Surg pre-2017 Flashcards
A 48 year old woman is admitted for coronary artery bypass surgery. How would you explain the surgery to her?
S
I: triple vessel disease or left main (or failed/contraindicated PCI)
P: preop ix and meds (stop smoking, give beta blocker, CCB, nitrates, aspirin), GA, I+V, IDC, heart-lung bypass machine, veins from arm/leg to bypass stenosed coronary arteries, postop abx and BAAS. Takes months to recover, may not recover completely.
R: anaesthetic, bleeding (-> transfusion) and infection (-> wound/s, IE), damage to surrounding structures (arrhythmia, chest wall pain and numbness), hypotension (short term memory loss and visual blurring/stroke, MI, kidney failure), failure, postop (atelectasis, VTE)
A: PCI
C
One of your patients has been advise to have a colonoscopy because of rectal bleeding. Describe how you would explain to the patient what the procedure involves and what are its risks and benefits.
S
I: screening/diagnostic/therapeutic: colonic path suspected eg CRC, IBD
P: preop bowel prep + NBM + anaesthetic assessment; sedation, PR, introduction of scope +/- biopsy, postop recovery + monitoring for 1-2hr and then home (avoid exertion for 24 hours)
R: anaesthetic, bleeding and infection, damage to surrounding structures eg bowel perforation, failure, postop unlikely
A: CT colonography, flex sig
C
A 62 year old woman is to undergo a hemicolectomy for carcinoma of the colon. She is informed that she may require a blood transfusion and asks about the risks. How would you explain the risks to her?
S
I: active bleeding, low Hb
P: take blood preop and G&XM, attach blood to cannulae and give
R: short term: transfusion reaction (AHTR, TRALI, sepsis, TACO, anaphylaxis); medium term: delayed transfusion reaction (delayed haemolysis, thrombocytopaenia, GVHD, transmission of blood borne viruses
A: fluids, cell saver
C
A 70 year old man has been advised to have a total hip replacement because of osteoarthritis and severe pain. What would you advise him about the risks and benefits of the procedure?
S
I: restricted function from significant hip arthritis with failure of conservative treatment
P: preop bloods and workup, intraop GA, I+V, UO, saw off head of humerus and hammer in prosthesis, glue; rehab, return to normal function in 3-6 monthsuuraoirhm
R: anaesthetic, bleeding (?transfusion), infection (septic arthritis, osteomyelitis), damage to surrounding structures (nerve/vessel damage, osteolysis), failure (loosening on implant, breakage, unequal leg lengths, difficulty walking), postop (atelectasis, VTE)
A: max medical management, total hip resurfacing - resurfacing joint surfaces but has higher risk of need for revision
C
A 59 year man has inoperable pancreatic cancer with extensive retroperitoneal spread. He has severe upper abdominal and back pain. How would you manage him?
Cancer pain
Assessment
- pain hx
- rule out other complications: obstructive jaundice, gastric outlet obstruction, infection
- thorough cancer hx
- other medical comorbidities, meds, allergies
- SHx: esp ECOG, ADLs
Management: MDT, WHO pain ladder
- paracetamol, NSAIDs
- weak opioids
- strong opioids - syringe driver
- adjuvant agents: neuropathic agents, ketamine, antidepressants, anticonvulsants, steroids, nerve blocks (eg coeliac plexus, intrathecal/epidural)
- pal cancer treatment: rtx, (chemo, debulking, bisphosphonates)
A 50 year old man has a sigmoid colectomy for carcinoma. He is catheterised and the nursing staff report he has an inadequate urine output. How would you assess and manage him?
Postop oliguria
PDx: hypovolaemia
DDx: renal - nephrotoxicity; postrenal - obstruction
Concern: AKI
- volume overload
- hyperkalaemia
- acidosis
- uraemia
Assessment
- check op notes
- urine output
- hydration - sources of loss, adequacy of intake - check fluid balance
- check for nephrotoxins in the past 2-3 days
- assess fluid status clinically, check catheter
- Ix: UEC, CMP, LFTs, bladder U/S
Management
- fluid challenge -> if responding, continue
- review meds
- catheterise if not already, uro referral if unable to catheterise due to obstruction
- treat underlying causes
- continue monitoring: fluid balance, UO, daily weights, EUC/CMP
A 52 year old labourer presents with acute lower back pain after a lifting injury at work. He is experiencing considerable difficulty moving and pain radiating down his left leg. How would you manage him?
Sciatica
PDx: disc herniation compressing L5-S1 nerve root
DDx: spinal cord compression (disc herniation, malignancy), arthritis/spondylosis, fracture, infection
Concerns
- spinal cord compression
- malignancy
- infection
Assessment:
- ask about symptoms of cauda equina/SCC: change in bowel or bladder, falls, fait instability, weakness/sensory changes
- ask about malignancy
- ask about sx or rf for infection
- known hx of back disease
- neuro exam lower limb incl SLR, saddle anaesthesia, wink reflex; spinal exam
- if benign: xray spine
- if any concerns about malignancy/spinal cord compression: MRI spine, presurgical bloods, neurosurg referral
Management
- analgesia, physiotherapy, consider steroid injections
- urgent neurosurgery if spinal cord compression
A 52 year old man presents with a lump in the right scrotum. How would you assess him?
PDx: testicular cancer to rule out
DDx: hernia, hydrocoele, varicocoele, torsion/orchitis if acute
Assessment
- ask about lump - acute vs chronic; painful vs painless; always there vs hernia
- ask about sx and rf of cancer
- sx (incl hernia complications) and previous hx of any of above conditions
- functional impact
- examine - is the lump part of the testis/epididymis, can you get above it/transilluminate, is it tethered/hard/invading, worms etc
- consider looking for metastatic disease
- U/S, consider tumour markers (AFP, beta-hCG, LDH), UEC
Management
- testicular cancer: biopsy (radical inguinal orchidectomy), stage (CT chest abdo pelvis), radical orchiectomy +/- lymph node dissection, chemoradiotherapy; consider cryopreservation of sperm
- hernia: assess impact/risk and conservative/repair
A 75 year old man is admitted for repair of an aortic aneurysm. He has symptoms suggestive of early leakage. While being prepared for surgery, he decides that he does not wish to have surgery and requests that the IV line and the urinary catheter be removed. How would you manage this situation?
Issues
- DAMA
- Leaking AAA
Primary survey and resus under ‘duty of care’ as leaking indicates high risk of impending rupture
Discussion and consent
- Appropriate environment
- Elicit patient’s perspective
- Explain
procedure, -usually stent graft inserted through femoral artery-
indications,
risks and benefits -technical success of 99% but 1/10 have major complication and 1/20 die, risk of anaesthetic/bleed and vessel occlusion (-> AKI, mesenteric ischaemia, paraplegia, impotence, buttock or foot necrosis) /infection/failure/postop-
alternatives -palliation-
- Assess capacity - consider contacting next of kin
- Address concerns - risks of repair, poor communication with clinicians, anecdotes, religious concerns
A 60 year old man presents with pain, redness and swelling of the right leg. There is cellulitis involving the lower leg. How would you manage him?
PDx: cellulitis
DDx: chronic venous insufficiency, DVT, deeper infection
Primary survey and resus if septic
Assessment
- course of symptoms
- associated symptoms, risk factors (immunocompromise/trauma, venous disease, DVT risk factors)
- rest of history
- examine legs: extent of swelling, mark borders, palpate for hardness (?nec fasc), check lungs for PE if suspicious
- wound swab MCS, FBC, CRP, consider blood cultures, UEC, LFTs if very unwell
AND/OR Well’s score, D-dimer, duplex U/S
IF ?osteomyelitis/nec fasc: xray/MRI
Management
- abx: fluclox
- supportive care: fluids, analgesia, DVT prophylaxis
- wound drainage and washout if no response
- treat underlying predisposing factors eg DM
A 60 year old man is admitted for a hemicolectomy for diverticular disease. How would you manage his potassium requirements in the postoperative period?
Concerns
- hyperkalaemia secondary to AKI, K-sparing diuretics, ACEi/ARB, beta blockers
- hypokalaemia secondary to hypovolaemia activating RAAS, excess fluid admin, ileus, diuretics
Assessment
- HoPC hemicolectomy - how extensive, how extensive the diverticular disease, what is the current periop plan
- PMHx any underlying comorbidities/meds that could affect K eg CKD, diuretics, ACEi/ARB
- Check vitals incl ECG (for baseline) and fluid status and then examine as per history
- Baseline preop bloods incl UEC, CMP
Management
- Close monitoring postop: UO, fluid balance, daily weights, daily UEC + CMP
- Minimise fluid losses (good anti-emesis control, intraoperative haemostasis) and support kidneys
- Aim to maintain K > 4 - consider KCl in NS (1mmol/kg in first 24 hours) while NBM, especially if low; consider Ca+insulin+resonium if high
A 73 year old woman has surgery for a fractured neck of femur. Five days later she is complaining of abdominal discomfort and her abdomen is distended. Plain x-ray shows diffuse colonic dilatation without fluid levels. How would you assess and manage her?
PDx: colonic ileus
DDx: mechanical LBO
Concerns
- GI losses, dehydration, malnutrition
- LBO -> perforation, sepsis
Assessment
- symptoms
- exclude LBO symptoms incl cancer, diverticular disease sx
- assess for contributing factors incl drugs, infection, metabolic derangement
- examine hydration and abdo -> ileus shouldn’t be peritonitic, less intense pain, no tinkling bowel sounds or systemic sx
- bloods (FBC, CRP, EUC, CMP, LFTs) and consider CT abdo
Management
- supportive care: NBM, IVF, consider NG
- cease/treat contributory causes eg drugs, infection, metabolic derangement
- TPN if ONS not tolerated
A 72 year old man presents with a 6 months history of dysphagia. How would you assess him?
PDx: oesophageal cancer
DDx: webs/strictures/ring (esp secondary to reflux), neuro dysfunction (achalasia, diffuse oesophageal spasm, stroke, MS, PD, dementia)
Assessment
- oropharyngeal vs oesophageal
- progression of dysphagia esp solids vs liquids
- associated sx: cancer sx, reflux sx, neuro sx, systemic diseases
- cancer rf: tobacco, alcohol, FHx, Barrett’s oesophagus, hiatus hernia
- PMHx, meds etc
- examine mouth (observe swallowing), lymph nodes, neuro exam, look for scleroderma
- mech: endoscopy (with biopsy and U/S), manometry if neuro
Management
- staging: CT-PET chest abdo; preop bloods
- oesophagectomy (Ivor-Lewis) +/- chemoradiotherapy
A 58 year old asymptomatic man has a PSA performed and the result is elevated (4.7ng/mL). How would you assess and manage him?
PDx: BPH
DDx: prostate cancer, prostatitis, recent trauma
Assessment
- prostatism sx, cancer+met sx incl progression
- prostatitis sx, recent hx of trauma
- abdo + DRE, consider met sites as per hx, urinalysis
- repeat PSA in 3 months if normal (when no UTI/recent ejaculation or exercise or DRE), urine MCS if ?prostatitis, TRU/S-guided biopsy if suspicious DRE
Management
- unworried: education
- staging: CT chest abdo pelvis
- biopsy: Gleason score
- watchful waiting, active surveillance or active treatment: radical prostatectomy (stage I) or XBRTx (stage II or III)
- can do brachytherapy if stage I, low Gleason, low PSA
You are asked by the surgical registrar to arrange a blood transfusion for a 65 year old woman who is otherwise ready for discharge following an uncomplicated hernia repair. She is asymptomatic and her haemoglobin is 96 g/L (115-165) and you don’t think she requires a blood transfusion. How would you manage this situation?
Issues
- risks and benefits of transfusion - Hb high enough
Assessment
- assess patient’s indication for transfusion: current status (vitals, symptoms), underlying comorbidities, Hb trend
- ask registrar to explain rationale for transfusion
- explain your concerns, with reference to uptodate/other reliable resource
- discuss with consultant/head of surgery/DMS if necessary
