surgery card passmed take home Flashcards
mild acute panc?
mx?
pseudocyst/ early fluid cyst?
pancreatic necrosis?
IGETSMASHED?
drug cx?
absences of organ failure and local complications
GB - early cholecystectomy
obstructed - ERCP
necrosis -debridement
pseudocyst: abdo fullness, 6 weeks, fluid,
can be infectied - abscess (abscence of necrosis)
<4 weeks - early fluid collection, no wall. can become pseudocyst
necrosis - first few days of illness
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 (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valProate)
SAH cx? treatment?
how do we prevent vasospasm?
when can we do LP? what do we see?
complications?
head injury that presents with lucid interval and raised ICP?
which one is fluctuating consciousness?
high speed RTA, remains in vegetative state with normal CT scan?
berry aneuysms - ADPKD, coa, EDS, HTN. bleed to basila, anterior circulating A. TX: coiling of aneurysm/ craniotomy and opening clip of aneurysm
prevent vasospasm by giving nimodipine
LP 12 hrs after sx onset - xanthochromia, raised or normal opening pressure
SIADH vasospasm,
hydrocephalus
vasospasm - 7 to 14 days after
extradural haematoma (lucid interval). raised ICP - cushing reflex (HTN, bradycardia, irregular breathing). middle meningeal A.
subdural - acute, subacute and chroic types (brigding vein bleed)
diffuse axonal injury - multiple haemorrhages, damage in white matter. in high acceleration/decelleration
woman, below and lateral to pubic tubercule hernia? mx?
woman with bowl obstruction hernia?
inguinal hernia in children/ adults?
direct vs indirect?
inguinal hernia as testicular swelling?
femoral hernia, repair as strangulation likely
obturator hernia
inguinal hernia - ant and medial to pubic tubercule (inguinal lig), disappears when patient lies down. repair in children asap, common right sided. in adults - stangulation rare but routine referral as can cause sx eventually
direct - through abdo wall/ hesselback’s triangle
indirect - through inguinal canal
testicular swelling: cant be palpated above the swelling. indirect
Fibroadenoma
B. Paget’s disease of the breast
C. Breast cancer
E. Fibroadenoma
F. Fibroadenosis
G. Duct papilloma
H. Breast abscess
I. Fat necrosis
J. Mammary duct ectasia
breast cyst
most common type of breast cancer?
breast cancer with orange peel like texture?
fibroadenoma (lipoma not likely in breast)- discrete mobile lump painless. <30YO, breast mice. excise if 3cm+ no cancer risk
B. Paget’s disease of the breast - red, thickening nipple, eczematous. AF invasive carcinoma
C. Breast cancer - irregular, hard, skin thethering
F. Fibroadenosis - lumpy middle ages breast before menstruation
G. Duct papilloma - blood stained discharge. no malignanc. microdoectomy
H. Breast abscess - lactating, red, hot swolllen. cx staph A
I. Fat necrosis - similar to cancer, post trauma obese. increase in size then become irregular. imagin and core biopsy
J. Mammary duct ectasia - menopausal, green nipple discharge with tender tump around areola
breast cyst: smooth, disease, risk of cancer in young women. aspirate and biopsy/ excise if recurrent/ blood stained
common: invasive ductal carcinoma
orange feel - inflammatory breast cancer
Renal stones MX?
meds fr pain and passage of stone?
types of stone and how can we reduce them/.
5mm+/ ureter stone - shockwave lithotripsy pain: IM diclofenac
alpha 1 blocker may help - relaxes smooth muscle or CCB
calcium (hypercalcuria) - thiazide diuretics, limit salt, avoid fizzy drinks, high ivi
oxolate - prevent by pyridoxine/ cholestyramine
uric acid - allopurinol/ hco3 urine alkalization
penile cancer RF? most common?
HIV/HPV/balantiits/ phimosis/ poor hygeien, scc- has ulcer
volvulus
sigmoid vs caecal?
sigmoid - older, chronic constipation, coffee bean sign, dilated. do right sigmoidoscopy with rectal tube
cecal - all ages. need right hemicolectomy. caused by adhesions/ pregnancy
colon cancer:
most common?
screening?
sx: blood mixed with stool/clots? bloating and fatique?
sx: fe loss/ no sx
abdomino-perineal resection is? what kind of cancer is it for?
low anterior resection? risk of this?
what is high anterior resection?
what do left and right hemicolectomy remove?
in and emergency, a tumour with perforation, what tx?
common: descending colon/ sigmoid - mixed blood/ stool/ bloating
right sided tumours normally no sx/ fe low.
screening: FIT in 60-74 (UK)/ scotland 54-74) 2 yearly. 5-15% PPV
abdominoperineal resection- anus, rectum and section of sigmoid colon with permanent end colostomy. ( tumours in distal third of the rectum)
Low anterior resection (tumour in upper two thirds of rectum)
risk post op: incontinent, flatulency, urgency. normally defunctioning loop ileostomy placed to reduce complications
high anterior resection: for sigmoid removal
righ hemi: cecum, AC, prxmal TC
left: distal TC/ DC
hartman’s: emergency perforation. sigmoid colon resection then end colostomy and then can later be reversed. grater risk of anastomosis.
pre op and DM meds:
for sulfonylurea?
Od insulin - lantus/ levemir?
BD insulin: novomix30/ humulin m3
Metformin take as normal unless TDS - omit lunchtime dose
sulfonylureas - take when eating again
OD insulin - levemir/lantus? - reduce dose by 20% day before
BD insulin - novoix/ humulin m3 - half morning dose.
Ct head within 1 hr?
BANGSS
CT head within 8 hrs ABCD?
- Basal skull fracture signs
- Any 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
- Age over 65
- Bleeding risk: anti-coagulation, clotting disorder
- Concussion: retrograde amnesia 30 mins+ before head injury
- Dangerous mechanism of injury: e.g. hit by car / fall from height / from 1m height or >5 stairs
breast cancer: when to do wide local excision vs mastectomy?
RF for breast cancer?
what IX to do before surgery regarding lymph nodes?
when is radiotherapy indicated?
Post op hormonal therapy?
option in pre an dperi menopausal? post menopausa?
when is herceptin used?
main use of neo adjuvant chemo?
mastectomy - DCIS 4cm+, large lesion in small breast, central tumour, multifocal. do radiotherapy for T3/T4
WLE: solitary, small, DCIS < 4cm, peripheral. always will whole breast radiotherapy
RF: nulliparity, 1st child 30+, COCP, early menarch, late menopause, obesity, not breastfeeding, brca 1 and 2
no LN palpable - need pre op USS, if negative do sentinal node biopsy. if positive/ palpable will need node clearance
hormonal therapy for E positive tumour.
Pre/peri menopausal@ tamoxifen 5 yrs risk endometrial cancer, VTE, menopausal sx
post menopausal: aromatase inhibitors -anostrazole (SE: hot flushes, osteoporosis, - do DEXA, arthralgia, malgia, insomnia
herpectin biologic - HER2 positive. CI heart disorders
chemo - mainly used to downsize to have breast conserving surgery
ano rectal diseae:
A. Fistula in ano
B. Fissure in ano
C. Ischiorectal fossa abscess
D. Haemorrhoids
E. Crohn’s disease
F. Internal rectal prolapse
G. Solitary rectal ulcer
A. Fistula in ano
B. Fissure in ano - common painful PR. sentinel skin tag. GTN, sphincterotomy after 8 weeks
C. Ischiorectal fossa abscess
D. Haemorrhoids - 3, 7, 11 o clock. do proctoscopy and DRE.
grading: grade 3 manually reducable, grade 4 -not reducale, grade 1 - no prolapse, 2 - prolapse on defecation
E. Crohn’s disease - loose stools, bleed
F. Internal rectal prolapse - child birth hx, inteussusception
G. Solitary rectal ulcer - chronic constipation, straining, occasional bleeding, mucosal thickenign
breast cancer screening normal?
when to refer early?
2ww?
50-70 3 yearly mammogram, 70YO - patient lead
early:
refer if 1st degree/ 2nd degree has:
<40 at dx, B/L breast, any ovarian, male breast, jewish, sarcoma <45YO, other cancers, parents breast ca hx
3 relatives with breast cancer any age,
30+ any unexplained breast lump.
50+ nipple sx discharge/ retraction
max local naesthetic doses?
reversal
Lignocaine 1% plain - 3mg/ Kg - 200mg (20ml)
Lignocaine 1% with 1 in 200,000 adrenaline - 7mg/Kg - 500mg (50ml)
Bupivicaine 0.5% - 2mg/kg- 150mg (30ml)
iv lipid emulsion
CN palsies which are ipsilateral and contralateral?
7, 10, 5, 12?
7+10=17 (remember 0 in 10 as ‘O’pposite) contralateral
7 - angle of mouth, 10 uvula
uvula away
5+12=17 (5 resembles an S) , hence ‘S’ame ipsilateral
5- jaw deviation
12- tongue deviation
which anaesthetic is useful for following?
anti-emetic effcts post op?
does not cause drop in BP, good for trauma? can cause hallucinations
has Se of laryngospasm?
is sed hypotensive than etomidate?
can cause malignant hypethermia, myocardial depression?
propofol - pain on induction, post op anti emetic effects causes hypotension
ketamine - used for trauma. no bp drop
thiopental - lipdid soluble, laryungospasm,
etomidate - good for haemodynamic instability, myoclonus, adrenal suppression
liquid anaesthetics - isoflurane/desflurane/sevoflurane
testicular cancer RF:
infertility (increases risk by a factor of 3)
cryptorchidism
family history
Klinefelter’s syndrome
mumps orchitis
germ cell tumours- seminomas (better prognosis) only HCG, non seminomas - AFP/ hcg. and LDH
abdo swelling cause with alcohol excess/ cardiac failure?
ascites
ABPI <0.9
what meds to start?
tx?
this is peripheral arterial disease. start statin 80mg and clopidogrel
tx: exercise training/ surgery
lipodermatosclerosis, hyperpigmented, hard skin, leg swelling worse at end of day with irregular ulcers. normal ABPI. dx?
chronic venous insufficiency (complications of varicose veins) - do venous duplex USS to show retrograde flow
tx: leg elevation, graduated compression stockings, cvd rf control,
simple - radiofrequency ablation, foam sclerotherapy, ligation/stripping
bladder cancer - TCC vs SCC RF?
SCC: schistosomiasis, smoking
TCC: common, smoking, dyes, cyclophospamide, rubber
epididymo-orchitis empirical tx?
STI likely - ceftriaxone 500mg IM+ doxy 100mg 10-14 days
enteric likely - msu and oral quinalone 2 weeks
post op patient extubated and no respiratory effort made? observed in ICU and weaned off. cx?
other side effects of this drug?
which non depolarising muscle relaxant responsible for following?
- histamine reaction after injection - flushing, tachy, hypotension?
- prolonged effect in person with CKD/ liver disease
reversal agent of non depolarising MR?
suxamethonium apnoea (autosomal dominant - lack specific acholinesterase in plasma to break down)
SE: malignant hyperthermia, high K,
- Atracurium
(AH - hisamine, high HR, low BP, flushed) - Vecuronium
(very ppoorly kidneys+liver) - neostigmine/ partirally reverses pancuronium
biliary tree disorders:
biliary colic
acute cholecystitis
ascending cholangitis
cancer
colic: intermitted. RF: DM/ chrons, fertile (pregnnacy), raid WL, COPC. electiv lap col. choledocholithiasis - in commbon bile duct
acute chol: raised WVV, RUQ pain, no obstruction (SBR mild raised/normal, no jaundice)
ascneding cholangitis - complte obstruction. jaundice, fever,
suspected DVT with well’s <2 but patient is obese, painful red thigh with hardened saphenous vein ?
thrombophreblitis - risk of VTE so do USS even if wells is <2, d-dimer can be raised with superficial thrombophlebitis.
inflamed and 5cm+ is associated with DVT/
normal tx is nsaids and compression.
consider 30 days prophylaxis
peptic ulcer disease - which is better when you eat?
duodenal ulcer
sx of basal skull fracture?
Bleeding from ruptured vessels can leak into the middle ear (haemotympanum) or mastoid area (Battle’s sign), while ruptured CSF spaces may cause fluid to leak into the nose or auditory canal (CSF rhinorrhoea and otorrhoea).
alcoholic, intermittent pain in left/ back, steatthorea, weight loss?
other cx?
tests to assess function?
chornic pancreatitis
cx: CF, haemochromatosis, tumours, stones, pain worse 30 mins after meal risk of DM.
faecal elastase tests exocrine function
Se of aromatase inhibitors (anastrozole?)
osteoporosis, - dexa, hot flushes, arthralgia/myaglia, insomnia
SE of tamofixen (SERM - selective estrogen receptor modulator)
use din E positive breast cancer per menopausal women/ pre menopausal. SE
hot fluses, mentrual disturbance, endometrial cancer, VTE
post op ileus tx?
keep NBM and insert NGT
penis cancer aRF?
HIV, HPV, genitl warts, phimosis, balantitis, 50+, poor hgeine
patient presents post lap cholecystecomy and has ongoing jaundice an dpain?
gallstones present in comon bile duct (choledochlithiasis)
CI to laryngela mask airway?
not being fasted
prep on prednisolone, how will you supplement this during op?
IC hydrocortisone before induction. moderae - 50mg in induction, 25mg every 8 hrs for 28 days. major surgery: 100mg hC in induction and 50mg 8 hourly for 24 hrs
stoma that can be easiest to reverse in the future?
loop ileostomy (normally in RIF)
post prostatectomy PSA levels?
should be indetectable
most comon cx of small bowel obstruction?
how does it present?
adhesions, then hernias
central abso pain, billous vomiting, tinkling bs to complete no bs
dilated bowel 3cm+
haemorrhagic shock:
which classes have normal B
which have reduced?
class 1: normal BP, no sx HR <100, UO 30ml+
class 2: normal BP
3) low bp, HR 120,
4)low bp, lethargic, HR 140+
Describe ASA classifiction?
1 non smoker, mild drinker
2 - social smoker, controlled dm, BMI 30-40
3 - severe disease. ESRD, cva, BMI 40+/ cva/ htn/ copd/ MI
4 - not expected to survive without the procedure - ruptured AAA/ ICB
5 - brain dead
