Surgery (multiple) Flashcards

Question

Brainstem compression (coning) / life threatening ICP mx

Answer 1

osmotherapy with hypertonic saline or manitol, neurosurgical decompression -> decompressive craniotomy ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT scan.

Answer 2

physiological nervous system response to raised ICP Cushing triad of widened pulse pressure (increasing systolic, decreasing diastolic), bradycardia, and irregular respirations

Answer 3

Bilaterally: Opiates Pontine lesions Metabolic encephalopathy Unilateral: Sympathetic pathway disruption

Answer 4

fixed pupil w sluggish/no response to light - CN3 compression (uni-/bi-lateral) - poor CNS perfusion (if bilateral) cross reactive (RAPD) - optic nerve injury

Answer 5

GCS < 13 on initial assessment GCS < 15 at 2 hours post-injury suspected open or depressed skull fracture any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign). post-traumatic seizure. focal neurological deficit. more than 1 episode of vomiting

Answer 6

loss of consciousness or amnesia since the injury with: >= 65 years hx of bleeding or clotting disorders including anticogulants dangerous mechanism of injury more than 30 minutes' retrograde amnesia of events immediately before the head injury If a patient is on warfarin & no other indications

Answer 7

hypertension,adult polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta berry aneurysms -> spontaneous SAH

Answer 8

non-contrast CT head - acute blood = hyperdense/bright - If w/in 6hrs & normal -> NO lumbar puncture - If >6hrs & normal -> LP 12hrs post symptom onset LP findings: xanthochromia, normal/ raised opening pressure Once confirmed, find cause - CT intracranial angiogram +/- digital subtraction angiogram

Answer 9

supportive VTE prophylaxis stop antithrombotics - reversal if needed vasospasm prevented w oral nimodipine prompt intervention needed due to risk of rebleeding of aneurysm - w/in 24hrs: coil by interventional neuroradiologists / craniotomy & clipping

Answer 10

SCC (other: melanomas, lymphomas, and adenocarcinomas)

Answer 11

anal margin tumours ->inguinal lymph nodes more proximal -> pelvic lymph nodes.

Answer 12

HPV infection!! - esp for SCC ( HPV16 or HPV18 subtypes) Anal intercourse High sexual partners Men sex men Immunosuppressants Woman w cervical ca or CIN smoking

Answer 13

(examination, including a digital rectal examination, anoscopic examination with biopsy, and palpation of the inguinal nodes) TX - cannot be assessed T0 - no evidence Tis - carcinoma in situ T1 - tumor 2cm or less T2 - 2cm-5cm T3 - more than 5cm T4 - any size, invading adjacent organ (not incuding rectum/ sphincter muscle)

Answer 14

90% - posterior midline if elsewhere, likely underlying cause, e.g. Chron's

Answer 15

<1wk - soften stool (high fibre & fluid diet), bulk-forming laxatives 1st line --> 2nd: lactulose - lubricants before defecation (petroleum jelly) - topical anaesthetics - analgesia chronic (>6wks) - continue above - 1st line: topical GTN - 2nd: if GTN not effective after 8wks -> surgery (shincerotomy) or botulinum toxin

Answer 16

(all pts diagnosed w CRC should have:) - carcinoembryonic antigen (CEA) - CT of the chest, abdomen and pelvis - colonoscopy or CT colonography - tumours below the peritoneal reflection should have their mesorectum evaluated with MRI. TNM (Tumour, Node, Metastasis) staging system to stage CRC from prognosis & tx

Answer 17

( Faecal Immunochemical Test (FIT) ) NHS bowel cancer screening programme (every 2yrs, 60-74) & to guide referral for CRC: -abdominal mass -change in bowel habit - iron-deficiency anaemia - aged 40 and over with unexplained weight loss and abdominal pain - aged under 50 with rectal bleeding and abdominal pain or weight loss, - aged 50 and over with any of the following unexplained symptoms: rectal bleeding abdominal pain weight loss, - aged 60 and over with anaemia even in the absence of iron deficiency (abnormal results are offered a colonoscopy)

Answer 18

- increased fibre - mild diverticulitis: Abx - Peri colonic abscesses: surgical/ radiological drainage - Recurrent episodes of acute diverticulitis requiring hospitalisation - surgical resection - Hinchey stage IV perforations (generalised faecal peritonitis) - resection and usually a stoma, laparoscopic washout and drain insertion, potential HDU admission due to high risk post op complications

Answer 19

extent of spread of colorectal cancer a - confined to mucosal wall b - invading bowel wall c - lymph node met d - distant met

Answer 20

(internal - above dentate line, usually painless) 1 - do not prolapse out of anal canal 2- prolapse on defection, reduce spontaneously 3 - manually reduced 5 - cannot be reduced

Answer 21

- soften stools: increase dietary fibre and fluid intake - topical local anaesthetics and steroids - outpatient treatments: rubber band ligation is superior to injection sclerotherapy - surgery - large symptomatic haemorrhoids which do not respond to outpatient treatments newer treatments: Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy Acutely thrombosed external haemorrhoids <72hrs - referral considered for excision - otherwise conservative: stool softeners, ice packs, analgesia

Answer 22

'thumbprinting' may be seen on abdominal x-ray due to mucosal oedema/haemorrhage likely in in 'watershed' areas such as the splenic flexure

Answer 23

Abdo x ray 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 Management sigmoid volvulus: rigid sigmoidoscopy with rectal tube insertion caecal volvulus: management is usually operative. Right hemicolectomy is often needed

Answer 24

Few hours after birth, RF- downs synd. AXR shows double bubble sign, contrast study may confirm Duodenoduodenostomy

Answer 25

3-7 days after birth Upper GI contrast study- DJ flexure is more medially placed, USS - abnormal orientation of SMA and SMV Ladd's procedure

Answer 26

24-48 hours of life , RF- cystic fibrosis, Air - fluid levels on AXR, sweat test to confirm cystic fibrosis Surgical decompression, serosal damage may require segmental resection

Answer 27

Usually second week of life Dilated bowel loops on AXR, pneumatosis and portal venous air Conservative and supportive for non perforated cases, laparotomy and resection in cases of perforation of ongoing clinical deterioration

Answer 28

more pain in RIF than LIF when palpating LIF

Answer 29

cholecystitis- hyperaesthesia felt by the patient to light touch in the right lower scapular region or the right upper quadrant of the abdomen

Answer 30

only the antimesenteric border of the bowel herniates through the fascial defect can present with strangulation without symptoms of obstruction

Answer 31

Should be surgically repaired soon after diagnosis as at risk of incarceration

Answer 32

Symmetrical bulge under the umbilicus, rf: premature and Afro-Caribbean babies The vast majority resolve without intervention before the age of 4-5 years

Answer 33

Coverage of the wound with saline impregnated gauze (on the ward) IV broad-spectrum antibiotics Analgesia IV fluids Arrangements made for a return to theatre

Answer 34

thin, male patients - clinical females - USS (free fluid) In UK, don't use CT scans

Answer 35

laparoscopic appendicectomy (can be open) prophylactic intravenous antibiotics

Answer 36

liver haemangioma- benign

Answer 37

linked to COCP use USS: mixed echocity & heterogeneous texture leave it, if haemorrhage or symptoms -> removal beware of cytadenoma (rare w malignant potential, solitary multiloculated lesions, surgical resection always)

Answer 38

Amoebic liver abscess (fever RUQ) USS: fluid filled structure with poorly defined boundaries Aspiration: odourless fluid which has an anchovy paste consistency Tx: metronidazole

Answer 39

Seen in echinococcosis infection -> parasitic infection caused by tapeworm Px: abnormal LFTs & eosinophilia USS: septa & hydatid sand / daughter cysts Tx: sterilisation w mebedazole then surgical resection.

Answer 40

Lay open if low, no sphincter involvement or IBD if complex, high or IBD insert seton

Answer 41

TNF alpha inhibitor Crohns disease Rheumatoid disease

Answer 42

Anti VEGF (anti angiogenic) Colorectal cancer Renal Glioblastoma

Answer 43

HER receptor Breast cancer

Answer 44

Tyrosine kinase inhibitor Gastrointestinal stromal tumours Chronic myeloid leukaemia

Answer 45

IL2 binding site Renal transplants

Answer 46

Epidermal growth factor inhibitor EGF positive colorectal cancers

Answer 47

congenital undescended testis failed to reach the bottom of the scrotum by 3 months of age surgical correction! -> 40x more likely to get testicular cancer (seminoma)

Answer 48

Orchidopexy at 6- 18 mo Intra-abdominal testis -evaluated laparoscopically and mobilised After the age of 2 years - better to do orchidectomy due to degradation

Answer 49

Patients identified as being malnourished - BMI < 18.5 kg/m2 - unintentional weight loss of > 10% over 3-6months - BMI < 20 kg/m2 and unintentional weight loss of > 5% over 3-6/12 AT RISK of malnutrition - Eaten nothing or little > 5 days, who are likely to eat little for a further 5 days - Poor absorptive capacity - High nutrient losses - High metabolism

Answer 50

diarrhoea aspiration metabolic: hyperglycaemia & refeeding syndrome

Answer 51

fem canal is at the medial aspect of femoral sheath laterally - femoral vein Medically - Lacunar ligament Anteriorly - inguinal ligament Posteriorly - pectineal ligament Contents Lymphatic vessels Cloquet's lymph node significance- allows expansion of fem vein to allow for increased venous return. Potential space & site of fem hernias

Answer 52

Incarcination - herniated tissues cannot be reduced Strangulation - Surgical emergency, ischemia due to comprised blood supply, tender & likely non-reducible & systemically unwell Bowel obstruction - also emergency Bowel ischemia

Answer 53

Surgical repair is a necessity, given the risk of strangulation, laparoscopically or via a laparotomy (usually for emergencies)

Answer 54

>15% total body area burns in adults (>10% children)

Answer 55

For Fluid resuscitation in burns in the first 24hrs- Crystalloid only Total fluid requirement in 24 hours = 4 ml x (total burn surface area (%)) x (body weight (kg)) 50% given in first 8 hours 50% given in next 16 hours

Answer 56

Colloid infusion is begun at a rate of 0.5 ml x(total burn surface area (%))x(body weight (kg)) --> albumin & FFP Maintenance crystalloid (dextrose-saline) - rate of 1.5 ml x(burn area)x(body weight)

Answer 57

(rolling or sliding) ix - barium swallow (usually found incidentally on endoscopy -occurs first due to nature of symptoms. Mx - conservative mx: weight loss - medical: PPI surgical: most do not need surgery. Only in symptomating rolling(paraoesophagheal) hernias

Answer 58

small = 35mm large = 55mm

Answer 59

treat medically fit patients even if they are asymptomatic - mesh repair has lowest recurrence - unilateral - open approach - bilateral & recurrent - laparoscopic hernia truss if not fit for surgery (cannot use this in femoral hernias due to high risk of strangulation) if stagnated do not manually reduce!

Answer 60

3mg/kg 200mg (or 500mg if given in solutions containing adrenaline), which equates to 3mg/kg for a 66kg patient. equivalent of 20ml of 1% solution or 10ml of 2% solution

Answer 61

hypoglossal nerve

Answer 62

Hyperacute. This occurs immediately through presence of pre formed antigens (such as ABO incompatibility). Acute. Occurs during the first 6 months and is usually T cell mediated. Usually tissue infiltrates and vascular lesions. Chronic. Occurs after the first 6 months. Vascular changes predominate.

Answer 63

APC gene, dominant over 100 colonic adenomas Cancer risk of 100% mx: if at known risk do genetic testing as teen. Annual flexi sigmoidoscopy from 15yrs. If no polyps = 5 yearly colonoscopy from 20. Polyps found = resectional surgery

Answer 64

Multiple benign intestinal hamartomas. Episodic obstruction and intussusception Increased risk of colorectal, gastric, breast, ovarian, cervical, pancreatic & testicular ca. Annual examination Pan intestinal endoscopy every 2-3 years

Answer 65

Germline mutations of DNA mismatch repair genes increased risk of colorectal. endometrial & gastric ca Scanty colonic polyps may be present Colonic tumours likely to be right sided and mucinous colonoscopy every yr from age 25.

Answer 66

intial steps: - NBM - IV fluids - nasogastric tube with free drainage some patients settle with conservative management but otherwise will require surgery

Answer 67

ultrasound is the first-line investigation of choice if the diagnosis remains unclear then cholescintigraphy (HIDA scan) may be used

Answer 68

intravenous antibiotics early laparoscopic cholecystectomy, within 1 week of diagnosis

Answer 69

serum lipase - more sensitive and specific, & longer half life serum amylase dx can be made without imaging if characteristic pain + amylase/lipase > 3 times normal level early ultrasound imaging important for aetiology to determine mx

Answer 70

Ranson score, Glasgow score and APACHE II. P - PaO2 (< 7.9 kPa). A - age (>55). N - neutrophils (white cell count > 15x 109/L). C - calcium (calcium < 2 mmol/L). R - renal function (urea > 16 mmol/L). E - enzymes (lactate dehydrogenase > 600 IU/L). A - albumin (albumin < 32 g/L). S - sugar (blood glucose > 10 mmol/L). actual amylase level is not of prognostic value

Answer 71

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)

Answer 72

fluid resuscitation - aggressive & early hydration w crystalloids aim urine output >0.5mls/kg/hr nutrition - NOT routinely nil by mouth unless vomitting lots, enteral nutrition should be offered w/in 72hrs NO routine Abx

Answer 73

Diagnosis is CT contrast swallow.

Answer 74

Primary sclerosing cholangitis & raised CA 19-9 levels

Answer 75

alcohol excess most common !! idiopathic genetic: cystic fibrosis, haemochromatosis ductal obstruction: tumours, stones, structural abnormalities including pancreas divisum and annular pancreas