Section B

Malignant kidney tumours - epi + etio

- 2% of all malignancies in adults; 10% of childhood - highest incidence in CR = 70y Etio: - exogenous (smoking, obesity) - endogenous (HTN, ESRD, dialysis) - intrinsic (VHL, HPRCC)

Delayed transfusion reaction

- 3-10d after etio: destruction of transfused RBC by newly formed alloAb or AutoAb - esp in patients previously alloimmunised via transfusion or in pregnancy sym: asymptomatic, fever, jaundice, malaise, rarely hemolysis w hemorrhage labs: dec Hct, reticulocytes; inc LDH + BR, dec haptoglobin

Whole blood transfusion

- 450-500ml donor blood - contains RBC, plasma, clotting factors, anticoagulant - Hct 35-45% - Platelets + granulocytes are non-fx - I = massive blood loss; not routinely available

Tumours of renal pelvis + calyces

- 90% transitional cell ca; 5% SCC or adenoCa etio: rf = smoking, chemical exposure, phenacetin sym: flank pain, painless hematuria (gross or microscopic) - symptoms can be dt obstrucing blood clots or bone/lung/liver mets - no paraneoplastic syndromes dx: PE unhelpful; labs only show microscopic hematuria - ureteroscopy + direct biopsy - IV urography + retrograde pyelography confirmation - US/CT for staging; XR/CT for met assessments tx: - nephrouterectomy (incl ureteral orifice of bladder) - transurethral or percutn endoscopic resection for low-grade lesions

Chronic epididymitis

- >6w course etio: recurrent acute, TB, amiodarone Sym: recurrent bouts of scrotal pain w minimal swelling but thickened epididymis

unconscious patient - Immediate management

- ABC: IVF, intubate if GCS <8, O2 - Stabilise cervical spine unless trauma is expressly ruled out Asses causes: - hypogly = IV 10% glu 200ml - Wernicke's = IV thiamin - Opiate intoxication = IV or IM naloxone - BZD intoxication = IV flumazenil - Meningitis = cefotaxime - Malaria = quinines - Meningitis = aciclovir

Pleural empyema tx

- ATB for pneumonia (IV unless fever free >24h) CAP: 5-21d w coamoxiclav/moxifloxacin/doxycycline/macrolide HAP: 7d w meropenem/levofloxacin + vancomycin/linezoid if MRSA risk + gentamycin/aztreonam of high mortality/CF/VAP - chest tube drainage + repeated thoracocentesis - intrapleural fibrinolytics (DNAase, tPA) - VATS or open thoracoscopy w decortication - simple rib resection (1-3 ribs w tube placement for drainage) - Eloesser procedure if decortication is CI

Hydronephrosis prognosis

- Acute is reversible if quickly treated - Chronic inc intratubular pressure = compression of surrounding vessels = dec renal perfusion - Ischemic tubular atrophy, thinning of renal cortex + medulla, loss of renal fx (irreversible) = CKD, HTN, oliguria, edema, uremic syndrome

17. Anorectal abscess - definition, anatomy, pathophys

- Acute manifestation of purulent infection of perianal area - Pus-filled cavity develops from infected anal crypt gland (assoc w systemic disease) - Anal canal contains 6-14 glands btw int + ext sphincter; drain into crypts - Crypt occlusion = stool + bacteria trapped within gland = infection - If crypt doesn't decompress to canal = abscess - Risk of fistula formation

1. Acute mediastinitis - definition + anatomy

- Acute mediastinitis = life threatening (80% mortality) inflammation of mediastinal space - Often extends to pleura Mediastinum: central space of thoracic cavity - behind sternum, between lungs + respective pleura - in front of verbebrae, above diaphragm

Prostate tumour cx

- After surgery = incontinence (transient usually), ED, infertility - After RT = proctiits, enteritis (diarrhea), cystitis, urethritis - Anti-androgen tx = hot flushes, lethargy, gyne

8. Asepsis

- Aims to prevent access of MO into open wounds, body cavities + internal tissue - Secure conditions of sterility Aseptic technique = procedure performed under sterile conditions in theatre - theatre is isolation zone to be entered in clean attire - all open wounds should be aseptically dressed to protect from cross-infection

Unconscious patient - eye neurological examination

- All patients w ARAS pathology have eye findings Visual fields: hemianopia, CL hemisphere lesion Pupils: - Intact midbrain = normal direct + consensual reflexes - Midbrain lesion = mid-position non-reactive + irreg - CN III compression - unilat dilated + unreactive - Pontine lesion or drugs - small, reactive (pin-point) - Ipsilateral medulla or hypothalamus - miosis (Horner) Extraocular movements: - Observe resting position + spontn movement - Vestibulo-ocular reflex: if present, implies lesion is on BS doll-head manoeuvre - normal if eyes keep point as head moves ice water calorics - normal if eyes deviate to cold ear w CL nystagmus Fundi: paplliedema, subhyaloid hemorrhage, HTN/DM retinopathy

Rh-immune globulin transfusion

- Anti-D Ig derived from pooled human plasma - I = prophylaxis against alloimmunisation to Rh Ag in Rh- patients

Dura mater reconstruction

- Avoid CSF leakage + prevent entry of organisms (meningitis) - Fibrin glue or primary closure - If primary closure isn't possible, can close with patches from cadaveric DM, xenographs, synthetic grafts, vascularised autografts (from fascia lata or greater omentum)

Loss injury of hand - procedure steps

- Bone stabilised w Kirschner wire or metal plates - Vascular repairs done w microscopic magnification = ischemic tissue reperfusion (Failure is often dr venous outflow problems + anticoag help maintain perfusion) - nerve + tendon repairs - soft tissue to cover repaired structures - muscle + skin flaps from distant sites can be used

19. Dupuytren's contracture - definition + etio

- Common fibroproliferative dsr affecting palmar fascia of 4th + 5th digit - Esp in males 40-60y etio: - genetic predisposition; 70% of patients have positive fam hx - RF = smoking, recurrent trauma, DM, alcohol, cirrhosis (cause ischemic injury) - Possible AI component = evidence of T-cell accumulation in fibrotic tissue

Pylorospasm etio

- Congenital pyloric stenosis - Lesions of stomach. GB, appendix - Hyperacidity (abnormal gastric juice secretion)

Hydronephrosis dx

- Depends on age (self limiting in babies by 3y) - Bloods - BUN:Cr, hypoNa, hyperCl MAc - Urinalysis - blood, leuk, nitrites, pH, impaired concn ability - Imaging - IV urogram, US, CT, MRI, antero-/retrograde pyelography US = hypoechoic dilation of pelvis

Dupuytrens contracture cx

- Digital infarction, ishemic skin flaps, hematoma, fibrosis, anesthesia, pain - High rate of recurrence Reflex sympathetic dystrophy: painful debilitating neurlogical disorder that may occur after surgery

SVCS sym

- Face plethora, venous pattern on face, chest, UE - Orthostatic hypotn, syncope, AKI, JVD - Headache, visual impairment, confusion - Symptoms worsen if patient is supine or bent over

Skin flaps - definition

- Flap consists of tissue that is moved from one part of body to another w vascular pedicle to maintain blood supply - Flap = tongue of tissue; Pedicle = step w vascular supply - Pedicle can be kept intact or transected for microvascular anastomosis

Hydrocele sym

- Fluctulant, painless swelling - Palpation above swelling = normal spermatic cord + inguinal ring - positive transillumination (light through testicles)

Chemical sterilisation

- For devices that can't be sterilised w physical methods Formaldehyde: thermolabile material, metal - formaldehyde gas + water vapour at 60-80C Ethylene glycol: thermolabile materials (esp liquids) - both require ventilation as fumes are toxic

Hanging clinical features

- Hangman fracture: fracture of both pedicles of axis - Inverted V mark on neck - Death erection: post mortem erection dr cerebellum compression - Tongue protrusion dt pressure on jaw - Petechiae in eyes, face, legs, feet - Cerebral hypoxia

ischemic cerebrovascular accidents dx

- History, PE, ECG, labs (CBC, coag screen, U+E, troponin) - Non-contrast CT (exclude hemorrhage - detects ischemia after 6h) - Diffusion-weighted MRI (detects ischemia after <30min) - CTAngio to localise occlusion - Perfusion-weighted imaging = visualises areas of dec perfusion + gives data on cerebral bf + bv - Perfusion-diffusion mismatch MRI - identifies penumbra (tissue at risk)

Penetrating neck injury - approach

- If bleeding: direct pressure, balloons - ABCDE, resuscitation, tetanus shot, ATB, analgesia, intubation - Surgical exploratory thoracotomy/sternotomy if necessary - Evaluate extent - CTA, pan-endoscopy

Soft tissue defects

- If periosteum + underlying m intact = secondary closure possible - Full (all layers) or split (epiderm + some derm) skin grafts - Free flap or regional flaps used when bulk is needed for a better contour

Anorectal anomalies - tx

- Immediate opening for passage of faeces Primary anoplasty (for rectoperineal/rectovestibula fistuli) 2 stage procedure -Defx colostomy w/i 48h of birth - Reconstruction: pos sagittal anorectoplasty (thru midline perineal incision - Closure of colostomy

Branchial fistula

- Incomplete closure of 2nd brachial arch in embryo = hole in lower neck - Sinus is freq assoc w track running up neck (as high as pos pharynx = bronchial fistula) sym: 1yo children as mucus discharging orifice in ant border of SCM tx: surgical excision of fistula

Pulmonary abscess sym

- Indolent course, symptoms evolve over w-m - Non-specific: fever, anorexia, WL, night sweats, cachexia - Cough + foul smelling sputum, hemoptysis - Finger clubbing - Dental decay (esp in children + alcoholics) - Percussion dullness + bronchial breath sounds

Autosomal dominant PKD

- Inherited ch16 mutation = altered polycystin-1 or -2 - Progressive cystic dilation of tubular system w extrarenal involvement sym: usually >30y; bilat; polymorphic cysts - Renal: CKD (headache, n+v, WL), UTIs, nephrolithiasis, flank pain (dt cyst rupture) - Extrarenal: hepatic cysts (or pancreatic, splenic, testicular/ovarian); HTN, valvular defects, berry aneurysm; diverticula, ab/inguinal hernias Prognosis: 50% have ESRD by 60y w chronic HTN + cerebral aneurysms

Autosomal recessive PKD

- Inherited ch6 mutation w cystic dilation of collecting ducts + hepatic fibrosis sym: childhood; bilateral; monomorphic cysts - Renal: CKD (hematuria, proteinuria), renal/liver enlargement (protruding abdomen) - Extrarenal: oligohydramnios, portal fibrosis, HTN - Oligohydramnios = Potter sequence = craniofacial abnormalities, clubbed feet, pulmonary hypoplasia, posterior urethra valves Prog: severe neonatal cysts = <1m LE; normal = >15y LE

Dupuytren's contracture - pathophys

- Injury (trauma/ischemia) to palmar fascia triggers myofibroblast proliferation + collagen III deposition = thickening of fascia + formation of nodules - Nodules adhere to overlying dermis = palmar skin puckering - Nodules for cords = flexion contractures (cannot be straightened)

Regional reconstruction

- Lack of local tissue - Pedicled flaps from trapezius or supraclavicular - Crane principle: healthy part is used to re-sruface defect > flap takes > skin returned to original site (leaving subcutis on defect as a split skin graft)

Blunt injuries - consequences + complications

- MC = cervical fracture, cervical spinal injury, vascular injury, laryngeal and/or tracheal injury - Sometimes CSF cysts Cx: airway obstruction, tracheal stenosis, sepsis, air embolism, exsanguination, AV fistula, paraplegia, quadriplegia

Prostate - epi + etio

- MC in elderly men - mostly adenoCa etio: >50y, fam hx, BRCA/Lynch, obesity

Cystic hygroma

- MC lymphangioma - congenital multiloculated latic lesion that can arise anywhere - MC on left pos triangle of neck + armpit Sym: dyspnea + dysphagia Dx: prenatal US Tx: surgery or sclerosing agents (bleomycin, ethanol)

16. Tumours of retroperitoneum

- Most are secondary to intraperitoneal cancers Primary Secondary - lymphoma - distant spread from testicle, cervix, ovary, endometrium, colon, rectum - contiguous spread from kidney, pancreas, ureters

Epididymis - dx

- Mostly clinical Labs: urinalysis (pyuria, bacteriuria), urine culutre, urethral swabs (culture, nucleic acid amplification test), CBS (leu) Scrotal US: rule out torsion or suspect abscess - enlarged epididymis w inc bf Ddx: testicular torsion, hydro- + varicocele, inguinal hernia

Bone defects

- Need to be closed to protect brain (skull deformities inc ICP = seizures + death) - Small defects filled w morcellized bone (bone ground down into lumps) - Large defects filled w rib grafts or synthetic implants

Retroperitoneal fibrosis - definitoin + etio

- Ormond's disease - Rare disease of unknown etiology; affects ~50y men - Inflammation + fibrosis = compression + encasement etio: Primary (idiopathic) MC - Immune reaction to Ag within aortic atherosclerotic plaques - Systemic AI disease of large arteries = peri-aortic fibrosis - Ig-G4 infiltrative disease Secondary - Drugs: dopamine antagonists, BB, hydralazine, infliximab - Infections: TB, histoplasmosis - RF: tobacco, asbestos

Anal fissures- pathophys

- Overdistension or disease of anal mucosa = laceration of anoderm - Leads to spasm of exposed internal sphincter + pulling along laceration = impaired healing + worsening of wound w each bowel movement - Resultant pain = voluntary avoidance of defecation + constipation + tf worsening of distension - Pos fissures have poor blood supply + tf may predispose to ischemia

Anorectal fistula - dx

- PE (PR); no imaging necessary if uncomplicated - Complex cases = transrectal EUS, CT, MRI, fistula probe w methylene blue Ddx: CD, pilonidal disease, hidradenitis, TB, carcinoma, trauma

Spontn pneumothorax sym

- Pleuritic chest pain (sudden severe, stabbing), cough, dyspnea - Severe (tesion or pre-existing severe lung disease) = diaphoresis, cyanosis, hypotn, CV collapse, JVD, subcutn emphysema - o/e = tachypnea, tachycardia, dec breath sounds, hyperresonance, dec vocal fremitus on involved side, mediastinal shift in tension pneumothorax

PKD tx

- Prevent or delay progression to ESRD by monitoring, avoidance of nephrotoxic substances, anti-HTN (ACEi/ARB), UTI tx, low protein, hydration - Hemodialysis or peritoneal dialysis for ESRD - Surgical = aspiration/resection of obstructive cysts/tissue; kidney transplant curative

Loss injuries of hand - what to do

- Prioritise saving as much thumb as possible, even at expense of other digits - Amputate part in plastic bag in ice water (not frozen + shouldn't be directly touching ice) - Patient taken urgently to theatre for revascularisation and/or reimplantation (ischemia >6h = revascularisation failure) - Clean amputations are reimplanted - children recover fx better than adults - Reimplantation of entire arm at elbow or above is controversial - usually amputuate - Assess for other less obvious injuries - neurological, intraabdominal etc - Clean, moist dressing + elevation

15. Prolapse of anus + rectum - definition + classification

- Protrusion of rectal mucosa or entrie rectom through anus - Bimodal incidence: children <3 (MC partial); adults >50 (MC complete) Classification: - Complete (full thickness) - all layers of rectal wall >4cm - Partial (mucosal) - only mucosal layer, <4cm - External (visible externally) x Internal (not visible) - Circumferential - whole circumference of wall prolapses - Segmental - only part of circumference

Gastric outlet obstruction sym

- Recurrent vomiting of food that has accumulated in stomach - Stomach dilation to accommodate food intake + secretions - Sever pain in case of ulcer

Acute mediastinitis sym

- Retrosternal +/- chest pain, epigastric pain, commonly radiates to back - Acute = fever, chills, tachypnea + tachy, sepsis, shock - Obstruction = SVCS, dysphagia, hoarseness, dyspnea - Pneumomediastinum = subcutn emphysema of neck + face (assoc w esophageal perforation) Hamman's: crunching sound on auscultation, sync w sys - Pleuritis, pericarditis

Anal fissure sym

- Sharp severe knife-like pain during defecation - Rectal bleeding (minimal, bright red - don't confuse w CRC or hemorrhoids) - Perianal pruritus + chronic constipation cx = pain, bleeding, infection (can lead to fistula)

Local skin reconstruction

- Skin defect <3cm = tension-free primary closure (if tension-free closure impossible, use underlying CT for mobility) - Flaps used to close defects: Rotation, Advancement + Transposition - Transposition types incl: V-Y, Z (forgot to picture), pinwheel, orticochea Secondary healing is aesthetically inferior + can result in alopecia

Dupuytren's contracture - sym

- Skin puckering near flexor crease - Palmar nodules + cords - Affects (mostly) 4th + 5th digits - Skin can be hard, raised + fused w underlying fascia - Doesn't adhere to vessels, nerves, or tendons Severe = Garrod nodes (knuckle pads) Ledderhose disease (plantar fibromatosis) Peyronie disease (tunica albuginea of penis)

Anorectal abscess - classification

- Supralevator space - Ischorectal space - Perianal (subctun, mucocutn, submucous) space - Intersphincteric space

Anorectal abscess sym

- Throbbing pain, worsens when ambulating or straining - Swelling + discharge - Fever, malaise, urinary retention, sepsis Perianal abscess: discomfort, pruritus, subcutn mass, erythematous Perirectal abscess: drainage, fever, chills (esp ischiorectal), pain on sitting + defecation Cx: if undrained = infection spread, tissue loss, sphincter injury, death

Malignant kidney tumour sym

- Usually asymptomatic until late stages (often incidental on routine tests) - Anemia (EPO), WL, fatigue, night sweats, fever - Classic triad = hematuria, ab pain, palpable mass Paraneoplastic: - polycythemia (RCC secretes EPO) - hyperCa (PTH related protein; lytic bone lesions) - leukamoid reaction - 2ndary hypercortisolism Local spread: - varicocele that doesn't go in supine - Budd-Chiari (IVC infiltration = liver damage) Met spread: IVC, lungs, bone, brain, liver - back pain, fractures, ascites, fluidothorax

22. Thoracic outlet syndrome - definition + etio

- Variety of disorders caused by abnormal compression of arterial, venous and/or neural structures in base of neck - mainly brachial plexus + subclavian vessels Mechanisms of compression - Trauma: cervical rib (hyperextension neck injuries) - Bone abnormalities: exostoses of cervical rib or collarbone - Soft tissue abnormalities: hypertrophic scalenius ant, poor posture, obesity, hematoma, tumours (Pancoast) - Position: changes that alter normal relation of 1st rib to structures that pass over it - Motion: repetitive motion of abducted + ext rotated shoulder (tennis, baseball, swimming, heavy objects)

Pylorospasm - dx

- XR + tube feeding tests show delayed emptying + inc gastric secretion - Labs show hypochloremic MAlk + inc BUN - sometimes jaundice (dt CBD obstruction)

40. Varicocele - definition, etio

- abnormal enlargement + tortuosity of pampiniform plexus in scrotum dt proximal obstruction of spermatic v etio: Primary (idiopathic) - mostly left testis dt longer spermatic vein + angle of insertion to l renal v - nutcracker phenomenon = l. renal v gets compressed btw aorta + SMA Secondary - retroperitoneal mass obstructing IVC or l renal v - persists in supine position dt physical obstruction of bf

testicular torsion sym

- abrupt onset of testicular pain +/or ab pain - swollen + tender testicle +/or lower abdomen - n+v, edema + erythema of hemiscrotum - abnormal position (transverse lie, elevation, undescended) - Negative Prehn sign: pain relief when lifting testicles - Absent cremasteric reflex: elevation of scrotum after thigh stimulation

PE sym

- acute onset/worsening of SOB at rest - chest pain, cough, syncope, hemoptysis (if pulmonary infarction) - sudden cardiac death - tachycardia, tachypnea, ARHF, hypotn, cardiogenic shock

32. Inflammation of breast - etio

- aka mastitis etio: RF = puerperal x non-puerperal - puerperal = >30y, primiparous, late delivery, improper bf, cracks on nipples - non-puerperal = tight-fitting clothing, over-restricting bras, trauma to breast, contamination during implants or nipple piercing, smoking, hyperPL - pathogens = S. aureus, Strep, G- (E.coli, Salmonella)

Interstitial cystitis

- aka painful bladder syndrome - rare, chronic, non-infectious cystitis, idiopathic sym: suprapubic pain + discomfort relieved by voiding + worsened by filling, sex, exercise, alcohol or sitting - urgency + freq >6w dx: clinical, dx of exclusion tx: behavioural micturition (avoid triggers, fluid management, bladder training) - amitriptyline can be used; invasive procedure

43. Periannular subluxation of radial head - definition etio

- aka painful rotation - partial dislocation of head of radius at radiohumeral joint - radial head cartilaginous in children, tf only occurs in 1-5y etio: - Traumatic (MC): sudden axial traction of pronated + extended arm (adult pulls falling child by hand, or drags by arm) - Congenital structural anomaly: collagen anomaly, abnormal endochondral ossification of growth plate

27. Pleural empyema - definition + etio

- aka pyothorax; accumulation of pus w/i pleural cavity etio: - parapneumonic empyema (MC) - pneumonia, abscess, bronchiectasis (Strep pneumo MC; + some G- (E. coli, Pseudomonas)) - surgery - trauma - rarely: esophageal rupture; mediastinal infections; subphrenic/hepatic abscess; instrumentation of pleural space (thoracocentesis, chest tubes)

Renal sarcoma

- all very rare - rhadbomyosarcoma; liposarcoma; fibrosarcoma; leiomyosarcoma - highly malignant + usually detected late w poor prognosis dx: similar as above (although no neovascularity on MRA) tx: wide local excision

Scarring

- area of fibrous CT produced by healing - flat + pale > red, itchy + raised > flat + pale again Types - Hypertrophic = firm, red, itchy, elevated w borders of injury (regress w time) - Keloid = red itchy, extends past wound borders (doesn't regress) - Scar contractures Tx: conservative (massage, pressure, intralesional CS) - surgical = excision + closure

DVT - sym

- asymptomatic + present later as CVI - fever (dt pro-inflammatory cytokines) - localised unilateral swelling, tightness, heaviness, warmth, erythema, progressive tenderness, dull pain Homan: calf pain on dorsiflexion of foot Meyer: compression of calf causes pain Payr: pain on pressure of medial part of sole - distension of spf veins w normal distal pulse May-Thurner syn: compression of left iliac v btw r iliac a and lumbar vertebral spur = left iliofemoral VT

39. Gynecomastia - definition + etio

- benign proliferation of mammary tissue in males dt inc est +/or dec tst etio: Physiological gyne - 90% neonates dt placental transfer of maternal est (resolves w/i w>m) - 50% adolescent boys dt pubertal est/androgen imbalance - small mobile firm plaques in sub-areal region; resolves by 17 or requires surgical removal Pathological gyne - Est excess = onco (germ cell, HCC, SCLC), cirrhosis, hyperthyroidism - Tst dec = CKD, Klinefelter, orchitis, starvation, castration - Drug induced TST-rcp inh = anti-androgens (flutamide), H2RB TST-synth inh = spironolactone, ketoconazole, MTX Androgens = TST, androgenic steroids Est-rcp stim = estrogen Idiopathic (25%)

DVT - definition, location, etio

- blood clot in deep vein of leg/thigh/pelvis - popliteal, ilio-femoral, pos tibial veins - above knee = high risk - Virchow's triad = hypercoagulability, endothelial damage, stasis)

Freezing pathophy

- body loses heat by conduction, convection +/or radiation - hypothalamus usually compensates via VC + shivering = dec immune respose, dec CO + MAP, CNS depression - ice crystals form btw tissues + grow dt intracellular water content = dehydration + ischemia - inc viscosity of blood = ischemia - skin + muscle more susceptible than tendons + bone - peripheral VC maintains core body temp (centralisation)

Medullary sponge kidney

- calcified cysts originating from papillary collecting tubules; congenital or sporadic, usually incidental finding sym: asymptomatic, hypercalciuria, recurrent UTI, nephrolithiasis, CKD if bilateral dx: US + IVP tx: nephrolithiasis prophylaxis w thiazide diuretics

Anorectal anomalies - dx

- check for VACTERL assoc US: type of imperforate anus, determine whether colostomy is needed (w/i 24h of birth) Lat pelvic XR: determine position of rectal pouch Fistula screening: methylene blue screen - urinalysis (meconium in urine = rectourethral fistula) - augmented pressure distal colonography

Periannular subluxation of radial head sym

- child holds extended or slightly flexed + pronated arm - pain aggravated by movement (limited ROM) - no swelling

mastitis dx

- clinical - if no response to tx = milk culture or US imaging

Periannular subluxation of radial head dx

- clinical - successful closed manual reduction (I by cessation of pain + inc ROM) is therapeutic + confirms dx XR: in case of atypical or irreducible cases, ID displacement US: prevent misdx, esp in infants MRI: suspected congenital structural abnormalities

testicular torsion dx

- clinical dx (imaging only if atypical presentation) - significant risk of infertility, treat asap duplex US (if inconclusive) - whirlpool sign (twisting of spermatic cord) - reduced/absent bf - heterogeneous appearance of testicular parenchyma (indicates necrosis) radionuclide imaging (rule out epididymitis) - torsion = areas don't absorb radioncl dt dec bf (cold spots) - epididymitis = areas of inc radioncl absorption (hot spots) Labs: rarely used; urinalysis (leu + ery = epididymitis)

Cryoprecipitate

- cold-insoluble precipitate formed when FFP is thawed at 1-6C + resuspended in 10-15ml plasma - contains fibrinogen, factor VIII, vWF, factor XIII, fibronectin - I = correction of hypofibrinogenemia in dilutional coagulopathy - improved platelet aggregation + adhesion, dec bleeding in uremic patients

Granulocyte transfusion

- collected by leukophoresis from donors stimulated w C-GSF + steroids to mobilise neutrophils from marrow to peripheral blood - I = severe neutropenia w sepsis; also before autologous HSCT

Platelet transfusion

- collected from single donor by apheresis after ABO + cross matching - concentrates prepared from whole blood - I = active bleeding in TCP patients w massive blood loss; minor surgery for patients <50000/ul; major surgery when <75000/ul

29. Spontn pneumothorax - definition + etio

- collection of air within pleural space = partial/complete pulmonary collapse - usually males 16-24y w hx of smoking etio: Primary spontn pneumothorax - patients w/o clinically apparent lung disease - rupture of subpleural blebs dt inc transpleural pressure, mostly at apex - coughing, rapid falls in atmP, rapid decompression (scuba), high altitudes - menstruation (catamenial pneumothorax) Secondary spongnt pneumothorax - complication of underlying lung disease - blebs rupture despite normal transpleural pressure in CT dsrs (e.g. Marfan) - apical bullae (COPD), Pneumocystis Carnii (AIDS), mets (sarcoma) - rupture of esophageal or lung abscess, CF, TB

Allergic transfusion reaction

- commonly in frequently transfused patients dt recipient hypersensitivity to donor plasma proteins sym: mild urticaria, fatal anaphylaxis tx: stop transfusion + give anti-H if milkd - anaphylaxis tx

Branchial cleft cyst

- congenital epithelial cyst - MC in children, on lat side of neck ant to SCM - failure of obliteration of 2nd bronchial cleft in embryogenesis (4w GA) - cyst wall = squamous/columnar w fluid infiltration Types: 1. in mandible angle to ext auditory canal (a/w facial n) 2. (MC) along ant border of SCM, thru carotid bifurcation 3 + 4. rare, also on SCM sym: asymptomatic but can become infected - inc in size after URTI dx: FNA to differentiate btw malignancy or LAP tx: none or surgical excision/sclerotx if necessary

31. Drowning - effects

- death dt aspiration of fluid - rf incl intoxication or inadequate supervision of children effects: - hypoxemia (LoC) + aspiration 3-5min after total immersion of water - cessation of breathing = hypocapnia = forced breathing + aspiration - freshwater: fluids fast absorbed = hypervolemia, hypotonicity, dilution of electrolytes + IV hemolysis = surfactant injury (pulm edema) + debris in alveoli - saltwater: water drawn from alveoli = hypovolemia, hemoconcn, hypertonicity - risk of MO deposition = infection if they survive

Skin grafts - definition, types, indication + CI

- detaching epidermis + varying amounts of dermis from blood supply in donor area + placing in new bed of blood supply in recipient area I: close wounds, prevent fluid/electrolyte loss, reduce bacterial burden CI: contaminated wound, insufficient blood supply Split thickness grafts x Full thickness grafts x Other

Feibrile non-hemolytic transfusion reaction

- during or <4h after - rise in temperature >1C w shaking chills tx: stop transfusion; fever is self-limiting + responds to antipyretics

testicular torsion tx

- emergency, tx w/i 6h of symptoms - only 10% success if >24h Manual detorsion - in ER, attempt before surgery for pain relief - rotate laterally, towards thigh - if this doesn't provide relief, try medial rotation - surgery is still performed to resolve remaining torsion + prevent recurrence Exploratory surgery - immediate surgical exploration of scrotum w reduction + orchidopexy - orchidopexy: suture fixation to hemiscrotum in 3 places, often done w CL testis too dt risk of torsion - orchiectomy: if testis is grossly necrotic

Hanging management

- endotracheal intubation - positive end-expiratory pressure - hyperventilation w supplement O2

DVT tx

- enoxaparin/fondaparinux 4-5d infusion (target = aPTT 1.5x mean) - warfarin once aPTT is within range prev: warfarin w target INR 2-3 for 3-6m OR rivaroxaban 3+mo Thrombolysis, thromectomy, IVC filter

Retroperitoneal fibrosis sym

- fever, malaise, WL, flank/lower back pain Bilat ureteral obstruction w hydronephrosis Infrarenal aorta/iliac a obstruction = - mesenteric ischemia - lower limb + gluteal caludication IVC/iliac v obstruction = DVT, renal vein thrombosis Gonadal vessels = hydrocele, varicocele, testicular pain Lymphedema

thyroglossal duct cyst

- fibrous cyst that forms from persistent thyroglossal duct sym: midline neck lump, dysphagia, throat pain cx: infection, thyroglossal fistula dx: ask patient to stick tongue out, if mass moves = pos - also moves on swallowing, to diff from goitre tx: Sistrunk procedure = resection of duct to base of tongue + removal of medial hyoid bone

High-degree disinfection

- for medical devices that can't be sterilised (endoscopes) Stage 1: mechanical cleaning + AB disinfectant solution Stage 2: disinfection class ABCVT, rinse in sterile water

Loss of hand injury - secondary procedures

- free tendon adhesions - reduce bulky flaps - transfer tendons in motor nerve injuries - use toes to reconstruct thumbs - pollicisation (transfer index finger to thumb position) - leave stump that is painless + has good tissue coverage - flexor tendon must not be sutured to extensor tendon for soft tissue coverage as this would cause tendons to pull on each other - local flaps preferred to cover stumps (rather than grafts) for better sensation - prosthetic reconstructions can be done for fx + cosmetic effects

42. Congenital anorectal anomalies - definition, etio

- imperforate anus/anal atresia = rectum malformation etio: - VACTERL (Vertebral, Anorectal, Cardiac, ToF, Renal Limb) - a/w Down's or maternal DM

25. Acute + Chronic lymphedema - definition + etio

- inability of lymphatic system to accomodate protein + fluid entering interstitial compartment at tissue level etio: Primary (idiopathic) - abnormal lymphatic development, mostly hypoplasia = reduced number + diameter of lymph vessels - Onset <1y = congenital or familial (Milroy disease), bilat - Onset 1-35y = lymphedema precox (MC) or familial (Meige disease), unilat - Onset >35y = lymphedema tarda Secondary - occurs dt acquired obstruction of lymphatic system - Filariasis (Wuschereria bancrofti) - MC globally - Resection/ablation of LN (e.g. in surgery for tumour, trauma, infection) - MC in developed countries

spontn pneumothorax pathophys

- inc intrapleural pressure = alveolar collapse, dec V/Q ratio + inc r-to-l shutning Spontn: rupture blebs + bullae move air into pleural space w inc positive pressure, compressing + collapsing ipsilat lung Traumatic: - closed: air enters through hole in lung (blunt trauma) - open: air enters through lesion in wall (penetrating trauma) - enters on inspiration + leaks out on expiration Tension: - disrupted pleura + tracheobronchial tree means air enters pleural space on inspiration + cannot exit = progressive inc of positive pressure in chest - leads to collapse of iplsilateral lung + compression of contralateral lung, trachea, heart, SVC (mediastinal shift) - impaired resp fx, reduced VR + CO, hypoxia, HD instability

Primary wound closure

- incision, debridement of edges, eversion of margins, tension-free approximation Minimalise tension by: - using buried deep dermal + subdermal sutures or - aligning sutures along relaxed skin tension lines Types of sutures: - interrupted - mattress - deep dermal - continuous - subcuticular

Skin grafts - FTSG

- include epiderms + all dermis - donor sites = groin, lateral thigh, lower abdomen, lateral chest - usually used for small, well vascularised wounds - most aesthetically desirable, great trauma resistance, least contractions - donor site heals w scarring + risk of necrosis

Pilonidal sinus - pathophys

- infl = sinuses extend + interlink = lateral tracks that may run into neighbouring buttock tissue - sitting/bending = hair follicles stretch + break = open pore = collection of debris + broken hair roots - movement = negative pressure (suction) = further penetration of hair into subcutn tissue - can lead to abscess of fistula

Orchitis

- inflammation of one or both testes etio: MC STD or mumps; often cx or UTI epididymitis sym: fever, n+v, swollen tender testicles Tx: mumps = self-limiting - paracetamol (fever), bed rest, fluids, ice pack Cx: subfertility, atrophy Prev: MMRV

33. Loss injuries to the hand - definition

- injuries where hand (whole or part) is amputated or crushed - MC = improper use or malfunction of machinery - Sharply amputated or partially devascularised parts are likely to be saved - severe crushing or avulsion = wide neurovascular injury = impossible to repair

Chronic fibrosing mediastinitis

- intense fibrotic process leading to compression of mediastinal structures - SVCS, tracheal narrowing, pulmonary vascular obstruction etio: TB, histoplasmosis (MC), sarcoidosis, silicosis dx: CT Tx: anti-TB tx if TB; otherwise supportive (stents)

Intestinal ischemia

- intestines can tolerate ischemia for 6h Ischemic colitis: transient hypoperfusion (TE, hypotn, hypovolemia) or occlusion = necrosis + sepsis - hyperactive phase (cramps, diarrhea) - paralytic phase (pain, no bowel sounds, ditension) - shock (acute abdomen Acute mesenteric ischemia: arterial TE (vascular ileus) - periumbilical pain, n/v/d, sepsis (if gangrenous) dx: lactate, DD, LDH, CK, MAc; colonoscopy, CTA, US tx: laparotomy, balloon angioplasty, stent, thrombolysis

pilonidal sinus sym

- irritative - intermittent discharge + inflammation w pain + swelling - acute sepsis - acute abscess formation w swelling, pain, erythema that may discharge or form fistula - chronic sepsis - follows unresolved acute - purulent, mucoid, bloody discharge

Small artery occlusive disease

- mainly in arteries <3mm diameter (radical, ulnar, tibial) - MC in diabetic patients tx = amputation

Transfusion-associated circulatory overload

- mainly in older patients - can precipitate pulmonary edema - dyspnea, cough, wheezing, tachycardia, hypoxemia, elevated BP, S3 gallop (S3 overload), JVD tx: stop transfusion, IV diuretics

ACS

- mismatch btw myocardial O2 supply + demand Unstable angina (partial occlusion w ischemia) - dyspnea/angina at rest; doesn't respond to nitro; no labs + non-specific ECG - ECG + troponin > ASA (250mg) + DOAC - TIMI >3 = PCI/thrombolysis +/- eptifibatide > clopidogrel - TIMI <3 = UFH/LMWH/DOAC until discharge or PCI NSTEMI: subendocardial infarction - detectable troponin + non specific ECG - ECG + troponin > ASA > PCI/thrombolysis > clopidogrel STEMI: transmural infarction - VFib or coma might be initial presentation - ECG + troponin > ASA + UFH > PCI +/- eptifibatide (GpIIb/IIIa inh) - PCI + clopidogrel > ECG improvement = UFH until discharge, DAPT 6mo, ASA after no improvement = CABG > DAPT 1y Inferior infarct: - detectable in II, III, aVF; often STel - vagus irritation = bradycardia, hypotn, sweating

Pleural empyema sym

- mostly asymptomatic; sym of underlying disease - fever, pleuritic chest pain, chest heaviness, dyspnea, hemoptysis, purulent productive cough O/E: anemia, tachypnea, tachycardia, dec breath sounds w dull percussion, dec tactile fremitus, pleural friction rub, clubbing

UTI dx

- mostly clinical Dipstick: leukocytes + nitrites suggest UTI Microscopic urinalysis: inc WBC, G+, no leu casts Urine culture: in cx cases, elderly, recent ATB use, recurrence - midstream collection, suprapubic tap or catheterisation US, CT, IV pyelogram, cystoscopy - if cx or suspected abnormalities Ddx: tuberculous cystitis, drug-induced cystitis, vaginitis, PID, prostatitis, STD, trauma, structural abnormalities

Peripheral micro-emboli

- mostly from valvular disease, most damaging when they occlude digital arteries sym: cold, numbness, pain, cyanosis of affected digit (blue toe syndrome) tx: arterial reconstruction + acute anticoag

Pulmonary embolism - definition, etio, RF

- obstruction of pulmonary a by embolus etio: TE (MC DVT, renal/pelvic v, RH, IVC or SVC) - fat, air (trauma, surgery), amniotic fluid, tumour RF: congenital/acquired thrombophilia (immobilisation, surgery, CHF, malignancy); predisposing factors (age, obesity, hx), triggering factors (travel, trauma pregnancy, venous catheter, thrombus)

RBC transfusion

- obtained by apheresis or from whole blood centrifugation + removal of plasma - Hct 55-60% - I = anaemia (Hb<70), acute hemorrhage Washed: w saline to remove >98% plasma proteins + resuspend w saline - Hct 50%; I = anaemic px w allergies Irradiated: w y-radn to inactivate lymphocytes - I = patients at risk for GVHD (immunodef; ChT/RT) Leukocyte-reduced: reduced by filtering - I = febrile non-hemolytic transfusion reactions or prophylaxis for patients w long-term transfusions Frozen deglycerolised: RBC frozen in glycerol + washed w saline to remove cryoprecipitant + resuspended in saline - Hct >5%; >99% plasma removed, few leukocytes remain - I = severe IgA deficiency

Thyroglossal fistula

- originates in midline of neck - usually after infection or inadequate removal of thyroglossal cyst - rarely congenital sym: discharging orifice in midline of neck (in line of thyoid), may become infected + pus tx: excised along w thyroglossal tract up to base of tongue - removal of 1/3 of hyoid bone (sistrunk)

Blood substitutions

- oxygen carrying solutions that expand blood volume + oxygenate tissues - modified Hb, liposome encapsulated Hb

Varicocele sym

- painful enlargement w dull acheing pain + heaviness in hemiscrotum - soft bands/strands palpable ("bag of worms)) - symptoms worsen w standing + valsalva - neg transillumination

Hydrocele - definition + etio

- painless accumulation of fluid in sac around one or both testicles - derives from tunica vaginalis (tissue covering testes) etio Idiopathic (MC) Congenital - Communicating (failed development = peritoneal fluid flows into scrotum during Valsalva); reducible - Non-Communicating (excessive secretion/dec resorption of fluid; not a/w Valsalva); irreducible Acquired: trauma, tumour, torsion, infection, Wuchereria bancrofti

FFP

- plasma removed by apheresis or centrifugation from whole blood - frozen w/i 8h of collection (no cells left) - AB universal donor; Rh doesn't matter - contains normal levels of clotting factors, albumin + fibrinogen - I = replace coag factors in DIC, warfarin OD, massive transfusion - used if INR > 1.5, only for active bleeding or risk of bleeding - 1st choice for patients w TTP undergoing plasma exchange

Congenital anorectal anomalies - sym

- presents at birth w failure to pass meconium, distension, bile-stained vomit - flat bottoms (poorly developed gluteal cleft) - absence of anal opening w thin anal membrane (meconium visible through membrane) - may present obstipation + ileus

Rectal prolapse - sym

- protruding painless rectal mass, constipation, fullness, pruritus - fecal incontience (dt stretched anal sphincter) - rectal bleeding dt ulceration (in chronic) Internal intussusception: rectal fullness, tenesmus, incomplete defecation, incontinence Rectal prolapse: mucosal discharge, progressive incontinence, bleeding, rectum falling out Cx: nerve injury, bleeding, incontinence, ischemia + gangrene

Post-transfusion purpura

- rare, in multiparous women tx: IVIg

Obstructive cystic dysplasia

- renal dysplasia w cystic dilation secondary to fetal obstruction (e.g. ureteral stenosis); onset birth-childhood sym: aysmptomatic if mild; AKI if severe (obstructive; oligohydramnios in pregnant dx: US w unilateral or bilateral cysts of varying size tx: eliminate obstruction (curative)

Multicystic dysplastic kidneys

- renal dysplasia w multiple cystic dilations of nephrons during embryonic development; sporadic occurrence Sym: onset at birth-childhood; rarely symptomatic, maybe impaired UO dx: US w unilateral cysts of varying size; tx same as above

Drowning tx

- restore ventilation - correct hypoxemia or acidosis (100% O2) + electrolyte imbalance - endotracheal intubation + ventilation - MAc self-corrected w restored circulation (NaCO3 IV if severe acidosis) - Hburia = osmotic diuretics, alkalinisation; dialysis if kidney failure cx: seizures, arrhythmias (VFib, VTach, brady)

Infection

- risk when platelets stored at room temp Bacteria: Staph, Enterobacter, Yersenia, Pseudomonas, Syphilis - Sym = fever during/hours after transfusion - Tx = ATB, fluids Viral: HBV, HCV, HIV, HTLV, CMV Others: Malaria, Creutzfield-Jacob

Renal cysts

- solitary or multiple, frequently in dialysis patients or >50y sym: flank pain, obstruction, infectino class: Bosniak classification determines malignancy risk I - simple, smooth, clear fluid II - benign, minimal septations III - complex, septations, calcifications, thick wall IV - thick irregular wall w mass inside dx: benign incidental finding; normal RFT tx: not needed unless symptomatic or cx cx: rupture, infection, compressive

Acute arterial embolism

- sudden occlusion of previously patent artery etio: embolus, thrombosis (PAD), trauma dissection sym: 6Ps, swelling, acute tenderness tx: immediate IV heparin; non-operative if good collaterals - operative: catheter thrombolysis, percutn mechanical thrombotomy - severe = surgical embolectomy (balloon Fogarty catheter) - ischemic = fasciotomy for compartment syn

torsion of testicle - pathophys

- sudden twisting of spermatic cord a/w poorly secured testicle = venous engorgement, arterial compromise, tissue ischemia, infarction - irreversible damage after 6-12h

24. Testicular torsion - definition + etio

- sudden twisting of spermatic cord within scrotum - MC in neonates + young men - considered urological emergency etio - idiopathic intravaginal: testes rotate on spermatic cord dt inappropriately strong attachment to tunica vaginalis bell clapper: testicle deformity = horizontal; usually bilat extravaginal: during testicular descent, prior to fixation in scrotum = both spermatic cord + tunica vaginalis are torse - trauma, strenuous activity (rare) - predisposing factor (undescended testes)

Hanging - definition, types, effect

- suspension of person by ligature around neck types: - suspension hanging: suspension of body around neck - drop hanging: calculated drop designed to break neck (less painful) effect: - cerebral anoxia = brain damage - fracture of larynx, cervical spine, trachea - pharynx + carotid artery laceration - compression of carotid a, jugular v + airways = 13s LoC; 1.5min loss of muscle tone; 4min death

Phimosis

- tight foreskin that cannot be retracted etio: congenital; post-balanoposthitis (infl of glans + foreskin dt poor hygiene); scarring after trauma/circumcision sym: difficulty or inability retracting foreskin (relative v full phimosis) - painful erection +/or dyspareunia dx: clinical tx: topical CS, stretching exercise, vertical incision cx: forskin tear w hemorrhage, penile necrosis

Gyne tx

- tx underyling - medical (cosmetic or if tender TST replacement (if hypogonadism) Selective Est-Rcp Modulator (tamoxifen) - if severe pubertal or idiopathic >3mo Surgical (persistent >1y) - subcutn mastectomy - liposuction assisted mastectomy - laser assisted liposuction - laser lipolysis w/o liposuction

Mastitis sym

- unilateral breast tenderness, warmth, swelling, erythema - pain or burning sensation continuously or during breastfeeding - malaise, fever >38.3C, flu-like - aches, chills, fatigue - abscess - pain, erythema, edema, purulent discharge

SVCS dx

- urgent contrast CT (st biopsy) - Pemberton's test: lift arms over head for >1min = facial plethora/cyanosis, non-pulsatile JVD, inspiratory stridor - Confirmed by measuring UE venous pressure - Venography for location + extent - Biopsy - FNA, st bronchoscopy or mediastinoscopy (rarely used)

Antisepsis - definition

- use of antimicrobrial substances applied to living tissue to reduce risk of infection, sepsis + putrefaction - distinguished from ATB (destroy MO within body) + disinfectants (destroy MO on non-living objects)

Transfusion related acute lung injury

- within 6h - can be caused by all plasma containing blood products - Ag-Ab complex + complement activation = aggregation, margination + sequestration of neutrophils in pulmonary vasculature = release of lysosomal enzymes, vascular endothelial damage, capillary leakage into interstitium + alveolar spaces sym: fever, hypotn, respiratory distress, severe hypoexemia, respiratory failure tx: rapid intense respiratory + circulatory support

Acute and chronic lymphedema - pathophys

0 (latent): no swelling yet 1 (irreversible swelling): soft pitting edema - protein rich fluid accumulation in interstitium 2 (gradual fibrosis): non-pitting edema - accumulation of fibroblasts, adipocytes + macrophages = local inflammation 3 (irreversible elephantiasis): fibrosis + scarring - inflammation + recurrent infection (dt minimal subclinical breaks in skin)

Tumours of anteriosuperior compartment

4 T's Thymoma (MC) Terrible lymphoma (HL mostly) Teratoma Thyroid lesion

Disinfection classes

A - bactericidal B - virucidal C - sporicidal V - fungicidal T - tuberculocidal M - mycobactericidal P - protozoa H - helminths

Spontn pneumothorax dx

ABG: RAc w hypoxia + hypocapnia ECG: axis deviation, non-specific ST changes, T inversion CXR (PA + lat): dec lung markings CT: if uncertain, pre-surgery, rule out ddx

Pulmonary abscess tx

ATB: dependent on pathogen - usually ampicillin-sulbactam, carbapenem - IC = cotrimoxazole, amphotericin B - Remember cotrimoxazole = co-op of trimethoprim + sulfamethoxazole Early percutn drainage: - I = if medical failed; if mediastinum shifts from tension of abscess; if septic after >72h ATB Surgery: - Thoracotomy w lobectomy/segmentectomy - Hemoptysis, empyema, bronchial obstruction - Pyo-pneumothorax is surgical emergency

Internal hemorrhoids

Above dentate/pectinate line - Endoderm derived tissue - Arterial supply = superior rectal a (from inf mesenteric a) - Venous drainage to superior rectal v > inf mesenteric v > splenic > portal > IVC - Innervated by enteric system (inf mesenteric, inf hypogastric plexi, splanchnic n) sym: mass, painless bright-red blood w mucus + rectal fullness + pruritus - becomes symptomatic if internal complex becomes chronically enlarged + prolapses into anal canal - may become incarcerated, thrombotic or necrotic - examination can show normal perineum; edema near hemorrhoids + gangrene if incarcerated Internal hemorrhoid stages I - bleed II - bleed; prolapse w straining + spontaneous reduction III - bleed; prolapse requiring manual reduction IV - bleed; prolapse cannot be reduced, may strangulate

Hydronephrosis sym

Acute UTO Supravesical: renal/ureteric colic, hematuria, n+v, oliguria, fever chills Infravesical: urinary rtn, suprapubic pain, palpable bladder Chronic UTO Supravesical: asymptomatic, HTN, progressive renal failure Infravesical bladder outlet obstruction producing LUTS

Pleural empyema - pathophys

Acute exudative phase (2-5d after pneumonia) - out-pouring of sterile pleural fluid - pleura remains mobile - low viscosity, WBC, LDH, normal Glu + pH - tx: ATB, intrapleural fibrinolytics + chest tube (thoracostomy) Fibrinopurulent phase (5-14d after) - inc in turbidity, WBC, LDH content w progressive dec of Glu + pH - fibrin deposited on both pleural surfaces, limiting empyema + lung movement - tx: ATB, chest tube drainage, VATS procedure (decortication - removal of fibrous tissue) Chronic organising phase (7-28d) - pleural fluid Gly + pH low, exudate thick - fibrin deposits thicken, immobilising lung - erosions through chest wall may occur - tx: ATB, VATS debridement, thoracotomy decortication, pleurectomy Eloesser procedure: (open flap drainage) chest wall flap sewn to parietal pleura + short rib resection = one-way valve

Transfusion cx

Acute hemolytic transfusion reaction Delayed transfusion reaction Febrile non-hemolytic transfusion reaction Allergic transfusion reaction Transfusion-associated circulatory overload Transfusion-related acute lung injury Post-transfusion purpura Infection HypoCa, hyperK, hypothermia

SVCS tx

Acute: sit up, IV access in foot (avoid UE punctures), 100% O2, GC (dexamethasone) Balloon venoplasty + SVC stenting (prior to ChT/RT/palliative lung ca tx) Thrombosis prophylaxis Small benign mass = surgical excision

Care of unconscious patient

Acutely unconscious - Ensure airway free + O2 - Move away from harmful gases, remove false teeth, open windows - Regularly assess GCS, vitals, pupils, limb movement, tendon reflex Chronically unconscious - Parenteral nutrition to avoid aspiration pneumonia - Passive movement to prevent contracture + promote circulation - Place in lateral position: keeps airway patent, helps secretion drainage - Monitor hydration status: membranes, skin, UO, urine colour - Grooming + cleansing: skin clean + dry, teeth brushed - Regular GCS assessment, vitals, pupils, limb movements, tendon reflexes

Thoracic outlet syndrome - PE

Adson (scalene) test: patient inspires maximally + holds breath while neck is fully extended + head is turned towards affected side - narrowed space btw scalenus ant + medius = compression of subclavian vessels = absent radial pulse Halsted (costoclavicular) test: patient places shoulders in military position, narrowing costoclavicular space (btw clavicle + 1st rib) - same results Wright (hyperabduction) test: - hyperabduction of arm narrows space btw pectoral tendon, head of humerus, coracoid process Roos test: - 90 degree abduction w external rotation + opening + closing hand rapidly for 3 mins Tinel sign: percussion of brachial plexus in supraclavicular fossa/injurved nerve trunk to elicit tingling distal to lesion Phalen sign: flexion of elbow + wrist can reproduce symptoms

Prolapse of anus + rectum - etio

Adults: - inc IAP dt chronic straining (constipation/BPH), cough, pregnancy - weakened pelvic floor dt age, multipara, vaginal delivery, CT disease (Ehler-Danlos) Children: - dec resting sphincter tone; weak pelvic floor; loose mucosa - chronic straining, recurrent diarrhea, CF, parasites, WL

10. Care of unconscious patient - Degree of impaired consciousness

Alert Somnolence - drowsiness - can be aroused - responds normally but w slight delay Stupor - insensitivity bordering on unconsciousness - not easily woken except with strong external stimuli - communication not possible, usually only responds to pain Coma - patient cannot be aroused, no response

Anal fissures - definition + causes

Anal fissure = longitudinal tear of perianal skin distal to dentate line - often dt inc sphincter tone - chronic fissures = ulcers w skin tags - Goligher's rule: 90% pos; 10% ant; <1% both Causes: Primary: dt local trauma, mainly pos - chronic spasm (inc internal sphincter tone), chronic constipation, diarrhea, anal sex, vaginal delivery Secondary: dt underlying disease, lat or pos - previous anal surgery (stenosis) - IBD (CD) - granulomatous disease (TB) - infections (chlamydia, HIV) - malignancies (leuk)

14. Anorectal fistulas - defintion, anatomy + pathophys

Anorectal fistulas = chronic manifestations of purulent infection in peri-rectal areas (abscesses are acute) - ductal connections between abscesses + anal canal or perianal skin - Anal canal contains 6-14 glands/sacs between internal + external sphincter that drain to crypts - Occlusion of crypt = trapped stool + bacteria w/i gland = infection - Abscess develops in inter-sphincteric plane - Undrained abscess can communicate w crypt + form fistula

Primary retroperitoneal tumours - sym

Asymptomatic until >20cm

28. Cystic disease of kidneys

Autosomal dominant PKD Autosomal recessive PKD Multicystic dysplastic kidneys Obstructive cystic dysplasia Medullary sponge kidney Renal cysts

Unconscious patient - Vital signs

BP - low (shock), high (SAH, stroke, ICP) HR - low (OD, AV block), high (hypovolemia, infection, anemia, thyrotoxicosis, drugs) Temp - infection, drugs, toxins, environmental RR - CNS, drugs, toxins, metabolic

External hemorrhoids

Below dentate/pectinate line - Ectoderm derived tissue - Inf rectal a (from internal pudendal) - Inf rectal v > int pudendal > int iliac > common iliac > IVC - Inf rectal branch of pudendal nerve Sym: acute severe pain, swelling/lump at anus - May show as external skin tag w pruritus - Hemorrhoid can be purple/black + can cause ischemia of overlying skin

Gastric outlet obstruction - etio

Benign: PUD, TB, amyloidosis - Bouveret syndrome = obstruction a/w gallstones - Congenital pyloric stenosis - Pancreatic pseudocyst Malignant: stomach adenoCa, lymphoma, GIST

Free flaps

Best solution for large defects that can't be closed locally + have unfavourable wound conditions (infection, exposed sinuses, CSF leak, radiation damage) Flaps should: - detach completely from donor site (easier to reattach) - have robust vascular supply - provide additional muscle bulk - cover defects well cx: flap necrosis

23. Tumours of mediastinum - anatomy

Borders - Superior: thoracic inlet - Inferior: diaphragm - Lat: mediastinal pleura - Pos: vertebral column - Ant: sternum Compartments - Anterosuperior: sternum, pericardium, visceral pleura - Middle: thoracic inlet, pericardium, vertebral column - Post: middle compartment anteriorly, costophrenic angle laterally

9. Cervical cysts + fistulas

Branchial cleft cyst Thyroglossal duct cyst Cystic hygroma Branchial fistula Thyroglossal fistula

Pleural empyema - dx

CXR: D-shaped posterolat density or diffuse consolidations CT: split pleura sign (thickening of parietal + visceral pleura by adherent fibrin w vascular proliferation), lung septation Thoracocentesis: exudation w low glu + pH, high LDH + leu

mediastinal tumours dx

CXR: PA + left lat planes FDG-PET: for thymomas MIBG scan: for pheochromocytomas Markers: b-HCG, AFP, metanephrines, PTH, CEA Biopsy: via FNA, cor needle, mediastinoscopy, thoracoscopy, open thoracotomy

Malignant kidney tumours classification

Clear cell (MC), papillary, chromophobe RCC Wilm's (nephroblastoma) - contains bone, muscle, cartilage

rectal prolapse dx

Clinical (MC): PE (best seen if patient squats or strains) - Internal prolapse = enema, evacuation + evaluation - Mucosal = pink radial folds (like plum coloured, painful hemorrhoids) - Complete = concentric folds - PR = dec/absent sphincter tone Video defecography = Ba, radiolucent Anoscopy = loss of normal hemorrhoidal tissue Others = colonoscopy, manometry, MRI (if weak pelvic floor), biopsy (ulcers) ddx: hemorrhoids

Prostate tumours dx

Clinical: PE, PR = irregular nodular prostate Blood: - PSA (>4ng/ml) - false elevation dt cystoscopy, biopsy, catheter; true elevation in BPH, prostatitis, trauma (Prostatic acid phosphatase no longer used) - Urinalysis + urine culture (rule out UTI or hematuria) - Trans-rectal US-guided biopsy (12 samples) Gleason score: microscopy from 2 sites 1. small uniform glands 2. more stroma btw glands 3. distinct infiltration of glands at mragins 4. irregular masses of neoplastic cells w fewer glands 5. lack of glands, sheets of neoplastic cells Staging: AUS, A/P CT, A/P MRI, spinal XR, bone scintigraphy

PKD dx

Clinical: fam hx, PE (palpable tender bilat abdominal masses) Labs: CBC (anemia), RFT, urinalysis - Genetic testing AXR: enlarged kidneys w spider calyceal pattern US: enlarged cystic kidneys - AR = fibrous cyst capsules have inc echogenicity; liquid-filled cysts are anechoic; hepatic cysts - AD = varying anechoic masses Intravenous pyelogram: (XR of urinary tract) - shows obstructions in renal pelvis + UT

Periannular radial subluxation tx

Closed manual reduction - affected arm must be moved in a way that causes the joint to move back into normal position - Supination of forearm w elbow in slight flextion OR - Hyperpronation of forearm (preferred, seen prev) - "click" heard - post-reduction control of normal ROM (may require multiple attempts) Surgeru: if manual reduction unsuccessful

Antisepsis - examples, technique + hygiene

Common skin antiseptics: alcohols, chlorhexidine, iodine - alcohol efficacy: propanol > isopropanol > ethanol Skin antiseptic techniques - Hand scrub: use chlorhexidine soln - 1st scrub of day = 5min scrub w brush, esp at fingernails + tips - btw cases = 2min scrub - in theatre, patient skin is prepped w 70% alcohol or 2% Iodine in 90% alcohol (don't use I on face, genitals or inflamed skin) - wound dressing = polyester adhered Hand hygiene - Resident flora of skin = S. epidermis, Strep hominis - Transiet flora of skin = S. aureus, Proteus, Klebsiella - Hygienic hand-rub = dec transient flora - Surgical antisepsis = eliminate transient, dec resident

Primary retroperitoneal tumours tx

Complete surgical resection - En block resection including adjacent organs (kidney, pancreas, hemicolon) - Resection of peritoneum, muscles, even vessels (embolise to prevent blood loss) Cave: sarcomas have pseudocapsule but extend beyond Adj ChT

Other skin graft types

Composite grafts - usually used in face - contain 2+ layers of tissue including skin, cartilage or other - high metabolic demand = high risk of failure - e.g. dermal fat graft, hair transplant, skin + cartilage grafts from ear Cultured epithelial + dermal grafts - cells growns in special medium in vitro will coalesce into thin sheets used to cover full thickness wounds

Indications for scalping + cx

Congenital: aplasia cutis, nevus, vascular malformations, tumour Acquired: burns, traumatic injury, tumour invasion, infection, radiation, wound-healing difficulties, alopecia, BCC/SCC - BCC/SCC reconstruction is usually post excision, best to use Mohs surgery (layer by layer removal of cancerous skin lesions) to keep defect minimal Cx: wound infection, hematoma, seroma, graft failure

Pylorospasm sym

Congenital: presents w/i first months of life - early = child is hungry + lethargic - late = malnutrition + dehydration; palpable pylorus - progressively worsening vomiting (projectile, no bile)

Dupuytrens contracture tx

Conservative (in early disease - puckering + nodules) - no fx disability - observation, physiotx, hand splint/brace Intralesional injections (rapidly progressive/painful nodules) - CS (triamcinolone), collagenase Surgery (fx disability) - fasciotomy = division of cords, skin grafts required - Fasciectomy = removal of diseased fascia

Gastric outlet obstruction tx

Conservative = PUD tx, IVF, electrolyte replacement, PPI Surgical = endoscopic balloon dilation - Antrectomy = removal of antral portion of stomach - Others = vagotomy, Billroth I, anastomosis of distal stomach

Anal fissure tx

Conservative agents in 90% cases - diet, stool softeners (docusate), bulking agents - anti-inflammatory, analgesic creams or suppositories (lidocaine) - botox injections + nitroglycerine cream into internal sphincter aids healing Surgery if persist after >8w conservativ tx - endoscopy to exclude IBD (as this could explain failed conservative tx) Low risk patients: risk of fecal incontinence - lateral internal sphincterotomy - anal dilation High risk patients: multiparous, elderly - anal advancement flap - fissurectomy cx: bleeding, infection, fecal incontinence

Skin flaps - classification based on composition

Cutn flaps: local flaps; same size + thickness as defect - avoid important anatomical landmarks (e.g. eyebrow) - risk of failure + necrosis of distal prtion Musculocutn: classified according to blood supply Type I- single pedicle (gastrocnemius, tensor fascia lata) Type II- dominant pedicle w minor pedicle (gracilis, trapezius) Type III- dual dominant pedicles (gluteus max, serratus ant) Type IV- segmental pedicles (sartorius, tibialis ant) Type V- dominant pedicle w secondary segment (latissimius dorsi) - dominant pedicle sustains entire muscle independently - minor pedicle only maintains lesser portion of muscle Other types: fasciocitn; bone; perforator

UTI sym

Cystitis: dysuria, urgency, freq, suprapubic pain, incontinence, no fever Pyelonephritis: ab/flank pain, fever, malaise, n+v+d Asymptomatic bacteriuria: pos urine culture w/o symptoms; becomes symptomatic if untx; exclusive to women Non-specific in newborns/infants: v+d, FoT, poor feeding, prolonged neonatal jaundice, incontinence, malodorous urine O/E: costovertebral tenderness

Malignant kidney tumours - metastatic tx

Cytoreductive radical nephrectomy - I = refractory/unsuitable T1 or T2-4 - Laparoscopic: trans-peritoneal or retroperitoneal specimen removed whole or morsellated in bag through iliac incision - Open (for large or locally advanced): removal of kidney + Gerotas fascia, adrenal gl + regional LN (mobilise renal a; divide ureter; ligate a before vein (prevent kidney swelling) Metastatecotmy: for >2 mets Immunomod/targeted tx: IFN-a, sorafenib (TKi), bevacizumab (anti-VEGF), temsirolimus (mTORi) (RCC = chemoresistant)

Electric injuries tx

Debridement - lesions underlying healthy tissue (devitalise + excise dead tissue) - Secondary debridement (24-48h after injury) when necrosis is more extensive - Usually requires many re-explorations until wound is completely debrided Fasciotomy - nerve decompression (e.g. carpal tunnel or Guyon canal) - escharotomy Microvascular flaps: replace long tissue loss Amputation: extensive muscle necrosis Skin grafts or soft tissue vascular flaps

Disinfection - definitions, types

Decontamination: eliminate contamination of environment; comes before mechanical cleaning Mechanical cleaning: remove dirt + reduce no of MO Disinfection: measures that lead to destruction of some MO by physical + chemical processes that interrupt RoT - Efficacy depends on intensity, time, start count of MO, temp, pH Methods: immersion, wiping, spraying, gassing, evaporating, foam Chemical x Physical x High-degree

Hydronephrosis classification

Degree I - distension of pelvis, not calices II - slight distension of pelvis + calices III - obvious distension of p+c, partly pushing parenchyma IV - completely pushing away parenchyma

Acute mediastinitis - etio

Direct contamination: MC esophageal perforation - Boerhaave/Mallory Weiss, trauma, corrosive esophagitis, carcinoma Hematogenous/lymphatic spread of infection Extension of infection from neck/retroperitoneum: - oral surgery, cellulitis, external trauma Extension of infection from pleura or lungs

Blunt neck injuries - dx, tx, px

Dx: arteriography, CT, US, endoscopy, XR Tx: - Control of airways, early intubation, IVF - Vascular = debridement w end-to-end anastomosis or grafts; ligation - Esophageal = sutures, muscle flaps, sys ATB - Laryngeal = tracheostomy, st temporary stent - Nerve = primary neurorrhaphy (surgical suturing of divided nerve) - Cervical fracture = ext immobilisation using rigid collars Px: severe lacerations often result in paralysis, death rate is only 10%

Malignant kidney tumours dx + staging

Dx: usually incidental - labs, CT/US/bone scan (ALP); NOT biopsy Staging: ISUP I - <7cm II - >7cm III - IVC IV - mets to other organs

Prostate tumours sym

Early: asymptomatic, found during screening tests (PSA) Advanced: fatigue, loss of appetite, WL - urinary rtn, terminal hematuria, incontinence, hydronephrosis - ED -anemia (BM replaced by tumour) - Azotemia, uremia (bilat ureteral obstruction dt compression) Mets: lumbosacral bone pain, neuro deficits (SC compression); lymphedema

34. Injuries by electric current - definition

Electric trauma: damage by current passing through body = contact wounds (low voltage) or deep injury (high voltage) Electrical injury: - visible areas of necrosis represent small portion of destroyed tissue (unlike other burns) - current passes through tissue w lowest resistance (mainly nerves, blood vessels + muscles), whereas skin has relatively high resistance + is mostly spared - current leaves in grounded area; heat generated + current itself lead to major muscle damage that isn't directly visible

Kinds of electrical injuries

Electrothermal burns from arcing current - flash or arc burns = therman injuries to tissue caused by high tension current - thermal injury is intense + deep (arc has temp of 2500C, high enough to melt bone) Flame burns from ignition of clothing - often most serious part of injury Electric current injuries - Ohms law = damage is directly proportional to intensity - Amperage depends on resistance provided by various parts of body - Voltage >40V causes damage - AC = tetanic contractions + arrhythmias - DC = single violent contraction throwing you away from source

30. Embolisms - definition + types

Embolism: unattached mass that migrates through bloodstream to possibly cause obstruction at different site - MC = thromboembolism Types: - Mass: thrombus, chol, air, fat, septic, tissue, FO, amniotic fluid - Arterial: mass forms + embolises in artery, leading to tissue infarction - commonly arise in heart (AF, MV stenosis, endocarditis), coronary arteries, aneurysms, microangiopathoes, DIC - Venous: mass forms in vein, gets dislodged + causes venous or arterial occlusion - DVT or PE

Epididymitis tx

Empiric ATB: - UTI = fluoroquinolones - STD = ceftriazone + doxycycline Conservative: scrotal elevation, ice packs, NSAIDs, drainage if abscess Chronic: NSAIDs + prolonged ATB; anti-TB - epididymectomy and/or orchidectomy

UTI tx

Empiric tx: if sym persist after 2-3d ATB, change - 1`= co-trimoxazole, nitrofurantoin - 2`= fluoroquinolone, ciprofloxazine, amoxiclav Cx: fluoroquinolones, cephalosporines, co-trimoxazole Recurrent: chemoprophylaxis w co-trimoxazole Prevention: inc fluid intake, post-coital voiding, intermittent catheterisation

UTI etio

Entry - ascending bacterial infections from urethra - blood spread (adenovirus, S. aureus) in neonates + immunocomp - lymph spread via rectal , colonic or peri-uterine lymph - direct extension from adjacent organs - intraperitoneal abscess, fistulas Pathogens - bacteria = E. coli (MC), Klebsiella, Proteus, Staph saprophyticus, Ureaplasma - viruses = adenovirus (hemorrhagic cystitis) - fungal = candida (rare) - sterile = interstitial nephritis, drug-induced RF: women, sex, spermicide use, catheters, structural abnormalities, pregnancy, DM, immunocompromised, uncircumcised, chronic constipation

testicular torsion ddx

Epididymitis: gradual onset, pyuria, voiding symptoms, fever, positive Prehn's sign Hydatid of Morgagni (cystic structure arising from Mullerian vestiges that can torse): gradual onset w point tenderness, visible necrotic lesions on scrotal transillumination (blue dot sign) - self limiting as appendages necrose + auto-amputate Testicular tumour: slow progression, painless, solid mass; inc AFP, b-HCG

Retroperitonitis - etio, sym, dx, tx

Etio: - Ruptured appendix, perforated PUD, perforated colon, ruptured diverticulitis - Medical procedures: GI surgery, feeding tubes, contaminated catheters - Spread from peritonitis or pancreatitis - Trauma Sym: abdominal pain, bloating, bowel issues, fatigue, fever, dec appetite, WL, urination problems Dx: AXR/CT/MRI, labs (infl markers, anemia), biopsy Tx: ATB x surgery

Acute hemolytic transfusion reaction

Etio: Ag-Ab complex formation - immune mediated: donor RBC are lysed by host Ab = hemolysis (caused by ABO incompatilibility) - non-immune mediated: donor RBC lused by microbial contamination, medications, hypotonic solution or thermal damage Sym: fever, rigors, anxiety, vomiting, chest pain, abdominal pain, dyspnea, hypotn, diffuse bleeding, Hburia Tx: stop infusion, give normal saline, monitor, Coomb's test, test ABO again

Hemorrhoids - in-patient surgical tx

Excision hemorrhoidectomy - suturing of vascular pedicle + ligation w excision of hemorrhoidal tissue - careful excision of mucosa + submucosa only (preserve sphincter m) + conservative mucosa removal to avoid stenosis - Ferguson approach (closed) x Milligan-Morgan (open) - cx = urinary rtn; bleeding; infection; pain; fecal impaction; anal stenosis Stapled hemorrhoidoplexy (anoplexy) - for internal prolapsing hemorrhoids - circular stapling device used to devascularise tissue + stable back to original position Hemorrhoidal devascularisation procedures - Hemorrhoidal Artery Ligation Operation (HALO) - doppler US guided or blind - done when CI to topical tx + surgery

Primary retroperitoneal tumours - epidem

Extremely rare (MC is soft tissue sarcoma) 40-50y

Unconscious patient - GCS

Eye-opening (1-4): spontn, to verbal command, to pain, no response Verbal (1-5): oriented, confused, inappropriate, incomprehensible, none Motor (1-6): obeys, localised (moves to localised pain), withdraws, decorticate, decerebrate, none

Cardiospasm etio

Failure of LES to relax dt degeneration of inhibitory neurons + loss of ggl cells in myenteric plexus = deficiency of inhibitory NT (NO, VIP) Primary (MC): idiopathic/AI dt HSV1 2ndary (pseudo): cancer, amyloidosis, sarcoidosis

35. Freezing + frostbites - definitions + etio

Frostbite: freezing of interstitial + cellular spaces of tissues Hypothermia: core body temp <35C, measured by probes in bladder, rectum +/or esophagus etio: Primary - exposure to cold - effects can be magnified by moisture or wind - contact w metal or gasoline can cause instant freezing - risk inc by generalised hypothermia (produces peripheral VC to maintain core body temp) Secondary - issues w regulation - inc heat loss - drugs (VDors), erythroderma, sepsis - dec heat production - hypopituitary, hypothyroid, malnutrition, hypogly - impaired thermoregulation- hypothalamic damage (stroke, trauma, Parkinson's)

Freezing sym

Frostnip: minor variant w transient blanching, redness, numbness - progresses to frostbite if not immediately detected + tx - tips of fingers, ears, nose, chin, cheeks - tx = reheat w warm air or warm parts of body Spf frostbite: skin + subcutn tissue Deep frostbite: underlying tissue - wooden consistency of extremity - rewarming = mottled blue/purple, painful, tender skin w blisters Hypothermia: Stage I (mild, excitement stage) - temp 32-35C - confusion, amnesia, dysarthria, ataxia, tachypnea, cold diuresis Stage II (moderate exhaustion stage) - 28-32C - worsening of CNS depression - lethargy, stupor, paradoxical undressing - hypoventilation, hyporeflexia, oliguria, bradycardia, arrhythmia Stage III (severe paralysis stage) - <28C - Vfib or PEA if <28X; asystole if <20C - Areflexia, fixed pupils, rigidity, pulm edema, apnea, hypotn, coma

ischemic cerebrovascular accidents - sym

General - contralat paralysis + sensory loss; gaze shift to infarction site - aphasia, dysarthria, abulia (inability to intiate actions, speech or thought), visual field defects - sudden focal neuro deficit = impaired consciousness, n+v, headache, seizures Depends on location: - Cortical = aphasia, hemianopsia, agnosia, apraxia - Supratentorial (middle cerebral a (MC)) - Infratentorial (cardiac origin, vertebral a stenosis) - Ant cerebral x Pos cerebral occlusion - Carotid (internal or common)

Gyne classification + sym

Grade I - minor enlargement, no skin excess Grade II - moderate enlargement, no skin excess Grade III - moderate enlargement, skin excess Grade IV - marked enlargement, skin excess Sym: firm, concentric mass at nipple-areolar, may be tender, may lactate (sign of PL-secreting tumour)

Skin graft cx

Graft failure Graft heals by developing new blood supply; failure can be dt: - Haematoma or seroma forming under graft - Infection (strep), shearing forced - Unsuitable graft bed, technical error Graft contraction All grafts undergo primary or secondary contraction - Primary = immediate; recoil of freshly harvested skin (more pronounced in full-thickness grafts) - Secondary = during healing, after application (more pronounced in split thickness grafts)

Skin graft healing stages

Graft stages: Stage 1 (adherence): immediate, mediated by fibrin Stage 2 (imbibition): 0-3d; graft received nutrients from plasma via diffusoin Stage 3 (inosculation): 3-7d; re- + neovascularisation Stage 4 (regeneration): dermal appendages + sweat glands regenerate Stage 5 (reinnervation): grafts take on nerve pattern of recipient site

13. SVCS - mediastinal syndrome

Group of disorders characterised by infiltration, entrapment, or compression of mediastinal structures w symptoms dependent on location + size of mass SVC compression = venous distension, edema of face + upper extremities, nerve symptoms

Chemical disinfection

H2O2 + formaldehyde (work on all classes) Halogen + alcohol (don't work on spores) Phenols (don't work on spores + TB) Quarternary ammonium compounds (only G+ bacteria)

2. Hemorrhoids - definition + anatomy

Hemorrhoids = perianal excess tissue arising from cushion of dilated AV blood vessels + CT in anal canal - may become abnormally large + protrude - assoc w inc IAP Anal cushions: thickened anal mucosa w AV blood vessels, SM (Treitz) + fibroelastic tissue - located at 3, 7 + 11 o'clock positions Anal column: longitudinal muscle folds that form valves Anal sinuses: between columns Ext anal sphincter: lower 1/3, pudendal n, voluntary control Int " ": upper 2/3, involuntary

Gyne dx

History + PE - breast tissue, penile size/development, testicular development, secondary sexual characteristics - assess for other causes - mastitis, breast cancer, lipoma, sebaceous cysts, dermatoid cysts, hematoma, duct ectasia, fat necrosis Hormone lvls: TST, est, LH, hCG Labs: LFT, RFT, TFT Mammography, US guided biopsy: breast cancer suspected - FNA (gyne = inc fibrosis + ducts) Testicular US: primary hypogonadism, high hCG Ddx: pseuo-gyne, male breast ca, mastitis, lipoma

Unconscious patient - hx + PE + labs + other

History: (from family, ambulance, bystanders) - onset, how found, recent complaints, medical hx, exposure PE - pupillary response, heart/lung auscultation, abdomen, PR, foci of infection If dx is still unclear Labs - CBC, U+E, ABG, ammonia, TFT, urinalysis, CSF Other - ECG, CT head/neck/angio, CXR, lumbar puncture

Physical sterilisation

Hot air: metal, porcelain, glass, ceramics - circulating air of thermal energy (160-180C) Steam: steam under pressure at 120C - 13mins = all vegetative bacteria + most resistant spores - 1h = + prions - Air is usually removed from autoclave chamber Plasma: paper + textiles (60C) - high freq electromag field in vacuum w H2O2 vapour - Free reactive particles react w live matter to deactivate Radiation: industrial production of disposable sterile equipment - gamma rays at 25kGy w high penetration

Gastric outlet obstruction dx

Hx, PE, endoscopy Labs = hypoCl MAlk (loss of HCl + K); high BUN:Cr AXR = gastric fluid level Ddx = early gastric Ca, hiatal hernia, GERD

Anal fissure dx

Hx, clinical, PR, anoscopy, flexible sigmoidoscopy - spf or deep laceration in ant/pos/lat canal - chronic fissures may be fibrotic + infective = raised edges w skin tags + papillae - biopsy + histology to exclude cancer ddx: ulcerating (HIV, CD, cancer, herpes, syphilis) fistula, abscess

Acute mediastinitis dx

Hx: vomiting, alcoholism, mental disease, fam hx of Ca CXR: widened mediastinum, emphysema CT: determine extent of soilage (use if hemodynamically stable) Endoscopy aggravates perforation; DO NOT USE

5. Hydronephrosis - definition + etiology

Hydronephrosis: refers to dilation of renal pelvic, calyces and/or proximal ureter due to obstruction to urine outflow Etio: Structural abnormality - congenital x acquired (injury, surgery, RT) Ureter compression - uni-/bilateral - fetal, pregnancy, BPH Vesicoureteral reflux Supravesical obstruction (renal x ureteropelvic x ureter) - renal = nephrolithiasis, urothelial Ca, papillary necrosis, DM, pyelonephritis - ureteropelvic jx = congenital (malformation, aberrant renal a), acquired (as ureteral obstruction) - ureter = nephrolithiasis, thrombosis, stricture, ligation, neoplasia, AA, hematoma, CD, diverticulitis Infra-vesical obstruction (bladder x urethra) - bladder = urothelial Ca, neurogenic blader (upper motor neurons), flaccid (lower motor neurons) - urethra = BPH, strictures, plugged catheter

Thoracic Outlet Syndrome - dx

Imaging: cervical XR, st cervical CT, MRI, myelography Vascular TOS: doppler US for venous, MRA for arterial Neurogenic TOS: EMG, nerve conduction studies

SVCS types + etio

Incomplete: extrinsic compression by mass Complete: extrinsic compression + intravascular thrombus etio: lung ca (MC, 90%), any mediastinal mass

Acute mediastinitis - tx

Initial measures: Resus; IV ATB; chest tube drainage + decompression (pneumothorax) Right thoracotomy (6th IC space): MC access to intrathoracic esophagus Esophageal perforation = <24h (iatrogenic): primary closure w interrupted absorbable sutures (for complete mucosal closure) - close esoph m but leave flap of parietal pleura, intercostal mm +/- diaphragm for irrigation + drainage >48h: drainage + resection of non-fx tissue - gastric pull-up + reconstruction if necessary

Unconscious patient - neurological examination

Initial: - Diffuse, bilateral cortical dysf: loss of awareness, normal arousal - Damage to ascending reticular activating system: located throughout brainstem from medulla to thalami = loss of arousal w unassessable awareness Systemic evaluation: Level of consciousness: GCS Respiratory pattern: - Cheyne-Stokes (periods of deep breathing + apnea) - Hyperventilation - Ataxic (complete irregularity) - Apneustic (regular deep insp > pause > inadequate exp) CNS asymmetry: - tone, spontn movements, reflexes - hemiplegia test - raise limbs + compare how they fall under gravity Eyes: cont'd

ischemic cerebrovascular accidents tx

Initial: IVF, O2, glucose, analgesia - control ICP (head elevation, hyperventilation, IV mannitol, no CS) - maintain perfusion (tx hypotn; HTN (if >220/120) w labetalol) Reperfusion tx: - IV thrombolysis (rtPA - alteplase), risk of hemorrhage + edema - Intra-arterial thrombolysis; mechanical thrombectomy - Antiplatelet tx (ASA) Surgery: - Supratentorial = decompressive craniectomy - Infratentorial = pos fossa craniotomy - Endarterectomy in carotids (prevention)

Blunt neck injuries - sym

Injuries to larynx/trachea - asymptomatic - hoarseness, laryngeal stridor, dyspnea, hemoptysis - subcutn emphysema Injuries to esophagus - severe chest pain, dysphagia, bloody saliva - perforation = mediastinitis + sepsis Injuries to cervical spine + cord - quadriplegia, dec reflexes, dec awareness, hyperventilation Injuries to vasculature - blood loss, hematoma, bruit, pulse deficit, shock Injuries to nerves CN VII = drooping corner of mouth CN IX = dysphagia CN X = recurrent laryngeal n, hoarseness CN XII = tongue fasciculations

PE dx

Labs: DD, BNP, trop T, ABG ECG: S1Q3T3, tachy, RBBB, r deviation, CXR: Hampton bump (wedge opacity infarction), Fleischner sign (prominent pulmonary artery), atelectasis, effusion Pulmonary arteriography CT-PulmoAngio: high sensitivity/specificity (CI contrast nephritis, preg) SPECT (VQ): PE excluded if negative, but requires confirmation if positive

Retroperitoneal fibrosis dx

Labs: infl markers, U+E, ANA, ANCA Contrast CT: paraaortic mass encasing/compressing surrounding vessels CT-guided/laparoscopic biopsy Rarely: MRI/MRA, IV urography, renal US

Pulmonary abscess dx

Labs: leukocytes, inflammatory markers, sputum culture, G-stain - aerobic G+ cocci (S. aureus, S. pyogenes) - facultative G- (K. pneumoniae, E. coli, Pseudomonas) - rarely C. gangrenosum, Bacterioides, Candida CXR: irregular rounded cavity w air-fluid level in lung - Air-fluid level = fluid + gas accumulation; implies bronchial tree rupture or gas-forming MO - Dependent on body position Trans-tracheal/-bronchial aspirate: for culture Fibre-optic bronchoscopy: exclude obstructive lesions - can only be used to drain pus FNA: for isolation of pathogen

Hemorrhoids tx - medical + outpatient surgical

Lifestyle (grade I + II): diet + exercise Medical: topical/suppository analgesia; topical CS + antispasmodic Out-patient Surgical (persistent grade III) Elastic band ligation: bands placed at base of hemorrhoid complex - scar forms after 7-10d + inhibits further prolapse + bleeding - can lead to severe sepsis in IC px (ATB proph); avoid NSAIDs (bleeding) Injection sclerotx: inject sclerosing agent in CT above complex - inflammatory response, scar tissue formation, stops bleeding Infrared coagulation: coagulate + induce fibrosis

Skin flaps - classification based on method of movement

Local transfer (immediately adj) - Advancement = flap slides directly into defect from nearby tissue (e.g. V-Y advancement flap) - Rotation = semicircular flap rotates into adj defect - Transposition = moved into defect over intact skin - Interpolation = rotates around pivot to nearby but not adj - Rhomboid = rhomboid flap > rhomboid defect - Z-plasty = transposes 2 inter-digitating triangular flaps Regional transfer (close but not immediately adj) Distant transfer (remote donor site) - Pedicle flap = transferred while still attached to original blood supply - Microvascular free flap = detached from native supply + reattached to vessel at recipient site

Prostate tumour tx

Localised: surveillance w regular follow-ups RT: external beam, brachytx, androgen deprivation tx Radical prostatectomy: if RT unsuccessful - Removes prostate, capsule, seminal vesicle, vas deferens, + pelvic LN - post-op monitoring of PSA Anti-androgen tx: for high grade or metastatic cases - Medical castration = GnRH antagonist (degarelix) or agonist (leuprolife) - Surgical castration = bilat orchiectomy Advanced disseminated: palliative - anti-androgen tx; ChT (docetaxel); osteoclast inhibitors (bisphosphonates); RT

Congenital anorectal anomalies - types

Low/intermediate anomalies - rectum is present + passes thru normal sphincter complex - boys = fistula to perineum on ant scrotum - if meconium is visible on perineum, local cut-back procedure to open fistula back to rectum - girls = rectum opens into back of introitus as rectovestibular fistula - VUR common High anomalies (rare in girls) - Sphincter complex poorly developed, mediocre prospects of continence - Boys = fistula from rectum to urethra

6. Pulmonary abscess - definition + etio

Lung abscess: localised section of pus w/i cavity, formed by disintegration of surrounding tissue - Pus = leukocytes + liquor puris (protein rich fluid) - uncommon dt ATB but can happen in IC - Cystic lesions =/ true abscesses (occur in pre-formed spaces) Etio: Primary - Aspiration of oropharyngeal contents (MC) - Acute necrotising pneumonia (S. aureus, Klebsiella) - Chronic fungal pneumonia, opportunistic infections Secondary - Bronchial obstruction (cancer, foreign body) - Cavitating lesions (cancer, infarction)

12. Tumours of kidneys - types

Malignant Renal sarcoma 2ndary malignant renal tumours Benign Tumours of renal pelvis + calyces

Primary retroperitoneal tumours - types

Malignant: - Liposarcoma (80%); Leiomyosarcoma (20%) - Malignant fibrous histocytoma - Rhabdomyosarcoma, fibrosarcoma - Malignant peripheral sheath tumours - Hemangiopericytoma - Extragonadal germ cell tumours - Primary retroperitoneal adenoCa Benign: - Neurogenic; paragangliomas; fibromatosis - Renal angiomyolipomas - Benign retroperitoneal lipomas

Unconscious patient - causes

Metabolic: drugs (BZD, opiate, TCA) poisoning (CO, alcohol) glu (hypo/hyper, DKA, hyperosmolar hypergly state) gas (hypoxia, CO2 narcosis (COPD)) infection (septicemia/hypothermia) endo (myxedema, addisonian) liver (uremic encephalopathy) vitamin (Wernicke's encephalopathy (B1 def)) haematological (TTP, AML) Neuro trauma infection (meningitis, encephalitis, malaria) - HSV encephalitis = IV aciclovir on suspicion tumour vascular (stroke, SAH, HTN encephalopathy) epilepsy (non-convulsive, post-ictal)

Thoracic outlet syndrome tx

Mild = postural correction + phyiotx Surgery if no response after 6mo tx - trans-axillary 1st rib resection - supraclavicular 1st rib resection - scalene m + fibrous bands excised Symptomatic arterial stenosis = decompression via angioplasty or venous arterial bypass Effort thrombosis of subclav v = catheter guided thrombolysis + TO decompression surgery +/- venous reconstruction w stent

mediastinal tumours tx

Mostly surgery: median sternotomy + Video Assissted Thoracoscopic Surgery (VATS) - transverse sternotomy or "clam shell" incision for more extensive approach - ChT/RT according to type

rectal prolapse tx

Mucosal: non-surgical tx - digital repositioning + application of salt - confirm via PR, padding to prevent recurrence - 2nd line = sclerotx (adhere to mucosa + muscular layer) Full thickness: - Medical = diet (dec constipation), stool softeners Surgical Abdominal approach: low recurrence, preserves rectal reservoir fx - resection w rectopexy = mobilised + fixed to sacrum w stitching or mesh, accompanies by sigmoidectomy Perineal approach: high recurrence, but for older patients (use spinal anaesthesia) - Delorme procedure: for short prolapse = circumferential resection of mucosa + muscularis - Altemeier procedure: for long prolapse = perineal rectosigmoidoscopy + coloanal anastomoses

Effects of electrical current injuries

Neuro: seizures, LoC, death Burns: - at points of entrance + exit - depressed yellow areas of full thickness destruction - surrounded by zone of hyperaemia + charring Muscle injuries: - spasms, fractures, dislocations - may lead to myoglobinuria (ATN > AKI) (maintain UO at 2-3x normal w IVF + diuretics) - more damage closer to bone Thrombosis: destruction of RBC Deep tissue hemorrhage: disruption of vessels

Electric current injury - cx

Neurological deficits: up to 9mo after - CNS - cortical encephalopathy, hemiplegia, aphasia, brainstem dysf - PNS - demyelination, reactive gliosis Cataracts: in 30% of patients

Anorectal abscess dx

No imaging in uncomplicated, just clinical (tender perianal or rectal mass) Complicated = US, CT, MRI

Types of scalp reconstruction

Non skin reconstruction Dura mater reconstruction Bone defects Soft tissue defects Skin reconstruction Local reconstruction Regional reconstruction Skin grafts Free flaps

Urinary bladder tumour tx

Non-muscle invasive: - Low-risk = TURBT (transurethral resection of bladder tumour) w immediate intravesical ChT (gemcitabine) - High risk = TURBT + intravesical BCG or ChT Muscle invasive: - radical cystectomy + neoadjuvant cisplatin Mets: palliative ChT, RT or Sx Follow up: cystoscopy every 3m for 1-2y + met analysis annually

PE - initial management

Observation, ECG, ABG (RAlk, hypocapnia, SpO2) - Well's score >4 = anticoag + CTPA - <4 = DD, ABG (CTPA if high DD) - HD unstable = IVF, vasporessors, O2, anticoagulants, CTPA

mediastinal tumours sym

Obstructive (mediastinal syndrome) - trachea/main bronchus = stridor, dyspnea, cough - esophagus = dysphagia - sympathetic trunk = Horner syn (ipsilay miosis, ptosis, anhidrosis) - pericardium = effusion + pericarditis - phrenic n = diaphragm paralysis - l recurrent laryngeal n = hoarseness - SVCS Tumour specific - Pel Ebstein fever (mediastinal HL) - Recurrent mediastinal infection (pneumonitis, fever, sepsis) - Endocrine tumour (thyrotoxicosis, HTN, hyperCa) - Thymoma - myasthenia, pure RBC aplasia, Cushing's, dermatomyocytis, SLE

Skin graft - procedure

Obtaining graft: razor blades, skin grafting knives, manual-drum dermatomes, electric/air-powered dermatomes Recipient area: requires adequate vascularity, complete contact btw graft + bed, immobilisation of graft-bed unit, few bacteria in area Donor area: colour, thickness, allow donor wound to heal spontaneously (open dry method or closed moist method (wet gauze dressing enhances epithelisation))

Unconscious patient - posture

Opisthotonos - meningitis, tetanus Decerebrate (extension) - midbrain damage, below red ncl Decorticate (flexion) - damage above red ncl Pain stimulus - fingernail bed pressure, sternal pressure, suprascapular squeeze Meningism - do not move neck unless cervical spine is cleared through

Hemorrhoids dx

PR: usually enough - abnormal mass, tenderness, bleeding, swelling - ask patients to push/strain to see all positions of anal canal Anoscopy: anus + distal rectum - assess internal hemorrhoids Flexible sigmoidoscopy: rule out malignancy in patients w rectal bleeds - hemorrhoids rarley start in >55y tf ddx necessary Ddx: skin tags, hypertrophic papillae, condyloma acuminata (HPV anogenital warts) - Painless bleed: CRC, IBD, diverticulosis, AP - Painful bleed: ulcer, fistulas, fissures

Malignant kidney tumours - local tx

Partial nephrectomy: - nephron sparing, w/o adrenalectomy - unilaterla, single tumours (st multifocal/bilaty, or VHL) - open transperitoneal or loin approach - resection w margin - Radiofreq ablation, renal a embolisation or cryosurgery can also be used

PE - pathophys, classification

Pathophys - infarction + inflammation of lungs + pleura = pleuritic chest pain + hemoptysis, surfactant dysf + atelectasis - dec PaO2 = hyperventilation, tachypnea, RAlk w hypocapnia - obstruction (blocked nutritional supply, non fx) - V/Q mismatch - HD significant PE pulmonary HTN = RV pressure + dilation + acute RHF - massive embolism = dec minute volume = hypotn - irritation of stretch rcp = hyperventilation = hypoxemia, hypocapnia Classification: based on extent, localisation + HD status - massive (high-risk, saddle) = obstructive shock, SBP <90, tachycardia - sub-massive = no hypotn but RH dysfx + inc cardiac markers (tricuspid regurg) - small = other sym

11. Injuries of neck

Penetrating x Blunt

Skin grafts

Performed if skin is missing but requires good vasculature to avoid necrosis

41. Sacrococcygeal pilonidal sinus - definition, etio

Pilonidal sinus: local infl of superior midline gluteal cleft w formation of single or multiple sinuses that may progress to abscess or fistula formation - usually contain hair, inspissated secretions, debris etio: - local trauma causing hair retention - predisposing factors = dark haired men, hirsute, arab/Mediterranean, deep gluteal cleft - RF: sedentary lifestyle, obesity, poor anal hygiene, local irritation, fam hx

Cardiospasm tx

Pneumatic dilation: 60% success rate - endoscopically guided dilation of sphincter w balloon Heller's myotomy: abdominal approach (young patients) - longitudinal incision of lower esophagus + upper gastric muscle walls until mucosa bulges thru - used w Nissen Botox: endoscopic administration into sphincter (older patients)

Penetrating injury - structures

Pos neck: vertebral collumn, spinal cord, vertebral a, neck musculature Ant neck: larynx, trachea, esophagus, thyroid, carotids, subclavian + jugular v, thoracic duct

37. Plastic surgery of skin + transplantation - reconstructive ladder

Primary wound closure Skin grafts Skin flaps (local, regional, microvascular free tissue transfer) Scarring (not really a step but important to observe)

Retroperitoneal fibrosis tx

Primary: high dose CS - tamoxifen if CI - immunosupp if CS-resistant Secondary: underlying cause Decompression of obstructed structures - Kidney/ureters: cystoscopy-guided stent or open/laparoscopic ureterolysis - Aorta/iliac a: revascularisation - IVC/iliac v: DVT tx

Lymphedema - sym

Primary: painless edema oft in adolescent girls w fam hx of lymphedema Secondary: hx of RT/surgery; painless, develops slowly - often around ankle, dorsum of foot (buffalo hump), toes - pitting > fibrosed > non-pitting - skin thickening + hyperkeratosis - Stewart Treves syn: lymphangiosarcoma

Sterilisation - definition + types

Process that leads to killing of all MO capable of reproduction Physical x Chemical

mastitis tx

Puerperal - freq + proper breast emptying - ATB, analgesia - Light mastitis = massaging + application of heat prior to feeding + cold btw feeding - Severe mastitis = massaging makes worse + apply cold compress Non-puerperal: ATB, analgesia, aspiration, drainage Abscess: surgical incision + drainage; needle aspiration; ATB ATB - oral penicillinase-resistant penicillin or cephalosporin - MRSA = clindamycin, cotrimoxazole - Abscess = metronidazole

Mastitis types

Puerperal (a/w pregnancy or breastfeeding) - caused by blocked milk ducts or milk excess - milk stasis is common - may be prevented by frequent breastfeeding/pumping + stress avoidance Non puerperal Duct ectasia - bimodal incidence <20y + 40-50y - duct widening + inflammation of lactiferous ducts - cx by necrosis or 2ndary bacterial infection = abscess - sub-areolar abscess (Zuska's disease) = freq aseptic inflammation a/w squamous metaplasia of lactiferous ducts Granulomatous mastitis - multincl giant cell + epithelioid histiocytes around lobules - difficult to distinguish from breast ca Comedo mastitis - rare; similar to granulomatous but w necrosis

Embolism - classification by destination

Pulmonary embolism Small artery occlusive disease Acute arterial embolism Intestinal ischaemia DVT Peripheral micro-emboli Air emboli Fat emboli ACS

18. Pylorospasm, Cardiospasm

Pylorospasm - common dx applied to stomach troubles of difficult interpretation - Acquired hypetrophy of pyloric m = gastric outlet obstruction Cardiospasm (aka achalasia) = failure of LES to relax

Pylorospasm - tx

Ramsteds procedure: pylorotomy dividing pylorus to open gastric outlet - incision through outer layer, allowing inner lining to bulge out, opening channel

Skin flap - classification based on blood supply

Random pattern - skin + subcutn tissue from area w no orientation or pattern - derives blood supply from dermal + subdermal plexus supplied by perforating arteries Axial pattern - well defined AV system running along axis - good vascular supply that's long in relation to wifth - designed to include vessel running longitudinally along axis of flap to penetrate overlying cutn circulation at multiple points along course of flap's length

Lymphedema surgery

Reconstructive procedures: I = patients w proximal lymphatic obstruction + distal dilated lymph vessels (2ndary only; not primary LE) - residual lymphatics anastomosed to nearby veins or transposed to healthy lymphatics from healthy extremity - Lympho-venous anastomosis; lympho-venous bypass; lymphatico-lymphatic bypass Excisional procedures: I = patients w/o residual lymphatics for reconstruction - Charles procedure: for pronounced LE w infected skin = complete circulferential excision, subcutis, deep fascia + graft - Thompson procedure: indirect lymphatic reconstruction = dermis flap buried into muscle compartment to connect subdermal + deep lymphatics - Homan prodedure: wide skin flaps raised for excision of subcutn tissue in medial leg (+ lat leg 3mo later) - Direct lymphatic reconstruction: lympho-venous anastomosis

Hydronephrosis tx

Removal of obstruction + drainage of urine via catheter insertion Upper tract - Acute - insertion of nephrostomy tube - Chronic - insertion of ureteric stent or pyeloplasty Lower tract - Insertion of urinary catheter or suprapubic catheter

Benign tumours of kidney

Renal adenoma (MC): aggressively tx as malignant Renal oncocytoma: asymptomatic, a/w paraneoplastic - central stellate scar, requires total excision + cryotx Mesoblastic nephroma: benign congenital in infancy - must be distinguished from highly malignant nephroblastoma - excellent prognosis - curative w/o RT or ChT Angiomyolipoma: benign hamartoma a/w tuberous sclerosis - mostly bilat but can be unilat in women - detected following spontn retroperionteal hemorrhage - dx = multiple large tumours seen on CT - tx = surgical removal or angio-infarction if >5cm Fibroma: parenchymal fibrous (capsular or peri-nephritic) Lipoma: adipose deposit w/i or around kidney Leiomyoma: retroperitoneal or capsular Hemangioma: can cause hematuria

3. Inflammation of retroperitoneum - anatomy + diseases

Retroperitoneal space = space behind peritoneum - Perirenal space = adrenal, kidney, renal vessels + fat capsule - Ant pararenal space = pancre, asc colon, duodenum - Pos pararenal space = only contains fat (paranephric body) Retroperitoneal organs: organs w peritoneum anteriorly - Not suspended by mesentery - Primary: adrenal, kidneys, ureter, aorta, IVC, anal canal - Secondary: (once suspended in mesentery but migrated pos during embryogenesis) distal 2/3 duodenum, asc + desc colon Retroperitonitis x Retroperitoneal fibrosis (Ormond's)

SVCS - definition

SVC compression (not an emergency by itself) SVC + tracheal compression = sup mediastinum syndrome

Anorectal fistula tx

Salmon-Goodsal rule: ID of direction of tract - relates external opening to internal opening - curvilinear tract: perianal skin opening is pos to transverse anal line + fistula tr opens in anal canal in pos midline - radial tract: perianal skin opening is ant to transverse line Setons: non-absorbable nylon or silk left in fistula tract (w-m) to leave it open + promote healing - cutting seton: tied tightly around sphincter complex w periodic re-tightening - drainage seton: tied loosely, only for drainage Low fistula-in-ano: - Fistulotomy: lay open track, remove chronic granulation tissue + allow to heal spontn - risk of impairment of continence (dt minimal sphincter division) High fia: - Core fistuloectomy + endorectal flap advancement: removal + closure of internal opening - Cutting seton - Fibrin glue/fistula plug: biodegradable dissolvable glue that promotes scar tissue formation

4. Scalping - definition + anatomy

Scalping = surgical technique for scalp reconstruction - not all layers of scalp are elastic + scalp has convex shape tf use of primary closure is limited 5 layers of SCALP: Skin, subCutis (contains all vessels + nerves) Aponeurotic galea (separates bone from upper layers, no vessels) Loose CT (mobile; everything above this can be removed w minimal blood loss/nerve damage Periosteum (can be separated from scalp except near sutures) Supply: supratrochlear, supraorbital, spf temporal, occipital + pos auricular a Drainage: accompanying veins drain into dural sinuses Lymph: parotid, submandibular, deep cervical, pos auricular + occipital Innervation: CNV (trigeminal - sensory), supratrochlear, supraorbital, zyogomaticotemporal, auriculotemporal, greater + lesser occipital n

Unconscious patient - signs for initial diagnosis

Signs of trauma: hematoma, laceration, CFS/blood in orifices, SC emphysema Signs of other disease: liver, DM, myxedema Skin: needle marks, cyanosis, pallor, rash, poor turgor Breath smell: alcohol, hepatic fetor, ketosis, uremia

Main complications of immobility

Skin = pressure sores, lacerations Resp = hypostatic pneumonia, PE CV = DVT, postural hypotn, TE GI = paralytic ileus, constipation, distension Urology = UTI, stones Musculoskeletal = contractures, osteoporosis, dystrophy, weakness Neuro = foot drop

spontn pneumothorax tx

Small: stable, asymptomatic, otherwise healthy - observe, resolves w/i weeks; follow up CXR Large: asymptomatic for 2-3w - aspirate to dec trapped lung dt fibrin deposition Symptomatic: evacuate by aspiration Significant pneumothorax: - Tube thoracostomy: chest tube, 4th IC space btw ant + mid midaxillary line - Needle thoracostomy: emergency only; 2nd IC midclavicular line Surgery - I = prolonged, tension, hemothorax, recurrence - Axillary thoracotomy + apical bullectomy - Mechanical or chemical pleurodesis (talc, bleomycin) - Partial/complete parietal pleurectomy (last line)

Penetrating neck injury - sym

Soft signs: tachypnea, non-expanding hematoma, dyspnea Hard signs: expanding hematoma, severe bleeding, shock, dec pulse, vascular bruit, cerebral ischemia, airway obstruction

36. Venous thrombosis - types

Spf thrombophlebitis DVT Axillary subclavian venous thrombosis

lymphedema dx

Stemmer's sign: inability to lift skin fold at base of toe - venous duplex scans can rule out venous insufficiency - lymphoscintigraphy (confirmatory) = sentinel LN, identify point of blockage - CT/MRI for 2ndary lymphedema ddx: CHF, CKD, liver failure, hypoproteinemia

7. Surgical tx of ischemic cerebrovascular accidents - definitions

Stroke: acute neurological condition caused by acute cerebrovascular event Ischemic stroke: cerebral infarction dt insufficient blood flow Hemorrhagic stroke: infarction secondary to SAH or ICH

Thoracic outlet syndrome - sym

Subclavian artery compression: - 6Ps: pain, pallor, poikilothermia, pulseless, paresthesia, paralysis - dec BP by 20mmHg - bruit heard w arm abduction - thromboses are rare, but distal embolisation = Reynaud's Subclavian vein: Paget-Schroetter's syndrome - compression = effort thrombosis = upper extremity pain + swelling on exercise - unilateral swelling, venous distension, heaviness, pain, cyanosis Brachial plexus: - pain + paresthesia w overhead shoulder positions - numbness that can wake patient up - Gillat-Summer - atrophy of intrinsic hand m

SVCS - mediastinal masses

Superior - thymomas, lymphomas, thyroid lesions Anterior (4 t's) - thymoma, teratoma, thyroid lesions, terrible lymphoma Middle - lymphomas, LAP (TB, mets), bronchogenic cysts, hiatal hernia, lung Ca, abscess, vascular mass Pos - neurogenic tumours (NF, NET), esoph Ca, MM, lymphoma, abscess, aneurysm

spontn pneumothorax cx

Surgical cx - fistula, contn air leak, injury to nearby structures, infection Disease cx - respiratory or CV collapse, pneumomediastinum/pneumoperitoneum

Anorectal abscess tx

Surgical drainage: (in theatres under anaesthesia) - Inter-sphincteric abscess = sphincterectomy w drainage + crypt destruction - Perirectal + ischiorectal abscess = drainage w catheter + excision of skin to prevent premature closure + re-accumulation of abscess Post-op sitz bath, analgesia, stool softener (ATB only in case of sepsis)

Dupuytren's contracture dx

Tabletop test: inability to flatten palm against surface of table (dt MCP contractures) US = nodules + cords

Skin grafts - STSG

Thin split thickness - Pros = faster vascularisation, better graft survival, fast healing - Cons = higher degree of post-graft contraction, less trauma resistance, poor sensation + quality, aesthetically inferior Thick split thickness - Pros = less contraction, more qualities of normal skin, more resistant to trauma, fair sensation + aesthetically superior - Cons = worse graft survival, slow healing Meshed grafts - thin/intermediate split thickness rolled under meshing machine to inc size of graft (2-9x) - can be placed on irregular wound bed - poor appearance (alligator look) - donor site heals spontaneously by epithelisation

SVCS - sym of mediastinal masses

Trachea/main bronchus: stridor, dyspnea, cough, lung collapse Esophagus: dysphagia Sym trunk: Horner (ipsilat miosis, ptosis, anhidrosis) atypical NSCLC = stellate ggl compression = Pancoast tu Pericardium: effusion, pericarditis Phrenic n: diaphragmatic paralysis L recurrent laryngeal n: hoarseness

ischemic cerebrovascular accidents - types

Transient ischemic attacks (TIA): <24h, usually minutes + regresses w/o residual symptoms Reversible ischemic neurological deficits (RIND): >24h, complete restitution Complete stroke (CS): fixed neurological deficit Lacunar stroke: non-cortical infarct characterised by abscence of cortical signs

Urinary bladder tumour class

Transitional cell (urothelial) MC SCC, AdenoCa

PE tx, cx, prev

Tx - HD stable = DOAC/LMWH start asap before confirming; contn 3mo/life-long - HD unstable = thrombolysis (IV/catheter), suction cup embolectomy last resort Cx: recurrence, RHF, sudden cardiac death, atelectasis, pulmonary infarctino Prev: mobilisation, stockings, LMWH/fondaparinux, IVC filter if recurrent DVT

Freezing tx

Tx hypothermia first (if concurrent) - ABCDE + IV cannula (fluid shift when rewarming) - Mild = passive external warming (remove wet clothes, warm room) - Moderate = active rewarming (warm blankets, radiant heat, warm air) - Severe = IV warm crystalloids (warm irrigation of peritoneum + thorax, extracorporeal blood rewarming) Frostbite: - rewarm extremity in water bath 37-39C for 20-30min - if thermometer unavailable, water should be warm not hot to touch - keep blisters intact, no scrubbing/massaging - tissue heals gradually, dead tissue falls off (avoid surgical debridement as its nearly impossible to tell) Structural sym: - concomitant dislocations should reduce immediately - open fractures = operative reduction - closed fractures = splint

Physical disinfection

UV radiation (doesn't work on spores, HIV, HBV) - used on surfaces, air, water Flame, filtration, combustion, pasteurisation Atmospheric pressure boiling Overpressure boiling (30min)

26. Non-specific inflammation of urinary tract - classification

Upper: pyelonephritis Lower: cystitis, urethritis Asymptomatic: bacteriuria w/o symptoms Cx: pregnant, menopausal, DM, immunocomp, fx/anatomical anomalies (stone, tumour, VUR, impaired renal fx, BPH etc.) Recurrent UTI: >2 infections w/i 6mo, or >3/y Nosocomial UTI: catheter induced

ischemic cerebrovascular accidents - etio

Vascular: AS, thrombosis, inflammation Cardiac: embolis (AF), CVD Hematological: hypercoagulable states, hemorrhage Hypoxia Carotid dissection: MC in young people RF: smoking, HTN, ACS, hyperchol, AS, DM

DVT dx

Well's criteria: <2 unlikely; >2 likely Compression duplex US - absence of spontn flow, loss of flow variation w respiration, failure to inc flow velocity after distal augmentation - chronically occluded veins are narrows; nearby collaterals are prominent - chronic thrombi are highly echogenic (acute thrombi are anechoic) MR venography: for obese patients or patients w severe edema (gadolinium contrast)

21. Blood transfusions - types

Whole blood RBC Platelets FFP Cryoprecipitate Granulocytes Rh-immune globulin Blood-substitutes

Hemorrhoids etio + classification

Younger males: inc resting pressure in anal canal = dec venous return, venous engorgement + disruption of supportive structures - Excessive straining (constipation, inc freq, chronic cough, BPH, older age) - Sedentary lifestyle, pregnancy, obesity, CT dsr (Ehler Danlos) Internal x External x Mixes

Penetrating injuries of neck - anatomical zones

Zone 1: level of thoracic outlet, from cervical cricoid cartilage to clavicles - contains proximal carotid artery, subclav v, major chest veins - control of injury to vascular structure requires thoracotomy/sternotomy Zone 2: btw cricoid cartilage + mandibular angle - easiest to expose + evaluate Zone 3: btw mandibular angle + base of skull - high injuries may be inaccessible - control of hemorrhage may require ligation of major vessels or angiographic embolisation

Primary retroperitoneal tumours dx

cross-sectional CT, MRI, PET/CT (grading) Pre-op histology by core needle biopsy

Varicocele dx, tx, cx

dx: US = dilated >2mm hypoechoic pampiniform vessels tx: conservative = scrotal supportive - invasive (I = testicular atrophy, pain, infertility) = laparoscopic varicocelectomy (ligation of affected v) cx: infertility (hemostasis = inc temp = dec spermatogen)

Pilonidal sinus dx tx prog

dx: clincial dx, test for occult DM - MRI of buttocks tx: Conservative = shave hairs, wash cavity, ATB Surgical - drainage under LA w removal of granulation tissue + inspissated hair + flattening of natal cleft to prevent recurrence - definitive tx if this fails after 3mo = incision/surgical resection, drainage + Z-plasty prog: recurrence <15% after surgery

Hydrocele dx tx

dx: clinical - US = hypoechoic fluid; ddx from inguinal hernia tx: congenital resolves spontn w/i 6mo - surgery if doesn't resolve by 1y or if severely symptomatic or infertile - Surgical excision (Jaboulay or Lord's) - Percutn aspiration

38. Epididymitis - acute

etio - UTI (E. coli, Pseudomonas, Proteus, Klebsiella) - STD (C. trachomatis, N. gonorrhea, T. pallidum) sym: - unilat scrotal pain, swelling radiating to ipsilat flank - tenderness along pos testis - scrotal skin over epididymis = red, shiny, edematous - low grade fever, UTI sym (dysuria, freq, urgency) - + Prehn sign (reduced pain when hemiscrotum elevated)

Secondary malignant renal tumours

etio: - distant mets from lung, stomach, breast - contiguous spread from adrenal, colon, pancreas, retroperitoneum - lymphoma, leukemia, MM sym: asymptomatic (rarely microscopic hematuria) dx: IV urograms normal

Anal fistula - etio + sym

etio: M>F, 40y - MC dt flow obstruction: IBD, diverticuli, appendicitis, iatrogenic (hemorrhoidectomy), foreign body, CRC - RF: DM, immunosuppression, obesity sym: Anorectal abscess = - throbbing continuous pain, worsening w ambulation + straining - fever, malaise, urinary rtn, sepsis Fistula-in-ano = - severe pain, bloody purulent discharge (relieves pain) - can lead to chronic discharge + pain during defecation Examination = tender perianal mass, internal/external openings visible

Axillary subclavian venous thrombosis

etio: hypercoagulability (FVL) - Paget Schroeter - effort induced upper extremity DVT, intermittent obsctruction of vein in costoclavicular space during repetitive motion sym: - aching axilla pain w edema + cyanosis of upper limb - spf v distension of arm, forearm, shoulder, ant chest wall - tingling, numbness, pain dt compression of brachial plexus (neurogenic TOS) dx: US venous duplex - positive = venography + thrombolysis - CXR to rule out cervical rib presence tx: remove catheter, arm elevation, analgesia, IVF, repeat positional venography - selective catheterisation w thrombolytic infusion - if TOS = surgical repair, post-op venography, warfarin for 1-3mo, aspiring lifelong

Fat embolism

etio: long bone fractures, joint replacement, blood trasfusions, IV fat emulsions, BM transplant, pancreatitis, osteomyelitis sym: triad of hypoxia (dyspnea, cyanosis, crackled), neuro deficit + petechiae (axilla, chest wall, head, neck) - starts 12-24h after dx: low Hct + platelets, CXR, microscopy urine/sputum tx: supportive

Spf thrombosis

etio: stasis (varicose veins MC), local trauma, inflammation, hypercoagulability, Behcte location: saphena magna + parva sym: inflammatory response to thrombus produced in venous wall + surrounding tissue = - pain, swelling, erythema, palpable cord dx: clinical, Doppler US (thickened, edematous, non-compressible) tx: remove precipitating factors, usually self limiting, can give NSAIDs - LMWH if >5cm affected - Recurrent migratory thrombophlebitis = Trousseau syndrome = check for underlying malignancy (pancreatic head) - Spf thrombophlebitis of breast = Mondor syndrome

air embolism

etio: surgery (neurosurgery, laparoscopy), trauma, barotrauma, mechanical ventilation (w + pressure), injections, venous line insertion sym: hypotn - IV air lodges in right atrium, preventing filling of right heart - arterial = neurological dysfx; AMI, AHF, AKI - venous = cardiac arrhythmias, tachy, JVD dx: CXR (air shadows), echo, CT (ischemia) tx: emergency aspiration of air w syringe in Trendelenburg position

testicular torsion cx

ischaemia = subfertility or infertility varicocele, hydrocele testicular salvage after neonatal torsion

Urinary bladder tumour dx

labs urinalysis urine cytology CT urography/cystoscopy (for all patients w gross hematuria) - CXR, CT, LFT, ALP, bone scan to assess spread

Tumour of middle compartment

lymphoma lymphadenopathy mets bronchogenic cysts lung carcinoma vascular mass

lymphedema - conservative tx

manual compression compression garments limb elevation exercise management of underlying cause

posterior compartment

neurogenic tumours - schwannoma - neurofibroma (arise from nerve sheath + fibres) - ganglioneuroma (MC in children) - neuroblastoma (rarely malignany; also children) - paraganglioma (from chemorcp around aorta + carotid) NET (carcinoid) = Cushing syn, rarely carcinoid syn Pheochromocytoma = rare in mediastinum Oesophageal ca MM, lymphoma, lung cancer

Urinary bladder tumour sym

painless gross hematuria dysuria, freq, urgency, rarely obstruction pain + palpable mass

20. Tumours of urinary bladder - etio

smoking, fam hx dyes, arsenic stones, infection cytotoxic drugs (cyclophosphamide (Mesna)), irradiation

Cardiospasm sym + dx, ddx

sym: dysphagia, regurgitation, WL, retrosternal pain dx: OGD + Ba + manometry ddx: Diffuse esophageal spasm (corkscrew): simultaneous peristaltic contractions instead of progressive - retrosternal pain, solid + liquid dysphagia - tx = CCB, nitrates, botox Hypertensive peristalsis (nutcracker): high amplitude progressive peristalsis - statistical nutcracker = stress related episodic dysphagia (tx like DES) - true nutcracker = extreme HTN, neurological isse (pain does not improve w CCB)