Vascular, Breast & Thyroid Surgery Flashcards
(41 cards)
1
Q
Surgical sieve
A
Vasc
Inf
Trauma
AI
Metabolic
Idiopathic/iatrogenic
Neoplasia
Congenital
Degenerative/drugs
2
Q
General inspection signs & assoc Dx
A
3
Q
Vascular legs DDx?
A
4
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:
5
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
6
Q
Arterial vs venous insufficiency in legs signs
A
7
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
8
Q
PAD Mx?
A
Conservative: smoking cessation
Medical: ACEi, clopidogrel, statin, DM control
Surgery: angioplasty/stent/bypass graft/amputation
9
Q
Neck lump DDx?
What can I add to a differential for a neck lump (or a lump anywhere else) if stuck?
Non-functional thyroid nodule Ix?
A
Neck lump ddx:
- GOITRE –> midline, firm, thyroid status
- LNs –> reactive/malignant
- Thyroglossal cyst –> midline, moves with tongue
- Branchial cyst –> fluctuant, anterior triangle
Everywhere lumps = sebaceous cysts, lipoma or lymphadenopathy
US of neck ± FNA
10
Q
Graves’ Mx?
A
11
Q
Thyroid neck exam process? Goitre complications? Further Ix?
A
Thyroid status exam:
- Hands - hands out straight
- Hyperthyroidism - sweating, onycholysis, palmar erythema, peripheral tremor, thyroid acropatchy (looks like clubbing, only in Graves’)
- Hypothyroidism - thin/dry skin
- Arms - pulse (rate, rhythm - low HR in hypo; high HR in hyper; AF in hyper)
- Pemberton’s sign - hands above head (SVC obstruction)
- Face:
- Inspection:
- Hyperthyroidism - sweating
- Hypothyroidism - outer 1/3 eyebrow loss, dry skin
- Eyes - in thyrotoxicosis (e.g. Graves):
- Look at eyes from front, side & above:
- Lid retraction
- Exophthalmos (proptosis)
- Eye inflammation
-
H-test (head still):
- Diplopia & pain during eye mov
- Hold finger high and bring down –> Lid lag (upper lid does not move down with downgaze)
- Look at eyes from front, side & above:
- Neck:
- Lymph nodes assessment - for LN mets
- Tracheal deviation (in large goitre)
- Thyroid:
- Inspect neck from front & side (goitre, prev thyroidectomy scar):
- Swallow water:
- Thyroid & thyroglossal cysts move up
- LNs move little
- Invasive thyroid malignancy may not move if tethered to underlying tissue
- Stick out tongue:
- Thyroglossal cysts move up
- All others stay still
- Swallow water:
- Palpation:
- Stand behind and place 3 fingers of each hand along the middle neck - locate thyroid cartilage (adam’s apple) and then cricoid cartilage - below this is the thyroid - feel the isthmus in the middle & lobes on either side
- Swallow water while palpating - if not symmetrical elevation = unilateral mass
- Stick out tongue while palpating - if thyroglossal cyst will rise
- NOTE:
- Size
- Symmetry
- Consistency
- Masses (position, shape, mobility, consistency)
- Palpable thrill (increased vascularity in Graves)
- Percussion from sternal notch - retroperitoneal extension
- Auscultate thyroid with bell - bruit (increased vascularity in Graves
- Inspect neck from front & side (goitre, prev thyroidectomy scar):
- Further tests:
- Knee jerk reflex (hyporeflexia in hypothyroidism)
- Pretibial myxoedema (waxy induration of skin on anterior lower leg) - Graves
- Proximal myopathy (hands crossed over chest, stand up) - multinodular goitre/Graves
- Inspection:
Local goitre complications:
- SVC obstruction
- Dysphagia, upper airway obstruction
- Recurrent laryngeal nerve compression (hoarse)
Further Ix:
- Bedside: ECG - AF
- Bloods: TFTs
- Imaging: thyroid USS
- Invasive: thyroid biopsy - FNA
12
Q
Diabetic foot - what are they secondary to? presentation? How to identify neuropathic ulcer? Mx?
A
Secondary to: PVD, small vessel disease, neuropathy, infection
Presentation:
- Callus, deep ulcers
- Single toe amputation due to osteomyelitis
- ± features of peripheral vascular disease
- Finger marks from BM monitoring
- Lipoatrophy/lipohypertrophy from insulin injection sites
Neuropathic ulcer = insensate + punched out
13
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
14
Q
Surgery - observations & assoc Dx
A
- Groin lump above inguinal ligament –> inguinal hernia
- Reduced pulses –> PVD
- Midline neck lump –> Graves’ disease, Multinodular goitre
- Abdominal scar + lump –> incisional hernia
- Toe amputation –> diabetic foot disease
- Oedematous legs –> venous insufficiency
15
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
16
Q
Chest pain through to scapula & connective tissue disorder (e.g. Marfan’s) - Dx?
A
Aortic dissection
17
Q
Aneurysmal sac enlargement post-EVAR (endovascular aneurysm repair) - what should you think?
A
Endoleak
18
Q
IVC collapse/”Halo sign” on CT - what should you think?
A
Hypovolaemic shock
19
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
20
Q
Vascular exam - upper, abdo & lower? Arterial & venous anatomy?
A
NOTE: if press harder and it is there = my own pulse; if press weaker and it is there = their pulse
- If can’t feel pulses can use doppler USS: triphasic signal
- 1st phase - forward rush of blood
- 2nd phase - reverse flow from elastic recoil (in arterial wall)
- Lost in arterial disease = biphasic/monophasic signal
- 3rd phase - forward flow on vessel relaxing
EXAMINATION:
General inspection – smoking, inhalers, diabetic meds, fistula, dressings, walking stick
Upper:
- Hands – splinter haemorrhages, nicotine stains, missing digits (more common in trauma, Buerger’s disease), temperature + CRT
- Supra-aortic pulses:
- Radial – rate, rhythm, radio-radial delay
- Brachial pulse – character
- Subclavian pulse, in supraclavicular fossa
- Carotid pulse
- BP
- Listen for bruits in neck, breathe in and out slowly
Abdo:
- Inspect for scars, look around sides
- Palpate for aneurysms - abdominal aortic pulse
- Listen for aortic and renal bruits (above umbilicus and to either side)
Lower:
- Inspect (colour, swelling, scars, varicose veins)
- Palpate:
- Temp in feet, calves, thighs (run back of hand along)
- Tenderness - squeeze ankles/calves (DVT)
- CRT, pitting oedema
- Measure leg diameter 10cm below tibial tuberosity (If <3cm between = not significant)
- Femoral arteries (ASIS & pubic symphysis midpoint):
- Feel simultaneously as weak femoral pulse difficult to determine
- Radio-femoral delay
- Auscultate femoral pulse for bruits (can also listen to iliacs - below umbilicus on either side) –> sometimes only picked up on exercise
- Popliteal arteries – reach around back of knee, behind the knee, slightly lateral, lift leg up to 30 degrees so weight resting on fingers
- Pedal arteries – anterior (dorsalis pedis) & posterior tibial (behind medial malleolus)
- BUERGER’S TEST (for peripheral vascular disease)
- Both feet held up – angle foot goes white is Buerger’s angle –> when foot blanches swing legs over side of bed and let them hand down –> ischaemic foot will go brick red = severe peripheral vascular disease of lower limb = SUNSET SIGN
- Ideally, I should hold feet for 1 minute but still say -ve test if no blanching
- ABPI:
- BP cuff above ankle with leads upwards – find dorsalis pedis pulse with doppler USS
- 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
- 0.5-0.8 = claudication (mild-moderate disease); <0.5 = rest pain (severe disease); <0.2 = gangrene
Finally - complete relevant neuro exam, vascular exam where not been done in exam, CV & abdo exams
- Bloods - FBC, U&E, coag
- D-dimer, duplex USS (venous - DVT/arterial - perfussion) –> CTPA (PE)
- Tx: DOAC/Warfarin if high-risk DVT
Leg Anatomy:
-
Arterial:
- External iliac artery > femoral artery (pulse):
- Profunda artery (minor branch)
- Superficial femora artery (main branch) > Popliteal artery (pulse):
- Anterior tibial artery - form dorsalis pedis artery (pulse)
-
Posterior tibial artery - goes around medial malleolus (pulse)
- Peroneal artery (branch of PTA)
- External iliac artery > femoral artery (pulse):
-
Venous:
- Great-saphenous vein (medial) - meets deep femoral vein in medial upper thigh (as goes into groin)
- Small-saphenous vein (lateral)
- Connected via perforating vein
21
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
22
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
23
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
24
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
25
Breast carcinoma - RFs? types (incl. receptors, axilla involvement)? Presentation? Dx? Mx?
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)
26
Aortic dissection - def? Sx? Ix? Mx?
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)
27
What profile group do Phyllodes commonly affect? What are they?
Older women
Fibroepithelial breast tumour - epithelial & stromal elements (similar histologically to fibroadenoma)
Can become malignant, normally require surgical resection
28
Breast anatomy? Breast exam? Triple assessment?
Breast anatomy - Lobules \> ducts \> nipple
* Ligaments suspending breast = _Cooper's ligaments_
* Most lymphatic drainage to _axilla_ (& intercostal, interthoracic LNs)
* Blood supply - _perforating intercostal arteries_
Intro - WIPE + chaperone
Inspection:
* **SITTING** Positions:
* Relaxed arms
* Hands rested on thighs
* Hands-on hips - tense pectoralis
* Hands behind head - accentuate dimpling/asymmetry
* Lift breasts - submammary fold (ask patient)
* Look for:
* Asymmetry, local swelling, scars (look under breasts)
* Skin changes:
* Dimpling/puckering - tethering due to cancer
* Peau d'orange - lymphatic oedema due to cancer
* Nipple changes:
* Paget's disease of breast - unilateral nipple = cancer
* Eczema - areola (rarely nipple), bilateral
* Inversion - normal variant/cancer
Palpation: **LYING DOWN** + hand on the side being examined _behind head_ + check for pain (start on normal side)
* Use palmar surface of middle 3 fingers to feel for any lumps starting in centre and going round in concentric circles
* Pinch along axillary tail (first 2 fingers & thumb)
* Ask patient to squeeze each nipple to check for discharge
* Localise + describe lump: **3Ss, 3Cs, 3Ts**
* Site, Size, Shape
* Consistency, Contours, Colour
* Tenderness, Temperature, Tethering/Transillumination
* Lymph nodes:
* Axillary - ask patient to hold bicep:
* Palpate apical, lateral, medial, anterior, posterior aspects
* Cervical LN exam
* Offer to examine lungs and liver for mets
Triple assessment:
* Examination
* Imaging (USS \<35yrs; MMG + USS ≥35yrs)
* Biopsy (FNA if cystic, core biopsy if solid)
29
Comparing different types of vascular ulcers:
* Hx
* Location
* Characteristics - ulcer & surrounding skin
* Tx
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
30
Hypertension BP targets? Ix? Mx?
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
* 1. a) \<55yrs/DM --\> ACEi (ramipril)/ANG-II receptor antagonist (Losartan)
* 1. b) ≥55yrs/black --\> CCB (amlodipine)/thiazide diuretic (bendroflumethiazide)
* 2. _ACEi + CCB_ OR _ACEi + thiazide diuretic_
* 3. ACEi + CCB + thiazide diuretic
* 4. Add:
* Spironolactone (or other diuretic)
* Alpha-blocker
* Beta-blocker
* Specialist advice
31
Breast triple assessment?
Clinical examination
Breast imaging (MMG, USS)
Breast biopsy
32
DVT - def? RFs? Presentation? Scoring & Ix? Mx?
Def: occlusion of deep vein in lower limb
RFs: SICC - Surgery, Immobility, Cancer, COCP
Presentation: pain, swelling (if extends proximally to iliacs --\> bilateral swelling), pitting oedema, warmth, erythema
Scoring & Ix: Well's score
* 0-1= D-Dimer --sign raised--\> as below
* ≥2 = proximal leg vein USS + D-Dimer
* Obtain baseline before starting anti-coag: FBC, U&E, LFTs, clotting screen
Mx:
* Ongoing anticoagulation - DOAC/Warfarin
* Provoked - 3 months (SICC)
* Unprovoked - \>6 months + thrombophilia testing
33
* Itchy after showers, abdo pain & distension, prev DVT
* Exam - dilated veins on abdo, ascites, hepatomegaly
* Bloods - hepatitis picture
Dx? Assoc condition(s)? Ix? Mx?
NOTE: hot water --\> histamine release from basophils
Dx: **Budd-Chiari syndrome = hepatic vein thrombosis**
* 50% associated with **JAK2** _myeloproliferative disorders e.g. Polycythaemia Rubra Vera_ (and essential thrombocythaemia) - this is what causes itching after showers
* NOTE: any portal vein thrombosis (different to hepatic vein thrombosis) is related to cirrhosis and may be painless/asymptomatic
Ix: **urgent doppler USS of hepatic veins**
Mx: tx as any DVT - DOAC (e.g. apixaban)
34
Thyroglossal duct cyst - def? presentation? Tx?
Most common _congenital_ neck mass
* Thyroglossal duct - embryological duct connecting back of tongue & thyroid gland
* Cyst results from failure of thyroglossal duct closing before birth
Presentation: painless fluctuant midline mass
* Often presents in childhood following inf (painful red)
* On exam moves upwards when sticking out tongue due to attachment of duct
Tx: surgical resection of cyst & duct
35
Thyroid function hormonal axis?
Hypothalamus releases **thyrotrophin-releasing hormone (TRH)**
TRH stimulates ant. pituitary gland to release **thyroid-stimulating hormone (TSH)**
Stimulates thyroid to release **triiodothyronine (T3) & thyroxine (T4) --\> -ve feedback**
Outcomes:
* Hyperthyroidism - low TSH, high T3/4
* Primary hypothyroidism - high TSH, low T3/4
* Secondary hypothyroidism - low TSH, low T3/4
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Case:
* 40yrs woman had a thyroidectomy 12hrs ago
* Developed neck pain & swelling, complaining of difficulty breathing
* Exam: raised RR, stridor, bandage overwound is soaked with blood & swollen
What do you do?
1. Take off the bandage, take out sutures
2. Open skin to expose strap muscles
3. Open strap muscles to expose trachea
4. Pack overwound
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Describing a lump?
Localise + describe lump: 3Ss, 3Cs, 3Ts
* Site, Size, Shape
* Consistency, Contours, Colour
* Tenderness, Temperature, Tethering
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Pre-cancerous breast masses
Ductal carcinoma in-situ
* Def:
* Limited to mammary ducts by basement membrane --\> can't metastasise
* Can transform into invasive (ductal) malignancy
* Presentation: often not palpable, picked up on screening
* Mx: breast-conserving surgery - wide local excision
Lobular carcinoma in-situ
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Allen's test - process? When do you do this test?
Process:
* Find radial & ulnar pulse - patient makes tight fist
* Occlude both vessels --\> ask to open hand --\> release radial side --\> observe for re-perfusion
* Repeat & release on ulnar side
NOTE: ulnar artery is dominant artery in the hand
When do you do this in daily practice - before doing ABG
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What is the cervical rib? What can it cause?
**Cervical rib** is an abnormal rib at C7
* Compression of subclavian artery when raising arms/neck flexion (thoracic outlet obstruction syndrome)
* Obliteration of _radial pulse_
Can cause - **Subclavian Steal Syndrome**
* Proximal obstruction in subclavian artery
* Retrograde flow through vertebral/internal thoracic artery
* Reduces cerebral blood flow --\> _syncopal Sx_
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Types of obstructive vasculitis?
* **Takayasu's arteritis** = occlusive large-vessel vasculitis (aorta & main branches)
* Upper limb claudication, diminished/absent pulse
* **Thromboangitis obliterans** (Buerger's disease) - affects small & medium vessels in lower limb
* Segmental occlusion, young male smokers, tortuous corkscrew collateral vessels on angiography
