DVT

Question 2

DVT SS, RX, Score Mnx and prevention

Answer 2

S+S: calf erythema, tenderness, swelling, warmth.

Risk factors: thrombophilia, synthetic oestrogen, obesity,
past DVT, trauma, ↑ age, pregnancy, surgery, cancer,
immobility.
Wells Score: 1 point – previous DVT, non-varicose collateral
superficial veins, pitting oedema, entire leg swollen, calf
swelling >3cm (measured 10cm below tibial tuberosity),
local tenderness, recently bedridden >3d, major surgery
<12w, immobilization of leg, active cancer (<6m). -2 points –
alternative diagnosis as likely.
0-1 points: unlikely, do d-dimer, if positive do USS and treat,
if negative DVT is excluded.
>1 point: do USS, if positive treat, if negative do d-dimer, if
d-dimer positive repeat USS in 1 week, if d-dimer negative
DVT is excluded.

Management: LMWH e.g. enoxaparin, DOAC e.g. apixaban.

Prevention: LMWH, mobilize early, stop OCP 4w pre-op,
intermittent pneumatic compression device, graduated
compression stockings, fondaparinux.

Question 3

PE

Answer 3

S+S: hemoptysis, syncope, dizziness, pleuritic chest pain,
acute breathlessness, ↑ JVP, pleural effusion, pleural rub,
AF, hypotension, cyanosis, right ventricular heave, loud P2,
pyrexia, tachypnoea, tachycardia, swollen calf (DVT).
Risk factors: HRT, OCP, post-partum, malignancy,
thrombophilia (anti-phospholipid syndrome), previous PE,
immobility, recent surgery.
Causes: usually from venous thrombosis in legs or pelvis,
right ventricular thrombus post-MI, amniotic fluid, parasites,
air, fat, neoplastic cells, septic emboli (right sided
endocarditis).
Prevention: heparin if immobile, stop HRT and OCP 4w preop.
Investigations: U&E, FBC, ABG, ECG (tachycardia, right axis
deviation, RBBB, right ventricular strain V1-3, SIQIIITIII –
deep S waves in I, Q waves in III, inverted T waves in III),
clotting, d-dimer, CTPA, CXR (atelectasis, small pleural
effusion, wedge shaped infarction, ↓ vascular markings).
Modified PE Wells score: <4 = unlikely, >4 = likely. If unlikely
= d-dimer. If likely/positive d-dimer = CTPA or LMWH if
delayed.
Management: oxygen (hypoxia), morphine (pain/distress)
and anti-emetic, LMWH/fondaparinux, fluid bolus (hypotension), thrombolysis e.g. alteplase
(hemodynamically unstable), LMWH/unfractionated
heparin 5d (hemodynamically stable) then switch to DOAC
or warfarin.

Question 4

Pancreatitis

Answer 4

Pathology: pancreatic enzyme autodigestion, oedema and
fluid shifts.
Causes GET SMASHED: Gallstones, Ethanol, Trauma,
Steroids, Mumps, Autoimmune, Scorpion venom,
Hyperlipidaemia, Hypothermia, Hypercalcemia, ERCP and
Emboli, Drugs.
S+S: severe epigastric/central abdominal pain relieved by
sitting forward, radiates to back, ileus, jaundice, fever, shock,
rigid abdomen, tachycardia, Cullen’s and Grey Turners.

Investigations: serum amylase (↑), serum lipase, glucose,
U&E, ABG, CRP, AXR (no psoas shadow, sentinel loop), erect
CXR (excludes perforation), CT, US (gallstones), ERCP.

Management: NBM, IVI, catheterize, analgesia, hourly
observations, daily bloods, ERCP and gallstone removal,
?antibiotics, CT monitor, assess severity (PANCREAS: PaO2
<8, Age >55, ↑Neutrophils, ↓Calcium, Renal function
↑urea, ↑Enzymes, Albumin <32, Sugar >10).
Complications: early – shock, ARDS, renal failure, sepsis, DIC,
↑glucose, ↓calcium. Late – pseudocyst, pancreatic
necrosis, abscesses, bleeding, fistulae, thrombosis, recurrent
oedematous pancreatitis.

Question 5

gallstones

Answer 5

S+S: colicky RUQ pain, after meal, worse if fatty (high CCK
and ↑ gallbladder concentration), more symptoms if
smoking, parity.
Investigations: LFTs, USS, MRI cholangiography, intra-op
imaging.

Management: cholecystectomy, endoscopic retrograde
cholangiopancreatography (risks: pancreatitis, cholangitis,
duodenal perforation, bleeding).

Complications: gallstone ileus, obstructive jaundice,
cholangitis, pancreatitis, empyema, carcinoma, mucocele,
cholecystitis, colic, Mirizzi’s syndrome.

Question 6

biliary colic

Answer 6

Pathophysiology: gallstones symptomatic with cystic duct
obstruction/ passed into common bile duct.
S+S: radiates to back, ± jaundice.
Investigations: urinalysis, ECG, CXR.
Management: analgesia, NBM, rehydrate, elective
laparoscopic cholecystectomy.

Question 7

acute cholecystitis

Answer 7

Pathophysiology: follows stone/sludge impaction in neck of
gallbladder, inflammation.
S+S: mildly deranged LFTs, local peritonism, gallbladder
mass, Murphy’s sign, vomiting, fever, RUQ/epigastric pain,
can radiate to right shoulder.

Investigations: FBC (↑ WCC), USS (thick walled, ↓ size
gallbladder, ↑ fluid, stones, ± dilated common bile duct),
abdominal x-ray (± stones, ± porcelain gallbladder).

Management: NBM, pain relief, IVI, co-amoxiclav,
laparoscopic cholecystectomy, perforation = open surgery.

Question 8

chronic cholecystitis

Answer 8

CHRONIC CHOLECYSTITIS
Pathophysiology: chronic inflammation ± colic.
S+S: vague abdominal discomfort, nausea, fat intolerance,
flatulence, distension.
Investigations: MRCP, USS.
Management: cholecystectomy, ERCP and sphincterotomy
(if dilated CBD and stones).

Question 9

cholangitis

Answer 9

CHOLANGITIS
Pathophysiology: bile duct infection.
S+S (Charcot’s triad): jaundice, fever, RUQ pain, severely
septic/unwell.
Management: fluid resus, tazobactam, correct
coagulopathy, early ERCP.

Question 10

acalculos cholecystitis

Answer 10

Pathophysiology: gallbladder inflammation in absence of
any stones.
S+S: high fever, intercurrent illness (diabetes, organ failure,
systemically unwell).
Management: cholecystectomy.

Question 11

gallbladder abscess

Answer 11

S+S: prodromal illness, systemically unwell, swinging
pyrexia, no generalized peritonism.
Investigations: USS, CT.
Management: percutaneous drainage, cholecystectomy

Question 12

Post cholecystectomy syndrome

Answer 12

Pathophysiology: abdominal symptoms remain postgallbladder removal. Gallstones escape from the gallbladder
during surgery through CBD, ampulla of Vater and block at
the sphincter of Oddi. Back-up of pancreatic enzymes and
liver bile. Distention and inflammation of ducts, pancreatitis.
S+S: jaundice, deranged LFTs, upper abdominal pain,
epigastric pain radiating to back.

mnx - ERCP

Question 13

intestinal obstruction

Answer 13

Adynamic: pseudo-obstruction, no clear obstruction, ↓
findings on examination. Examples – mesenteric vascular
occlusion, paralytic ileus.
Dynamic: clear blockage, absolute constipation, ↑
peristalsis. Intraluminal – foreign body, fecal impaction,
gallstones, bezoar. Intramural – inflammation, strictures,
malignancy. Extraluminal – volvulus, malignancy, obstructed
hernia, intussusception, adhesions, and bands.
Pathophysiology:
Proximal: ↑ peristalsis, dilation/distention of gas and fluid,
reduces strength of peristalsis, alters motility,
leads_to_flaccidity_and_paralysis.
Distal: normal bowel motility.
Cardinal S+S: vomiting, constipation, central abdominal
pain, tinkling bowel sounds.
General management: NG tube, NBM, IV fluids, laparoscopy.
Investigations:erect_AXR.
Small bowel obstruction: no/minimal gas, central and
transverse, straight segments, ileum is featureless, jejunum
has_ladder(valvulae_conniventes).
Large bowel obstruction: haustral folds (incomplete lines),
caecum is a large, rounded gas shadow in the RIF.
Investigation_clues:
Strangulation: ↑ amylase, ↑ LDH, ↑ WCC, hyperkalemia.
Dehydration: ↑ urea, ↑ hematocrit, 2O polycythemia.
Fever causes: abscess, ischaemia, perforation, inflammation.
Hypothermia causes: septicemia.

Question 14

volvulus

Answer 14

Pathophysiology: larger mesentery in sigmoid so easily
twists on own axis.
Management: pass flexible or rigid sigmoidoscopy and flatus
tube, keep for 24h, consider elective sigmoid colectomy if
fails.

Question 15

intussuception

Answer 15

Pathophysiology: proximal bowel enters the distal lumen,
typically a lead point – lipoma, polyp, tumour.
S+S: severe colicky pain, sausage lump, empty RIF, red
currant jelly stool, blood-stained finger on PR.
Management: hydrostatic reduction with enema, manual
push.

Question 16

upper gi haemorrhage

Answer 16

Causes: malignancy, peptic ulcer, oesophageal varices,
Mallory-Weiss tear, duodenitis, gastritis/gastric erosions,
drugs (NSAIDs, steroids, aspirin, anticoagulants,
thrombolytics).
S+S: ↓ GCS, hematemesis, melaena, weight loss,
tachycardia, ↓ urine output, clammy/cool, encephalopathy,
hypotension.
Investigations: FBC, LFT, U&E, clotting, crossmatch, ABG,
CXR, ECG, urgent endoscopy.
Management:
Acute: high flow oxygen, 2 large-bore cannula, correct
clotting abnormalities (FFP, vitamin K, platelets), fluids,
transfuse if Hb <70, catheterize, calculate Rockall score,
endoscopy and if fails surgery or mesenteric angiography/
embolization.
General: monitor hourly (CVP, BP, pulse), assess rebleed risk
(high = NBM).

Question 17

gastrooesophageal varices

Answer 17

Pathophysiology: submucosal venous dilation secondary to
↑ portal pressures.
Causes:
Pre-hepatic: thrombosis (portal/ splenic vein).
Intra-hepatic: cirrhosis, schistosomiasis, congenital hepatic
fibrosis,_myeloproliferative,_sarcoid.
Post-hepatic: veno-occlusive disease, right heart failure,
constrictive pericarditis, Budd-Chiari.
Risk factors: variceal wall, ↑ portal pressure, advanced liver
disease, large variceal size.
Management: IV terlipressin and broad antibiotics.
Primary prophylaxis: propranolol (selective β-blocker),
endoscopic_banding_or_sclerotherapy.
Secondary prophylaxis: banding, non-selective β-blocker,
transjugular intrahepatic porto-systemic shunt.

Question 18

peptic ulcer bleed

Answer 18

PEPTIC ULCER BLEED
Management: treat H. pylori if positive, PPI. If high risk –
endoscopic hemostasis.

Question 19

lower GI haemorrhage

Answer 19

Investigations: mesenteric angiography, colonoscopy.
Management: 2 large-bore IV cannula, IV fluids/bloods,
withhold anticoagulants, correct coagulopathy, hemostasis
via colonoscopy

Answer 20

Pathophysiology: disrupted and dilated anal cushions
(usually contribute to anal closure) which are attached by
smooth muscle and elastic tissue. Become painful when they
thrombose or when venous return is blocked. Can protrude
(piles), and if anus is too tight can lead to increased
congestion, hypertrophy and further protrusion, eventually
strangulates.
S+S: bright red PR bleed, anaemia, pruritis ani, mucous
discharge.
Causes: constipation with prolonged straining, congestion
(portal hypertension, pregnancy, congestive cardiac failure,
pelvic tumour).
Investigations: flexible sigmoidoscopy, colonoscopy, rigid
speculum.
Classification: 1st degree = in rectum, 2nd degree = only
prolapse when defecating, 3rd degree = prolapse when
defecating and manually reduce, 4th degree = persistently
prolapsed.
Management:
General: ↑ fluid and fiber intake, topical analgesic,
short_term_topical_steroid.
Prolapsed and thrombosed: analgesia, ice packs, stool
softeners,_self-resolves_in_2-3w.
Non-surgical: rubber band ligation (ulcer to anchor to
mucosa, low recurrence, SE: bleeding, infection, pain),
sclerosants (injected to get fibrotic reaction, SE: prostatitis,
impotence), infra-red coagulation (coagulates vessels and
tethers mucosa to subcutaneous tissue), bipolar diathermy
and direct current electrotherapy (coagulation and fibrosis).
Surgery: excisional hemorrhoidectomy (most effective),
stapled hemorrhoidopexy (↓ pain, ↓ stay, quicker return to
normal, higher recurrence). Complications – infection,
stricture, bleeding, constipation.

Question 21

neoplastic lower gi haemorrhage

Answer 21

Pathophysiology: mucosal defects on tumour surface, colon
polyps, colorectal cancer.
S+S: occult, painless, intermittent

Question 22

intra abdominal abscess

Answer 22

Causes: acute appendicitis (pelvic), sigmoid diverticulitis
(paracolic), severe acute cholecystitis, upper GI perforation
(subphrenic), post-anastomotic leakage, infected acute
pancreatitis (parapancreatic), post-trauma.
S+S: malaise, anorexia, constant localized abdominal pain,
tachycardia, localized mass, swinging fever (peaks BD).
Investigations: CRP, U&E, FBC, G&S, helical CT scan, pelvic
USS.
Management:
Emergency: IV morphine, IV antibiotics if septic, large bore
IV access, if hypotensive catheterize and fluid balance.
Definitive: Causes: acute appendicitis (pelvic), sigmoid diverticulitis
(paracolic), severe acute cholecystitis, upper GI perforation
(subphrenic), post-anastomotic leakage, infected acute
pancreatitis (parapancreatic), post-trauma.
S+S: malaise, anorexia, constant localized abdominal pain,
tachycardia, localized mass, swinging fever (peaks BD).
Investigations: CRP, U&E, FBC, G&S, helical CT scan, pelvic
USS.
Management:
Emergency: IV morphine, IV antibiotics if septic, large bore
IV access, if hypotensive catheterize and fluid balance.
Definitive: radiologically guided via uss or ct, open surgical drainage

Question 23

cellulitis

Answer 23

CELLULITIS
Pathophysiology: acute infection of dermis and
subcutaneous tissue.
S+S: pain, erythema, oedema, warmth, well-defined border,
temperature, tachycardia, typically lower limb.
Investigations: USS, swab, FBC, U&E.
Management: antibiotics, elevate affected part.
Complications: infectious myositis, osteomyelitis,
necrotizing fasciitis, soft-tissue abscess

Question 24

nec fasc

Answer 24

Pathophysiology: rapidly progressive necrotizing soft tissue
infection, spreads along fascia, typically fatal, rare.
Organisms: polymicrobial, staphylococcus aureus,
clostridum difficle.
S+S: foul grey dish water exudate, friable superficial fascia,
hypotension, crepitus, fever, skin necrosis and bullae, acute
onset severe pain, erythema, oedema.
Investigations: FBC, U&E, swabs, MRI.
Management: broad spectrum antibiotics (clindamycin,
benzylpenicillin), prompt surgical fasciotomy, aggressive
debridement of necrotic tissue, amputation.

Question 25

stoma complications

Answer 25

Early: ischaemia, hemorrhage, high output (hypokalemia),
obstruction, adhesions, retraction.
Late: site dermatitis, intussusception, parastomal hernia,
psychological problems, obstruction, stenosis, fistulae,
prolapse.

Question 26

urinary obstruction

Answer 26

Management:
Pyeloplasty: widen PUJ for idiopathic PUJ obstruction.
Nephrostomy/ureteric stent: common side effects – fever,
hematuria, infection, trigonal irritation, tissue inflammation,
biofilm formation, encrustation, significant discomfort (αblockers reduce ureteric spasm). Rare complications – tissue
hyperplasia, ureteric rupture, obstruction, kinking, stent
misplacement, stent migration.
ACUTE
S+S: loin to groin pain, loin tenderness, enlarged kidney,
superimposed infection.

Question 27

acute renal failure

Answer 27

Investigations: U&E (hyperkalemia, ↑ urea, ↑ phosphate,
↓ chloride, ↓ sodium, ↓ calcium), VBG (potassium), fluid
balance, lactate, daily creatinine (↑), urine-dip, USS (small =
CKD, asymmetry + renal vascular disease), platelets (↓
?HUS/TTP), LFT, clotting, ECG, intrinsic renal disease – autoantibodies, immunoglobulins, complement, paraproteins.
Management: find and treat underlying cause. Monitor fluid
balance and electrolytes, especially hyperkalemia. If
acidosis, consider renal replacement if delayed effect of
treatment.
Renal referral: hypertension, due to intrinsic renal disease,
stage 3, complications, not responding to treatment, difficult
fluid balance (HF, pregnancy, hypoalbuminemia)

Question 28

Pneumonia

Answer 28

Pathophysiology: acute LRTI associated with fever, S+S in
chest and CXR abnormalities. 21% mortality in hospital.
Epidemiology: ↑ incidence in very young or old.
Organisms in immunocompromised: CMV, pneumocystis
jirovecii, strep pneumoniae, H influenzae, M pneumoniae,
staph aureus.
S+S: confusion, cyanosis, pleural rub, tachycardia, signs of
consolidation (↑ vocal resonance, bronchial breathing, dull
percussion, ↓ expansion), anorexia, cough, dyspnoea,
hemoptysis, fever, rigors, malaise, pleuritic pain, purulent
sputum.
CURB-65: assess severity. Confusion (AMT <9), Urea >7, RR
>29, BP <60/90, age ≥65.
Investigations: FBC, U&E, LFT, CRP, atypical organism/viral
serology, urine (legionella/pneumococcal antigens), ABG,
pleural fluid aspiration and culture, sputum culture, CXR
(infiltrates, pleural effusion, cavitation), ± bronchoscopy and
bronchoalveolar lavage if ITU/immunocompromised.
Management: antibiotics, ± fluids, analgesia e.g.
paracetamol, oxygen PRN, CPAP if hypoxic and not
responding to oxygen, ventilation if hypercapnic.
Pneumococcal vaccine: every 5y, CI: pregnancy, lactation,
pyrexia, previous anaphylaxis to vaccine or components. For
at risk groups – >64yo, immunosuppression, diabetes
mellitus not controlled by diet, chronic heart, liver, renal or
lung conditions.

Question 29

aspiration pneumonia

Answer 29

Seen in: ↓ consciousness (post-ictal, intoxicated), stroke,
bulbar palsy, myasthenia, poor dental hygiene, oesophageal
disease (reflux, achalasia).
Organisms: strep pneumonia/ anaerobes.
Management: cephalosporin and metronidazole IV.

Question 30

HAP

Answer 30

HOSPITAL ACQUIRED PNEUMONIA
Pathophysiology: >48h after admission.
Organisms: commonly gram negative enterobacteria or
staphylococcus aureus, can be pseudomonas, klebsiella.
Management: PO co-amoxiclav (alt: doxycycline) if nonsevere, IV tazocin (alt: meropenem) if severe, plus IV
vancomycin if MRSA.