surgery Flashcards
causes of dupytrens
most commonly idiopathic DIABETES LIVER DIESEASE ALCOHOL SMOKING ANTIEPILEPTIC DRUGS (PHENYTOIN) AUTOSOMAL DOMINANTLY INHERITED TB AIDS
deafest pail
ddx contracted hand
differential of contracted hand
- dupytrens
- volkmans
- shortening of intrinsic muscles
- ulnar nerve palsy
- klumpkes palsy
causes of gynecomastia
3 P’S
PHYSIOLOGICAL common at puberty PATHOLOGICAL 1. decreased androgens --reduced andro prod like in hypogonad -- test atrophy (bilateral und testes, post orchitis or bilat torsion -- klinefeltes --hyperprolact -- renal failure
2increased oestroens
- -increased sec (test tumour lung ca)
- increased peripheral aromatization (liver disease, adrenal, thyrotoxicosis
POTIONS
recreational marijuana, amphetamines diaz
gi drugs like cimetidine ranitidine
cvs drugs: spironolactone, digoxin, acei, nifedipine, verapamil
abx: metronidazole, ketoconazole, isoniazid
causes of hepatomegaly
commonest in ireland:mets, ccf, cirrhosis and infections like hepatitis and infectious mono!
causes:
- infectious: hepatits, inf mono, hydatid cysts, amoeba, schistosomiasis, bacterial absecesses, cholangitis, portal pyaemia
- cellular proliferation leukaemias, lymphoma, polycythemia
- cellular infiltrates : amyloid and sarcoid
- metabolic: hemochromatosis, wilsons, galactosemia, drugs
5: SOL: abscesses, cysts, syph gumma, haemangioma, hepatoma, cholangiocarcinoma, mets, - ccf and bud chiri
Types of renal stones
Calcium oxalate 40% Opaque
Mixed calcium oxalate/phosphate stones 25% Opaque
Triple phosphate stones* 10%. Opaque
Calcium phosphate 10%. Opaque
Urate stones 5-10% Radio-lucent
Cystine stones 1% Semi-opaque, ‘ground-glass’ appearance
Xanthine stones <1% Radio-lucent
*stag-horn calculi involve the renal pelvis and extend into at least 2 calyces. They develop in alkaline urine and are composed of struvite (ammonium magnesium phosphate, triple phosphate). Ureaplasma urealyticum and Proteus infections predispose to their formation
Talk about all abdo wall hernias
Details
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.
Above and medial to pubic tubercle
Strangulation is rare
Femoral hernia Below and lateral to the pubic tubercle
More common in women, particularly multiparous ones
High risk of obstruction and strangulation
Surgical repair is required
Umbilical hernia Symmetrical bulge under the umbilicus
Paraumbilical hernia Asymmetrical bulge - half the sac is covered by skin of the abdomen directly above or below the umbilicus
Epigastric hernia Lump in the midline between umbilicus and the xiphisternum
Most common in men aged 20-30 years
Incisional hernia May occur in up to 10% of abdominal operations
Spigelian 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)
Obturator hernia A hernia which passes through the obturator foramen. More common in females and typical presents with bowel obstruction
Richter hernia A rare type of hernia where only the antimesenteric border of the bowel herniates through the fascial defect
Rfs for renal stones
dehydration
hypercalciuria, hyperparathyroidism, hypercalcaemia
cystinuria
high dietary oxalate
renal tubular acidosis
medullary sponge kidney, polycystic kidney disease
beryllium or cadmium exposure
Risk factors for urate stones
gout
ileostomy: loss of bicarbonate and fluid results in acidic urine, causing the precipitation of uric acid
Drug causes
drugs that promote calcium stones: loop diuretics, steroids, acetazolamide, theophylline
thiazides can prevent calcium stones (increase distal tubular calcium resorption)
Features of all the breast disorders
Fibroadenoma
Common in women under the age of 30 years
Often described as ‘breast mice’ due as they are discrete, non-tender, highly mobile lumps
Fibroadenosis (fibrocystic disease, benign mammary dysplasia) Most common in middle-aged women
‘Lumpy’ breasts which may be painful. Symptoms may worsen prior to menstruation
Breast cancer Characteristically a hard, irregular lump. There may be associated nipple inversion or skin tethering
Paget’s disease of the breast - intraductal carcinoma associated with a reddening and thickening (may resemble eczematous changes) of the skin/areola
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’
Duct papilloma Local areas of epithelial proliferation in large mammary ducts
Hyperplastic lesions rather than malignant or premalignant
May present with blood stained discharge
Fat necrosis More common in obese women with large breasts
May follow trivial or unnoticed trauma
Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
Rare and may mimic breast cancer so further investigation is always warranted
Breast abscess More common in lactating women
Red, hot tender swelling
Charcot pentad
fever is the most common feature, seen in 90% of patients
RUQ pain 70%
jaundice 60%
hypotension and confusion are also common
Epidemiology bph
age: around 50% of 50-year-old men will have evidence of BPH and 30% will have symptoms. Around 80% of 80-year-old men have evidence of BPH
ethnicity: black > white > Asian
Mx of fissures
Acute ( 6 weeks)
the above techniques should be continued
topical glyceryl trinitrate (GTN) is first line treatment for a chronic anal fissure
if topical GTN is not effective after 8 weeks then secondary referral should be considered for surgery or botulinum toxin
Fast track to colorectal services
patients > 40 years old, reporting rectal bleeding with a change of bowel habit towards looser stools and/or increased stool frequency persisting for 6 weeks or more
patients > 60 years old, with rectal bleeding persisting for 6 weeks or more without a change in bowel habit and without anal symptoms
patients > 60 years old, with a change in bowel habit to looser stools and/or more frequent stools persisting for 6 weeks or more without rectal bleeding
any patient presenting with a right lower abdominal mass consistent with involvement of the large bowel
any patient with a palpable rectal mass
unexplained iron deficiency anaemia in men or non-menstruating women (Hb < 11 g/dl in men, < 10 g/dl in women)
Talk bout varicocele
A varicocele is an abnormal enlargement of the testicular veins. They are usually asymptomatic but may be important as they are associated with infertility.
Varicoceles are much more common on the left side (> 80%). Features:
classically described as a ‘bag of worms’
subfertility
Diagnosis
ultrasound with Doppler studies
Management
usually conservative
occasionally surgery is required if the patient is troubled by pain. There is ongoing debate regarding the effectiveness of surgery to treat infertility
Talk bout hydrocele
A hydrocele describes the accumulation of fluid within the tunica vaginalis. They can be divided into communicating and non-communicating:
communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life
non-communicating: caused by excessive fluid production within the tunica vaginalis
Hydroceles may develop secondary to:
epididymo-orchitis
testicular torsion
testicular tumours
Features of hydrocele
soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
the swelling is confined to the scrotum, you can get ‘above’ the mass on examination
transilluminates with a pen torch
the testis may be difficult to palpate if the hydrocele is large
