surgery Flashcards
A 44-year-old woman is diagnosed with breast cancer. She has no past medical history of note, is pre-menopausal and has no family history of breast or ovarian cancer. Staging suggests early disease and she has a wide-local excision followed by whole-breast radiotherapy. Pathology results show that the tumour is oestrogen receptor positive, HER2 negative. Which one of the following adjuvant treatments is she most likely to be offered?
Tamoxifen
You are reviewing the medications of a 38-year-old woman in the surgical ward admitted for an elective open cholecystectomy. You notice the patient is currently prescribed the combined oral contraceptive pill (COCP) and she tells you she had not been instructed to stop taking this prior to the planned operation.
Which of the following is the most appropriate next action?
Prescribe thromboprophylaxis
The mother of a 2-month-old boy comes to surgery as she has noticed a soft lump in his right groin area. There is no antenatal or postnatal history of note. He is breast feeding well and is opening his bowels regularly. On examination you note a 1 cm swelling in the right inguinal region which is reducible and disappears on laying him flat. Scrotal examination is normal. What is the most appropriate action?
Refer to paediatric surgery
A 60 year old man comes to see you in GP complaining in difficulty in swallowing, which has been getting slowly worse over the past 3 months. After taking a full history you discover that he has lost around two kilos in weight, although he puts this down to not eating as much, he has no pain when swallowing and has not had any episodes of regurgitating food.
While he is telling you this, you notice that his voice sounds a little different to how it normally is.
What is the most likely diagnosis?
Oesophageal carcinoma
A 65-year-old male undergoes a Hartmann’s procedure for a sigmoid cancer. On day 2 post-op, nurses are concerned as his colostomy has not passed any wind or stool yet and he is complaining of increasing bloatedness. You review the patient and witness him vomit profusely.
How would you manage this common post-operative complication?
Place the patient nil by mouth and insert a nasogastric tube
Post-operative ileus is a common complication in colorectal surgery due to intra-operative bowel handling. Management is conservative with nasogastric tube insertion for stomach decompression for symptom control and placing the patient nil by mouth to allow bowel rest. The recommencement of fluids/light diet should be in stages and guided by the clinical state of the patient.
A 10-year-old boy presents with a 2 day history of abdominal pain and anorexia. On examination he is tender over McBurney’s point with rebound and percussion tenderness. You diagnose acute appendicitis and the registrar books and consents for a open appendectomy. What must be done prior to taking the patient to theatre?
Commence IV antibiotics
A 55-year-old man with a history of gallstone disease presents with a two day history of pain in the right upper quadrant. He feels ‘like I have flu’ and his wife reports he has had a fever for the past day. On examination his temperature is 38.1ºC, blood pressure 100/60 mmHg, pulse 102/min and he is tender in the right upper quadrant. His sclera have a yellow-tinge. What is the most likely diagnosis?
Ascending cholangitis
A 33-year-old is admitted to the Emergency Department with suspected renal colic. He has a ultrasound that shows a probable stone in the left ureter. What is the most appropriate next step with respect to imaging?
Non-contrast CT (NCCT)
A 67-year-old man with a 10-year history of gastro-oesophageal reflux disease is investigated for dysphagia. An endoscopy shows an obstructive lesion highly suspicious of oesophageal cancer. What is the biopsy most likely to show?
Adenocarcinoma
A 63-year-old man attends for a GP appointment and states that he has had two episodes of visible blood in his urine. One episode occurred last week and the other this morning. There was not any pain. He denies any lower urinary tract symptoms. A urinalysis shows +++ blood and is negative for all other markers. What investigation should be requested?
Cystoscopy
A 69-year-old man is started on tamsulosin for benign prostatic hyperplasia. Which one of the following best describes the side-effects he may experience?
Dizziness + postural hypotension
Which one of the following is most associated with male infertility?
Varicoceles
A 63-year-old man is admitted with obstructive jaundice that has developed over the past 3 weeks. He was previously well and on examination has a smooth mass in his right upper quadrant.
Carcinoma of the head of the pancreas
Carcinoma of the pancreas (Courvoisier’s law). The development of jaundice in association with a smooth right upper quadrant mass is typical of distal biliary obstruction secondary to pancreatic malignancy. A bile duct stricture would not present in this way, all the other choices are related to gallstones and Fitz Hugh Curtis syndrome is a complication of pelvic inflammatory disease.
A 51-year-old woman presents with recurrent episodes of epigastric pain radiating through to her back, typically brought on by eating a heavy meal. She drinks around 20 units of alcohol per week. During the current episode she noticed that her sclera were yellow.
Common bile duct stones
This is a typical history of common bile duct stones. Patients often complain of epigastric pain rather than the typical right upper quadrant discomfort. This often leads to gallstones being mistaken for dyspepsia.
A 78-year-old lady presents with colicky abdominal pain and a tender mass in her groin. On examination there is a small firm mass below and lateral to the pubic tubercle. Which of the following is the most likely underlying diagnosis?
Incarcerated femoral hernia
Femoral herniae account for <10% of all groin hernias. In the scenario the combination of symptoms of intestinal compromise with a mass in the region of the femoral canal points to femoral hernia as the most likely cause.
A 43-year-old lady with a metallic heart valve has just undergone an elective paraumbilical hernia repair. In view of her metallic valve, she is given unfractionated heparin perioperatively. How should the therapeutic efficacy be monitored, assuming her renal function is normal?
Measurement of APTT
A 42-year-old lady has suffered from hepatitis C for many years and has also developed cirrhosis. On routine follow up, an ultrasound has demonstrated a 2.5cm lesion in the right lobe of the liver. A. Haemangioma B. Hepatocellular carcinoma C. Hepatic metastasis D. Polycystic liver disease E. Simple liver cyst F. Hyatid cyst G. Amoebic abscess H. Mesenchymal hamartoma
Hepatocellular carcinoma
In patients with cirrhosis the presence of a lesion >2cm is highly suggestive of malignancy. The diagnosis is virtually confirmed if the AFP is >400ng/mL.
A 25-year-old man from the far east presents with a fever and right upper quadrant pain. As part of his investigations a CT scan shows an ill defined lesion in the right lobe of the liver. A. Haemangioma B. Hepatocellular carcinoma C. Hepatic metastasis D. Polycystic liver disease E. Simple liver cyst F. Hyatid cyst G. Amoebic abscess H. Mesenchymal hamartoma
Amoebic abscess
Amoebic abscesses will tend to present in a similar fashion to other pyogenic liver abscesses. They should be considered in any individual presenting from a region where Entamoeba histiolytica is endemic. Treatment with metronidazole usually produces a marked clinical response.
A 42-year-old lady presents with right upper quadrant pain and a sensation of abdominal fullness. An ultrasound scan demonstrates a 6.5 cm hyperechoic lesion in the right lobe of the liver. Serum AFP is normal. A. Haemangioma B. Hepatocellular carcinoma C. Hepatic metastasis D. Polycystic liver disease E. Simple liver cyst F. Hyatid cyst G. Amoebic abscess H. Mesenchymal hamartoma
Haemangioma
A large hyperechoic lesion in the presence of normal AFP is likely to be a haemangioma. An HCC of equivalent size will almost always result in rise in AFP.
A 19-year-old lady is admitted to ITU with severe meningococcal sepsis. She is on maximal inotropic support and a CT scan of her chest and abdomen is performed. The adrenal glands show evidence of diffuse haemorrhage.
A. Nelsons syndrome B. Conns syndrome C. Cushings syndrome D. Benign incidental adenoma E. Malignant adrenal adenoma F. Waterhouse- Friderichsen syndrome G. Metastatic lesion H. Walker - Warburg syndrome I. Phaeochromocytoma
Waterhouse- Friderichsen syndrome
This is often a pre-terminal event and is associated with profound sepsis and coagulopathy.
A 34-year-old lady is admitted with recurrent episodes of non-specific abdominal pain. On each admission all blood investigations are normal, as are her observations. On this admission a CT scan was performed. This demonstrates a 1.5cm nodule in the right adrenal gland. This is associated with a lipid rich core. Urinary VMA is within normal limits. Other hormonal studies are normal.
A. Nelsons syndrome B. Conns syndrome C. Cushings syndrome D. Benign incidental adenoma E. Malignant adrenal adenoma F. Waterhouse- Friderichsen syndrome G. Metastatic lesion H. Walker - Warburg syndrome I. Phaeochromocytoma
Benign incidental adenoma
This is typical for a benign adenoma.Benign adenomas often have a lipid rich core that is readily identifiable on CT scanning. In addition the nodules are often well circumscribed.
A 38-year-old man is noted to have a blood pressure of 175/110 on routine screening. On examination there are no physical abnormalities of note. CT scanning shows a left sided adrenal mass. Plasma metanephrines are elevated.
A. Nelsons syndrome B. Conns syndrome C. Cushings syndrome D. Benign incidental adenoma E. Malignant adrenal adenoma F. Waterhouse- Friderichsen syndrome G. Metastatic lesion H. Walker - Warburg syndrome I. Phaeochromocytoma
Phaeochromocytoma
Hypertension in a young patient without any obvious cause should be investigated. Urinary VMA and plasma metanephrines are typically elevated.
