General Surgery Key Flashcards

Question

10 ◙ Prolonged Redness around the areola. Hx of using antibiotics which may improve symptoms slightly. Greenish fluid is aspirated from the breast.

Answer 1

Periductal mastitis. 11 ◙ Persistent nipple discharge that is non-bloody and occasionally milky or serous fluid. It is spontaneous. No breast masses. No Nipple retraction. No skin changes. → Mamillary duct fistula (abnormal connection between lactiferous ducts of the breast and skin surface → leads to spontaneous nipple discharge that is not purulent nor bloody. It can appear as a milky or serous fluid).

Answer 2

: → The development of painful fluctuating swelling + fever → indicates a formation of an abscess. → Local Exploration is required. Sometimes followed by → Antibiotics + Drainage.

Answer 3

In a patient with recurrent attacks of biliary colics who presents complaining of right upper quadrant pain → Repeat the U/S as he might be in another attack of biliary colic.

Answer 4

◙ Biliary colic is when a colic (sudden pain) occurs due to a gallstone temporarily blocking the cystic duct. Typically, the pain is in the right upper part of the abdomen. Pain usually lasts from one to a few hours. Often, it occurs after eating a heavy meal, or during the night. Repeated attacks are common. Gallstone formation occurs from the precipitation of crystals that aggregate to form stones. The most common form is cholesterol gallstones. ◙ Cholecystitis is associated with fever + high WBCs ± Peritonitis (Inflammatory elements) as there might be bacterial infection due to the permanent obstruction of the cystic duct by a stone. On the other hand, Biliary colic does not have this inflammatory component as the obstruction is transient (Temporary). ◙ In both cases → Abdomen U/S.

Answer 5

Ultrasound: A Gallstone impacted in the neck of the gallbladder and leading to cholecystitis. + Gallbladder wall thickening. Important Note: ERCP is now rarely done without a therapeutic intent.

Answer 6

◙ Hypocalcemia: Damage or removal of parathyroid glands → Hypoparathyroidism → Hypocalcemia. ♠ Hypocalcemia Features → Tingling of lips and fingertips “initial” SPASMODIC **Neuronal Hyperexcitability** Spasms, Perioral Paraesthesia, Anxious, Seizures, Muscle tones increased in smooth muscles, Orientation impaired and confusion, Dermatitis, Impetigo Herpetiform (rare and serious), Chvostek’s sign, Carpopedal Spasm, Cardiomyopathy (prolonged QT interval on ECG). - Trousseau’s signs → after occlusion of brachial artery → wrist flexion - Chvostek’s sign → Tapping over parotid (Facial nerve) → twitching of facial muscles. • Rx → give 10 ml of 10% Calcium Gluconate (initially).

Answer 7

- Soon after the operation (in the first 24 hours) → Airway Obstruction. - Rx → Open the surgical incision to evacuate the hematoma.

Answer 8

• Unilateral Injury to the Recurrent laryngeal nerve → Hoarseness of voice • Bilateral Injury to the Recurrent laryngeal nerve → Aphonia and Airway obstruction. • Injury to the External branch of (superior) laryngeal nerve → Loss of high- pitched sound = (Dysphonia) = (Mono-toned voice).

Answer 9

Due to manipulation of the thyroid gland during a surgery in a patient with hyperthyroidism. ♠ Features: • Tachycardia, palpitation, High body Temperature, Diarrhea, Vomiting reduced consciousness, Tremors. ♠ Treatment: - Beta-blockers (Propranolol) → To control Tachycardia and Tremors. - High dose steroids → it inhibits the conversion of T4 to T3 Wound Infection (rare: 1-2%)

Answer 10

◙ Acute Mesenteric Ischemia ♠ The resulted Gangrene is Irreversible. ♠ Rx → O2, IV fluids, Analgesics, Antibiotics → then, Urgent Surgery. ♠ From its name “Acute” → Sudden onset of SEVERE abdominal pain and tenderness which exceed the physical signs. ♠ Also, Abdominal distension + Absent Bowel Sounds. ♠ Again, from its name “Acute”, there is something that has caused this abruptly, likely AF has caused emboli to occlude the blood supply of a large segment of the mesentery. Another possibility is that a patient with myocardial ischemia has developed Hypotension which has caused low blood reaching the mesentery. ♠ VBG → High Lactate (↑ lactate).

Answer 11

♠ Transient interruption of the blood supply to the colon. ♠ “Gradual Onset – Over Hours”. ♠ Abdominal pain and tenderness that are moderate to severe but not as severe as in acute mesenteric ischemia. ♠ The cause is multifactorial e.g. Heart failure, shock, MI. ♠ Pain usually starts at the left iliac fossa. ♠ ± Bloody diarrhea. ♠ Rx → Conservative or Surgical.

Answer 12

Acute Mesenteric Ischemia Ischemic Colitis 1. Sudden onset Onset is gradual over hours 2. VERY SEVERE pain and tenderness. Moderately Severe. 3. Hx of AF. AF → embolization to superior mesenteric artery → acute mesenteric ischemia. Multifactorial (transient interruption of blood supply) e.g. HF ▐ MI leading to HF - Usually starts at left iliac fossa 4. VBG → High Lactate (↑ lactate). ± Bloody diarrhea. 5. Rx: Urgent Surgery Conservative or Surgical

Answer 13

→ Reduce the O2. This is a case of hyperoxemia (Excess of O2 with Low CO2 due to rapid O2 delivery via the oxygen mask).

Answer 14

1.Strong Family History of breast cancer. 2. Inherited Mutations in Breast Cancer Susceptibility genes (BRCA1 and/or BRCA2). These genes are Autosomal Dominant. 3. √ imp. Previous breast cancer in one breast. 4) Biopsy that shows → Lobular Carcinoma in Situ and/or atypical hyperplasia.

Answer 15

√ Mammogram is offered for all women aged 50-70 YO every 3 years. √ If there is a strong family history or BRCA mutations → Mammogram should be carried out on Women aged 40-70 every year (Annually).

Answer 16

Do not forget: Prophylactic bilateral Mastectomy/ Oophorectomy can be offered if the patient has Strong FHx of cancer and genetic markers of that cancer.

Answer 17

. Other Notes on Breast: followed by Core biopsy. (Core takes entire ♠ Paget’s disease or Skin changes → Punch Biopsy. (Punch takes parts of the skin changes). ♠ Suspicious Breast lump → FNA tissues not only cells as in FNAC) ♠ Ductal Papilloma (Bleeding per nipple in 20-40 YO ♀) → Galactogram. ♠ Fibroadenoma (firm, non-tender, mobile beast mass in a young ♀) + FNA → Clinical + Ultrasound ♠ ♀ < 35 YO → Ultrasound. ♠ ♀ > 35 YO → Mammogram.

Answer 18

• 50-70 YO → Mammogram every three years. • If strong Family Hx, BRCA genes → 40-70 YO Annually.

Answer 19

→ Intra-abdominal bleed. It is likely a case “Reactionary” haemorrhage. Remember that: • Primary Hemorrhage → bleeding during the surgery. • Reactionary Haemorrhage → bleeding within 24 hours after an operation usually due to slipping of ligatures/ dislodgement of clots/ warming up of the patient leading to a rise in BP into normal. Example: Bleeding while in the recovery room. This needs resuscitation with IV fluids and if heavy, packed RBCs + Surgical re- exploration. • Secondary Haemorrhage → 1-2 weeks post-op (Usually related to infection) Note that, Appendectomy does not have anastomosis! Just removal.

Answer 20

→ Fibrocystic changes [Fibroadenosis] (Benign).

Answer 21

Another Histological Description of Fibroadenoma that is frequently asked → A well circumscribed lump with clear margins and separate from the surrounding fatty tissue. There are overgrowths of fibrous and glandular tissue. • Or: duct-like epithelium surrounded by fibrous bridging.

Answer 22

→ Hamartoma (Benign).

Answer 23

→ Paget’s disease. (Rare Malignant)

Answer 24

→ Breast cancer (The commonest form of breast Malignancy)

Answer 25

◙ However, in the UK, because of the fear of UTI and urinary sepsis that might be caused by a long-time placed urinary catheter, it is recommended that the catheter is removed as early as possible (within 24-48 hours post-op) sometimes immediately in small operations. ◙ The patient is then instructed to report any discomfort during voiding, feeling of bladder fullness, inability to void, urinary retention and so on Sometimes these symptoms can occur as a result of using epidural analgesia during the operation (e.g. in Caesarean section). ◙ If any of these symptoms develop, is performed to measure the Post Void Residual Volume (PVRV) “the amount of urine remaining in the bladder after one urinates”. ◙ If PVRV is > 500 ml → Re-insert a urine catheter. BLADDER SCAN Bladder Scan ◙ Thus, in a post-op patient who has received epidural analgesia and now complains of inability to void/ Feeling of fullness → Perform measure PVRV and decide on re-inserting the urine catheter accordingly).

Answer 26

♠ If there is nothing wrong with the urinary catheter and the patient is hypotensive and oliguric → (Iv fluid challenge There might be internal Bleeding or Acute renal injury)!

Answer 27

The likely Dx → Anorectal Abscess Management → Incision + Drainage + Antibiotics Anorectal abscesses tend to develop in patients with DM, Immunocompromised (e.g. prolonged steroids intake), Crohn’s disease.

Answer 28

→ Fibroadenoma.

Answer 29

Axillary Lymph nodes clearance (removal) during radical mastectomy can lead to → Upper Limb Lymphoedema (Redness and Swelling) + Frozen shoulder. Rx → Physiotherapy and arm exercise.

Answer 30

◙ Superficial = Simple = Low Fistula → Lay Open (Fistulotomy). ◙ Deep = Complex = High = Fistula that crosses internal and external sphincters → Seton Suture, Ligation of inter-sphincteric fistula tract

Answer 31

• Benign. • The commonest breast tumour in Adolescence and Young women. • Firm, Painless “Non-tender”, Mobile. • Some of them are extremely mobile that they can slip between the examining fingers and are thus called “Breast mice”. • Dx → Clinical + U/S + FNAC

Answer 32

Pre-op Management of DM 2 (on oral hypoglycemics): • If Major surgery → Stop oral hypoglycemic before surgery. • If Minor surgery → Continue the same routine. Pre-op Management of DM 1 (on insulin): • If Major surgery → Start sliding scale IV insulin before surgery and continue until diet per-mouth is re-established. ♠ Another possible Answer for PLAB 1: → Start IV Insulin, Dextrose and Saline pre-op. • If Minor surgery: Omit insulin on the day of the surgery. In all cases, restart the previous regimen when per mouth diet is re- established + Check Blood glucose 4 hourly

Answer 33

32 ◙ No gastric Bubbles → Oesophageal Atresia. ◙ Single Bubble → Gastric/ Pyloric Atresia. ◙ Double Bubbles (Double bubble sign: Oesophagus + Stomach) → Duodenal Atresia. ◙ Triple bubble sign → Jejunal Atresia.

Answer 34

. ◙ RFx of Inguinal Hernia → Male sex, Lifting heavy objects, old age, chronic cough, previous abdominal surgery. ◙ Indirect inguinal hernia → Passes through the deep and the superficial inguinal ring (Passes through the entire length of the inguinal canal) and lies LATERAL to the inferior epigastric artery. ◙ Direct inguinal hernia → Passes through the Posterior wall of the inguinal canal “directly” and lies MEDIAL to inferior epigastric artery. It does not pass through the deep and then the superficial ring of the inguinal canal as the indirect hernia does

Answer 35

post-operative complications. ◙ One of the known ◙ Manipulation and handling of the bowel loops during an intra-abdominal operation → bowel stops functioning “No motility”. ◙ Causes other than surgery → Electrolyte imbalance (HYPOKALEMIA, HYPERCALCEMIA), Anti-cholinergic, Post-trauma, Opiates, Peritonitis, Immobilisation. ◙ Important, even if it is not an abdominal operation (e.g. Hip joint replacement), the prolonged immobilisation alone can cause paralytic ileus.

Answer 36

◙ Features → √ Abdominal Distension “bloating”, No passage of flatus “gases”. √ Absent Bowel Sounds. √ Nausea, Vomiting. √ Percussion → Hyperresonance. ◙ What to do Next? → Abdominal X-ray. ◙ Erect Abdominal X-ray → Gases/ air-fluid levels/ dilated small loops Note, in mechanical obstruction → Noisy (high-pitched) bowel sounds + more intense abdominal pain. ◙ Rx of paralytic ileus → NGT + IV fluids. (Drip and Suck) ♠ Insertion of Nasogastric tube → deflate the gases and sucks the fluids and thus relieve the distension, nausea and vomiting.

Answer 37

→ Fat Necrosis

Answer 38

3 ◙ Hx of Trauma to the Breast (redness or bruises around the lump) + firm, round, solitary and localized lump → Fat Necrosis 4 ◙ Bleeding per nipple in 20-40 YO ♀ ± skin changes → Ductal Papilloma 5 ◙ Bleeding discharge per nipple in an Old woman with eczema-like changes in the nipple ± areola ± Ulcers → Paget’s disease (Malignant) 6 ◙ Firm, non-tender, highly mobile mass in a breast of a young ♀ (15-30 YO) → Fibroadenoma 7 ◙ Breast pain (Mastalgia), ↑ breast size, lumpiness (nodularity) of the breast, ♀ in the reproductive age, tend to appear just before or during menstrual cycle and disappear after it → Fibroadenosis. 8 ◙ Fixed, irregular, hard, painless lump ± nipple retraction ± fixed to skin (Peau d’orange) or muscle (+) Local, fixed, firm, axillary LNs → Breast Cancer

Answer 39

10 ◙ Prolonged Redness around the areola. Hx of using antibiotics which improved symptoms slightly. Greenish discharge per nipple. ± nipple retraction ± small lump around the nipple is felt. → Periductal mastitis. (commonly young age, smoking is a risk factor, treated with antibiotics, if left untreated it may develop into an abscess that needs drainage by fine needle) 11 ◙ Persistent nipple discharge that is non-bloody and occasionally milky or serous fluid. It is spontaneous. No breast masses. No Nipple retraction. No skin changes. → Mamillary duct fistula (abnormal connection between lactiferous ducts of the breast and skin surface → leads to spontaneous nipple discharge that is not purulent nor bloody. It can appear as a milky or serous fluid)

Answer 40

◙ Unilateral Injury to the Recurrent laryngeal nerve → Hoarseness of voice. ◙ Bilateral Injury to the Recurrent laryngeal nerve → Aphonia ± Airway Obstruction. ◙ Injury to the External branch of (superior) laryngeal nerve → Loss of high-pitched sound = (Dysphonia) = (Mono toned voice).

Answer 41

: • Proliferation and expansion of the stroma with low cellularity. Or: • A well circumscribed lump with clear margins and separated from the surrounding fatty tissue. There are overgrowths of fibrous and glandular tissue. Or: • Duct-like epithelium surrounded by fibrous bridging.

Answer 42

Itching around the breast + “Greenish” foul nipple discharge → Duct ectasia.

Answer 43

♦ If there is a lump → Think of breast Cyst. ♦ If there is a mention of an association with menstruation → Cyclic Mastalgia. Breast pain (Mastalgia), ↑ breast size, lumpiness (nodularity) of the breast, ♀ in the reproductive age, tends to appear just before or during menstrual cycle and disappears after it → Fibroadenosis.

Answer 44

Even if WBCs and CRP are high, this is expected post-operatively; therefore, all that is needed is to → Repeat WBCs and CRP after 24 hours.

Answer 45

One common regimen: → Cefuroxime (Cephalosporin) “good coverage against Gram +ve and -ve” . Plus: → Metronidazole “Good coverage against Anaerobic bacteria”. ◙ They are given in the first 30 minutes of the first incision made or: √ At the induction of anaesthesia (Important). ♦ In short, for a patient undergoing colectomy, the prophylactic antibiotics → Cefuroxime + Metronidazole.

Answer 46

→ Suspect → Request the hepatic tumor marker → Hepatocellular Carcinoma (HCC) Alpha-fetoprotein (AFP). ◙ Remember that AFP is also a tumor marker for Teratoma

Answer 47

Perianal Abscess ◙ Rx → Incision and drainage (immediately to prevent the development of fistula

Answer 48

. The first step to do is to → Cut the subcutaneous Sutures. This is likely a post-thyroidectomy complication called (Hematoma). It compresses the trachea and causes upper airway obstruction. Cutting the sutures would relieve the pressure and improve breathing. If not → Consider intubation.

Answer 49

◙ For a patient undergoing colorectal surgery, the prophylactic antibiotics → IV Cefuroxime + Metronidazole √ At the induction of anaesthesia ◙ They are given in the first 30 minutes of the first incision made or: (Important).

Answer 50

◙ Abdominal pain that started centrally (Peri-umbilical) then shifted to the Right iliac fossa → McBurney’s sign. Remember that umbilical region and appendicitis share the same dermatome (T10). However, later on when there is peritoneal irritation, the pain will become localised to its origin (Right iliac fossa). ◙ Nausea, Vomiting, Loose stools. ◙ Tenderness, Rebound Tenderness over the Right iliac fossa. ◙ Fever. ◙ High WBCs and CRP. ◙ +ve Rovsing’s sign → applying pressure on the left iliac fossa → pain is felt on the right iliac fossa. ♦ Note: Do not get tricked by a Hx of Pregnancy in a patient.

Answer 51

→ Think of Appendicitis.

Answer 52

For Urinary Bladder cancer → Smoking is the most important risk factor.

Answer 53

→ Elective Laparoscopic Cholecystectomy. Notes: ♦ As there are symptoms (RUQ pain) → Reassurance is wrong. ♦ As he is vitally stable and no signs of perforation → Emergency Laparotomy is wrong.

Answer 54

Acute Mesenteric Ischemia Ischemic Colitis Sudden onset Onset is gradual over hours VERY SEVERE pain and tenderness. Moderately Severe. Hx of AF AF → embolization to superior mesenteric artery → acute mesenteric ischemia. Multifactorial (transient interruption of blood supply) e.g. HF. HF on top of MI. - Usually starts at left iliac fossa VBG → High Lactate (↑ lactate). ± Bloody diarrhea. Rx: Urgent Surgery Conservative or Surgical

Answer 55

→ Acute mesenteric ischemia

Answer 56

→ Ischemic Colitis.

Answer 57

Gradual onset pain + Bloody stools + MI → Ischemic colitis. The question also asked about the site. You need to know that Ischemic Colitis is commonest at the Splenic Flexure as this area has fewer collaterals (called: weak spots/ watershed) The answer is: → Ischemic colitis at the splenic flexure Another correct answer: → ischemia at watershed areas of splenic flexure and rectosigmoid. The stem does not mention signs of flare-up of CD.

Answer 58

The most appropriate Investigation → ULTRASOUND Not FNAC! Ultrasound alone is sufficient to confirm the diagnosis of thyroglossal cyst in the majority of cases.

Answer 59

→ Ductal Fistula (Mamillary Fistula)

Answer 60

→ Pharyngeal pouch (Zenker’s Diverticulum) ♦ Endoscopy is Contraindicated as it may perforate the pouch. Instead, request → Barium Swallow.

Answer 61

Old age + Gradually Worsening Dysphagia (initially for solid food and then for soft food and liquids) + Longstanding Gastric Reflux → Think of Oesophageal Carcinoma. ♦ Diagnosis is made by → Upper GI Endoscopy + Biopsy.

Answer 62

√ a lump or ulcer in the mouth or throat, √ referred otalgia, √ persistent sore throat and painful swallowing, √ in a typically old and smoker patient.

Answer 63

• Swollen cervical LNs → a painless swelling or lump in the upper neck. • Eustachian tube obstruction → Otitis media, Epistaxis “recurrent nose bleeds”, Nasal obstruction. • Others: Conductive hearing loss, Tinnitus. • RFx: EBV (specific), Smoking, Alcohol. N.B: EBV → Hodgkin’s lymphoma, Nasopharyngeal carcinoma.

Answer 64

• Persistent sore throat (over weeks). • Progressive Hoarseness of voice. • Dysphagia and painful swallowing. • Feeling of a persistent lump in the throat. • Palpable lump on the anterolateral portion of the neck. • N.B. the absence of weight loss does not exclude the tonsil cancer! • Tonsillar cancer spreads to → Mandible (important) → Pain in the throat + Trismus (spasm of the jaw muscles, causing the mouth to remain tightly closed).

Answer 65

√ severe trismus (which is lockjaw = spasm of jaw muscles), √ Drippling of saliva, √ Otalgia (as CN IX glossopharyngeal nerve supplies both the ears and tonsils), √ Hot potato voice, √ uvular deviation. √ Red and inflamed bulge (or) swelling beside the tonsil (above and lateral to a tonsil)

Answer 66

√ Iron Deficiency Anemia (IDA), √ Glossitis, √ Dysphagia (due to post-cricoid oesophageal web). It is a risk factor for oropharyngeal carcinoma It is common in postmenopausal women.

Answer 67

√ Bulk-forming laxatives are first-line – if not tolerated then lactulose should be tried. √ Lubricants such as petroleum jelly may be tried before defecation. √ Topical anaesthetics. √ Analgesia.

Answer 68

: √ The above techniques should be continued. √ Topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure. √ If topical GTN is not effective after 8 weeks, then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin.

Answer 69

◙ Direct inguinal hernia → Passes through the Posterior wall of the inguinal canal “directly”. It does not pass through the deep and then the superficial ring of the inguinal canal as the indirect hernia does. So, indirect inguinal hernia passes through the deep inguinal ring

Answer 70

The structure to be pierced → Cricothyroid membrane

Answer 71

If after surgery → “Mechanical bowel obstruction” “due to post-operative adhesions” Chest X-ray would show → multiple air-fluid levels. The next best step → Urgent refer to surgical ward. Imp √ Note, this resembles paralytic ileus. However, in paralytic ileus, bowel sounds are absent. Also, in paralytic ileus, there is usually a Hx of recent abdominal surgery or immobilisation and it is managed by NGT and IV fluid). ◙ In a patient with intestinal obstructions, the emergency team’s role is to deliver IV fluids and analgesics and order X-ray and then to → send the patient to the surgical team. At surgical ward, they can decide whether the patient needs surgery or conservative management.

Answer 72

Think → Cancer head of pancreas

Answer 73

Management of cancer head of pancreas. • In patients without metastasis → Whipple’s resection (Pancreaticoduodenectomy). • In patients with metastasis → palliative ERCP with Stent.

Answer 74

→ Internal oblique muscle and external oblique aponeurosis.

Answer 75

is → Linea Alba

Answer 76

• Colorectal Cancer Screening: √ Fecal Immunochemical Test (FIT). √ 60-74 YO every 2 years in England And 50-74 in Scotland • Breast Cancer Screening: √ (Mammogram). √ ♀ 50-70 YO every 3 years. √ Those with high risk → 40-70 YO annually. • Cervical (Cervix) Cancer Screening: √ (Pap smear: Cytology, HPV) √ 25-49 YO → every 3 years. √ 50-64 → every 5 years.

Answer 77

→ Inguinal Hernia. Note: Only indirect inguinal hernia can descend into the scrotum. Note: Incisional hernias do not exist in scrotum, they develop at the “Incision Site” of a previous wound of surgery.

Answer 78

◙ In breast Abscess, the commonest causative organism is → Staphylococcus aureus. A lady presents with Dry skin around the areola, Itching in the area, Discharge per nipple sometimes bloody → Paget’s disease (do: Punch biopsy). ◙ An old man with abdominal distension and pain, vomiting. O/E, empty rectum and high-pitched exaggerated bowel sounds. (Bowel Obstruction in managed by a Surgical team).

Answer 79

Recurrent laryngeal nerve is a branch of the Vagus nerve (10th CN)

Answer 80

A lady underwent radical mastectomy. Later on, she developed upper limb swelling and redness. The likely Dx → Lymphoedema. Axillary Lymph nodes clearance (removal) during radical mastectomy can lead to (Redness and Swelling) ± Frozen shoulder. → Upper Limb Lymphoedema Rx → Physiotherapy and arm exercise.

Answer 81

79 A 55 YO lady was found to have high glucose in urine after surgery. → Stress Hyperglycemia. Stress hyperglycemia: Post-op or stress or post-trauma or some diseases → high cortisol → high glucose → glycosuria (glucose in urine) This subsides on its own in a few days. What to do next as follow up? FASTING blood glucose phenomenon, we

Answer 82

◙ Elective Surgery: ♠ If Hb is > 10 → Proceed with the surgery ♠ If Hb is between 8-10→ Delay “defer” “Postpone” the surgery and Investigate for the anemia reasons first. ♠ If Hb is < 8 + Symptomatic → Transfuse Blood and also Defer the surgery. ◙ Emergency Surgery: ♠ If Hb is > 10 → Proceed with the surgery ♠ If Hb is between 8-10 → Proceed with the surgery. ♠ If Hb is < 8 → Transfuse Blood and Proceed with the surgery “it is emergency”!

Answer 83

→ Fat Necrosis.

Answer 84

The question asked about the site also, you need to know that Ischemic Colitis is commonest at the Splenic Flexure as this area has fewer collaterals (called: weak spots/ watershed) The answer is: → Ischemic colitis at the splenic flexure Another correct answer: → ischemia at watershed areas of splenic flexure and rectosigmoid. The stem does not mention signs of flare-up of CD.

Answer 85

→ Commence O2 by face mask immediately. (ABC: Airways, breathing, circulation). Remember that (opioid toxicity → ↓ RR -resp. depression-). Here, ↑ RR.

Answer 86

Coiled NGT after Road Traffic Accident → Diaphragmatic Rupture.

Answer 87

Testis cancer → request LDH (lactate dehydrogenase)

Answer 88

A patient is on warfarin and has surgery in a few days → Stop Warfarin and commence LMWH LMWH = Low Molecular Weight Heparin [e.g. fondaparinux, enoxaparin].

Answer 89

Periductal mastitis. (commonly young age, smoking is a risk factor, treated with antibiotics , if left untreated it may develop into an abscess that needs drainage by fine needle

Answer 90

a) b) exploratory laparotomy c) give furosemide D) fluid challenge check the catheter for blockage

Answer 91

Admit for IV antibiotics A. B. Admit for FFP and Vit k C. Discharge home with oral antibiotics D. urgent surgical exploration of wound site Tonsillectomy Complications • 1ry Bleeding (within the first 24 hours) → Return to the theatre may be required. Usually due to inadequate haemostasis, displacement of a tie, loss of eschar. • 2ry or Reactive Bleeding (occurs more than 24 hours post-op = 1-10 days post op, and usually after discharge Usually due to wound infection that leads to vessel erosion; thus, Admit the patient and give IV Antibiotics. (Antibiotics and Antiseptic mouthwashes are also indicated).

Answer 92

Generally: ♠ ♀ < 35 YO → Ultrasound. ♠ ♀ > 35 YO → Mammogram. √ Fine needle aspiration may follow (based on the US result). √ Punch biopsy is for Paget’s disease of the breast (eczema like, Dry skin around the areola, Itching in the area, Discharge per nipple sometimes bloody).

Answer 93

Despite the Hx of breast cancer in mother, the features of the mass and the young age are suggestive of fibroadenoma (young age, MOBILE mass, not attached to the underlying structures). ◙ Firm, non-tender, mobile mass in a breast of a young ♀ (15-30 YO) → Fibroadenoma → Clinical + Ultrasound + FNA

Answer 94

If bowel obstruction occurs due to advanced malignancy or as a complication of chemotherapy, conservative treatment is not an option as in most cases it fails. So, the answer for this question is → C. Palliative colostomy.

Answer 95

Proctoscopy is a scope that visualises the Rectum. Based on the age and the features (blood stained toilet tissues), this is likely a case of internal haemorrhoids (Piles). An episode of passing fresh blood only means that the defect is distal (mostly in the rectum). Because internal haemorrhoids are often too soft to be felt during a rectal exam, your doctor might examine the lower portion of your colon and rectum with an anoscope, proctoscope or sigmoidoscope. Kindly note that if this patient was an old age and with other symptoms such as a change in bowel habits, anemia, abdominal pain → colorectal carcinoma should be among the possible differentials and → colonoscopy is to be done

Answer 96

Likely primary hemorrhage. He is hypotensive. The (initial) = (next) step is IV fluid.

Answer 97

Types of Surgical BleedingG 1. Primary hemorrhage Bleeding at the time of surgery. Rx: Replacing Blood or return to theatre if severe. 2. Reactionary hemorrhage Bleeding within 24 hours after surgery/ Trauma. e.g. a patient bleeding and hypotensive while in the recovery room. Usually due to slipping of ligatures, dislodgement of clots, warming up post-op leading to vasodilatation and rising of BP to normal. Rx: Replacing blood (IV fluids and Packed RBCs if heavy), wound re-exploration. 3. Secondary hemorrhage 1 to 2 weeks post-op Usually due to necrosis of blood vessels related to the previous repair, and precipitated by wound INFECTION. The patient may require admission and IV antibiotics. But in this stem, it asks about the next step. ABC [C = Circulation → correct the low BP by IV fluid NS first. If still low BP → Packed RBCs].

Answer 98

“rectovaginal fistula”. If Not in the options, pick → √ Although the rectum is rarely involved in CD, it is the most common site of fistula (Rectovaginal fistula). √ Ileum is the most common part to be involved in CD; “ileitis” but rarely forms fistula. √ Remember, in males with CD, the fistula is usually between the urinary bladder and the rectum.

Answer 99

√ Above and medial to pubic tubercle. √ Impulse on cough. √ Mostly in Males. ○ Direct inguinal hernia → passes through the posterior wall of the inguinal canal directly. Lies medial to inferior epigastric artery. ○ Indirect inguinal hernia → passes through the superficial and the deep inguinal ring “passes through the whole length of the inguinal canal”. Lies lateral to inferior epigastric artery. Can descend into the scrotum. • These descending into the scrotum will not trans-illuminate and it is not possible to ‘get above’ the swelling. • Cases that are unclear on examination, but suspected from the history, may be further investigated using ultrasound or by performing a herniogram.

Answer 100

Management of Inguinal Hernias (If surgery is required): ◙ First time hernias may be treated by performing an open inguinal hernia repair; the inguinal canal is opened; the hernia is reduced and the defect is repaired. A prosthetic mesh may be placed posterior to the cord structures to reinforce the repair and reduce the risk of recurrence. ◙ Recurrent hernias and those which are bilateral are generally managed with a laparoscopic approach. This may be via an intra or extra peritoneal route. As in open surgery, a mesh is deployed. However, it will typically lie posterior to the deep ring.

Answer 101

√ More common in females. √ Below and lateral to pubic tubercle. √ usually irreducible, and with a high risk of strangulation. √ Careful: Femoral hernias need to be surgically repaired even if asymptomatic!

Answer 102

→ No surgery is required. √ This is likely an inguinal hernia and since it is asymptomatic and particularly, he is old age, no surgery is required as explained in the precious key. √ However, he should be instructed to seek medical advice if symptoms such as pain have developed in the future.

Answer 103

→ Inguinal hernia. Although anatomically, it should be femoral hernia. However, the approach used in radical orchidectomy in adults is the (inguinal) approach. So, this patient has (inguinal hernia). Kindly note that determining the type of hernia by only physical appearance is very difficult and there are conflicting views

Answer 104

→ Pelvic abscess. √ Pelvic abscess has developed here either due to CD or as a post-operative complication. √ Being diabetic increases the risk this complication √ Investigation → CT scan. (important) √ Rx → Drainage + Antibiotics.

Answer 105

The likely Dx → To diagnose? → Internal haemorrhoids “piles”. Proctoscopy or rigid sigmoidoscope. ◙ A man presents with severe pain in anus especially on defecation, blood streaks on the stools and Hx of constipation. The likely Dx → Anal Fissure.

Answer 106

IMPORTANT NOTES: ♠ Haemorrhoids → Blood + Intermittent, bearable “tolerable” pain or painless, splashes of blood. (internal hemorrhoids are usually painless unless they have started to prolapse out). ♠ Perianal Abscess → Throbbing pain, swelling, Usually No blood. ♠ Anal fissure → Intense pain (unbearable), acute pain, streaks of blood.

Answer 107

Very IMPORTANT: What if the patient DID NOT receive pre-splenectomy vaccines? If the patient did not receive pneumococcal vaccine before splenectomy (eg, in emergency splenectomy), the most crucial vaccine to be given post splenectomy (after operation) is → Pneumococcal vaccine. √ Additional notes: √ Pneumococcal and Meningococcal vaccines are also given every 5 years after splenectomy. √ All patients with asplenia or hyposplenia should receive annual influenza vaccine due to the high risk of 2ry bacterial infection. The best time is autumn (October, November) before the onset of the “peak flu season”.

Answer 108

→ Colon or Rectal cancer.

Answer 109

◙ The likely diagnosis → Bleeding diverticulitis. ◙ The most appropriate step → Urgent admission to the surgical ward. ◙ The most appropriate “INITIAL” step → IV fluid (she is hypotensive). In a case of acute diverticulitis “without rectal bleeding”. E.g., there is fever, tachycardia, left iliac fossa pain, tenderness and guarding, Hx of constipation → Start IV antibiotics.

Answer 110

→ Morphine (opiates). √ Morphine overdose can cause all these side effects, including the respiratory depression (low RR). √ Atelectasis, pulmonary embolism and hemorrhage do not present with hypopnea (low respiratory rate).

Answer 111

→ Advise her to take paracetamol. √ • If the pain is unilateral and there are lumps, nodularity, and is related to menstruation, think of Fibroadenosis . •If the pain is bilateral, no lumps, and is related to menstrual cycles, think of cyclical Mastalgia. Breast pain (Mastalgia), ↑ breast size, lumpiness (nodularity) of the breast, ♀ in the reproductive age, tends to appear just before or during menstrual cycle and disappears after it → Fibroadenosis.

Answer 112

A) Recent MI. (within the last 6 months)

Answer 113

Likely primary hemorrhage. He is hypotensive. The (initial) = (next) step is IV fluid.

Answer 114

◙ Old age + Anemia + Weight loss + Right lower quadrant pain/mass → Caecal Carcinoma.

Answer 115

- It usually occurs 5 to 10 days after the surgery. - It presents with severe, generalized abdominal pain and tenderness over the site of the anastomosis + fever + reduced bowel sounds. ± Hypotension. - RFs → DM, smoking, immunocompromised (e.g., prolonged use of steroids such as for RA, Asthma, COPD), rectal anastomosis, peritoneal contamination). Important: Anastomotic leakage can lead to Peritonitis or Intrabdominal abscess which needs → “with contrast”. • Broad spectrum antibiotics should be initiated. CT scan of Abdomen and Pelvis An important risk factor for anastomotic leakage and abscess is → DM.

Answer 116

→ The right colon (Cecum). Iron deficiency anemia (IDA) alone is a common presentation of right-sided colon cancer (as it is wider than the left side, thus usually no symptoms of obstruction until very late). Also, bleeding from the right colon may go unnoticed for a while. On the other hand, left-sided colon cancer (e.g., sigmoid) can present with constipation, abdominal pain, blood in stool as well as IDA. (Not all features have to be present at the same time!). You always need to suspect colorectal cancer in any patient who is Old age + Weight loss ± IDA

Answer 117

→ Refer to the breast clinic to be seen within 2 weeks. (even if she has had mammography recently, the unexplained breast lump can be cancerous and just developed today!). In a breast clinic, triple assessment are done: √ Clinical → History and examination. √ Imaging → U/S (< 35 YO) ▐ Mammogram (> 35 YO). √ Biopsy → FNAC or core biopsy.

Answer 118

◙ If the patient is hemodynamically stable → Pick a non-surgical option (e.g., admit and observe under surgical team). ◙ If the patient is hemodynamically unstable → Exploratory laparotomy ± splenectomy.

Answer 119

. A newly formed ulcer on top of a previous Leukoplakia Think → SCC “Squamous cell carcinoma”.

Answer 120

◙ If haemodynamically unstable → take to theatre (exploratory laparotomy). ◙ If haemodynamically stable (SBP > 90), it depends: √ If young fit male → straight to theatre “laparoscopic appendectomy”. √ If young fit female → do Ultrasound first before taking her to theatre “to rule out gynaecological cause”. √ any gender > 50 YO → CT scan “to rule out cancer as a cause of the symptoms”.

Answer 121

The NEXT step → Ultrasound (before doing laparoscopic appendectomy; to rule out any gynaecological pathology).

Answer 122

◙ Unexplained weight loss + Abdominal pain + Iron deficiency anemia Think → colorectal cancer. ◙ Patients with Ulcerative colitis have a higher risk of developing colorectal cancers. ◙ The most common type of colorectal cancer is → Adenocarcinoma.

Answer 123

→ CT abdomen. √ He likely has ileal Abscess on top of Crohn’s disease. The mass felt on the right abdomen and tenderness along with the elevated inflammatory markers and the gradual worsening pain, all point towards internal right abdominal abscess. √ CT scan would identify the abscess size and location. After that, the surgeons will decide to make image-guided percutaneous drainage or a surgical drainage + broad spectrum antibiotics should be initiated.

Answer 124

→ Cyclical Mastalgia. → Advise her to wear a supportive bra. √ Another valid answer: → Advise her to wear a better fitting bra during the day and a soft support bra at night. √ Another valid answer: → Advise her to take paracetamol. √ √ Oral paracetamol, Ibuprofen or topical NSAIDs can help alleviate the pain. As per NICE recommendations for cyclical Mastalgia, NONE of the following is recommended: stopping COCP, reducing caffeine intake, Primrose oil. √ So, the management of cyclical Mastalgia: Analgesia + Supportive bra.

Answer 125

The likely Dx → “due to morphine” (look for his respiratory depression). CRP is normally high after surgery. If the Dx is infection, RR would be high. Opioid toxicity ◙◙ Opioid toxicity → LOW respiratory rate “the key feature in this stem”, Nausea, Vomiting, fever and Decreased bowel motion that can leads to abdominal distension. ◙◙ Paralytic ileus is a good differential diagnosis here as his criteria are: √ Abdominal Distension “bloating”, No passage of flatus “gases”. √ Absent Bowel Sounds. √ Nausea, Vomiting. √ Erect Abdominal X-ray → Gases/ air-fluid levels/ dilated small loops. However, the presence of respiratory depression makes opioid toxicity more likely the cause, especially that it can also cause nausea, vomiting and decreased bowel motion

Answer 126

- It usually occurs 5 to 10 days after the surgery. - It presents with severe abdominal pain and tenderness over the site of the anastomosis + fever + reduced bowel sounds. - Anastomotic leakage can lead to Peritonitis or Intrabdominal abscess which needs → “with contrast”. - An important risk factor for anastomotic leakage is → DM. - There is no respiratory depression in anastomotic leakage. (Infection would increase the respiratory rate, not depress it)!

Answer 127

The most likely cause of his discomfort → paralytic ileus due to Hypokalemia. In a recent exam, the term: “paralytic ileus” was not given. Hypokalemia was the answer. Remember: one of the common causes of paralytic ileus is electrolyte disturbance, including hypokalemia and hypercalcemia; not hypocalcemia.

Answer 128

The likely Dx → Femoral hernia. ◙ Inguinal Hernia → Impulse on cough, reducible. ◙ Femoral Hernia → rarely impulse on cough (but it can impulse on cough) + Irreducible as the femoral canal is narrow + tends to occur more in females + easy to strangulate (painful and tender) + often irreducible + appear below inguinal ligament.

Answer 129

Acute diverticulitis. The likely Dx → The Most appropriate management? → Start IV antibiotics (after admission). √ Guarding is a sign of peritonitis → it requires admission and IV antibiotics. This patient will need to be kept NPO and IV fluids should be given until surgical review. √ The fact that there is Fever + Acute abdomen + long history of constipation supports the diagnosis of acute diverticulitis. Fever and sepsis are caused by the leakage of the colon content into the peritoneum → Peritonitis. √ Bear in mind that diverticulitis is one of the complications of diverticulosis (which is outpouches of the colon outer wall seen mostly in the sigmoid colon). That is why the tenderness and pain here is in the left iliac fossa (the site of the sigmoid colon). √ When these pouches get stuck with stools → infection occurs → acute diverticulitis (constipation, fever, pain and tenderness in left lower abdomen). √ This would need admission and IV antibiotics. √ NSAIDs eg, ibuprofen should be avoided in diverticulitis (it ↑ perforation).

Answer 130

The likely outcome of acute diverticulitis after treating with IV antibiotics, IV fluids, observation and keeping the patient NPO → Complete resolution (recovery). • Only 20% of acute diverticulitis cases develop complications such as fistula, abscess, bowel obstruction, perforation and or peritonitis.

Answer 131

√ The fever, guarding, high WBCs and CRP suggest the presence of abscess at the site of the surgery “guarding + inflammation = fluid collection”. √ CT scan of the abdomen would identify the abscess size and location. After that, the surgeons will decide to make image-guided percutaneous drainage or a surgical drainage + broad spectrum antibiotics should be initiated. √ ERCP is done when there is a suspected bile leak “usually results after difficult cholecystectomy such as in patients with high BMI, several abdominal surgeries causing adhesions, complications during the surgery”. √ ERCP can both diagnose and treat the bile leak by a stent.

Answer 132

A 60 YO woman presents complaining of blood in her stools for 6 months. She has good appetite. She lost 3 Kg of her weight over the past 6 months. She does not have constipation or abdominal pain. → Refer for Colonoscopy. Age ≥ 50 (+) Unexplained Rectal Bleeding → Colonoscopy. “suspected colorectal cancer” . This patient also has unexplained weight loss despite having good appetite. Eventhough it is a small weight loss, it is still significant for her condition.

Answer 133

• Previous abdominal surgery can lead to adhesions around intestine. • with time, these adhesions can lead to intestinal obstruction. • Manifestations of Intestinal Obstruction: √ Vomiting, √ Colicky abdominal pain, √ Abdominal distension, √ Not passing stools for days (constipation), √ Typanic -resonant- abdominal percussion, √ Hyperactive high-pitched bowel sound on auscultation, √ Erect abdomianl X-ray → air-fluid levels, and distended loops of bowel.

Answer 134

Initial Management: The emergency department (A&E doctors) should: as an initial step to decompress the bowels. √ Resuscitate with IV fluids. √ Give IV analgesics. √ Obtain X-rays. After that, they should refer the patient to the surgical team for further management. (This is because resulting ischemia, strangulation, closed-loop bowel obstruction would require urgent surgery).

Answer 135

The likely Dx → Pulmonary Embolism The investigation of choice → As PE is suspected → guidelines”. CT pulmonary angiogram. start therapeutic dose of DOAC eg, apixaban. “New

Answer 136

• Compression stockings. • “Prophylactic dose SC LMWH eg, enoxaparin”. Nothing is suspected. If there was a suspected PE, a treatment dose is needed. Here, these are just preventative measures. So, “prophylactic” dose not treatment dose. These 2 preventative measures are important especially after a long surgery that would require a patient stay immobile for a while.

Answer 137

? → Encourage early mobilisation.

Answer 138

→ Intermittent pneumatic compression. (Useful after stroke)

Answer 139

→ Packed RBCs. This is heavy reactionary hemorrhage (within the first 24 hours after surgery), which requires: • Resuscitation with IV normal saline. (First). • If still low BP or if the patient had bled heavily → Packed RBCs. • Surgical re-exploration.

Answer 140

→ Femoral hernia. ◙ Inguinal Hernia → ABOVE and Medial (some sources say lateral) to the pubic tubercle. ◙ Femoral Hernia → BELOW and lateral to the pubic tubercle. ◙ Inguinal Hernia → Impulse on cough, reducible ◙ Femoral Hernia → rarely impulse on cough (but it can impulse on cough) + Irreducible as the femoral canal is narrow + tends to occur more in females + easy to strangulate + often irreducible + below inguinal ligament.

Answer 141

• Mild pain at the surgical site is expected after surgery (eg, appendectomy). • As long as the patient’s vital signs and observations are within normal, and the pain is mild, you can discharge the patient with analgesics such as paracetamol and NSAIDs (ibuprofen).

Answer 142

- Example: a few days after stroke (recent stroke), and the patient has started to get swallowing difficulties. We start with NGT feeding as his swallowing might improve with time. So, we feed him via NGT slowly and refer him to SALT (Speech and Language Therapist) who will assess and encourage his swallowing. If no improvement after a few weeks → PEG.

Answer 143

- Example (1): A patient with an old stroke (months) and no improvement of dysphagia or swallowing, and he becomes thin (losing weight). This patient needs a long-term feeding method (PEG). Example (2): A patient with motor neuron disease (MND) with “progressive” difficulty of swallowing. We know that MND is a chronic degenerative progressive disease. So, we do not expect improvement, but deterioration. Therefore, a long-term feeding would be required (i.e., PEG). The examples are important and were asked in previous exams

Answer 144

√ The next of kin (e.g., wife, brother, parents) do not have the legal authority to decide even if the patient lacks metal capacity. √ If the patient who is now lacking mental capacity has an advance directive that states that he does not want to receive a specific intervention such as artificial feeding, doctors should follow his advance directive. ◙ Advance Directive = a living well A legal document in which a patient writes the treatments/ the procedures that he/she does not want to receive if they become unable to make decisions.

Answer 145

1. • The best feeding for him pre-operative → Total parenteral nutrition (TPN) “A temporary method until surgery”. NGT and PEG deliver nutrition to his stomach. Thus, they are not suitable as he has gastric outlet obstruction. Any nutrition directed to his stomach would not pass down to small intestine. 2. • The post-operative method for him would be → Jejunostomy feeding tube (J-tube). This is a plastic tube that would be inserted (during the gastrectomy surgery) through the skin of the abdomen into the jejunum so that that patient would be able to have enteral feeding after surgery. He would not have a stomach and thus he would need a feeding tube directly to his small intestine (jejunum).

Answer 146

• The likely outcome of acute diverticulitis after treating with IV antibiotics, IV fluids, observation and keeping the patient NPO → Complete resolution (recovery). Only 20% of acute diverticulitis cases develop complications such as fistula, abscess, bowel obstruction, perforation and or peritonitis.

Answer 147

A newly formed ulcer on top of a previous Leukoplakia Think → That’s why Leukoplakia should be biopsied. As it is premalignant. Also remember, half the cases of SCC of the mouth have cervical LN metastasis at the time of diagnosis. SCC “Squamous cell carcinoma”.

Answer 148

◙ Pilonidal disease is a type of skin infection which typically occurs as a cyst between the cheeks of the buttocks and often at the upper end. It is an inflammatory skin condition usually in the midline of the natal cleft. ◙ Presentations: √ Asymptomatic (non-tender pits in the natal cleft). √ Acute abscess (painful tender lump with purulent pus). √ Chronic cyst. √ Chronic sinus with persistent discharge. It is often present as painful swelling with occasional discharge in the sacrococcygeal region. It is aggravated by prolonged sitting positions. ◙ Risk factors include obesity, family history, prolonged sitting, greater amounts of hair, and not enough exercise. ◙ The underlying mechanism is believed to involve a mechanical process. The lesions may contain hair and skin debris. ◙ Diagnosis is based on symptoms and examination.

Answer 149

◙ Management: √ If asymptomatic → Wait and watch. √ If Abscess → Incision and drainage (same-day). √ Chronic sinus with persistent discharge → Referral to surgery (general or colorectal surgery unit) for surgical excision (lay open/ closed/ laser).

Answer 150

• While antibiotics can help in treating the infection, they often cannot penetrate the thick wall of the abscess cavity. So, (I & D) is the most appropriate management of perianal abscess. • Warm sitz baths can provide symptomatic relief but do not treat the root cause.

Answer 151

• Offer lifestyle advice on diet and physical activity if: √ BMI: 25-29.9 kg/m2 (overweight) • Orlistat (1ry drug choice) if: √ BMI: ≥ 30 kg/m2 √ or BMI: ≥ 28 kg/m2 with associated risk factors (eg, diabetes, hypertension, dyslipidemia). • Refer to bariatric surgery if: √ BMI: ≥ 40 kg/m2 √ or BMI: 35-40 kg/m2 with associated significant comorbidities (eg, diabetes, hypertension)

Answer 152

After abdominal surgery: Mechanical bowel obstruction can follow surgery especially within weeks to months after abdominal surgery due to post-operative adhesions. It is characterised by high-pitched (noisy, hyperactive) bowel sounds. Paralytic ileus can follow surgery especially within days, not weeks, after abdominal surgery. It is characterised by absent bowel sounds. On percussion → hyperresonance. ◙ In a patient with intestinal obstructions, the emergency team’s role is to insert NGT if needed, deliver IV fluids and analgesics and request X-ray and then to → send the patient to the surgical team. At surgical ward, they can decide whether the patient needs surgery or conservative management.

Answer 153

→ CT scan of the abdomen and pelvis usually with IV contrast”. → CT scan of the abdomen and pelvis

Answer 154

Obstructive Jaundice = choledocholithiasis: It results when stones form in the gallbladder Acute and then pass into the common bile duct (CBD), where they may become lodged and cause obstruction. • Occurs frequently during pregnancy. • Presents with: √ Right Upper Quadrant Pain (sometimes with epigastric pain) “the pain is often colicky and related to meals” + √ Obstructive features ► Jaundice, Dark urine, and Pale stools, (and ↑ ALP = serum ALkaline Phosphatase). • The most appropriate investigation → Ultrasound of the Abdomen → as it will most likely show the CBD stones” Choledocholithiasis”

Answer 155

Why not pancreatic cancer? → The epigastric pain in this stem is colicky and related to meals, which is more typical of conditions involving liver or gallbladder. On the other hand, the abdominal pain in pancreatic cancer is more constant “not related to meals”, deep-seated, and chronic. ◙ Why not primary biliary cirrhosis? → Around 50% of patients with primary biliary cirrhosis are asymptomatic. If symptoms present, they usually start with fatigue and pruritus “itching”. Obstructive jaundice may present but it is a “late” sign. ◙ Why not primary sclerosing cholangitis (PSC)? → The predominant features of PSC are → jaundice, steatorrhea “fatty stool”, pruritus, and weight loss. Here, noting but jaundice is present.

Answer 156

→ Think: Anastomotic leak → Perform: CT scan of abdomen and pelvis with contrast.

Answer 157

. → Think: Paralytic ileus. → Perform: Erect Abdominal X-ray → (Gases/ air-fluid levels/ dilated small loops). Remember: One of the common causes of paralytic ileus is electrolyte disturbance, including hypokalemia and hypercalcemia; not hypocalcemia.

Answer 158

Thoracic outlet syndrome (TOS): A condition in which there is compression of the nerves, arteries, or veins in the superior thoracic aperture, the passageway from the lower neck to the armpit, also known as the thoracic outlet. • There are three main types: neurogenic, venous, and arterial. • The neurogenic type (compressing brachial plexus → mixed nerve symptoms) is the most common and presents with pain, weakness, paraesthesia (numbness), and occasionally loss of muscle at the base of the thumb (thenar muscles). It presents gradually, and it is unilateral. • The venous type results in swelling, pain, and possibly a bluish coloration of the arm

Answer 159

• The arterial type results in pain, coldness, and pallor of the arm. • TOS may result from trauma, repetitive arm movements, tumors, pregnancy, or anatomical variations such as a cervical rib. • The diagnosis may be supported by nerve conduction studies and medical imaging. TOS is difficult to diagnose and there are many potential differential diagnoses as well as other diseases that are often co-occurrent with TOS. • Initial treatment for the neurogenic type is with exercises to strengthen the chest muscles and improve posture. NSAIDs such as naproxen may be used for pain. Surgery is typically done for the arterial and venous types and for the neurogenic type if it does not improve with other treatments . Blood thinners may be used to treat or prevent blood clots.

Answer 160

→ Thoracic outlet obstruction. There are some key points to remember for thoracic outlet syndrome: √ Unilateral. √ Presents gradually. √ weakness and atrophy may be seen in the thenar muscles (innervated by the median nerve) particularly abductor pollicis brevis. √ It can involve the muscles that are innervated by the ulnar nerve “eg, in the forearm”. √ Pain and or numbness in the hand or forearm, commonly affecting the ulnar side. √ Sometimes: pulsatile mass below clavicle or in the supraclavicular area. Also: depending on which neurovascular structures are involved, it may be seen together with a weak radial pulse, forearm cyanosis (bluish), and or thenar muscle weakness. (may or may not).

Answer 161

Colonoscopy Sigmoidoscopy). Next Step → (or if not in the options → √ This is to visualise colon/ sigmoid and take biopsy for histopathology to confirm or exclude colorectal cancer. √ CT scan is important for staging, but it is not the next step for rectal masses.

Answer 162

). • LMWH (low molecular weight heparin) eg, enoxaparin >>> recommended for VTE prophylaxis after major abdominal surgeries eg, cholecystectomy, open colectomy when the patient has a risk factor or will be immobilized for a long time postoperatively. DOACs (direct oral anticoagulants) eg, dabigatran, rivaroxaban, apixaban, edoxaban >>> recommended for VTE prophylaxis in medical patients or after orthopaedic surgeries eg, hip or knee replacement when the patient has a risk factor or will be immobilized for a long time postoperatively

Answer 163

) Colonoscopy. (To rule out colorectal carcinoma). Next step → • +ve FIT indicates occult blood in stools, suggesting GI bleeding. • Even if there are no symptoms or weight loss, we need to rule out colorectal cancer in elderly people who have iron deficiency anemia and positive FIT.

Answer 164

Answer → The patient’s symptoms of progressive jaundice, dark urine, pale stools, and significant weight loss are indicative of an obstruction in the biliary system, most likely caused by a malignancy. The palpable, non-tender mass in the right upper quadrant is a key finding that helps narrow down the diagnosis. Let's evaluate each option: • A. Hepatocellular carcinoma: This type of cancer is typically associated with underlying liver conditions such as cirrhosis or hepatitis. It can cause jaundice, but the presence of a palpable mass would more commonly be in the setting of diffuse liver involvement rather than a solitary mass causing biliary obstruction without significant liver disease history. • B. Pancreatic cancer: Pancreatic cancer, especially when it involves the head of the pancreas, is known to cause obstructive jaundice due to its location near the bile duct. This can lead to symptoms such as dark urine, pale stools, and significant weight loss. A palpable mass in the right upper quadrant further supports this diagnosis, as it may represent the enlarged head of the pancreas or an associated lymph node. • C. Primary sclerosing cholangitis: This condition usually presents with chronic liver disease symptoms and is commonly associated with inflammatory bowel disease. It does not typically present with a palpable mass or such rapid weight loss in the absence of advanced disease complications. • D. Chronic pancreatitis: Chronic pancreatitis often presents with recurrent abdominal pain, and while it can cause jaundice, it is not usually associated with a palpable mass in the absence of a pseudocyst or significant fibrosis. The lack of pain in this patient makes this diagnosis less likely.

Answer 165

• E. Cholangiocarcinoma: This is a cancer of the bile ducts and can cause symptoms similar to pancreatic cancer. However, it is less likely to present with a palpable mass unless it is very advanced or has caused significant enlargement of nearby structures. Given the clinical presentation of jaundice, dark urine, pale stools, significant weight loss, and a palpable right upper quadrant mass, the most likely diagnosis is B. Pancreatic cancer. The involvement of the head of the pancreas can lead to bile duct obstruction, causing the described symptoms. The absence of pain is also consistent with pancreatic cancer, which can often present insidiously until it causes significant biliary obstruction

Answer 166

Answer → B. (No treatment is necessary). The patient's presentation of intermittent, mild lower abdominal discomfort led to the incidental finding of third-degree hemorrhoids during the examination. The hemorrhoids have been present for years without causing pain, bleeding, or other symptoms, and the patient denies any significant changes in her health. Third-degree hemorrhoids are those that prolapse with straining and require manual reduction. The appropriate management focuses on addressing any potential for future symptoms while avoiding unnecessary treatment. Management Options: • A. Surgical excision: This is a treatment option for severe hemorrhoids that are symptomatic and have not responded to less invasive treatments. Given the patient’s lack of symptoms, surgical excision would be unnecessary and too aggressive. • B. No treatment is necessary: Since the hemorrhoids are asymptomatic and the patient has no complaints related to them, conservative management is appropriate. This option focuses on observation and lifestyle modifications to prevent future issues, such as increasing fiber intake and ensuring proper hydration.

Answer 167

C. Hydrocortisone cream: This treatment is typically used to reduce inflammation and discomfort in symptomatic hemorrhoids. Since the patient is not experiencing symptoms, hydrocortisone cream is not necessary. • D. Oral corticosteroids: These are not used for the treatment of hemorrhoids. They are more appropriate for inflammatory conditions and are not indicated here. • E. Rubber band ligation: This minimally invasive procedure is used for symptomatic hemorrhoids, particularly those that prolapse. It involves placing a rubber band around the base of the hemorrhoid to cut off its blood supply, causing it to fall off. While effective, it is typically reserved for symptomatic hemorrhoids. Most appropriate management: B. No treatment is necessary is the most appropriate choice in this scenario. The patient's third-degree hemorrhoids are not causing any discomfort or other symptoms, so invasive treatments or medications are not required. Instead, advising the patient on lifestyle modifications, such as increasing fiber intake and proper hydration, can help prevent any future symptoms. Regular follow-up can ensure that any potential future issues are promptly addressed. Remember: No matter how terrible the hemorrhoids look, they need no treatment until symptomatic.

Answer 168

Correct answer → E) Superficial thrombophlebitis. This patient presents with a painful, swollen, and tender area with a palpable cord-like structure and erythema, which is characteristic of superficial thrombophlebitis. The gradual onset, absence of trauma, and lack of significant skin temperature change further support this diagnosis. Superficial thrombophlebitis typically affects superficial veins, causing redness and tenderness along the course of the vein.

Answer 169

Explanation of other options: A) Cellulitis. Cellulitis typically causes more diffuse redness, warmth, and swelling, often accompanied by systemic symptoms such as fever. The localised, cord-like structure in this case is not consistent with cellulitis. B) Deep vein thrombosis. Deep vein thrombosis (DVT) would generally cause swelling of the entire limb rather than a localized area and is less likely to present with a palpable cord-like structure. C) Medication side effects. While medications like lisinopril may cause swelling, drug-induced oedema is more likely to be bilateral and occur in lower areas such as the ankles. The cord- like structure seen here is not a typical feature of medication side effects. D) Lipoma. Lipomas are typically soft, non-tender, and painless, unlike the painful, tender swelling described in this case.

Answer 170

Correct answer → E) Total parenteral nutrition (TPN). In this case, total parenteral nutrition (TPN) is the most appropriate method for providing nutritional support preoperatively. TPN delivers complete nutrition intravenously, bypassing the gastrointestinal tract. This is crucial for a patient with advanced gastric carcinoma, as their stomach is likely compromised by the tumour, making enteral feeding (through the digestive tract) ineffective. TPN ensures that the patient’s nutritional needs are met in preparation for surgery, especially given the severity of his malnutrition.

Answer 171

A) Jejunostomy tube. A jejunostomy tube is invasive and is typically placed during surgery rather than before it. It relies on the gastrointestinal tract’s ability to absorb nutrients, which may be impaired in patients with advanced gastric cancer. It is better suited for long-term postoperative feeding in patients who cannot use their stomach, rather than preoperative nutritional support. B) Nasogastric tube. In this patient, the tumour likely obstructs the stomach or upper gastrointestinal tract, making nasogastric feeding inefficient. The NG tube may not deliver adequate nutrition due to the compromised stomach function caused by the advanced cancer. C) Intramuscular vitamin injections. While intramuscular vitamin injections can provide essential vitamins, they do not provide comprehensive nutrition. They are insufficient for addressing the patient’s caloric, protein, and overall nutrient needs in this preoperative setting. D) Percutaneous endoscopic gastrostomy (PEG). A PEG tube is inappropriate for this patient as it provides direct access to the stomach, which is likely obstructed or severely compromised by the tumour. This makes PEG feeding ineffective for ensuring adequate nutrition.

Answer 172

For patients with advanced oesophageal, gastric, or pancreatic cancer who are unable to meet their nutritional needs due to nausea, early satiety, or gastrointestinal obstruction, Total Parenteral Nutrition (TPN) is the preferred method of nutritional support before surgery. TPN bypasses the gastrointestinal tract entirely, providing essential nutrients intravenously, which is vital when the stomach is compromised. Other options like jejunostomy tubes, nasogastric tubes, and PEG are not appropriate due to the impairment of the digestive system caused by the tumour, while intramuscular injections alone are inadequate for full nutritional support.