Surgery Flashcards by Toby Hay

Clinical features of a ruptured AAA

Abdo pain
Back or loin pain
Pulsatile abdo mass
Distal embolisation causing limb ischaemia 
Shock, syncope

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What is an aneurysm

Dilatation of an artery to more than 50% of its normal diameter

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AAA screening programme

Abdominal USS for men in their 65th year (50% mortality reduction from screening programme)
If detected then 3-5 yearas in surveillance

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Investigations for AAA

USS

Followed by a CT with contrast

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Management for AAA

Lifestyle- smoking cessation, BP control, commence statin and aspirin, weight loss and exercise
MEDICAL
3-4.4cm then a yearly USS
4.5-5.5 3 monthly USS
SURGICAL
>5.5cm in diameter, symptomatic or expanding more than 1cm annually
Open repair or endovascular repair- similar outcomes

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Management of ruptured AAA

High flow oxygen
IV access- 2X large bore cannulae
Urgent bloods- FBC, U&Es, clotting
Crossmatch, minimum 6 units 
Keep BP <100mmHg
Local vascular consultant referral- if unstable then transfer to theatre for open surgical repair

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Causes of acute mesenteric ischaemia

Thrombus in-situ- atherosclerosis
Embolism- cardiac causes (eg. AF)
Non-occlusive cause- hypovolaemic or cardiogenic shock
Venous occlusion and congestion- coagulopathy, malignancy, autoimmune

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Clinical features of acute mesenteric ischaemia

Generalised abdo pain, out of proportion to clinical findings, diffuse and constant
Nausea and vomiting associated
In later stages, globalised peritonitis

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Investigations for acute mesenteric ischaemia

ABG- acidosis and serum lactate
Bloods- FBC, U&Es, clotting, amylase, LFTs, group and save
Imaging- CT scan with IV contrast

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Management of acute mesenteric ischaemic

Urgent resuscitation with early senior involvement
IV fluids, catheter, fluid balance chart
Broad-spectrum antibiotics (potentially perforating and faecal contamination and bacterial translocation
early ITU input
Excision of necrotic or non-viable bowel and/or revascularisation of the bowel

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Risk factors for peripheral arterial disease

Smoking
DM
Hypertension
Hyperlipidaemia
Increasing age
Family history 
Obesity and physical activity

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Clinical features from mild to severe for peripheral arterial disease

Asymptomatic
Intermittent claudication (after a fixed distance)- relived by rest within minutes
Ischaemic rest pain
Ulceration or gangrene

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Critical limb ischaemia definition

Two weeks of ischaemic rest pain
Presence of ischaemic lesions or gangrene
ABPI <0.5

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Normal ABPI

> 0.9

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Investigations for peripheral arterial disease

ABPI
Doppler USS
CT or MR angiography
Cardiovascular risk assessment- ECG, BP, BM, lipid profile

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Management of peripheral arterial disease

Conservative- lifestyle advice,
Medical- statin therapy, anti-platelet therapy, optimise DM control
Surgical if critical- Angioplasty, bypass grafting, amputations

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Causes of haematuria

Infection- pylonephritis, cystitis, prostatitis
Malignancy- prostate adenocarcinoma, urothelial carcinoma
Renal calculi
Trauma or recent surgery
Radiation cystitis
Parasitic eg. schistosomiasis

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Clinical features of renal calculi

Ureteric colic pain- sudden onset, severe, flank–>pelvis pain
Nausea and vomiting
Haematuria (often non-visible)
Rigors, fever or lethargy (may indicate concurrent infection)

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Differential diagnoses for flank pain

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Renal calculi
Pyelonephritis 
Ruptured AAA
Biliary pathology
Bowel obstruction 
Lower lobe pneumonia 
MSK related

Investigations for renal calculi

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Urine dip- microscopic haematuria (90%) and infection
Bloods- FBC, CRP, U&Es, urate and calcium levels
Retrieval of the stone and analysis
Non-contrast KUB

Management of renal calculi

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Adequate fluid resuscitation- likely to be dehydrated
Majority of cases pass spontaneously- sufficient analgesia and NSAIDs per rectum
Sepsis management
Stent insertion or nephrostomy if obstructive or significant infection

Clinical features of pyelonephritis

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Classical triad of fever, unilateral loin pain and nausea and vomiting
Co-existing features of lower UTI may be present- frequency, dysuria, urgency
Visible or non-visible haematuria
Features of sepsis

Investigations for pyelonephritis

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Urinalysis- nitrates and leucocytes
Urinary beta HCG if fertile age
Urine culture and start empirical treatment once sent
Routine bloods- FBC, CRP, U&Es
Renal USS and if obstruction is suspected then non-contrast CT KUB

Management of pyelonephritis

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If systemically unwell then A to E and appropriate resuscitation
Empirical antibiotics according to local protocols and IV fluids as appropriate
Suitable analgesia and anti-emetics
If complicated consider admission- catheterisation and HDU monitoring

Clinical features of testicular torsion

Sudden onset unilateral testicular pain, often associated with n&v Referred abdo pain Testis will have a higher position compared to the contralateral side Can appear swollen and is extremely tender Absent cremasteric reflex Pain continues despite elevation (unlike epididymo-orchitis)

Investigations for testicular torsion

Clinical diagnosis so suspected cases go straight to theatre for scrotal exploration Doppler USS can be used to investigate Urine dipstick for potential infective component

Management of testicular torsion

Surgical emergency in 4-6 hours before significant ischaemic damage occurs Urgent surgical exploration Strong analgesics and anti-emetics NBM with maintenance fluids Bilateral orchidopexy to prevent further episodes

Triple assessment for breast pathology

2-week-wait referral criteria Full history and examination Ultrasound (<35 or male) or mammography Biopsy of any suspicious mass or lesion

Aetiology of galactorrhoea

Idiopathic- 40% Pituitary adenoma- prolactinoma Drug induced- SSRIs, anti-psychotics, H2-antagonists Neurological- through inhibition of dopamine Hypothyroidism- elevated TRH can stimulate prolactin Renal or liver failure

Clinical features of mastitis

Tenderness, swelling and erythema | Important to ensure there is no localised abscess formation occurring (may be systemic features-fever and lethargy)

Management of mastitis, lactational vs non

Lactational- continued milk drainage or feeding | Systemic antibiotic therapy and simple analgesics

Clinical features of mammary duct ectasia

Coloured nipple discharge (blood stained requires triple assessment) A palpable mass Nipple retraction Shows dilated calcified ducts on mammographic examination

Clinical features of fat necrosis of the breast

Usually asymptomatic or a lump | Can present with fluid discharge, skin dimpling, pain or nipple inversion less commonly

Clinical features of a fibroadenoma

Highly mobile lesions Well-defined and rubbery on palpation May be multiple and bilateral Very low malignant potential

Clinical features of a papilloma

Often present with bloody or clear nipple discharge but if larger can present as a mass Can appear similar to ductal carcinomas on imaging and so often require triply assessment

Physiological gynaecomastia

In adolescents commonly occurs due to delayed testosterone surge relative to oestrogen Less commonly in older population from reducing testosterone levels

Aetiology of increased oestrogen leading to pathological gynaecomastia

``` Liver disease Hyperthyroidism Obesity Adrenal tumours Certain testicular tumours ```

Medications that can cause gynaecomastia

``` Digoxin Metronidazole Spironolactone Chemotherapy Antipsychotics Anabolic steroids ```

Most common type of non-invasive breast malignancy

Ductal Carcinoma in Situ

Clinical features of breast cancer

``` Breast lumps, asymmetry, swelling Abnormal nipple discharge Nipple retraction Skin changes Mastalgia Palpable lump in axilla ```

Breast screening service in the UK

Women aged 50-70 invited for a mammogram every 3 years | Abnormalities--> triple assessment

Clinical presentation of Paget's disease

Itching or redness in the nipple or areola Flaking and thickened skin Painful or sensitive Often underlying neoplasm

Genetic mutations associated with breast malignancy

BRCA1, BRCA2, PTEN or TP53

CT head immediately head injury guidelines

``` GCS <13 initially GCS <15 at 2 hours post-op Suspected open or depressed skull fracture Signs of basal skull fracture Post-traumatic seizure Focal neurological deficit >1 episode of vomiting ```

Signs of basal skull fracture

Haemotympanum Panda eyes Battle's sign (post-auricular ecchymosis) CSF leakage from ear or nose

Murphy's sign positive

Acute cholecystitis | RUQ palpation on inspiration- pain

Surgery Flashcards

(46 cards)