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, Csurgery + 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