Vascular, Breast & Thyroid Surgery Flashcards
1
Q
Acute limb ischaemia - Def? Presentation? Ix? Mx?
A
-
Def: a sudden decrease in limb perfusion that threatens the viability of limb
- AF = major RF for acute limb ischemia
-
Presentation - 6Ps:
- Pale
- Pulseless
- Painful
- Perishingly cold
- NOTE: need immediate vascularisation (<6hrs) if:
- Paralysis
- Paraesthesia (esp worrying)
-
Ix (after initial Mx):
- Bedside: ABPI (PAD), ECG (AF)
- Bloods: FBC, U&E, clotting, HbA1c, lipid profile
- Imaging: duplex USS, CT/MR angiography
-
Mx:
- Initial:
- A-E, IV access, analgesia
- IV heparin infusion - reduces the chance of the clot getting worse
- Limb viability:
- Immediate - tender muscles, loss of power, loss of sensation
- Urgent - pale, pulseless, painful, cold
- Irreversible - fixed, mottled skin, woody, hard muscles
- Refer to vascular surgery:
- Thrombotic - local intra-arterial thrombolysis, angioplasty, bypass
- Embolic - embolectomy/local intra-arterial thrombolysis/bypass
- Initial:
2
Q
Peripheral vascular (arterial) disease - Def? RFs? Spectrum? Ix? Special test?
A
Def: limb ischemia (chronic) from atherosclerosis in lower limb vasculature
RFs: male, older, smoker, HTN, DM
Spectrum:
-
Intermittent claudication (mild) - cramping leg pain after walking (& have to stop) + relieved by rest
- NOTE: the equivalent of stable angina (worse on exertion)
- Worse going uphill/upstairs
-
Critical limb ischemia (severe) - ulcers, gangrene, night pain & rest pain
- NOTE: the equivalent of unstable angina (present at rest)
Ix:
- Bedside:
- Exam special test = Buerger’s angle - elevation pallor –> sudden drop feet down = sunset sign
- exercise-treadmill ABPI (ankle-brachial pressure index) - <0.8 (<0.3 = CLI)
- Bloods - FBC, U&E, LFTs, CRP, clotting
- Imaging:
- Arterial duplex USS
- CT/MR angiography
Mx: dealt with by vascular surgeons –> optimise meds + surgery (bypass)
- Conservative: smoking cessation
- Medical: ACEi, clopidogrel, statin, DM control
- Surgery: angioplasty/stent/bypass graft/amputation
3
Q
Peripheral vascular disease localisation & type of bypass graft?
A
- Both sides all reduced pulse = aorta-iliac –> aorto-bifemoral
- One side reduced pulse from the popliteal down = femoro-popliteal
- One side reduced pulse distally in anterior tibial = femoro-distal
- One side reduced pulse distally in posterior tibial = femoro-distal
4
Q
Chronic venous insufficiency & varicose veins - presentation? Ix? Mx? Complications of varicose veins?
A
Presentation:
- Oedema, haemosiderin deposition, lipodermatosclerosis (inverted-champagne bottle), eczema, venous ulcers
- Varicose veins - dilated tortuous, superficial veins
- Pain, swelling, itching, restless legs, cramps
- Feel for thrombosis (hard = thrombophlebitis)
- Cough impulse at SFJ (for Saphena Varix - dilation of saphenous vein @junction w/ femoral vein)
-
Trendelenburg test
- Lying flat, lift up leg & empty veins
- Compression over SFJ –> stand up (maintain pressure) - if do not fill = competent valves below SFJ
- If do fill = incompetent valves below SFJ (blood flow from deep to superficial vein via perforating veins)
- Repeat with pressure lower down until filling stops
- Perthe’s test - apply tourniquet to mid-thigh + walk for 5-mins –> compresses superficial vein
- Less distended - normal deep veins as calf compression pushes blood into deep venous system
- Remain distended - impaired deep veins
- Doppler US for reflux
- Warfarin - previous DVT
- Abdo mass with compression
Ix: duplex USS (allow DVT to be ruled out)
Venous insufficiency Mx:
- ABPI > 0.8 –> Compression bandaging
- Varicose veins:
- Conservative - weight loss, avoid standing for prolonged periods
- Minimally invasive procedures - injection sclerotherapy, endovenous radiofrequency ablation
- Surgical - vein ligation
Varicose Veins complications:
- thrombophlebitis - Tx for superficial: NSAIDs
- Eczema
- Bleeding
- Haemosiderin deposition
- Lipodermatosclerosis (champagne bottle)
- Ulceration
5
Q
AAA key Sx & ruptured Sx? Ix? Mx?
A
Sx:
- Central abdo pain
- Radiates to back
- Bloating
- Pulsatile mass on palpation (expansile - moves to sides)
- NOTE: always consider if abdo pain + RFs (male, >65yrs, HTN, smoking etc.)
Ruptured AAA Sx:
- Severe pain radiating to back
- Visible pulsating abdo mass
- Shock (circulatory compromise)
Ix:
- Abdo duplex USS if part of national screening - male age 65yrs
- CT angiography if stable but suspicious of rupture
Mx:
-
<5.5cm –> Conservative: monitor w/ USS + RF modification
- <4.5cm –> yearly USS
- 4.5≤x<5.5com –> 3 monthly USS
- Medical: optimise BP control, statin, aspirin
- Sx/>5.5cm/expanding >1cm/yr –> Surgical: endovascular (catheter into aorta to insert stent)/open repair
6
Q
How to calculate ABPI? ABPI value range?
A
- BP cuff above ankle with leads upwards – find dorsalis pedis pulse with doppler
- Inflate cuff until signal disappears – let down cuff until signal reappears = ankle pressure
- Repeat procedure in arm using brachial artery signal to record the brachial pressure
- ABPI = ankle pressure/brachial pressure
Range:
- 0.8-1 = normal
- 0.6-0.8 = claudication (may only drop to this with exercise)
- Below 0.6 = critical limb ischaemia
7
Q
Breast Diagnostics
A
Screening MMG
- ≥50yrs - 3yrly
- >40yrs - attending clinics
USS focused:
- <40yrs USS only
- ≥40yrs USS + MMG
Biopsy:
- all breast lumps in women >25yrs
- USS-guided
8
Q
Benign breast diseases - types? presentation? Dx? Mx?
A
Breast pain
- Presentation:
- Benign breast pain, cyclic/non-cyclic (fibrocystic breast)
- Other causes - inf, trauma (fat necrosis), haematoma (on anti-coag)
- Dx: nothing if no masses/concerning features on exam
- Mx:
- Reassurance, supportive bra
- Ibuprofen/voltarol gel
- Evening primrose oil
Breast Cyst
- Presentation:
- Sudden tender, small, smooth lump –> disappears after a period
- Multiple w/ previous similar episodes
- Younger
- Dx:
- USS only <35ys; USS + MMG ≥35yrs
- USS - fluid-filled, well-circumscribed collection
- Disappears after aspiration, biopsy if solid posterior residual lesion
- Mx: USS-guided aspiration only if large + painful
Fibroadenoma - common benign breast tumours of both glandular and stromal tissue
- Presentation:
- Mobile, easily palpable, can be lobulated
- Young women
- Dx:
- Age-dependent
- Biopsy >25yrs/very large/concerns over phyllodes tumour
- Re-scan small FAD again in 3-6 months to monitor for rapid enlargement
- Mx:
- Surgical excision - if rapid enlargement/>4cm
- Reassurance otherwise
Mammary duct ectasia (periductal mastitis)
- Presentation:
- Milk ducts dilate and fill with fluid –> breast pain + green-white nipple discharge
- Assoc w/ smoking, menopause
- Dx: can mimic breast cancer –> need triple assessment
- Mx: conservative ± abx ± surgery for complications
Breast abscess
- Presentation:
- breast-feeding, DM, post-op, smokers
- Red, hot, tender fluctuant mass, systemic (febrile, unwell)
- Acute Hx
- Dx:
- Too painful to tolerate MMG - USS only initially
- MMG on resolution if ≥35yrs
- Mx:
- USS-guided aspiration + Abx
- Clinical review in 48hrs –> possible repeat aspiration
- Incision & drainage under GA if overlying necrotic skin
9
Q
Nipple discharge - causes? presentation? Dx? Mx?
A
Causes:
- Physiological (90%)
- Duct ectasia - benign, normal in post-menopausal, multi-duct
- Intraductal papilloma - papilloma growth in single duct
- Epithelial hyperplasia
- Galactorrhoea - pregnancy/prolactinoma
Presentation:
- Smokers - green multi-duct
- Duct ectasia (dilated ducts) - yellow multi duct –> cheesy watery discharge ± bloodstained
- Prolactinoma/pregnancy - b/l milky, multi duct
- Underlying pathology (cancer, PCIS, papilloma) - bloody discharge from a single duct (can be watery/serous)
- Epithelial hyperplasia has a similar but less severe presentation
Dx:
- Age-related ± MRI
- USS retro-areolar w/ biopsy of visible lesions
Mx:
- Treat cancer incl. excision of NAC
- Papilloma - single/total duct excision
10
Q
Gynaecomastia - causes? presentation? Dx? Mx?
A
Causes:
- Failures:
- Liver cirrhosis due to alcoholism (failure of liver to metabolise oestrogens)
- Renal failure
- Neoplasm:
- Bronchial carcinoma
- Pituitary tumours (hyperprolactinaemia)
- Testicular tumours
- Hyperthyroidism, Hypogonadism
- Drug-related (spironolatone)
Presentation: elderly/puberty
Dx: bilateral USS
Mx:
- Cause
- Tamoxifen
- Surgery
- NOTE: do not stop meds just because they are causing gynecomastia
11
Q
Breast carcinoma - RFs? types (incl. receptors, axilla involvement)? Presentation? Dx? Mx?
A
RFs:
- Increase:
- FHx (breast, ovarian, colon)
- Genetic mutations (BRCA1/2 - sign increase risk of breast/ovarian cancer)
- Post-menopausal, ≥40yrs, early menopause/late menarche
- OCP (decreases risk of endometrial/ovarian/colorectal)
- Decrease: pregnancy, breastfeeding
Types:
- Invasive ductal carcinoma - 70%, firm/hard
- Lobular carcinoma - 10%, bilateral in 20%, multicentric
- Tubular - 10%, small stellate lesions, picked up on screening
- Other: medullary (soft/fleshy, good prog), mucoid (rare, good prog), Paget’s (nipple excoriation, underly intraductal tumour, poor prog)
Receptor involvement: ER (oestrogen), PR (progesterone), HER2 (Herceptin)
- ER/PR-receptive = good prognostic signs
- HER2 = bad prognostic sign (but now Tx for it)
Presentation:
- Post-menopausal
- Firm mass ± skin tethering/dimpling
- LNs in axilla
Ix:
- Triple assessment:
- ≥35yrs - MMG + USS + biopsy (FNA/core biopsy)
- <35yrs - USS + biopsy –if proven cancer–> MMG + MRI
- Axilla - USS + biopsy if any abnormal LNs
-
Staging CT & bone scan if >3cm/LNs involved - TNM
- T1-4 (size, 4= invasive), N0/1 (no/yes), MO/1 (no/yes)
- Mets - bone, lung, liver
- Nottingham prognostic index - size & grade of tumour & LNs
- MRI if lobular cancer
Mx:
- ALWAYS - Surgery:
- __Mastectomy/wide local excision - depends on tumour size vs breast size
- ALWAYS - SLNB/ALNC
- Sentinel LN biopsy vs axillary LN clearance = remove all
- Chemo - if involve LNs/large cancer/young patient/HER2 +ve/Triple -ve disease
- Radio - >4cm, LN involvement, skin/muscle involvement
- Endo: ONLY if ER +ve
- Tamoxifen pre-menopausal
- Letrozole if post-menopausal
- Herceptin (Trastuzumab) for HER2+
- MDT approach (incl psychological support)
12
Q
Aortic dissection - def? Sx? Ix? Mx?
A
Def: tear in tunica intima (inner layer of BV) –> blood collection between tunica intima and tunica media –> false lumen (can occlude blood flows through aorta) –> AR, myocardial ischaemia, stroke
Sx: sudden onset, central tearing chest pain –> radiating to between shoulder blades
- Hx of intermittent claudication
- Haemodynamic instability (high HR, low BP)
- Before left subclavian artery - left arm smaller than right arm
- After left subclavian artery - lower body less developed than upper body
Ix:
- BP in both arms - radio-radial delay
- ECG, CXR (widened mediastinum)
- Gold-standard: CT-aortogram w/ contrast
Mx:
- Stanford A (ascending aorta) - more WORRYING (compromise blood to brain, cause aortic regurg):
- BP control - B-blockers & CCB (aim 100-120mmHg)
- Immediate referral for vascular surgery
- Stanford B (descending aorta)
- BP control - B-blockers & CCB (aim 100-120mmHg)
- Urgent referral to vascular surgery (repair likely if complicated)
13
Q
Comparing different types of vascular ulcers:
- Hx
- Location
- Characteristics - ulcer & surrounding skin
- Tx
A
Venous:
- Hx: varicose veins, previous DVT, obesity, preg, recurrent phlebitis
- Location: lower calf-medial malleolus
- Characteristics: mild pain
- Ulcer - shallow/flat margins, exudate, sloughing @base, granulation tissue
- Surrounding skin - haemosiderin staining, eczematous, oedematous, thickening skin, (normal CRT)
- Tx: compression bandaging, leg elevation, surgical Mx
Arterial:
- Hx: HTN, DM, smoking, prev vascular disease
- Location: pressure points, toes/feet, lateral malleolus, tibia
- Characteristics: painful
- Ulcer - punched-out/deep, irreg shape, necrosis, no exudate (unless inf)
- Surrounding skin: thin, shiny, reduced hair, 6Ps (pallor, pain, perishingly cold, pulselessness, paraesthesia, paralysis)
- Tx: revascularization (e.g. bypass), anti-platelet, manage RFs
Neuropathic:
- Hx: DM (peripheral neuropathy), trauma, prolonged pressure
- Location: plantar foot, tip of toe, lateral-fifth metatarsal
- Characteristics: no pain
- Ulcer - deep, surrounded by callus, insensate (no feeling)
- Surrounding skin - dry, cracked, callus, insensate
- Tx: off-loading pressure, topical GF
Pressure:
- Hx: limited mobility
- Location: bony prominence, heel
- Characteristics:
- Ulcer - deep, macerated (moist, wrinkly)
- Surrounding skin - atrophic skin, lost muscle mass
- Tx: off-loading pressure, reduced moisture, increased nutrition
14
Q
Hypertension BP targets? Ix? Mx?
A
BP targets:
- <140/90
- <150/95 for over 80yrs
- Causes of hypertensive crisis ≥180/120: pregnancy, scleroderma, vasculitis, renovascular, endo, cocaine –> reduce BP slowly
Ix:
- Bedside - ECG, urine dip
- Bloods - FBC, U&E, lipids, BM, TFTs
Drug treatment:
- Conservative management - diet (low salt), exercise, reduce alcohol
- a) <55yrs/DM –> ACEi (ramipril)/ANG-II receptor antagonist (Losartan)
- b) ≥55yrs/black –> CCB (amlodipine)/thiazide diuretic (bendroflumethiazide)
- ACEi + CCB OR ACEi + thiazide diuretic
- ACEi + CCB + thiazide diuretic
- Add:
* Spironolactone (or other diuretic)
* Alpha-blocker
* Beta-blocker
* Specialist advice
- Add:
15
Q
Breast triple assessment?
A
Clinical examination
Breast imaging (MMG, USS)
Breast biopsy
