Fast Track Surgery: General, Vascular and Urology - PasTest

Fast Track Surgery:General, Vascularand Urology

Also by Manoj Ramachandran:Intercollegiate MRCS: An Aid to the Viva Examination (with Alex Malone andChristopher Chan) published by PasTest.The Medical Miscellany (with Max Ronson) published by Hammersmith Press.Clinical Cases and OSCEs in Surgery (with Adam Poole) published by ChurchillLivingstone.Coming soon from Manoj Ramachandran:Basic Orthopaedic Sciences: The Stanmore Guide published by Hodder Arnold.Coming soon from Aaron Trinidade and Manoj Ramachandran:Mnemonics in Surgery published by PasTest.Fast Track Surgery: Trauma, Orthopaedics, and the Subspecialities published byPasTest.

Fast Track Surgery:General, Vascularand UrologybyAaron Trinidade MBBS MRCS(Ed)Senior House Officer in Otolaryngology, Whipps Cross UniversityHospital, LondonandManoj Ramachandran BSc(Hons) MBBS(Hons)MRCS(Eng) FRCS(Tr&Orth)Paediatric and Young Adult Orthopaedic Fellow, Royal NationalOrthopaedic Hospital Rotation, Stanmore, Middlesex

© 2006 PASTEST LTDEgerton CourtParkgate EstateKnutsfordCheshireWA16 8DXTelephone: 01565 752000All rights reserved. No part of this publication may be reproduced, stored in aretrieval system, or transmitted, in any form or by any means, electronic,mechanical, photocopying, recording or otherwise without the prior permission ofthe copyright owner.First published 2006ISBN: 1904627854A catalogue record for this book is available from the British Library.The information contained within this book was obtained by the author fromreliable sources. However, while every effort has been made to ensure itsaccuracy, no responsibility for loss, damage or injury occasioned to any personacting or refraining from action as a result of information contained herein canbe accepted by the publishers or author.PasTest Revision Books and Intensive CoursesPasTest has been established in the field of postgraduate medical educationsince 1972, providing revision books and intensive study courses for doctorspreparing for their professional examinations.Books and courses are available for the following specialties:MRCGP, MRCP Parts 1 and 2, MRCPCH Parts 1 and 2, MRCPsych, MRCS,MRCOG Parts 1 and 2, DRCOG, DCH, FRCA, PLAB Parts 1 and 2.For further details contact:PasTest, Freepost, Knutsford, Cheshire WA16 7BRTel: 01565 752000 Fax: 01565 650264www.pastest.co.uk enquiries@pastest.co.ukText prepared by Type Study, Scarborough, North YorkshirePrinted and bound in the UK by Cambridge University Press, Cambridge, UK

CONTENTSSECTION 1IntroductionUsing this book and studying for surgery 3Surviving the surgical rotation 5Getting started: THE BASICS1. Surgical jargon 11a. Surgical abbreviations 11b. Glossary of surgical terminology 16c. Surgical signs, tests, laws, syndromes and eponyms 202. Incisions 263. Wounds, stomas, fistulae, anastomoses, tubes and drains 284. Fluid, electrolyte and acid–base balance 405. Surgical nutrition 516. Post-operative complications 557. Anaesthesia 628. Minimal access surgery 859. Sutures 90SECTION 2A. The General Surgical take10. The acute abdomen 9511. The trauma call 10312. Appendicitis 13513. Upper gastrointestinal bleeding 14014. Oesophageal tears, perforation and rupture 14215. Perforated peptic ulcer 14416. Cholecystitis, cholangitis and empyema of the gallbladder 14617. Pancreatitis 15018. Bowel obstruction 15819. Diverticular disease 16920. Inflammatory bowel disease: ulcerative colitis and Crohn’s disease 17321. Lower gastrointestinal bleeding 17822. Abdominal aortic aneurysm: leakage and rupture 18123. The acutely ischaemic limb and amputation 18424. Furuncles, carbuncles and abscesses 18925. Burns 20126. Haematuria 20527. Acute testicular disorders: torsion and epididymo-orchitis 208v

B. Non-acute General Surgical conditions28. Abdominal wall: herniae 21329. Upper gastrointestinal tract disorders 224a. Oesophagus 224b. Stomach 229c. Small bowel 240d. Liver 242e. Biliary tree 249f. Pancreas 257g. Spleen 25930. Lower gastrointestinal tract disorders 263a. Colon and rectum 263b. Anal canal 27431. Vascular disease 285a. Arterial disorders 285b. Venous disorders 292c. Lymphatic disorders 29832. Benign breast disease 29933. Endocrine disorders 303a. Thyroid 303b. Parathyroid 311c. Adrenal 316d. Multiple Endocrine Neoplasia (MEN) syndrome 32534. Urological disease 326a. Urinary tract infections (UTIs) 326b. Renal calculi 327c. Prostate 333d. Testes, scrotum, and penis 33835. Skin: lumps and bumps 347C. Surgical malignancy36. Oesophageal carcinoma 35737. Gastric carcinoma 36038. Small bowel carcinoma 36539. Large bowel carcinoma: colorectal and anal 36640. Pancreatic carcinoma 37441. Hepatic carcinoma 37742. Gallbladder and biliary tree carcinoma 38043. Breast cancer 38444. Renal carcinoma 39645. Bladder carcinoma 40146. Prostatic carcinoma 40447. Testicular, penile and scrotal carcinoma 40948. Endocrine: thyroid, parathyroid and adrenals 41749. Skin cancer 42550. Lymphomas and sarcomas 432vi

ACKNOWLEDGEMENTSI must firstly thank my parents Austin and Lorna, who have supported methroughout this endeavour, and to whom this book is dedicated. I would like tothank the surgeons who have taught (and grilled) me throughout my professionthus far, and in particular, two of my earlier mentors, Mr Steve Budhooram andMr Patrick Harnarayan. It is from their often nerve-wracking question and answersessions that this book sprung, and under their tutelage that I developed thefoundation of my surgical knowledge. Stacey, Adrian, and Joelle, thank you foryour continuing interest, support, and encouragement. Thanks to PasTest fortaking this project on board. Finally, thanks to the many students whom I havehad the pleasure of teaching since graduating from medical school. They havebrought to me the questions that their own consultants have asked them, andhave given me further insight into what they, today’s medical students, areexpected to know.Aaron TrinidadeAs always, I would first like to thank my wife, Joanna. She has been myinspiration and constant source of support. My parents and my brother, Navin,also deserve special mention. PasTest and in particular, Kirsten Baxter, havebeen very supportive of all my projects, numerous that they are. I don’t thinkthey really know what they’ve let themselves in for . . .Manoj RamachandranDear student,This book was written specifically with you in mind. Your comments, suggestionsand corrections are appreciated. If you would like to submit questions you’vebeen asked or mnemonics of your own, we will gladly consider them. If weinclude it in the next edition of the book, we will add your name on a list ofstudent contributors (good for your curriculum vitae!). In this way, it will trulybecome your book too! E-mail us at: fasttracksurgery@pastest.co.ukAaron TrinidadeManoj Ramachandranvii

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CONTRIBUTORSJudith Pearson, MBChB MRCS(Glas)Registrar in General Practice, St George’s Rotation, Bridge LanePractice, BatterseaChapter 22: Abdominal aortic aneurysm: leakage and ruptureChapter 31: Vascular diseaseAzhar Ahmad Khan, MBBS MRCS(Ed)Research Fellow in Urology, Bristol Urology Institute, SouthmeadHospital, BristolChapter 34c: ProstateChapter 44: Renal carcinomaChapter 46: Prostatic carcinomaSyed Gilani, MBBS MS MRCS(Ed)Senior House Officer in ITU, Good Hope Hospital, BirminghamChapter 28: Abdominal wall: herniaeMark Prempeh, MBBS MRCS(Glas)Senior House Officer in Burns & Plastics, Selly Oak Hospital,BirminghamChapter 49: Skin cancerDaniel Horner, BSc MBBSSenior House Officer in Accident & Emergency, Royal Albert EdwardInfirmary, WiganChapter 11: The trauma callJames Stuart Taylor, BSc MBBSSenior House Officer in Urology, University College of London Hospital,LondonChapter 6: Post-operative complicationsChapter 8: Minimal access surgeryix

Andrew Skingsley, BSc MBBSSenior House Officer in ITU/Anaesthetics, Guy’s & St Thomas’ Hospital,LondonChapter 7: AnaesthesiaJodie Lam, BSc MBBSSenior House Officer ITU/Anaesthetics, Manly Hospital, Sydney, AustraliaChapter 32: Benign breast diseaseChapter 37: Gastric carcinomaChapter 43: Breast cancerChapter 45: Bladder carcinomaCharan Koka, BSc MBBSSenior House Officer in General Practice, Royal Sussex County Hospital,BrightonChapter 35: Skin: lumps and bumpsAmit Parmar, BSc MBBSHouse Officer in General Surgery, Whipps Cross University Hospital,LondonChapter 41: Hepatic carcinomaChapter 50: Lymphomas and Sarcomasx

SECTION 1Introduction

USING THIS BOOK AND STUDYING FOR SURGERYThis book was written for you, the medical student on surgical rotations,by registrars and senior house officers (people who are not too far offfrom where you are right now). Its aim is to serve as a summary ofcommon surgical conditions you are likely to come across during thattime. It serves as a rapid-access study aid and is not meant to be acomplete surgical text.Surgery is a logical and practical science, and studying it should be thesame. Ideally, after seeing a case on the ward, you should read about itextensively in your standard surgical text and then use this book torefresh and highlight salient points and concepts. Reading should bedone daily (or nightly!). The average surgical attachment isapproximately 10 weeks. That equates to 70 days. Reading an averageof 10 pages a day (approximately 1 hours worth of reading), and 20 aday on Saturday and Sunday mornings from a standard surgicaltextbook (and this one!), equals 900 pages by the end of the rotation:enough to give you a broad, sound base of surgical knowledge and stillleaving adequate time to go on take, and even squeeze in a social life(just about). Sorted!The book is designed in a question-and-answer type format, and makesuse of questions commonly asked on the wards, with the answers givenin the succinct and structured way they should be answered. Thequestions are largely derived from what the authors remember beingasked when they were medical students themselves. Applied anatomy isincluded where relevant (an essential survival tool in the operatingtheatre!). The book also makes use of tables and mnemonics whereappropriate, and gives management plans in list form as you might seewritten in patients’ notes. Blood investigations and radiology are listedwith explanations on why they are ordered, as the reasons usuallyevade medical students! Keep this book with you at all times duringyour clerkship and use it for a bit of cramming from it in your sparemoments on the wards. Its two-columned format makes it useful forrevision as the answers can be covered up while you test yourself withthe questions.3

When studying surgery, the following mnemonic is useful to keep inmind:Dressed In A Surgeon’s Gown, A Physician Is Truly Progressing:DefinitionIncidenceAge DistributionSexGeographyAetiologyPresentationInvestigationsTreatmentPrognosisThis will form a framework on which to build your understanding of eachcase. The best way to learn is, of course, to clerk patients continuously,no matter how dull it may seem at times. Patients are a wealth ofinformation. Following up the patient reveals investigations performedand management decisions made. This serves to bring to life whatyou’ve read and reinforces this information in your mind. But most ofall, enjoy your time in surgery – medical school should be fun!4

SURVIVING THE SURGICAL ROTATIONThe surgical clerkship can be a hectic time. Stress can run high,especially in the operating theatre. The following tips will help you tocope and make the most out of your experience amongst surgeons.APPEARANCEDress smartly and make an effort to appear neat. You will see hundredsof patients, but the patients only see a few of you. White coats help,but be willing to take yours off if it makes a patient anxious (white coathypertension). Remember you’re on a ward dealing with patients, andnot in a fashion show. Conservative is always better.ATTITUDEYou must be a keener, but in measured amounts so as not to nauseatefellow students and junior doctors! Strike a balance. A lacklustreattitude leads to lacklustre teaching. Develop thick skin quickly.Sarcasm is common in surgery. Take things in your stride, not personally(unless it was meant to be personal). Be polite, especially to the wardsister who runs the show. Offer to do jobs. Speak up when spoken to,but never backchat. Humility is a virtue. If you can’t be humble withyour knowledge (or lack thereof), be confident with caution, but nevercocky. Share information with colleagues and never show others up.Keep skiving to a minimum and make sure everyone pulls his or herweight: the adage ‘one bad apple spoils the whole lot’ rings true wheremost busy consultant surgeons are concerned, and you’ll then have toreally shine to avoid being grouped with slackers.WHAT TO CARRYHave the following handy at all times:• Notebook and pen (have one extra for junior doctors)• Stethoscope• Penlight (handy for lumps and bumps)• Blood and X-ray forms• This book!5

FIRST THING IN THE MORNING, DON’T LOITER!• Make sure you’re there first and say good morning to nursing staff• Update your personal list of the firm’s patients (new admissions, etc)• Check patients’ vitals, blood results and X-rays and have them handy• Ask the nurses if anything happened overnight• Have blank blood and X-ray forms handy for the ward round (unlessthe hospital ordering system is digitalised).PRESENTING ON THE WARD ROUNDPresenting is an art form to try and perfect. Keep focused and presentrelevant positives and salient negatives only, but be prepared to answerany question asked (eg knowing who an elderly woman with rectalbleeding lives with is important but need not be presented in the samebreath as her current clinical status!). During a presentation, eventsshould be given in a chronological sequence. The following is anexample of how a patient should be presented:[Ms SP, acute appendicitis]‘This is Ms SP, a 26-year-old diabetic secretary who presented at8 o’clock last night with a 1-day history of worsening abdominal painradiating from her umbilicus to her right iliac fossa. She described thepain as constant, being aggravated with movement and coughing.Paracetamol did not help. There has been associated nausea, fever andanorexia, but no vomiting. Important negatives include no vaginaldischarge or bleeding and no urinary symptoms. Her last normalmenstrual period was on [date] and a urinary pregnancy test confirmedthat she is not pregnant. Examination revealed a temperature of 38°Cand a tachycardia of 95 bpm. All other obs were normal. Abdominalexam revealed a flat abdomen with a Pfannensteil incision from aprevious C-section. There was maximal tenderness in the right iliacfossa. There was localised rebound and guarding. Rovsing’s sign waspositive. Rectal exam revealed nothing of note. A clinical diagnosis ofacute appendicitis was made, which was supported by a WBC count of14. She has been started on antibiotics, analgesia, intravenous fluids, asliding scale of insulin, and has been NBM since [time]. This morningher vitals are stable [quote values]. She is due for an appendicectomyat [time].’Presentation time is about 5 minutes, giving plenty of time forquestions!6

OPERATING THEATRE: DO’S AND DON’TSDO have a good night’s sleep and a proper breakfast before attendingDO review the relevant anatomy beforehandDO ask the theatre sister to teach you how to scrub up properly (arriveearly for this)DO know the patients inside out before they arriveDO make sure that there is a medical student scrubbed for every caseDO use time between cases wisely by either reviewing cases orpractising knotsDON’T disturb the surgeon without asking permission firstDON’T annoy the scrub nurse: do as she saysDON’T chit-chat with other students during an operation if not scrubbedDON’T touch instruments unless given explicit instruction to do soDON’T look bored no matter how long and tedious the operation is.POST-OPERATIVE ROUNDIf asked to present a patient on post-op rounds, don’t panic. Start bystating the procedure the patient had and then use the following list ofthings that you should be interested in post-operatively:• General clinical status of patient (alert, vomiting or in pain?)• Examination (in particular, wound site, chest, calves and bowelsounds)• Vital signs (look at trends as opposed to single values)• Fluid charting and input–output balance (is the patient producingurine?)• Stomas and drains (function and contents)• Post-operative blood results• Drug chart (receiving appropriate medications in the appropriatedosages?)Have gloves for everyone handy in your pockets. Always be the first oneto pick up the nursing chart and make a show of checking the vitals.Ask if wounds need to be observed, and if so, take the initiative toremove the dressing yourself (don’t forget gloves!). Have yourstethoscope handy as surgeons rarely carry one!7

Getting started:THE BASICS

CHAPTER 1: SURGICAL JARGONa. SURGICAL ABBREVIATIONS# Fracture1ry, 2ry, etc . . . Primary, Secondary, etc . . .a/aaArtery/arteriesAAAlcoholics AnonymousAAA Abdominal aortic aneurysm (triple A)ABGArterial blood gasAbxAntibioticsABPIAnkle-brachial pressure indexADHAntidiuretic hormoneAFAtrial fibrillationAKAAbove knee amputationAmpAmpicillinAPRAbdomino-perineal resectionARDSAdult respiratory distress syndromeASAAmino-salicylic acid (aspirin)ASISAnterior superior iliac spineAXRAbdominal X-rayBabdBKABPBSCACABGCBDCCFCefchrmCISCMVC/OCOPDCPAPCRPBariumbis die (twice daily)Below knee amputationBlood pressureBowel soundsCarcinomaCoronary artery bypass graft (cabbage)Common bile ductCongestive cardiac failureCefuroximeChromosomeCarcinoma in situCytomegalovirusComplains ofChronic obstructive pulmonary diseaseContinuous positive airway pressureC-reactive protein (inflammatorymarker)11

CVACVPCXRD5WDKADICDIPDREDMDTDUDVTDxECGEchoERCPESRETOHEUAFAPFBCFDPFFPFNA[C]GAGCSGentGPG&SGTNGUGXMHNPCCHONK12Cerebrovascular accident (stroke is abetter term)Central venous pressureChest X-rayDextrose 5% in waterDiabetic ketoacidosisDisseminated intravascularcoagulationDistal interphalangealDigital rectal examinationDiabetes mellitusDelirium tremensDuodenal ulcerDeep vein thrombosisDiagnosisElectrocardiogramEchocardiogramEndoscopic retrogradecholangiopancreatographyErythrocyte sedimentation rateAlcoholExamination under anaesthesiaFamilial adenomatous polyposisFull blood countFibrin degradation productsFresh frozen plasmaFine needle aspirate [cytology]General anaestheticGlasgow Coma ScaleGentamicinGeneral practitionerGroup and saveGlyceryl trinitrateGenitourinaryGroup and cross-matchHereditary non-polyposis colorectalcancerHyper-osmolar non-ketotichyperglycaemic coma

HRTHTNHIVHPVIBDICPI&DIHDITUIMVIPPVIRVIVCIVDUIVFIVP/UJVPKUBLALAPLAP APPYLAP CHOLELBOLFTLIFLIHLNMPLUQ/LLQM/C/SMENMetroMIMOFMSUn/nnN/AHormone replacement therapyHypertensionHuman immunodeficiency virusHuman papilloma virusInflammatory bowel diseaseIntracranial pressureIncision and drainage (abscesses)Ischaemic heart diseaseIntensive therapy unitIntermittent mandatory ventilationIntermittent positive pressureventilationinverse ratio ventilation/inspiratoryreserve volumeInferior vena cavaIntravenous drug userIntravenous fluidsIntravenous pyelogram/urogramJugular venous pressureKidneys, ureters and bladder (plainfilm)Local anaestheticLaparotomyLaparoscopic appendicectomyLaparoscopic cholecystectomyLarge bowel obstructionLiver function testLeft iliac fossaLeft inguinal herniaLast normal menstrual periodLeft upper/lower quadrantMicroscopy, culture and sensitivityMultiple endocrine neoplasiaMetronidazoleMyocardial infarctionMultiorgan failureMid-stream urineNerve/nervesNot applicable13

NADNBMNGTNOFN/SNSAIDsOCPodOGDORIFOTPCAPCWPPEPEEPPEGPERLAPIDPIPPOPRPRNPTCPTCAPUDPUJPVNil abnormality detectedNil by mouthNasogastric tubeNeck of femurNormal salineNon-steroidal anti-inflammatory drugsOral contraceptive pillomni die (once daily)OesophagogastroduodenoscopyOpen reduction and internal fixationOperating theatre/occupationaltherapistPatient-controlled analgesiaPulmonary capillary wedge pressurePulmonary embolismPositive end expiratory pressurePercutaneous endoscopicgastrostomyPupils equal and reactive to light andaccommodationPelvic inflammatory diseaseProximal interphalangealper os (orally)per rectum (rectally)pro re nata (as needed)Percutaneous transhepaticcholangiogramPercutaneous transluminal coronaryangioplastyPeptic ulcer diseasePelvi-ureteric junctionper vaginum (vaginally)qds quater die sumendus (to be taken 4times daily)qxhevery x hours (eg q3h = every3 hours)RBSRIFRIH14Random blood sugarRight iliac fossaRight inguinal hernia

RxTreatmentRTARoad traffic accidentRUQ/RLQRight upper/lower quadrantSBOSmall bowel obstructionSCCSquamous cell carcinomaSIRSSystemic inflammatory responsesyndromeSLESystemic lupus erythematosusSOBShortness of breathstatImmediatelySVCSuperior vena cavaSxSurgerySXRSkull X-rayTBTuberculosistds ter die sumendus (to be taken 3times daily)TIATransient ischaemic attackTOETransoesophageal echocardiogramTPNTotal parenteral nutritionTURBTTransurethral resection of bladdertumourTURPTransurethral resection of prostateUCUlcerative colitisU&EsUrea and electrolytes (and creatinine)U/OUrine outputUSSUltrasound scanUTIUrinary tract infectionv/vvVein/veinsVancVancomycinVEVaginal examinationVUJVesico-ureteric junctionWBC/WCCWhite blood cells/white cell countZESZollinger–Ellison syndrome15

. GLOSSARY OF SURGICAL TERMINOLOGYAsepticAdhesionsAdeno-AfferentAnastomosisAngio-AnomalousAtelectasisAtresiaBezoarBimanual examBiopsyCachexiaCalculusCalorCaseationCaudalCephal-Chole-Choledocho-CicatrixColicColonoscopyComplete absence of diseasecausingmicro-organisms.Bowel ‘stickiness’, usually occurringpost-op, and predisposing to bowelobstruction. Can be treated withadhesiolysisPertaining to glandsTowardSurgically created connectionbetween two tubular structures (egbowel, blood vessels, etc)Pertaining to blood vesselsDeviating from the normAlveolar collapseCongenital absence of abnormalnarrowing of an opening or lumen(adj. atretic)Swallowed mass of foreign material,usually hair or fibreVaginal examinationTissue sample obtained and sent forhistopathologyGeneralised wasting associated withchronic disease or malignancy (adj.cachectic)StoneOne of the classic signs ifinflammation; signifies warmthBreakdown of diseased tissue intocheese-like material (adj. caseous)Relating to lower part of the bodyPertaining to the headPertaining to the gallbladderPertaining to the bile ductScarPain which occurs in waves; usuallyoccurs in tubular organsEndoscopic examination of the colon16

CoprophagiaCurettageCystDiaphoresisDiverticulumDolorDysphagiaDyspareuniaEcchymosis-ectomyEntero-EpistaxisExcision biopsyFaecatemesisFaeculentFistulaIngestion of faeces; one of thecauses of faecatemesisScraping of the internal surface of anorgan or body cavity with a spoon-lineinstrument (curette)Abnormal sac lined by epithelium andfilled with fluid or semi-solid materialExcessive sweatingA small sac or pouch projection fromthe wall of a hollow organ. The wall ofa true diverticulum comprises allthe layers of the parent organ (egMeckel’s diverticulum). The wall of apseudo-diverticulum contains onlysome of the layers (eg diverticulardisease of the colon)One of the classic signs ofinflammation; signifies painDifficulty swallowing (as opposed toodynophagia which is painfulswallowing)Painful sexual intercourse (infemales)BruisingSurgical removal (egcholecystectomy)From enteric; pertaining to bowelNosebleedBiopsy in which entire tumour isremovedVomiting of faeces (seen only ingastrocolic fistula andcoprophagia)Pertaining to faeces (NB faeculentvomiting resembles faeces in smelland colour due to intestinal floralaction, but is not stool as infaecatemesis)An abnormal, epithelialisedcommunication between twosurfaces 17

FrequencyFunctio laesaHaemangionaHaematemesisHaematomaHaematuriaHaemoptysisHaemothoraxHesitancyIcterusIncisional biopsyIndurationIntussusceptionLaparotomyLaparoscopyLumenMelaenaNocturiaObstipationOdynophagiaOrchid--orraphyAbnormally increased rate of urinationOne of the classic signs ofinflammation; signifies loss offunctionBenign tumour of blood vesselsVomiting of bloodBlood clot within tissues which formsa solid mass. May resolve or becomesuper-infectedBlood in the urineCoughing-up of bloodBlood within the pleural spaceDifficulty in initiating urinationJaundiceBiopsy in which only a core of thetumour is removedAbnormal hardening of a tissue ororganTelescoping of one part of the bowelinto adjacent bowelOpening the abdominal cavity via asurgical incisionVisualisation of peritoneal cavity witha laparoscope (makes use of fibreoptics)Cavity within a tubular organ (adj.luminal)Black, tarry stool representingdigested blood, most commonlyoccurring due to an upper GI bleed(must be more than 100 ml)Abnormal urination at night usuallyinterrupting sleepTotal failure to pass either flatus orstoolPainful swallowingPertaining to the testiclesSurgical repair (eg herniorraphy)18

-oscopy-ostomy-otomy-pexyPhlegmonPneumaturiaPneumothoraxPusRuborSinusSteatorrhoeaStenosisStrangurySuccus entericusSuppurationTenesmusTransectionUrgencyVisual examination of the interior ofthe abdomen (through anendoscope)Surgically created opening (egcolostomy). (From stoma whichmeans mouth)Surgical incision into an organ (eglaparostomy)Surgical fixation (eg orchidopexy)Solid, swollen, inflamed pancreatictissue massAir in the urine (usually due to anenterovesical fistula)Air within the pleural spaceFluid product of inflammation (seeChapter 24) (Adj. purulent, notpussy!)One of the classic signs ofinflammation; signifies rednessAbnormal, blind-ending, epithelialisedtract in an organFatty stools due to decreased fatabsorptionAbnormal narrowing of a lumen,passage or openingA painful discharge of urine, drop bydrop, caused by spasmodic bladdercontractionFluid from the bowel lumenFormation of pusSensation of rectal fullness with urgeto defecateTransverse divisionSudden urge to urinate19

c. SURGICAL SIGNS, TESTS, LAWS, SYNDROMES ANDEPONYMSAaron’s signAfferent loop syndromeAllen’s testBattle’s signBeck’s triadBoas’ signBoerhaave’s syndromeCarcinoid syndromeCharcot’s triadPressure in RIF causes epigastric andcardiac discomfort in chronicappendicitisChronic obstruction of duodenumand jejunum proximal togastrojejunostomy performed inBillroth II procedureTest of hand circulation. Ask pt. todrain hand by forming a fist, andcompress radial and ulnar aa. Ask pt.to open blanched fist. Release oneartery and observe for palmar flushing(arterial patency). Repeat test forother arteryPeriorbital ecchymoses in basal skull#Seen in cardiac tamponade. Consistsof:1. Jugular venous distension2. Muffled heart sounds3. ↓BPRight subscapular pain incholelithiasisOesophageal rupture (traumatic orafter binge drinking)Syndrome caused by serotoninrelease from carcinoid tumour.Consists of:1. Bronchospasm2. Flushing3. Diarrhoea4. Right-sided heart failureSeen in ascending cholangitis.Consists of:20

Chvostek’s signCompartment syndromeCourvoisier’s lawCullen’s signCushing’s triadCushing’s syndromeDercum’s diseaseDumping syndrome1. Fever with rigors2. Jaundice3. RUQ painSeen in hypocalcaemia. Tapping overfacial n. causes twitching of facialmusclesCondition of increased pressure in aconfined anatomical space adverselyaffecting circulation and threateningthe function and viability of tissuestherein‘If, in the presence of jaundice, amass is present in the right upperquadrant, the jaundice is unlikely tobe due to stones.’ (The cause istherefore most likely carcinoma ofpancreatic head, since in gallstonesthe gallbladder is fibrotic andshrivelled)Periumbilical ecchymosis 2ry toretroperitoneal haemorrhage (as seenin haemorrhagic pancreatitis)Seen in raised ICP. Consists of:1. ↑BP2. Bradycardia3. Irregular respirationsClinical syndrome of glucocorticoidexcess. If due to excess ACTH levels(as in pituitary tumour or ectopicproduction), known as Cushing’sdiseaseMultiple, painful lipomatosis (mainlytruncal)Seen after gastric vagotomy,pyloroplasty and gastrojejunostomy.Caused by rapid passage of large21

Fox’s signGardner’s syndromeGoodsall’s line and lawGrey Turner’s signHoman’s signKaposi–Stemmer signKehr’s signamounts of hyperosmolar chyme intosmall bowel. Consists of:1. Autonomic instability (flushing,sweating, dizziness, vasomotorcollapse)2. Abdominal pain3. DiarrhoeaInguinal ligament ecchymosis 2ry toretroperitoneal haemorrhage (as seenin haemorrhagic pancreatitis)Autosomal dominant premalignantsyndrome consisting of:1. Multiple colonic polyposis2. Skull osteomas3. Epidermoid cysts4. FibromasLine: imaginary line drawnhorizontally through the anus of apatient in the lithotomy position.Law: anal fistulae occurring above thisline (anterior fistulae) take a straightcourse to the anal canal; those belowit (posterior fistulae) take a curvedcourseFlank ecchymosis seen inretroperitoneal haemorrhage (as seenin haemorrhagic pancreatitis).Mnemonic: Turner = turn pt. on side= flankSeen in DVT. Calf pain on footdorsiflexion. Dangerous (may dislodgea clot!) and rarely usedInability to pick up or pinch a fold ofskin in lymphoedemaIntense left shoulder tip pain insplenic rupture. Caused by referredpain due to diaphragmatic irritation22

Krukenburg tumourLeriche’s syndromeMcBurney’s point and signMendelson’s syndromeMirrizi’s syndromeMurphy’s signObturator signOgilvie’s syndromePanda eyesPeutz–Jegher’s syndromePlummer–Vinson syndromeMetastatic tumour to ovary,classically from stomachSeen in iliac occlusive disease.Consists of:1. Buttock claudication2. Buttock atrophy3. ImpotencePoint: Starting from the umbilicus, apoint 2/3 along a line drawn from theumbilicus to the right ASISSign: Pressure on this point causespain in acute appendicitisChemical aspiration pneumonitisfollowing aspiration of gastriccontentsExtraluminal compression of CBDfrom a cystic gallstone. May causeobstructive jaundiceSeen in cholecystitis. Palpation ofRUQ causes pain on inspiration asinflamed gallbladder movesdownward and ‘hits’ the palpatinghandSeen in appendicitis and pelvicabscess. Pain on internal rotation ofright lower limb with knee and hipflexedMassive non-obstructive colonicdilation.Syn: pseudo-obstructionSee Raccoon eyesSyndrome of benign GI polyps withcircumoral pigmentationSyndrome of the oesophageal websand dysphagia caused by irondeficiency. May develop into SCC(10%)23

Psoas signRaccoon eyesRefeeding syndromeReynold’s pentadRovsing’s signSaint’s triadShort-gut syndromeSipple syndromeSister Mary Joseph’s signSuperior vena cava syndromeThoracic outlet syndromeTietze’s syndrome24Seen in appendicitis and psoasinflammation. Pain on extending thehip with knee in full extensionSeen in basal skull #. Bilateralperiorbital ecchymoses. Syn: Pandaeyes↓K, ↓Mg and ↓PO 4 followingrefeeding of a starved patientSeen in suppurative cholangitis.Consists of:1. Fever with rigors2. Jaundice3. RUQ pain4. CNS alteration5. Shock/sepsis(Basically Charcot’s triad + 2)Seen in appendicitis. Palpation in LIFcauses pain in RIF.3 conditions which usually co-exist. Ifyou find 1, look for other 2:1. Cholelithiasis2. Hiatal hernia3. Diverticular diseaseMalnutrition resulting from

Trousseau’s signTrousseau’s syndromeVirchow’s nodevon Hippel–Lindau syndromeWerner’s syndromeWhipple’s triadZollinger–Ellison’s syndromeSeen in hypocalcaemia. Carpopedalspasm after blood occlusion (with BPcuff) in forearm or legSyndrome of DVT associated withcarcinomaMetastatic tumour to leftsupraclavicular node(s)An autosomal dominant syndrome ofretinal and cerebellar angiomataoccasionally associated with renalcell carcinoma andphaeochromocytomaMEN ISeen in insulinoma. Consists of:1. Hypoglycaemia2. CNS and vasomotor symptoms(syncope and diaphoresis)3. Symptomatic relief followingglucose administrationSyndrome of gastrinoma and PUD25