CBE 2020 + 2019 Flashcards
Anaesthetics - Case 1
Little old lady on the ward who is in for pain management of a vertebral fracture. She’s on heaps of pain medications, including celecoxib and various opioids. You get called to the ward because she has collapsed and has been found on the floor of her room. Didn’t lose consciousness, HR high, BP low, diaphoretic, GCS 15. What do you do?
a. Call for help
b. Check for response
c. Check airway – adjuncts if required
d. Check breathing – RATES – give oxygen
e. Check circulation – CRT/BP/pulse – gain IV access and give fluids if required
f. Disability – check BGL/recent medications/allergies/check pupils
g. Exposure – look for signs of bleeding/trauma/injury
Anaesthetics - Case 1
Little old lady on the ward who is in for pain management of a vertebral fracture. She’s on heaps of pain medications, including celecoxib and various opioids. You get called to the ward because she has collapsed and has been found on the floor of her room. Didn’t lose consciousness, HR high, BP low, diaphoretic, GCS 15. On examination, the PR examination showed melaena.
a. What is the likely diagnosis?
b. You get this ECG. What’s wrong?
a. Upper GI bleed
b. Ischemia - Diffuse ST depression with ST elevation in aVR in a 12-lead ECG may indicate the possibility of CAD involving the left main coronary artery or proximal LAD, pulmonary embolism or takotsubo cardiomyopathy.
A pattern of widespread ST depression plus ST elevation in aVR > 1 mm is suggestive of left main coronary artery occlusion.
Anaesthetics - Case 1
Little old lady on the ward who is in for pain management of a vertebral fracture. She’s on heaps of pain medications, including celecoxib and various opioids. You get called to the ward because she has collapsed and has been found on the floor of her room. Didn’t lose consciousness, HR high, BP low, diaphoretic, GCS 15. On examination, the PR examination showed melaena.
You get an ECG showing widespread ST depression plus ST elevation in aVR > 1 mm suggestive of left main coronary artery occlusion. 6. What is your further management of this patient?
Transfusion of blood products – 4 units
Summary of Immediate Management:
1. Cardiac stabilization: Oxygen, aspirin, nitrates, inotropic support, and urgent cardiology consultation for coronary angiography.
2. GI bleeding management: PPI infusion, gastroenterology consultation, endoscopy, and possible blood transfusion. Balance anticoagulation for ACS with the risk of worsening GI bleeding, in close collaboration with cardiology and gastroenterology.
Anaesthetics - Case 1
Little old lady on the ward who is in for pain management of a vertebral fracture. She’s on heaps of pain medications, including celecoxib and various opioids. You get called to the ward because she has collapsed and has been found on the floor of her room. Didn’t lose consciousness, HR high, BP low, diaphoretic, GCS 15. The PR examination showed melaena and you suspect an upper GI bleed. You get an ECG showing widespread ST depression plus ST elevation in aVR > 1 mm suggestive of left main coronary artery occlusion. You get an ABG with the following results. What is the diagnosis?
Metabolic acidosis with high anion gap, lactate was high, calcium was low = Lactic acidosis from hypovolaemic shock
Causes of High Anion Gap metabolic acidosis = CAT MUDPILES
Anaesthetics - Case 2 Pre-op assessment. 72 year old man going to have a knee replacement. Has T2DM, HTN, hyperlipidaemia, AF. On rivaroxaban, metformin, dapagliflozin, two anti-hypertensives. How should you manage the patient’s anticoagulants?
a. Assess thromboembolic risk
b. Assess bleeding risk
c. Cease NOAC 2-3 days beforehand
d. Consider bridging with LMWH
The Padua score can be applied to hospitalized patients who have the potential risk of VTE. Patients who are high risk (Padua ≥4) could benefit from thromboprophylaxis.
How to calculate stroke risk in patient with AF?
The CHA₂DS₂-VASc score is one of several risk stratification schema that can help determine the 1 year risk of a TE event in a non-anticoagulated patient with non-valvular AF. Helps with long-term stroke risk stratification for atrial fibrillation patients.
Anesthesia Case 2 - Pre-op assessment. 72 year old man going to have a knee replacement. Has T2DM, HTN, hyperlipidaemia, AF. On rivaroxaban, metformin, dapagliflozin, two anti-hypertensives.
What should you advise him to do with his other medications? (ie. not his anticoagulants)
= Withold on day of surgery
- Metformin: Typically continued unless the patient has renal impairment, in which case it may need to be stopped temporarily to reduce the risk of lactic acidosis.
- Dapagliflozin: Consider holding for 24-48 hours before surgery to reduce the risk of euglycemic diabetic ketoacidosis.
- Antihypertensives: Continue these medications but consider withholding ACE inhibitors or ARBs on the day of surgery to avoid intraoperative hypotension.
Anaesthetics - Case 2
Pre-op assessment. 72 year old man going to have a knee replacement. Has T2DM, HTN, hyperlipidaemia, AF. On rivaroxaban, metformin, dapagliflozin, two anti-hypertensives. After the operation he experiences significant PONV that can’t be controlled with ondansetron and cyclizine. How should this complication be managed?
a. Multimodal analgesia – opioid sparing
b. Regular PRN antiemetics
c. Good hydration
d. Good oxygenation
- Prokinetics like metoclopramide should be used cautiously in patients with AF and on rivaroxaban, as these medications can promote gastric emptying and increase the risk of drug absorption fluctuations.
- Careful assessment of fluid status, pain, and electrolytes may also help in controlling PONV, particularly in the elderly, to avoid further complications such as dehydration or aspiration.
ICU CBE - 45yo man presents with 7 days post chemotherapy feeling unwell, feverish, hot and cold. He had a PICC line in), warm peripheries, low BP, high HR, some bibasal crackles, some tenderness on deep palpation of abdomen but no guarding. There is no new murmur, the PICC site looks clean. What is your initial management?
This 45-year-old man presents with signs and symptoms of sepsis following chemotherapy, a high-risk scenario given his likely immunocompromised status due to chemotherapy. The clinical findings of fever, hypotension, tachycardia, warm peripheries, bibasal crackles, and abdominal tenderness suggest sepsis, potentially progressing to septic shock.
a. Call for help
b. ABC
c. Sepsis 6
i. Give oxygen
ii. Take ABG/VBG and blood cultures
iii. Give antibiotics and fluids
iv. Insert foley catheter
ICU CBE - 45yo man presents with 7 days post chemotherapy feeling unwell, feverish, hot and cold. He had a PICC line in), warm peripheries, low BP, high HR, some bibasal crackles, some tenderness on deep palpation of abdomen but no guarding. There is no new murmur, the PICC site looks clean. What are four likely sources of sepsis? What investigations will you do?
- PICC line
- Pneumonia
- Colitis (mucositis from chemo)
- UTI
Septic Screen:
1. Urine MC&S
2. FBC
3. CRP
4. Cultures x 2 (min - from lines + 1 peripheral)
5. Line swabs
6. Sputum microscopy
7. CXR
ICU CBE - 45yo man presents with 7 days post chemotherapy feeling unwell, feverish, hot and cold. He had a PICC line in), warm peripheries, low BP, high HR, some bibasal crackles, some tenderness on deep palpation of abdomen but no guarding. There is no new murmur, the PICC site looks clean. Shown blood results: anaemia, neutropenia, thrombocytopenia – what are these results and how will you manage?
Pancytopenia (Febrile Neutropenia) – requires broad spectrum antibiotic - Tazocin
Definitions
- Neutropenia: ANC < 500/mcL OR expected to decrease to < 500/mcL within 48 hours
- Fever: single oral temperature ≥ 38.3°C (101°F) OR ≥ 38°C (100.4°F) for at least 1 hour
The 45-year-old man presents with fever, hypotension, tachycardia, and other signs suggestive of sepsis or septic shock, post-chemotherapy. His blood results showing anaemia, neutropenia, and thrombocytopenia are consistent with bone marrow suppression, a common complication following chemotherapy, putting him at high risk for febrile neutropenia and infections.
ICU CBE - 45yo man presents with 7 days post chemotherapy feeling unwell, feverish, hot and cold. He had a PICC line in), warm peripheries, low BP, high HR, some bibasal crackles, some tenderness on deep palpation of abdomen but no guarding. There is no new murmur, the PICC site looks clean. What investigations will you do? Shown blood results: anaemia, neutropenia, thrombocytopenia – what are these results and how will you manage? The consultants are concerned that this patient has septic shock. Given another ABG, also metabolic acidosis. PICC line cultures Pseudomonas, blood cultures so far negative. How do you interpret these findings? List three different antibiotics (from three different classes) that can be used to treat pseudomonas.
Regardless of blood cultures, he’s still clinically in septic shock!
a. Tazocin
b. Meropenem
c. Ciprofloxacin
ICU CBE - 45yo man presents with 7 days post chemotherapy feeling unwell, feverish, hot and cold. He had a PICC line in), warm peripheries, low BP, high HR, some bibasal crackles, some tenderness on deep palpation of abdomen but no guarding. There is no new murmur, the PICC site looks clean. What investigations will you do? Shown blood results: anaemia, neutropenia, thrombocytopenia – what are these results and how will you manage? The consultants are concerned that this patient has septic shock. Given another ABG, also metabolic acidosis. PICC line cultures Pseudomonas, blood cultures so far negative. How do you interpret these findings? List three different antibiotics (from three different classes) that can be used to treat pseudomonas. You give him vitamin T (Tazocin) and he gets better in a few days. He then starts developing diarrhea and an abdominal XR is performed.
Toxic megacolon is an acute complication seen in both types of inflammatory bowel disease and, less commonly, in infectious colitis and other types of colitis. It is due to fulminant colitis, which causes loss of the neurogenic tone of the colon, leading to severe dilatation and increasing the risk of perforation.
ICU CBE - 45yo man presents with 7 days post chemotherapy feeling unwell, feverish, hot and cold. He had a PICC line in), warm peripheries, low BP, high HR, some bibasal crackles, some tenderness on deep palpation of abdomen but no guarding. There is no new murmur, the PICC site looks clean. What investigations will you do? Shown blood results: anaemia, neutropenia, thrombocytopenia – what are these results and how will you manage? The consultants are concerned that this patient has septic shock. Given another ABG, also metabolic acidosis. PICC line cultures Pseudomonas, blood cultures so far negative. How do you interpret these findings? List three different antibiotics (from three different classes) that can be used to treat pseudomonas. You give him vitamin T (Tazocin) and he gets better in a few days. He then starts developing diarrhea and an abdominal XR is performed and shows Toxic megacolon/pseudomembranous colitis. She is diagnosed with c.diff infection. How do you manage this?
Vancomycin/ Metronidazole
MSK - Case 1 - 52 year old comes in with isolated right knee pain that he’s had for a 3-4 months, worse when he bends down at work. What history features do you want to know about his knee pain?
- SOCRATES
- Mechanical vs inflammatory signs/symptoms
- Swelling
- Deformity
- Instability
- Trauma
- Function issues
- Systemic features – rash/diarrhea/conjunctivitis/urethritis
- Recent URTI/gastro
- Previous Tx?
- Family Hx
PMH, Meds, Allergies, etc.
MSK - Case 1 - 52 year old comes in with isolated right knee pain that he’s had for a 3-4 months, worse when he bends down at work. Man has 3-4 months of pain, worse at the end of the day and with use. No locking or instability. No recent trauma. No information sounds inflammatory.
- What would you look for on examination?
- What are two tests that can be done to determine if there is an effusion?
MSK - Case 1 - 52 year old comes in with isolated right knee pain that he’s had for a 3-4 months, worse when he bends down at work. Man has 3-4 months of pain, worse at the end of the day and with use. No locking or instability. No recent trauma. No information sounds inflammatory. On examination there is reduced ROM and some tenderness on the medial joint line. No ligamentous laxity.
- Based on the exam findings what are two differentials?
- What is the one single investigation that would help with Dx?
a. Meniscal injury
b. Collateral ligament injury
Do an xray of the knee
MSK - Case 1 - 52 year old comes in with isolated right knee pain that he’s had for a 3-4 months, worse when he bends down at work. Man has 3-4 months of pain, worse at the end of the day and with use. No locking or instability. No recent trauma. No information sounds inflammatory. On examination there is reduced ROM and some tenderness on the medial joint line. No ligamentous laxity. You send him for an xray. What do you see?
= likely OA
MSK - Case 2 - 32 year old woman presents with a 6 year history of lower back pain. What history features do you want?
The red flags for back pain can be recalled using the mnemonic TUNA FISH:
- Trauma
- Unexplained weight loss
- Neurological symptoms / signs
- Age > 50
- Fever
- Intravenous drug use
- Steroid use
- History of cancer
MSK - Case 2 - 32 year old woman presents with a 6 year history of lower back pain. Gives an inflammatory back pain picture, onset during pregnancy and worsened over the past year. Her father has psoriasis. What examination findings would you look for?
Positive SIJ pain provocation tests
1. Faber
2. Mennell sign
Forward & lateral flexion
MSK - Case 2 - 32 year old woman presents with a 6 year history of lower back pain. Gives an inflammatory back pain picture, onset during pregnancy and worsened over the past year. Her father has psoriasis. Gives you exam findings for AS. What single investigation would you do for Dx?
HLA B27
MSK - Case 2 - 32 year old woman presents with a 6 year history of lower back pain. Gives an inflammatory back pain picture, onset during pregnancy and worsened over the past year. Her father has psoriasis. Gives you exam findings for AS. HLA-B27 comes back positive, her ESR is up a bit. What imaging would you want next?
Pelvic x-ray.
Laboratory findings in AS
- CRP and ESR are typically elevated.
- HLA-B27: Positive in 90–95% of patients with axial spondyloarthritis
- Autoantibodies (e.g., RF, ANA) are negative
- CBC: may show anemia
- Interpret a positive HLA-B27 test in conjunction with clinical features as only ∼ 1% of individuals who are positive for HLA-B27 have AS.
MSK - Case 2 - 32 year old woman presents with a 6 year history of lower back pain. Gives an inflammatory back pain picture, onset during pregnancy and worsened over the past year. Her father has psoriasis. Gives you exam findings for AS. HLA-B27 comes back positive, her ESR is up a bit. She has a pelvic x-ray performed. What do you interpret?
Sacroiliitis = inflammation of one or both sacroiliac (SI) joints. It is a common cause of buttocks or lower back pain and can manifest as a wide range of disease processes.
MSK - Case 2 - 32 year old woman presents with a 6 year history of lower back pain. Gives an inflammatory back pain picture, onset during pregnancy and worsened over the past year. Her father has psoriasis. Gives you exam findings for AS. HLA-B27 comes back positive, her ESR is up a bit. She has a pelvic x-ray performed which confirms sacroilitis suggestive of AS. What 2 management things would you do for her?
Exercise & NSAIDs
First-line therapy is primarily focussed on NSAIDs and non-pharmacological measures including education, exercise, physiotherapy and group therapy. Together, these treatments can lead to substantial clinical improvement in 70-80% of patients. Local steroid injection and DMARDs (sulfasalazine and methotrexate) can also help with peripheral manifestations. Second-line therapy includes TNF-alpha blockers (etanercept, infliximab, adalimumab, certolizumab, golimumab) and IL17 inhibitors (secukinumab). Whether TNF-alpha blockers can inhibit radiographic disease progression has been the subject of some debate and continues to be investigated.
ENT - Case 1 - Little old lady from nursing home comes in with epistaxis. She has HTN, cognitive impairment, on warfarin and aspirin plus anti-hypertensives.
1. What is your initial management?
2. She continues bleeding with lots of blood and coughing up clots. Describe how you manage an anterior epistaxis?
3. Her FBC comes back (low Hb) and INR comes back at 3.5. What do you want to do?
4. Despite the anterior packing, she continues to have blood down the back of her throat. What are two things you should do now?
- Initial Stabilization - ABC: Ensure the patient’s airway is clear and that they are breathing comfortably. Suction any significant blood from the airway if needed. Assess hemodynamic status, check for signs of hypovolemia, and monitor vital signs, particularly BP and O2 sats.
- Positioning: Keep the patient sitting upright with their head tilted slightly forward. This prevents blood from flowing into the throat and helps with drainage.
- Nasal Pinching: Pinch the soft part of the nostrils (below the bony bridge) for 10-15 minutes continuously while the patient breathes through their mouth.
ENT - Case 2 - 47yo man comes in with a 3 month history of lesion on his tongue. Shown a photo that looks like an ulcer on his tongue. What are three serious differentials / illnesses that could cause this?
- What are 6 risk factors he could have for head and neck cancer?
- Oral tobacco consumption (e.g., snuff, paan/betel quid), smoking
- Long-term alcohol consumption
- Poor oral hygiene & chronic mechanical irritation (e.g., badly positioned dentures)
- Human papillomavirus, particularly HPV 16, 18, 31, and 33
- Presence of precancerous lesions : leukoplakia , erythroplakia , erythroleukoplakia
- Age
- Immunosuppresion
- Exposure to Certain Chemicals: Occupational exposure to substances like asbestos, formaldehyde, and certain industrial chemicals.
- Radiation Exposure: Previous radiation treatment for other cancers, particularly to the head and neck area.
- Prevoius personal hx
- Family hx
ENT - Case 2 - 47yo man comes in with a 3 month history of lesion on his tongue. Shown a photo that looks like an ulcer on his tongue. You examine him and turns out he’s got a 2-4cm lump on his neck as well. The tongue lesion is a SCC and the FNA neck lump is metastasis. CT head shows 4cm extension into base of tongue. What is the most appropriate management?
- Breaking bad news - SPIKES
- Refer to MDT & ENT/Onc
CBE - ED 1 - Old lady presents to the ED after waking up acutely short of breath. No chest pain, but she’s diaphoretic. BP is high, HR is high. History of HTN, NSTEMI, other stuff, mild cognitive impairment. Listen to her chest and she’s got coarse crackles bilaterally.
- You do an ECG. What is. the diagnosis & management in the ED?
CBE - ED 1 - Old lady presents to the ED after waking up acutely short of breath. No chest pain, but she’s diaphoretic. BP is high, HR is high. History of HTN, NSTEMI, other stuff, mild cognitive impairment. Listen to her chest and she’s got coarse crackles bilaterally. You do an ECG and it comes back with NSTEMI (ST depression). You suspect she has APO. How would this look on CXR?
A: alveolar opacification
B: batwinging
C: cardiomegaly
D: diffuse interstitial thickening (septal lines) and diversion (vascular upper zone diversion, cephalisation)
E: effusions (pleural)
CBE - Emergency 1 - Old lady presents to the ED after waking up acutely short of breath. No chest pain, but she’s diaphoretic. BP is high, HR is high. History of HTN, NSTEMI, other stuff, mild cognitive impairment. Listen to her chest and she’s got coarse crackles bilaterally. You do an ECG and it comes back with NSTEMI (ST depression). You suspect she has APO. She’s been given GTN and frusemide but still looking pretty crap. You do an ABG and it comes back, interpret the ABG.
Interpretation:
- pH: Low, indicating acidosis.
- PaCO₂: Elevated, indicating respiratory acidosis.
- PaO₂: Low, indicating hypoxemia (type II respiratory failure).
- HCO₃⁻: Slightly elevated, indicating a compensatory metabolic alkalosis.
This ABG suggests type II respiratory failure (also known as hypercapnic respiratory failure) due to inadequate ventilation, often seen in conditions such as COPD, severe asthma, or respiratory muscle weakness.
CBE - Emergency 1 - Old lady presents to the ED after waking up acutely short of breath. No chest pain, but she’s diaphoretic. BP is high, HR is high. History of HTN, NSTEMI, other stuff, mild cognitive impairment. Listen to her chest and she’s got coarse crackles bilaterally. You do an ECG and it comes back with NSTEMI (ST depression). You suspect she has APO. She’s been given GTN and frusemide but still looking pretty crap. Her ABG shows respiratory acidosis and type II respiratory failure. Your consultant is considering starting NIV. The patient is very anxious. Outline your management. This was very unclear what they wanted – 4 mark question.
You need to explain NIV to the patient but no one was quite clear what else. Like do you explain the BIPAP settings, do you start in ED? No clue
CBE - ED 2 - 22yo woman presents to ED with friends after sitting in a park and feeling lightheaded. Proceeds to struggle breathing, not feeling good, only responding to pain, losing consciousness. Gurgling sound but NOT stridor. SpO2 88%, HR is 140, BP can’t get a reading.
- List your 4 most likely differentials.
- What immediate interventions can improve her oxygenation?
- Outline your initial management in a ‘organised and logical manner’ for 6 marks? (A to E) & ALS algorithm.
This 22-year-old woman is critically ill with hypoxia (SpO₂ 88%), tachycardia (HR 140), and inability to obtain a BP, suggesting severe shock. Her decreased consciousness, gurgling sounds (likely from airway obstruction due to secretions), and respiratory distress are highly concerning. The priority is to stabilize her airway, breathing, and circulation.
Differentials
1. Anaphylaxis - Give 0.5mg IM Adrenaline
2. Severe Asthma attack
3. PE
4. Septic shock
CBE - ED 2 - 22yo woman presents to ED with friends after sitting in a park and feeling lightheaded. Proceeds to struggle breathing, not feeling good, only responding to pain, losing consciousness. Gurgling sound but NOT stridor. SpO2 88%, HR is 140, BP can’t get a reading.
- What are 6 investigations you’d like to perform?
- ECG
- FBC
- ABG
- CXR
- Mast cell tryptase
- UECs
CBE - ED 2 - 22yo woman presents to ED with friends after sitting in a park and feeling lightheaded. Proceeds to struggle breathing, not feeling good, only responding to pain, losing consciousness. Gurgling sound but NOT stridor. SpO2 88%, HR is 140, at first you can’t get a BP reading but when you finally do its 70/40. She starts to get an urticarial rash and you think she’s got anaphylaxis so you give her IM adrenaline (I had already done this in the above question) and a 500mL fluid bolus. She doesn’t respond that well. What further management can you do? (7)
- Repeat IM/IV adrenaline
- IV fluids (more aggressive resuscitation)
- Oxygen and potential airway support.
- IV antihistamines and corticosteroids
- Bronchodilators if needed
- Vasopressors for refractory hypotension
- ICU transfer for close monitoring and continued resuscitation.
CBE - ED 2 - 22yo woman presents to ED with friends after sitting in a park and feeling lightheaded. Proceeds to struggle breathing, not feeling good, only responding to pain, losing consciousness. Gurgling sound but NOT stridor. SpO2 88%, HR is 140, at first you can’t get a BP reading but when you finally do its 70/40. She starts to get an urticarial rash and you think she’s got anaphylaxis so you give her IM adrenaline and a 500mL fluid bolus. She doesn’t respond that well so you give a second dose of adrenaline, hydrocortisone and more fluid. She perks up and all her vitals are normal. She tells you she was stung by a bee before she became unwell. What is your ongoing management now? You tell her she has to be observed in the ED for 6-8h but she doesn’t want to wait. How do you manage this? For 3 marks
Monitoring and disposition
- Monitor in acute-care setting at least 4–8 hours
- Continuous pulse oximetry monitoring
- Continuous cardiac monitoring
- Clinical reassessment for biphasic anaphylactic reactions
- Prior to discharge:
1. Patient counseling on identification and avoidance of triggers
2. Prescription and training on epinephrine autoinjector use
3. Consider allergy/Immunology referral (e.g., anaphylaxis due to Hymenoptera stings)
Pathway for Anaphylaxis management?
CBE - Gen Surgery 1 - Patient comes into GP with a pigmented lesion on her back that her husband spotted about 8 months ago and she’s coming to get it checked.
- What are 8 things on history that you want to know?
- 13 Risk factors?
Risk Factors - Melanoma:
1.History of skin cancer, melanoma, or atypical naevi
2.Family history of melanoma
3.Pale skin (Fitzpatrick skin type I and II)
4.Red or light-coloured hair
5.High freckle density
6.Light coloured eyes
7.History of sunburn
8.Sun exposure or tanning bed exposure
9.Large amounts of moles
10.Increasing age
11.Immunosuppression
12.Outdoor occupation
13.Genetic syndromes with skin cancer predisposition (for example, xeroderma pigmentosum)
CBE - Gen Surgery 1 - Patient comes into GP with a pigmented lesion on her back that her husband spotted about 8 months ago and she’s coming to get it checked. CBE - Gen Surgery 1 - Patient comes into GP with a pigmented lesion on her back that her husband spotted about 8 months ago and she’s coming to get it checked. You get shown a picture of the lesion and the history (sounds like melanoma). You examine the lesion and it tells you about it, 1.5cm, gotten bigger in the past few months. It’s 10cm above the PSIS. Using the criteria for a pigmented lesion, list 5 things that make this a melanoma? Or something along those lines. Essentially does this fit the ABCDE of melanoma?
- List lesions which should not be confused with melanoma? (5)
List the 9 main types of pigmented lesions and their malignant potential?
CBE - Gen Surgery 1 - Patient comes into GP with a pigmented lesion on her back that her husband spotted about 8 months ago and she’s coming to get it checked. You get shown a picture of the lesion and the history (sounds like melanoma). You examine the lesion and it tells you about it, 1.5cm, gotten bigger in the past few months. It’s 10cm above the PSIS. You examine the lesion using the ABCDE approach. What are 2 more things you need to do when examining?
- Check the rest of the skin
- Check regional nodes
Specifically which 2 groups of nodes should you check?
What is the genetic condition that leads to melanoma?
Genetic mutations, including:
BRAF gene mutations
Seen in 50% of melanomas
V600E mutation (most common): an activating mutation in the BRAF gene that substitutes glutamic acid for valine at amino acid position 600
CDKN2A gene mutations
Some people, such as those with xeroderma pigmentosum (XP), inherit a change in one of the XP (ERCC) genes, which normally help to repair damaged DNA inside the cell. Changes in one of these genes can lead to skin cells that have trouble repairing DNA damaged by UV rays, so these people are more likely to develop melanoma, especially on sun-exposed parts of the body.
CBE - Gen Surgery 1 - Patient comes into GP with a pigmented lesion on her back that her husband spotted about 8 months ago and she’s coming to get it checked. You get shown a picture of the lesion and the history (sounds like melanoma). You examine the lesion and it tells you about it, 1.5cm, gotten bigger in the past few months. It’s 10cm above the PSIS. Once you have examined the lesion and assessed for lymphadenopathy. What do you want to do next?
What staging investigations are required?
What staging investigations are required?
Staging tests, including blood tests, computed tomography (CT) scans and positron emission tomography (PET) scans are not recommended in patients who present with American Joint Committee on Cancer (AJCC) stage 1 or stage 2 disease (ie. with an invasive primary melanoma of any thickness and no clinical evidence of metastatic disease).
Gen Surgery 2 - 27yo man comes in with right scrotal swelling. He’s also had a bit of a cough lately.
Give 4 differentials.
Differential Diagnosis of a Scrotal Mass
a. Stand the patient up and see if you can feel above the mass:
1. If not it is probably a hernia.
2. If you can, then palpate to decide whether or not it is part of the testis. A mass within the body of the testis is cancer until proven otherwise and demands an ultra-sound.
b. Transilluminate the mass:
1. If it is translucent, it is a hydrocele or a large epididymal cyst, but there may still be a testicular mass hidden within, so still needs further investigation.
2. If it is opaque it is probably a tumour or a varicocele. Again it demands an ultrasound.
Gen Surgery 2 - 27yo man comes in with right scrotal swelling. He’s also had a bit of a cough lately. What history do you want that will help you determine the cause?
Key Differentiators:
1. Testicular Cancer: Gradual painless swelling, weight loss, lung symptoms (possible metastasis).
2. Inguinal Hernia: Swelling increases with standing or straining, can reduce when lying down.
3. Hydrocele: Painless, transilluminating swelling.
4. Epididymitis/Orchitis: Painful swelling with urinary or sexual history.
5. Varicocele: “Bag of worms” feeling, may get worse with standing or during coughing.
Gen Surgery 2 - 27yo man comes in with right scrotal swelling. He’s also had a bit of a cough lately. History reveals hard lump present for months. Patient has undescended testicles as a child. Patient has had no weight loss but a dry cough. On examination there is hard lump on his right testicle. Painless, can’t separate it from the testes, can get above it. The lump does not transilluminate. What are the 2 most likely DDx now?
- Testicular tumour
- Varicocele
Gen Surgery 2 - 27yo man comes in with right scrotal swelling. He’s also had a bit of a cough lately. History reveals hard lump present for months. Patient has undescended testicles as a child. Patient has had no weight loss but a dry cough. On examination there is hard lump on his right testicle. Painless, can’t separate it from the testes, can get above it. The lump does not transilluminate. You think he’s got a testicular tumour.
- What Ix do you order? (3 Bloods & 3 Imaging)
- Should FNA be performed – why/why not?
No, FNA should NOT be performed in cases of suspected testicular cancer.
- FNA or biopsy carries a risk of tumor seeding along the needle tract and may delay definitive treatment.
- The standard approach in suspected testicular cancer is a radical inguinal orchiectomy (surgical removal of the testis) for both diagnostic and therapeutic purposes. The pathology from this will confirm the diagnosis.
- Performing a biopsy of a suspected testicular tumor is contraindicated because it risks disseminating cancer cells, compromising the patient’s prognosis.
Gen Surgery 2 - 27yo man comes in with right scrotal swelling. He’s also had a bit of a cough lately. History reveals hard lump present for months. Patient has undescended testicles as a child. Patient has had no weight loss but a dry cough. O/E: there is hard lump on his right testicle. Painless, can’t separate it from the testes, can get above it. The lump does not transilluminate. You think he’s got a testicular tumour. You order AFP, BHCG, LDH, USS of testicle, CXR for his cough. The BHCG or alpha-feto protein (conflicting recollections!!) is elevated – what type of tumour is this?
- HCG is always elevated in choriocarcinoma and sometimes elevated in seminoma.
- AFP is always elevated in yolk sac tumors.
- Both AFP and HCG may be elevated in mixed germ cell tumors.
- Testicular tumors metastasize early into the retroperitoneum via the lymphatic system (drain to the para-aortic lymph nodes first), with the exception of early hematogenous metastasizing choriocarcinomas.
Types of Testicular Tumours - Seminoma?
Types of Testicular Tumours - Non-Seminomas? (METTY)
- Mixed germ cell tumours
- Embryonal carcinoma
- Teratoma
- Testicular choriocarcinoma
- Yolk sac tumour
Types of Testicular Tumours - Non-Germ Cell Tumours? (LS) & Secondary?
Gen Surgery 2 - 27yo man comes in with right scrotal swelling. He’s also had a bit of a cough lately. History reveals hard lump present for months. Patient has undescended testicles as a child. Patient has had no weight loss but a dry cough. O/E: there is hard lump on his right testicle. Painless, can’t separate it from the testes, can get above it. The lump does not transilluminate. You think he’s got a testicular tumour. The BHCG or alpha-feto protein (conflicting recollections!!) is elevated.
Shown the CXR and he’s got lots of pulmonary metastases. Interpret this CXR.
Multiple variable sized confluent soft tissue nodules and masses are again seen bilaterally, many of which demonstrate interval growth.
Pulmonary Mets - Pulmonary metastases typically appear as multiple, peripheral, rounded nodules scattered throughout both lungs 1. Larger nodules and masses may be termed cannonball metastases. Atypical features include consolidation, cavitation, cystic change, calcification, ossification, haemorrhage, and secondary pneumothorax.
Gen Surgery 2 - 27yo male with confirmed testicular malignancy with pulmonary mets. What is the most appropriate definitive management?
= Radical inguinal orchiectomy
