Surgical Flashcards
(33 cards)
2 types of Hydrocele
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 and Management of Hydrocele
Features
Non tender swelling of the hemi scrotum - anterior and below the testicle
you can ‘get above it’ on examination
transilluminates with a pen torch
the testis may be difficult to palpate if the hydrocele is large
Diagnosis may be clinical but ultrasound is required if there is any doubt about the diagnosis or if the underlying testis cannot be palpated.
Management
infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years
in adults a conservative approach may be taken depending on the severity of the presentation. Further investigation (e.g. ultrasound) is usually warranted however to exclude any underlying cause such as a tumour
Varicocele Features and Management
Enlargement of testicular veins, usually asmptomatic but can be associated with infertility
Varicoceles are much more common on the left side (> 80%).
Classically descibed as ‘ bag of worms’
Diagnosis
ultrasound with Doppler studies
Management
usually conservative
occasionally surgery is required if the patient is troubled by pain.
Epididymo-orchitis features and management
Commonly due to clamydia, gonorrohea, e colie UTI
Features
unilateral testicular pain and swelling
urethral discharge may be present, but urethritis is often asymptomatic
** Torison is differential to rule out**factors suggesting testicular torsion include patients < 20 years, severe pain and an acute onset
Treat the cause:
If STI is the most likely cause advise urgent referral to a local specialist sexual health clinic
if the organism is unknown BASHH recommend: ceftriaxone 500mg intramuscularly single dose, plus doxycycline 100mg by mouth twice daily for 10-14 days
Anal Fissure Management
First-line management of chronic anal fissures includes conservative measures such as bulk-forming laxatives, maintaining good hygiene, dietary advice to increase fibre intake, and application of lubricant prior to defecation.
Aims to soften stools and reduce straining which can exacerbate and prolong the healing process of an anal fissure.
If above fails, topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure
if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin
Management of overactive bladder ( men)
incontinence,
bladder physio and managing fluid intake
If needed anti muscarinics ( NICE recommend oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily preparation)
mirabegron may be considered if first-line drugs fail)
Assessment of LUTS in Men
DDX: Prostate cancer, BPH, OAB, Infection
Examination
urinalysis: exclude infection, check for haematuria
digital rectal examination: size and consistency of prostate
a PSA test may be indicated, but the patient should be properly counselled first
Pt tools
urinary frequency-volume chart: distinguish between urinary frequency, polyuria, nocturia, and nocturnal polyuria.
International Prostate Symptom Score (IPSS): assess the impact on the patient’s life. This classifies the symptoms as mild, moderate or severe
Management of voiding difficulty and BPH
Conservative: pelvic floor muscle training, bladder training, prudent fluid intake and containment products
Medical :
1)Alpha-blocker ( tamsulosin improve vaso dilation and urinary flow, can cause hypotension/dizziness)
2) If BPH: 5-alpha reductase inhibitor should be offered ( finesteride, reduce testosterone to reduce size of BPH)
3) If ‘severe’ symptoms offer both an alpha-blocker and 5-alpha reductase inhibitor
4) If there are mixed symptoms of voiding and storage not responding to an alpha blocker then a antimuscarinic (oxybutynin) ( reduce detrusor muscle contractions)
Surgical
TURP (Transurethral resection of the prostate)
NICE criteria for CT head post injury within 1 hour
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
NICE guidelines for CT head 8 hours post injury
age 65 years or older
any history of bleeding or clotting disorders including anticogulants
dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
more than 30 minutes’ retrograde amnesia of events immediately before the head injury
Prostate cancer investigations
** look at nice cKS pathway **
PI RADDS or Likert scale (1-5 liklihood of prostate cancer) to decide if biopsy vs MRI:
Transrectal ultrasound-guided (TRUS) biopsy
Multiparametric MRI as a first-line investigation.
Most common breast cancers
Invasive ductal carcinoma ( invasive + slightly spread) . This is the most common type of breast cancer. Recently been renamed ‘No Special Type (NST)’. Sub type is tubal ( less common)
Invasive lobular carcinoma
Ductal carcinoma-in-situ (DCIS) ( not spread)
Lobular carcinoma-in-situ (LCIS)
Inflammatory breast cancer is a rare and aggressive form of breast cancer that causes visible changes to the skin covering the breast, such as redness, swelling and an orange-peel like texture. It represents only 1-5% of all breast cancers.
Paget’s disease of the nipple is another less common type of breast cancer, accounting for around 1-3% of cases. It initially presents with changes to the skin on and around the nipple, such as flaking or crusting, but may also involve a lump in the breast.
FIT testing criteria
Every 2 years to all men and women aged 50 to 74 years
If abnormal = colonoscopy
Caecal volvulus signs
Rarer (20%) often need surgical management. would cause signs snd symptoms of small bowel obstruction rather than large bowel ( vomit ++) and the x-ray would underline enlargement of the small bowel.
Risk Factors for sigmoid volvulus
older patients
chronic constipation
Chagas disease
neurological conditions e.g. Parkinson’s disease, Duchenne muscular dystrophy
psychiatric conditions e.g. schizophrenia
Metformin rules for surgery
Sulphonurea rules for surgery
Insulin rules for surgery
Metformin (inhibits gluconeogenesis, and increases insulin sensitivity) - only reduce dose on the day of taking TDS, otherwise keep
Sulphonurea (gliclazide, increase insulin sensitivity of panc) ) omit morning dose day of surgery
long acting Insulin
eg daily (lantus) - reduce by 20% on day of surgery ( when fasting )
twice daily long acting
novomix / humalin M3 ( half dose)
Warafin rules for surgery + what do wo if emergency surgery required
Stop 5 days before
check INR the day before; give oral vitamin K if INR ≥ 1.5.
If high thromboembolic risk (e.g. VTE <3 months ago, mitral mechanical valve, AF with prior stroke):
bridge with treatment-dose LMWH, stopping 24 hours before surgery
dried prothrombin complex can be given in addition to IV vitamin K and the INR checked before surgery
Restart at usual warfarin dose evening or day after surgery
DOAC Rules prior to surgery
stop 24 hours before low/moderate bleeding risk surgery (e.g. hernia repair).
stop 48 hours before high bleeding risk surgery (e.g. cardiothoracic surgery).
in renal impairment (e.g. CrCl <30), stop up to 72 hours before high-risk surgery.
restart:
6–12 hours post-op for minor procedures with low bleeding risk.
after 48 hours for high-risk surgery or increased bleeding risk.
Steriod rules for day of surgery
Often need supplemental steriods due to aid stress response due to supresson of HPA axis ( from being on long term steriods)
-> conversion from PO to IV hydrocort
-> back on steroids asap after surgery
-> taper back down to maintenence dose
ACEi/ARB rules for surgery
Withold 24hours before ( due to hypotension risk)
Ileostomy features
Usually ileostomy is on the right iliac fossa * they can be located on any part of the abdomen*
spouted (small bowel’s contents are irritant to the skin)
Liquid content
End = final due to defunctioning colon, Loop = often is reversed
Colostomy features
colostomy is on the left iliac fossa
flushed to the skin (non irritant bowel product)
slightly more solid content
Blood vessles that bleed with subdurals
Subdural haemorrhage results from bleeding of damaged bridging veins between the cortex and venous sinuses
