1. Carcinoma of the breast
a. Regional lymph node involvement is a bad prognostic factor
b. Ductal carcinoma is the most common type of malignant tumor
c. Local radiotherapy is indicated after wide local excision
d. CEA scanning is used to localize sentinel lymph nodes
e. Fine needle aspiration cytology is not a reliable test in diagnosing breast
cancer
TTTFF
Breast cancer staging is done by TNM system:
T1
= < 2 cm
T2
= 2-5 cm
T3
= > 5 cm
N0
N1
N2
N3
= no nodes
= ipsilateral mobile
= ipsilateral fixed
= ipsilateral internal mammary nodes
M0
M1
= no mets
= distant mets or ipsilateral supraclavicular nodes
Stage I
= T1 N0 M0
Do wide local excision. If margins CLEAR, no further treatment needed.
If margins NOT CLEAR, re-excise or total mastectomy
Adjuvant therapy may be wanted, and can be given after surgery
Chemotherapy is considered in all masses > 1cm, or > 0.6cm with unfavorable
pathological features. Chemotherapy included anthracycline based
(CAF/FAC) or taxane based (FEC) therapy.
CAF= cyclophosphamide, doxorubicin, fluorouracil = FAC reversed!
FEC= fluourouracil, epirubicin, cyclophosphamide
Stage II = T0 N1 M0
T1 N1 M0
T2 N0 M0
T2 N1 M0
T3 N0 M0
Stage III
= T4 Nx M0
Tx N3 M0
Stage IV = Tx Nx M1
Ragarding type, the percentage of each type:
Infiltrating ductal carcinoma
80%
Infiltrating lobular carcinoma
10%
Paget’s disease
2%
Inflammatory carcinoma
2%
Male breast cancer
<1%
Others (papillary, medullary, mucinous, tubular) GENERALLY have better
prognosis
Sentinel lymph node mapping involves the injection of a radioactive dye and a blue dye
(1% lymphazurin), into the area of the neoplastic growth. A Geiger-counter probe then
can be used to establish the first lymph node to which this area drains, or the surgeon can
simply remove the blue node during surgery. Failure to observe the sentinel node occurs
in about 5% of patients. Also, contraindications include:
- prior surgery in the area that would change lymphatic flow (eg. Mastectomy)
- already believed to have cancer in the lymph nodes
- already received chemotherapy (causes tissue changes altering lymph flow)
- ideally, the SLNM is done before surgery to assure accurate map
CEA is carcinoembryonic antigen, and commonly used as a marker in colon cancer. It
can be immunohistostained, but it is not used yet in conjunction with sentinel lymph node
mapping in the colon. Sentinel lymph node mapping in the colon has been used with
limited success.
CEA-scan is a monoclonal antibody (to CEA) attached to radioactive technicium. It is
injected into a vein, and pictures taken several hours later, to locate metastases or tumor
cells. It is not considered a form of sentinel lymph node mapping.
The triple assessment for breast cancer includes:
1. History and clinical examination
2. Radiological imaging (mammogram/MRI)
3. Sample (by Fine needle aspiration OR by excision biopsy)
FNAC is reliable, although sometimes larger samples are needed by excisional biopsy.
2. Cholelithiasis
a. Gall-stones can be dissolved with bile salts therapy
b. Is a common cause of carcinoma of the gall-bladder
c. Acalculous cholecystitis is an auto-immune disease
d. Ascending cholangitis required emergency decompression of the
common bile duct
e. Alkaline phosphatase is not raised in obstructive jaundice
TTFTF
An alternative method of treating gallstone disease (to cholecystectomy) without
removing the gallbladder involves dissolving gallstones with drugs. Ingestion of bile
acids (ursodeoxycholic acid), for example, can dissolve some gallstones. Daily therapy
can dissolve tiny stones in 6 months; larger stones may take up to 1 to 2 years. The
success rate varies from about 80% for very small stones to less than 40% for large
stones, which are the most common. However, even if the stones are successfully
dissolved, half of the people so treated develop gallstones again within 5 years.
Gallbladder carcinoma is rare and almost always associated with gallstones. It is four
times more common in women than men, and 90% are adenocarcinomas, the remainder
being SCC. 5 year survival is less than 5%. It is often clinically indistinguishable from
gallstones, and only discovered at surgery.
Incidentally, Bile duct carcinoma is associated with chronic inflammation (primary
ascending cholangitis) which is associated with ulcerative colitis 75% of the time.
Acalculous cholecystitis is a severe illness that is a complication of various other medical
or surgical conditions. The condition causes approximately 5-10% of all cases of acute
cholecystitis and is usually associated with more serious morbidity and higher mortality
rates than calculous cholecystitis. It is most commonly observed in the setting of very ill
patients (eg, on mechanical ventilation, with sepsis or severe burn injuries, after severe
trauma). In addition, acalculous cholecystitis is associated with a higher incidence of
gangrene and perforation compared to calculous disease. The usual finding on imaging
studies is a distended acalculous gallbladder with thickened walls (>3-4 mm) with or
without pericholecystic fluid. Acalculous cholecystitis factors include:
- late HIV infection
- TPN (especially if long term)
- Sepsis
- Gallbladder dysmotility
Acalculous cholecystitis is more common in men, unlike calculous cholecystitis which is
more common in women.
Cholangitis is inflammation/infection of the bile duct, secondary to obstruction, most
commonly by stones. It is common but life threatening. The infecting organisms are
usually gram-negative bacilli (eg, E coli, Klebsiella, Pseudomonas, and Enterococcus).
The clinical picture is characterized by:
Charcot’s triad:
- fever
- jaundice
- RUQ pain
Reynold’s pentad:
- fever + jaundice + RUQ pain (Charcot’s triad)
AND
- mental confusion and hypotension
Reynold’s is more likely to indicate septicemia.
Patient management includes fluid resuscitation and antibiotics (Ampicillin, gentamicin
and metronidazole or ciprofloxacin) with biliary drainage (“decompression”) either short
term by percutaneous transhepatic drainage, or definitely by ERCP.
Obstructive jaundice causes raised alkaline phosphatase and smaller rise in AST.
3. Fractures
a. 1.5-2 litres of blood can be lost in a fracture of the femur
b. Bennett’s fracture involves the proximal end of the radius
c. The junction of the body at C7 and T1 should be visualized in every
suspected cervical trauma
d. Fractured ribs invariably cause pneumothorax
e. The leg is externally rotated in fractured neck of femur
TFTFT
The femur is very vascular and fractures can result in significant blood loss into the thigh.
Up to 40% of isolated fractures may require transfusion (thus I say true). Femoral
fracture patterns vary according to the direction of the force applied and the quantity of
force absorbed. A perpendicular force results in a transverse fracture pattern, an axial
force may injure the hip or knee, and rotational forces may cause spiral or oblique
fracture patterns. The amount of comminution present increases with the amount of
energy absorbed by the femur at the time of fracture. Most femoral diaphyseal fractures
are treated surgically with intramedullary nails or plate fixation. The goal of treatment is
reliable anatomic stabilization, allowing mobilization as soon as possible. Surgical
stabilization is also important for early extremity function, allowing both hip and knee
motion and strengthening. Injuries and fractures of the femoral shaft may have significant
short- and long-term effects on the hip and knee joints if alignment is not restored.
In 1882, Edward Hallaran Bennett, MD, described the fracture of the base of the first
metacarpal that bears his name. Unless properly recognized and treated, this intraarticular fracture subluxation may result in an unstable arthritic joint with secondary loss
of motion and pain. Because the thumb carpometacarpal (CMC) joint is critical for pinch
and opposition, this injury may severely affect function. Comminution (breaking into
small fragments) worsens prognosis significantly.
Incidentally, a Rolando fracture is similar to a Bennett fracture, different though
cause it has an intraarticular comminution
A “routine cervical spine series” includes:
- lateral cross table to top of T1
- AP of lower C spine
- AP of atlanto-axial joint
Simple rib fractures are the most common injury sustained following blunt chest trauma,
accounting for more than half of thoracic injuries from nonpenetrating trauma.
Approximately 10% of all patients admitted after blunt chest trauma have one or more rib
fractures. These fractures are rarely life-threatening in themselves but can be an external
marker of more severe visceral injury inside the abdomen and the chest. The most
common mechanism of injury for rib fractures in elderly persons is a fall from height or
from standing. In adults, motor vehicle accident is the most common mechanism. Youths
sustain rib fractures most often secondary to recreational and athletic activities. In one
study of patients with rib fractures, the mortality rate reached 12%; of these, 94% had
associated injuries and 32% had a hemothorax or a pneumothorax. More than half of all
patients required either operative or ICU management. Average blood loss per fractured
rib is reportedly 100-150 mL. Rib fractures may compromise ventilation by a variety of
mechanisms. Pain from rib fractures can cause respiratory splinting, resulting in
atelectasis and pneumonia. Multiple contiguous rib fractures (ie, flail chest) interfere with
normal costovertebral and diaphragmatic muscle excursion, potentially causing
ventilatory insufficiency. Fragments of fractured ribs can also act as penetrating objects
leading to the formation of a hemothorax or a pneumothorax.
Fractured neck of femur causes external rotation and leg shortening.
4. Abdominal aortic aneurysm (AAA)
a. Ultrasound can reliably measure the size and site of AAA
b. The risk of rupture is greater than 50% in a year if the size of the AAA is
greater than 6 cm
c. Renal failure is not a common complication of ruptured AAA repair
d. The mortality rate of ruptured AAA is 30%
e. AAA does not cause micro-embolisation
TFFFF
An aneurysm is a permanent localized dilatation of an artery to the extent that the artery
is 1.5x it’s normal diameter. A pseudo or false aneurysm is an expanding pulsating
hematoma in continuity with a vessel lumen. Causes include atherosclerosis, familial (CT
disorders), bacterial (mycotic) and syphilitic (thoracic aneurysm).
Symptoms: - back pain, lower limb ischemia, gross edema
On PFA aortic calcification
On U/S best way to detect and measure aneurysm size
On CT relationship between AAA and renal arteries
Angiography not routine for AAA, only done if concerns about lower limb, renal
and visceral disease
Mortality rate for ruptured AAA is about 85% (70% die before getting to hospital, and of
those who get to hospital, perioperative mortality=50%).
Median age of presentation is 65 for elective and 75 for emergency cases.
Presentation of AAA:
- 30% asymptomatic: Found incidentally on physical exam, xray, or most
commonly, AAA scan for another reason
- 20% symptomatic: pain in central abdomen, back, loin, groin. Thrombus may be
source of emboli to lower limbs. May become thrombosed and occluded.
May compress ureter, duodenum, IVC…
- 50% rupture: may rupture into retroperitoneum, peritoneal cavity, IVC
(aortocaval fistula)
The 30 day mortality for this procedure is about 5-8% elective, 10-20% emergency
symptomatic, 50% for ruptured AAA. The elective procedure is undertaken when the risk
of rupture is greater than the risk of surgery.
Generally, after repair, prognosis is good, with the patients experiencing a life expectancy
the same as the normal population. Thus, while renal failure may be a concern in the
acute phase, after successful repair it is not…So take your pick..
5. Fluid and electrolyte balance
a. Crystaloids should be used for resuscitation in hypovolemia
b. Short gut syndrome does not predispose to renal calculi
c. The value of 110 meq/L of sodium in plasma is within normal limits
d. A urine output of 0.1 mL/kg/hour in an adult patient is satisfactory
e. Insulin and glucose infusion may be used to treat hyperkalemia of 6.5
mEg/L
TTFFT
More of colloid gets into intravascular space, while crystalloid gets mostly into the
interstitial space (>2/3). Crystalloids include Hartmann’s (aka Ringer’s lactate) and
normal saline. In most cases the clinical differences between the two fluids may be
marginal. The patients own adaptive neuroendocrine systems senses fluid overload and,
with intact kidneys, will correct it. Moreover the lymphatic system also becomes a hero
of fluid abuse. They drain excessive fluid from the ISS, thus limiting fluid expansion
which would otherwise result in peripheral and pulmonary oedema. As expected, clinical
differences in the amount of peripheral oedema are accentuated with crystalloids
compared to colloids. Similarly, with pulmonary oedema, crystalloids cause greater
oedema and hypoxia. There is also a good evidence that increased leaky capillaries in the
lungs does not occur with sepsis and that it is more likely related to simple overexpansion
of the ISS by excessive crystalloid solution. However, using extreme end-points such as
mortality, some larger comparative studies favour crystalloids and other studies favour
colloids. A meta-analysis of colloid versus crystalloid studies in 1989 demonstrated that
pooled data from eight studies showed no difference. However, in the eight studies which
did not use mortality as an end-point, six showed colloids to be more efficacious, one
showed more benefit from crystalloids and one showed no difference. More recent metaanalysis studies have been similarly inconclusive. Some have clearly favoured crystalloid
therapy. In a Cochrane Review, there was no evidence that resuscitation with colloids
reduced the risk of death in patients with trauma, burns and following surgery. When
albumin was used as the colloid solutions, there was no overall benefit of that particular
colloid. The use of meta-analysis can be questioned as most studies do not use mortality
as the end-point. It seems obvious that we need more original research in this area rather
than attempting to match all trials with new statistics.
The average length of the adult human small intestine is approximately 600 cm, as
calculated from studies performed on cadavers. According to Lennard-Jones and to
Weser (1983), this figure ranges from 260-800 cm. Any disease, traumatic injury,
vascular accident, or other pathology that leaves less than 200 cm of viable small bowel
or results in a loss of 50% or more of the small intestine places the patient at risk for
developing short-bowel syndrome. The short-bowel syndrome is a disorder clinically
defined by malabsorption, diarrhea, steatorrhea, fluid and electrolyte disturbances, and
malnutrition. The final common etiologic factor in all causes of short-bowel syndrome is
the functional or anatomic loss of extensive segments of small intestine so that absorptive
capacity is severely compromised. Although resection of the colon alone typically does
not result in short-bowel syndrome, its presence or loss can be a critical factor in the
management of patients who lose significant amounts of small intestine.
There are a number of other problems which patients with SBS may develop. These
include: gastric hypersecretion, gastric emptying disorders, fluid and electrolyte losses,
malabsorption of vitamins, minerals and bile salts, oxylate hyperabsorption, and bacterial
overgrowth. Each of these problems demands close monitoring for deficiencies and a
fairly detailed analysis of patients with high stool outputs. Patients with diarrhea may
have a rapid transit time, however, a number of other etiologies must be addressed first
before placing the patient on an agent which slows motility (i.e., immodium or
loperamide). Chronic complications of SBS include gallstone formation. Up to 44% of
SBS patients will be found to develop gallstones. In general only symptomatic stones
ever require a cholecystectomy. Kidney stones are also frequent. This is most commonly
due to excess oxalate in the diet. Patients should have their urine screened for
hyperoxaluria, and if present need to be placed on an oxalate restricted diet.
Normal serum concentrations are as follows:
Sodium
135-145 mM
Chloride
98-106 mM
Potassium
3.5-5 mM
Albumin
35-50 g/L
Bicarbonate 22-30 mM
Calcium
2.2-2.7 mM
Glucose
4.5-5.5 mM
Urine output should be:
Adults 0.5-1.0 mL/kg/hour
Children 1.0-1.5 mL/kg/hour
Hyperkalemia is treated with: Calcium gluconate (protect heart), then insulin and
dextrose therapy to lower the potassium without rendering patient hypoglycemic.
6. Hernias
a. Irreducible hernias in children are treated by herniorraphy
b. Incisional hernias are more common after transverse than midline
incisions
c. Testicular atrophy may occur after inguinal hernia repair
d. Strangulation is more common in indirect than direct inguinal hernia
e. A Spigelian hernia is readily diagnosed with a herniogram
FFTTF
Excision of hernial sac = herniotomy
Tightening of deep ring and strengthening of posterior wall = herniorrhaphy
In children, hernias are treated by herniotomy in young children, and herniotomy and
herniorraphy in older children.
Incisional herniae occur after 3-5% of all abdominal operations, and midline vertical
incisions are the most often affected. Poor technique, wound infection, obesity and chest
infection are also predisposing factors.
Repair of inguinal hernias can cause the following side effects:
- pain (number one)
- hematoma (wound or scrotal)
- urinary retention
- wound infection
- testicular pain and swelling, which may  atrophy
Complications of hernias include:
- irreducibility
- obstruction (abdominal pain, vomiting, distension)
- strangulation
(venous congestion, then exudation of blood, compromise
of arterial blood flow, ischemia, then gangrene)
*In Richter’s hernia, only part of bowel wall circumference is included, so
strangulation can occur in absence of obstruction.
Strangulation of inguinal hernias occurs in 30% indirect inguinal hernias and 10% direct
inguinal hernias.
For curiosity sake:
Indirect hernia follows the tract through the inguinal canal. This results from a
persistent process vaginalis. The canal begins in the intra-abdominal cavity at the internal
inguinal ring, located approximately midway between the pubic symphysis and the
anterior iliac spine. The canal courses down along the inguinal ligament to the external
ring, located medial to the inferior epigastric arteries, subcutaneously and slightly above
the pubic tubercle. Contents of this hernia then follow the tract of the testicle down into
the scrotal sac.
Direct hernia occurs due to a defect or weakness in the transversalis fascia area of the
Hesselbach triangle. The triangle is defined inferiorly by the inguinal ligament, laterally
by the inferior epigastric arteries, and medially by the conjoined tendon.
Femoral hernia follows the tract below the inguinal ligament through the femoral canal.
The canal lies medial to the femoral vein and lateral to the lacunar (Gimbernat) ligament.
Because femoral hernias protrude through such a small defined space, they frequently
become incarcerated or strangulated.
Umbilical hernia occurs through the umbilical fibromuscular ring, which usually
obliterates by 2 years of age. Umbilical hernias are congenital in origin and are repaired if
they persist in children older than 2-4 years.
Richter hernia occurs when only the antimesenteric border of the bowel herniates
through the fascial defect.
A Richter hernia involves only a portion of the circumference of the bowel. As such, the
bowel may not be obstructed, even if the hernia is incarcerated or strangulated, and the
patient may not present with vomiting. Richter hernia can occur with any of the various
abdominal hernias and is particularly dangerous, as a portion of strangulated bowel may
be reduced unknowingly into the abdominal cavity, leading to perforation and peritonitis.
Incisional hernia occurs in 2-10% of all abdominal operations secondary to breakdown
of the fascial closure of prior surgery. Even after repair, recurrence rates approach 2045%.
Spigelian hernia This rare form of abdominal wall hernia occurs through a defect in the
spigelian fascia, which is defined by the lateral edge of the rectus muscle at the semilunar
line (costal arch to the pubic tubercle).
Obturator hernia This hernia passes through the obturator foramen, following the path
of the obturator nerves and muscles. Obturator hernias occur with a female-to-male ratio
of 6:1, because of a gender-specific larger canal diameter. Because of its anatomic
position, this hernia presents more commonly as a bowel obstruction than as a protrusion
of bowel contents.
Reducible hernia This term refers to the ability to return the contents of the hernia into
the abdominal cavity, either spontaneously or manually.
Incarcerated hernia An incarcerated hernia is no longer reducible. The vascular supply
of the bowel is not compromised. Bowel obstruction is common.
Strangulated hernia A strangulated hernia occurs when the vascular supply of the bowel
is compromised secondary to incarceration of hernia contents.
There appears to be a lot of controversy about herniograms-while several places in the
US still use them, especially in athletes for sports hernias, they haven’t gained
widespread acceptance in the UK. Some studies show they have low sensitivity while
others show the opposite. For Spigelian hernias (defect in lateral edge of rectus allows
abdominal wall to herniate out), the hernia is most often small, meaning obstruction is
less common but strangulation is common. They must be repaired. I’d say no to this
given the fact that they are so small and the sensitivity of herniography is suspect.
7. Paediatrics
a. 95% of umbilical hernias in children younger than 5 years do not need
surgery
b. Pyloric stenosis commonly occurs between ages of 5-10
c. An undescended testicle may be found in the hilum of the spleen
d. Recurrence of intusussception is common in the first few days after
reduction
e. Mesenteric adenitis is an uncommon cause of abdominal pain in
children
TFFTF
An umbilical hernia in an infant is caused by the incomplete closure of the umbilical ring
(muscle), through which the umbilical blood vessels passed to provide nourishment to the
developing fetus. The hernia generally appears as a soft swelling beneath the skin that
often protrudes when the infant is upright, crying, or straining. Depending on the severity
of the hernia, the area of the defect can vary in size, from less than 1 to more than 5
centimeters in diameter. Small (less than 1 cm) hernias usually close spontaneously
without treatment by age 3 to 4 years. Those that do not close may require surgery.
Umbilical hernias are usually painless. Umbilical hernias are common in infants. The
exact incidence is unknown, but may be as high as 1 in 6 infants. Umbilical hernias occur
slightly more frequently in infants of African American descent. The vast majority of
umbilical hernias are not related to any disease condition. However, umbilical hernias can
be associated with rare diseases, such as mucopolysaccharide storage diseases, BeckwithWiedemann syndrome, Down syndrome, and others. 90% close within 3 years, according
to Wikepedia. Thus I’d say this is close enough to True.
Pyloric stenosis presents usually between 2 and 7 weeks of age.
A testis absent from the normal scrotal position may be found in:
1. The “path of descent” from the kidney to the inguinal ring
2. Inguinal canal
3. Ectopic, meaning wandered slightly from path of descent, most commonly in
the skin of thigh, perineum, femoral canal
4. Undeveloped or severely abnormal of vanished
Recurrence of intussusception varies from 5 to 20% depending on the technique of
reduction used. Pneumatic reduction has a recurrence rate of 3-4% within 24 hours after
the technique, and all children with intussusception have an approximately 10%
recurrence rate regardless of reduction technique.
Mesenteric adenitis is found in about 10% of patients in whom appendicitis is also found;
thus, it is common!
8. Salivary glands
a. Pleomorphic adenoma is the commonest benign tumour of the parotid
gland
b. Incisional biopsy is performed in all salivary gland tumours
c. Frey’s syndrome is common after submandibular gland surgery
d. Lymphomas do occur in the parotid gland because embryologically the
gland grows enclosing the lymphatic tissue in it
e. The lingual nerve can be damaged in surgery on the submandibular
gland
TFFTT
A mass in the parotid gland is most often a pleomorphic adenoma (90%), followed by
Warthin’s tumor (cystic lymphoepithelial lesion), or hemangioma. Malignant masses may
be malignant pleomorphic adenoma, adenoid cystic carcinoma, acinic cell tumours,
lymphoma, SCC.
Treatment of salivary gland tumors is gland excision (parotidectomy, etc).
Frey’s syndrome is characterized by warmth and sweating in the malar region of the face
on eating or thinking or talking about food, brought on by eating foods that produce a
strong salivary stimulus. It may follow damage in the parotid region by trauma, mumps,
purulent infection or parotidectomy. It is thought that autonomous fibres to salivary
glands have become connected in error with the sweat glands when they become
reconnected after the damage which originally caused their connection to be interrupted.
Flushing prevalent in females, sweating in males. It can persist for life. Some cases are
congenital and probably due to birth trauma. It is also known as Baillarger’s syndrome
Dupuy’s syndrome, or Frey-Baillarger syndrome.
As salivary glands grow, they do enclose lymphoid tissue within it, that can
develop lymphoma later on in life.
Submandibular gland excision can damage the marginal mandibular branch of facial
nerve or the lingual nerve.
9. Trauma
a. A flail chest is commonly associated with ARDS
b. U/S is gold standard in diagnosis of ruptured thoracic aorta
c. Liver is the solid organ most often injured in blunt abdominal trauma
d. Right diaphragmatic rupture is more common than left
e. Esophageal rupture in the neck is diagnosed by Gastrograffin swallow
in more than 90% of cases
TTFFF
Flail chest is traditionally described as the paradoxical movement of a segment of chest
wall caused by fractures of 3 or more ribs anteriorly and posteriorly within each rib.
Variations include posterior flail segments, anterior flail segments, and flail including the
sternum with ribs on both sides of the thoracic cage fractured. Flail chest is foremost a
clinical finding and observation that is often accompanied by physiologic derangements,
which are sometimes globally lumped into the diagnosis. Flail chest requires significant
blunt force trauma to the torso to fracture the ribs in multiple areas. Such trauma may be
caused by motor vehicle accidents, falls, and assaults in younger, healthy patients. Flail
chest is an indicator of significant kinetic force to the chest wall and rib cage but also
may occur with lesser trauma in persons with underlying pathology, including
osteoporosis, total sternectomy, and multiple myeloma. Death from flail chest is often
associated with pneumonia and ARDS, since many will need to be on respiratory support
in ICU, and we all remember that ICU and ARDS are like toast and jam!
Ultrasound is best for infrarenal AAA (~70%). Thoracic aorta aneurysms are best seen by
CT (with or without contrast).
In blunt abdominal trauma, the liver and spleen seem the most frequently injured organs,
although reports vary. Small and large intestines are the next most injured organs,
respectively. Recent studies show an increased number of hepatic injuries, perhaps
reflecting increased use of CT scanning and concomitant identification of more injuries.
Acute diaphragmatic rupture occurs in 1% to 7% of patients after major blunt trauma and
the diagnosis is missed on initial presentation in up to 66% of these patients. It is at least
8 times more common in the left than in the right. This is because the left side is weaker
congenitally.
Esophageal rupture occurs secondary to iatrogenic causes (endoscopy) 50%, trauma 33%,
or spontaneously 10%. It is also known as Boorhaave syndrome. Symptomatically, it
causes pain, vomiting, fever, hematemesis, subcutaneous emphysema, dyspnea. It is
diagnosed on the basis of the history, and urgent posteroanterior and lateral chest and
upright abdominal x-ray films are diagnostic in 90% of cases. Gastrografin (water-soluble
contrast) and/or barium esophagram following plain radiography may be performed to
look for extravasation of contrast and location and extent of rupture/tear, however this
has a false negative rate of about 10% in distal and 40-60% in proximal/cervical
perforations. If sufficient clinical suspicion is had, a barium swallow may be needed, as
smaller leaks can be found, and the false negative rate is much lower.
10. Pancreatitis
a. Raised CRP is a specific test in diagnosis of acute pancreatitis
b. U/S examination would show a stone in the lower end of the CBD in
>80% of cases
c. A pseudocyst should be drained within 2 weeks of acute attack
d. The treatment of sterile necrotizing pancreatitis is always surgery
e. Pancreatitis can be reliably diagnosed in a patient if serum amylase is
more than 1000 units per liter.
FFFFT
Causes of pancreatitis (acute) include “GET SMASHED”
Gallstones (50%)
Ethanol (20-30%)
Trauma (5% : includes idiopathic, blunt or penetrating injury)
Steroids
Mumps
Autoimmune (PAN)
Scorpion bites
Hyperlipidemia, Hypercalcemia, and Hypothermia
ERCP or Emboli
Drugs (diuretics, azathioprine, mercaptopurine)
Idiopathic 20%
Tests in pancreatitis are serum amylase (> 1000 is considered diagnostic, but this falls
within 1st 48 hours, so urinary amylase or serum lipase are better indicators). CRP can be
a helpful marker, but it is not specific for acute pancreatitis.
A pancreatic pseudocyst is a collection of amylase-rich, lipase-rich, and enterokinase-rich
fluid. It is most frequently located in the lesser peritoneal sac in proximity to the
pancreas. Large pseudocysts can extend into the paracolic gutters; pelvis; mediastinum;
and, rarely, to the neck or scrotum. Some pseudocysts in the pancreatic parenchyma are
loculated. The most common etiologies for pancreatic pseudocysts include chronic
pancreatitis, acute pancreatitis, and pancreatic trauma. In addition, pseudocysts are
associated with pancreatic ductal obstruction and pancreatic neoplasms. The imaging
modality of choice is abdominal CT. The major weakness of CT scanning is the relative
inability to distinguish pseudocyst from cystic neoplasms, especially mucinous
cystadenomas and intraductal papillary mucinous tumors (IPMT). If the patient has had
no prior history of pancreatitis yet has a cystic mass associated with the pancreas, an
alternative diagnosis should be entertained. Controversy exists over the optimal timing
for treatment of pancreatic pseudocysts. Authors advocating conservative therapy and
observation state that the old rule dictating intervention on all pseudocysts larger than 6
cm that have been present for longer than 6 weeks is not founded on solid scientific data.
However, the complication rates associated with pancreatic pseudocysts are, in fact,
positively correlated with the duration of the cyst's presence. Percutaneous or surgical
drainage can be done, and surgical drainage is associated with lower rates of recurrence.
A paper from Journal of the Pancreas 2000: neither the presence nor extent of pancreatic
necrosis constitutes an absolute indication for surgical intervention. Subsequently, a
number of prospective studies from other centers also supported the value of nonoperative therapy in sterile pancreatic necrosis. While these efforts have established
beyond doubt that non-operative management of sterile pancreatic necrosis can be
successful in 90-95% of those cases remaining persistently sterile, there remains the
possibility that smaller subgroups of patients with sterile necrosis can be benefited by
surgical debridement. In particular, patients who develop "re-feeding" pancreatitis,
characterized by abdominal pain and hyperamylasemia six to eight weeks following
recovery from a bout of severe sterile necrotizing pancreatitis, can be restored by
debridement of the necrotic tissues. The pathophysiologic mechanism appears to be one
of obstruction of the pancreatic duct secondary to the necrotic process. Other small subgroups of patients with sterile necrosis, who might be improved by debridement, are
being sought. On balance, however, it now seems quite clear that surgical debridement in
sterile pancreatic necrosis will be the exception, rather than the rule.
Incidentally, the GLASGOW criteria for acute pancreatitis, giving an idea of the
prognosis of the condition (Ranson validated for alcohol only, Glasgow for alcohol and
gallstones), include: “PANCREAS”
PO2 < 8 kPa
Age > 55
Neutrophils > 15E9/L
Calcium < 2mM
Renal function: urea > 16mM
Enzymes LDH>600 and AST>200
Albumin < 32 g/L (normal 35-50)
Sugar: blood glucose > 10mM (normal 4.5-5.5 fasting)
11. Anemia
a. Cecal carcinoma commonly presents with microcytic hypochromic
anemia
b. Resection of the terminal ileum may cause megaloblastic anemia
c. Total gastrectomy is not associated with Vitamin B12 deficiency
d. The cause of anemia in chronic disease is multi-factorial
e. Mastectomy is a major cause of iron deficiency anemia in surgical
practice
TTFTF
Presentations of colorectal cancers include:
Location
Presentation
Elective Tx
Cecal + right side
Anemia (bleeding) R. hemicolectomy
RIF mass (can rarely cause SBO)
Emergency Tx
R. hemicolectomy
Left and sigmoid
Altered bowel habit
Altered blood PR
1/3 LBO
L/Sigmoid
hemicolectomy
Hartmann’s procedure
Rectal
Altered bowel habit
Fresh blood PR
Mucus PR
Mass PR
Tenesmus
Anterior resection or APR
APR= Abdominoperineal resection of rectum
The bleeding in cecal Ca can lead to iron deficiency and thus hypochromic microcytic
anemia. It is one of the many causes of iron-therapy non-responsive microcytic
hypochromic anemia.
Terminal ileum is where intrinsic factor bound B12 is absorbed. No terminal ileum
decreased B12 absorption  megaloblastic anemia
Total gastrectomy causes parietal cell deficiency, causing no instrinsic factor to bind B12,
means no B12 absorbed and thus deficiency.
Chronic disease anemia is caused by:
1. Transferrin is an acute phase reactant used in chronic inflammation for
processes other than carrying iron, so iron deficiency ensues.
2. Chronic raise in cytokines, especially interleukin 1, inhibits erythropoiesis
3. premature destruction of rbc because of their increased fragility as a result of
going through diseased and inflamed tissues.
4. Some cause raised EPO, some (eg. Renal disease) are associated with lower
EPO.
Regarding mastectomy and iron deficiency anemia, I can’t see how this is possibly true
unless women have a storage of iron in their breast I don’t know about.
12. Nutrition
a. Parenteral nutrition is superior to enteral nutrition
b. Parenteral nutrition can cause derangements in liver function tests
c. In a septic patient, the brain uses fat as its energy source
d. TNF may be responsible for protein catabolism in a very sick patient
e. Parenteral nutrition is usually indicated in a healthy patient undergoing
major abdominal surgery
FTFTF
Enteral nutrition is safer, cheaper, and at least as efficacious.
TPN is normally used following surgery, when feeding by mouth or using the gut is not
possible, when a person's digestive system cannot absorb nutrients due to chronic disease,
or, alternatively, if a person's nutrient requirement cannot be met by enteral feeding (tube
feeding) and supplementation. It has been used for comatose patients, although enteral
feeding is usually preferable, and less prone to complications. Short-term TPN may be
used if a person's digestive system has shut down (for instance by Peritonitis), and they
are at a low enough weight to cause concerns about nutrition during an extended hospital
stay. Long-term TPN is occasionally used to treat people suffering the extended
consequences of an accident or surgery. Chronic TPN is performed through a Hickman
line or a Port-a-Cath (venous access systems). In infants, sometimes the umbilical artery
is used. The most common complication of TPN use is bacterial infection, usually due to
the increased infection risk from having an indwelling central venous catheter. Liver
failure may sometimes occur; a recent study at Children's Hospital Boston on the cause
suggests it is due to a large difference in omega-6 to omega-3 ratio. When treated with a
different fatty acid infusion (which is not approved for use in the U.S.) two patients were
able to recover from their condition.
Complications include sepsis (commonly from skin eg. Staph, Candida), thrombosis (add
heparin to nutrient solution), metabolic disturbance (K+, Mg++, Zn++, glucose),
mechanical (pneumothorax). Transient changes in serum lipids and LFTs are common.
Protein catabolism can occur due to many factors in a very sick patient, including
starvation or chronic inflammation, of which TNF is a common culprit.
Parenteral nutrition is usually NOT indicated in young patient with major abdominal
surgery, unless he will be unable to eat for at least 7 days. Even then, it is avoided as long
as possible.
13. Gastrointestinal
a. A pressure of 100 mmHg is needed in the esophageal balloon of
Minnesota tube to control bleeding from esophageal varices
b. Mallory-Weiss syndrome is associated with vomiting
c. Bleeding from a duodenal ulcer is usually from the gastro-duodenal
artery
d. An unstable patient, despite adequate fluid resuscitation, requires
emergency surgical intervention
e. A high output enterocutaneous fistula is defined as a fistula with output
of 100-200 mL in 24 hours
FTTFF
The Minnesota tube to control bleeding for esophageal varices can also be used for
bleeding gastric ulcers. IT is inserted and then marked externally to make sure it doesn’t
move once it has been inflated in the desired position. Even if the esophagus is the source
of bleeding, the gastric balloon is filled first to prevent migration of the esophageal
balloon causing upper airways obstruction. So:
1. Inflate gastric balloon to 70-80 mm Hg
2. Inflate esophageal balloon to 25-45 mm Hg
3. Reduce esophageal balloon pressure 5 mm Hg every 3 hours until 25 mm Hg
is reached. If no bleeding is present, maintain esophageal balloon placement
for 12 hours.
Mallory-Weiss syndrome is an esophageal tear associated with vomiting and
hematemesis. Other causes of hematemesis include gastritis, gastric carcinoma, gastric
ulcer, esophageal varices, esophagitis, esophageal carcinoma, duodenal ulceration,
angiodysplasia, Diuelafoy’s lesion. “Pseudo” or “apparent” hematemesis or hemoptysis
can occur with bleeding in the nasopharyngeal area.
The duodenum has four parts. The first part runs from the pyloric outlet to 5 cm distal. It
is the most common location for peptic ulceration to occur, and it is supplied by the
gastroduodenal artery.
Incidentally, the blood supply for the stomach arises from the splenic artery (left
gastroepiploic), common hepatic artery ( right gastric), left gastric (directly off of
celiac trunk) and gastroduodenal ( superior pancreaticoduodenal artery and right
gastroepiploic) arteries.
The duodenum receives the gastroduodenal artery, the superior
pancreaticoduodenal artery (from SMA) and inferior pancreaticoduodenal artery (from
SMA).
The adequate fluid resuscitation is a prerequisite for most abdominal surgeries, but
whether emergency intervention is needed after fluid resuscitation is largely dependent
on the reason surgery may or may not be needed.
A high output fistula is defined as one with output >500mL/day.
14. Oesophagus
a. Plummer Vinson syndrome predisposes to esophageal cancer
b. Failure of relaxation of the esophageal sphincter is characteristic of
achalasia
c. 90% of hiatus hernias are associated with reflux esophagitis
d. Severe dyspepsia in reflux disease is an indication for surgery
e. The overall 5 year survival rate of carcinoma of the esophagus is more
than 80%
TTFTF
Esophageal cancer risk factors:
- reflux (adenoCa)
- obesity
- alcohol (SCC)
- smoking
- leukoplakia
- achalasia
- chewing tobacco
- Betel nuts
- salted fish or pickled vegetables
- Plummer-Vinson syndrome
Achalasia is the failure of the lower esophageal sphincter to relax.
Hiatus hernias can be of two main types:
Sliding: stomach slides through diaphragmatic hiatus, so GE junction lies in chest cavity.
Paraesophageal: stomach rolls up anteriorly through hiatus, but cardia remains in
position, the GE junction remains intact.
Weakness of the muscles around the hiatus causes both types, and they are more common
in the obese, and in women.
Clinical features of sliding hiatus hernias:
- heartburn and regurgitation (worse laying flat, better with antacids)
- esophagitis from acid reflux ulceration, anemia, fibrosis, stricture formation
- epigastric and lower chest pain
Confirm diagnosis by barium swallow and meal.
Treatment of sliding= as for reflux (thus, surgery MAY be indicated in severe reflux; Do
a Nissen fundoplication or a Mark IV procedure (270 degree turn + repair R and L
crura)
Treatment of paraesophageal= surgery since risk of strangulation.
Most hiatus hernias are asymptomatic, though the most common symptom is esophagitis.
Esophageal cancer prognosis is awful, at less than 5% over 5 years.
15. Endocrine
a. Cervical lymph nodes are usually involved at the time of diagnosis of
medullary carcinoma of the thyroid
b. Phaeochromocytoma is associated with renal artery stenosis
c. Parathyroid adenoma is the most likely cause of hyperparathyroidism
d. Total thyroidectomy is indicated in follicular carcinoma of the thyroid
gland
e. Recurrent laryngeal nerve is damaged in >15% of cases in thyroid
surgery
TTTTF
The major cause (>90%) of hyperparathyroidism is parathyroid adenoma. Secondary and
tertiary hyperparathyroidism are both much less common.
The three conditions that cause hyperthyroidism are Graves, toxic multinodular goiter
and toxic adenoma.
Thyroid neoplasms can be:
Neoplasm type
% Total
Method of spread Prognosis
Papillary
50
lymph
90% 10 year survival
Treatment = total thyroidectomy (often multifocal)
Follicular
30
hematogenous
50% 10 year survival
Treatment = total thyroidectomy (preserve parathyroids)
Anaplastic
10
local+lymph+blood death within 6 months
Treatment = resection rarely possible. Chemo and radiation palliative only
Medullary
5
May be aggressive or very mild
Associated with MEN II syndrome, calcitonin elevated
Ret oncogene involved and prophylactic thyroidectomy may be required
Cervical lymph node involvement 50% at presentation
Treatment = total thyroidectomy + lymph node dissection
Lymphoma
5
Usually associated with autoimmune thyroiditis
Treatment = radiotherapy and chemotherapy
Phaeochromocytomas are tumours of the adrenal medulla (90%) that secrete large
amounts of adrenaline and noradrenaline.
- 10% multiple
- 10% malignant
- 10% extra-adrenal
- 10% genetic (either MEN-2 or VonHippel Lindau)
Causes HTN (paroxysmal) precipitated by exercise, pressure or postural change.
Headache, palpitation, sweating, extreme anxiety, chest and abdominal pain.
Phaeochromocytomas are associated with neurofibromatosis, MEN2, duodenal ulcers and
renal artery stenosis.
Thyroidectomy is done by:
- expose gland through transverse incision 3 cm above sternal notch
- divide fascia and separate strap muscles
- divide middle and inferior thyroid veins
- identify and protect recurrent laryngeal nerves
- preserve parathyroids if possible
Complications of thyroidectomy include:
1. haemmorrage (assure meticulous hemostasis): can  compression of thoracic
inlet venous engorgement tracheal compression asphyxia
2. hoarseness - nerve damage- superior laryngeal nerve
- recurrent laryngeal nerve: temporary paralysis in 5%, recovery
within 3 months is rule (cause is traction or bruising)
For medicolegal reasons, cords should be photographed
before+after thyroidectomy.
3. hypothyroidism (standard dose is 100 ug thyroxine daily)
4. hypoparathyroidism
16. Diverticular disease
a. The most common cause of major bleeding per rectum is diverticular
disease of the colon
b. Surgery is indicated in more than 50% of patients with diverticular
disease
c. Diverticulitis is never associated with pseudopolyps
d. Diverticular disease is associated with severe perianal disease
e. The treatment of diverticular disease is oral steroids
TFFFF
Most patients with diverticulitis are asymptomatic and thus will not require surgery.
Diverticular disease can be congenital rarely (colonic diverticular disease), and if this
becomes obstructed by a fecolith and inflamed, it may present like appendicitis. Colonic
(acquired) diverticular disease is far more common and rare by 35, but by 65 about 1/3 of
the population is affected. Diverticulae emerge between the taenia coli, by herniation of
mucosa through the circular muscle at the sites of penetrating blood vessels.
SIMPLE disease:
Presentation intermittent lower abdominal and left iliac fossa
pain, altered bowel habit, minor rectal bleeding.
Treatment: high fibre diet, stimulant laxatives. Sigmoid colectomy
with primary anastomoses may be indicated.
COMPLICATED:
- inflammation (abscess)
- intestinal obstruction (stricture, adherent bowel loops)
- perforation (purulent or fecal peritonitis)
- fistula formation (colovesical, colevaginal, enterocolic, cutaneous)
- bleeding (massive lower GI bleed or chronic intermittent blood loss)
The causes of major lower GI bleeding are: - diverticular disease 33%
- angiodysplasia #2
Treatment of diverticular disease is:
Type of diverticular disease
Treatment
Painful or asymptomatic
high fibre diet and increased fluid intake
Acute diverticulitis
Antibiotics, bed rest, drainage of abscesses
Surgery may be needed for complicated disease, or peritonitis, or recurrences, or fistulae,
or perforations…ie. The complications are associated with morbidity/mortality.
17. Skin
a. SCC is resistant to radiotherapy
b. BCC metastasizes in 15-20% cases
c. Prognosis of nodular type of malignant melanoma is worse than
superficial spreading
d. Depth of skin involvement in melanoma may predict the state of distant
metastases
e. Melanoma is more common in the white population of Australia and
New Zealand as compared to their European counterparts
FFTFT
BCC= hard pearly nodule, dimpled in center, covered in telangiectasia. May be cystic,
nodular, sclerosing. Never metastasizes but locally very invasive (“rodent ulcer”).
Surgical excision and radiotherapy are treatments of choice.
SCC= particularly sun exposed areas. Hard erythematous nodule cauliflower like
excrescence or ulcerates to form malignant ulcer with raised fixed hard edge. Treatment
is surgery or radiation or both. Regional lymphadenectomy.
MM= predominantly in fair skinned people, with sun exposure being major precipitant.
Most common in Australia where there is sun and white people, as opposed to Europe,
where white people have less sun! Of all MM, 50% arise in preexisting naevus. MM
spreads rapidly by lymphatics and bloodstream.
Types include
MM type
% total
Superficial spreading 60%
Nodular
25%
Lentigo maligna
10%
Acral lentiginous
5%
Prognosis
Best prognosis
Most aggressive
Notes
Ulcerate+bleed with growth
May be amelanocytic
On palms, subungual, plantar
Sentinel node status is single most important prognostic factor for recurrence+survival.
The depth of melanoma can not predict whether lymph nodes are involved. Sentinel node
mapping is used for this purpose.
Use Breslow thickness to establish stage. The ABCDE checklist has 92% sensitivity and
100% specificity.
A
Asymmetry
B
Border (irregular)
C
Color (varied)
D
Diameter (>6mm)
E
Enlargement, elevation
Treatment= excisional biopsy + lymph node dissection
Chemotherapy high dose IFN, BCG, cis-platinum not great results.
Radiotherapy curative for uveal melanomas, palliative for bone and brain mets.
18. Vascular
a. Rest pain in peripheral vascular disease is an indication for surgical
intervention
b. Necrotic changes in the diabetic foot are never worse than perceived on
inspection
c. Short vascular stenotic segment in iliac vessels are not amenable to
angioplasty
d. The most common cause of TIAs and stroke in carotid disease is
complete occlusion of the carotid vessel
e. Varicose ulcers are treated by femoral popliteal bypass graft procedure
TFFFF
Always check peripheral pulses on all arteriopaths.
Ankle:brachial pressure index:
- should be 1 in healthy
- Int Claud 0.5-0.9
- Critical limb ischemia <0.5
Of all middle aged men, 5% have intermittent claudication, and of those who comply to
best medical therapy, only 1-2% per year require amputation or revascularization.
Without revascularization, patients with critical limb ischemia will lose their limb in a
matter of weeks or months.
Diabetic foot: - sensory neuropathy. Because of this, diabetic patients are unaware
(can’t perceive) of pain and thus present late. Contributes to
aetiology of Charcot’s joints
- motor neuropathy: affects the flexors more than the extensors, meaning
the toes are hyperextended, increasing pressure on metatarsal heads.
- autonomic neuropathy: dry foot deficient in sweat scaling and fissuring of
skin+ entry of bacteria.
About 80% of strokes are ischemic, and about half of these are thought to be due to
atheroembolism from carotid bifurcation. In general, the tighter the degree of stenosis,
the more likely the plaque is to rupture and embolize. However, if the lumen is
completely thrombosed, emboli do not occur and thus CEA (carotid end arterectomy) is
contraindicated. If emboli enter the ophthalmic artery amaurosis fugax.
The presence of carotid bruit bears no relationship to the severity of underlying
ICA disease or risk of stroke. Such a bruit may arise from ECA or the blood flow to ICA
may be so slow to make audible turbulence impossible.
Only a small proportion of patients with varicose veins go on to develop chronic venous
insufficiency and its complications (leg ulcers, haemorrage, thrombophlebitis). Clinical
features include cosmetically disconcerting, dull aching leg pain and heaviness worse in
evening or standing long-time, itch/eczema, superficial thrombophlebitis, bleeding,
ulceration or saphena varix. Management includes:
- limb elevation
- wear support socks
- injection sclerotherapy (Sodium tetradecyl) - surgical ablation
Varicose ulcers are treated by compression sclerotherapy
19. Colorectal carcinoma
a. More than 90% of colorectal cancer arises from adenomatous polyps
b. Chemotherapy is administered as an adjuvant therapy for Duke A
carcinoma
c. Liver metastases in colorectal cancer cannot be treated surgically
d. Colorectal cancer is one of the commonest cancers in the western world
e. Colonoscopy is a reliable diagnostic tool in expert hand in 95% of cases
for colorectal cancer
FFTTT
Polyps can be classified by type:
Type polyp
Solitary
Neoplastic
Adenoma
Hamartomatous
Peutz-Jeghers
Inflammatory
Benign lymphoid polyp
Unclassified
Metaplastic
Adenomas can be classified into:
Adenomatous polyps:
Villous polyps
Multiple
FAP
Peutz-Jeghers syndrome
Benign lymphoid polyposis
Multiple metaplastic polyps
- 90% large bowel polyps
- 5% risk of malignancy if >1cm
- 10% large bowel polyps
- most often rectosigmoid
- 1/3 go to malignancy
Villous polyps give rise to Ca more frequently than do adenomatous polyps
FAP
- chromosome 5 defect
- rectal and colonic polyps in childhood
- 100% risk of malignant transformation
Liver metastases cant be treated surgically…True…This implies Dukes D or Stage 4,
which is palliative, meaning surgery only on bowel (none additional to increase
morbidity).
Remember the staging of CRC:
Dukes
A
invasion of submucosa
B
invasion of muscularis propria
C
involves lymph nodes
D
involves metastases
OR TNM system
Tx
can’t be assessed
Tis
in situ
T1
invades submucosa
T2
invades muscularis propria
T3
invades perirectal tissues or serosa
T4
perforates peritoneum or invades adjacent organs
Nx
N1
N2
N3
can’t be assessed
1-3 pericolic or perirectal nodes
>4 pericolic or perirectal nodes
any node along named vascular trunk
Mx
M0
M1
can’t be assessed
No mets
Distant mets
Modified Astler-Coller system
Dukes A
submucosa
Dukes B1
muscularis propria
Dukes B2
subserosa fat
Dukes B3
adjacent organs
Dukes C1
B1 + nodes
Dukes C2
B2 + nodes
Dukes C3
B3 + nodes
Dukes D
mets
Stage A/B1
Stage B2
Stage B3/C
Stage D
(T1, N0, M0)
(T2, N0, M0)
(T3, N0, M0)
(T4, N0, M0)
(T2, N1-2, M0)
(T3, N1-2, M0)
(T4, N1-2, M0)
(Tx, Nx, M1)
90%
75%
50%
25%
Treatment of Dukes A, B1  surgery
Treatment of Dukes B2, B3, Csurgery + chemotherapy
Treatment of Dukes D
 surgery + chemotherapy + radiation + palliation
Colonoscopy is 91% sensitive in any source I could find. Close enough to 95%...
20. Urology, Thoracic and Neurosurgery
a. The most common tumour of the bladder is adenocarcinoma
b. 90% of renal stones are radiolucent
c. A thoracostomy tube is usually inserted in the fourth or fifth intercostal
space in the mid-axillary line for the treatment of pneumothorax
d. Thoracoscopic sympathectomy is a treatment of hyperhydrosis of the feet
e. CT scan of brain is indicated in depressed skull fracture
FFTTT
Bladder tumours presents with painless intermittent hematuria (95%), dysuria or
frequency (10%). Prognosis for superficial tumors is good (75% 5 year survival)
while for invasive tumours is poor (10% 5 year survival). Almost all bladder tumours
are transitional cell carcinomas. Squamous carcinomas occurs in urothelium that has
undergone metaplasia (chronic inflammation from stone). Adenocarcinomas are even
more rare, and occur in urachal remnamnts in trigone.
Renal calculi:
- oxalate
- phosphate
- urate
- cystine
60%
30%
5%
1%
Causes include hypercalciuria, reduced inhibition theory, dehydration, infection
(Proteus, Klebsiella, Schistosomiasis). While some stones can’t be seen on PFA, 90%
are radio-opaque (Surgery at a Glance), thus only about 10% are radiolucent.
In order to perform a thoracostomy, sedate the patient. Locate the fifth or sixth
intercostal space (i.e. space between the 5th and 6th or 6th and 7th ribs) along the
mid-axillary line. Make an incision of 3cm length over the 5th or 6th rib along the
linea axillaris media.After using a curved haemostat to dissect through the soft tissue
all the way down to the rib, push the haemostat over the superior part of the rib avoiding contact with the intercostal neurovascular bundle that is right underneath the
inferior aspect of the next higher rib - and puncture the intercostal muscles and
parietal pleura. Hold the puncture open by placing your finger alongside the
haemostat while removing the haemostat. Keep your finger in place to facilitate
insertion of the chest tube. A clamp may be used to steady the tube at the proximal
(closest to the insertion point) end. If the tube has been properly placed, it will fog up
as it fills with the air from the pleural cavity. Now that the tube has been inserted into
the pleural cavity, it must be hooked up to an external underwater seal and suction
device (e.g. Pleur-Evac ®). After connecting to external suction, the tube must be
sutured and taped to hold it in place. Then, confirm lung re-expansion
radiographically.
The initial treatment for hyperhidrosis is usually medical and does not involve surgery.
There are ointments and salves available (i.e., Drysol) that are astringents that tend to dry
up the sweat glands. Another treatment is iontopheresis. This consists of a treatment of
electrical stimulation, usually in the hands. Patients place their hands in a bath through
which an electrical current is passed. This treatment tends to "stun" the sweat glands and
can decrease the secretion of sweat for periods of 6 hours to one week. One of the most
recent treatments proposed is the injection of botulinum toxin (Botox) into the area of
excessive sweating. This is a toxin that affects nerve endings and decreases the
transmission of the nerve impulses to the sweat glands thus resulting in decreased
sweating. It generally requires several injections in the palms or underarms and it remains
effective from one to six months. Repeated injections are nearly always required to
maintain an adequate level of dryness. In addition to the above treatments, many
medicines have been utilized with varying success. These include both sedatives (in those
patients with stress-induced hyperhidrosis) and medications that affect the nervous
system. The surgical treatment of hyperhidrosis involves destroying or removing a
specific portion of the main sympathetic nerve. In order to treat palmar (hand)
hyperhidrosis, the T2 ganglion is removed or destroyed. Many surgeons will also remove
the third ganglion to maximize the chance of completely preventing sweating of the
hands. In order to treat the armpit, the second and third ganglia are removed or destroyed.
Similarly, some surgeons will also destroy the fourth ganglion to once again maximize
complete relief from armpit sweating.
Skull Xray is insufficient in suspected fractures. A CT is essential.
21. In primary hyperparathyroidism
a. Most patients present with urinary tract calculi
b. Serum calcium is always higher than normal
c. PTH is usually within normal limits
d. Chloride:Phosphate ratio is higher than normal
FFFT
Primary hyperparathyroidism:
Presentation: 50% asymptomatic with hypercalcemia
- renal calculi (~20% get)
- neuromuscular disease, decreased bone density
While hypercalcemia is often present, it need not be.
PTH is usually elevated.
The decrease in serum phosphate causes increased ratio of chloride:phosphate.
Detect using Technicium and Sestamibi (combined sensitivity 95%)
22. Which of the following suggests that a thyroid swelling is malignant
a. Thyrotoxicosis
b. Hoarseness
c. Palpable lymph nodes
d. Increased radioiodine uptake
FTTF
Thyrotoxicosis can be caused by Graves, toxic adenoma, or toxic multinodular goiter.
Malignant thyroid swellings are most often not active.
Hoarseness in conjunction with a thyroid swelling may indicate invasion of the recurrent
laryngeal nerve and thus malignancy.
Spread of neoplasm to lymph nodes (usually papillary carcinoma) is strongly suggestive
of malignancy. Medullary carcinoma involves lymph nodes more than 50% of time at
presentation, and anaplastic and lymphoma may also involve nodes (while follicular
CAN, it most often spreads hematogenously).
Increased radioiodine uptake simply means an area of active thyroid tissue. This is more
likely in Graves disease or hyperthyroidism, and thus doesn’t necessarily mean
malignancy. However, after thyroidectomy, I131 is often given to treat distant metastases,
thus I suppose it depends on WHEN the increased radioiodine uptake occurs.
Incidentally, spread can cause dysphagia, hoarseness, stridor, hemoptysis.
Complications of thyroidectomy:
INTRAOPERATIVE:Bleeding, thyrotoxic storm, pneumothorax, laryngeal edema
EARLY:
Hypocalcemia, Hematoma, Hoarseness (palsy recurrent laryngeal)
LATE:
Hypothyroidism, recurrence
23. The following are recognized complications of Crohn’s disease
a. Iritis
b. Ascending cholangitis
c. Sclerosing cholangitis
d. Erythema nodosum
TFTT
Complications of Crohn’s disease include:
Dermatological
erythema nodosum
Pyoderma gangrenosum
Perianal skin tags
Apthous ulcers
Rheumatological
Ankylosing spondylitis
Sacroiliitis
Peripheral arthritis
Ocular
Uveitis or episcleritis
Hepatobiliary
Cholelithiasis
Primary sclerosing cholangitis
Fatty liver
Urological
Calculi
Fistulas
Others
Vitamin deficiencies, vasculitis, osteoporosis…
24. First degree haemorrhoids
a. Are commonly diagnosed by digital examination
b. Frequently present with bleeding
c. May be treated by rubber band ligation
d. Often prolapse
FTTF
They can rarely be diagnosed by digital examination, they need to be seen by endoscopy
Haemorrhoids are either internal or external.
Haemorrhoid type
Vein plexus
Internal
Superior haemorrhoidal
External
Inferior haemorrhoidal
Dentate line
Above
Below
Circulation .
Portal
Systemic
Of the internal haemorrhoids, they can be graded:
Degree Prolapse
Reducible
Treatment
1
No
Not necessary
High fibre, sclerotherapy,
rubber band ligation, photocoagulation
2
With straining Spontaneous
Rubber band ligation, photocoagulation
3
Yes
Digitally
As 2 + closed hemorrhoidectomy
4
Permanently No
Closed hemorrhoidectomy
25. Postoperative agitation is associated with
a. Sedation
b. Hypoxemia
c. Cardiac arrhythmias
d. Urinary retention
FTTT
Given cardiac arrhythmias may be associated with hypoxemia or hypotension, certainly
yes, it can cause agitation.
Postoperative agitation has a wide-spread aetiology including:
- pain
- sleep disturbance
- anxiety
- discomfort
- urinary retention
- obstruction of orotracheal tube
- hypoxemia
- hypotension
- hypoglycemia
- hyponatremia
- hypocalcemia
- sepsis
- delirium tremors
- withdrawal from addictive drugs
- cerebral embolus
- antibiotics or steroids
- residual effect of anaesthetic (esp. ketamine, propofol, anticholinergics)
26. A right carotid bruit may often be found in patients with
a. Amaurosis fugax
b. Right sided stroke
c. Left eye blindness
d. Ischaemic heart disease
TTFT
Carotid bruit are an unreliable sign of internal carotid artery stenosis, which can lead to
microemboli. The passage of emboli into the ophthalmic artery can cause amaurosis
fugax (sensation of curtain falling over vision-it’s transient by definition). The passage of
emboli from the right carotid artery into the cerebrum involves either the anterior or
middle cerebral arteries. Since the occipital lobe is supplied by the vertebral arteries, the
ICA emboli wouldn’t affect the occipital lobe, instead causing homonymous hemianopia
by affecting the optic tract/radiation, or complete loss of vision if the central retinal artery
is affected. This would occur in the right eye, only for the left field of vision (still false).
Total blindness of left eye is unlikely unless by severance of the left optic nerve which
couldn’t happen from the Right ICA. Also, it tends to involve the opposite side (right
optic tract lesion left homonymous hemianopia).
Given the major aetiology of carotid bruit is atherosclerosis, which can occur anywhere
else, it is likely this person also has ischemic heart disease as well.
27. A Meckel’s diverticulum of the small intestine
a. Is situated 60 cm from the jejuno-ileal junction
b. Contains all coats of the intestinal wall
c. May be associated with fibrous band connecting it to the umbilicus
d. Always contains ectopic gastric mucosa
FTTF
Meckel’s diverticulum is a remnant of the embryonic vitelline duct. It may contain
several types of mucosa including gastric, pancreatic, colonic, but gastric mucosa is
found in 80% of those investigated. It is a TRUE diverticulum in that all three layers of
the intestinal wall are included. The rule of 2’s applies:
- 2% of population have them
- Symptomatic 2% of time
- Found within 2 feet of ileocecal valve
- 2 inches long
- Present by 2 years of age
Rarely, there may be a fibrous band connecting the Meckel diverticulum to the umbilicus.
Umbilical anomalies occur in up to 10% of patients with a symptomatic Meckel's
diverticulum. The anomalies consist of fistulas, sinuses, cysts, and fibrous bands between
the diverticulum and umbilicus. A patient may present with a chronic discharging
umbilical sinus, superimposed by infection or excoriation of periumbilical skin. There
may be a history of recurrent infection, sinus healing, or abdominal wall abscess
formation. When a fistula is present, intestinal mucosa may be identified on the skin. A
discharging sinus should be approached surgically with a view toward correction.
Exploratory laparotomy may be required. When found at laparotomy, a fibrous band,
should be excised because of the risk of internal herniation and volvulus.
28. Rupture of the spleen
a. Always occurs with rib fracture
b. May occur with ruptured diaphragm
c. May occur with ruptured kidney
d. Conservative treatment in children
e. Is associated with shoulder tip pain
FTTTT
While a rib fracture commonly occurs in conjunction with splenic rupture, rib fractures
may occur without splenic rupture or vice versa. Posterior lower rib fractures can be
associated with splenic fracture. About 11% of rib fractures cause liver rupture, and 11%
cause splenic rupture.
In recent years there has been an increasing tendency to avoid splenectomy unless it can
not be conserved by hemostatic agents, local suturing or partial splenectomy. In children,
the conservative, non-operative approach to the management of splenic injury is now
standard practice. Patients need to be closely monitored in paediatric intensive care unit
with appropriately trained surgeons at hand. Indication for surgical intervention in
children is need to replace more than half (80mL/kg) blood volume.
Shoulder tip pain may be referred from diaphragmatic irritation caused by intraabdominal
blood.
Blunt trauma can cause ruptured diaphragm about 2%, as we already know it can cause
ruptured spleen (spleen second most commonly affected organ in blunt abdominal trauma
after liver).
Blunt trauma can cause liver, spleen, kidney, diaphragm, bowel and pancreas
problems…ALL of em can happen!
29. Ulcerative colitis
a. Always confined to large bowel
b. Always involves rectum
c. Fistula is common
TTF
A depends on how you define it. Reflex ileitis can occur, but given I assume they want to
see if you can tell the difference between Crohns and UC, I’ll say true.
UC involves a continuous segment going proximally from rectum to as far as the cecum.
Fistula are not nearly as common in UC as in CD.
30. Carcinoma of the rectum
a. May present with inguinal lymphadenopathy
b. Always treated by abdominal resection
c. Has 5 year survival rate of 25%
d. Responds to chemotherapy
FFFT
Carcinoma of the rectum goes to the inferior mesenteric nodes.
Carcinoma of the ANUS goes to the inguinal lymph nodes. Incidentally, other popularly
asked questions about lymph node drainage includes:
Testicle retroperitoneal
Lower limb inguinal
Cervix iliac
Uterus inguinal
Anus inguinal
Rectum inferior mesenteric
Rectal carcinoma can be surgically treated by anterior resection or abdominoperineal
resection (APR).
Survival rates or rectal cancer are:
Stage
5 year survival
A/B1
90%
Surgery
B2/B3
75%
Surgery + Radio + Chemo
C
40%
Surgery + Radio + Chemo
D
5%
Consider S/R/C (palliation)
Overall five year survival rate is about 40%.
31. Carcinoma of esophagus
a. Adenocarcinoma in lower one third
b. 5 year survival rate is 45%
TF
For carcinoma of the esophagus, Barrett’s occurs in the lower 1/3, and is associated with
adenocarcinoma. Smoking is associated more with squamous cell carcinoma. The five
year survival rate for esophageal carcinoma is less than 5%.
32. Melanoma
a. Always from pre-existing naevus
b. May be non-pigmented
c. May have a halo
d. Commonly occurs in children less than 12 years
e. Spreads by lymphatics and not blood
FTTFF
About 50% of melanomas arise from a pre-existing naevus. The nodular melanoma
(worse prognosis) has an amelanocytic (non-pigmented) subtype. Melanomas spread
rapidly by lymphatics AND bloodstream. Bloodborne metastases are common in liver,
skin, lungs, brain. While melanomas can occur in younger people (especially sunexposed
Caucasians), they don’t commonly occur in children less than 12.
A halo melanoma is a rare condition in which a melanoma is surrounded by an irregular
area of depigmentation. Thank god for google! It must be differentiated from a halo
naevus (Sutton’s naevus).
33. Blood transfusion
a. Stored at 4 degrees C
b. Stored at 0 degrees C
c. Contains factor V and VIII
d. Contains platelets
e. Best given within 7 days
This question is very poorly worded. Since there are few situations in which plasma,
proteins and red cells are all needed (whole blood), it is unlikely this is to mean “whole
blood transfusion.” However, it makes a difference whether it’s whole blood, rbc in
additive solution, platelets, FFP or cryoprecipitate. If we were to use whole blood, the
platelets become non-functional at 4 degrees (although it still “contains platelets” and
thus true), and the activities of factors 5 and 8 decrease to about 30% at one week (but
still contains them thus its true). Likewise, the sample is leukodepleted. So on the basis
that this is actually WHOLE blood transfusion
TFTTF
Blood product
Storage T
Shelf Life
Number of donors/sample
Whole blood (leukopleted)
4+20 C
35 days
1
0
Red blood cells
4+2 C
42 days
1
Platelets
20-240 C
5 days
4
* always contains small amounts of rbc so should be ABO and Rh matched
Fresh frozen plasma
-300 C
365 days
4
Cryoprecipitate
-300 C
365 days
10
34. Acute osteomyelitis
a. Is caused by Staph aureus
b. Treated by penicillin
c. Xray changes present after 2 weeks
d. Sequestration present
e. May cause septic arthritis
f. Caused by Strep
g. Responds to cloxacillin
h. Requires urgent blood culture
i. Early surgery rarely needed
TFTTTFTTT
Acute osteomyelitis is caused by Staphyloccus in 90% of cases. Other organisms may be
Salmonella, Haemophilus influenzae. Presentation is fever + localized pain + overlying
erythema. Subacute osteomyelitis is associated with chronic abscess within bone
(Brodie’s abscess). Complications of osteomyelitis include arthritis (septic), abscess
(Brodie’s), deformity. Treatment is with immobilization and antibiotics (flucloxacillin
and fusidic acid). Surgical drainage and removal of dead bone (sequestrum) may be
needed. Xrays are done to rule out fractures, but changes are only evident after 2 weeks.
Investigations include blood cultures, FBC, CRP/ESR, radiographs (to exclude fracture).
35. TB lymphadenitis
a. Not common in persons > 60
b. Decreasing in Ireland
c. Involves Reed-Sternberg cells
d. Rubbery and discrete
e. May cause chronic sinus
TFFTT
TB lymphadenitis (aka scrofula) typically causes masses in the neck. Incidence is rising
because of immigration from developing countries, and the increasing incidence of HIV,
with which TB is commonly associated. It may be associated with chronic sinus
discharging to skin.
Massive cervical lymph node enlargement with discharging sinuses, in TB, is known as
scrofula. Initially the nodes are firm and discrete, but later they become matted and
suppurating with sinus formation. This is most common in children and young adults.
Reed-sternberg cells are pathognomonic of Hodgkins lymphoma.
36. Chronic fistula persist
a. If foreign body present
b. If streptococcus in wound
c. If TB in wound
d. If obstruction further down
e. If lined by epithelium
TTTTF
A fistula is an abnormal granulating tract connecting two epithelially lined surfaces. If
can discharge, in which case it is high output if >500mL/day. Management of intestinal
fistulae include:
- ensure adequate external drainage
- maintain fluid and electrolyte balance
- provide nutritional support
- protect skin (esp. small intestine)
- ensure no distal obstruction by contrast studies
-
37. Bladder diverticulum
a. Usually congenital
b. Associated with obstruction
c. Associated with infection
d. Contains mucous membrane
e. Never seen on cystoscopy
TTTFF
Bladder diverticula are herniations of the bladder mucosa through bladder wall
musculature (detrusor muscle). Diverticular size can vary greatly, with some attaining a
size equal to or greater than the volume of the bladder. Diverticula can be wide or narrow
mouthed, as dictated by the size of the musculature (detrusor) defect. The size of
diverticular openings has functional implications because narrow-mouthed diverticula
often empty poorly. Stasis of urine within diverticula can also lead to stone formation or
epithelial dysplasia. Depending on the size and location, bladder diverticula may cause
ureteral obstruction, bladder outlet obstruction, or vesicoureteral reflux. Ureteral
obstruction is unusual, occurring in approximately 5% of children with bladder
diverticulum. Bladder outlet obstruction is rare. However, vesicoureteral reflux is more
common, affecting from 8-13% of patients. Bladder diverticula most commonly occur
lateral and superior to the ureteral orifices. They may also occur at the dome of the
bladder, particularly in such disorders as bladder outlet obstruction (ie, posterior urethral
valves) or Eagle Barrett syndrome (prune belly syndrome). Bladder diverticula may be
congenital or acquired. In the pediatric population, most cases are congenital. Congenital
deficiency or weakness in the Waldeyer fascial sheath has been implicated as a cause.
Congenital diverticula tend to be solitary and are located at the junction of the bladder
trigone and detrusor. This anatomic location, close to the insertion of the ureter to the
bladder, is important because large diverticula can impinge upon or distort the ureteral
orifices. Therefore, undertake surgical excision of these diverticula with care to avoid
injuring the ureter. Acquired diverticula are the result of obstruction, infections, or
iatrogenic causes. They tend to be multiple and occur in trabeculated bladders. Examples
of loci of obstruction include posterior urethral valves, anterior urethral valves, urethral
strictures, neuropathic bladder, and external sphincter dyssynergy. An example of
iatrogenic diverticula is herniation of the bladder mucosa through the ureteral hiatus after
antireflux surgery because of inadequate closure of the ureteral hiatus. Many diverticula
that are related to obstruction spontaneously resolve after relief or correction of the
obstruction.
38. Chronic pancreatitis may be a result of:
a. Gallstones
b. Alcohol
c. ERCP
d. Trauma
FTFF
The causes of acute pancreatitis include: ‘GET SMASHED”
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune (PAN)
Scorpion venom
Hypercalcemia, Hyperlipidemia, Hypoglycemia
ERCP
Drugs (azathioprine, thiazides)
The causes of chronic pancreatitis include:
Alcohol
CF
Hyperparathyroidism
Haemochromatosis
Pancreatic duct obstruction (stones or cancer)
Familial
39. Perforation of a duodenal ulcer
a. Always gas under diaphragm
b. Insidious onset
c. Rolling around the bed
d. Shoulder tip pain
e. Uncommonly get back pain
FFFTF
Perforation of a duodenal ulcer leads to free air under the diaphragm about 70-80% of the
time. Perforated ulcer causes: - sudden pain (burrowing into back if posterior perf)
- acute abdomen (rigid, diffuse guarding)
- ileus
- chemical and bacterial peritonitis (tend to lie still!)
- haemorrage can cause diaphragmatic irritation and
referred shoulder tip pain
40. Extradural haemorrhage
a. Usually arterial
b. Often venous
c. Needs immediate surgery
d. Comes on insidiously
e. Always associated with fracture of the skull
TTTFF
EDHs are usually arterial in origin but result from venous bleeding in one third of
patients. Occasionally, torn venous sinuses cause EDH, particularly in the parietaloccipital region or posterior fossa. These injuries tend to be smaller and associated with a
more benign course. Usually, venous EDHs only form with a depressed skull fracture,
which strips the dura from the bone and, thus, creates a space for blood to accumulate. In
certain patients, especially those with delayed presentations, venous EDHs are treated
nonsurgically. Expanding high-volume EDHs can produce a midline shift and subfalcine
herniation of the brain. Compressed cerebral tissue can impinge on the third cranial
nerve, resulting in ipsilateral pupillary dilation and contralateral hemiparesis or extensor
motor response. Spinal extradural haemorrage has a more varied aetiology. SEDH may
be spontaneous or may follow minor trauma, such as lumbar puncture or epidural
anesthesia. Spontaneous SEDH may be associated with anticoagulation, thrombolysis,
blood dyscrasias, coagulopathies, thrombocytopenia, neoplasms, or vascular
malformations. The peridural venous plexus usually is involved, though arterial sources
of hemorrhage also occur. The dorsal aspect of the thoracic or lumbar region is involved
most commonly, with expansion limited to a few vertebral levels.
41. Intussusseption in children
a. Assumed with mass in LIF
b. Should never do a barium enema
c. Surgery is always required
d. Commonest at 1-2 months
e. Examination may be normal
FFFFT
Intussussception is the telescoping of one bowel segment into another. The most common
location is ileocecal (right iliac fossa). It is most commone from 2 months to 2 years of
age. It can be treated by air insufflation, successfully 75% of the time. It recurs in 10%.
Examination may be normal, but may also reveal a sausage-shaped mass in the upper
abdomen. It presents with paroxysmal, severe colicky pain and pallor. Child draws legs
up in attacks. Late sign is red currant jelly stools, and abdominal distension and shock
may occur. A barium enema can both diagnose AND treat intussusception.
42. Hiatus hernia
a. Usually treated medically in children
b. Usually treated by surgery in adults
c. Achalasia at junction of upper 2/3 and lower 1/3
TFF
Hiatus hernias, in adults, are treated as is reflux. Medical therapy first, then if so
symptomatic that it becomes necessary, Nissen or MarkIV procedure. Achalasia is the
failure of the lower esophageal sphincter (at gastroesophageal junction) to relax.
43. Plummer-Vinson syndrome
a. First demonstrated by Patterson and Kelly
b. Assume with esophageal web
c. Is premalignant
d. Causes dysphagia
e. Occurs in middle-aged men
TFTTF
Plummer-Vinson syndrome was originally known as Patterson-Brown-Kelly syndrome. It
is caused by a post-cricoid web and iron deficiency anemia. Sometimes glossitis and
angular stomatitis can also be found. It mainly affects women and its aetiology is
unknown. Dilatation of the web is needed. It is a cause of dysphagia, and occurs more.
It IS premalignant.
Rings or webs can also be found at the lower esophagus, due to a ridge of mucosa or
fibrous membrane. Dilatation is occasionally necessary.
44. Ganglion
a. May be painful
b. May be painless
c. Must be excised
d. May become malignant
e. May become recurrent
TTFFT
A ganglion is a jelly-filled, often painless swelling caused by a partial tear of the joint
capsule. The wrist is a common site. Treatment is rarely needed as most resolve or cause
little trouble. They rarely respond to injection, and surgical excision is possibly the best
option. They occur most often in the 20–60 age group and are three times more common
in females. They are benign but need to be differentiated from more serious conditions.
They contain clear fluid similar to synovial fluid (a clear, lubricating, viscous fluid found
in the synovial cavity of joints). They are not generally considered harmful and are
normally asymptomatic. Sometimes they may cause limitations of movement and can
also cause weakness, pain and paraesthesia (pins and needles) if they press on adjacent
nerves. If a ganglion cyst is symptomatic, it can be managed by aspiration or excision.
Aspiration of the cyst is the simpler method, but cysts will develop again in about 50% of
cases. Recurrence rate after surgery is only 5–10%; the procedure is simple, and usually
there are no complications. Recurrence rates are lower when the hand or finger is
immobilized for 1–2 weeks. Ganglion cysts are benign and no malignancies in ganglions
have been reported.
45. Duct papilloma
a. Commonest age 35-50
b. Bloody discharge
c. May feel a lump
TTT
Breast duct papilloma can present with:
- blood stained or serous nipple discharge
- nipple bleeding
- lump behind to next to nipple
- nipple ulceration
- enlarged axillary lymph nodes
Patients are generally premenopausal and thus age 35-50 is a good bet!
46. Varicocele
a. Common on the left side
b. Associated with oligospermia
c. Like a bag of worms when lying down
d. Treated by tight underpants
e. May be painful
TTTFF
The veins of the pampiniform plexus are dilated and tortuous, producing a swelling in the
line of the spermatic cord that resembles a “bag of worms.” It is more common on the left
side because of the right-angled drainage of the left testicular vein into the renal vein,
rendering it more liable to stasis. In some men, varicocele is associated with infertility. A
dragging sensation is most common. Treatment is by ligation of spermatic vein.
47. Molluscum sebaceum
a. Is a sebaceous cyst
b. Is Bowen’s disease
c. Is an epithelioma
d. Is a keratoacanthoma
e. May heal spontaneously
FFTTT
Molluscum sebaceum is also known as keratoacanthoma. They are rapidly growing
epidermal tumours with central necrosis and ulceration. They occur on sun exposed skin
in later life and can grow up to 2-3 cm across. Whilst they may resolve spontaneously
over a few months, they are best excised to exclude SCC, and this can also improve the
cosmetic outcome.
Bowen’s disease is intraepidermal carcinoma in situ (SCCin situ). It has a strong link to
HPV and best treated by topical 5-fluourouracil, cryotherapy, curettage, or tissuedestructive laser.
48. Tetanus
a. Is an endotoxin
b. Spreads to CNS via NN (what is NN??)
c. Spasm  respiratory arrest
d. Active immunity confirmed by increase in IgE
e. Children more than 1 year immunized
FFTFF
There are almost no cases of people with all 5 injections (and one within last 10 years)
getting tetanus. However, children can get it because they have not yet received 5 shots,
and it takes quite some time to build up active immunity.
Active immunity is confirmed by the presence of antitoxin titres.
Tetanus is due to toxin secreting clostridium C. tetani. The organism is found in soil, and
illness usually results from contaminated wounds. Tetanolysin and tetanospasmin are
both excreted and reach the motor synapses by blood and lymphatic flow. Tetanolysin is
not thought to be involved significantly in the clinical manifestations. Clinical
manifestations of the disease are due to neutoxin tetanospasmin, which acts on both alpha
and beta motor synapses, causing disinhibition. This toxin is secreted and is thus an
exotoxin, not an endotoxin. The end result if a marked flexor muscle spasm and
autonomic dysfunction. Children are immunized at 2, 4, and 6 months, then again at age
4-5, then again a booster shot at 10-14. They are not fully immunized until they have had
5 shots.
Laryngeal spasms can cause asphyxia and respiratory arrest.
49. Chronic fissure in ano
a. Is painful
b. Involves squamous epithelium
c. Involved columnar epithelium
d. Treated by total sphincterotomy
e. Treated by partial internal sphincterotomy
TTFFT
Anal fissures occur distal to the dentate line, where the surface epithelium changes from
columnar to squamous.
An anal fissure is a superficial linear tear in the anoderm most commonly caused by
passage of a large, hard stool. This tear is distal to the dentate line. Anal fissures are
among the most common anorectal disorders in the pediatric population; however, adults
also are affected. They are characteristically painful and cause bleeding on the surface of
stools. Anal fissures are thought to be caused by chronic diarrhea, passage of very hard
stools, habitual use of cathartics, and anal trauma.
Treatment of anal fissures can be:
Conservative: “WASH” procedure
Warm water, shower after defecation
Analgesics
Stool softener
High fiber diet
Or Surgical: always involves stretching or cutting internal sphincter.
The most common surgical procedure is lateral internal sphincterotomy. Botulin
toxin has also been used with great success for treatment of anal fissures.
50. K+ depletion
a. Associated with villous papilloma
b. Associated with nasogastric suction
c. Occurs 24 hours post-op due to increased output
d. Treated freely by IV potassium with no danger
e. Causes muscle cramps
TTFFT
Villous papilloma of the rectum or colon can cause hypokalemia. Nasogastric suction
causes depletion of HCl, leading to increased renal excretion of K+ and intracellular
transfer of K+ to exchange for H+ in blood, both leading to hypokalemia.
Hypokalemia Associated with a Low (<10 mmol/L) Urinary Potassium
Gastrointestinal loss Diarrhea: acute, chronic
Villous adenoma: colon, rectum
Pancreatic fistula
Ureterosigmoidostomy
Extracellular to intracellular shift
Insulin therapy
Drugs: salbuterol (salbutamol), epinephrine
Vitamin B12 therapy for pernicious anemia
Barium intoxication
Inadequate intake
Inappropriate intravenous therapy
Alcoholism
Anorexia nervosa
Geophagia
Hypokalemia Associated with High (>10 mmol/L) Urinary Potassium
Alka!osis
Diuretic therapy
Thiazides
Furosemide, ethacrynicacid
Carbonic anhydrase inhibitors
Mineralocorticoid excess
Pnmary hyperaldosteronism
Secondary hyperaldosteronism
Cushing’s syndrome
Ectopic corticotropin syndrome
Congenital adrenal hyperplasia: C11- and C17-hydroxylase defect
Bartter’s syndrome
Liddle’s syndrome
Drugs:
steroids, carbenoxolone, licorice
Renal disease
Renal tubular acidosis; types 1 & 2
Post-obstructivediuresis
Diuresisof post-acute tubular necrosis
Post-transplantkidney
Miscellaneous
Leukemia: lysozymuria
Hypomagnesemia
Poorly reabsorbable anions: carbenicillin, penicillin
Muscle cramps can be caused by hypokalemia, hypomagnesemia, hypocalcemia.
51. In grown toe nail
a. Should be cut conversely
b. Corners should be cut back
c. Needs patients cooperation
d. Koilonychia is common
FFTF
In grown toe nail usually presents after the patient has made several misguided attempts
to cut the nail back at corners, and infection ensues. The condition is painful. A gauze
soaked in antiseptic is used to lift out the ingrowing portion, then the patient is instructed
to cut the nail square, or shorter in the center than at the edges, and to avoid narrow shoes
(listen to this women!). Once the nail is deeply embedded, avulsion under general
anaesthesia is advised (IGTN excision). This procedure can involve minimally cut
toenail, vertically, followed by ablation of the matrix by phenol. The nail remains, but is
less wide than previously.
Koilonychia is the dystrophy of fingernails often associated with iron deficiency,
also referred to as spoon shaped nails. It is more common in the finger nails than in the
toe nails, and is completely separate from the aetiology of IGTN.
52. History
a. Hippocrates described inflammation
b. Pasteur was a professor of medicine
c. Halsted and rubber gloves
d. Mendel was a geneticist
e. Christmas disease was first described at Christmas time
Why can’t I find any of this stuff on pubmed? haha
53. Boy, 10 days post-op from appendicectomy and febrile with pus from wound
a. Requires a laparotomy
b. Requires NG suction and IV fluid
c. Needs local dressing only
d. Requires strict bed rest
e. Requires antibiotics
FFFFT
Needs dressing change, and antibiotics.
Post-appendicectomy, wound infection can cause the skin to become red and inflamed
and pus to leak from the incision site. In this case, antibiotics are started and discharge
from the hospital may be delayed, depending on the severity of the infection. On rare
occasions, the site must be reopened to allow the wound to drain.
Surgical site infections are defined as follows:
- superficial incisional SSI
o within 30 days after operation
o involves only skin/SC tissue
o At least 1 of:
purulent discharge
organisms isolated from incisional site
1 sign of inflammation (rubor, calor, dolor,
functiona leasa, tumor)
wound is deliberately opened
- deep incisional SSI
o within 30 days after operation OR 1 year (if implant present)
o involves fascia and or muscle
o At least 1 of:
purulent discharge from deep incision
Fascial dehiscence or fascia separated intentionally
Deep abscess identified
- Organ/space SSI
o Within 30 days after operation OR 1 year (if implant present)
o Involves structures not manipulated during operation
o At least 1 of:
purulent discharge from drain
Organisms isolated from organ/space
Abscess identified in organ/space
54. Fracture of the neck of femur
a. Prostheses it the treatment of choice
b. Mobilization without surgery
c. Bed rest
d. Plating
e. None of the above
FFFTF
Femoral neck fracture (sometimes Neck of Femur (NOF), subcapital, or intracapsular
fracture) denotes a fracture adjacent to the femoral head in the neck between the head and
the greater trochanter. These fractures have a propensity to damage the blood supply to
the femoral head, potentially causing avascular necrosis. Most hip fractures are treated by
orthopedic surgery, which involves implanting an orthosis. For low-grade fractures
(Garden types 1 and 2), standard treatment is fixation of the fracture in situ with screws
or a sliding screw/plate device. This treatment can also be offered for displaced fractures
after the fracture has been reduced. In elderly patients with displaced fractures many
surgeons prefer to undertake a Hemiarthroplasty, replacing the broken part of the bone
with a metal implant. The advantage is that the patient can mobilize without having to
wait for healing.
A prosthesis is an artificial extension that replaces a missing body part. An
orthosis is an orthopedic appliance or apparatus use to support, align, prevent, or correct
deformities or to improve the function of movable parts of the body.
Bedrest after a fractured neck of femur can increase the likelihood of a DVT and
should thus be avoided for long periods of time.
55. Fracture of the clavicle
a. May be diagnosed clinically
b. Usually caused by direct trauma to shoulder
c. Delayed union common
d. Often causes damage to brachial plexus
TFTT
Clavicular fractures are common injuries that account for approximately 5% of all
fractures seen in the ED. In neonates and children, these fractures are very common and
generally heal well. In adults, the force required to fracture the clavicle is greater, healing
occurs at a slower rate, and risk of potential complications is higher. The clavicle is the
sole articulation of the shoulder girdle to the trunk. It protects major underlying vessels,
lung, and brachial plexus. Displaced clavicle fractures can injure these structures because
of their proximity and sharp edges. Approximately 80% of clavicle fractures occur in the
middle third (class A), 15% involve the distal or lateral third (class B), and 5% the
proximal or medial third (class C). Causes include fall onto shoulder or outstretched
upper extremity, or direct trauma to clavicle. Direct trauma to shoulder is not the usual
cause (fall onto outstretched upper extremity most common cause). Delayed union is
especially common in distal 1/3 (Class B) injuries.
56. Carbuncle
a. Caused by strep
b. Multilobulated
c. Treated with gentamycin
d. Exquisitely tender
e. Associated with DM
FTFTT
A carbuncle is a non-necrotizing skin infection composed of multiple furuncles, usually
due to Staphylococcus aureus. Multiple draining sinuses are common, and
immunocompromise (eg. DM) may be a factor. Furuncle is infection of hair follicle. The
condition is “exquisitely painful” (who in god’s name ever called pain “exquisite?”).
Treatment is with cloxacillin antibiotics.
57. The following are anaerobes
a. Proteus
b. Staph aureus
c. Clostridium perfringens
d. Clostridium difficile
e. Bacteroides
58. Removal of sutures
a. Face, head and neck
b. Hands
c. Palm
d. Rest of upper limb
e. Trunk
f. Lower limb
g. Scalp
h. Feet
3 days
5 days
8 days
7-10 days
7-10 days
10-14 days
5 days
10-14 days
TFFTTTFT
From University of Ottawa Surgery site:
Location
Number of days
Face
3-5
Scalp
7
Backs of hands
7
Chest and extremities
8-10
High tension (joints, hands) 10-14
Legs and tops of feet
10-14
Back
10-14
Palms or soles
14
59. History
a. Harvey described circumcision in 1616
b. Microscope was not invented until 1590
c. Fleming discovered streptomycin
d. Rhesus factor discovered 1935
What a load of horseshit is this?
60. Dukes staging of colon Ca
a. B Associated with lymph nodes
b. A survival 100%
c. Staging done pre-op
d. Staging done post-op
e. C survival 50%
FFFTT
Staging of colon cancer is by Duke’s, modified Duke, or TNM
Duke Stage
A
submucosal involvement
B
muscularis propria involvement
C
lymph node involvement
D
metastases
TNM system
T0
No tumor detectable
Tis
In situ
T1
submucosa
T2
muscularis propria
T3
subserosa
T4
perforates peritoneum/invades adjacent organs
N0
N1
N2
N3
No nodes detectable
1-3 pericolic/perirectal nodes
>4 pericolic/perirectal nodes
any node along named vascular trunk
M0
No mets
M1
Mets
Modified Dukes (Astler-Coller)
A
T1, N0, M0
B1
T2, N0, M0
B2
T3, N0, M0
B3
T4, N0, M0
C1
T2, N1-2, M0
C2
T3, N1-2, M0
C3
T4, N1-2, M0
D
Tx, Nx, M1
Stage
A/B1
B2
B3/C
D
Survival
90%
75%
50%
20%
61. Increased intraluminal pressure with
a. Esophageal diverticulum
b. Bladder diverticulum
c. Pharyngeal diverticulum
d. Meckel’s diverticulum
e. Diverticular disease
TTTFT
Pharyngeal diverticulum (pouch) occurs almost exclusively in the elderly and is thought
to be due to failure of the cricopharyngeus part of the inferior constrictor to relax during
swallowing, thus building up pressure above it.
Bladder diverticula may be congenital or acquired. In the pediatric population, most cases
are congenital. Congenital deficiency or weakness in the Waldeyer fascial sheath has
been implicated as a cause. Congenital diverticula tend to be solitary and are located at
the junction of the bladder trigone and detrusor. Acquired diverticula are the result of
obstruction, infections, or iatrogenic causes. They tend to be multiple and occur in
trabeculated bladders. Examples of loci of obstruction include posterior urethral valves,
anterior urethral valves, urethral strictures, neuropathic bladder, and external sphincter
dyssynergy. An example of iatrogenic diverticula is herniation of the bladder mucosa
through the ureteral hiatus after antireflux surgery because of inadequate closure of the
ureteral hiatus. Many diverticula that are related to obstruction spontaneously resolve
after relief or correction of the obstruction. In some cases, the diverticula that occur in
response to obstruction serve a beneficial function by acting as pressure pop-off
mechanism, protecting the kidney and ureters from high pressures.
Esophageal diverticulae results from outpouching of the weakness in the wall associated
with increased intraluminal pressure or traction from fibrosis in the mediastinum.
Incidentally, Zenker’s diverticulum is a common, false (not all three layers) pharyngeal
diverticulum that arises above the cricopharyngeus muscle.
Diverticular disease certainly is associated with dietary insufficiency of fibre and
increased intraluminal pressure.
Meckel’s diverticulum is a congenital remnant of the vittelointestinal duct, with ectopic
gastric tissue about 80% of the time. Remember the rule of 2’s.
Present in 2% of people
2% are symptomatic
Usually 2 feet from ileocecal valve
62. Boy, 7 days post-op, gets fever. Likely causes include
a. Atelectasis
b. UTI
c. Wound abscess
d. Pelvic abscess
e. Anaerobic abscess
FTTTT
Post op fever is best categorized into the time after surgery
POD0-2:
- atelectasis (#1 cause)
- early wound infection (Clostridium, Streptococcus)
- aspiration pneumonia
- thyroid storm, Addisonian crisis, transfusion reaction
POD 3+
Infections more likely
- UTI, wound infection, IV site injection, septic thrombophlebitis
POD 5+
Leaking bowel anastomoses
- intra-abdominal and pelvic abscess (POD 5-10)
- DVT/PE (POD 7-10)
- drug fever (POD 6-10)
Remember the 5 W’s of post-op fever:
Wind (pulmonary)
Water (UTI)
Wound
Walk (DVT/PE)
Wonder drugs (drug fever)
63. Strep pyogenes
a. Causes carbuncle
b. Causes erysipelas
c. Commonest cause of wound infection today
d. Produces enzyme destroying cloxacillin
FTFF
Carbuncles are most often caused by Staphylococcus aureus.
Folliculitis is caused by Strep.
The commonest cause of wound infection today is:
Pathogen
Frequency
Staphylococcus aureus
20
Coagulase-negative staphylococci
14
Enterococci (E. faecium/E. faecalis)
12
Escherichia coli
8
Pseudomonas aeruginosa
8
Enterobacter species
7
Proteus mirabilis
3
Klebsiella pneumoniae
3
Other streptococci
3
Candida albicans
3
Bacteroides fragilis
2
So, the most common causes of wound infection at Staphylococcus aureus (20%),
Coag(-)staphylococci (14%), enterococci (E.faecium and E. faecalis) (12%) and
Escherichia coli (8%).
Erysipelas is a brownish depigmentation, often of the axillary regions, face and legs
caused by group A streptococcus (Streptococcus pyogenes). Group A strep produces:
- Streptolysin O (causes hemolysis)
- Streptolysin S (causes hemolysis)
- Pyrogenic exotoxin (directly stimulates T cells to release cytokines, causing
pyrexia)
- Streptokinase, hyaluronidase, DNAses…
- Penicillinase (kills action of penicillin, but has NO effect on cloxacillin!)
64. Perthes disease
a. Commonest in teens
b. Involves acetabulum
c. Involves femoral head
d. Treatment by surgery usually
FFTF
Perthes disease is defined as avascular necrosis of the femoral head, followed by
revascularization and reossification over 18-36 months. Mainly effects boys age 5-10,
and presents with limp. Often mistaken for transient synovotis.
IN as much as the femoral head needs to stay in acetabulum, this could mean it involves
the acetabulum, but really it involves primarily the femoral head. The process of
revascularization and reossification is ideal if the femoral head approaches the
acetabulum closely however…true or false?
Treatment depends on severity of the disease, as determined by the amount of the
epiphyses involved. In most children prognosis is good, especially when less than half the
epiphysis is involved. When over half epiphysis is involved and child is over 6 years old,
deformity of femoral head and metaphyseal damage area more likely, resulting in
degenerative arthritis in adult life. Usually only bed rest and traction are needed at the
most, but severe cases may require maintaining hip in abduction with plaster, or by
performing femoral or pelvic osteotomy.
65. Internal fixation needed for
a. Fracture of neck of femur
b. Colles fracture
c. Pott’s fracture
d. Fracture of shaft of femur
66. Haemoptysis caused by
a. Pulmonary embolus
b. Coarctation of aorta
c. Carcinoma of lung
d. Mitral stenosis
TFTT
The causes of hemoptysis include:
Pulmonary: bronchitis, bronchial carcinoma, bronchiectasis
Pulmonary embolus
Foreign body
TB
Aspergilloma
Vasculitis:
Goodpastures, Wegeners, SLE, RA…
CVS:
Mitral stenosis
Left ventricular failure (frothy pink+pulmonary edema)
Spurious:
Mouth and nose bleeding
67. Regarding cysts
a. True cysts are lined by squamous epithelium
b. External angular dermoid is an example of congenital cyst
c. Spermatocele is an acquired cyst
d. A hydrocele is a retention cyst
e. Implantation dermoid cysts are common in fingers of women who sew
FTFFT
A cyst is a fluid filled space lined by epithelium. The type of epithelium is not specified,
and may indeed be columnar or glandular epithelium.
Retention cyst is caused by blockage of the excretory duct of a gland, so glandular
secretions are retained (eg. Spermatocele).
The soft tissues of the face are formed by the convergence of three facial processes
(frontal, maxillary, and mandibular). As a consequence, there are lines of fusion where
islands of ectodermal tissue may become submerged, later to secrete sebaceous material
and present as obvious cystic swellings known as dermoids. The commonest site for this
phenomenon is at the upper lateral part of the forehead (an external angular dermoid),
but other sites include the upper medial part of the eye or along the midline of the face
and neck.
A spermatocele is a benign retention cyst, accumulation of sperm that arises from the
head of the epididymis. Such collections have been described in many locations, ranging
from the testicle itself to locations along the course of the vas deferens. Nevertheless, in
common usage, spermatoceles are intrascrotal, paratesticular cystic collections of sperm
that arise from the epididymis. Surgical intervention is not indicated for the incidental
asymptomatic spermatocele. However, if discomfort, pain, or progressive enlargement is
bothersome to the patient, discussion regarding excision may ensue. However, any
surgical procedure can impact his fertility, and thus should be undertaken with great
caution. Spermatocele is a retention cyst.
A dermoid cyst is a teratoma that contains developmentally mature skin, with hair
follicles and sweat glands, sometimes luxuriant clumps of long hair, and often pockets of
sebum, blood, fat, bone, nails, teeth, eyes, cartilage, and thyroid tissue. Because it
contains mature tissue, a dermoid cyst almost always is benign. The rare malignant
dermoid cyst usually develops squamous cell carcinoma. Most congenital dermoid and
epidermoid cysts probably arise due to an embryologic accident during the early stages of
development, between 3 and 5 weeks of gestation. Enclosed ectodermal cysts can occur
when the surface ectoderm fails to separate completely from the underlying neural tube.
Implantation can be iatrogenic, caused by a diagnostic or therapeutic lumbar puncture
performed with an open needle (without a stylet), or can be brought about by stab and
puncture wounds. Given implanted dermoid cysts may occur with needle puncture skin
and placing cells farther down, I suppose this could be true.
68. Wound dehiscence
a. Is commoner in midline vertical incisions
b. Patients who are hypoproteinemic/malnourished are at a higher risk
c. Occurs within 2-3 days postoperatively
d. The issue of serosanguinous fluid from the wound is an ominous sign
e. Tension sutures should be left for 5-7 days
TFTT
Wound dehiscence is an uncommon early postoperative complication affecting about 1%
of abdominal wounds. It usually occurs about 1 week after an operation. Dehiscence may
be preceded by a pink serous discharge (serosanguinous), following which the stitches of
the wound actually pull out of the tissues. Though alarming, there is often little pain
experienced by the patient. The cause of dehiscence may be divided into preoperative,
intraoperative and postoperative factors.



Preoperative
Intraoperative
Postoperative
Management includes:
poor nutritional state, malignancy, obesity, re-operation
poor technique, long procedure time
infection, haematoma, coughing, abdominal distention
- replace abdominal contents
- cover with sterile swabs in saline
- administer analgesia
- return to theatre to repair wound with tension sutures.
Tension sutures stay in for at least 5 days minimum in abdominal surgery.
69. History
a. Lister introduced aseptic surgery in 1867
b. Simpson introduced chloroform as an anaesthetic drug in 1847
c. ABO blood groups discovered 1935
d. Hippocrates lived and worked in Alexandria
e. Harvey described circulation of the blood in 1628
This history shit is starting to piss me off…
70. Metabolic response to trauma includes
a. Antidiuresis for 16-24 hours
b. Fever
c. Rise in serum sodium concentration
d. Renal retention of potassium
e. Leucocytosis
TTTFT
Trauma is bodily injury accompanied by systemic as well as local effects. Any stress,
which includes injury, surgery, anaesthesia, burns, vascular occlusion, dehydration,
starvation, sepsis, acute medical illness, or even severe psychological stress will initiate
the metabolic response to trauma.
Following trauma, the body responds locally by inflammation and by a general response
which is protective, and which conserves fluid and provides energy for repair. Proper
resuscitation may attenuate the response, but will not abolish it. The response is
characterised by an acute catabolic reaction, which precedes the metabolic process of
recovery and repair. This metabolic response to trauma was divided into an ebb and flow
phase by Cuthbertson. The ebb phase corresponds to the period of severe shock
characterised by depression of enzymatic activity and oxygen consumption. Cardiac
output is below normal, core temperature may be subnormal, and a lactic acidosis is
present. The flow phase can be divided into a catabolic phase with fat and protein
mobilisation associated with increased urinary nitrogen excretion and weight loss, and an
anabolic phase with restoration of fat and protein stores, and weight gain. In the flow
phase, the body is hypermetabolic, cardiac output and oxygen consumption are increased,
and there is increased glucose production.
PHASE
Duration
Role
Hormones
Ebb
< 24 hours
Flow- catabolic
3-10 days
maintain blood V
catecholamines
maintain energy
Flow- anabolic
10-60 days
replace lost tissue
catecholamines, cortisol and
aldosterone
glucagon, insulin, cortisol
catecholamines
GH and IGF-1
Ebb:
Decrease BMR, body temperature, O2 consumption
Vasoconstriction, Increased cardiac output and acute phase reactants
Flow: catabolic:
Increase BMR, body temperature, O2 consumption
negative nitrogen balance
anabolic:
positive nitrogen balance
71. Carcinoma of anterior 2/3 of tongue
a. Metastasizes first to deep cervical nodes
b. Metastasizes first to submandibular nodes
c. Is rare in males
d. Is an adenocarcinoma
e. Can be treated by ionizing radiation
TTFFT
The most common cancer of the tongue is SCC.
All structures above the clavicles eventually drain to the deep cervical nodes. Drainage of
the neck is incredibly complicated, and thus best left to ENT surgeons, but a few simple
things to remember:
Submandibular:
receives face, submental nodes, maxillary teeth, and most of lips,
gingivae, and tongue
Submental
central part of lower lip, tip of tongue, and anterior floor of mouth
Retropharyngea
posterior nasal cavity, nasopharynx, soft palate, middle ear, EAM.
Paratracheal, Pretrachea, Prelaryngeal, Infrahyoid drain larynx, trachea, pharynx, and
esophagus
Lips
Submandibular (drains upper lip, and most of lower lip) and
submental (drains central area of lower lip).
Tongue:
Deep cervical nodes: drains median part of anterior two-thirds;
Retropharyngeal - drains posterior third
Submandibular: - drains lateral part of anterior two-thirds;
Submental - drains tip of tongue (through tongue muscles and
mylohyoid).
Treatment of tongue carcinoma is with surgery and or radiation depending on stage.
72. Is an intracapsular fracture of the femur, the characteristic findings are:
a. External rotation of LL
b. Internal rotation of LL
c. Knee flexion
d. Ecchymosis of thigh
e. Shortening
TFFTT
Intracapsular fracture of femur is also known as femoral neck fracture. It causes external
rotation and leg shortening. Blood loss into the thigh (ecchymosis) is common and may
even be fatal. Knee flexion is not a feature.
73. Virulence of Strep pyogenes is tested by
a. Antibiotic sensitivity
b. Ability to form
c. Ability to hemolyse blood
d. Phenotyping
e. Ability to form fibrinolysins
F?TTT
Measurement of antistreptolysin O antibodies in humans is used as an indicator of recent
streptococcal infection. Streptolysin S is produced by the organism in the presence of
serum and is nonantigenic. Streptolysin O can be inactivated by oxygen. Streptolysin O is
an immunogenic single-chain protein that induces a brisk antibody response. Streptolysin
S consists of a polypeptide that has lytic effects for red and white blood cells and is
responsible for the hemolysis observed on culture plates. The other extracellular products
of streptococci are deoxyribonuclease A, B, C, and D and hyaluronidase, which destroys
hyaluronic acid found in connective tissue. Anti-C5a protease is also produced in some
strains or phenotypes. Streptolysins and fibrinolysins are the most commonly pathogenic
virulence factors after M protein.
74. The following are correctly paired:
a. Hypokalemia and acidosis
b. Carcinoma of gallbladder and cirrhosis of liver
c. Gallstones and abnormal liver bile
d. Thrombophlebitis and cerebral embolism
e. Heparin and treatment of DIC
FTTFF
Hypokalemia is more commonly associated with alkalosis, as in prolonged vomiting.
Carcinoma of the gallbladder is most often associated with gall stones. Cirrhosis causes
the abnormal metabolism of bile pigment and thus gallstones develop twice as often in
cirrhosis patients as in those without the disorder.
Abnormal bile may contain excessive cholesterol and insufficient bile salts. This can be
related to the development of gall stones.
Thrombophlebitis is the inflammation of a vein associated with thrombus formation.
Cerebral emboli usually originate from the left heart, or internal carotid artery, unless
there is an AV malformation…So in other words false.
The treatment of DIC involves giving fresh frozen plasma to replace the clotting factors,
and keeping the patient well hydrated.
75. Non-union is common in fractures of the
a. Humeral shaft
b. Waist of scaphoid
c. Neck of femur
d. Head of radius
e. Shaft of femur
76. Extra-dural haemorrage may
a. Occur spontaneously
b. Run a chronic course
c. Involve middle meningeal artery
d. Result from indirect injury
e. Cause rapid death
TTTTT
Please note I have taken the word “may” to mean “can sometimes” but not necessarily
“usually.”
Extradural hematoma (aka epidural) can occur spontaneously, but more often occurs
secondary to trauma to the temporal area, affecting the middle meningeal artery. Venous
bleeding may also occur, usually with dural venous sinuses especially in the posterior
fossa. In some patients, especially those with delayed presentations, venous EDHs are
treated nonsurgically. Classically, a lucid interval occurs between the trauma and the
slow onset of unconsciousness or slow resolution of symptoms. A chronic course is more
commonly associated with subdural hematoma in which bridging veins may bleed in the
elderly, causing chronic bleeding and slow onset. Extradural hematoma is seen as a
biconvex shape on CT as the bleeding is confined to the sutures. Subdural hematoma is
seen as a crescent shaped opacity (increased density) on CT not confined by sutures.
EDH may be acute (58%), subacute (31%), or chronic (11%).
Spontaneous EDH can occur associated with anticoagulation, thrombocytopenia,
neoplasms, vascular malformations, thrombolysis…
Mortality rates range from 5 to 45%. Some of these can be within 24 hours, so
“rapid death” may certainly occur. Similarly, patients with posterior fossa EDH may have
a dramatic delayed deterioration. The patient can be conscious and talking and a minute
later apneic, comatose, and minutes from death.
Just to be comprehensive, and to make sure my printer runs out of ink before I can
print all this document, here are the causes:
Causes of EDH:
- trauma
- anticoagulation
- thrombolysis
- lumbar puncture
- epidural anesthesia - coagulopathy
- AV malformation - hepatic disease with portal hypertension
- Pagets disease
- Valsalva maneouvre
- HTN
77. Acute osteomyelitis
a. Is usually streptococcal
b. Involves epiphysis
c. May cause septic arthritis
d. Is always secondary to trauma
e. Is always sensitive to penicillin G
FFTFF
See 34
Usually the metaphyses affected in osteomyelitis.
78. In an adult fracture of the shaft of femur, adequate treatment
a. Allows traction
b. Plaster of paris
c. Intramedullary nail
d. Skeletal traction in Thomas splint
e. Early mobilization with none of the above
TFTTF
The 3 types of femoral shaft fractures are as follows:



Type I - Spiral or transverse (most common)
Type II - Comminuted
Type III – Open

Immediate treatment at the site of the accident
If the patient is treated at the site of the accident then shock should be treated and the
fracture splinted before the patient is moved. A Thomas' splint is ideal for transport of the
patient: this device involves threading the leg through the ring of the splint and pulling it
straight; traction is then maintained by tying the shod foot to the cross-piece; the splint
and the limb are firmly bandaged together.
Definitive treatment
A closed fracture is treated by closed reduction and closed nailing e.g. by inserting an
intramedullary nail from the proximal end of the bone, under x-ray control, without
exposing the fracture. In many centres open fractures of the femoral shaft are also treated
by intramedullary nailing. Exercises are begun after the operation. The patient may be
allowed to walk with the aid of crutches, allowing limited weight-bearing, within a week
or two of the operation. The patient can only resume full weight-bearing when the
fracture is seen to have united on x-ray.
INCIDENTAL BUT USEFUL AND INTERESTING
It is not possible to precisely estimate the time that it will take for a fracture to heal. A
rough estimate is:




most upper limb fracture repair completely in 6-8 weeks
lower limb fractures take twice as long
children take half as long
add 25% if the fracture involves the femur or is not spiral
MANAGEMENT OF ALL FRACTURES
Primary aim - healing with preservation of function. Stages:




resuscitation - ATLS - airway, breathing, circulation, disability, exposure
reduction - restore anatomy, relieve pressure on nerves, vessels, muscle
stabilisation - hold the reduced fracture
rehabilitation - restore function
Assume all open fractures are contaminated and prevent progress to infection.
There is evidence that multiply-injured patients with limb fractures have a reduced
mortality rate if these are dealt with at the time of admission rather than after a delay in
order to stabilise cardiorespiratory function.
79. In bronchial carcinoma, surgical exploration is contraindicated if
a. There is lobar collapse
b. There is recurrent laryngeal nerve paralysis
c. Axillary glands are palpable
d. There is pulmonary osteo-arthropathy
e. There is Horner’s syndrome
FTFFT
Pulmonary osteoarthropathy is a paraneoplastic phenomenon that does not imply
metastases. It is a painful periosteal reduction affecting joints and long bones, in
conjunction with finger clubbing. Other paraneoplastic phenomena include ectopic
hormone secretion.
Remember ya got 2 SOCs, A? Small/oat cells cancer secrete two hormones starting with
letter A, being ADH and ACTH. The other hormone commonly secreted is PTH, by SCC.
Surgical exploration is not indicated in locally irresectable or incurable lung cancer.
Thus, the following features are indicators of locally irresectable or incurable lung cancer
and thus contraindications to surgical exploration:
Clinical finding
Local
Horner’s syndrome
Hoarseness
Upper body venous congestion
Severe shoulder/inner arm pain
Disseminated
Scalene node involvement
Hepatomegaly
Focal bone pain
Skin deposits
Behavioral/balance disturbance
Pathological Implication
Involved upper sympathetic chain
Involved left recurrent laryngeal nerve
Involved SVC
Involved lower brachial plexus (Pancoast tumor)
Nodal spread out of operative field
Hepatic mets
Bone mets
Cutaneous mets
Cerebral mets