Surgery

Surgery

Surgery

🦿 Trauma & Orthopaedics

‣
🦿 General
‣
What are the stages of bone remodelling?
  1. Haematoma
  2. Inflammation
  3. Fibrocartilaginous callus formation
  4. Hard callus formation (cancellous bone)
  5. Bone remodelling (cancellous → cortical bone)

OpenStax College, CC BY 3.0
OpenStax College, CC BY 3.0 creativecommons.org/licenses/by/3.0, via Wikimedia Commons. No changes were made.
‣
X-ray interpretation
‣
Describe a systematic approach to reading any skeletal X-ray.
  1. Patient details
  2. Type of X-ray (AP or PA) & location (e.g. left femur & pelvis)
  3. Discuss soft tissues (Bowel, muscle, fat)
  4. Discuss bone
    • Location: Epiphysis/metaphysis/diaphysis
    • Type of fracture
    • Angulation
    • Varus/valgus deformity
    • Lytic or sclerotic change?
‣
What are the causes of lytic and sclerotic appearances and what are they, respectively?

Lytic: Reduced bone turnover → Thin bone

  • Thyroid metastases
  • RCC metastases
  • Ewing sarcoma

Sclerotic: Increased bone turnover → Thick bone

  • Prostate metastases
  • Breast metastases
  • Transitional cell carcinoma metastases
‣
What are the findings on the following X-rays:
James Heilman, MD, CC BY-SA 4.0
James Heilman, MD, CC BY-SA 4.0 creativecommons.org/licenses/by-sa/4.0, via Wikimedia Commons. No changes were made.
‣
X-ray 1

Osteomyelitis, features to consider:

Yousef Samir, CC BY-SA 4.0
Yousef Samir, CC BY-SA 4.0 creativecommons.org/licenses/by-sa/4.0, via Wikimedia Commons. No changes were made.
‣
X-ray 2

Osteosarcoma, features:

  • Codman's triangle
  • Sunburst appearance
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Fat emboli
‣
When does a fat embolism commonly occur?
  • Femoral shaft fracture or surgical fixation of this (IM nailing)
‣
What are the features?

Respiratory:

  • Early persistent tachycardia
  • Hypoxia (72h after injury), tachypnoea, dyspnoea
  • Pyrexia

Dermatological:

  • Non-blanching petechial rash (differential for meningococcal septicaemia)

Common bone pathologies:

‣
Osteomyelitis
‣
Physiology
‣
Name the 3 routes in which infection can spread to bone.
  1. Haematogenous (most common)
  2. Direct inoculation (normal vascularity): Open wound from trauma or surgery.
  3. Contiguous spread (poor vascularity): Diabetic foot infections / peripheral vascular disease
‣
What is the pathophysiology?
  1. Pathogen in the bone → Apoptosis & biofilm formation (in antibiotic resistant infections)
  2. Inflammation → Subperiosteal reaction → Periosteum lifts from the bone
    3. ‣
    What is the XR finding called when periosteum lifts from bone?
    • "Onion skin" finding
    ‣
    What effect does this have on treatment?
    • Antibiotics stuggle to penetrate due to reduction in bone blood supply
  3. Restricted bone blood supply & nutrition → Subperiosteal abscess (bone necrosis)
    4. ‣
    What are the 3 XR findings that may be visible at this point and what do they represent?
    1. Sequestrum: A piece of dead bone has become separated during necrosis
    2. Cloaca: Site of pus escape
    3. Involucrum: Separation of bone from periosteum stimulates new bone formation from the periosteum
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Presentation
‣
How may they present?
  • Bone pain, effusion, swelling
  • Systemic: Fever, WL, malaise (consider sepsis)
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What are the 2 most important points in the history?
  1. Timing:
    • Acute infection (< 2W)
    • Chronic infection (> 3M)
  2. Age: Paediatric / adult
‣
Name 5 risk factors.
  1. Age: Children & elderly
    2. ‣
    Why are children at risk?
    • Highly vascular bone and immune system isn't fully developed
  2. Diabetes
  3. Peripheral vascular disease
  4. Trauma
  5. Immunosuppression
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What area of the bone is likely to be affected in children?
  • Metaphysis due to high vascularity
‣
What organism is likely to have caused OM in the following patients:
‣
Child
  • S. aureus (80%)
‣
Patient with sickle cell anaemia
  • Salmonella
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IVDU
  • P. aeruginosa
  • E. coli
  • Klebsiella
  • S. aureus
‣
Immunosuppressed patient
  • Bartonellla
  • Fungal
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What organism should be considered in all patients?
  • TB
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How would you investigate these patients?
  • Bloods:
    • Blood culture (before antibiotics)
    • FBC, U&E, CRP, ESR, LFT, VBG (for lactate)
  • Radiology:
    • X-ray: "Onion skin", sequestrum, cloaca, involucrum
      • No changes are seen in < 2 weeks
    • MRI
  • Tissue biopsy: Culture & histology looking for tumour
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How would you manage these patients?
  1. ABCDE
  2. High dose IV antibiotics
    • Empirical: IV Flucloxicillin & rifampicin/fusidic acid
    • Minimum 6 weeks (acute), lifelong oral (chronic) - discuss with microbiology for a thorough individualised plan
  3. Surgical: Remove sequestrum, debride soft tissue, amputation
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Fractures
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What is the technical definition of a fracture?
  • Disruption in the continuity of a bone
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What are the key risk factors for avascular necrosis (AVN)?
  1. Long-term steroid use
  2. Chemotherapy
  3. Alcohol excess
  4. Trauma
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What is an avulsion fracture?
  • Fracture occurring when a tendon or ligament pulls away from a bone and carries a fragment of bone with it.
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What is compartment syndrome?

Trauma → Increased compartmental pressure → Compromised perfusion → Muscle & nerve damage within that compartment.

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What is the risk with compartment syndrome?
  • Acute compartment syndrome threatens the limb it affects and is a surgical emergency.
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What are the 5 characteristic signs & symptoms?
  1. Pain (early & common)
    • Pain out of proportion with the severity of the injury
    • Pain on passive movement
  2. Paraesthesia (ischaemia of nerves)
  3. Pallor (vascular insufficiency, uncommon)
  4. Pulseless (rare)
  5. Paralysis (rare & late)
‣
Name 2 fractures that are commonly associated with compartment syndrome.
  1. Tibial shaft fracture
    2. ‣
    X-ray
    Kinderradiologie Olgahospital Klinikum Stuttgart, CC BY-SA 3.0
    Kinderradiologie Olgahospital Klinikum Stuttgart, CC BY-SA 3.0 creativecommons.org/licenses/by-sa/3.0, via Wikimedia Commons. No changes were made.
  2. Supracondylar arm fracture
    3. ‣
    X-ray
    • Sail sign on an elbow radiograph indicates an intra-articular fracture.
    James Heilman, MD, CC BY-SA 4.0
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What are the key management steps for a fracture?
  1. ABCDE, immobilise +/- reduce, check for catastrophic haemorrhage
  2. Monitor neurovascular status throughout
  3. Manage infection:
    • Tetanus prophylaxis
    • IV broad-spectrum antibiotics
    • Thorough debridement
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What is the Salter-Harris system used to classify?

Fractures involving the epiphyseal growth plate.

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What are the grades?
  1. Physis
  2. Physis & metaphysis
  3. Physis & epiphysis
  4. Physis, metaphysis & epiphysis
  5. Crush fracture involving the physis

SalterHarris.png: Dr Frank Gaillard (MBBS, FRANZCR) (
‣
Classify the following fractures:
Gilo1969 at English Wikipedia, CC BY 3.0
Gilo1969 at English Wikipedia, CC BY 3.0 creativecommons.org/licenses/by/3.0, via Wikimedia Commons. No changes were made.
‣
Fracture 1
  • Salter-Harris 1
Gilo1969 at English Wikipedia, CC BY 3.0
Gilo1969 at English Wikipedia, CC BY 3.0 creativecommons.org/licenses/by/3.0, via Wikimedia Commons. No changes were made.
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Fracture 2
  • Salter-Harris 4
Gilo1969 at English Wikipedia, CC BY 3.0
Gilo1969 at English Wikipedia, CC BY 3.0 creativecommons.org/licenses/by/3.0, via Wikimedia Commons. No changes were made.
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Fracture 3
  • Salter-Harris 2
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Bone tumours
‣
What are the salient points from the history?

May be presenting with bone pain, swelling, WL, fever; ask:

  1. Age of patient
  2. Onset & duration of symptoms
  3. Location of pain
  4. Previous history of cancer

Two types:

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Primary
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Benign
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Name 3 differentials for a benign bone tumour.
  1. Osteoid osteoma (young)
  2. Haemangioma
  3. Aneurysmal bone cyst (0-20 years)
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Why are these tumours still treated aggressively?
  • High risk of malignant transformation
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Malignant
‣
Sarcoma

A sarcoma is a malignant tumour of mesenchymal origin: Muscle, bone, haematopoietic, connective tissue.

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Osteosarcoma (most common)
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How would they present?
  • Bone pain, swelling and erythema around the metaphysis of a long bone
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What’s the most common primary site?
  • Femur
‣
What X-ray findings are you looking for?
  1. Codman's triangle
  2. Sunray spicules
Yousef Samir, CC BY-SA 4.0
Yousef Samir, CC BY-SA 4.0 creativecommons.org/licenses/by-sa/4.0, via Wikimedia Commons. No changes were made.
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What other investigations would you like to do?
  • MRI
  • CT thorax, abdomen, pelvis → Metastases
  • Biopsy
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How would you manage it?
  • Medical: Chemotherapy
  • Surgical: En-bloc resection & arthroplasty, amputation
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Where do they most commonly metastasise to?
  • Lung
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Ewing sarcoma
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How would they present?
  • Young patient with unexplained pain and swelling in a limb
  • Can affect the pelvis / spine
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What are you looking for on X-ray?
  • Lytic bone change
  • Soft tissue reaction
  • "Onion skin" periosteal change
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How is it managed?
  • Medical: Chemotherapy, radiotherapy
  • Surgical: En-bloc resection & arthroplasty, amputation
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Chondrosarcoma
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What age group present with this?
  • Elderly adults
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What area of the skeleton is affected?
  • Axial
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How is it managed?
  • Surgical resection (not responsive to chemo/radiotherapy)
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Multiple myeloma
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How do these patients present?
  1. Calcium - Hypercalcaemia
  2. Renal failure - Antibodies block the tubule flow
  3. Anaemia - Bone marrow infiltration
  4. Bone pain/fractures - ↑ Osteoclast activity caused by cytokines released by plasma cells
  5. Bleeding - thrombocytopenia
  6. Infection
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Investigations
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What are the initial diagnostic investigations?
  1. Urine Bence-Jones protein
  2. Serum-free Light-chain assay
  3. Serum Immunoglobulins
  4. Serum Protein electrophoresis
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What result will ALP & phosphate show?
  • Normal ALP, differentiates from bone metastases where it will be high
  • Normal phosphate
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What is seen on blood film?
  • Rouleaux - Stacks of aggregated RBCs
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What is the best diagnostic investigation?
  • Bone marrow aspirate & biopsy: > 10% plasma cells in bone marrow
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What X-ray findings may you see?
  • Punched out lytic lesions
  • Raindrop skull
Mikael Häggström, CC0, via Wikimedia Commons
Mikael Häggström, CC0, via Wikimedia Commons
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How do we prevent pathological fractures?
  • Bisphosphonates: Zolendronic acid
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How are they managed?
  1. Suitable for transplant: Allogenic/autologous HPSC transplant
  2. Not suitable: MPT → Melphalan, prednisolone, thalidomide
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Secondary: What common primaries metastasise to bone?

‘Lead kettle’: PB-KTL

  • Prostate
  • Breast
  • Kidney
  • Thyroid
  • Lung
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Bone disorders
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Paget's disease

Focal bone resorption → ↑ Chaotic bone deposition → Sclerotic bone

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Where does it commonly affect?
  • Proximal long bones
  • Pelvis
  • Skull
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What may are you looking for on bloods?
Calcium
↔︎
Phosphate
↔︎
ALP
↑↑
PTH
↔︎
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What are you looking for on X-ray?
  1. Cortical thickening
  2. Sclerosis
Jmarchn, CC BY-SA 3.0
Jmarchn, CC BY-SA 3.0 creativecommons.org/licenses/by-sa/3.0, via Wikimedia Commons. No changes were made.
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How do you manage these patients?
  • Bisphosphonates
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Osteoporosis

↑ Bone resorption & ↓ bone formation → Demineralised bone → Weak bones

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How do you assess their risk?
  • FRAX score: Estimates the 10-year risk of fragility fracture
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If risk is > 10%, what do you do?
  • DEXA scan
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When do you immediately start treatment without scanning?
  • In post-menopausal women with a fracture
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How do you manage them?
  • Bisphosphonates
  • Calcium replacement
  • Vitamin D replacement
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💪 Upper Limb
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Anatomical cases

What nerve is likely to be affected following these injuries:

‣
Head of humerus fracture/shoulder dislocation
  • Axillary
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Humeral mid-shaft fracture
  • Radial
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Proximal radial fracture
  • Radial
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Medial epicondyle fracture
  • Ulnar

What nerve is affected based on the following symptoms:

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Wrist drop
  • Radial
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Loss of forearm pronation and weak wrist flexion
  • Median (elbow)
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Thenar muscle wasting and inability to oppose the thumb
  • Median (wrist)
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Claw hand
  • Ulnar
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Winged scapula
  • Long thoracic

Neonatal presentation:

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12 hour old child has an internally rotated arm with an extended elbow. What likely occurred during birth and what has been damaged?
  • Shoulder dystocia → Brachial plexus damage (C5/6) → Erb-Duchenne palsy
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Fracture cases

Diagnose the following fractures:

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Patient fell forwards onto an outstretched hand. X-ray shows a fracture of the distal radius with volar displacement and angulation of the distal fragment.
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Patient fell onto outstretched palm and now has snuffbox tenderness, pain on wrist movements and on thumb compression.
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Patient fell forwards onto an extended outstretched hand and now has dorsal wrist displacement & angulation.
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Patient presents with hand swelling and pain following punching a wall earlier.
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Fracture of the distal third of the radial shaft with dislocation of the radio-ulnar joint.
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Fracture of the proximal third of the ulnar shaft and anterior dislocation of the radial head at the capitulum.

Anatomy:

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Shoulder
‣
Shoulder dislocation
‣
In which direction is the shoulder most likely to dislocate?
  • Anterior (95%)
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When do you see Hill-Sachs lesion?
  • Anterior dislocation
  • This is a "dent" of the postero-supero-lateral humeral head that occurs in association with anterior instability or dislocation of the glenohumeral joint
Mikael Häggström, M.D., CC0, via Wikimedia Commons
Mikael Häggström, M.D., CC0, via Wikimedia Commons
‣
What does a positive light bulb sign on X-ray indicate?
  • Posterior dislocation
Hellerhoff, CC BY-SA 3.0
Hellerhoff, CC BY-SA 3.0 creativecommons.org/licenses/by-sa/3.0, via Wikimedia Commons. No changes were made.
‣
How do you manage this?
  1. Reduction of the arm (relocate)
    • Check neurovascular status before & after
  2. X-ray to check for fractures from relocation
  3. Collar & cuff for 2-4 weeks
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What are the differentials for shoulder pain worse on abduction with a painful arc?
  1. Rotator cuff muscle tear (supraspinatus)
    2. ‣
    How would we identify this?
    • Arc is painful in the first 60 degrees
  2. Sub-acromial impingement
    3. ‣
    How would we identify this?
    • Painful would be between 60-120 degrees
  3. Calcific tendonitis

What’s the diagnosis based on the following presentations:

‣
Patient fell onto an outstretched hand playing rugby and now has significant pain on the scarf test.
  • Acromion fracture
‣
40 year old female presents with a progressively stiffening shoulder over the last 6 months, especially affecting external rotation (both active and passive).
  • Adhesive capsulitis
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A patient presents with pain, bruising and swelling of his left shoulder following taking down a heavy box from a high shelf. On examination there is a bulge in the middle of the upper arm.
  • Biceps tendon rupture: 'Popeye deformity' is present
James Heilman, MD, CC BY-SA 3.0
James Heilman, MD, CC BY-SA 3.0 creativecommons.org/licenses/by-sa/3.0, via Wikimedia Commons. No changes were made.
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Elbow

What’s the diagnosis based on the following presentations:

‣
A patient presents with pain worse on wrist flexion and pronation. They have 4th & 5th finger numbness.
  • Medial epicondylitis affecting the ulnar nerve
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A patient presents with pain worse on resisted wrist extension and supination of the forearm with the elbow extended.
  • Lateral epicondylitis
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A middle-aged male patient presents with swelling, pain, warmth and erythema over the posterior aspect of the elbow.
  • Olecranon bursitis
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Hand
‣
Carpal tunnel syndrome
‣
Name 4 causes.
  1. Overuse (desk work)
  2. Rheumatoid arthritis
  3. Pregnancy
  4. Oedema
  5. Lunate fracture
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Describe a classic presentation.

Pins & needles in thumb, index, middle finger classically at night. Can be relieved by the patient shaking their hand.

  • Motor: Weakness of thumb abduction and thenar eminence wasting
  • Signs:
    • Tinel's sign: Tapping flexor retinaculum causes paraesthesia
    • Phalen's sign: Upside down praying recreates symptoms
      • Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". CC BY 3.0
      Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". CC BY 3.0 creativecommons.org/licenses/by/3.0, via Wikimedia Commons. No changes were made.
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How is carpal tunnel managed?
  1. Wrist splints (at night)
  2. Corticosteroid injection
  3. Decompression surgery

What’s the diagnosis based on the following presentations:

‣
A patient presents with radial wrist pain and radial styloid tenderness. On examination, when the thumb is flexed and the wrist undergoes ulnar deviation there is pain.
  • De Quervain's tenosynovitis: Sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed
    • Finkelstein's test is described
‣
Patient has a lost mobility in the ring and little finger with thickening of the palm and inability to fully extend the MCP joints.
  • Dupytren's contracture
    • ‣
    What are the specific causes for this?
    1. Manual labour
    2. Alcoholic liver disease
    3. Drugs, e.g. phenytoin
    4. Diabetes mellitus
    5. Hand trauma
    ‣
    When would you consider active management?
    • When the patient cannot place their hand flat on a surface
‣
🎒 Spine
‣
Cauda equina syndrome

Compression of the lumbosacral nerve roots that extend below the spinal cord.

‣
What can cause this compression?
  • Disc prolapse at the L4/5 or L5/S1 level (common)
  • Stenosis of the spinal canal
  • Tumour
  • Infection
  • Trauma
‣
What are the typical symptoms & signs?
  • Bladder dysfunction
  • Low back pain
  • Bilateral or unilateral sciatica
  • Lower limb weakness or numbness
  • Bowel dysfunction
  • Sexual dysfunction
‣
How would you investigate?
  1. MRI lumbar spine without contrast
  2. CT lumbar spine without contrast (if MR is unavailable or contraindicated)
‣
How are they managed?
  • Decompression surgery (if appropriate in clinical context)
‣
Ankylosing spondylitis

A chronic progressive inflammatory arthropathy leading to radiological changes in the spine and sacroiliac joints.

‣
Diagram: The pathophysiological process
Senseiwa
Senseiwa, CC BY-SA 3.0 creativecommons.org/licenses/by-sa/3.0/, via Wikimedia Commons. No changes were made.
‣
Who typically presents with this?
  • Men between 20-30 years
‣
What symptoms will they have?
  • Lower back pain & stiffness
    • Early sign: Reduced lateral flexion of spine
  • Usually worse in the morning & improves with exercise
‣
What will you look for on examination?
  • Reduced lumbar mobility
    • Reduced lateral spinal movement (first sign)
    • Shöber's test: Distance between lines changes by < 5cm
  • Reduced chest expansion
‣
Name the other features.
  1. Aortic regurgitation
  2. AV node block
  3. Amyloidosis
  4. Apical fibrosis
  5. Anterior uveitis
  6. Achilles tendonitis
‣
What is the key XR finding for diagnosis?
  • Sacroiliitis
‣
What features are present on the following X-rays:
‣
X-ray 1
‣
Answer
  • Bamboo spine: Fusion of vertebrae
  • Dagger sign: Ossification of supraspinous and interspinous ligaments
Stevenfruitsmaak, CC BY-SA 3.0
Stevenfruitsmaak, CC BY-SA 3.0 creativecommons.org/licenses/by-sa/3.0, via Wikimedia Commons. No changes were made.
‣
X-ray 2
‣
Answer
  • Squaring of lumbar vertebrae: Osteitis of anterior corners
  • Syndesmophytes: Ossification of annulous fibrosus
James Heilman, MD, CC BY-SA 4.0
James Heilman, MD, CC BY-SA 4.0 creativecommons.org/licenses/by-sa/4.0, via Wikimedia Commons. No changes were made.
‣
How would you manage a patient with AS?
  1. NSAIDs & regular exercise
  2. Physiotherapy
  3. Anti-TNF drugs: Etanercept & adalimumab
    • Indicated after 2 NSAIDs have been tried

What’s the diagnosis based on the following presentations:

‣
A patient had sudden onset back pain after bending to pick something up.
  • Disc prolapse
    • ‣
    Patient has severe pain on supine straight leg raise (sciatic stress test). What spinal levels are affected?
    • L5/S1
      • ‣
      How do you differentiate between them?
      • Testing sensation:
        • L5 → Dorsum of foot
        • S1 → Lateral foot
          • Absent ankle reflex
    ‣
    A different patient has a positive femoral stretch test and absent knee reflex. What spinal levels are affected?
    • Spinal levels: L3/4 (Both supply knee reflex)
      • ‣
      How do you differentiate them?
      • Test sensation:
        • Anterior thigh → L3
        • Anterior knee/medial calf → L4
    ‣
    How are they managed?
    1. Analgesia (NSAIDs first-line)
    2. Physiotherapy (if no red flags)
‣
A patient presents with back pain, pyrexia, rigors and lower limb neurological signs.
  • Discitis
    • ‣
    How is this managed?
    • 6-8 weeks IV antibiotics
    ‣
    2 weeks after treatment has finished, the symptoms return, her NEWS is now 9. Likely diagnosis?
    • Epidural abscess
‣
A young man presents with lower back pain and stiffness worse in the morning and improves with activity.
  • Ankylosing spondylitis
‣
A patient presents with claudication of the buttocks and thighs, muscle atrophy in the legs and impotence.
  • Leriche syndrome: Atherosclerotic occlusive disease involving the abdominal aorta and/or iliac arteries
‣
A 47 year old male presents with gradual onset leg pain, numbness and weakness worse on walking. It is relieved by sitting & leaning forward.
  • Spinal stenosis (neurogenic)
    • ‣
    How do you investigate this?
    • MRI spine
    ‣
    How are they managed?
    • Analgesia
‣
A patient presents with lower back pain, urinary incontinence/retention, perianal paraesthesia and decreased anal tone.
  • Cauda equina syndrome
‣
An IVDU patient has severe back pain with pyrexia. Relieved by laying on their back and keeping their left knee slightly flexed and hip externally rotated. Hip extension is particularly painful.
  • Psoas abscess
‣
A diabetic smoker presents with pain on walking 50 metres, that is relieved by rest. Foot pulses are absent.
  • Peripheral arterial disease
‣
🦵 Lower Limb
‣
Nerve damage cases

What nerve may be damaged and what are the subsequent symptoms in the following injuries:

‣
Anterior hip dislocation
  • Obturator nerve
‣
Posterior hip dislocation
  • Sciatic nerve
    • ‣
    How do you check if it is intact?
    • Sensation: Dorsum of foot (L5), lateral aspect of foot (S1)
    • Ankle reflex (S1)
‣
Neck of fibula fracture
  • Common peroneal nerve
‣
Misplaced IM injection placed in the upper outer quadrant of the buttock
  • Superior gluteal nerve → Hip abduction dysfunction → Positive trendelenburg

Anatomy:

‣
Hip
‣
Neck of femur (NOF) fracture
‣
What are the risk factors?
  • Old age
  • Falls risk
  • Female
  • Post-menopausal
  • Family history of osteoporosis
  • Alcoholic
‣
How do you investigate?
  1. Bloods: FBC, U&E, clotting, G&S.
  2. X-ray pelvis & lateral views of the affected hip
  3. Consider MRI / CT pelvis (if X-ray negative but high clinical suspicion)
‣
What analgesia is given to all of these patients?
  • Iliofascial nerve block

Key questions:

  1. Is the fracture intracapsular or extracapsular?
    2. ‣
    How would you manage each of the following patients:
    ‣
    Intracapsular displaced fracture with a mobile patient
    • Mobile: Total hip replacement
    • Not mobile: Hemiarthroplasty
    ‣
    Trochanteric fracture.
    • Dynamic hip screw
    ‣
    Subtrochanteric fracture.
    • Intramedullary nail
  2. Is the fracture displaced or not?
    3. ‣
    If displaced, what are they at risk of?
    • Avascular necrosis of the femoral epiphysis
      • ‣
      What imaging will pick this up & how long before visible changes can be seen?
      • MRI
      • ~ 4 weeks

Cases:

‣
Adult

What’s the diagnosis based on the following presentations:

‣
Patient fell from 40m and has severe left leg pain associated with a shortened, adducted, internally rotated leg.
  • Posterior hip dislocation (90%)
    • ‣
    How are they managed?
    1. ABCDE & check for major haemorrhage
    2. Reduction under general anaesthetic within 4 hours
      • Check neurovascular status throughout and X-ray after to check for fractures
    3. Long-term physiotherapy
    ‣
    What are the complications?
    1. Sciatic/femoral nerve injury (common)
    2. Avascular necrosis (AVN)
    3. Osteoarthritis
‣
An elderly female falls onto her hip causing severe pain, her leg is shortened and externally rotated.
  • Neck of femur (NOF) fracture
‣
Patient was in a road traffic accident and now has an abducted and externally rotated right leg.
  • Anterior hip dislocation (not shortened as a fracture would be)
‣
An IVDU patient has back pain and cannot lie flat on the bed. He is pyrexial and flexing his hip against pressure and OE when you hyperextend his hip it causes pain.
  • Psoas abscess
    • ‣
    How are they managed?
    • IV antibiotics & percutaneous drainage
‣
Pain on palpation of the greater trochanter and on passive external rotation.
  • Trochanteric bursitis
‣
Patient presents with a burning sensation over the antero-lateral aspect of her right thigh.
  • Meralgia paraesthetica: Compression of the lateral cutaneous nerve of thigh
‣
Child

What’s the diagnosis based on the following presentations:

‣
Newborn has positive Barlow's and Ortolani's tests.
  • Developmental dysplasia of the hip (DDH)
‣
5 year old has a viral infection and develops acute hip pain following this.
  • Transient synovitis
    • ‣
    How would you investigate them?
    • Joint aspiration to rule out septic arthritis
    • USS: Effusion is common
    ‣
    What are the Kocher criteria & what are they used for?
    • The Kocher criteria are used to differentiate septic arthritis from transient synovitis. They are:
      1. Non-weight bearing on affected side
      2. Temp > 38.5°C
      3. ESR > 40
      4. WCC > 12x10⁹
‣
7 year old boy has progressively worsening left hip pain and limp. XR shows flattening of femoral head and widening of joint space.
  • Perthes' disease: AVN of femoral head
‣
13 year old obese boy presents with knee pain and loss of internal rotation of the leg.
  • Slipped upper femoral epiphysis
    • ‣
    How would you manage them?
    • Internal fixation
‣
14 year old boy with pain and swelling in the knees, ankles and elbows that has been going on for 6 months. ANA positive.
  • Juvenile idiopathic arthritis: Arthritis in < 16 years
‣
Patient with hip pain, stiffness and erythema associated with pyrexia, hypotension and tachycardia.
  • Septic arthritis
‣
Knee & Shin
‣
Ligament injuries
‣
Anatomy
Mysid, Public domain, via Wikimedia Commons
Mysid, Public domain, via Wikimedia Commons
‣
How would you investigate for these?
  • X-ray: Rule out avulsion fractures, do not directly identify ACL injury.
  • MRI: Visualise ACL tear, along with associated injury to the menisci and other structures.
‣
How are they managed?
  • Initial: Protection, rest, ice, compression, elevation, and analgesia (as appropriate)
  • Bracing
  • Physiotherapy, and activity modification
  • Surgical reconstruction (either early or delayed)

Types:

‣
Anterior cruciate ligament (ACL)
‣
Diagram
BruceBlaus, CC BY-SA 4.0
BruceBlaus, CC BY-SA 4.0 creativecommons.org/licenses/by-sa/4.0, via Wikimedia Commons. No changes were made.
‣
What is a typical history?
  • A sudden, painful, audible pop noise presenting with joint instability
  • Immediate swelling after injury → Haemarthrosis
  • Usually occurs as a result of an acute non-contact deceleration injury, forceful hyperextension, or excessive rotational forces around the knee
‣
What signs could you elicit?
  • Positive anterior drawer test
  • Often tender at lateral femoral condyle, lateral tibial plateau, and tibiofemoral joint lines
‣
Posterior cruciate ligament (PCL)
‣
What is a typical history?
  • Direct blow to the front of the knee, e.g. a bent knee hitting a dashboard in a car crash, or a fall onto a bent knee in sports
  • Twisting or hyperextension injury → Pulling or stretching the ligament
‣
What signs could you elicit?
  • The knee may appear to sag backwards when bent.
  • Positive posterior drawer test
‣
Medial collateral ligament (MCL)
‣
What is a typical history?
  • Force applied to the lateral knee
‣
How do you examine for this?
  • Knee 15° → Apply lateral force to foot → Valgus leg position
‣
Lateral collateral ligament (LCL)
‣
What is a typical history?
  • Outward force to the knee, often during sport
  • Twisting on the side of the foot
  • Extending the knee beyond its normal range of movement
‣
How do you examine for this?
  • Knee 15° → Apply medial force to foot → Varus leg position
‣
Meniscus tear
‣
What is a typical history?
  • Twisting injury
  • Joint locking
  • Delayed knee swelling
‣
How do you examine for this?
  • Positive McMurray's test

What’s the diagnosis based on the following presentations:

‣
An 18 year old athletic teenager presents with knee pain and tenderness over the tibial tuberosity.
  • Osgood-Schlatter's disease: Multiple micro-fractures at the point of insertion of the tendon into the tibial tuberosity
‣
An athletic teenage girl complains of pain on going downstairs or at rest with pseudolocking.
  • Chondromalacia patellae: Patella cartilage deteriorates & softens
‣
A 14 year old patient presents with knee pain and swelling, typically following exercise. OE there is knee catching and locking.
  • Osteochondritis dissecans
‣
X-ray shows the quadriceps tendon has torn from the patella, taking a section of bone with it.
  • Avulsion fracture
‣
65 year old with gout and knee OA has a swelling behind the knee that is more painful when the knee is extended.
  • Baker's cyst: Common following a minor trauma to the knee
    • ‣
    How would you manage them?
    • Conservative (resolve spontaneously in children)
‣
40 year old fractures his tibial shaft and is put into a cast. 2 days later he presents with leg pain, numbness and inability to dorsiflex his foot. Dorsalis pedis present.
  • Compartment syndrome
    • Inability to dorsiflex foot → Common fibular nerve afffected
    • Microvasculature is affected first so dorsalis pedis being present is irrelevant → Condition still severe
      • ‣
      How would you investigate?
      • Measure intracompartmental pressure.
        • Pressure > 40mmHg → Diagnostic
      ‣
      How would you manage them?
      • Fasciotomy to relieve the pressure
‣
Foot & Ankle
‣
Patient 'went over' on their ankle and heard a crack. How do you decide if they need an XR?

Ottawa criteria

  1. Cannot weight bear for 4 steps
  2. Medial malleolus tenderness
  3. Lateral malleolus tenderness

‣
If the ankle is fractured, how do you manage it?
  1. Displaced → Promptly reduce fracture → Prevents AVN of overlying skin
  2. Stable → Plaster of paris
  3. Unstable/comminuted → Surgical fixation (compression plate)
‣
What is the syndesmosis?
  • Fibrous joint between the tibia & fibula
‣
How do you classify fibular fractures?

Weber classification

  • A: Below the syndesmosis: Able to weight bear as tolerated in a controlled active motion (CAM) boot
  • B: At level of the syndesmosis
  • C: Above the syndesmosis
DrFO.Tn
DrFO.Tn, CC BY 4.0 creativecommons.org/licenses/by/4.0, via Wikimedia Commons. No changes were made.

What’s the diagnosis based on the following presentations:

‣
Patient presents with gradual onset of posterior heel pain, worse following activity and in the morning.
  • Achilles tendonitis
    • ‣
    How do you manage this?
    1. Lifestyle: Rest the foot
    2. Medical: NSAIDs & physiotherapy
‣
Patient was running and heard a 'pop' in the ankle, followed by sudden onset pain in the calf and is now struggling to walk.
  • Achilles tendon rupture
    • ‣
    What risk factors may he have?
    • Medications: Quinolones (ciprofloxacin)
    • Hypercholesterolaemia: Xanthomata
    ‣
    The patient is lying prone on the bed, what signs do you look for?

    Simmond's triad:

    1. Affected foot is more dorsifexed than unaffected
    2. Gap in tendon on inspection/palpation
    3. Feel along tendon - Discontinuation
‣
Patient who is an avid runner presents with severe heel pain that is worse after running.
  • Plantar fasciitis
‣
A 58-year-old lady presents with a sharp pain in her left foot. On examination, palpation is very painful on the dorsum of the foot and the second & third metatarsals are displaced outwards.
  • Morton's neuroma
  • Investigation: USS

🔪 General Surgery

‣
🤮 Acute Abdomen
‣
General
‣
Name 5 medical causes of abdominal pain.
  1. Lead poisoning
  2. Acute intermittent porphyria
  3. Gastritis
  4. DKA
  5. Hypercalcaemia
  6. UTI
  7. Gastroenteritis
  8. Pneumonia
  9. MI
‣
What investigations would you consider for a patient with acute abdominal pain? What are you looking for on each?
  • Bedside:
    • Urinalysis - UTI
    • BM - DKA
  • Bloods:
    • FBC - WCC (infection), Hb (anaemia)
    • U&E - Kidney dysfunction
    • LFT - Liver, gallbladder, bile duct status
    • CRP - Infection
    • Ca²⁺ - Hypercalcaemia
    • Amylase - Pancreatitis
    • INR - Synthetic liver function
    • Lactate - Tissue ischaemia
  • Radiology:
    • AXR - Bowel obstruction
    • Erect CXR - Bowel perforation
    • CT abdo - Everything
    • USS
‣
Abdominal surgical scars
‣
Which incision can be used for an appendicectomy?
  • Lanz
‣
Which incision can be used for a liver transplant?
  • Mercedes benz
‣
Which incision can be used for an open cholecystectomy?
  • Kocher
‣
Which incision can be used for a C-section?
  • Pfannenstiel
‣
Which incision can be used for a renal transplant?
  • Rutherford Morrison (extended Lanz)
‣
Which incision can be used for a Whipple's procedure??
  • Rooftop
‣
Common Cases
‣
A 55 year old smoker presents with sudden onset abdominal pain radiating to the back. He has collapsed and is currently unconscious. Femoral pulses are weak. Diagnosis?
  • Ruptured AAA
    • ‣
    When screening for AAA, what size dilation is referred?
    • > 5.5cm
‣
A 12 year old patient presents with high fever and generalised abdominal discomfort following a recent URTI. Diagnosis?
  • Mesenteric adenitis
‣
A 14 year old female is admitted with sudden onset RIF pain, otherwise well. OE: RIF tenderness but no guarding, afebrile. Urinary dipstick is normal. LMP: 2 weeks ago, normal and pregnancy test is negative. Diagnosis?
  • Mittelschmerz - Ovulatory pains
‣
A 27 year old female, with multiple sexual partners, presents with suprapubic pain and PV discharge for 3 days. She now has new RUQ pain. She has a history of STI. Diagnosis? Management?
  • Fitz-Hugh Curtis syndrome
    • Chlamydia infection → Peri-hepatic inflammation
  • Management: PO Doxycycline/azithromycin
‣
A 60 year old patient presents with colicky abdominal pain & vomiting. OE they have abdominal distension & tinkling bowel sounds. Diagnosis?
  • Bowel obstruction
  • Investigations:
    • AXR
    • CT abdomen
‣
A patient with AF presents with sudden-onset abdominal pain out of proportion with physical signs. They have fever and N&V. Diagnosis?
  • Mesenteric infarction
    • Do an ABG to check for pH (acidotic) & lactate (high due to anaerobic respiration)
‣
A 13 year old girl presents with abdominal pain that started centrally but is now localising to the RIF. She also has vomiting and anorexia. What signs should you look for?
  • Signs:
    • Tenderness on McBurney's point
    • Guarding
    • Rigidity
    • Rosving's sign (LIF tenderness)
‣
What is the likely diagnosis?
  • Appendicitis
‣
What are your other differentials?
  • Ovarian torsion
  • Ectopic pregnancy
  • Mittelschmerz
  • Meckel's diverticulum
  • Mesenteric adenitis
‣
Management?
  • ABCDE
  • NBM
  • Fluids
  • Analgesia
  • Laparoscopic appendicectomy
‣
🥐 Upper GI

What is the likely diagnosis based on the following presentations:

‣
A 45 year old obese lady presents with RUQ pain and right shoulder pain. She also has a fever and feels nauseous. OE: RUQ tenderness and palpable mass.
  • Acute cholecystitis
    • ‣
    Why do Crohn's patients get gallstones?
    • Bile salts are absorbed in the terminal ileum and the inflammation in Crohn's stops this → Less solubility for pigment
    ‣
    What sign can you try to elicit on examination?
    • Murphy’s sign
    ‣
    What pathogens are likely to have caused this infection?
    • E. coli
    • Klebsiella
    • Enterococci
    ‣
    How do you investigate them?
    • Bloods:
      • FBC, CRP, U&E, LFT (typically normal), clotting, G&S
    • Radiology:
      1. USS
      2. Cholescintigraphy (HIDA scan)
    ‣
    How is the infection managed?
    • IV antibiotics: Tazocin & metronidazole
    ‣
    What is a gallbladder empyema? How is it managed?
    • Build up of pus within the gallbladder
    • Cholecystostomy for drainage & IV antibiotics.
‣
A patient with a history of gallstones presents with symptoms of bowel obstruction & pneumobilia.
  • Gallstone ileus: Fistula forms between bowel & gallbladder
    • ‣
    What is pneumobilia?
    • Air in the biliary tree
‣
Patient presents with RUQ pain, fever and jaundice.
  • Ascending cholangitis: Can also have hypotension and confusion.
    • ‣
    How would you investigate them?
    1. USS: Looking for bile duct dilation and bile duct stones
      1. MRCP if USS shows bile duct dilation but no stones
      2. ERCP if stones identified on either USS or MRCP
    ‣
    How would you manage them?
    1. Tazocin: Manage ongoing infection
    2. ERCP/PTC after 24-48 hours
‣
A 45 year old alcoholic presents with sudden-onset, constant epigastric pain radiating through to the back. He has red tender fingers.
  • Pancreatitis
  • Red, tender fingers represent migratory thrombophlebitis (Trousseau's syndrome).
    • ‣
    What key blood tests would confirm your suspicion?
    • Amylase: 3X normal (raised in 75%)
    • Lipase (more sensitive, specific & expensive)
    ‣
    What are the other causes of pancreatitis?
    • Idiopathic
    • Gallstones
    • Ethanol
    • Trauma
    • Steroids
    • Mumps
    • Autoimmune
    • Scorpion sting
    • Hypercalcaemia, hypertriglyceridaemia
    • ERCP
    • Drugs - Azathioprine
    ‣
    How do you assess severity?
    • Glasgow scoring system
      • Hypocalcaemia (< 2): Indication of severe pancreatitis (common exam question)
      • Hyperglycaemia: Limiting insulin production
    ‣
    How is it managed initially?
    1. ABCDE
    2. Aggressive fluid resuscitation (see local guidelines)
    3. Interventional:
      • Drain pseudocysts
      • Antibiotics if infection/necrosis
      • Surgery for removing necrotic tissue
    ‣
    Name 4 complications.
    1. ARDS
    2. Pancreatic pseudocyst
    3. Chronic pancreatitis
    4. Pancreatic necrosis/infection
‣
70 year old patient presents with painless jaundice & unintentional weight loss. They have pale stools and dark urine. Gallbladder is not palpable and there is no tenderness on examination. Diagnosis?
  • Pancreatic cancer
    • ‣
    How would you investigate them?
    • Bloods: CA19-9
    • Radiology: CT TAP (thorax, abdomen, pelvis), endoscopic USS w/ biopsy
    ‣
    How are the following cases managed:
    ‣
    Pancreatic head tumour.
    • Whipple's procedure
    ‣
    Pancreatic body/tail tumour.
    • Distal pancreatectomy
    ‣
    What other management should be considered in both of these scenarios?
    • Chemotherapy (adjuvant)
‣
A rugby player gets tackled and experiences severe abdominal pain following this.
  • Splenic rupture
    • ‣
    How would you manage this?
    • Splenectomy
      • ‣
      Name 3 other indications for splenectomy.
      1. EBV → Splenic rupture
      2. Lymphoma
      3. Hypersplenism (hereditary spherocytosis)
      ‣
      Is any prophylaxis needed after surgery? If so, what and how long for?
      • Penicillin V for minimum 2 years but often lifelong
      ‣
      What would be seen on FBC post-splenectomy?
      • Thrombocytosis - Spleen breaks down platelets
      ‣
      Name a feature seen on blood film after a splenectomy.
      • Howell-Jolly bodies
‣
A patient presents with severe haematemesis. What are your differentials?
  • Differentials:
    1. Oesophageal varices
      2. ‣
      How would you manage them?
      1. Terlipressin
      2. Banding/sclerotherapy
      3. Sengaksten-Blakemore tube
    2. Perforated ulcer
    3. Mallory-Weiss tear
    4. Dieulafoy Lesion: AVM around the oesophagus
‣
What scoring system is used to assess them?
  • Blatchford score
‣
🥜 Hernia
‣
What are important features to elicit in the history and examination?
  1. “Where is it?” → Inguinal or femoral
  2. “Is it reducible?” → Risk of obstruction
  3. “Is it painful?” → Strangulated
  4. “Have your bowel habits changed? Passing faeces? Passing wind?” → Risk factors

Exam:

  • Examine them both lying and standing (may not be present when lying)

Types:

‣
Inguinal hernia
‣
How can you distinguish a direct from indirect hernia through examination?
  • Reduce the hernia → Occlude the deep inguinal ring → Ask patient to cough or stand
    • Hernia present → Direct
    • Hernia absent → Indirect
‣
Anatomy of the inguinal canal
‣
Diagram
Henry Vandyke Carter, Public domain, via Wikimedia Commons.
Henry Vandyke Carter, Public domain, via Wikimedia Commons.
‣
If the processus vaginalis doesn't degenerate, what conditions can is cause?
  • Indirect inguinal hernia
  • Hydrocoele
  • Cryptorchidism
‣
Where are the deep and superficial inguinal rings?
  • Deep: Mid-point of inguinal ligament
  • Superficial: Above & medial to pubic tubercle
‣
What runs through the inguinal canal? How does this differ between male and female?
  1. Male: Spermatic cord. Female: Round ligament.
    2. ‣
    What structures are in the spermatic cord? (Rule of 3s)
    • Vas deferens
    • Arteries to vas, cremaster & testis
    • Pampiniform plexus
    • Genital branch of genitofemoral nerve & sympathetic nerve fibres
  2. Ilioinguinal nerve
  3. Fascia - External spermatic, cremasteric, internal spermatic
‣
What structure is at most risk of damage during an inguinal hernia repair?
  • Ilioinguinal nerve

Types:

‣
Direct (20%)
‣
Name the predisposing factors.
  • Chronic cough, constipation, heavy lifting, ascites, past surgery
‣
What is the cause?
  • Weakness in the anterior abdominal wall → Herniation of bowel through the Hesselbach triangle
‣
Where will the lump be found?
  • Above & medial to the pubic tubercle
‣
What is the anatomy of this? (Relation to inferior epigastric artery)
  • Medial
‣
What is the risk of strangulation?
  • Low
‣
How would you manage based on the following symptoms:
‣
Asymptomatic
  • Lifestyle advice: WL & stop smoking.
  • Watch & wait
‣
Symptomatic unilateral
  • Open mesh repair
‣
Abdominal distension & tinkling bowel sounds
  • Open reduction & mesh insertion
‣
Bilateral herniae in a 20 year old male patient
  • Laparoscopic reduction & mesh inertion
‣
Indirect (80%)
‣
What is the cause?
  • Failure of the processus vaginalis to close
‣
Where will the lump be found?
  • Above & medial to pubic tubercle
  • If large: Out of superficial inguinal ring and into scrotum
‣
What is the anatomy of this? (Relation to inferior epigastric artery)
  • Lateral
‣
What is the risk of strangulation?
  • Low
‣
How would you manage them?
  • Immediate repair due to risk of future complications

Cases:

‣
40 year old man presents with a lump in his groin after lifting a heavy couch when moving house. Diagnosis?
  • Direct inguinal
‣
A 3 year old presents with a testicular swelling. Bowel sounds can be heard within it, you cannot get above it but it is reducible. Diagnosis?
  • Indirect inguinal hernia
‣
Femoral hernia
‣
What is the cause?
  • Weakness of the abdominal wall → Herniation of bowel through the femoral canal
‣
Where will the lump be found?
  • Below & lateral to the pubic tubercle
‣
What is the anatomy of this?
  • Herniation through the femoral canal, medial to the femoral artery
Dennis M. DePace, PhD, CC BY-SA 4.0
Dennis M. DePace, PhD, CC BY-SA 4.0 creativecommons.org/licenses/by-sa/4.0, via Wikimedia Commons. No changes were made.
‣
Is there a high risk of strangulation?
  • High: Refer all for urgent surgery, even if observations are okay
‣
How do you manage them?
  • Surgical reduction & mesh insertion
‣
🫃 Obstruction
‣
Presentation
‣
Name 3 risk factors for obstruction.
  1. Adhesions (previous abdominal surgery)
  2. Herniae
  3. Malignancy
‣
What key symptoms & signs are you looking for?
  1. Distended abdomen
  2. Tinkling/absent bowel sounds
  3. Absolute constipation
‣
Name the types of bowel obstruction.

What is the likely diagnosis based on the following presentations:

‣
Patient who has recently underwent a Whipple's procedure 2 days ago has abdominal distension and absolute constipation. They are now vomiting. AXR: Dilated bowel loops.
  • Ileus: Temporary cease of peristalsis
    • ‣
    How would you manage them?
    1. Drip & suck
    2. Mobilise patient → Stimulates peristalsis
‣
Patient with ulcerative colitis presents with a grossly distended abdomen.
  • Toxic megacolon, but also could be obstruction.
‣
78 year old patient presents with abdominal pain, anaemia, change in bowel habit and has a distended abdomen. Bloods show hypercalcaemia and bowel loops are distended on AXR.
  • Colorectal cancer (accounts for 60% of LBO cases)
‣
Investigations
‣
What is your first investigation?
  • AXR
‣
What’s a more sensitive investigation?
  • CT abdomen
‣
Management
‣
What is the immediate management?
  • ABCDE: Analgesia
  • NBM
  • 'Drip & suck': Ryles tube & IV fluids
‣
What is the definitive management?
  • Laparotomy (although some recover under conservative management)
    • If obstruction is due to adhesions, surgery may just cause more adhesions to form. Must weigh the pros & cons.
‣
💩 Colorectal
‣
Colon
‣
Name 3 genetic conditions predisposing to colonic adenomas and their classic features.
  1. Lynch syndrome (HNPCC): Germline mutation → Small colonic polyps
    • Most common cause
  2. Familial adenomatous polyposis (FAP): APC mutation → Hundreds of colonic adenomas
    3. ‣
    What other features suggest FAP?
    1. Lipomas
    2. Osteomas
    3. Extra teeth
  3. Peutz-Jegher's syndrome: AD mutation in STK11 → Benign intestinal hamartomas & pigmentation spots around the mouth

What is the likely diagnosis based on the following presentations:

‣
70-year-old patient with IBD presents with a change in bowel habit, weight loss & PR bleeding.
  • Colorectal cancer
    • ‣
    What are the red flags for a 2WW referral to investigate for CRC? (4)
    1. ≥ 40 years with unexplained weight loss AND abdominal pain
    2. ≥ 50 years with unexplained rectal bleeding
    3. ≥ 60 years with Fe deficiency anaemia OR change in bowel habit
    4. Faecal occult blood positive
    ‣
    Who is screened for CRC and what test is used to screen them?
    • One-off flexible sigmoidoscopy at 55 years
    • Faecal Immunochemical Test (FIT) screening every 2 years to all men and women aged 60-74 years in England
      • ‣
      Is faecal occult blood useful for diagnosis in patients presenting with symptoms of CRC?
      • No
    ‣
    How is it investigated? (3)
    1. Colonoscopy +/- biopsy (Gold-standard)
    2. Staging CT scan
      3. ‣
      Stage the following tumours:
      ‣
      Tumour invading through the muscularis but not through the serosa. 2 lymph nodes involved. No metastases.
      • T3N1M0
      ‣
      Tumour present in submucosa only. No lymphadenopathy or metastases.
      • T1N0M0
      ‣
      Tumour in the muscularis. 4 lymph nodes involved. Metastases in liver found.
      • T2N2M1
    3. CEA: Used in predicting relapse of previously treated bowel cancer
    ‣
    What surgical resection should be done for the following tumours:
    ‣
    Descending colon tumour
    • Left hemicolectomy +/- adjuvant chemotherapy
    ‣
    Sigmoid colon tumour
    • High anterior resection
    ‣
    Low rectal tumour
    • Anterior resection
    ‣
    Anal verge tumour
    • Abdomino-perineal excision of rectum
    ‣
    What is an ileostomy? Why is it used following a bowel resection for CRC?
    • Small bowel is diverted through the skin to allow for anastomotic healing after bowel surgery
      • ‣
      What is the difference between loop and end ileostomy?
      • Loop: Defunctions the bowel temporarily to allow the anastomosis to heal
      • End: Non-reversible due to the distal bowel being lost
      ‣
      When is a colostomy indicated?
      • After removal of low rectal cancers. Produces stools like an anus.
      • Always on left.
‣
Elderly obese man presents with LIF pain & tenderness, fever and diarrhoea.
  • Diverticulitis
    • ‣
    How would you manage them?
    1. Antibiotics: Tazocin & metronidazole (refer to local guidelines)
‣
60-year-old patient with AF presents with abdominal pain, PR bleeding, diarrhoea & weight loss.
‣
70-year-old patient with AF presents with non-specific abdominal pain, disproportionate to their abdominal findings.
  • Acute mesenteric ischaemia
    • ‣
    How would you investigate? (2)
    • Lactate
    • CT angiogram
    ‣
    How would you manage them?
    • Thrombolysis / surgery
‣
15-year-old presents with recurrent central lower abdominal pain worse after meals. Normal inflammatory markers and no abnormalities found on colonoscopy.
  • Meckel's diverticulum
    • ‣
    Why is it related to eating?
    • Ectopic gastric mucosa secretes acid within the diverticulum causing local pain
    ‣
    What is the rule of 2s?
    • 2% of the population
    • 2 feet proximal to the ileocecal valve
    • 2 inches long
    • Commonly presents in children < 2 years
‣
Rectum

Name the diagnosis based on the following presentation:

‣
A constipated patient presents with bright red painless rectal bleeding, with a lump at the 3 o'clock. It is sore & itchy.
  • Haemorrhoid
    • ‣
    How would you manage them?
    1. Anusol cream (itch) & topical steroid
    2. Rubber band ligation: Excess blood loss
    3. Haemorrhoidectomy
‣
A 24-year-old man presents with a 2 week history of bright red PR bleeding and a sharp pain on defecation. He is constipated and OE there is a skin tag at 6 o'clock.
  • Anal fissure: Skin tag is commonly in the midline [6 (90%) & 12 o'clock]
    • ‣
    What are the risk factors?
    • Constipation: Opiate analgesia
    ‣
    How would you manage them?
    1. Laxatives: Bulk forming → Lactulose
    2. Topical GTN
    3. Sphincterotomy
‣
30 year old female presents with severe ano-rectal pain and a fever.
  • Proctitis / ano-rectal abscess
    • ‣
    2 months later this patient begins passing dark urine and developing recurrent UTIs.
    • Anal fistula

🍆 Urology

‣
🥠 Renal

What’s the diagnosis based on the following presentations:

‣
A smoker with metabolic syndrome presents with haematuria, vague loin pain, weight loss, fatigue & night sweats.
  • Renal cell carcinoma
    • ‣
    When doing an FBC and calcium what secondary features might you see and why?
    • FBC: ↑ Hb due to ↑ EPO secretion (from interstitial fibroblasts)
    • Calcium: ↑ Calcium due to ↑ 1-ɑ-hydroxylase
    ‣
    Why may they also present with haemoptysis?
    • Cannon ball metastases to lung
      • ‣
      What type causes this?
      • Adenocarcinoma
    ‣
    How is this managed if localised to the kidney?
    • Laparoscopic radical nephrectomy
    ‣
    What does the following CXR show:
    ‣
    Answer
    • Canonball metastases
    image
‣
Mother noticed an abdominal mass in her 4 year old child. He has abdominal pain, haematuria and fever.
  • Wilm's tumour (nephroblastoma)
    • ‣
    Investigations?
    • Abdominal USS
    • CT/MRI (Staging)
    • Biopsy (Confirm diagnosis)
‣
Patient presents with sudden onset excruciating, colicky loin to groin pain associated with haematuria and N&V.
  • Renal stones
    • ‣
    Why are they in pain?
    • Colic pain caused by ureteric spasm behind the stone. This causes ischaemia which results in pain.
    ‣
    What is the most common type of stone?
    • Calcium oxalate
    ‣
    A staghorn calculus is seen within the kidney. What is this made up of? What infection predisposes to this?
    • Struvite
    • Proteus infection
    ‣
    What type of stone is radiolucent?
    • Urate
    • Xanthine
    ‣
    What is the gold standard investigation?
    • CT KUB (non-contrast enhanced)
      • ‣
      What does periureteric fat stranding tell you in the absence of a stone?
      • Spontaneously passed stone
    ‣
    What is the best initial analgesia?
    • IM diclofenac
    ‣
    How would you investigate and manage a patient with hydronephrosis secondary to a stone?
    • Investigations: USS
    • Management: Nephrostomy
    ‣
    How would the following patients be managed:
    ‣
    Stone < 2cm
    • Shockwave lithotripsy
    ‣
    Stone < 2cm in pregnant lady
    • Ureteroscopy
    ‣
    Staghorn calculus
    • Percutaneous nephrolithotomy (surgical exploration): Intra-corporeal lithotripsy or stone fragmentation
    ‣
    Stone < 5mm
    • Conservative → Stones will likely be passed in the next 4 weeks
    • Medications:
      • Analgesia, fluids, antiemetics, antibiotics
      • Tamsulosin - Dilates ureter
    ‣
    Stone 4mm causing hydronephrosis
    • Nephrostomy +/- IV antibiotics if infected
‣
Diabetic female patient presents with a high fever and rigors. She has loin to groin pain and dysuria.
  • Pyelonephritis
    • ‣
    What are the common organisms that cause this?
    • E. coli
    • Klebsiella
    • Enterococci
    • Pseudomonas
    ‣
    How would you investigate them?
    • Bedside: Urinalysis
    • Bloods: FBC, U&E, CRP, Blood culture
    • Radiology: CT, USS (in children for structural assessment)
    ‣
    How would you manage them?
    1. Managing patient: Analgesia (antipyretic), antiemetic, IV fluids
    2. Medical: IV co-amoxiclav until MC&S result
‣
💦 Prostate & Bladder

What’s the diagnosis based on the following presentations:

‣
75 year old male patient presents with urgency, straining, intermittent flow, post-micturition dribbling and a feeling of incomplete emptying. Differentials?
  • Urinary obstruction: BPH, prostate cancer, prostatitis
    • ‣
    How would you assess this patient?
    1. Urinalysis: ? Infection
    2. PSA
    3. PR examination
    ‣
    What are your management options?
    • Lifestyle: Reassurance and monitoring if symptoms are manageable
    • Medical: Tamsulosin (ɑ-1-blocker), finasteride (5-ɑ-reductase inhibitor)
    • Surgical: Transurethral resection of prostate (TURP)
      • ‣
      What are the complications of a TURP?
      1. TURP syndrome: Irrigation fluid enters systemic circulation → Hyponatraemia & fluid overload
      2. Urethral stricture/UTI
      3. Retrograde ejaculation
      4. Perforation of the prostate
    ‣
    What are the options for a patient with chronic urinary retention secondary to BPH that doesn't want surgery?
    1. Intermittent self-catheterisation
    2. Long-term catheter
‣
75 year old man presents with urinary frequency, straining and urgency accompanied by haematuria, erectile dysfunction and weight loss.
  • Prostate cancer
    • ‣
    Investigations
    ‣
    What bedside investigations & bloods can be done?
    • Bedside: Urinalysis (haematuria), PR (PSA always before PR)
    • Bloods: PSA (> 4)
      • ‣
      In what scenarios is PSA not valid?
      • Prostatitis (wait 1 month)
      • Ejaculation (wait 48 hours)
      • Vigorous exercise (wait 48 hours)
    ‣
    What is the first-line investigation for suspected prostate cancer?
    • Multiparametric MRI
    ‣
    What follows this if it indicates prostate cancer?
    • Biopsy
      • ‣
      What system is used to grade prostate cancer and what features does it use to classify them?

      Gleason grading system

      • Features:
        1. Well differentiated
        2. Moderately differentiated
        3. Moderately differentiated
        4. Poorly differentiated
        5. Anaplastic
      ‣
      What’s the difference between grading and staging?
      • Grading: Individual cells
      • Staging: Cells in relation to surrounding tissues
    ‣
    When is a radical prostatectomy indicated? What are the side effects?
    • Indication: Localised tumour (T1/2)
    • Side effects:
      • Erectile dysfunction
      • Urinary incontinence
    ‣
    How do you manage advanced disease?
    • Hormonal therapy
      1. GnRH analogues (agonists): Goserelin
        • Negative feedback on hypothalamus → ↓ LH → ↓ testosterone
      2. Anti-androgen therapy: Cyproterone acetate
      3. Orchidectomy
    ‣
    Where does it commonly metastasise to?
    • Bone (hip, spine, pelvis)
    • Liver
    • Lung
‣
Dye factory worker presents with painless haematuria.
  • Bladder cancer
    • ‣
    Name 3 other risk factors for this.
    1. Smoking
    2. Rubber manufacturing
    3. Industrial paint
    ‣
    What is a RF for bladder SCC?
    • Schistosomiasis
    ‣
    How would you investigate this?
    • Flexible cystoscopy & biopsy
    • CT/PET-CT: Assess for metastases
    ‣
    What do you need to know to determine management?

    Stage of the cancer: Has it invaded the muscle?

    ‣
    Yes
    • Cystectomy & reconstruction using an ileal pouch
    ‣
    No
    • Transurethral resection of bladder tumour (TURBT)
‣
A patient has suffered a pelvic fracture and have not passed urine since. Differentials?
  1. Membranous urethral rupture
    2. ‣
    What other feature would suggest this?
    • Displaced (non-palpable) prostate on PR
  2. Bladder rupture
    3. ‣
    What other feature would suggest this?
    • Lower abdominal peritonism
‣
A patient has urinary urgency and has had several episodes of incontinence. He has good urinary flow with no hesitancy or straining, and a normal PR.
  • Overactive bladder
    • ‣
    How would you investigate for this?
    • Urodynamic studies
    ‣
    How would you manage this?
    • Antimuscarinics: Oxybutynin / tolterodine
‣
🍒 Penis & Testes
‣
How do you investigate all testicular lumps (that need it)?
  • Ultrasound scan
‣
What risk factors predispose people to erectile dysfunction?
  1. Cardiovascular disease
  2. Alcohol
  3. Drugs (SSRIs, β-blockers)
  4. Diabetes

What’s the diagnosis based on the following presentations:

‣
A 20 year old presents with a painless, hard, irregular testicular lump that is not fluctuant and doesn’t transilluminate.
  • Testicular tumour
    • ‣
    What are the 2 types? How do you differentiate them with investigations?
    1. Teratoma - ↑ AFP
    2. Seminoma - ↔︎ AFP & hCG
    ‣
    What is orchidopexy & what significance does it have?
    • Undescended testes in young patients: ↑ prostate cancer risk
    ‣
    How do you manage this?
    • Orchidectomy +/- adjuvant chemotherapy
‣
A 6 year old boy with sickle cell anaemia presents with a persistent (> 4 hrs) painful erection.
  • Priapism: Impaired vasorelaxation (vaso-occlusive crisis)
    • ‣
    What specific investigation can you do for this?
    • Cavernosal blood gas analysis
    ‣
    What else can cause this
    • Leukaemia
    • Metastasis
    • Trauma
‣
A 15 year old presents with an acute onset, severe left testicle pain.
  • Testicular torsion
    • ‣
    When should you examine for torsion?
    • In any young boy with lower abdominal pain.
    ‣
    How may they present?
    • N&V at onset of symptoms.
    • Extremely tender and firm testicle.
    • Horizontal lie of teste.
    • Absent cremasteric reflex.
      • Ask them to cough, if the testes don't rise then the cremasteric reflex is absent.
    ‣
    What are the differentials?
    • Epididymo-orchitis
    • Strangulated hernia
    • Strangulation of epididymal appendage
    ‣
    Why is this an emergency? When does irreversible damage occur?
    • Torsion → Occlusion of testicular artery → Testicle ischaemia
    • Irreversible damage ≥ 6 hours
    ‣
    How is it managed?
    • ≤ 6 hours: Surgical exploration → Fixation of both testes to prevent future recurrence
    • > 6 hours: Assess for necrosis → Orchidectomy
‣
A mother brings in her 6 month old child with a soft, fluctuant scrotal lump. It is transilluminates and does not have bowel sounds within it.
  • Hydrocele
    • ‣
    If a hydrocele is found in a middle-aged man, how do you investigate & why?
    • USS looking for testicular cancer
‣
A 23 year old presents with a left-sided scrotal lump that feels like a soft “bag of worms”, accompanied by a soreness and a dragging feeling.
  • Varicocele
    • ‣
    How do you investigate this?
    • Renal USS: Look for RCC because this could be compressing the left testicular vein
‣
A diabetic male patient presents with white non-urethral discharge and itching after intercourse.
  • Fungal balanitis (candidiasis)
    • ‣
    How would you manage this?
    • Topical antifungals (fluconazole)
    ‣
    What would indicate a bacterial balanitis?
    • Yellow non-urethral discharge, painful
    ‣
    What autoimmune conditions can cause balanitis?
    • Contact dermatitis
    • Eczema
    • Psoriasis
‣
25 year old presents with gradual onset (minutes-hours) tender & swollen right teste. They have had a swollen face and have felt ill over the last few days.
  • Epididymo-orchitis caused by mumps
    • ‣
    What else can cause this in young men?
    • Chlamydia & gonorrhoea
    ‣
    What causes this in older men (> 35 yrs)?
    • E. coli secondary to retention & UTI
‣
40 year old presents with a soft fluctuant lump at the top/back of the testicle.
  • Epididymal cyst
‣
55 year old presents with a soft, reducible scrotal lump separate from the testicle. Bowel sounds can be heard within it.
  • Inguinal hernia

🌰 Breast Surgery

‣
🌰 General
‣
What is a tumour?
  • Excessive proliferation of a group of abnormal cells.
‣
Name 7 risk factors.
  1. FH: BRCA 1/2
    2. ‣
    How is this inherited?
    • Autosomal dominant
  2. Obesity
  3. Early menarche
  4. Late menopause
  5. Nulliparity
  6. HRT
  7. Radiation
‣
Describe the screening programme.
  • Mammogram every 3 years between 50-70 years.
‣
When would you use a 2WW referral?
  • ≥ 30 years: Unexplained breast lump OR skin changes indicative of breast cancer
  • ≥ 50 years: Discharge/retraction/other abnormal feature from one nipple
‣
What is triple assessment?
  1. Clinical history & examination
  2. Imaging: Mammogram/USS
  3. Biopsy:
    • Fine needle aspiration: Cytology (cell analysis)
    • Core biopsy: Histology (tissue analysis)
‣
Name 5 features that would suggest a malignant tumour rather than benign.
  1. Size > 2 cm
  2. Shape: Irregular shape/border
  3. Division: Rapid
  4. Infiltration: Peau d' orange
  5. Movement: Fixed (tethering)
‣
🧐 Benign

What’s the diagnosis based on the following presentations:

‣
22 year old girl presents with a mobile, firm, non-tender breast lump. Diagnosis?
  • Fibroadenoma: Core biopsy shows epithelial and stromal elements
    • ‣
    Management? (3 cm)
    1. < 3 cm - Conservative (watch & wait)
    2. > 3 cm - Surgical excision
‣
45 year old presents with a discrete lump that fluctuates in size with menstrual cycle. "Halo sign" is positive on mammogram.
  • Breast cyst: Halo sign occurs when the cyst compresses the surrounding fat
    • ‣
    Management?
    • Aspiration / excision if persistent
‣
35 year old woman presenting with 'lumpy', painful breasts that are worse before menstruation
  • Fibroadenosis
‣
40 year old woman presents with generalised lumpiness of breasts and on biopsy there are atypical cellular features.
  • Epithelial hyperplasia
    • ‣
    Management?
    • No atypical features: Conservative
    • Atypical features: Monitoring/resection
‣
25 year old woman was in a car crash and her seatbelt caused chest trauma. She now has swelling, pain and tethering of her breast tissue.
  • Fat necrosis
‣
35 year old woman presents with blood-stained nipple discharge, on examination she has no palpable mass and nothing is found on mammorgraphy.
  • Intraductal papilloma
    • Fluid is often clear, although it may be blood stained
    • Microdocechtomy may be performed
‣
Breastfeeding woman presents with an erythematous breast and is systemically unwell.
  • Mastitis: Lactation → Dry, cracked skin → Staphylococcal infiltration
    • ‣
    How would you manage this?
    1. Continue breastfeeding
    2. Systemic symptoms: PO/IV flucloxacillin
‣
57 year old woman presents with thick, green discharge coming from the nipple.
  • Duct ectasia
    • Thickening of the mammary duct walls → Obstruction
    • Discharge can be creamy & associated with nipple inversion
      • ‣
      How is it managed?
      • Conservative if not bothering the patient
      • Microdochectomy if bothering them
‣
A 33 year old presents with a snowstorm appearance of axillary lymph nodes on USS.
  • Extracapsular breast implant rupture
‣
👹 Malignant
‣
Types & Classification
‣
Why does Peau d'orange occur?
  • Tumour → Oedema → Stretching of the suspensory ligaments → Skin dimpling
‣
Describe the lymphatic drainage of the breast. (2)
  • Most: Axillary lymph nodes
  • Some: Parasternal lymph nodes
‣
What are the 2 main cell types in breast cancer?
  1. Ductal
    • Ductal carcinoma-in-situ (DCIS): Comedo necrosis, calcification
    • Invasive ductal (most common)
  2. Lobular
    • Lobular carcinoma-in-situ (LCIS)
    • Invasive lobular carcinoma
‣
How do you describe their position in the tissue?
  • Carcinoma in situ: Only in local tissue
  • Invasive: Spread to surrounding tissue

What’s the diagnosis based on the following presentations:

‣
Patient presents with itching and dry skin on the nipple and areola.

Two differentials:

  1. Paget's disease of the nipple: Nipple affected first then may spread to areola & skin
    2. ‣
    What breast malignancy is this associated with?
    • Invasive ductal carcinoma
    ‣
    How is a diagnosis made?
    • Punch biopsy
  2. Eczema: Skin & areola affected but the nipple is spared, eczema elsewhere
‣
Patient presents with progressive erythema & oedema of breast tissue. No systemic signs of infection and inflammatory markers aren't raised.
  • Inflammatory breast cancer: Cancer blocks lymphatic drainage → Inflammation
‣
Staging
‣
Describe the T staging (of TNM).
  • T1 < 2cm
  • T2: 2-5cm
  • T3: ≥ 5cm
  • T4 (invasive):
    • a: Invades chest wall
    • b: Invades skin (fungating)
    • c: Invades chest wall and skin
    • d: Inflammatory breast cancer
‣
Stage the following tumours:
‣
2 cm tumour confined to the breast tissue.
  • T2N0M0
‣
6 cm fungating tumour that is invading the chest wall with supraclavicular lymphadenopathy.
  • T4cN3M0
    • Fungating: Skin invasion
‣
5.5 cm tumour with mobile lymphadenopathy in the axilla and bone metastases
  • T3N1M1
‣
Where do breast tumours commonly metastasise to?
  • Lung
  • Liver
  • Bone
  • Brain
‣
Management
‣
Surgical
‣
What are the indications for a wide local excision?
  • < 4cm
    • ‣
    What is done after all wide local excisions?
    • Radiotherapy
‣
When would you choose to do a mastectomy over a wide local excision?
  • Multifocal tumour
  • Central tumour
  • Large lesion in small breast
  • DCIS ≥ 4 cm
‣
How do you assess whether you need to clear the axillary lymph nodes?
  1. Pre-op USS & if positive:
  2. Sentinel node biopsy:
    3. ‣
    What is this?

    Inject blue dye into the tumour → First LN to drain the tumour is blue → Biopsy of this & send for histology → If negative then unlikely spread to lymph nodes so don't remove

    ‣
    What is the main complication of axillary LN clearance?
    • Arm lymphoedema
‣
Radiotherapy
‣
When is this indicated?
  • Adjuvant
    1. All wide local excisions
    2. Mastectomy in a T3/4 tumour
    3. ≥ 4 positive axillary LNs (when patient doesn't want surgical clearance)
‣
Biological therapy
‣
What are the two options for ER+ patients, and how do you decide which to give?
  1. Tamoxifen (ER antagonist): Pre-menopausal women
    2. ‣
    SEs?
    1. DVT
    2. Endometrial cancer
    3. Vaginal bleeding
  2. Anastrozole/letrozole (aromatase inhibitor): Post-menopausal women
    3. ‣
    What is the key SE?
    • Osteoporosis
‣
What can you give to HER2+ patients?
  • Herceptin: Trastuzumab
‣
Chemotherapy
‣
Why is neo-adjuvant chemotherapy given?
  • Shrink the tumour to give clear margins and consider a wide-local excision
‣
When is adjuvant chemotherapy indiated?
  • LN involvement in patients with HER2- & ER- cancer: FEC-D chemotherapy
  • Metastases

👅 Ear, Nose & Throat

‣
👹 Head & Neck Cancer
‣
Name symptoms/signs that would require a 2WW referral for:
‣
Oral cancer
  • Unexplained oral ulcer lasting > 3 weeks
  • Unexplained lip/oral/neck lump
  • Erythroleukoplakia/erythroplakia
‣
Laryngeal cancer
  • Unexplained hoarse voice
  • Unexplained neck lump
‣
Thyroid cancer
  • Unexplained thyroid nodule
‣
Nasopharyngeal carcinoma
‣
What are the risk factors for this?
  • EBV infection (glandular fever)
  • Southern china
‣
What symptoms may they present with?
  • Local:
    • Persistent dry cough and/or sore throat
    • Recurrent unilateral otitis media
    • Otalgia
    • Nasal congestion, discharge or epistaxis
    • Cranial nerve palsies (III-VI)
  • Systemic:
    • Cervical lymphadenopathy
‣
How do you investigate it?
  • Flexible nasendoscopy
  • CT & MRI
‣
What is the first-line management?
  • Radiotherapy
‣
Oropharyngeal carcinoma
‣
What infection is this associated with? What test confirms this?
  • HPV
  • p16 test
‣
What cell type is it likely to be?
  • Squamous cell carcinoma
‣
Thyroid carcinoma

Surgery complications:

‣
What nerve is most likely to be damaged?
  • Recurrent laryngeal nerve
‣
If they present post-op with stridor, what is the likely problem? How would you manage this?
  • Bleeding → Haematoma → Airway obstruction
  • Management:
    1. Immediate suture removal to relieve the pressure on the airway
    2. Back to theatre
‣
Why may they present with prolonged QT?
  • Damage to parathyroid glands → ↓ parathyroid function → ↓ Ca²⁺ → Prolonged QT
‣
🦻 Ear
‣
Symptoms

Name differentials for the following:

‣
Vertigo
  1. BPPV
  2. Meniere's disease
  3. Acoustic neuroma (vestibular schwannoma)
  4. Viral labyrinthitis
  5. Vestibular neuronitis
  6. Multiple sclerosis
  7. Posterior circulation stroke
  8. Ototoxicity: Gentamicin
‣
Tinnitus
  1. Loud noise/presbyacusis
  2. Meniere's disease
  3. Acoustic neuroma
  4. Glue ear/impacted ear wax
  5. Otosclerosis
  6. Drugs: NSAIDs, gentamicin, loop diuretics, quinine
‣
Hearing loss
‣
Conductive hearing loss (CHL)
  1. Otitis externa
  2. Ear wax / foreign body
  3. Tympanic perforation
  4. Otosclerosis
  5. Otitis media
‣
Sensorineural hearing loss (SNHL)
  1. Presbyacusis
  2. Meniere's disease (low frequencies)
  3. Acoustic neuroma
  4. Noise-induced
  5. Viral labyrinthitis
  6. Gentamicin ototoxicity
‣
Audiograms

Name the condition based on the audiogram below:

image
‣
Answer
  • Bilateral conductive HL
image
‣
Answer
  • Bilateral SNHL
image
‣
Answer
  • Bilateral mixed HL
image
‣
Answer
  • Right-sided Meniere's disease

Anatomically:

‣
External ear

What is the likely diagnosis based on the following presentations:

‣
8 year old boy presents with right ear pain and conductive hearing loss. OE: red, swollen canal with yellow discharge, temperature 38°C.
  • Otitis externa
    • ‣
    How would you manage them?
    1. Mild/moderate: Otomize drops (Antibiotic: Neomycin. Steroid: Dexamethasone)
    2. Severe: PO antibiotics
‣
A 10 year old diabetic has severe, unrelenting left otalgia with temporal headaches. OE: granulation tissue on otoscopy, loss of facial muscle function.
  • Malignant otitis externa (temporal bone infection). Caused a facial nerve palsy.
    • ‣
    How would you manage them?
    • IV antibiotics
‣
15 year old patient presents with foul smelling, non-resolving discharge and conductive hearing loss. OE: there is attic crust.
  • Cholesteatoma
    • ‣
    How would you investigate them?
    1. CT head: Assess temporal bone involvement
    2. Pure tone audiometry: Assess extent of the HL
    ‣
    How would you manage them?
    1. Temporal involvement: Tympanomastoidectomy
    2. No bone involvement: Tympanoplasty
‣
Patient with recurrent otitis media presents with sudden hearing loss and otorrhoea.
  • Tympanic perforation
    • ‣
    Management:
    • Conservative: Most heal within 6-8 weeks
    • Consider antibiotics if infective signs
    • Myringoplasty if not healing
‣
Patient presents with pain, conductive hearing loss & tinnitus. OE: thick wax, TM not visible.
  • Ear wax
    • ‣
    How would you manage them?

    Two steps:

    1. Olive oil drops → Soften wax
    2. Ear syringing → Remove wax
‣
Middle ear

What is the likely diagnosis based on the following presentations:

‣
2 year old presents with right otalgia, temperature of 38.2°C.
  • Diagnosis: Otitis media
    • ‣
    How would you manage them?
    1. Analgesia: Most cases are viral so don't require antibiotics, if no improvement after 3 days then move on.
    2. PO amoxicillin/clarithromycin (5 days)
      • If eardrum perforates and child appears to be getting better, still prescribe antibiotics
    ‣
    How is otitis media with perforation managed?
    • Keep dry & review after 6 weeks (90% will heal)
‣
Same child comes back 4 weeks later with a similar presentation but with conductive hearing loss and tinnitus.
  • Otitis media with effusion
    • ‣
    What would tympanometry show?
    • Flat curve with normal canal volume
    ‣
    How would you manage them?
    • Antibiotics
    • Grommet insertion
‣
The same child comes back 6 weeks later looking very unwell with severe otalgia, mastoid swelling, erythema and tenderness.
  • Diagnosis: Mastoiditis
    • ‣
    How would you investigate them?
    • CT head: Subperiosteal abscess may be present
    ‣
    How would you manage them?
    1. IV antibiotics
    2. Mastoidectomy if severe
    ‣
    If they had otorrhoea, pain deep inside the ear and eye & ipsilateral VI nerve palsy, would your diagnosis be different?
    • Yes - petrositis
‣
A 30 year old with a family history of early hearing loss presents with progressively worsening conductive hearing loss and tinnitus.
  • Diagnosis: Otosclerosis
    • ‣
    What will Rinne’s & Weber's tests show?
    • Rinne's: Bone louder than air (negative) in both
    • Weber's: Doesn't lateralise
    ‣
    What is the pathophysiology?
    • Autosomal dominant genetic → Fixation of the stapes bone to the oval window
    ‣
    How would you manage them?
    • Stapedectomy
‣
Inner ear

What is the likely diagnosis based on the following presentations:

‣
Patient presents with hearing loss, tinnitus & vertigo on the left side with an associated facial nerve palsy and absent corneal reflex.
  • Acoustic neuroma: Benign tumour of the Schwann cells of the vestibulocochlear nerve.
    • ‣
    If they present with bilateral acoustic neuromas, what would this suggest?
    • Neurofibromatosis type II
    ‣
    How would you investigate them?
    • Audiometry: Sensorineural hearing loss
    • CT/MRI head: Assess size of tumour
    ‣
    How does proximity to the brainstem affect management?
    1. Near brainstem: Surgery
      • Translabyrinthine, retrosigmoid and middle fossa approaches
      • Not fit: Stereotactic radiosurgery (a form of radiotherapy)
    2. Not near: Repeat scan in 6 months
‣
47 year old presents with recurrent vertigo not associated with hearing loss. They mention they had a viral illness 2 weeks ago.
  • Vestibular neuronitis
    • ‣
    What’s the acute management?
    • Prochlorperazine (~ 3 days)
‣
Patient presents with hearing loss (low frequencies), tinnitus & vertigo in the left ear with a sensation of aural fullness.
  • Meniere's disease
    • ‣
    What’s the pathophysiology?
    • Membranous labyrinth dilatation causing episodes of vertigo lasting for 12-24 hours
    ‣
    How would you manage them?
    1. Acute: Prochlorperazine
    2. Prophylaxis: Betahistine
‣
Elderly person notices they need to turn up the radio and having difficulty having conversations.
  • Presbyacusis
    • ‣
    How would you manage them?
    • Hearing aid
‣
Patient presents with left sided auricular pain and facial nerve palsy. On examination they have a vesicular rash around and within the ear.
  • Ramsay-Hunt syndrome
    • ‣
    What infection causes this?
    • VCV infection in C.N. VII
    ‣
    How would you manage them?
    • PO aciclovir & steroids
‣
Patient presents with vertigo lasting 20 seconds following rolling over in bed.
  • Benign paroxysmal positional vertigo (BPPV)
    • ‣
    How would you investigate them?
    • Dix-Hallpike manoeuvre → Rotatory geotropic nystagmus
    ‣
    How would you manage them?
    • Epley manoeuvre
‣
58 year old had a cold a week ago and now presents with SNHL, vertigo, tinnitus & horizontal nystagmus to the opposite side.
  • Viral labyrinthitis
‣
👃 Nose
‣
A patient presents with recurrent unilateral epistaxis. In GP, how would you refer them on?
  • 2 week wait ENT referral

What is the likely diagnosis based on the following presentations:

‣
Patient presents with a nosebleed, the source is visible and it came on after blowing the nose and coughing.
  • Anterior nose bleed
    • ‣
    How would you manage them?
    1. Acute: Torso forward, mouth open, pinch bridge of the nose for 15 minutes
    2. Cauterisation
    3. Nasal packing
    ‣
    If the source wasn't visible how would you manage it?

    Indicates a posterior bleed:

    1. Nasal packing
    2. Nasal balloon catheter
    3. Transnasal endoscopy with direct cautery/arterial ligation
‣
Patient presents with seasonal sneezing, nasal discharge and pruritus.
  • Atopic rhinitis
    • ‣
    How would you manage them?
    • Mild-moderate: Antihistamine nasal spray
    • Severe: Corticosteroid spray
‣
Patient with recurrent nasal discharge has a feeling of facial fullness and tenderness on palpation.
  • Sinusitis
‣
50 year old male patient presents with nasal obstruction, sneezing and poor sense of taste & smell. He also has asthma and aspirin sensitivity.
  • Nasal polyps: Samster's triad (avoid aspirin & other NSAIDs in asthmatics)
    • ‣
    When should this be urgently referred to ENT?
    • Unilateral polyp needs urgent referral
‣
Patient broke their nose earlier and now has a swollen septum that is boggy to palpation and painful.
  • Septal haematoma
    • ‣
    How would you manage them?
    • IV antibiotics
    • Surgical drainage
    ‣
    What are the potential complications?
    • Blood supply occlusion → Septal necrosis
‣
A patient with recurrent sinusitis presents with frontal bone tenderness & swelling. He has a temperature of 38°C.
  • Pott's puffy tumour (subperiosteal abscess → osteomyelitis of frontal bone)
‣
👅 Throat
‣
Sore throat
‣
How do you assess the need for antibiotics in tonsillitis? What antibiotic is given?

CENTOR criteria: 3-4 of these → Penicillin V for 7-10 days

  1. Absence of cough
  2. Tonsillar exudate
  3. Tender anterior cervical lymphadenopathy
  4. Temperature > 38°C
‣
What organism commonly causes tonsillitis?
  • S. pyogenes

What is the likely diagnosis based on the following presentations:

‣
10 year old with history of tonsillitis presents with severe throat pain, uvula deviation and OE there is large swelling of the right tonsil.
  • Quinsy: Peritonsillar abscess
    • ‣
    What constitutes the short-term and long-term management?
    • Short-term:
      1. Aspiration & IV penicillin V
      2. Incision & drainage
    • Long-term: Consider tonsillectomy
    ‣
    Name 2 complications of tonsillectomy?
    1. Immediate bleeding due to stitches not holding
    2. Infection presenting 5-10 days after surgery
‣
A 10 year old child presents with enlarged tonsils that meet in the midline. Oropharyngeal examination confirms this finding and you also notice petechial haemorrhages affecting the oropharynx. On systemic examination he is noted to have splenomegaly.
  • Glandular fever (infectious mononucleosis): EBV
    • ‣
    What happens if these patients are given amoxicillin?
    • Develop an intensely itchy maculopapular rash
    ‣
    How can you test for this?
    • Antibodies: IgM (acute infection), IgG (past infection/immunity)
    • Monospot test - Looks for heterophile antibodies (only positive 6W after infection)
‣
Patient that is a long-term smoker has had a dry cough for 6 weeks and has a right-sided glue ear.
  • Cancer: 2WW referral (adult with unilateral glue ear → red flag)
    • ‣
    What key infection is a risk factor for this?
    • EBV: Glandular fever
    ‣
    How is it investigated in hospital?
    • Flexible nasoendoscopy
‣
A 70 year old patient with a sore throat & odynophagia quickly deteriorates in A&E, he has a stridor and is saturating 95%, when given O₂ this doesn't come up.
  • Supraglottitis
    • ‣
    What is the immediate management?
    1. ABCDE
    2. Nebulised adrenaline (1:1000) and IV dexamethasone
      • If pyrexial: IV cephalosporins
    3. Call anaesthetics to secure airway
‣
A patient had a dental extraction 5 days previously and now has swelling around the site, tongue is displaced upwards and he can't protrude it.
  • Ludwig's angina: Infection of the floor of the mouth and surrounding soft tissues
‣
Neck lumps

Patients present with a neck lump and the following associated features:

‣
Large painless lymphadenopathy with fever, night sweats & splenomegaly.
  • Lymphoma
‣
History of recent local viral infection.
  • Reactive lymphadenopathy
‣
Moves upwards on swallowing.
  • Thyroid nodule
‣
Moves upwards with protrusion of the tongue.
  • Thyroglossal cyst - Thin walled and anechoic on USS
‣
Old man with dysphagia, regurgitation and aspiration has lymphadenopathy deep to the SCM muscle.
  • Pharyngeal pouch
Loki austanfell, CC BY-SA 3.0
Loki austanfell, CC BY-SA 3.0 creativecommons.org/licenses/by-sa/3.0, via Wikimedia Commons. No changes were made.
‣
Patient presents with halitosis, facial pain and discomfort while eating. They have a dry mouth and a swelling under the mandible.
  • Sialolithiasis: Blockage of Wharton's duct draining the submandibular gland
‣
Presents at 1 year with a soft swelling in the posterior triangle that transilluminates.
  • Cystic hygroma: Collection of dilated lymphatic sacs
‣
1 year old has a mobile mass between the SCM and pharynx (anterior triangle). OE it doesn't transilluminate.
  • Branchial cyst: Can present in later life with intermittent neck swelling due to the branchial cleft becoming infected
‣
Asymptomatic lump within the dermal layer that doesn't transilluminate.
  • Lipoma
‣
Sinusitis & gingivitis
‣
Name the common organisms causing sinusitis.
  • S. pneumonia
  • H. influenzae
  • Viral: Rhinoviruses
‣
What are the 3 stages of management of this?
  1. Intranasal anticongestants & washouts
  2. Intranasal corticosteroids
  3. PO antibiotics: Penicillin V
‣
Patient has painless, red gum swelling which bleeds on contact. Diagnosis? Management?
  • Simple gingivitis
    • ‣
    How would you manage them?
    • Dentist referral
‣
Patient has painful bleeding gums with halitosis and punched-out ulcers on them. Diagnosis?
  • Acute necrotising ulcerative gingivitis
    • ‣
    How would you manage them?
    • PO metronidazole
    • Chlorhexidine mouth wash
    • Referral to a dentist
‣
Name 3 drugs that may cause gingival hyperplasia.
  1. Phenytoin
  2. Ciclosporin
  3. Calcium channel blocker, e.g. nifedipine
‣
Salivary glands
‣
What gland most commonly forms tumours?
  • Parotid. What’s the diagnosis in the following cases:
    • ‣
    Slow growing, smooth and mobile swelling in the tail of the parotid gland.
    • Benign pleomorphic adenoma (most common ~ 80%)
    ‣
    Bilateral parotid gland enlargement in a male patient.
    • Warthin tumour
    ‣
    10 month old child with parotid enlargement.
    • Haemangioma
‣
What gland commonly forms stones blocking the ducts?
  • Submandibular
‣
Name 3 other causes of gland enlargement.
  1. Infection: Mumps, bacterial (in diabetics)
  2. Autoimmunity: Sjogren's
  3. Sarcoidosis

👀 Ophthalmology

‣
😵 Ophthalmology Differentials

Name differentials for the following symptoms:

‣
Sudden visual loss
  1. Ischaemia - Large (Amaurosis fugax)/small vessel (Central retinal artery/vein)
  2. Vitreous haemorrhage
  3. Retinal detachment
‣
Visual acuity loss
  1. Cataracts
  2. Glaucoma
  3. ARMD
  4. MS
  5. Anterior uveitis (later disease)
‣
Red eye
  1. Conjunctivitis
  2. Keratitis
  3. Scleritis/episcleritis
  4. Subconjunctival haemorrhage
  5. Glaucoma (closed angle)
  6. Anterior uveitis
‣
Tunnel vision
  1. Retinitis pigmentosa
  2. Pituitary adenoma (Bitemporal hemianopia)
  3. Glaucoma (Optic nerve damage)
  4. Blood loss
  5. Alcohol & drugs
  6. Extreme panic, stress or anger
‣
🥽 External
‣
Infective
‣
Patient presents with a red eye, photophobia and blurred vision following scratching his eye when taking out his contact lens. Diagnosis & do you refer?
  • Corneal inflammation (keratitis) → Potentially sight threatening → Urgent referral
    • ‣
    Common causes?
    1. HSV infection
    2. Pseudomonas: Contact lens use
    ‣
    If the patient presented with similar symptoms after freshwater swimming, what organism would you suspect?
    • Amoebic infection
    ‣
    If a dendritic ulcer is seen on slit lamp assessment with fluorescin drops, what is the cause?
    • HSV
    Corneal ulcer showing
    Corneal ulcer showing dendritic pattern
    ‣
    Management?
    • TOP quinolone (if bacterial - covers Pseudomonas)
    • Aciclovir (HSV)
‣
Patient presents with grittiness and erythema of both eyelids. OE there is 'crusting' at eyelid margins. Diagnosis?
  • Blepharitis - Inflammation of the eyelid margins
    • Meibomian glands, seborrhoeic dermatitis, S. aureus infection
      • ‣
      Management?
      • Hot compresses
‣
Patient has a vesicular rash around the eye and tip & side of the nose. Diagnosis?
  • Herpes Zoster Ophthalmicus (VCV infection)
    • ‣
    What is Hutchinson's sign?
    • Vesicular rash on the tip of the nose - Suggests high risk of ocular involvement
    ‣
    What part of the eye is commonly involved?
    • Anterior uveitis - Inflammation of the contents of the anterior chamber
    ‣
    Management?
    • PO antivirals
‣
6 year old boy presents with a red, swollen, painful eye with associated fever. No pain/restriction of eye movements or visual disturbance. Diagnosis? Management?
  • Periorbital cellulitis
  • PO Co-amoxiclav (likely admit due to risk)
‣
Patient presents with redness and swelling around the eye. They have visual disturbance, pain & restriction on eye movements and they are febrile. Diagnosis?
  • Orbital cellulitis
    • ‣
    Investigations?
    • CT orbit with contrast
    • Blood cultures
    ‣
    Management?
    • IV antibiotics (according to local guidelines) & admission
    ‣
    What are the complications?
    1. Glaucoma
    2. Central retinal artery occlusion
    3. Meningitis/encephalitis
    4. Cavernous sinus syndrome
‣
Patient presents with sore, red eyes associated with a discharge. How do you differentiate between bacterial and viral?
  • Viral: Thin, clear discharge
    • ‣
    Do they need school exclusion?
    • No
  • Bacterial: Discharge will be purulent and yellow.
    • ‣
    Management?
    • TOP chloramphenicol (antibiotic)
    ‣
    A newborn has conjunctivitis and the mother has discharge, differentials?
    • Chlamydia: 4-28 days of birth
    • Gonococcal: 1-3 days of birth
‣
Inflammatory
‣
Patient with RA presents with a severely painful red eye, photophobia and eye watering. OE: Reduced visual acuity, pain on eye movement. Diagnosis? Management?
  • Scleritis
  • Management:
    1. NSAIDs (TOP/PO)
    2. Steroids (TOP/PO)
    3. Immunosuppression appropriate to underlying condition (methotrexate in this case)
‣
Patient presents with itchy eyes and you notice conjunctival erythema and swelling, they have a history of atopy and it is seasonal. Diagnosis? Management?
  • Allergic conjunctivitis
  • PO/TOP antihistamines
‣
Patient presents with acute onset painless, segmental redness of the eye in the lateral sclera. The eye is watering and there is no discharge. Diagnosis? Management?
  • Episcleritis
  • Management: Conservative (Recovery → 1-4 weeks)
‣
Other
‣
Patient scratched their eye and now have eye pain, photophobia and the feeling there is something in there. Diagnosis? Examination? Management?
  • Corneal abrasion
  • Fluorescin drops → Abrasion appears yellow
  • Management: TOP chloramphenicol
‣
Patient tells you she has Horner's syndrome. What signs do you look for? Where is the pathology?

Signs:

  1. Ptosis
  2. Miosis
  3. Enophthalmos
  4. Anhidrosis

Pathology:

  • Sympathetic nervous system
‣
Patient presents with painful left eye, OE you notice eye dryness and a small abscess. Diagnosis?
  • Stye
    • ‣
    What is your other main differential and its features?
    • Chalazion (meibomian cyst) - Firm painless lump in the eyelid lasting a long time, cyst remnant after an internal stye
    ‣
    Mangement?
    • Hot compression & analgesia
‣
A mother brings in her child concerned that he may have a squint. Screening test?
  • Screening: Corneal light reflection test (Hirschberg's test) - Is it symmetrical?
    • ‣
    Types:
    image
    ‣
    Investigations?
    • Cover test - Cover dominant eye and abnormal eye will migrate to the centre and fixate on the object.
    ‣
    Management?
    • Eye patch covering dominant eye
    ‣
    Complications?
    • Amblyopia (Visual cortex increases area of the dominant eye)
‣
👓 Middle
‣
Differentials:
‣
Patient presents with miosis. Differentials?
  1. Horner's syndrome
  2. Argyll-Robinson pupil
  3. Cluster headaches
  4. Drugs:
    • Opiates
    • Nicotine

‣
Small pupils that don't respond to light but accommodate. Diagnosis? Commonly found in?
  • Argyll-Robinson pupil
  • Commonly found in neurosyphilis
‣
Patient presents with mydriasis (dilation). Differentials?
  1. C.N. III palsy
  2. Holmes-Adie pupil
  3. Pheochromocytoma
  4. Glaucoma
  5. Drugs:
    • Amphatamines / cocaine (sympathomimetic)
    • Tricyclic antidepressants (anticholinergic)

‣
What are the signs of a third nerve palsy?
  1. Ptosis
  2. Eye down & out
  3. Mydriasis

Cases:

‣
Patient arrives with a severely painful red eye, N&V & haloes around lights. OE there is a fixed, dilated pupil. Diagnosis?
  • Closed angle glaucoma
    • ‣
    If they have a positive FH, do they need screening?
    • Yes - Annual screening from 40 years
    ‣
    Immediate management?
    1. First-aid: Lie on back without pillow, analgesia, antiemetic
    2. Specific medications:
      • Pilocarpine drops → Pupil constriction
        • ‣
        SEs?
        1. Blurred vision
        2. Headaches
      • Timolol drops → ↓ Aqueous humour production
      • IV Acetazolamide → ↓ Aqueous humour production
    ‣
    Definitive management?
    • Bilateral peripheral (laser) iridectomy - Remove a section of iris to increase flow
    ‣
    Complications?
    • Optic nerve damage due to pressure
‣
Patient notices some tunnel vision, fluctuating eye pain and headaches. They also notice some blurred vision and haloes around lights at night. Diagnosis?
  • Open angle glaucoma
    • ‣
    Management?
    1. Latanoprost (Prostaglandin analogues) - Dilate outflow tract
    2. Timolol (β-blocker) - ↓ aqueous humour production
    3. Surgery
    ‣
    A patient's eye changes colour from blue to brown after being treated, what medication caused this?
    • Latanoprost
‣
Diabetic patient known to have proliferative retinopathy presents with acute painless visual loss with a red hue in the vision. Diagnosis?
  • Vitreous haemorrhage: Cause retinal tears in 90% of cases
    • ‣
    How do you investigate them?
    • B-scan USS: Helps determine if the retina has detached or not
‣
Elderly gentleman who smokes and takes steroids presents with generalised reduction in visual acuity (blurring) with starbursts around lights. Diagnosis?
  • Cataracts
    • ‣
    Management?
    • Pseudophakia: Lens replacement
    ‣
    What are potential complications following management?
    1. Endophthalmitis: Presents days after surgery with severe pain & visual loss (serious)
      2. ‣
      How is this managed?
      • Intravitreal vancomycin (GP organisms)
    2. Posterior lens capsule opacification: Presents weeks after surgery with blurred vision
‣
Patient with ankylosing spondylitis presents with a painful, red right eye. OE there is increased lacrimation & a small & irregular pupil. Hypopyon is present when examining the eye. Diagnosis?
  • Anterior uveitis
    • ‣
    What is a hypopyon?
    Hypopyon - Fluid level in the eye
    Hypopyon - Fluid level in the eye
    ‣
    How is this managed?
    • Steroid (reduces inflammation) & mydriatic (reduces pain) eye drops
‣
How do you elicit RAPD?
  • Swinging light test
    • Light in normal eye → Both pupils constrict (efferent intact). Light in affected eye → Both pupils dilate
‣
🔴 Inner
‣
Vascular
‣
How do you classify diabetic retinopathy?
  • Non-proliferative
    • Mild: ≥ 1 microaneurysm
    • Moderate:
      • Blot haemorrhage
      • Hard exudates (lipid leakage exudate)
      • Cotton wool spots (damage to nerve fibres → white patches)
    • Severe: Microaneurysms in all 4 quadrants, bleeding in ≥ 2 quadrants
  • Proliferative
    • ‣
    How do you treat proliferative retinopathy?
    • Anti–vascular endothelial growth factor therapy (Anti-VEGF)
    • Control diabetes
Renátó BesencziJános TóthAndrás Hajdu, CC BY-SA 4.0
Renátó BesencziJános TóthAndrás Hajdu, CC BY-SA 4.0 creativecommons.org/licenses/by-sa/4.0, via Wikimedia Commons. No changes were made.
‣
How do you classify hypertensive retinopathy?
  1. Silver wiring, ↑ tortuosity of arteries
  2. AV nipping
  3. Cotton wool exudates, flame & blot haemorrhages
  4. Papilloedema

What features are seen on the following images:

Frank Wood, CC BY 3.0
Frank Wood, CC BY 3.0 creativecommons.org/licenses/by/3.0, via Wikimedia Commons. No changes were made.
‣
Answer
  • Silver wiring
  • AV nipping: Thinning of the vessels where the arteries cross the veins
Shaofeng Hao, Changyan Liu, Na Li, Yanrong Wu, Dongdong Li, Qingyue Gao, Ziyou Yuan, Guanyan Li, Huilin Li, Jianzhou Yang, and Shengfu Fan., CC BY 4.0
Shaofeng Hao, Changyan Liu, Na Li, Yanrong Wu, Dongdong Li, Qingyue Gao, Ziyou Yuan, Guanyan Li, Huilin Li, Jianzhou Yang, and Shengfu Fan., CC BY 4.0 creativecommons.org/licenses/by/4.0, via Wikimedia Commons. No changes were made.
‣
Answer
  • Hard exudates
  • Microaneurysms
  • Blot haemorrhages
‣
Patient with temporal arteritis presents with a sudden loss of vision in their right eye (unilateral). RAPD present. Diagnosis?
  • Central retinal artery occlusion
    • ‣
    Fundoscopy findings?
    • 'Cherry red' spot on a pale retina
    ‣
    What other differential would you have for a GCA patient with visual loss?
    • Anterior ischaemic optic neuropathy (more common)
    • Fundoscopy: Swollen, chalky white optic disc
‣
Sudden painless loss of vision in a patient with metabolic syndrome who smokes. No RAPD. Fundoscopy looks as follows:
  • Retinal vein occlusion
Ku C Yong, Tan A Kah, Yeap T Ghee, Lim C Siang and Mae-Lynn C Bastion, Department of Ophthalmology, Universiti Kebangsaan Malaysia Medical Centre (UKMMC) and Universiti Malaysia Sarawak (UNIMAS), Kuala Lumpur, Malaysia., CC BY 2.0
Ku C Yong, Tan A Kah, Yeap T Ghee, Lim C Siang and Mae-Lynn C Bastion, Department of Ophthalmology, Universiti Kebangsaan Malaysia Medical Centre (UKMMC) and Universiti Malaysia Sarawak (UNIMAS), Kuala Lumpur, Malaysia., CC BY 2.0 creativecommons.org/licenses/by/2.0, via Wikimedia Commons. No changes were made.
‣
Fundoscopy shows the following:
DocSee04, CC BY 4.0
DocSee04, CC BY 4.0 creativecommons.org/licenses/by/4.0, via Wikimedia Commons. No changes were made.
‣
What can you see? What are the differentials?

Papilloedema is visible.

  1. Mass
  2. Intracranial haemorrhage
  3. Trauma
  4. Hydrocephalus
  5. IIH
  6. Hypercapnia
  7. Glaucoma
‣
Nerve/retina
‣
Elderly gentleman (any age) presents with sudden onset, painless and progressive visual field loss, described as a curtain from periphery to central vision. OE: RAPD. Diagnosis?
  • Retinal detachment
    • RFs: DR, PVD, Old age, trauma
      • ‣
      Fundoscopy:
      image
      ‣
      Differentials?
      • Posterior vitreous detachment
      • Vitreous haemorrhage
      ‣
      Investigations?
      • B-scan USS
      ‣
      Management?
      • Remove vitreous humour and insert gas/fluid to apply pressure which pushes the retina back onto the choroid
‣
Elderly female patient with myopia presents with a sudden appearance of floaters & flashes, blurred vision and appearance of a cobweb across vision. Diagnosis?
  • Posterior vitreous detachment (main RF for retinal detachment)
    • 'Photopsia' = flashes of light
    • 10% go on to have retinal detachment
‣
75 year old lady with subacute visual loss, struggling to see especially at night and fluctuations in visual disturbance day-to-day. Differentials?
  • Differentials: Dry/Wet ARMD
    • ‣
    Investigations?
    1. Amsler grid testing
    2. Slit-lamp microscopy
    3. Fluorescin angiography
    ‣
    Management?

    Wet:

    1. Anti-VEGF injection
    2. Laser photocoagulation of new vessels
‣
35 year old patient with a FH of eye problems presents having noticed tunnel vision and now has night blindness. Diagnosis?
  • Retinitis pigmentosa: Destruction of rods (tunnel vision & night blindness) followed by cones (↓ acuity & blindness)
‣
Unilateral loss of visual acuity over last few hours, red desaturation in affected eye, pain worse on movement of the eye. Diagnosis? Management?
  • MS
  • Management: High-dose prednisolone (40-60mg)
‣
A child with a positive FH of eye tumours has bilateral leukocoria on newborn eye examination, described as a 'cream white mass'. Diagnosis?
  • Retinoblastoma
    • ‣
    What is leukocoria?
    • White pupillary reflex
    ‣
    How do you differentiate sporadic from hereditary?
    • FH
    • Sporadic is unilateral, hereditary is bilateral

💉 Anaesthetics & ICU

‣
💉 Anaesthetics
‣
Assessing the patient
‣
ASA classification
‣
What is it for?
  • Grades a patient's fitness/physical status. Useful to give clinicians an immediate impression and allow comparison.
‣
What do each of the grades mean?
  • Grade 1: Normal healthy patient
  • Grade 2: Mild systemic disease
  • Grade 3: Severe systemic disease
  • Grade 4: Severe systemic disease that is a constant threat to life
  • Grade 5: Moribund patient not expected to survive with or without the operation
  • Grade 6: Declared brain dead patient whose organs are removed for donor purposes

Classify the following patients:

‣
Patient presenting with a ruptured AAA.
  • ASA V: Not expected to survive without operation
‣
Patient has had an MI in the last 3 months presents with ongoing cardiac ischaemia.
  • ASA IV: Severe systemic disease that is a constant threat to life
‣
A healthy, non-smoker with minimal alcohol use presents for an elective cholecystectomy.
  • ASA I: A normal healthy patient
‣
A patient presents with poorly controlled DM and renal disease requiring regularly scheduled dialysis.
  • ASA III: Severe systemic disease
‣
A 12 pack year smoker and social alcohol drinker with T2DM that is well-controlled.
  • ASA II: Mild systemic disease
‣
VTE prophylaxis
‣
When should post-op VTE prophylaxis be prescribed?
  • 6-12 hours after surgery
‣
How long should the following patients have VTE prophlylaxis prescribed for:
‣
Elective hip/hip fracture
  • 4 weeks
‣
Elective knee
  • 2 weeks
‣
Drugs
‣
How should a patient on warfarin be managed before surgery?
  • Stop warfarin 5 days before
  • Commence:
    1. LMWH: OD SC injection
    2. Unfractionated heparin: Rapid onset & offset when infusion is stopped, use in surgery
‣
When should the COCP be stopped prior to surgery?
  • 4 weeks before
‣
What antihypertensive should be stopped 24h before surgery?
  • Ramipril
‣
Why is it important to assess their neck function?
  • Intubation requires neck manipulation
‣
Who is at high risk of death in surgery?
  • 1.5X: MI, HF, stroke, renal failure, PAD
  • 2X: T2DM
  • 3X: T1DM
‣
Anaesthetic drugs
‣
What is the triad of anaesthesia?
  1. Anaesthesia
    2. ‣
    What is general anaesthesia?
    • A reversible drug-induced state of unconsciousness, characterised by a coma-like state. Always associated with profound amnesia and often muscle paralysis.
    ‣
    What are 2 main steps of this?
    1. Induction: Getting patients to sleep

        2. 2 options:

      1. IV drugs: Propofol
        • Rapidly distributed into peripheral tissues → Effects last 5-10 minutes
        • Has proven antiemetic properties
        • Other IV inducers: Ketamine, Thiopentone, Etomidate
      2. Rapid sequence induction: Sevofluorane (vapour)
    2. Maintenance: Keeping patients asleep
      • Volatile agents (vapour): Isoflurane (best because it has a short half life), sevoflurane
    ‣
    Give 2 examples of regional anaesthesia.
    1. Epidural anaesthesia
    2. Spinal anaesthesia
    ‣
    Local:
    ‣
    How does lidocaine (lignocaine) work?
    • Na⁺ channel blocker
    ‣
    What does lidocaine interact with?
    • Beta blockers
    • Ciprofloxacin
    • Phenytoin
    ‣
    If there is lidocaine toxicity, how does it present and how is it managed?
    • Present: Light-headed, mouth numbness and metallic taste → Shock
    • Managed: IV 20% lipid emulsion
  2. Analgesia
    3. ‣
    What hormonal changes occur during the surgical stress response?
    • Activation of sympathetic nervous system
    • ↑ ACTH → CV changes
    • ↑ GH
    • ↑ ADH → Fluid retention
    • ↑ Prolactin
    • ↑ Insulin resistance → Hyperglycaemia & electrolyte disturbances
    • ↑ CO₂ production → Acidosis
    • ↑ O₂ consumption
    ‣
    What is used in the following stages:
    ‣
    Pre-op
    • Ibuprofen 200mg
    ‣
    Peri-op
    1. IV fentanyl (before induction agent)
    2. IV morphine, paracetamol or diclofenac depending on situation
    3. Local/epidural anaesthesia
    ‣
    Post-op
    1. PO/SC morphine
    2. Diclofenac
    3. Paracetamol
    ‣
    Why is multi-modal analgesia used?
    • Reduces the individual doses needed for each drug, reducing their side effects
  3. Muscle relaxation
    4. ‣
    What are the 2 types?
    1. Competitive/Non-depolarising
      2. ‣
      Examples?
      • Vecuronium
      • Atracurium
      ‣
      How does it work?
      • Competitive antagonism of acetylcholine at the NMJ, preventing depolarisation
      ‣
      Onset and duration?
      • Slower onset than suxamethonium (2-3 mins) and longer duration (20-40 mins)
      ‣
      SE?
      • Hypotension
      ‣
      How do you reverse this?
      • Acetylcholinesterase inhibitors, e.g. neostigmine
    2. Non-competitive/Depolarising
      3. ‣
      Example?
      • Suxamethonium
      ‣
      How does it work?
      • Induces prolonged depolarisation of the skeletal muscle membrane, stopping further muscle contractions
      ‣
      Onset and duration?
      • Fast onset (within 30s) and short duration (2-6 mins)
      ‣
      When is this indicated?
      • Only in rapid sequence intubation in emergency settings due to fast onset
      ‣
      How can the mechanism be seen in the patient?
      • Fasciculations of the muscles due to prolonged contraction before profound paralysis
      ‣
      SEs? (3)

      Prolonged contraction can cause:

      1. Malignant hyperthermia
        2. ‣
        Features?
        • Hyperthermia
        • Muscle rigidity
        • Tachycardia
        • Acidosis
        ‣
        How is this managed?
        • IV dantrolene
      2. Hyperkalaemia (usually transient)
      3. Extra: ↑ IOP
      4. Profound bradycardia in high doses
      ‣
      Why can some patients present with no respiratory effort following being given this in surgery?
      • Suxamethonium apnoea secondary to acetylcholinesterase deficiency (AD inheritance)
      ‣
      When is it CI? (2)
      • Eye trauma / glaucoma
      • FH of suxamthonium apnoea (AD inheritance)
‣
Considering the triad discussed above, what drug combination is given initially?
  1. IV fentanyl
  2. IV propofol
  3. Rocuronium
‣
What IV induction agent is used in haemodynamically unstable patients?
  • Ketamine: Preserves BP and doesn't suppress heart function
  • Suxamethonium used alongside this for muscle relaxation
‣
Airway
‣
What is inserted while preparing for intubation?
  • Oropharyngeal (Guedel) airway: Can be used in very short procedures
‣
What are the intubation options and indications? (2)
  1. Laryngeal airway mask: Daycase surgery
    2. ‣
    What is a CI against this?
    • Non-fasted patients → Risk of aspiration
  2. Endotracheal tube: Long or short term ventilation
  3. Tracheostomy: Widely used in ITU and long-term ventilation
‣
What are contraindications against a nasopharyngeal airway? (2)
  1. Basal skull fracture
  2. Coagulopathy
‣
What is the anaesthetist's role in post-op management?
  • Effective post-op analgesia (reduces the surgical stress response)
  • Prevent N&V
  • Fluid homeostasis and bleeding management
  • Temperature maintenance
‣
What common complications might an anaesthetist have to deal with? (7)
  1. Atelectasis
  2. Anaphylaxis
  3. Awareness
  4. Bronchospasm
  5. Laryngospasm
  6. Malignant hyperthermia
  7. Suxamethonium apnoea
‣
What are the post-op fever causes?
  1. Wind (day 1-2)
    • Aka air through lung problem e.g. atelectasis or pneumonia
  2. Water (day 3-5)
    • UTI
  3. Walk (day 4-6)
    • DVT or PE
  4. Wound (day 5-7)
    • Surgical site infection
  5. Wonder about drugs (day 7+)
    • Can cause anaphylaxis early on, but also drugs or blood products can be incompatible with a person's system, always consider this
‣
What can we use to increase HR?

Inotropic support:

  • Atropine (crosses BBB)
  • Dobutamine (doesn't cross)
    • Dobutamine is a cardiac stimulant which acts on β₁ receptors in cardiac muscle, and increases contractility.
  • Noradrenaline
‣
😮‍💨 ICU
‣
Overview
‣
What criteria must be met before a patient comes into ICU? (4)
  1. Reversible pathology
  2. Physiological reserve to survive an ICU admission
  3. Need for organ support
  4. Patient willing to undergo aggressive and invasive treatment
‣
How is it different to regular wards care?
  1. Higher ratio of medical staff (1:1 nursing care), 2 ward rounds/day
  2. Supporting organ systems to 'buy time'
    3. ‣
    Name 5 examples of organ support.
    1. Airway: Definitive airway protection, e.g. endotracheal tube, tracheostomy
    2. Breathing: Ventilation, oxygen therapy
    3. Circulation: Vasopressors and inotropes, pacemakers, intra-aortic balloon pumps
    4. Disability: Neuroprotective measures in head injury
    5. Kidneys: Renal replacement therapy
  3. 75% critically unwell medical admissions, 25% post op surgical patients
‣
What is the difference between level 2 and 3 care?
  • Level 2: High dependency unit (HDU)
    • 1:2 nursing
    • Indication: Single organ support
  • Level 3: Full intensive care
    • 1:1 nursing
    • Indication: ≥ 2 organ systems need supporting or mechanical ventilation is required
‣
What is the trauma triad?
  1. Hypothermia
  2. Coagulopathy
  3. Metabolic acidosis
en:User:Cburnett, CC BY 3.0
‣
What are the options for IV access?
  1. Peripheral cannulae
  2. Intraosseous
    3. ‣
    Where is this commonly done?
    • Anteromedial aspect of the proximal tibia
    ‣
    Who is this commonly used in?
    • Children with difficult access
  3. Lines
    4. ‣
    What are the 3 types?
    1. Central line
      2. ‣
      Where is this inserted?
      1. Internal jugular vein (preferred)
      2. Femoral vein (high infection rate)
    2. Tunneled line
      3. ‣
      When are they used?
      • Long-term central access, the cuff around entry point becomes integrated into local tissues
      ‣
      What are the 2 types?
      1. Hickman
      2. Groshong
    3. PICC (peripherally inserted central catheter) line
      4. ‣
      Why are these beneficial?
      • Less prone to infection
‣
Reduced consciousness
‣
How do we measure conscious level? Constituents?
  • Glasgow coma scale (GCS)
    • ‣
    Motor response (M6)
    1. No response to pain
    2. Extensor response to pain
    3. Flexor response to pain
    4. Withdraws to pain
    5. Localises to pain
    6. Obeys commands
    ‣
    Verbal response (Vo5)
    1. None
    2. Incomprehensible
    3. Inappropriate speech
    4. Confused conversation
    5. Oriented
    ‣
    Eye opening (E4)
    1. No eye opening
    2. Opens to pain
    3. Open in response to speech
    4. Spontaneous
‣
When assessing their airway, what would suggest intubation is necessary?
  1. Airway patency: Snoring, GCS < 8 (mostly but not always)
  2. Oxygenation & ventilation: ↓ SpO₂, ↓ respiratory effort (↑CO₂)
‣
After intubation, what investigations would help rule out life-threatening emergencies?

Depends on clinical picture, but consider:

  1. Imaging: CT head (Bleed, stroke, SOL, bone trauma)
  2. Toxicity screen: Poisons
  3. LP: CNS infection
‣
CO poisoning
‣
What are the common features?
  • History of moving into a new house/car fumes, etc.
  • Cherry red lips, headache, low GCS
  • Arrhythmias
‣
How do you investigate?
  • ABG: ↑ Carboxyhaemoglobin
‣
How are they managed?
  • Supportive: Oxygen 100%
    • Serious cases: Hyperbaric oxygen
‣
Non-invasive ventilation
‣
BiPAP
‣
When is this commonly indicated?
  • T2RF: Two different levels of positive pressure on inspiration and expiration
‣
When is it CI? (6)
  1. Facial burns
  2. Vomiting
  3. Untreated pneumothorax
  4. Severe co-morbidities
  5. Haemodynamically unstable
  6. Patient refusal
‣
CPAP
‣
When is this commonly indicated?
  • T1RF: Providing positive pressure to keep the alveoli open for a longer period of time to facilitate gas exchange
‣
Burns
‣
What are the 4 types of burns?
  1. Thermal: Contact, flame (common in adults), scald (common in children)
  2. Electrical: High or low voltage
  3. Friction
  4. Chemical: Acid or alkali
‣
Pathophysiology: What happens to the 3 zones of tissue according in the Jackson burn model?
  1. Outer tissue: Coagulative necrosis
    • Immediate death of cells in the area nearest the heat source
  2. Surrounding tissue: Stasis
    • Area next to/surrounding necrosis, damage less severe but compromised circulation. Progression of depth of burn over 3-5 days
  3. Hyperaemia
    • Inflammatory mediators cause widespread dilatation of blood vessels
    • Tissue returns to normal of resolution of hyperdynamic response
‣
Assessing a burn
‣
How do you estimate the total body surface area affected by the burn?
  • Rule of 9s: The following anatomical regions represent 9% of body (different in children)
    • ‣
    What areas represent 9%?
    • Front and back of the head and neck
    • Front and back of each arm and hand (individually)
    • Chest
    • Stomach
    • Upper back
    • Lower back
    • Front of each leg & foot (individually)
    • Back of each leg & foot (individually)
‣
When are fluids indicated?
  • > 15% total body area burns in adults (>10% children)
    • Aims to prevent the burn from deepening
‣
How do you calculate the total fluid requirement of the patient in the first 24 hours?
  • Parkland's formula
    • 4ml x Total burn surface area (%) x Body weight (kg)
      • ‣
      How much of this is given in the first 8 hours?
      • 50% then the next 50% is given over the remaining 16 hours
      ‣
      What type of fluid is indicated?
      • Hartmann's
‣
Complications
‣
Name 4 consequences of severe burns?
  1. Hypermetabolism: Muscle breakdown
  2. Immunosuppression: Loss of gut barrier function and release of stress hormones
  3. Hypovolaemia: Evaporative loss, large volume fluid sequestration
  4. Increased vascular permeability
‣
What is an escharotomy?
  • Emergency procedure to remove burnt tissue to improve respiration and/or circulation to a limb

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