Surg 2017 Release Flashcards
A 68 year old man presents with difficulty passing urine and frequent nocturia. He has a generally enlarged prostate with a small hard nodule on its surface. How would you assess and manage him?
Priorities
- establish prostate ca dx
- establish prognosis: age, comorbidities, grade, stage
- management options are active surveillance, radical prostatectomy (+/- LN dissection), RTx (EB or brachytherapy) +/- ADT
A 60 year old woman presents with a breast lump she has found herself. You are unable to palpate the lump. How would you manage this situation?
Priorities
- triple assessment
- if cancer, treat (the breast, axilla and any suspected occult micromets): surgery, radiotherapy, systemic if susceptible
A 36 year old woman presents with a four day history of neck pain and swelling. She has a swollen painful thyroid. How would you assess and manage her?
Priorities: thyroiditis
- stabilise if necessary (thyroid storm)
- confirm PDx and rule out DDx: trauma, radiation, infection; other common non-painful causes (Graves, Hashimotos, rule out cancer)
- check if hyper- or hypothyroid
- clinical diagnosis, but rule out abscess - U/S (and Graves/tumour if pain less obvious)
- supportive care: analgesia +/- betablocker (hyperthyroid) or thyroxine (hypothyroid). Pred if severe.
A 50 year old healthy woman notices a lump on the side of her neck. Ultrasound reveals a 1.5cm solitary nodule in her thyroid. How would you assess her?
DDx: TA, TMN, thyroid cancer Priorities - resus if airway compromised - confirm PDx: papillary thyroid ca most common of the cancers - surgery +/- systemic therapy if cancer
A 58 year old man presents with painless progressive jaundice for 2 weeks. Investigations reveal cholestatic liver function tests, dilated bile ducts, and a 3cm mass in the head of the pancreas. How would you manage him?
Obstructive jaundice secondary to pancreatic adenocarcinoma
DDx
- benign: cystadenoma
- pancreatic neuroendocrine
- cholangiocarcinoma
- if periampullary: duodenal cancer, ampullary cancer
- other causes of jaundice: haemolysis, hepatitis
History
- Jaundice sx, cancer sx, metastatic sx
- Risk factors: smoking, alcohol, obesity, diabetes, radiation, recurrent pancreatitis, autoimmune incl IBD, FHx
Exam
- Vitals
- Abdo exam: mass, jaundice, ascites, hepatomegaly, Virchow’s node, Courvoisier’s sign, Trousseau’s sign
- Mets exam: orientation and neuro screening, bony tenderness, pleural effusion, (hepatomegaly done in abdo)
Investigations
1) Diagnostic
- LFTs incl conjugated and unconjugated bilirubin
- Abdo U/S
- CT abdo
- if equivocal, ERCP + biopsy
2) Staging (any coeliac axis/SMA involvement, mets = stage 4)
- Ca 19-9/neuroendocrine hormones (gastrin, insulin, VIP)
CT chest/abdo/pelvis and as per history
Management: MDT
- Surgical resection: Whipple’s procedure (remove all structures supplied by the gastroduodenal artery running through head of the pancreas: antrum, duodenum, prox jejunum, gallbladder, head of pancreas)
- Chemoradiation
- Palliative: biliary decompression, analgesia, pancreatic replacement therapy
A 30 year old woman presents with a 1cm pigmented lesion on the skin of the left calf. She thinks it has increased in size recently. How would you assess her?
Priorities
- assess likelihood of cancer: RF, appearance and irregularity in asymmetry/border/colour/large diameter/evolving, LN
- biopsy if any cancer suspected: complete full-thickness excisional biopsy with 1-3mm margin + some subcut fat
- treat: wide local excision (1-2cm margin) +/- LN dissection (if sentinel biopsy positive) +/- adjuvant immunotherapy or systemic therapy
- surveillance: hx and exam every 3-12 months; PET-CT every 6 months for stage 3 and 4
A 60 year old woman has known gallstones and suffered an attack of pancreatitis two months ago. She has been strongly advised to have a cholecystectomy but does not wish to undergo surgery. How would you manage this situation?
Priorities
- understand patient’s reasons eg fear, misunderstanding, time off, religion
- assess insight and capacity
- determine indication and contraindications for surgery
- counsel re: procedure - explain indications, outline procedure, explain benefits of procedure and risks, explain alternatives (optimise risk factors - metabolic syndrome essentially))
- document
An 87 year old man presents with a necrotic ulcer on the tip of his 4th right toe. He is known to have diabetes. How would you assess and manage him?
Priorities
- stabilise if septic/delirious/ischaemic
- assess wound
- assess and optimise factors affecting healing: vascular supply, infection (?osteomyelitis), diabetes
- wound care: debridement, local wound care, mechanical offloading
- vascular referral/abx/improve diabetes control/podiatry referral
A 63 year old man presents with a painless swelling in his left lateral neck. How would you assess him?
Lymphadenopathy
Priorities
- primary survey if necessary
- determine cause: cancer (incl GI), infection, inflammatory, non-LN - neck U/S, biopsy (excisional if possible and worried about lymphoma)
- RTx, chemo for lymphoma
An 80 year old woman presents with a painful swollen right knee. She has a temperature of 38.2°C. The knee joint is swollen, tender and warm. How would you manage her?
Priorities
- stabilise if septic
- confirm septic arthritis: ?predisposition, acute monoarthritis (poly might be gonococcal), positive synovial fluid aspiration, xray
- check infection status and drug-related baseline: FBC, CRP, blood cultures, EUC, LFTs
- abx and joint drainage (with serial joint aspirates afterwards to show it’s clear)
A 70 year old asymptomatic man is found to have a right carotid bruit. How would you assess and manage him?
Priorities
- Check for evidence of past CVA
- Check for vasculopathy, CVD
- Intensive medical therapy
- Assess suitability for revascularisation: bilateral, unilateral stenosis > 80% (or >70% if female and symptomatic, >50% if male and symptomatic), lifespan > 5y and low surgical risk
- CAS over CEA only if difficult to access lesion or radiation-induced stenosis
A 65 year old woman has a 7cm ulcer with a sloughy base situated just above the medial malleolus. There is brownish pigmentation of her left lower calf. How would you manage her?
Priorities
- determine cause: venous, arterial, neuropathic (eg diabetic), malignant
- determine extent of venous/arterial/etc compromise
- acute: wound care, abx/analgesia if necessary, stop immunosuppressants (incl smoking)
- chronic: trial conservative management, then if failure after three months (and evidence of reflux), definitive (ablation, surgery)
A 57 year old man has a central line inserted into his right subclavian vein. Immediately after the insertion, he develops acute shortness of breath. How would you assess and manage him?
Priorities
- Primary survey and resus as necessary: O2 (via 6-8L via Hudson mask, avoid pressure), ABGs
SAME TIME
- Confirm diagnosis with CXR, check subclavian line with blood gas
- Consider DDx (PE)
- Remove subclavian line
- Emergency decompression if required, otherwise chest tube in triangle of safety if >2cm (O2 also works as conservative therapy)
- Monitor: serial CXR
A 50 year old woman suffers a fractured tibia and fibula and a below knee plaster is applied. The following day, she has severe pain in the leg and foot and her toes are cold. How would you manage her?
Priorities
- assess extent of ischaemia: pain on passive movement, motor + vasc signs are LATE
- confirm PDx: xray, doppler, compartment pressure measurements
- SERIAL EVERYTHING
- rule out complications: CK, urinary myoglobin
- reduce the pressure (remove cast, fasciotomy if no return) and provide supportive care (O2, analgesia, fluids if hypotensive, pre-surg NBM and bloods)
- if concerned about rhabdo, consider giving fluids an diuresis, consider haemodialysis
An 80 year old woman with dementia from a nursing home is transferred with symptoms of a large bowel obstruction. An abdominal CT scan confirms evidence of an obstructing sigmoid colon cancer with multiple liver metastases. How would you manage her?
Priorities
- confirm LBO
- determine goals of care, with input from family, MDT
- supportive care (incl IDC, anti-emetics, analgesia) incl for delirium if necessary; for pal if necessary
- options: stenting, ostomy, colectomy, Hartmann’s
A 56 year old man presents with a painful, swollen right testis. He has recently experienced several urinary tract infections. How would you manage him?
Priorities
- primary survey and resus if necessary
- confirm epididymo-orchitis, rule out torsion
- look for chronic bacterial prostatitis
- abx and supportive care for epididymo-orchitis
- uro referral and abx for prostatitis
An 82 year old woman is transferred from a nursing home to the Emergency Department with a history of cramping abdominal pain, vomiting of dark green fluid and abdominal distension. Clinical examination reveals evidence of a 5cm hard right groin lump. How would you assess and manage her?
Irreducible/?strangulated femoral hernia Priorities - primary survey and resus - confirm SBO and assess severity - SBO mx: NBM, NGT, IVT - surgery within 4-6 hours of onset - open repair, abx - F/U
A 38 year old woman has a minimally invasive parathyroidectomy for a parathyroid adenoma which had caused hypercalcemia. Twenty-four hours later she complains of “pins and needles” around her mouth. How would you assess and manage her?
Priorities
- primary survey and resus if necessary (seizures can cause stroke)
- symptoms: palpitations, muscle twitching, seizures, coma
- check Ca: sx, Trousseau’s,
Chvostek’s, CORRECT serum level, ECG
- look for other surg complications (nerve palsy, airway obstruction)
- tell surgical team, transfer to HDU (because symptomatic) and monitor for arrhythmia, supplement other electrolytes (eg Mg, K)
- replace Ca: IV (with large bore cannula/central line) - PO caltrate if not symptomatic
A 65 year old man is booked for a radical prostatectomy for prostate cancer. He had a right leg deep venous thrombosis 5 months ago and is currently on Warfarin. What are the measures you would take to prevent
a recurrence?
Priorities
- assess for current VTE
- assess VTE risk factors
- assess bleeding risk
- mechanical and pharm prevention
A 40 year old woman is admitted for an elective laparoscopic cholecystectomy for gallstones. How would you explain the risks and benefits of the procedure to her?
Assess indication: gallstones disease, cholecystitis, cholangitis, pancreatitis, gallstone ileus etc
S I P: go home after 24 hours R: anaesthetic general surg: bleeding, seroma, infection, atelectasis +/- pneumonia, MI/CVA, VTE abdo surg: damage to bowel/bladder, hernia failure: open, reoperation, sx continue other: bile duct damage A: stone dissolution, cholecystotomy C
