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UKMLA Prep > Surgery conditions and presentations > Flashcards

Surgery conditions and presentations Flashcards

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1
Q

Define Volvulus

A

Volvulus refers to the abnormal twisting or rotation of a portion of the intestine, leading to obstruction and potential vascular compromise.

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2
Q

what are the three types of volvulus?

A
  1. Sigmoid volvulus
  2. Cecal volvulus
  3. Gastric volvulus
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3
Q

What are the typical symptoms of volvulus?

A

Abdominal pain, distention, constipation, nausea, vomiting, and sometimes visible abdominal mass.

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4
Q

How is volvulus diagnosed?

A

Diagnosis is usually made through clinical assessment, imaging studies such as abdominal X-ray (showing the “coffee bean” or “omega” sign), CT scan, or sigmoidoscopy/colonoscopy.

sigmoid volvulus: large bowel obstruction (large, dilated loop of colon, often with air-fluid levels) + coffee bean sign
caecal volvulus: small bowel obstruction may be seen

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5
Q

What is the management approach for volvulus?

A
  • fluid resuscitation
  • decompression (via nasogastric tube or rectal tube)
  • surgical consultation for definitive treatment
  • in some cases, endoscopic detorsion for sigmoid volvulus.
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6
Q

What are the potential complications of untreated volvulus?

A

Ischemia, necrosis, perforation, peritonitis, sepsis, and death if not promptly treated.

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7
Q

What are the risk factors for volvulus?

A

Risk factors include
* age (older adults)
* prior abdominal surgery
* history of volvulus
* chronic constipation
* Hirschsprung’s disease.

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8
Q

What conditions should be considered in the differential diagnosis of volvulus?

A

Intestinal obstruction (e.g., adhesions, hernias), appendicitis, diverticulitis, colitis, and mesenteric ischemia.

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9
Q

What is the epidemiology of volvulus?

A

Volvulus is more common in older adults and is more frequently seen in regions where there is a low-fiber diet and a higher prevalence of chronic constipation.

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10
Q

How can volvulus be prevented?

A

Prevention strategies include maintaining a high-fiber diet, staying hydrated, avoiding constipation, and seeking prompt medical attention for symptoms suggestive of bowel obstruction.

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11
Q

Sigmoid volvulus associations

A

-older patients
-chronic constipation
-Chagas disease

-neurological conditions e.g. -
Parkinson’s disease,

Duchenne muscular dystrophy

-psychiatric conditions e.g. schizophrenia

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12
Q

Caecal volvulus associations

A

-all ages
-adhesions
-pregnancy

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13
Q

specific volvulus managment

A

sigmoid volvulus: rigid sigmoidoscopy with rectal tube insertion

caecal volvulus: management is usually operative. Right hemicolectomy is often needed

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14
Q

varicose veins

A

Varicose veins are dilated, tortuous, superficial veins that occur secondary to incompetent venous valves, allowing blood to flow back, away from the heart

commonly occur in the legs due to reflux in the great saphenous vein and small saphenous vein. Whilst extremely common, the vast majority of patients do not require any intervention.

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15
Q

what are the symptoms of varicose veins?

A

aching, throbbing
itching
cosmetic concerns

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16
Q

what are risk factors for varicose veins?

A

increasing age
female gender
pregnancy
the uterus causes compression of the pelvic veins
obesity

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17
Q

what are the complications of varicose veins?

A

a variety of skin changes may be seen:
varicose eczema (also known as venous stasis)
haemosiderin deposition → hyperpigmentation
lipodermatosclerosis → hard/tight skin
atrophie blanche → hypopigmentation
bleeding
superficial thrombophlebitis
venous ulceration
-deep vein
-thrombosis

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18
Q

what are the investigations for varicose veins

A

venous duplex ultrasound: this will demonstrate retrograde venous flow

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19
Q

conservative treatment for varicose veins

A

Conservative treatments include:
leg elevation
weight loss
regular exercise
graduated compression stockings

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20
Q

what reasons to refer patients to secondary care with varicose veins

A

significant/troublesome lower limb symptoms e.g. pain, discomfort or swelling
previous bleeding from varicose veins
skin changes secondary to chronic venous insufficiency (e.g. pigmentation and eczema)
superficial thrombophlebitis
an active or healed venous leg ulcer

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21
Q

secondary care treatments for varicose veins

A

endothermal ablation: using either radiofrequency ablation or endovenous laser treatment
foam sclerotherapy: irritant foam → inflammatory response → closure of the vein
surgery: either ligation or stripping

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22
Q

What is acute urinary retention

A

Acute urinary retention is when a person suddenly (over a period of hours or less) becomes unable to voluntarily pass urine

UROLOGY EMERGENCY

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23
Q

Epidemiology of urinary retention

A

-Whilst acute urinary retention is common in men, it rarely occurs in women (incidence ratio of 13:1). It occurs most frequently in men over 60 years of age and incidence increases with age.

-It has been estimated that around a third of men in their 80s will develop acute urinary retention over a five year period.

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24
Q

Causes of acute urinary retention

A
  • benign prostatic hyperplasia
  • urethral obstructions; including urethral strictures, calculi, cystocele, constipation or masses.
  • anticholinergics, tricyclic antidepressants, antihistamines, opioids and benzodiazepines.
  • UTI
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25
Q

typical presentation of urinary retention

A

Inability to pass urine
Lower abdominal discomfort
Considerable pain or distress
an acute confusional state may also be present in elderly patients

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26
Q

Signs of Urinary retention (3)

A

-Palpable distended urinary bladder either on an abdominal or rectal exam

-Lower abdominal tenderness

-All men and women should have a rectal and neurological examination to assess for the likely causes above. Women should also have a pelvic examination.

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27
Q

Investigations of acute urinary retention

A

-Patients should all be investigated with a urine sample which should be sent for urinalysis and culture. This might only be possible after urinary catheterisation.
-Serum U&Es and creatinine should also be checked to assess for any kidney injury.
-A FBC and CRP should also be performed to look for infection
-PSA is not appropriate in acute urinary retention as it is typically elevated

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28
Q

what confirms diagnosis of acute urinary retention

A

A volume of >300 cc confirms the diagnosis

history or signs of the condition

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29
Q

managment of urinary retention

A

-Acute urinary retention is managed by decompressing the bladder via catheterisation

-Urinary catheterisation can be performed in patients with suspected acute urinary retention, and the volume of urine drained in 15 minutes measured.

-A volume of <200 confirms that a patient does not have acute urinary retention, and a volume over 400 cc means the catheter should be left in place. In between these volumes, it depends on the case.

-Further investigation should be targeted by the likely cause. In reversible causes such as UTI, resolution with treatment is sufficient and further investigation is not necessary.

-Men not diagnosed by BPH should be further evaluated by a urologist, Patients with neurological symptoms should be evaluated by a neurologist and women with gynaecological symptoms by a gynaecologist.

-Where no likely cause is identified, patients should be evaluated by a urologist for anatomical and urodynamic causes.

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30
Q

Peptic ulcer disease

A

Duodenal ulcers: more common than gastric ulcers, epigastric pain relieved by eating
Gastric ulcers: epigastric pain worsened by eating
Features of upper gastrointestinal haemorrhage may be seen (haematemesis, melena etc)

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31
Q

Appendicitis

A

Pain initial in the central abdomen before localising to the right iliac fossa
Anorexia is common
Tachycardia, low-grade pyrexia, tenderness in RIF
Rovsing’s sign: more pain in RIF than LIF when palpating LIF

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32
Q

Acute pancreatitis

A

Usually due to alcohol or gallstones
Severe epigastric pain
Vomiting is common
Examination may reveal tenderness, ileus and low-grade fever
Periumbilical discolouration (Cullen’s sign) and flank discolouration (Grey-Turner’s sign) is described but rare

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33
Q

Biliary colic

A

Pain in the RUQ radiating to the back and interscapular region, may be following a fatty meal. Slight misnomer as the pain may persist for hours
Obstructive jaundice may cause pale stools and dark urine
It is sometimes taught that patients are female, forties, fat and fair although this is obviously a generalisation

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34
Q

Acute cholecystitis

A

History of gallstones symptoms (see above)
Continuous RUQ pain
Fever, raised inflammatory markers and white cells
Murphy’s sign positive (arrest of inspiration on palpation of the RUQ)

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35
Q

Diverticulitis

A

Colicky pain typically in the LLQ
Fever, raised inflammatory markers and white cells

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36
Q

AAA

A

Severe central abdominal pain radiating to the back
Presentation may be catastrophic (e.g. Sudden collapse) or sub-acute (persistent severe central abdominal pain with developing shock)
Patients may have a history of cardiovascular disease

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37
Q

Intestinal obstruction

A

History of malignancy/previous operations
Vomiting
Not opened bowels recently
‘Tinkling’ bowel sounds

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38
Q

definition of constipation

A

efecation that is unsatisfactory because of infrequent stools (< 3 times weekly), difficult stool passage (with straining or discomfort), or seemingly incomplete defecation.

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39
Q

features of constipation

A

the passage of infrequent hard stools

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40
Q

Laxatives and constipation

A
  • first-line laxative: bulk-forming laxative first-line, such as ispaghula
  • second-line: osmotic laxative, such as a macrogol
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41
Q

Initial managment of constipation

A

investigate and exclude any secondary causes, consider red flag symptoms
exclude any faecal impaction
advice on lifestyle measures

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42
Q

complications of constipation

A
  • overflow diarrhoea
  • acute urinary retention
  • haemorrhoids
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43
Q

Femoral hernia

A

section of the bowel or any other part of the abdominal viscera pass into the femoral canal. Via the **femoral ring **

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44
Q

Features of femoral hernia

A
  • mildly painful lump in groin
  • femoral hernias are inferolateral to the pubic tubercle,
  • Typically non-reducible, although can be reducible in a minority of cases;
  • Cough impulse is often absent.
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45
Q

Epidemiology of femoral hernia

A
  • less common than inguinal hernias
  • more common in women
  • more common in multiparous women
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46
Q

Important differentials for femoral hernia

A
  • Lymphadenopathy
  • Abscess
  • Femoral artery aneurysm
  • Hydrocoele or varicocele in males
  • Lipoma
  • Inguinal hernia
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47
Q

Complications of femoral hernia

A
  • strangulation
  • incarcertation
  • Bowel obstruction, again a surgical emergency
  • Bowel ischaemia
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48
Q

Managment of femoral hernia

A
  • Surgical repair is a necessity-risk of strangulation, and can be carried out either laparoscopically or via a laparotomy
  • Hernia support belts/trusses should not be used for femoral hernias, again due to the risk of strangulation
  • In an emergency situation, a laparotomy may be the only option
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49
Q

Intussusception

A

one portion of the bowel into the lumen of the adjacent bowel, most commonly around the ileo-caecal region.

  • Affects infants between** 6-18** months old.
  • Boys are affected twice as often as girls
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50
Q

Features of intussuception

A
  • intermittent, severe, crampy, progressive abdominal pain
  • inconsolable crying
  • during paroxysm the infant will characteristically draw their knees up and turn pale
  • vomiting
  • bloodstained stool - ‘red-currant jelly’ - is a late sign
  • sausage-shaped mass in the right upper quadrant
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51
Q

Investigation of insusseption

A
  • Ultrasound
  • target like mass may be seen
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52
Q

Managment of intussusception

A
  • the majority of children can be treated with reduction by air insufflation under radiological control, which is now widely used first-line compared to the traditional barium enema
  • if this fails, or the child has signs of peritonitis, surgery is performed
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53
Q

Assocaitions with pancreatic cancer

A
  • increasing age
  • smoking
  • diabetes
  • chronic pancreatitis (alcohol does not appear an independent risk factor though)
  • hereditary non-polyposis colorectal carcinoma
  • multiple endocrine neoplasia
  • BRCA2 gene
  • KRAS gene mutation
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54
Q

What conditions are associated with BRCA2 gene?

A
  • Pancreatic cancer
  • Melanoma
  • Male breast cancer
  • Fallopian tube cancer
  • Peritoneal cancer
  • Prostate cancer
  • Pancreatic cancer
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55
Q

Features of pancreatic cancer

A
  • classically painless jaundice
  • non-specific anoreixa
  • loss of exocrine function (e.g. steatorrhoea)
  • loss of endocrine function (e.g. diabetes mellitus)
  • atypical back pain is often seen
  • migratory thrombophlebitis (Trousseau sign) is more common than with other cancers
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56
Q

Investigations for pancreatic cancer

A
  • ultrasound
  • High resolution CT scan
  • “double-duct” sign may be seen
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57
Q

Managment of pancreatic cancer

A
  • 80% pallative care
  • Whipple’s resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas. Side-effects of a Whipple’s include dumping syndrome and peptic ulcer disease
  • adjuvant chemotherapy is usually given following surgery
  • ERCP with stenting is often used for palliation
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58
Q

Features of ruptured AAA

A
  • severe, central abdominal pain radiating to the back
  • pulsatile, expansile mass in the abdomen
  • patients may be shocked (hypotension, tachycardic) or may have collapsed
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59
Q

Managment of AAA

A
  • immediate vascular review with a view to emergency surgical repair.
  • Fraile patients- pallative care
  • haemodynamically stable CT angiogram where the diagnosis is in doubt - this may also assess the suitability of endovascular repair.
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60
Q

inital

Intestinal obstruction- findings

A

History of malignancy/previous operations
Vomiting
Not opened bowels recently
‘Tinkling’ bowel sounds

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61
Q

inital

Ascities findings

A

History of alcohol excess, cardiac failure

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62
Q

initial

Urinary retention- findings

A

History of prostate problems
Dullness to percussion around suprapubic area

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63
Q

initial

Ovarian cancer- findings

A

Older female
Pelvic pain
Urinary symptoms e.g. urgency
Raised CA125
Early satiety, bloating

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64
Q

SAAG >11g/L

A

cirrhosis/alcoholic liver disease
* acute liver failure
* liver metastases

Cardiac
* right heart failure
* constrictive pericarditis

Other causes
* Budd-Chiari syndrome
* portal vein thrombosis
* veno-occlusive disease
* myxoedema

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65
Q

hypertension) SAAG <11g/L

A

Hypoalbuminaemia
* nephrotic syndrome
* severe malnutrition (e.g. Kwashiorkor)

Malignancy
* peritoneal carcinomatosis

Infections
* tuberculous peritonitis

Other causes
* pancreatitis
* bowel obstruction
* biliary ascites
* postoperative lymphatic leak
* serositis in connective tissue diseases

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66
Q

Managment of ascities

A
  • reducing dietary sodium
  • fluid restriction is sometimes recommended if the sodium is < 125 mmol/L
  • aldosterone
  • fluid draining
  • Prophylactic antibiotics prophylactic oral ciprofloxacin or norfloxacin
  • **TIPS procedure **
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67
Q

Features of breast cancer

A

breast lump: typically painless. Classically described as fixed, hard
breast skin changes
bloody nipple discharge
inverted nipple
axillary mass

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68
Q

Fibroadenoma findings

A
  • Develop from a whole lobule
  • Mobile, firm, smooth breast lump - a ‘breast mouse’
  • 12% of all breast masses
  • Over a 2 year period up to 30% will get smaller
  • No increase in risk of malignancy
  • If >3cm surgical excision is usual
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69
Q

Mastitis

A
  • affects 1 in 10 women
  • flucloxacillin for 10-14 days
  • continue breastfeeding
  • if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection
    *
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70
Q

Managment of breast engorgments

A
  • Normal after first few days baby is born
  • hand expression can help
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71
Q

Raynaud’s disease of the nipple

A
  • nipple, pain is often intermittent and present during and immediately after feeding.
  • Blanching of the nipple may be followed by cyanosis and/or erythema.
  • Nipple pain resolves when nipples return to normal colour.
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72
Q

Managent of Raynaud’s disease of the nipple

A
  • minimising exposure to cold
  • Heat packs following a breastfeed
  • avoiding caffeine
  • stopping smoking.

If symptoms persist consider specialist referral for a trial of oral nifedipine (off-license).

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73
Q

Managment of cyclical mastalgia

A
  • Conservative treatments include standard oral and topical analgesia
  • flaxseed oil and evening primrose oil
  • referral after 3 months if no change
  • Hormonal agents such as bromocriptine and danazol may be more effective. However, many women discontinue these therapies due to adverse effects.
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74
Q

Conservative managment of splenic trauma

A

Small subcapsular haematoma
Minimal intra abdominal blood
No hilar disruption

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75
Q

Laparotomy with conservation

A

Increased amounts of intraabdominal blood
Moderate haemodynamic compromise
Tears or lacerations affecting <50%

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76
Q

Splenic trauma ressection

A

Hilar injuries
Major haemorrhage
Major associated injuries

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77
Q

Thorcaic trauma- tension pnuemothorax

A

Often laceration to lung parenchyma with flap
Pressure develops in thorax
Most common cause is mechanical ventilation in patient with pleural injury
Symptoms overlap with cardiac tamponade, hyper-resonant percussion note is more likely in tension pnemothorax

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78
Q

Flail chest

A

Chest wall disconnects from thoracic cage
Multiple rib fractures (at least two fractures per rib in at least two ribs)
Associated with pulmonary contusion
Abnormal chest motion
Avoid over hydration and fluid overload

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79
Q

Pneumothorax

A

Most common cause is lung laceration with air leakage
Most traumatic pneumothoraces should have a chest drain
Patients with traumatic pneumothorax should never be mechanically ventilated until a chest drain is inserted

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80
Q

Hameothorax

A

Most commonly due to laceration of lung, intercostal vessel or internal mammary artery
Haemothoraces large enough to appear on CXR are treated with large bore chest drain
Surgical exploration is warranted if >1500ml blood drained immediately

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81
Q

cardiac tamponade

A

Beck’s triad: elevated venous pressure, reduced arterial pressure, reduced heart sounds.
Pulsus paradoxus
May occur with as little as 100ml blood

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82
Q

Pulmonary contusion

A

Most common potentially lethal chest injury
Arterial blood gases and pulse oximetry important
Early intubation within an hour if significant hypoxia

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83
Q

Blunt cardiac injury

A

Usually occurs secondary to chest wall injury
ECG may show features of myocardial infarction
Sequelae: hypotension, arrhythmias, cardiac wall motion abnormalities

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84
Q

Aortic disruption

A

Deceleration injuries
Contained haematoma
Widened mediastinum

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85
Q

Diaphragmic disruption

A

Most due to motor vehicle accidents and blunt trauma causing large radial tears (laceration injuries result in small tears)
More common on left side
Insert gastric tube, which will pass into the thoracic cavity

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86
Q

Mediastinal transversing wounds

A
  • Entrance wound in one hemithorax and exit wound/foreign body in opposite hemithorax
  • Mediastinal haematoma or pleural cap suggests great vessel injury
  • Mortality is 20%
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87
Q

Femoral hernia

A

type of hernia that protrudes through the femoral canal, below the inguinal ligament and lateral to the pubic tubercle.

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88
Q

Femoral hernia contents

A

Typically contains a part of the intestine

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89
Q

Risk factors for Femoral hernia

A
  • More common in females
  • increased intra-abdominal pressure (e.g., pregnancy, obesity)
  • chronic coughing
  • constipation
  • lifting heavy objects.
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90
Q

presentation of Femoral hernia

A

Painful groin lump that may be reducible or irreducible, may cause bowel obstruction or strangulation.

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91
Q

Managment of Femoral hernia

A

open or laparoscopic surgery

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92
Q

Inguinal hernia

A

A hernia that protrudes through the inguinal canal, typically located in the groin region

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93
Q

Types of inguinal hernias

A
  • **Direct inguinal hernia **(bulges through the posterior wall of the inguinal canal)
  • Indirect inguinal hernia (passes through the deep inguinal ring, lateral to the inferior epigastric vessels)
94
Q

Features of inguinal hernias

A
  • groin lump
  • superior and medial to the pubic tubercle
  • disappears on pressure or when the patient lies down
  • discomfort and ache: often worse with activity, severe pain is uncommon
  • strangulation is rare
95
Q

Managment of inguinal hernias

A
  • treat medically fit patients even if they are asymptomatic
  • hernia truss may be an option for patients not fit for surgery
  • unilateral inguinal hernias are generally repaired with an open approach
  • bilateral and recurrent inguinal hernias are generally repaired laparoscopically
96
Q

Department for Work and Pensions recommendations (inguinal hernia)

A
  • Open repair patients return to non-manual work after 2-3 weeks
  • following laparoscopic repair after 1-2 weeks
97
Q

Inguinal hernia repair complications?

A

early: bruising, wound infection
late: chronic pain, recurrence

98
Q

Types of bladder malignancird

A
  • Urothelial (transitional cell) carcinoma (>90% of cases)
  • Squamous cell carcinoma ( 1-7% -except in regions affected by schistosomiasis)
  • Adenocarcinoma (2%)
99
Q

Urothelial carcinomas

A
  • solitary lesions, or may be multifocal, owing to the effect of ‘field change’ within the urothelium
  • Usually superficial in location and accordingly have a better prognosis.
  • The remaining tumours show either mixed papillary and solid growth or pure solid growths.
100
Q

Nodes of uncertain significance investigation for bladder cancer?

A

PET CT

101
Q

Bladder cancer staging investigation

A

cystoscopy and biopsies or TURBT

102
Q

superficial lesion bladder cancer managment

A

TURBT in isolation.

103
Q

T2 disease bladder cancer managment

A

(radical cystectomy and ileal conduit) or radical radiotherapy.

104
Q

IgA nephropathy conditions associated

A

alcoholic cirrhosis
coeliac disease/dermatitis herpetiformis
Henoch-Schonlein purpura

105
Q

Pathophysiology of IgA neuropathy

A
  • thought to be caused by mesangial deposition of IgA immune complexes
  • there is considerable pathological overlap with Henoch-Schonlein purpura (HSP)
  • histology: mesangial hypercellularity, positive immunofluorescence for IgA & C3
106
Q

Typical presentation of IgA neuropathy

A
  • young male, recurrent episodes of macroscopic haematuria
  • typically associated with a recent respiratory tract infection
  • nephrotic range proteinuria is rare
  • renal failure is unusual and seen in a minority of patients
107
Q

IgA neuropathy managment

A
  • Blood Pressure Control: ACE inhibitors or angiotensin II receptor blockers (ARBs) for blood pressure control and reduction of proteinuria.
  • Immunosuppressive Therapy corticosteroids, immunosuppressive agents (e.g., cyclophosphamide, mycophenolate mofetil), or rituximab.
  • Dietary Modifications: Low-protein diet and salt restriction to manage hypertension and proteinuria.
  • Supportive Care: Symptomatic treatment of complications such as edema, hyperlipidemia, and infections.
108
Q

Prognosis of igA neuropathy

A
  • 25% of patients develop ESRF
  • markers of good prognosis: frank haematuria
  • markers of poor prognosis: male gender, proteinuria (especially > 2 g/day), hypertension, smoking, hyperlipidaemia, ACE genotype DD

end stage renal failure

109
Q

RCC associations

A
  • more common in middle-aged men
  • smoking
  • von Hippel-Lindau syndrome
  • tuberous sclerosis
  • incidence of renal cell cancer is only slightly increased in patients with autosomal dominant polycystic kidney disease
110
Q

RCC triad

A
  • haematuria
  • loin pain
  • abdominal mass
111
Q

Features of RCC

A
  • Classic triad
  • UOP
  • ACTH
  • paraneoplastic hepatic dysfunction syndrome
  • varicocele
  • Stauffer syndrome
112
Q

Stauffer syndrome

A
  • a paraneoplastic disorder associated with renal cell cancer
  • typically presents as cholestasis/hepatosplenomegaly
  • it is thought to be secondary to increased levels of IL-6
113
Q

RCC managment

A
  • alpha-interferon and interleukin-2
  • Receptor tyrosine kinase inhibitors (e.g. sorafenib, sunitinib)
  • patients with a T1 tumour (i.e. < 7cm in size) are typically offered a partial nephrectomy
114
Q

Umbilical hernia features

A

Symmetrical bulge under the umbilicus

115
Q

Paraumbilical hernia

A

Asymmetrical bulge - half the sac is covered by skin of the abdomen directly above or below the umbilicus

116
Q

Epigastric hernia

A

Lump in the midline between umbilicus and the xiphisternum
Risk factors include extensive physical training or coughing (from lung diseases), obesity

117
Q

Spigelian hernia

A
  • 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)
118
Q

Obturator hernia

A

A hernia which passes through the obturator foramen. More common in females and typical presents with bowel obstruction

119
Q

Richter hernia

A

A rare type of hernia where only the antimesenteric border of the bowel herniates through the fascial defect

Richter’s hernia can present with strangulation without symptoms of obstruction

120
Q

Hernia in chuldren

Infantile umbilical hernia

A
  • Symmetrical bulge under the umbilicus
  • More common in premature and Afro-Caribbean babies
  • The vast majority resolve without intervention before the age of 4-5 years
  • Complications are rare
121
Q

Hernia in children

Congenital inguinal hernia

A
  • Indirect hernias resulting from a patent processus vaginalis
  • Occur in around 1% of term babies. More common in premature babies and boys
  • 60% are right sided, 10% are bilaterally
  • Should be surgically repaired soon after diagnosis as at risk of incarceration
122
Q

Peptic ulcer disease presentation

A
  • epigastric pain, later becoming more generalised
  • patients may describe syncope
123
Q

Perforated peptic ulcer investigation

A
  • An upright (‘erect’) chest x-ray is usually required when a patient presents with acute upper abdominal pain
  • 75% of patients with a perforated peptic ulcer will have free air under the diaphragm
124
Q

Managment of peptic ulcer perforation

A
  • Eradication of H. pylori+ clarithromycin + amoxicillin/metronidazole)
  • PPI
  • Avoidance of NSAIDs
  • Repeat endoscopy to assess ulcer healing
125
Q

Epididymal cysts

A

A benign fluid-filled sac located on the epididymis, a tube located at the back of the testicle that stores and carries sperm.

126
Q

Presentation of epipididymal cysts

A
  • Typically asymptomatic
  • may present as a painless lump or swelling in the scrotum
  • often located above or behind the testicle.
127
Q

Conditions assoicated with epididymal cyst

A
  • polycystic kidney disease
  • cystic fibrosis
  • von Hippel-Lindau syndrome
128
Q

mode used to diagnose epididymal cyst

A

ultrasound

129
Q

Management of epididymal cyst

A
  • Supportive
  • surgical removal or sclerotherapy may be attempted for larger or symptomatic cyst
130
Q

varicocele

A

Abnormal enlargement of the testicular veins.

131
Q

Features of varioceles

A
  • typically asymptomatic
  • classically described as a ‘bag of worms’
  • subfertility
132
Q

variocele diagnosis

A

ultrasound with Doppler studies

133
Q

Variocele managment

A
  • 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
134
Q

Hydrocele

A

accumulation of fluid within the tunica vaginalis

135
Q

communicating and non-communicating hydrocele

A
  • communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum.
  • common in newborn males (clinically apparent in 5-10%)
  • resolve within the first few months of life
  • * non-communicating:
  • excessive fluid production within the tunica vaginalis
136
Q

Hydroceles may develop secondary to:

A
  • epididymo-orchitis
  • testicular torsion
  • testicular tumours
137
Q

Features of hydrocele

A
  • 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
138
Q

Diagnosis of hydrocele

A
  • clinical
  • ultrasound used if unsure
139
Q

Hydrocele managment

A
  • infantile hydroceles spontaneously by the age of 1-2 years
  • adults a conservative approach may be taken depending on the severity of the presentation.
  • ultrasound to exclude ddx
140
Q

Testicular cancer

A
  • common malignancy in men aged 20-30 years.
  • 95% of cases of testicular cancer are germ-cell tumours. Germ cell tumours may essentially be divided into:
  • seminomas
  • non-seminomas: including embryonal, yolk sac, teratoma and choriocarcinoma
141
Q

Risk factors for testicular cancer

A
  • infertility (increases risk by a factor of 3)
  • cryptorchidism
  • family history
  • Klinefelter’s syndrome
  • mumps orchitis
142
Q

Features of testicular cancer

A
  • a painless lump is the most common presenting symptom
  • pain may also be present in a minority of men
  • hydrocele
  • gynaecomastia
143
Q

Tumor markers

A
  • seminomas: seminomas: hCG may be elevated in around 20%
  • non-seminomas: AFP and/or beta-hCG are elevated in 80-85%
  • LDH is elevated in around 40% of germ cell tumours**
144
Q

Investigations for testicular cancer

A

ultrasound

145
Q

Managment of testicular cancer

A
  • treatment depends on whether the tumour is a seminoma or a non-seminoma
  • orchidectomy
  • chemotherapy and radiotherapy may be given depending on staging and tumour type
146
Q

AAA screening

A
  • Abdominal ultrasound
  • offered screening programme at 65

When follow up occurs
* Small AAA (3-4.4cm): Yearly repeat ultrasound is offered.
* Medium AAA (4.5-5.4cm): Repeat ultrasound every 3 months is offered.
* Large AAA (>5.5cm): Surgical intervention is generally recommended.

  • CT/MRI used for preoperative
  • full blood count
147
Q

What are the two methods of managment of AAA

A

Open repair and Endovascular Aneurysm Repair (EVAR)

148
Q

Acute limb ischaemia (ALI)

A
  • severe, symptomatic hypoperfusion of a limb, typically presenting for** less than 2 weeks. **
  • Surgical emergency demanding immediate intervention, 4-6 hours of presentation
149
Q

Causes of ALI

A
  • Thrombosis (40%)
  • Embolism (40%)
  • Vasospasm
  • External vascular compromise:
  • Trauma
  • Compartment syndrome
150
Q

Signs and symptoms of ALI

known as 6P’s

A
  • Pulseless
  • Painful
  • Pale
  • Paralysis
  • Paraesthesia
  • Perishingly cold
151
Q
A
152
Q

ALI investigations

A
  • FBC
  • kidney function
  • group + save
  • clotting profile
  • ECG
153
Q

Staging of ALI

A
154
Q

Managment of ALI

A
  • dependance on thrombotic cause or embolic

Thrombotic
* incomplete ischaemia
* angiograpgy
* Complete: urgent bypass

Embolic
* Immediate embolectomy
* embolectomy fails, on-table thrombolysis may be considered.

155
Q

Superficial thrombophlebitis

A

Formation of thrombus in the superficial venous system, predominantly in the lower extremities

156
Q

Epidemiology of superficial thrombophlebitis

A
  • more common females
  • advancing age
  • hx of past VTE
  • HX of malignancy
  • immobolised
  • recent surgery
157
Q

Signs and symptoms- superficial thrombophlebitis

A
  • Localised pain along the course of the vein
  • Itching
  • Erythema (skin redness)
  • Tenderness and warmth over the affected vein
  • Discolouration of the skin
  • Palpable, firm, cord-like vein
158
Q

Superficial thrombophleibits investigation

A
  • Doppler ultrasound: To confirm the diagnosis and rule out DVT.
  • D-dimer: May be elevated but is nonspecific.
  • FBC
  • coagulation profile
  • inflammatory markers: Useful in certain cases to identify underlying systemic diseases.
159
Q

Superficial thromobphlebitis managment

A
  • Compression stockings:
  • Non-steroidal anti-inflammatory drugs (NSAIDs):
  • Topical treatments: Such as warm compresses and topical NSAIDs.
  • Anticoagulation
160
Q

arterial ulcer investigation

A
  • Physical examination
  • Doppler ultrasound: To assess the patency of the arteries and veins.
  • Angiography- evaluate the extent of arterial blockage.
161
Q

Venous ulcer signs and symptoms

A
  • Predominantly found over the medial malleolus
  • Shallow and sloughy in nature
  • Hemosiderin deposition in the lower leg
  • Oedema
  • Skin thickening
  • Eczema
162
Q

Arterial ulcer symptoms

A
  • Occur distally (e.g. at the heel or toe tips)
  • Are small and deep
  • Have a ‘punched out’ margin
  • Do not bleed or ooze
  • Associated with other features of peripheral arterial disease (weak distal pulses, skin/hair atrophy)
163
Q

Wet gangrene

A
  • Infectious type of gangrene that includes:
  • necrotising fasciitis (infection of the subcutaneous fascia and fat),
  • **gas gangrene **(caused by Clostridium)
  • gangrenous cellulitis
164
Q

Dry gangrene

A
  • ischaemic type of gangrene that occurs secondary to chronically reduced blood flow.
  • common: atherosclerosis
  • thrombosis
  • vasospasm
    .
165
Q

causes of vasospasm

A
  • cocaine
  • Raynaud’s
166
Q

Wet gangrene symptoms

A
  • poorly demarcated from the surrounding tissue
  • fever
  • sepsis.
167
Q

Dry gangrene symptoms

A
  • well-demarcated necrotic area without signs of infection.
  • Auto-amputation
168
Q

Wet gangrene investigation

A
  • FBC, CRP, Lactate, blood culture
  • X-ray, ultrasound, or CT scan
  • Tissue biopsy
169
Q

Dry gangrene investigation

A
    • FBC, CRP, Lactate, blood culture
      glucose and coag panel
  • Doppler ultrasound or angiography
170
Q

Wet Gangrene managment

A
  • Surgical debridement or amputation
  • Broad-spectrum intravenous antibiotics.
171
Q

Dry gangrene managment

A

Surgical debridement or amputation

172
Q

PAD

A

common condition where significant narrowing of the arteries, distal to the aorta arch, most often occurs due to atherosclerosis

173
Q

Risk factors PAD

A
  • Smoking
  • Diabetes mellitus
  • Hypertension
  • Hyperlipidaemia,
  • Physical inactivity
  • Obesity
174
Q

PAD signs and symptoms

A
  • Impaired ability to walk
  • Pain in the buttocks and thighs, relieved at rest
  • Pale, cold leg
  • Hair loss
  • Presence of ulcers
  • Poorly healing wounds
  • Weak or absent peripheral pulses
175
Q

ABPI meaning

A
  • 1.2: suggests abnormal thickening of vascular walls (typically in diabetes)
  • 0.9 - 1.2: Normal
  • 0.8 - 0.9: Mild disease
  • 0.5 - 0.8: Moderate disease
  • <0.5: Severe disease
176
Q

PAD imaging

A
  • Duplex arterial ultrasound:
  • MR arteriogram:
  • CT arteriogram: when MR unsuitable
  • Digital subtraction angiography: typically performed at intervention or for monitoring disease.
177
Q

Pain managment in PAD

A

Naftidrofuryl oxalate

178
Q

PAD surgical managment

A
  • Endovascular methods, small discrete stenosis.
  • Surgical bypass larger, more extensive stenosis.
  • Amputation critical limb ischaemia
179
Q

Varicocele signs and symptoms

A
  • Aching or heavy feeling in the scrotum
  • Visibly enlarged or twisted veins in the scrotum, often described as a “bag of worms”
  • Testicular atrophy
  • Impaired fertility
180
Q

Varicocele investigation

A
  • Physical examination
  • Doppler ultrasound
  • valuation of testosterone, FSH, LH, and semen analysis can be useful.
181
Q
A
182
Q

aneurysm

A

localized dilation or expansion of a segment of a blood vessel, typically an artery, to more than 50% of its usual diameter.

183
Q

Aneurysms which blood vessels

A
  • abdominal aorta
  • thoracic aorta
  • cerebral arteries
    iliac artery
    femoral artery,
    popliteal artery
184
Q

Risk factors for aneurysm

A

age, smoking, hypertension, atherosclerosis, hyperlipidemia, and genetic predispositions.

185
Q

Larger vessel symptoms aneurysm

A

age, smoking, hypertension, atherosclerosis, hyperlipidemia, and genetic predispositions.

186
Q

Popliteal upper limb thrombosis symptoms

A

Ischemia distal to the site of occlusion
Pain
Pulselessness
Pallor
Paralysis
Paresthesia

187
Q

complications of aneurysm formation

A

Radiculopathy
Claudication

188
Q

Aneurysms investigation

A

Ultrasound
CT
Blood tests

189
Q

Management of aneurysms

A
  • observations and lifestyle advice
    Anticoag and anti platelets
  • EVAR
190
Q

Carotid artery stenosis

A

narrowing of the carotid arteries

191
Q

Epidemiology of carotid stenosis

A
  • advancing age
  • more common males
192
Q

Carotid stenosis signs and symptoms

A

Transient ischemic attack (TIA)
Stroke in the corresponding vascular territory

193
Q

Investigation for carotid artery stenosis

A
  • duplex ultrasonography
  • CT angiography and MR angiography
194
Q

Surgical management of carotid stenosis

A

carotid endarterectomy if there is carotid artery stenosis of 70-99%
* prev TIA

195
Q

Conservative management carotid stenosis

A

Anti-platelet agents (first line is clopidogrel 75mg)
Cholesterol lowering therapy
Blood pressure control
Lifestyle advice (diet, exercise, smoking cessation, alcohol moderation)

196
Q

Buerger’s disease

A

non-atherosclerotic vasculitis that predominantly affects young male smokers
Occlusion of small and medium arteries

197
Q

EPIDEMIOLOGY
Buerger’s disease

A
  • young male smokers
  • Mediterranean and Middle East origin
198
Q
A
  • acutely ischemic limb without a background of peripheral claudication.
  • severe pain in affected limb (hands and feet)

Raynaud’s phenomenon

Ulcers or non-healing wounds on the fingers and toes, often associated with gangrene.

199
Q
A

Arterial Doppler

Arterial duplex
CT/MR

200
Q

management of burgers

A

Smoking cessation
Nifedipine: A calcium channel blocker that promotes vasodilation and improves blood flow to the affected areas.
Iloprost: A synthetic prostacyclin analog that also promotes vasodilation and inhibits platelet aggregation.
Prostaglandin E1 (PGE1): Another vasodilator that can be used in the management of Buerger’s disease.

201
Q

Fluid resus

A

500mL crystalloid over <15 minutes

Further fluid boluses (up to 2000mL) may be required

202
Q

Maintenance fluids

A

25-30mL/kg/day water
1mmol/kg/day sodium
1mmol/kg/day potassium
1mmol/kg/day chloride
50–100g/day glucose to limit ketosis

203
Q

Complications of central line insertion

A
  • air embolism
  • bleeding
  • pneumothorax
  • infection
  • phrenic nerve palsy
204
Q

Air embolism management

A

Oxygen, patient positioning (left lateral and Trendelenburg), hyperbaric oxygen therapy if severe.

205
Q

Bleeding management

A

Pressure to site, vascular surgery consultation if severe.

206
Q

Pneumothorax management

A

Oxygen
Chest tube insertion

207
Q

Infection management (post line)

A

Antibiotics, catheter removal if indicated.

208
Q

Phrenic nerve palsy management

A

Supportive care
Possible surgical consultation

209
Q

TCA overdose signs

A

Drowsiness
Confusion
Cardiac arrhythmias
Seizures
Vomiting
Headache
Flushing
Dilated pupils

210
Q

TCA overdose investigations

A
  • VBG may show acidosis
  • Long QT syndrome
211
Q

TCA overdose management

A

Manage the patient in a monitored area and consider admitting the patient to the intensive care unit
Adminster IV Sodium Bicarbonate
Consider activated Charcoal within 2-4 hours of the overdose
Consider invasive ventilation
Intravanous fluids

212
Q

Cardiovascular drugs to stop before surgery

A
  • clopidogrel (7 days before
  • warfarin (5 days before) Lehman instead
  • ACE inhibitors (on day)
213
Q

Diabetes drugs to stop surgery

A
  • Insulin should be held on the day of surgery (only the short-acting preparations),
  • sulfonylureas should be held on the day of surgery (due to the risk of hypoglycaemia
  • long procedures- hold metformin and give sliding scale insulin
214
Q

COOP stop

A

4-6 weeks before surgery

215
Q

GCS

A

EMV
4,5,6

216
Q

GCS under 8

A

suggests that the patient is unable to maintain their own airway adequately, and warrants urgent assessment by the anaesthetic team.

217
Q

GCS eyes

A

4 - spontaneous

3 - open in response to speech

2 - opens to pain

1 - no eye opening

Therefore, the lowest GCS is 3/15.

218
Q

motor response scoring

A

6- obeys commands

5 - localises to pain

4 - withdraws to pain

3 - flexor response to pain

2 - extensor response to pain

1 - no response to pain

219
Q

Verbal response scoring

A

5 - oriented

4 - confused conversation

3 - inappropriate speech

2 - incomprehensible

1 - none

220
Q

Delirium tremens (DT)

A

a severe form of alcohol withdrawal that presents with
acute confusion
hallucinations, autonomic hyperactivity, and, in rare cases, seizures

221
Q

Signs and symptoms of delirium tremens

A

Confusion and disorientation
Hallucinations, which can be visual or tactile (e.g., formication – the sensation of crawling insects on or under the skin)
Autonomic hyperactivity, manifesting as sweating and hypertension
Rarely, seizures

222
Q

Alcohol withdrawal management

A

Administer Chlordiazepoxide. Eventually this can be tapered according to Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scoring
Ensure adequate hydration with fluids
Provide Anti-emetics to manage nausea
Pabrinex to replenish vitamins
Refer the patient to local drug and alcohol liaison teams for further support and management

223
Q

Epidural location

A

L3-4 or L4-5

224
Q

Epidural risks

A

maternal hypotension- foetal and maternal distress
Low pressure headache
Severe postural headache
Epidural haematoma

225
Q

<1 normal vital signs

A

RR 30-40
HR 110-160
SBP 70 -90

226
Q

1-2 normal vital signs

A

RR25-35
HR 100-150
SBP 80-96

227
Q
A

Re 25-30
Hr 95-140
80-100

228
Q

Anaesthetic toxicity management

A

lipid emulsion (20% intralipid) should be administered at a dose of 1mL/kg every 3 minutes up to a maximum dose of 3mL/kg,

229
Q

Peri-operative management steroids

A

Switch oral steroids to 50-100mg IV hydrocortisone.
If there is associated hypotension then fludrocortisone can be added.
For minor operations oral prednisolone can be restarted immediately post-operatively. If the surgery is major then they may require IV hydrocortisone for up to 72 hours post-op

230
Q

Malignant hyperthermia cause

A

Suxamethonium

231
Q

Malignant hyperthermia cause

A

Suxamethonium

UKMLA Prep (30 decks)

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