Common surgical presentations Flashcards
Acute abdomen
- Differentials
- Investigations
Differentials: ask about location
(Acute Bleeding)
- Ruptured AAA
- Ruptured ectopic pregnancy
- Bleeding peptic ulcer
- Traumatic injury
(Perforated Viscus)
- Peptic ulcer disease
- Untreated bowel obstruction
- Diverticular disease
- IBD
(Ischaemia)
- Acute mesenteric ischaemia
(Colic)
- Biliary
- Ureteric
- Bowel obstruction
Plus peritonism
Investigations:
(Bedside)
- Urine dipstick - infection or haematuria?
- Pregnancy test
- Arterial Blood Gas - useful in bleeding or acutely unwell patients, especially for the pH, pO2, pCO2, HCO3 and lactate
- Routine bloods– FBC, U&Es, LFTs, CRP, amylase, and a G&S
- Crossmatch - for any urgent surgery required
- ECG - ?referred myocardial pain and prep for surgery
(Imaging)
- Erect chest x-ray – ?evidence of free abdominal air
- USS - assess renal tract, biliary tree and liver, uterus and ovaries
- CT abdo-pelvis - for GI pathology
Haematemesis
- Differentials
- Investigations
Differentials:
- Oesophageal varices
- Gastric ulceration (into underlying blood vessel)
- Mallory-Weiss tear
- Oesophagitis
- Peptic / duodenal ulcer perforation
Investigations:
- Routine bloods
- OGD imaging (oesophagogastroduodenoscopy)
- Erect chest x-ray
- CT abdomen with IV contrast
Dysphagia
- Differentials
- Investigations
Differentials:
Obstructive causes
- Tumour (oesophageal)
- Strictures (oesophageal)
- Extrinsic compression
- Pharyngeal pouch
- Foreign body
Neuromuscular causes
- Post-stroke
- Damage to nerves supplying oesophagus (achalasia)
- Myasthenia gravis
Investigations:
- Routine bloods
- Endoscopy (potential biopsy)
- Manometry and 24hr pH studies
- Barium swallow (if pouch suspected)
Gastric Outlet Obstruction (mechanical obstruction of the proximal gastrointestinal tract)
- Differentials
- Investigations
Differentials:
- Peptic ulcer disease (stricturing)
- Tumour (gastric or small bowel)
- Iatrogenic
- Pancreatic pseudocyst
- Bouveret Syndrome
- Foreign object
Investigations:
- Routine bloods
- CT scan with IV contrast
- Upper GI endoscopy
Bowel obstruction
- Differentials
- Investigations
Differentials:
- Constipation
- Pseudo-obstruction
- Paralytic ileus
- Toxic megacolon
Investigations:
- Routine bloods
- Group and save
- VBG (signs of ischaemia)
- CT scan with IV contrast
Gastrointestinal perforation
- Differentials
- Investigations
Differentials:
- Diverticulitis
- Peptic ulcer disease
- Tumour
- Iatrogenic
- Trauma
- Foreign body (e.g. battery)
- Appendicitis
- Mesenteric ischaemia
- Colitis e.g. Crohn’s
Investigations:
- CT constrast
- Erect chest x-ray
Malaena
- Differentials
- Investigations
Generally from upper gastrointestinal bleed (occasionally from small bowel or ascending colon)
Differentials:
- Peptic ulcer disease
- Oesophageal varices
- Liver disease
- Ulcerating cancer (oesophageal or gastric)
- Oesophagitis/gastritis
- Mallory-Weiss tear
- Meckel’s diverticulum
Investigations:
- Routine bloods (Hb, liver function)
- Group and save
- Arterial blood gas (acutely unwell)
- OGD
- CT abdomen with IV contrast
Rectal bleeding
- Differentials
- Investigations
Differentials:
- Diverticulosis / diverticular disease
- Haemorrhoids
- Cancer (colorectal)
- Angiodysplasia
- Crohn’s or Ulcerative colitis
Investigations:
- Routine bloods
- Stool culture
- Flexible sigmoidoscopy (followed by OGD if nothing found)
Jaundice
- Outline some differentials for pre-hepatic, hepatic and post-hepatic jaundice
- Investigations
Prehepatic jaundice:
- Sickle cell anaemia
- Haemolytic anaemia
- Gilbert’s syndrome
Hepatic jaundice:
- Viral hepatitis
- Autoimmune hepatitis
- Cancer (hepatocellular carcinoma)
- Alcoholic liver disease
- Primary sclerosing cholangitis
- Iatrogenic, e.g. medication
Hereditary haemochromatosis
Post-hepatic jaundice:
- Intra-luminal causes e.g. gallstones
- Luminal causes e.g. cholangiocarcinoma or strictures
- Extra-luminal causes e.g. pancreatic cancer or abdominal masses
Investigations:
- Routine bloods including LFTs, FBC and UandEs
- Specific liver tests: Bilirubin
Albumin, AST / ALT / ALP,
Gamma-GT
- Coagulation testing
- Ultrasound abdomen
- MRCP
- Liver biopsy
Acutely painful limb (cold and pale)
- State the most likely diagnosis
- Suggest investigations
Acute limb ischaemia
CT angiogram
Sudden onset (hot and swollen) calf
- State the most likely diagnosis
- Suggest investigations
- Outline initial treatment (drugs)
- DVT
- Wells score
- Doppler scan (if Wells score >1)
- LMWH initially
- Swapped to DOACs for 3-6 months post-DVT
Haematuria
- Differentials
- Investigations
Differentials:
- UTI (upper more likely)
- Renal calculi
- Renal cancer
- Bladder cancer
- Prostate cancer
- BPH
- Foreign object / trauma
- Schistosomiasis
- Glomerulonephritis
Investigations:
- Routine blood tests (including CRP, UandEs, PSA levels)
- Urine dipstick or urine MC&S (for infection)
- Flexible cystoscopy
- Ultrasound KUB
- CT KUB
Scrotal pain
- Differentials
- Investigations
Differentials:
- Testicular torsion
- Epididymo-orchitis
- Scrotal/inguinal hernia
- Varicoele
- Hydrocoele
- Referred pain from renal calculi
Investigations:
- Routine bloods (including FBC, CRP, and UandEs)
- Urine dipstick
- Urethral swab (STI?)
- Transillumination
- Ultrasound of testes
Lower urinary tract symptoms
- Differentials
- Investigations
Differentials:
- BPH
- Chronic prostatitis
- Prostate cancer
- Bladder cancer
- UTI
- Detrusor muscle weakness
- Pelvic floor dysfunction
- Urethral strictures
- External compression e.g. other tumour
Investigations:
- Routine bloods
- Urine dipstick
- Flexible cystoscopy
- Post-void bladder scan
- Urodynamic studies
- CT KUB
- Ultrasound KUB
Scrotal lumps
- Differentials
- Investigations
Differentials:
- Hydrocoele
- Epididymal cyst
- Testicular cancer
- Varicoceles
- Inguino-scrotal hernia
- Epididymo-orchitis
- Testicular torsion
Investigations:
- Routine bloods (including CRP and tumour markers)
- Scrotal ultrasound
- Transillumination
- Scrotal exploration if testicular torsion is suspected
- Scrotal swab for STI
