Surg. ~ Short Answer

Question 1.

A 19 year old woman presents with a 12 hour history of right iliac fossa pain and tenderness.

 

A.) List your main differential diagnoses in order of priority.

Show Answer

  • Most common
    • Appendicitis
  • Life threatening
    • Ectopic pregnancy
  • Important
    • Ovarian torsion
  • Other more common
    • GIT
      • Ileitis – IBD; infective
      • Mesenteric adenitis
      • Meckels diverticulitis
      • Epiploic appendagitis
    • Gynae
      • Ovarian cyst
      • Mittlesmertz
      • PID/tuboovarian abscess
      • endometriosis
    • Renal
      • Renal calculi
      • Pyelonephritis/cystitis
    • Other less common
      • GIT
        • Biliary colic
        • Cholecystitis
        • Diverticulitis +/- abscess
        • Colon Ca
      • Musculoskeletal
        • Psoas abscess
      • Neuro
        • Radiculopathy
        • Shingles
      • Vascular
        • Iliac artery dissection

(8 marks)

B.) Describe your approach to imaging in this patient.

Show Answer

  • None if clinically indicative of appendicitis and going to OT
  • Main choices are US vs CT
  • US better utilised for gynae and CT for GIT conditions
  • US initially to rule out gynae conditions then CT if need ongoing investigations

(3 marks)

 C.) What are the advantages of ultrasound in this patient?

Show Answer

  • No radiation
  • Maybe done at bedside if patient unstable e.g. ectopic free fluid
  • Moderate sensitivity and specificity for appendicitis – Se 86% PPV 95%
  • Better Se/Sp than CT for mesenteric adenitis
  • Good sensitivity and specificity for gynae conditions e.g. ectopic, ovarian torsion, ovarian cyst, tuboovarian abscess
  • Dynamic so can test blood flow e.g. ovarian torsion
  • Can show hydronephrosis in renal conditions

(3 marks)

 D.) What are the disadvantages of ultrasound in this patient?

Show Answer

  • Operator dependant
  • Not as Se/Sp for most GIT and renal conditions
  • Not as Se/Sp for appendicitis
  • Often not as accessible as CT

(3 marks)

E.) What are the advantages of computed tomography in this patient?

Show Answer

  • Less operator dependant
  • Often accessible
  • Good Se/Sp for appendicitis (Se > 94%, PPV > 95%) and most GIT and renal conditions

(2 marks)

 

F.) What are the disadvantages of computed tomography in this patient?

Show Answer

  • Radiation
  • Have to move patient
  • Contrast
    • Reaction
    • Renal load
  • Poor Se/Sp for some gynae conditions e.g. ovarian torsion

(3 marks)

Author: J Haire

Re: Tintinalli p.521, 575-7, 673


 

Question 2.

A 52 year old man has been referred to you by his general practitioner because of the recent development of macroscopic haematuria.

 

A.) List your differential diagnosis in this patient.

Show Answer

  • Common
    • Cystitis/pyelonephritis
    • Renal calculi
    • Benign prostatic hypertrophy
  • Important
    • Renal cell carcinoma
    • Bladder carcinoma
    • Prostate carcinoma
    • AAA
  • other
    • Upper renal tract
      • Glomerulonephritis
      • Nephropathy
      • Trauma
    • Lower renal tract
      • Prostatitis
      • Trauma
    • Systemic
      • Supratherapeutic anticoagulation
      • Bleeding diatheses
      • Endocarditis/bacteraemia
      • Haemolytic uraemic syndrome
    • Non-haematuric
      • Rhabdomyolysis
      • Obstructive jaundice

(10 marks)

B.) Apart for diagnosis what other things are you going to assess this patient for?

Show Answer

  • Life-threats
    • Hypovolaemic/haemorrhagic shock
    • Sepsis
  • Pain
  • Complications
    • Anaemia
    • Urinary retention
    • Renal failure
    • Nephrotic syndrome

(5 marks)

C.) List 5 components of the presenting history required in this patient and why they will be helpful.

Show Answer

  • Timing of haematuria
    • Initial (beginning of urination)
      • Urethral disease
    • Between voiding
      • Distal urethral/meatal lesions
    • Throughout urination
      • Kidneys, bladder, urethra
    • Associated dysuria/frequency/urgency
      • Cystitis, pyelonephritis, prostatitis
    • Associated pain
      • Renal calculi
      • RCC
      • AAA
    • Weight loss
      • RCC
    • Fevers
      • Pyelonephritis, cystitis, prostatitis, endocarditis
    • Retention
      • Complication
    • Recent infection
      • HUS
      • Nephropathy
      • GN
    • Immobility
      • Rhabdomyolysis
    • Trauma
    • Symptoms of severe anaemia
      • SOBOE
      • Pre-syncope
      • PND
      • Orthopnoea

(5marks)

D.) What aspects of the patients past medical history, social history and medication history are important to find out and why?

Show Answer

  • PMHx
    • Bleeding diatheses
    • Previous GN, nephropathy
    • Artificial/congenital valves
    • IVDU
  • Meds
    • Anticoagulants
    • Antiplatelets
  • Smoking
    • Increased risk of bladder TCC

(3 marks)

 E.) What are the important aspects of physical examination in this patient and why?

Show Answer

  • Vitals (BP, HR, RR, temp)
    • Sepsis
    • Shock
  • Abdominal exam
    • Renal angle tenderness
      • Pyelonephritis
      • Trauma
      • Renal calculi
      • RCC
    • Renal angle mass
      • RCC
    • Bleeding diatheses/anticoagulants
      • Petechiae/ecchymosis
    • Hypertension, oedema in Nephrotic syndrome
    • PR
      • Prostatitis
      • Prostate Ca
    • Jaundice scleral skin
    • Anaemia pallor conjunctiva, skin
    • Pulmonary oedema secondary to anaemia or RF

(5 marks)

F.) Which bedside investigations are going to be the most useful in this patient and why?

Show Answer

  • VBG
    • Hb (anaemia)
    • Lactate/pH (sepsis, shock)
    • K (renal failure)
  • Urinalysis
    • Confirm haematuria
    • Leucs/nitrates – infective cause
    • Protein for GN

(2 marks)

G.) List 3 imaging investigations that may be of use in this patient and why.

Show Answer

  • CTKUB or non-contrast CT of abdomen
    • Renal calculi
    • Obstruction
    • May see stranding indicating pyelonephritis
  • Contrast CT abdo
    • RCC
    • Other carcinoma
  • US renal tract
    • GN, nephropathy
    • Bladder Ca
    • Prostate
    • Pyelonephritis
    • Hydronephrosis
    • Aortic size AAA

(6 marks)

H.) What would be the indications for admission in this man?

Show Answer

  • Life-threatening illness
    • sepsis
    • haemorrhagic shock
  • need for in-patient evaluation/treatment
    • renal calculi need for surgery, ongoing pain, obstructed, infected
    • GN, nephropathy further investigation/renal failure
    • Pyelonephritis
    • Bleeding/anaemia needing blood products
    • Anticoagulation requiring reversal
    • Traumatic injury

(3 marks)

Author: J Haire

Ref; Tintinalli p. 637-40


 

Quality 3.

A 26 year old man presents with a 24 hour history of a painful penis. There is no history of trauma.

Surgery Photo 1 Short Answer

 

A.) Describe the abnormalities in this picture

Show Answer

  • Oedematous foreskin
  • Oedematous glans
  • Tight band of foreskin proximal to glans with bleeding

(2 marks)

B.) What is the diagnosis?

Show Answer

  • Paraphimosis

(1 mark)

C.) How could you provide local anaesthetic to aid in reduction?

Show Answer

  • Ring block at base of penis with local anaesthetic (no adrenaline)
  • Dorsal nerve block; e. LA to base of penis and 10 and 2 o/clock; arteries very close to nerves; will only provide anaesthesia to the dorsal penis
  • Mild sedation as an adjunct

(2 marks)

D.) Describe the technique for manual reduction.

Show Answer

  • Compression for several minutes then reduce foreskin
  • Gentle steady pressure on glans with tips of thumbs whilst applying gentle traction to the foreskin
  • Can try wrapping in elastic bandage to apply pressure

(2 marks)

 E.) List and briefly describe 3 non-surgical techniques if manual reduction fails.

Show Answer

  • Osmotic reduction of swelling
    • Granulated sugar
    • Swab soaked with 50% dextrose wrapped onto penis for 1 hour
    • Injection of 1 ml of 150U/ml of hyaluronidase into 1 or 2 sites
  • Puncture method
    • About 20 puncture holes in oedematous tissue with 26G needle then manual compression
  • Ice glove method
    • Fill glove with ice and water
    • Invaginate thumb of glove over lubricated penis
  • Babcock clamp method
    • Use 6-8 Babcock’s to grasp foreskin then slowly retract

(6 marks)

F.) What are the indications for surgical intervention?

Show Answer

  • Inability to reduce
  • Evidence of ischaemia

(2 marks)

G.) Describe the surgical technique that can be done in ED

Show Answer

  • Dorsal slit
    • Penile block
    • Light sedation
    • Straight hemostats applied under the foreskin
    • Crush skin
    • Cut
    • Will likely need formal circumcision

(2 marks)

Author: J Haire

Ref: Roberts and Hedges 5th Ed p. 1001-5


 

Question 4.

A 70 year old woman presents with two days of increasing abdominal pain and vomiting.

Picture2

 

A.) List the abnormalities in this x-ray

Show Answer

  • Distended large bowel
  • Distended small bowel
  • No gas descending and sigmoid colon and rectum

(3 marks)

 B.) What is the diagnosis?

Show Answer

  • Small bowel obstruction with extension into large bowel

(1 mark)

 C.) What are the common causes of obstruction in the:

Show Answer

a.) Small bowel?

  • Adhesions
  • Hernias
  • Intussusception
  • Lymphoma
  • stricture

b.) Large bowel?

  • Carcinoma
  • Feacal impaction
  • Ulcerative colitis
  • Volvulus
  • Diverticulitis (stricture, abscess)
  • Intussusception
  • Pseudo-obstruction

(8 marks)

D.) List your management steps in the ED.

Show Answer

  • Analgesia
  • Anti-emetics
  • IV fluids
    • Aim normal HR, BP and adequate UO
  • NGT
  • Rest gut/NBM
  • Antibiotics if evidence of necrosis, volvulus, intra-abdominal sepsis
  • Consult surgeons

(5 marks)

Author: J Haire

Ref; Tintinalli p. 581-83


 

 

 

One Comment:

  1. Q4.
    is it large bowel obstruction with incompetent ileocecal valve?
    if small bowel only is obstructed there should be no gas beyond the obstruction as is the case with this one in sigmoid and rectum…..

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