Oncall scenrios

Question 1

Pancreatitis

Answer 1

Hx: Epigastric pain radiating to back, N + V

OE: Generalized tenderness and guarding

Ix: Bloods: FBC, U&E, CRP, LFT, Amylase, Lipid, Bone profile, LDH, Coag and G+S
ABG
CT abdo/US

Glasgow score:
PA02: <8
Age: >55
Neut >15
Calcium <2
Renal urea >16
Enzymes LDH >600 iu or AST inc
Albumin <32
Sugar Glucose >10

Mx: 
Dalteparin proph
IV fluids: Initially 1L over 1hr then need between 3-4 L in first 24hrs
Input, outptut monitoring
Catheter
IV Paracetamol, IV emetic, Oramorph

Question 2

Biliary colic

Answer 2

Biliary colic: Spasmodic epigastric/RUQ pain. Tender of GB if distended. Vomiting

Ix: Bloods: FBC, U&E, CRP, LFT, Amylase, Lipid, Bone profile, lactate, Coag and G+S
USS

Mx: Conservative NBM, DVT proph, IV fluids, Opiate analgesia, Review for lap chole

Question 3

Cholecystitis

Answer 3

Hx: Constant sharp/stabbing pain RUQ, may radiae to Rt shoulder/back, Fever and vomiting

OE: Tenderness, Rebound and guarding in RUQ, Murphys sign +ve

Ix: Bloods: FBC, U&E, CRP, LFT, Amylase, Lipid, Bone profile, lactate, Coag and G+S
USS

Mx: Dalteparin, NBM, IV fluids, analgesia, antiemetics, IV Antibiotics ( Metro and Cotrimox IV)

Question 4

Bowel obstruction

Answer 4

Hx: Abdo pain (Colicky, cramping), N + V, Contipation, Abdo distension,
Previous surgery, malignancy, hyperactive bowel sounds

Ix: FBC, U&E, CRP, LFT, Amylase, Lipid, Bone profile, lactate, Coag and G+S
AXR, Erect CXT, CT Abdomen

Mx: NBM, IV Fluids, Rhyls tube, Analgesia, Clear fluids once NG, DVT proph

Question 5

Perforated viscus

Answer 5

Hx: Abdo pain- sharp. Can be generalised/localised, vomiting, Vomiting,
Kwown Peptic ulcer disease, Aspririn/NSAIDs, Steroids, IBD/Malignancy

OE: Rigid abdomen

Ix: FBC, U&E, CRP, LFT, Amylase, Lipid, Bone profile, lactate, Coag and G+S, Erect CXT, CT Abdomen

Mx: Tx cause

Question 6

Diverticulitis

Answer 6

Hx: LIF pain, crampy +/- change in bowel habit, N + V, Constipation, diarrhea, flatulence, bloating
OE: Localised tenderness, guarding, rebound/percussion tenderness

Ix: FBC, U&E, CRP, LFT, Amylase, Lipid, Bone profile, lactate, Coag and G+S, Urine dip
CT Abdomen

Mx: IV fluids, DVT Proph, IV analgesia, antiemetics, IV Amox, Metro and Gent

Question 7

Appendicitis

Answer 7

Hx: Colicky central abdo pain followed by localisation of pain to RIF
OE: RIF pain, tenderness, guarding, Rovsings,

Ix: FBC, U&E, CRP, LFT, Amylase, Lipid, Bone profile, lactate, Coag and G+S, Urine dip
CT Abdomen

Mx: IV fluids, antiemetic, analgesia, DVT Proph, Abx

Question 8

GI bleed

Answer 8

Upper GI bleed: Hx: Causes alcohol, steroids/nsaids, oesophageal/gastric varices, MW tear, Angiodysplasia, Gastric ca,

Mx: 2 large bore cannula, Bloods, Fluids, Transfuse, Catheterise, 10g IV metochlopramide, Cross match blood, oncall endoscopy

PR bleeding: Hx: Colour, clots, duration, mixed with stool/separate, malaena/haematemesis, pruritus, tenesmus, urgency, WL/Appetite loss, FHx, Change bowel habit, urinary sx
Causes: Diverticular disease, angiodysplasia, colitis, Anorectal causes, NSAIDs, vascular causes

Mx: IV fluids, Bloods, PR, transfuse

Question 9

Hernias

Answer 9

Hx: Ask about when started, swelling, aggrevating factors,
Is it reducible, Any relieving factors, precipitating factors ?

Is there pain. Colicky-obstruction. Associated factors Vomiting/fever

Hx of complications - irreducibility/ obstruction/strangulation

PSHx, PMHx

OE: Generalised guarding, Mass in abdomen, scar from previous surgery
Any umbilical/epigastric/ insicional/ ventral hernia
Organomegaly ?
Malgaingne’s bulge

Local examination: Inspection - site, extent, size, shape, cough impulse, surface, inspect contra-lateral side

Palpation and tests for reducibility: Mark superficial ring. 4cm below and lateral to PT

Deep ring. Half inch above mid inguinal point (mid point ASIS and PS)

Palpation: warmth, tenderness, site (Lateral and below PT = Fem)

Medial and above PT = ing

Consistency, cough impulse,
can you get above swelling

Test for reducibility. One hand supercial and other deep. Push upwards

After reducing content patient in standing position occlude deep ring with thumb and ask pt to cough
Swelling appear = direct

Disappear = indirect

Auscultate

Question 10

Incisional Hernia

Answer 10

Protrusion of viscus through scar of previous op/injury

Can treat with truss/surgery

Question 11

Testicular torsion

Answer 11

Acute onset pain in testis, overlying scrotum may be red.

Tx: Urgent scrotal exploration, untwist testes.

Question 12

Vascular

Answer 12

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