics of hypovolaemic shock?

A
Skin = pale
Sweating
Temp = cold
Pulse = weak
Peripheries = shut down
Cap refill = >2s
CVP/JVP = low
Mental status = restless
73
Q

What are the symptoms of cardiogenic shock?

A
Skin = pale
Sweating = present
Temp = cold
Pulse = weak
Peripheries = shut down
Cap refill = >2s
CVP/JVP = HIGH
Mental status = quiet
74
Q

What are the symptoms of septic shock?

A
Skin = flushed
Temp = warm
Pulse = bounding
Peripheries = Vasodilatation
Cap refill = >2s
CVP/JVP = low
Mental status = drowsy
75
Q

What are the symptoms of anaphylactic shock?

A
Skin = urticarial rash
Temp = warm
Pulse = bounding
Peripheries = vasodilatation
Cap refill = >2s
CVP/JVP = low
Mental status = variable
76
Q

What common surgical conditions lead to disseminated intravascular coagulation?

A
Sepsis
Transfusion reaction
Drug reaction
Transplant rejection
Aortic aneurysm surgery
77
Q

What is disseminated intravascular coagulation?

A

Widespread activation of coagulation resulting from the formation of intravascular fibrin, fibrin degradation products, consumption of platelets and clotting factors, and ultimately thrombotic occlusion of vessels.

Basically clot like stink then bleed like stink.

78
Q

What are the types of surgical infection?

A

Superficial Incisional Infection
Deep Incisional Infection
Organ/Space Infection

79
Q

What are the principles of prophylactic antibiotics in surgery?

A

Identification of at risk pts = Op/pt factors

Choice of antibiotic = Cephalosporins, often with metronidazole

Dose and timing = Eu = parenteral at induction then 2 doses to complete 24h course

Route of administration = IV (best), Oral (minor), Rectal, Topical

Long term prophylaxis = vs. eg splenectomy

80
Q

What are the characteristics of impetigo?

A

Thin-walled vesicle with golden crust on erythematous base
Caused by Strep or Staph
Usually affects face and limbs

81
Q

What are the characteristic features of erythrasma?

A

Mild localised infection caused by corynebacterium
Asymptomatic or mildly itchy between toes and flexures
Well defined, reddish brown (coral pink lesions under Woods light), may = with scale

82
Q

What are the symptoms of staphylococcal scalded skin syndrome?

A
Rapidly developing fever
Irritability
Skin tenderness
Erythema
Blisters and superficial erosions
83
Q

What bacteria are you likely to encounter in a human bite wound and what antibiotics would you prescribe?

A

S. Aureus
Beta-haemolytic streptococci
E corrodens
Anaerobes

First generation cephalosorin (Cephalexin) or Pneinicillinase-resistant penicillin (dicloxacillin/nafcillin/cloxacillin/oxacillin)

84
Q

What are the likely bacteria you would encounter in a dog or cat bite and what antibiotics would you prescribe?

A

S Aureus
Beta haemolytic step
P multocida

First gen cephalosporin (Cephalexin) OR Penicillinase resitant penicillin (oxacillin/cloxacillin/nafcillin/dicloxacillin)

85
Q

What are the features of anaerobic gangrene (gas gangrene)?

A

Caused by clostridium perfringens

Initially = gas in affected tissues and skeletal mm
Then = oedema with spreading gangrene and systemic signs (sepsis?)
86
Q

How would you treat gas gangrene?

A

Aggressive debridement and fasciotomies

Penicillin 2g/4h IV and metronidazole

87
Q

What are the symptoms of synergistic spreading gangrene?

A

A.k.a necrotising fasciitis
Caused by aerobes and synergistic anaerobes

Severe wound pain and may = gas in tissues

Manage with systemic support, antibiotics, excision of involved tissues

88
Q

A pt post op has a fever, what should you check?

A
Wound (infection, haematoma)
Cannula sites (infection)
Chest (pulmonary collapse, infection, infarction, subphrenic abscess)
Legs vs DVT
Rectal exam (pelvic abscess)
Urine
Stool
89
Q

What antibiotics would you prescribe for staph infection?

A

Cephalosporins, particularly cefuroxime

Gentamicin

90
Q

What antibiotics would you use to treat MRSA?

A

Vancomycin
Teicoplanin
Fuisidic acid

91
Q

What antibiotics would you prescribe to treat Strep infection?

A
Penicillin
Erythromycin
Cephalosporins
Clindamycin
Mupirocin (topical)
92
Q

What antibiotics would you prescribe to treat an enterococci infection?

A

Ampicillin + glycoside e.g. teicoplanin

93
Q

What antibiotics would you use to treat a gram -ve rod infection?

A

e.g. E. coli, klebsiella, proteus, salmonella, enterobacter

Cephalosporins
Piparacillin
Tazobactam
Aminoglycosides (gentamicin, streptomycin, amikacin)

94
Q

What antibiotics would you use to treat an anaerobic infection?

A

Metronidazole

95
Q

What are the common locations for intra-abdominal abscess formation?

A

Alongside organ of origin = paracolic in diverticulitis, parapancreatic after infective pancreatitis

Pelvic = following pelvic sepsis (appendicitis)

Subphrenic = following upper GI perf

96
Q

What are the clinical features of an abscess?

A
Malaise and anorexia
Localised, constant abdominal pain
Swinging fever peaking in excess of 38.5 twice/day
Tachycardia following temperature
Mass
97
Q

How would you investigate an intra-abdominal abscess?

A

CT scan

USS only if pelvic abscess and pt not fit for CT

98
Q

What are the steps in abscess drainage and how would you dress the drained abscess?

A

Drain pus
Remove necrotic material

Small abscess = dry dressing
Deep abscess = leave open until healed with granulation tissue eg. corrugated drain/ribbon gauze soaked in aB