Clinical pathology Flashcards
18219 – Five days after an appendicectomy a 25 year old patient develops a tachycardia and a fever of 39.5oC. The most likely cause is which one of the following?
A. Chest infection
B. Urinary infection
C. Wound infection
D. Pelvic abscess
E. Deep venous thrombosis
C
Any of the complications listed could be present, but the timing most suggests a wound infection (C) in this young patient after appendicectomy for acute appendicitis.
18274 – You are asked to see a patient in the ward, seven days following a left hemicolectomy. The patient has a discharging wound. The discharge oozes freely between the skin sutures and is profuse, watery and bloodstained. There are no signs of surrounding inflammation. The most likely diagnosis is
A. subcutaneous wound dehiscence
B. an anastomotic leak
C. discharge from a wound haematoma
D. discharge from a deep wound infection
E. discharge from an intraperitoneal seroma
A
This ominous clinical picture is classical of a subcutaneous wound dehiscence.
18268 – A 40-year-old man is confused and restless 48 hours after upper abdominal surgery with anti-reflux repair of an oesophageal hiatus hernia. The most probable cause of his condition is
A. pulmonary embolism
B. narcotic overdose
C. pulmonary atelectasis
D. electrolyte imbalance
E. starvation ketosis
C
The development of confusion and restlessness at 48 hours post-operatively suggests a hypoxic cause. Pulmonary atelectasis (C) is the most likely of the first four responses considering its development on the second post-operative day. Starvation ketosis is unlikely at this stage.
887 – A 45 year old patient has an elective laparoscopic cholecystectomy for proven gall stones. No problems occurred and the visualisation was good. Operative cholangiography was performed and considered normal. Twelve hours after operation the temperature is 39oC and pulse rate is 110 per minute. You would suspect as the MOST likely cause
A. atelectasis.
B. intra-peritoneal biliary leak.
C. cholangitis.
D. reaction to the contrast medium.
E. wound infection.
A
After an upper abdominal operation such as elective laparoscopic cholecystectomy without bile duct exploration, the commonest complication is postoperative atelectasis, which is especially common in smokers or those with pre-existing chest disease. Atelectasis commonly presents within the first 12-24 hours after surgery with fever and tachycardia, often without obvious clinical findings in the chest (A correct). It is thus the most likely of thediagnoses listed. You would of course need to consider operative complications as well! Intraperitoneal bile leak is more likely to occur when the bile duct has been explored, but can follow simple cholecystectomy as a result of leakage from the liver bed or due to the cystic duct clip(s) slipping. Clinical presentation is often delayed until 24 hours or more after operation, and presentation may be with abdominal signs of varying degree associated with shock.
Cholangitis is rare after elective cholecystectomy without bile duct exploration. The frequency of infected bile rises in operations for acute cholecystitis and with bile duct stones. Reaction to the contrast medium is less common than atelectasis; and wound infection does not usually present within the first 12 hours.
15934 – The following are major risk factors for heroin addicts
1: hepatitis B
2: adult respiratory distress syndrome
3: infective endocarditis
4: malignant lymphoma
TTTT
Question updated 6 May 2002.
10215 – A patient has a subtotal thyroidectomy. Three hours after the operation she develops severe respiratory distress. The correct treatment is to
A. administer an anaesthetic and explore the wound
B. intubate the patient in bed
C. administer morphine to allay distress
D. remove the skin sutures
E. open the wound in the ward and divide the sutures in the deep fascia
E
18231 – You are called to see a 56-year-old man with dyspnoea and pleuritic chest pain. Five days earlier he had a laparotomy and gastric resection. On examination he has a temperature of 37.5oC, a respiratory rate of 25 per minute, a pulse rate of 90 and a blood pressure of 130/95 mm Hg. His heart sounds are normal and there are no added sounds or murmurs. There is good air entry to both bases and the percussion note is resonant in all areas. Which one of the following combinations of test results indicates a high probability of a pulmonary embolus in a particular zone of the lung:
A. Chest X-ray: NORMAL, Ventilation scan: NORMAL and Perfusion scan: REDUCED
B. Chest X-ray: NORMAL, Ventilation scan: ABNORMAL and Perfusion scan: NORMAL
C. Chest X-ray: CONSOLIDATION, Ventilation scan: NORMAL and Perfusion scan: REDUCED
D. Chest X-ray: CONSOLIDATION, Ventilation scan:ABNORMAL and Perfusion scan: NORMAL
E. Chest X-ray: NORMAL, Ventilation scan: ABNORMAL and Perfusion scan: REDUCED
A
A reduced lung perfusion scan, combined with a normal ventilation scan and normal chest x-ray is highly suggestive of a segmental pulmonary artery embolism (A).
905, 7144 – A 25 year old woman is admitted to hospital one hour after the sudden onset of severe pain in the right lower abdomen with nausea, vomiting and faintness. She is afebrile. She has a blood pressure of 100 mm Hg and a pulse rate of 120/min. On examination of the abdomen she is tender in the right lower abdomen with guarding and rigidity and rebound tenderness. The most likely diagnosis is
A. ruptured appendicitis
B. perforated peptic ulcer
C. ruptured ectopic pregnancy
D. salpingitis
E. torsion of ovarian cyst
C
The sudden onset in a young woman of severe acute abdominal pain in the right lower abdomen with nausea and vomiting, combined with faintness or syncope, and associated with signs of lower abdominal peritonitis, is classical of a ruptured ectopic pregnancy.
18225 – A 65 year old overweight woman has an emergency laparotomy and colostomy for an obstructing carcinoma. On the eighth post-operative day she develops left sided chest pain. This is associated with a low grade fever, dyspnoea and a blood pressure of 110/70, pulse rate 100 per minute and a respiratory rate of 30 per minute. The most likely diagnosis is:
A. pelvic abscess
B. pulmonary embolism
C. myocardial infarction
D. subphrenic abscess
E. pneumonia
B
Pulmonary embolism (B) is the most likely diagnosis of those listed in this high-risk patient.
