PaSSMed: surgery Flashcards
A 44-year-old female presents with right-sided pleuritic chest pain of sudden onset. The pain is 8/10 severity, constant, and does not radiate to anywhere. She has a past medical history of hypertension, type 2 diabetes, stage 4 chronic kidney disease, hypercholesterolaemia. She does not have any known allergies. On examination, she has a respiratory rate of 24/min, heart rate 120 bpm, temperature of 37.6ºC. There is reduced air entry and inspiratory crackles in the right lower zone. An ECG shows sinus tachycardia and right-sided bundle branch block. D-dimer is reported as elevated. Given the likely diagnosis, what is the diagnostic investigation of choice?
A V/Q scan is the preferred option if the patient has an allergy to contrast media or has renal impairment. The patient in this question has a background of chronic kidney disease and therefore to prevent contrast-induced nephropathy, a V/Q scan would be the preferred option.
Not CTPA (normally would be)- contra-indicated in patients who have a renal impairment or are allergic to contrast media.
Spontaneous bacterial peritonitis: most common organism found on ascitic fluid culture is
E. coli
first-line treatment for prolactinomas
Dopamine agonists (e.g. cabergoline, bromocriptine) are first-line treatment for prolactinomas, even if there are significant neurological complications
An 88-year-old man is admitted to the surgical assessment unit from a nursing home. He is mildly confused so obtaining a history is difficult, but on questioning his care assistant it becomes apparent that he has been complaining of increasing abdominal pain and has a markedly reduced appetite for a week. He has not opened his bowels for several days.
His temperature is 37.0°C, pulse 92 bpm, regular and BP is 172/86 mmHg. His abdomen is very distended with discomfort on palpation.
This patient has a closed-loop obstruction due to volvulus of the sigmoid colon. How would you manage this patient initially?
This patient is elderly and frail. He does need intervention to relieve his obstruction. Passage of a decompressing flatus tube will relieve symptoms and is relatively non-invasive. For some patients this treatment may suffice. Volvulus may be recurrent however, requiring sigmoid colectomy as would those with associated perforation.
A 63-year-old woman is recovering on the ward following a laparoscopic right hemi-colectomy and primary anastomosis for a Duke’s B adenocarcinoma of the colon. You are asked to see her two days post-operatively due to a heart rate of 103 bpm and a blood pressure of 95/73 mmHg.
On examination she has a temperature of 37.1ºC, her respiratory rate is 22 per minute and her saturations are 98% on air. She has a very distended abdomen which is tense and mildly tender but with no guarding, her chest is clear and her operative wounds look clean and healthy. She is not feeling nauseated and she has not opened her bowels since before her operation or passed wind but she is starting to sip clear fluids. Her fluid balance chart shows a net positive fluid balance since surgery. Prior to surgery she had normal renal function and a blood test now shows the following:
What is the most likely cause for the abnormalities in this lady’s observations?
Ileus occurs in the few days following surgery and can cause hypovolaemia and electrolyte disturbances BEFORE nausea and vomiting becomes apparent
ileus
Post-operative deterioration is the most common reason for seeing a patient when working as a junior in general surgery and being able to diagnose the cause of a deterioration is crucial to managing patients appropriately. Her observations demonstrate she is hypovolaemic and her blood tests shows she has an acute kidney injury and low electrolytes, this suggests she is losing salt and water. However as her overall fluid balance is positive, the fluid and salt must be being sequestered into a body compartment or what is often referred to as a ‘third space’. An ileus would cause fluid build up in the intestinal lumen as peristalsis stops as this results in an overall loss of water and salt from the intravascular space but an overall positive fluid balance. This is a very common post-abdominal surgery complication and often settles on its own within a few days. The main symptomatic complaints from patients are nausea and vomiting although this often doesn’t become apparent for a few days, and abdominal distension and tenderness. The main signs on examination are abdominal distension, absolute constipation and blood tests in keeping with fluid and electrolyte loss. The treatment would be insertion of a wide-bore nasogastric tube and replacement with intravenous fluids until the bowel becomes motile again.
A 67-year-old woman presents to the emergency department with central abdominal pain. She vomited twice since the onset of the pain. She did not pass any wind or faeces in the last twelve hours.
Her past medical history comprises a partial small bowel resection following traumatic perforation.
On examination, her abdomen looks distended and there is generalised tenderness on palpation. Her blood tests show the following:
small bowel obstruction
Serum amylase levels can rise in small bowel obstruction not just pancreatitis
A 23-year-old female is due to undergo implantation of a middle ear prosthesis for sensorineural hearing loss. Her previous surgical history includes an appendectomy, for which she developed severe post-op nausea and vomiting.
Which of the following anaesthetic agents would be most appropriate to use?
Propofol is an antiemetic and is therefore particularly useful for patients with a high risk of post-operative vomiting
- Nitrous oxide increases the risk of developing PONV.
Volatile liquid anaesthetics like isoflurane increase the risk of developing PONV.
IV ketamine can increase the chances of developing PONV.
The anaesthetic team is preparing a patient for elective knee replacement surgery. Her height is 1.60 metres and her weight is 80 kilograms. She is a non-smoker, non-drinker, and has no known medical conditions. She takes no regular medications.
What is the patient’s ASA score?
II
Patients with BMI between 30 and 40 are classified as ASA II
What is the muscle relaxant of choice for rapid sequence intubation?
Suxamethonium is the muscle relaxant of choice for rapid sequence induction for intubation
A 18-year-old female presents to the emergency department with a 2 day history of lower abdominal pain. She also complains of nausea and vomiting, and has not opened her bowels for 24 hours. She has mild dysuria and her last menstrual period (LMP) was 21 days ago. She smokes 20 cigarettes a day and drinks 15 units of alcohol per week. On examination she is haemodynamically stable, with pain in the right iliac fossa. Urinary pregnancy and dipstick are both negative. Which one of the following is the most likely diagnosis?
This is a fairly standard presentation of acute appendicitis (young age, site, associated symptoms)
- The urinary investigations have excluded a urinary tract infection and ectopic pregnancy.
- Mittelschmerz is also known as mid-cycle pain.
- Diverticulitis usually presents at older ages and commonly localises to the left iliac fossa.
A 72-year-old man is recovering from an inguinal hernia repair when he suffers from an extensive ischaemic stroke. He is managed on the rehabilitation unit. However, he is still not able to feed safely and repeated swallowing assessments have shown that he tends to aspirate. Which of the following is the best option for long term feeding?
A PEG tube is the best long term option although they are associated with a significant degree of morbidity. A feeding jejunostomy would require a general anaesthetic. TPN is not a good option. Long term naso gastric feeding is usually unsatisfactory.
A 62-year-old female is undergoing a routine cholecystectomy for recurrent gallstones. Her only comorbidity is end-stage renal disease, as a result of polycystic kidney disease. For this she is undergoing regular haemodialysis, three times a week. As part of her pre-operative assessment her American Society of Anaesthesiologists (ASA) classification must be calculated.
What is her ASA classification?
Patients with end stage renal disease undergoing regular scheduled dialysis are classified as ASA III
An 80-year-old man is due for an elective knee replacement at 1 pm. It is now 11 am and he reveals that he drank a black coffee 30 minutes ago.
What is the most appropriate step to take?
Patients can drink clear fluids up to 2 hours before an operation
A 34-year-old woman presents with a lengthy post-operative ileus after extensive small bowel resection for Crohn’s disease. The surgical consultant suspects total intestinal failure after a prolonged postoperative period in which her remaining gut has failed to absorb.
Which of the following routes of administration is most appropriate for the delivery of nutrition in this patient?
Total parenteral nutrition should be administered via a central vein as it is strongly phlebitic
A 67-year-old woman is brought to the Emergency Department with severe abdominal pain which has been worsening the past two days. It began in the lower left side of her abdomen and she has had diarrhoea with it. She has a past medical history of hypertension, chronic kidney disease and diverticular disease.
Her heart rate is 121 bpm, blood pressure is 132/81 mmHg, temperature is 38.2ºC and her oxygen saturation is 97% on air. Her abdomen is tender throughout and exhibits involuntary guarding throughout. Her bowel sounds are inaudible and she has rebound tenderness present throughout her abdomen. A blood test on admission shows the following:
Hb139 g/lNa+139 mmol/lBilirubin8 µmol/lPlatelets732 * 109/lK+4.1 mmol/lALP68 u/lWBC19.1 * 109/lUrea6.1 mmol/lALT34 u/lNeuts16.3 * 109/lCreatinine112 µmol/lγGT55 u/lLymphs1.9 * 109/lAmylase7 u/lAlbumin34 g/l
Which of the following investigations would be best to confirm your diagnosis?
An erect chest x-ray is used to identify bowel perforation
A 26-year-old is scheduled to undergo a proctocolectomy for ulcerative colitis. They currently take long-term daily prednisolone 10mg/day to help manage their ulcerative colitis. They take no other regular medications.
What, if any, alterations need to be made to their medications before surgery?
Hydrocortisone supplementation is required prior to surgery for patients taking prednisolone
A 38-year-old man attends the ED with a 3-day history of epigastric pain. The pain has become increasingly severe but eases on sitting upright. The patient has been vomiting bilious liquid and has not eaten or opened his bowels normally for several days. The patient is not taking any medication but does have a history of alcohol misuse spanning several years.
On examination, he looks unwell and is in pain, his temperature is 37.8°C, heart rate 100 bpm, and blood pressure 120/70 mmHg. His abdomen is mildly distended and bowel sounds are quiet and there is diffuse tenderness with guarding in the upper abdomen. Chest and cardiovascular examination are otherwise unremarkable.
What differential diagnoses would you consider?
acute pancreatitis
acute cholecystitis
perforated duodenal ulcer
This patient clinically has an ileus and the severe upper abdominal pain could relate to acute pancreatitis or cholecystitis, a perforated duodenal ulcer or possibly a myocardial infarction. Chronic pancreatitis will have a longer history of pain, often after meals or drinking alcohol and is associated with weight loss, and malabsorption. The history is not typical of ischaemia which is not relieved by sitting and is often associated with rectal bleeding.
The serum amylase measurement is 380 iU/L (normal range 0-150 iU/L). Which two of the following statements regarding amylase are correct?
In acute pancreatitis the amylase level may be very high (>1000 U/ml). If the pancreatitis has been going on for a few days the level may drop however and moderate elevation may also be seen occasionally in other conditions e.g. duodenal perforation, mesenteric infarction, acute cholecystitis.
6 paramater used to score the severity of pancreatitis
The Glasgow-Imrie criteria for the severity of acute pancreatitis is scored once, 48 hours after admission and uses the following parameters:
- PaO2
- WCC
- Serum calcium
- urea
- LDH
- Albumin
- Glucose
The patient recovers from this acute episode of pancreatitis, however returns to accident and emergency 6 weeks later with recurrence of upper abdominal pain. On this occasion there is fullness in the epigastrium although the symptoms and signs are less pronounced than at his initial presentation. His amylase is mildly elevated, having previously returned to normal What is the likely diagnosis?
pancreatic pseudocyst
US/CT will confirm and drainage is needed endoscopically, percutaneously or surgically.
- classic after 4 weeks resolution
causes of acute pancreatitis
- alcohol
- gallstones
- ERCP
- Hyperlipidaemia
- steroid therapy
important differential for appendicitis in children/teens
Mesenteric adenitis typically follows a respiratory tract infection but the patient would not be expected to have guarding
appendicitis in the elderly
may only present with confusion and minimal abdominal symptoms
infants with appendicitis may present with
diarrhoea and vomiting
A 42-year-old man has a productive cough one day after an open appendicectomy.
describe the findings of this x-ray
free air beneath the right hemi-diaphragm
normal finding after surgery: Free air is often present for a short time after abdominal surgery and is unlikely to be of significance in this patient who only has a cough.
Pabrinex
Intravenous High Potency contains vitamins B1, B2, B6, nicotinamide, vitamin C and glucose.
A 62-year-old man has vomiting with abdominal distension and discomfort. He is 2 days post elective sigmoid colonic resection for diverticular disease.
what does the axr show
Multiple dilated loops of small bowel are present – note the mucosal folds (valvulae conniventes) traversing the bowel lumen. The patient also has incidental Paget’s Disease of his pelvis – the bone is sclerotic and the trabecular pattern is coarsened.
A 62-year-old man has vomiting with abdominal distension and discomfort. He is 2 days post elective sigmoid colonic resection for diverticular disease
what is the likely diagnosis
small bowel ileus
His clinical presentation is of a post-operative ileus, small bowel obstruction would normally be associated with increased bowel sounds. Patients with small bowel ischaemia are extremely sick.
treatment of small bowel ileus after surgeyr
nasogastric tube to drain stomach content- decompress
- IV fluids
- analgesia
- electrolyte replacement
why give pabrinex to before commencing TPN
Pabrinex contains a mixture of B vitamins and vitamin C. The reason we give it is to make sure that the patient has plenty of thiamine available to them as they start feeding. Thiamine is required to process the food which has been given and if you have been in a state of starvation then thiamine levels will be low with a risk that it could be used up as feeding commences. This can result in Wernicke’s encephalopathy which is reversible if thiamine is given. If it is not identified and thiamine is not administered, then it will rapidly progress to Korsakoff’s Psychosis, an irreversible dementia.
A 58-year-old man presents to surgical out-patients with a 3-month history of weight loss and feeling unwell. Over the previous 10 days he has noticed he has become jaundiced and is itching over his trunk and limbs. He has lost his appetite but has no pain, nausea, vomiting or dysphagia. He is opening his bowels but the motions have become light coloured and loose, although no bleeding is evident. He smokes 5 cigarettes per day and does not drink alcohol. He had a coronary artery bypass grafting 6 years previously and is taking aspirin, bisoprolol, ramipril and atorvastatin.
On examination, he looks underweight and mildly icteric. His temperature is 37.0°C, pulse 62 bpm and regular, and BP 135/85mmHg. Cardio-respiratory examination is unremarkable. No nodes are palpable in his neck. On examination of his abdomen there is fullness in the right upper quadrant with the suggestion of a mass. He has no tenderness or guarding and bowel sounds are present and normal. Rectal examination reveals an empty rectum.
mostly likely diagnosis
carcinoma of the pancreas
cholangiocarcinoma
A 41-year-old phlebotomist from Birmingham presents to her GP with a 2 month history of vague right upper quadrant pain and nausea. It is constant, does not radiate, and does not change following food. She describes no history of altered bowel habit, weight loss or fevers. She drinks around 10 units of alcohol per week, is a non smoker, and has no medical history of note.
Her GP arranges a set of blood tests and an ultrasound of her liver. Results are below:
FBC, U+E, LFT and clotting profile are normal.
What is the most likely cause of the patients symptoms?
Hepatic haemangiomas are relatively common incidental findings on imaging, but larger lesions may present symptomatically
The presence of anti-HBs shows previous hepatitis immunisation or immunity. As a UK phlebotomist, she will have received hepatitis B immunisation.
inguinal hernia found
seen above and medial to the pubic turbercle
describe this x-ray
Chilaiditi syndrome
There is a loop of large bowel interposed beneath liver and diaphragm. This can be mistaken for air under the diaphragm at first glance.
A 59-year-old patient presents to the surgical assessment unit with a one-week history of worsening colicky right upper quadrant pain. This has been associated with nausea and she has vomited twice. The patient has also felt unwell and “shivery” and she has not opened her bowels normally for the last few days. Previously she has been fit and well and her only previous history to note is that of a cholecystectomy for gallstones several years previously.
On examination, she looks unwell and flushed with a heart rate of 95bpm, blood pressure 140/75 mmHg and temperature 38oC. Cardiac and respiratory examination is unremarkable. Abdominal examination demonstrates diffuse tenderness with mild guarding in the right upper quadrant. Bowel sounds are present but reduced – no definite masses are palpable. Cholecystectomy scar is present.
What is the most likely diagnosis?
The triad of acute pain, fever and jaundice is diagnostic of ascending cholangitis.
Although this patient is not obviously jaundiced, she has an obstructive picture in her liver function tests. The serum amylase is usually normal in ascending cholangitis and if gallstones are present in the duct in theory there may be pancreatitis also. Acute hepatitis is associated with a hepatitic picture in liver function tests.
