Senior Surgery Flashcards
(95 cards)
1
Q
A 23 y/o man presents to A&E with a 1 day history of 8/10 central abdominal pain, that is now more prominent in the RIF. He has not vomited but describes a loss of appetite and some diarrhoea. On examination he has a tender abdomen especially in the RIF, with rebound tenderness and Rovsing’s sign +.
What is the most appropriate next step?
A. Book a laparoscopic appendicectomy
B. Give I.V. fluids and analgesia, then observe the patient for 24 hours
C. Order a CTAP
D. Order an USS of the RIF
E. Discharge with oral rehydration salts and safety-netting
A
A. Book a laparoscopic appendicectomy
No imaging is required in this patient because there is a clear history of appendicitis, so it can be diagnosed clinically. Whilst there is debate about medical vs. surgical management of appendicitis, removing the appendix is the gold standard treatment, and would be most appropriate in this patient given the severity of the presentation. This patient would also receive I.V. fluids and analgesia.
2
Q
A 79 y/o man is brought to A&E by one of the nurses at his care home for new onset abdominal pain. The pain comes and goes in bursts, though the abdomen is still tender in between episodes. The abdomen is notably distended and resonant to percussion, and the nurse reports the patient has not passed stool for at least 24 hours. The patient has a background of severe Alzheimer’s disease and chronic constipation for which he takes Memantine and Movicol respectively.
Investigations:
HR - 106, BP - 134/78, Temp - 36.9, SO2 - 97% RA
An abdominal x-ray shows the coffee bean sign
Given the likely diagnosis, how should this patient be managed?
A. I.V. fluids, make the patient NBM, sigmoidoscope decompression, and insertion of a flatus tube
B. I.V. fluids, make the patient NBM, and order a colonoscopy
C. Urgent transfer to theatre for laparotomy
D. I.V. fluids, make the patient NBM, insert an NG tube, observe for 24 hours
E. I.V. fluids, make the patient NBM, give laxatives
A
A. I.V. fluids, sigmoidoscope decompression, and insertion of a flatus tube
This patient has presented with bowel obstruction, most likely due to a sigmoid volvulus - twisting of a section of bowel around its mesenteric axis causing obstruction and sometimes infarction of the bowel. Risk factors include laxative overuse, chronic constipation, neuropsychiatric disorders, advanced age, care home residence, male sex, and previous operations.
It is important to give fluid resuscitation to compensate for 3rd spacing of fluid, and the patient must be NBM in preparation for surgery (and because trying to pass food through obstructed bowel will only exacerbate symptoms). An NG tube serves to decompress proximal bowel, which may well be done here. However this does not actually address the volvulus and it is not suitable to insert an NG tube then leave the patient for 24 hours without addressing the issue.
Management depends on the type of volvulus. They can be sigmoid or caecal: sigmoid constitutes 80% of cases. The caecum doesn’t usually twist because it is retroperitoneal in most people, but in 20% of people it is not and so can twist causing volvulus. The ‘coffee bean’ sign on AXR indicates sigmoid volvulus, whereas the ‘embryo sign’ indicates caecal volvulus.
Management of a sigmoid volvulus starts with conservative measures: IV fluids, analgesia, and a rigid sigmoidoscope decompression with insertion of a flatus tube. If this fails then a flexible sigmoidoscope is needed for decompression. If decompression fails or there is evidence of bowel ischaemia or peforation then a laparotomy will be required.
NB: DO NOT give an obstructed patient laxatives - this will not solve the problem and increases the risk of perforation.
3
Q
A 56 y/o woman is admitted to hospital with severe epigastric pain and vomiting on a background of previous biliary colic. She is diagnosed with acute pancreatitis, and an USS of the biliary tree shows gallstones within the bile duct, which is dilated.
Which of the following steps should be taken in addition to treatment of the pancreatitis?
A. Give a 7-day course of broad spectrum antibiotics
B. An MRCP scan
C. ERCP, and later laparoscopic cholecystectomy within the same admission
D. Book an elective laparoscopic cholecystectomy within the next 3 months
E. Emergency cholecystectomy
A
C. ERCP, and later laparoscopic cholecystectomy within the same admission
ERCP is indicated for relieving the obstruction acutely given that gallstones were causative.
According to the UK guidelines on acute pancreatitis, patients presenting with disease caused by gallstones should ideally have a cholecystectomy within the same hospital admission. If this is not possible, then it should be done within 2 weeks to prevent recurrent, possibly serious attacks of pancreatitis.
Link to UK guidelines on acute pancreatiits:
https://gut.bmj.com/content/54/suppl_3/iii1
NICE guidelines:
https://www.bsg.org.uk/wp-content/uploads/2019/12/NICE-Guideline-Pancreatitis-September-2018.pdf
4
Q
A 24 year old woman presents to A&E with RIF pain that woke her up this morning. The pain is 8/10 in severity, and there is rebound tenderness and involuntary guarding over the RIF.
Describe how this patient should be managed:
A
This question is asking you how to mention a presentation, not a particular condition, so the approach to investigating and initial management is broader.
A-E assessment first
History + exam:
Abdo + gynae history
Abdo exam +/- gynae exam
Bedside:
Full set of obs
Urine dip + pregnancy test
Bloods: VBG FBC U&Es LFTs CRP
Action: Make NBM I.V. fluids Analgesia Potentially antibiotics Contact emergency/ general surgeons +/- gynae
Imaging:
USS +/- CTAP
5
Q
Describe the Modified Hinchley classification of diverticulitis
A
Stage 0 - Clinically mild diverticulitis Stage Ia - Pericolic inflammation Stage 1b - Pericolic abscess Stage II - Pelvic, distant intra-abdominal, or retroperitoneal abscess Stage III - Purulent peritonitis Stage IV - Fecal peritonitis
6
Q
At what age are men invited to routine AAA screening?
A
65 years old
Routine screening consists of a single USS aged 65, as a AAA is unlikely to develop if it hasn’t by that age. Women are not routinely offered screening.
7
Q
What are the 6 p’s of acute limb ischaemia?
A
Pale Pulseless Painful Paraesthesia Paralysis Perishingly cold
8
Q
A 52 year old man presents to his GP with a 2 week history of gradual onset back pain. He is otherwise fit and well with no significant PMHx. The GP performs routine examinations including an abdominal exam, and finds a pulsatile, expansile mass in the midline of the abdomen. An USS reveals a 6cm abdominal aortic aneurysm. The patient is referred urgently to surgeons who plan to operate.
Which imaging should be performed, and which surgical technique should be used in this patient?
A. MRI + endovascular repair B. CT angiogram + endovascular repair C. MRI + open repair D. Non-contrast CT + endovascular repair E. CT angiogram + open repair
A
E. CT angiogram + open repair
Open repairs are preferred if possible because they have lower rates of re-intervention and aneurysm rupture, though they do have a higher 30 day mortality and length of hospital stay. Because of this increased short term-risk open repairs are not suitable for frail or surgically risk patients. Similarly if there is abdominal pathology that will make open intervention complex, open repair may be unsuitable.
However in a relatively young, otherwise fit and well person, an open repair is generally preferred. This is because of the increased need for re-intervention and increased rate of long-term complications following EVAR. There is even evidence that in patients who are truly too frail to undergo open repair do not benefit in terms of life expectancy from EVAR over conservative management.
Thin-slice contrast-enhanced arterial-phase CT angiography is used to evaluate the aneurysm before surgery, both for elective repair and when there is suspicion of rupture.
The European Society for Vascular Surgery guidelines (see p31 for a summary of the evidence):
https://www.esvs.org/wp-content/uploads/2018/12/Wanhainen-A-et-al-ESVS-AAA-GL-2019-epublished-041218.pdf
9
Q
How often are patients with AAA offered surveillance?
A
3.0-4.4cm = every 12 months
4.5-5.4cm = every 3 months
Elective repair should be offered for aneurysms 5.5cm or above
10
Q
What is the most common position of the appendix?
A. Preileal B. Subcecal C. Retroileal D. Retrocecal E. Pelvic
A
D. Retrocecal
The appendix is most commonly located posteriorly to the caecum.
11
Q
A 31 y/o man presents with RIF pain which is diagnosed as appendicitis. The surgeon counsels him on laparoscopic appendicectomy, but he is reluctant for surgery and asks about the ramifications of antibiotic treatment.
Without surgery, what is his likely rate of recurrence?
A
NICE quotes 12-24%, but some studies estimate anywhere between 5-40%
This is a controversial point: some studies done on large numbers of patients bear out a 5-10% risk of recurrence, whereas others point to ~40% risk. Different surgeons will have different opinions on this, but it is important to be aware of the controversy of this and the range of estimates.
https: //cks.nice.org.uk/topics/appendicitis/management/managing-suspected-appendicitis/
https: //jamanetwork.com/journals/jamasurgery/fullarticle/508940
https: //www.ncbi.nlm.nih.gov/pmc/articles/PMC4998395/
https: //jamanetwork.com/journals/jama/fullarticle/2703354
12
Q
Where is the lump found in a femoral hernia, in relation to the pubic tubercle?
A
Infero-lateral to the pubic tubercle, and medial to the femoral pulse
This is an important piece of knowledge as it helps to distinguish femoral from inguinal hernias
13
Q
Why are adhesions far more likely to cause small bowel obstruction rather than large?
A
Because the small bowel is far more mobile, and so twists itself around the adhesions and obstructs, whereas large bowel is fixed at several points in the abdomen
14
Q
A 72 y/o woman presents to her GP with a lump at the top of her left leg. The lump is soft, continuous with the skin, infero-lateral to the pubic tubercle, and non-tender. The GP sends her to A&E where a hernia is diagnosed.
What is the best management option for this hernia?
A. Admission, I.V. fluids, insertion of an NG tube
B. Reduction, then surgery to resolve the hernia within 2 weeks
C. Manual reduction followed by discharge with safety-netting advice
D. Admission, I.V. fluids, and watchful waiting
E. Admission, I.V. fluids, and an emergency referral to surgeons
A
B. Reduction, then surgery to resolve the hernia within 2 weeks
Though the surgeons may well try to reduce the hernia manually, this patient will need surgery ideally within 2 weeks because of the risk of strangulation is high given the femoral canal is narrow and rigid.
15
Q
A 28 year old 32 week pregnant woman presents to A&E with crampy abdominal pain and vomiting. She has not opened her bowels all day, and says her abdomen looks more distended than it did a couple of days ago. An abdominal exam reveals lower abdominal tenderness. The CTG trace is reassuring and she denies vaginal bleeding.
Which of the following is the most important next step?
A. A DRE B. Inspection of the hernial orifices C. A urine dipstick D. An amylase measurement E. Faecel calprotectin
A
B. Inspection of the hernial orifices
This is a history of a patient with a femoral hernia, her risk factors being female sex and pregnancy. Femoral hernias can often present with obstruction +/- strangulation due to the narrow, rigid structure of the femoral canal.
16
Q
How does pancreatitis cause hypocalcaemia?
A
Fats are autodigested by lipase released outside the pancreas, and the free fatty acids forms complexes with serum calcium, thereby decreasing the serum calcium
17
Q
What is the most common cause of acute pancreatitis?
A
Gallstones
Alcohol is the second biggest cause, and is the biggest cause of chronic pancreatitis
18
Q
What is the basic pathophysiology of acute pancreatits?
A
Inappropriate activation of pancreatic enzymes, causing an inflammatory response which increases vascular permeability and causes third spacing of fluid.
Pancreatic enzymes enter the systemic circulation and autodigest fats and blood vessels (causing haemorrhage).
In gallstone-triggered pancreatitis, there is pancreatic duct hypertension and build-up of bile salts which triggers these changes. In alcohol-induced pancreatitis, the alcohol itself modifies plasma membrane function and disturbs the balance between proteases and protease inhibitors, leading to the cascade of enzyme activation and autodigestion.
https://pubmed.ncbi.nlm.nih.gov/8119636/#:~:text=The%20pathophysiology%20of%20acute%20pancreatitis,an%20activation%20of%20pancreatic%20enzymes.
19
Q
A 53 year old lady presents to A&E with rapid onset epigastric pain. She leans forward while sitting as this improves the pain, and has vomited a few times. She is not jaundiced, and provides a prodigious alcohol history. The F2 clerking her suspects alcoholic acute pancreatitis.
Which of the following forms of imaging would be indicated at this stage?
A. ERCP B. USS of the RUQ C. Contrast CT D. CXR E. AXR
A
D. CXR
According to the UK guidelines for pancreatitis,
“Immediate assessment should include clinical evaluation, particularly of any cardiovascular, respiratory, and renal compromise, body mass index, chest x ray, and APACHE II score”.
Th CXR is important because pleural effusions and ARDS are complications of acute pancreatitis.
An USS is unlikely to be helpful here, as there is evidence that this is alcoholic pancreatitis and wasn’t caused by gallstones.
An AXR is not generally helpful for acute pancreatitis.
An ERCP will not be helpful here as there is no suggestion of gallstones.
Contrast CT scans are not very helpful early on as the full extent of the damage takes at least 4 days to become apparent, hence early CT will underestimate the damage. Furthermore CT scans don’t generally affect decisions regarding management of the patient.
However CT scans with contrast are useful in cases where initial investigations are inconclusive or in patients with persisting/ new organ failure a few days after admission, or in those with signs of sepsis.
Link to UK guidelines on acute pancreatiits:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1867800/pdf/v054p0iii1.pdf
20
Q
Which of the following is NOT a predictor for a severe attack of acute pancreatitis when assessed within 24 hours of admission?
A. Amylase >3 times the upper limit of normal B. APACHE II score >8 C. Glasgow score >3 D. BMI >30 E. CRP >150
A
A. Amylase >3 times the upper limit of normal
Though a level >3 times the upper limit of normal is diagnostic of acute panreatitis, it does not correlate well with severity. Every other option is a predictor for a severe attack when assessed within 24 hours of admission.
Link to UK guidelines on acute pancreatiits:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1867800/pdf/v054p0iii1.pdf
21
Q
Name the 3 main branches of each of:
Coeliac artery
SMA
IMA
A
Coeliac artery - splenic, common hepatic, left gastric
SMA - right colic, ileocolic, middle colic
IMA - left colic, sigmoid artery, superior rectal artery
22
Q
A patient has a section of bowel from the mid-descending colon to the mid-rectum removed. They are left with a closed rectal stump and a colostomy.
Which operation have they had?
A. Right hemicolectomy B. Hartmann's procedure C. Anterior resection D. Elective sigmoidectomy E. Left hemicolectomy
A
B. Hartmann’s procedure
Hartmann’s procedure is an emergency resection of the sigmoid colon e.g. for perforation or obstruction. It involves the formation of a colostomy and stump instead of an anastomosis because there will be bowel dilation proximal to the lesion which would make anastomosis difficult. The colostomy can be reversed and the bowel rejoined to the rectum at a later time.
23
Q
Why does bowel resection for malignancy also involve removing the associated arteries?
A
Because the lymph nodes follow the arterial system, and the nodes must be removed for staging of the cancer and prognostic estimates.
There is also prognostic benefit to removing the nodes, as it reduces the chance of malignant spread.
24
Q
A patient has a rectal tumour that needs to be electively resected. The tumour is low in the rectum, 0.5cm from the anal sphincter.
Which operation would be most suitable?
A. Anterior resection B. Sigmoidectomy C. Hartmann's procedure D. APER E. Extended right hemicolectomy
A
D. APER
Bowel malignancies are typically resected with at least 1cm of clearance. If the anal sphincter is within the 1cm clearance range, then an anterior resection would leave this patient permanently incontinent. Accordingly they undergo APER (abdomino-perineal resection of the rectum) instead, which includes formation of a colostomy.
25
Why can a tumour in the splenic flexure not be treated with simple resection and anastomosis in that area?
Because it is within the watershed area - an area of bowel that receives dual blood supply from the most distal parts of two arteries. This means the blood supply is too poor to support an anastomosis in this area, and so surgery must either avoid the splenic flexure, or remove it.
26
Describe a Hartmann's procedure
An emergency resection of the recto-sigmoid colon (e.g. to relieve obstruction) involving formation of an end colostomy and a rectal stump (they are not anastomosed at the time but can be later once the downstream bowel has recovered).
```
Indications include:
Obstruction
Diverticulitis leading to perforation
Trauma
Ischaemia/ volvulus
```
27
On examination of a patient, you see a double-barrelled stoma on the left of the patient's abdomen which is flush with the skin.
What is the most likely purpose of this stoma?
To temporarily defunction the downstream bowel, e.g. after an anastamosis to allow it to heal. This type of stoma (loop stoma) is easier to reverse and so is preferable to forming an end stoma.
28
A 63 year old woman is brought to A&E by ambulance with acute left leg pain. On examination the limb is cold and the pulses cannot be felt. The patient has total loss of sensation below the knee, the limb is paralysed, and there is a fixed mottling pattern of the skin.
What is the most appropriate treatment?
```
A. Bypass grafts
B. Embolectomy via a Fogarty catheter
C. Amputation
D. Local intra-arterial thrombolysis
E. Angioplasty
```
C. Amputation
The paralysis, total loss of sensation, and fixed mottling all indicate that this limb is no longer viable and should be amputated. Patients who have had surgical management of acute limb ischaemia will often require HDU or ICU afterwards because of the consequences of reperfusion injury - hyperkalaemia, acidosis, AKI.
Acute limb ischaemia is classified using the Rutherford scale which correlates clinical features with viability of the limb.
Link to table of Rutherford classification:
https://www.researchgate.net/figure/Classification-scheme-for-acute-limb-ischemia-ALI_tbl2_260980080
29
A 70 y/o man presents to A&E with rapid onset right excruciating flank pain. When seen by the doctor he is sweaty and lying still in bed, but occasionally writhes around for short periods when his pain suddenly becomes worse and then abates. He has vomited several times and when he managed to pass urine it was bloodstained. His HR is 108, BP is 149/82, SO2 is 98 on room air, and temp is 37.0.
How should this patient be managed?
A. Contact the general surgeons and arrange for an urgent transfer to theatre
B. Give tramadol and I.V. fluids, and contact the general surgeons for a review
C. Give I.V. fluids, antibiotics, and oxygen, and take blood cultures, a VBG, and catheterise the patient to monitor urine output
D. Give I.V. fluids, tramadol, and tamulosin, then order an USS
E. Give NSAIDs, I.V. paracetamol, and I.V. fluids, and order an urgent non-contrast CT scan
E. Give NSAIDs, I.V. paracetamol, and I.V. fluids, and order an urgent non-contrast CT scan
This is a history of renal colic - a common condition especially in the summer as dehydration increases the risk. Treatment and investigations for renal colic are summarised below:
Pain relief:
1st: NSAIDs
2nd: add I.V. paracetamol
3rd: opioids e.g. tramadol
Investigations:
Urgent non-contrast CTKUB
Use USS if CTKUB contraindicated (e.g. in pregnancy) or in young people/ children
Bloods inc. calcium (given the high prevalence of primary hyperparathyroidism in patients presenting with renal stones)
Management:
I.V. fluids
Watch and wait if stone is <5mm, and sometimes in >5mm stones depending on patient wishes
Alpha blocker to facilitate passage of distal stones <10mm during watchful waiting
Surgery if other methods are insufficient, if stone is unlikely to pass, or if patient cannot tolerate pain
30
A 10 year old boy is brought to A&E with flank pain, dysuria, and blood in his urine. The clerking doctor suspects renal colic, and sees in the notes that the boy has a background of ongoing vesicoureteral reflux. A mid-stream urine sample is taken and sent for MC&S, and Proteus miribalis is grown. An USS shows a stone in the ureter.
What is the most composition of this stone?
```
A. Cysteine
B. Magnesium ammonium phosphate
C. Uric acid
D. Calcium oxalate
E. Xanthine
```
B. Magnesium ammonium phosphate
31
Match each of the scenarios with the most appropriate surgical intervention:
1. Severe currently flaring UC not responding to medical treatment
2. UC with colonoscopy showing dysplastic masses
3. Bowel obstruction due to malignancy
4. Adenocarcinoma of the descending colon
5. Rectal cancer within 1cm of the internal anal sphincter
6. High rectal malignancy
```
A. Pan proctocolectomy with ileoanal pouch
B. APER
C. Anterior resection
D. Left hemicolectomy
E. Sub total colectomy
F. Hartmann's procedure
```
1. Severe currently flaring UC not responding to medical treatment - E. Sub total colectomy
2. UC with colonoscopy showing dysplastic masses - A. Pan proctocolectomy with ileoanal pouch
3. Bowel obstruction due to malignancy - F. Hartmann's procedure
4. Adenocarcinoma of the descending colon - D. Left hemicolectomy
5. Rectal cancer within 1cm of the internal anal sphincter - B. APER
6. High rectal malignancy - C. Anterior resection
*****
Usually have to make ileoanal pouch at time of colectomy, can't do it afterwards if rectum removed
Ileoanal pouch is not usually recommended in perianal/ rectal Crohn's due to the high risk of fistula formation
32
What is the most common location of colorectal cancer?
Rectum ~40%
| Second commonest is sigmoid colon ~30%
33
A 68 year old woman visits her GP to discuss results of a recent routine blood test. Her FBC showed a microcytic anaemia, but she claims to have been feeling fine recently.
How should this patient be managed?
A. Make a 2 week wait referral
B. Order an anti-ttg antibodies test and fetal calprotectin
C. Perform a PR exam, if this is normal then review in 2 weeks
D. Safety net and ask her to return for repeat bloods in 1 month
E. Perform a FIT and act based on the result
A. Make a 2 week wait referral
This is a presentation of colon cancer - most likely right-sided given the insidious onset. Whilst this could easily be something else very benign, these are red flags that should be thoroughly investigated just in case. The criteria for 2 week wait colon cancer referral are:
≥40yrs with unexplained weight loss and abdominal pain
≥50yrs with unexplained rectal bleeding
≥60yrs with iron‑deficiency anaemia or change in bowel habit
Positive occult blood screening test
Faecal immunochemical tests (FIT) are used to guide referrals in cases where there is a possibility of malignancy but the patient doesn't meet the 2 week wait criteria. Doing a FIT wouldn't be the worst option here, but the point of this question is to emphasise that if someone has worrying criteria for bowel cancer, they should get a 2 week wait referral.
NICE 2 week wait criteria:
https://www.nice.org.uk/guidance/ng12/chapter/1-Recommendations-organised-by-site-of-cancer#lower-gastrointestinal-tract-cancers
34
A 58 year old man presents to A&E with a 2 day history of gradually worsening 6/10 lower left quadrant pain. He feels generally well, but has not passed stool for 2 days and feels bloated. O/E he has left lower quadrant tenderness and guarding, and a DRE elicits pelvic tenderness. He has a fever of 38.4 and a WCC of 14 with neutrophils of 10.
How should this patient be investigated further?
```
A. Colonoscopy
B. USS of the left iliac fossa
C. Exploratory laparoscopy
D. Pelvic MRI
E. CT abdomen and pelvis
```
E. CT abdomen and pelvis
This is a history of diverticulitis: lower left quadrant pain, fever, neutrophilia, and constipation are all common features.
Diverticulitis is investigated with a CTAP which also helps to stage the disease
NB: PR bleeding is uncommon in diverticulitis, and if it occurs it is usually abrupt, painless, profuse bright blood. This occurs when the diverticular disease erodes into an artery/ arteriole, and isn't usually associated with acute diverticulitis
35
Briefly describe the management of acute diverticulitis
Manage with analgesia alone if mild
If generally unwell or signs of complication (faeces via vagina, abdominal or rectal mass, peritonitic, septic, or obstructed) then:
Admit
I.V. fluids
Contrast CTAP
Oral antibiotics is generally unwell, but I.V. if complicated (fistula, obstruction, sepsis, abscess, or perforation)
May require drainage/ washout of collections, or emergency resection of the colon (Hartmann's procedure)
Liquid diet for a few days, then low fibre diet while recovering, then high fibre diet for future
36
A 28 year old woman presents to A&E with a 2 hour history of sudden onset headache which she describes as "the worst of my life". The clerking doctor suspects a sub-arachnoid haemorrhage (SAH).
Which of the following is the most useful way to confirm SAH at this stage?
```
A. Fundoscopy
B. Collation of physical symptoms
C. CT head
D. Lumbar puncture
E. MRI
```
C. CT head
Within the first 6 hours, CT head is a very sensitive and specific test with an extremely high negative predictive rate. Conversely an LP may well yield a false positive initially; this is because xanthochromia is caused by bilirubin which is a haemoglobin breakdown product. It takes time for the RBCs that have bled from the SAH to be destroyed and have their haemoglobin converted to bilirubin. Ideally an LP should be done 12 hours after onset of symptoms.
Symptoms are not a reliable way to diagnose SAH, as even classic symptoms like 'worst headache of their life' don't actually have very good sensitivity or specificity. Even the time of onset of the headache is not necessarily very helpful.
Good articles on CT head in SAH and general management:
https: //www.bmj.com/content/343/bmj.d4277
https: //www.bmj.com/content/339/bmj.b2874
37
A 55 year old man presents to A&E with a 1 hour history of headache following tripping and falling on the street. The headache came on suddenly after he hit the ground, is 10/10 in severity, and is accompanied by nausea, 2 episodes of vomiting, and photophobia. He has a 10 pack year smoking history and is taking Lisinopril and Amlodipine for hypertension. He is sent for a CT head which is normal.
What is the most appropriate next step?
```
A. Cerebral angiogram
B. Lumbar puncture after 6 hours
C. Skull x-ray
D. MRI
E. Repeat CT head in 24 hours
```
B. Lumbar puncture after 6 hours
This is a history of subarachnoid haemorrhage - the history of fall is significant because most subarachnoid bleeds are caused by trauma (albeit on a background of pre-existing aneurysm). CT head is a very sensitive investigation for detecting sub-arachnoid haemorrhage. If it is negative, a lumbar puncture should be done, but this should be at least 6 (preferably 12) hours after onset to give time for the haemoglobin in blood in the brain to degrade (it is the haemoglobin degradation products that produces xanthachromia).
If LP and CT head are both negative, SAH can be excluded. Repeating the CT head in 24 hours is unlikely to help, as CT head sensitivity decreases with time as the blood in the subarachnoid space is cleared.
CT angiography will be performed by the neurosurgeons when the diagnosis is established, but is not part of the diagnostic work up.
BMJ page on SAH:
https://www.bmj.com/content/339/bmj.b2874
NHS page on SAH:
https://www.nhs.uk/conditions/subarachnoid-haemorrhage/treatment/
38
A 55 year old man presents to A&E with a 1 hour history of headache following tripping and falling on the street. The clerking F2 suspects SAH and orders a CT head which confirms the diagnosis. The patient is referred to the neurosurgeons who control his blood pressure, give analgesia, monitor his fluid balance, electrolytes and nutritional status, and arrange for coiling of the aneurysm.
Which drug should be prescribed to reduce the chance of secondary cerebral ischaemia?
Nimodipine
Nimodipine is a calcium channel blocker which acts to dilate arteries. It is given to counteract a trend in SAH for vessels to spasm causing ischaemia and stroke around day 7 post-bleed.
39
Match each of the appearances on a CT head to the correct diagnosis:
1. Subarachnoid haemorrhage
2. Subdural haemorrhage
3. Epidural haemorrhage
A. A well demarcated convex area of increased density
B. A concave area of increased density
C. Increased density in the basal regions of the skull
1. Subarachnoid haemorrhage - C. Increased density in the basal regions of the skull
2. Subdural haemorrhage - B. A concave ares of increased density
3. Epidural haemorrhage - A. A well demarcated convex area of increased density
40
A 26 y/o male is brought to a major trauma centre having been in a high speed motorbike crash. He is haemodynamically stable, conscious, able to move all 4 limbs, and is immobilised in neck blocks. He has extensive abrasions and a suspected fracture to his left tibia. After his primary survey he suddenly deteriorates, his systolic blood pressure dropping to an unrecordable level.
What is the most likely cause?
```
A. Cardiac tamponade
B. Tension pneumothorax
C. Haemothorax
D. Aortic transection
E. Pulmonary embolus
```
D. Aortic transection
41
A 53 year old man attends A&E after a period of hot weather with sudden onset left flank pain. The pain is intermittent, with periods of almost total relief followed by periods of intense crampy pain that radiates towards his groin. His obs show the following:
Temp - 38.3
BP - 96/65
HR - 107
RR - 26
How should this patient be managed?
A. Give diclofenac, i.v. saline, and broad spectrum antibiotics
B. Initiate the sepsis 6, arrange for a nephrostomy
C. Give diclofenac, tamsulosin, i.v. saline, and broad spectrum antibiotics
D. Perform urgent ureteroscopy
E. Perform urgent shock wave lithotripsy
B. Initiate the sepsis 6, arrange for a nephrostomy
In cases where renal colic causes sepsis, dealing with the stone should be delayed. Instead the priority is to treat the sepsis and relieve the pressure of the renal collecting system. Either stents or a nephrostomy may be used, but resolving the stone should be delayed till the sepsis is resolved.
BAUS guidelines:
https://www.baus.org.uk/_userfiles/pages/files/Publications/Acute%20ureteric%20colic%202018.pdf
42
A 56 year old woman attends A&E with a 3 day history of severe epigastric pain accompanied by vomiting. She drinks ~45 units of alcohol each week and has been seen several times in the past for biliary colic (she was managed conservatively).
Given the likely diagnosis, what is the most appropriate next test?
```
A. ERCP
B. CXR
C. CT scan
D. Urine dip
E. Serum lipase
```
E. Serum lipase
Serum lipase is more sensitive and specific than serum amylase for acute pancreatitis, and stays elevated for longer than amylase (which may normalise after 24 hours in some cases).
ERCP may be indicated later if pancreatitis is confirmed and the cause is suspected to be gallstones (which it probably is in this case) but should wait till the diagnosis is confirmed.
A CT scan is not routinely indicated at presentation, but can be useful in severe cases after the first week to assess the extent of necrosis. The necrosis will not be fully visible before then, and so a CT scan won't affect management in the first week.
A CXR should be done in the initial workup of an acute pancreatitis patient, but is less appropriate than the test to confirm the diagnosis.
A urine dip may well be done just in case, but isn't hugely relevant to this presentation.
43
A 64 year old man undergoes a high anterior resection for rectal cancer, and after excising the tumour the surgeon anastomoses the two bowel ends. The surgeon wishes to rest the anastomosis and allow it to heal.
Which stoma would be most appropriate for this goal?
```
A. End colostomy
B. Caecostomy
C. End ileostomy
D. Loop ileostomy
E. Loop jejunostomy
```
D. Loop ileostomy
A loop stoma is commonly used to defunction downstream bowel and allow an anastomosis to heal. It involves bringing a section of bowel to the surface, and opening up one side of it vertically so that the stoma is double barreled. This is preferable to an end stoma because the reversal is simpler.
Loop ileostomies are preferred to loop colostomies for anterior resections because small bowel heals better than large so they have a lower rate of complications (this is somewhat debated).
44
A 51 year old man presents to A&E with right upper quadrant (RUQ) abdominal pain. He is feverish and nauseous, and has vomited twice. Examination reveals RUQ abdominal tenderness, guarding, and scleral icterus. He is tachycardic and looks generally unwell. The surgical registrar suspects ascending cholangitis with a differential list of:
Pancreatitis
Cholecystitis
Biliary colic
Perforated gastric ulcer
Which of the features of the history most supports ascending cholangitis over the other differentials?
```
A. Vomiting
B. Scleral icterus
C. Fever
D. Guarding
E. RUQ pain
```
B. Scleral icterus
Jaundice is a key feature of ascending cholangitis - Charcot's triad is fever, RUQ pain, and jaundice. Jaundice is not a feature of any of the other differentials, and all the other options occur in at least two of the differentials mentioned. This is a useful point as these differentials can sometimes be difficult to distinguish from each other.
45
A 73 year old man presents to A&E with 10/10 sudden onset abdominal pain accompanied by nausea and vomiting. He was discharged from the hospital 4 weeks ago following a STEMI. His abdomen is diffusely tender but soft, and his pulse is irregularly irregular. Bloods reveal the following:
```
Haemoglobin 117 g/L (135-180)
White cell count 21 × 109/L (3.8–10.0)
Urea 16.4 mmol/L (2.5–7.8)
Creatinine 158 µmol/L (60–120)
CRP 110 mg/L (<5)
Arterial blood gas breathing air pH 7.28 (7.35–7.45)
PO2 13.9 kPa (11–15)
PCO2 3.7 kPa (4.6–6.4)
Bicarbonate 16 mmol/L (22–30)
Lactate 4.5 mmol/L (1–2)
```
How should this patient be managed initially?
A. I.V. access, give fluids, urgent I.V. contrast CT
B. I.V. access, give fluids, trial insertion of a rigid sigmoidoscope
C. I.V. access, give fluids, make them NBM, insert an NG tube
D. I.V. access, cross match blood and transfuse, then reassess
E. I.V. access, give fluids, calculate an APACHE II score
A. I.V. access, fluids, urgent I.V. contrast CT
This is a description of acute bowel ischaemia, likely due to a thromboembolism from the patient's heart given the recent STEMI and current atrial fibrillation. The key giveaway for acute bowel ischaemia is 'pain out of proportion to the clinical findings' as is present here. Combined with a metabolic acidosis and elevated lactate, this is suggestive of acute ischaemia.
An I.V. contrast CT is the definitive investigation, and this patient will need urgent surgery either to revascularise, or to resect the bowel.
46
A 68 year old woman presents to A&E with severe pain in her left leg that woke her from sleep. The left leg is pale and cold to the touch. She can move her toes only a little, and is numb from the metatarso-phalangeal joints distally. She has a background of atrial fibrillation, for which she has not been taking her anticoagulation as it caused bruising. She is started on high-flow oxygen and given a heparin bolus with a follow-on infusion.
How should this patient be managed further?
```
A. Continue with heparin infusion
B. Give a nitric oxide infusion
C. Start a LMWH or Apixaban
D. Amputate the non-viable limb
E. Embolectomy with a Fogarty catheter
```
E. Embolectomy with a Fogarty catheter
This is a history of acute limb ischaemia, most likely due to a thromboembolus secondary to atrial fibrillation. Acute limb ishcaemia is classified using the Rutherford criteria, under which this limb would be classified as 'threatened: immediate' i.e. requires immediate intervention to salvage.
NB: they will likely need ICU intervention afterwards because of reperfusion syndrome (acidosis, hyperkalaemia, AKI).
Fogarty catheter is less useful when there is pre-existing disease; bypass surgery would be a better option in that case.
European guidelines on acute limb ischaemia:
https://www.esvs.org/wp-content/uploads/2020/02/Acute-Limb-Ischaemia-Feb-2020.pdf
47
Summarise the management options for a AAA
Conservative - surveillance, smoking cessation
Medical - cardiovascular risk factor control (anti-hypertensives, statins, antiplatelet therapy for peripheral vascular disease)
Surgical - open repair or EVAR. Open repair preferable especially if patient has good life expectancy.
48
Briefly describe the current bowel screening strategy
People between 60-74 are sent a FIT test (faecal immunochemical test) every 2 years automatically. People aged 75 or over can request one every two years.
49
What is the most significant risk factor in the general population for AAA?
Smoking
50
A 54 year old man visits his vascular surgeon for monitoring of his AAA. At his last visit 1 year ago it was 3.4cm, and it now measures 4.8cm. He has otherwise been well with no symptoms from his AAA, and gets a modest amount of exercise. He has diabetes and hypertension which he takes medication for, but which is not optimally controlled.
How should this patient be managed?
```
A. Advise smoking cessation and optimise cardiovascular risk factors only
B. Repeat the ultrasound in 12 months
C. Repeat the ultrasound in 3 months
D. Advise an open repair
E. Advise endovascular repair
```
D. Advise an open repair
The 3 main criteria that make you consider elective AA repair are:
Size >5.5cm
Size >4.0cm and size increase of >1cm per year
Symptomatic AAA
Whilst this patient should have their cardiovascular risk factors (hypertension, diabetes, smoking, high cholesterol) optimised, they also need to be considered for surgery. Given there is no mention of contraindications to open repair (adhesions, previous surgeries, abnormal anatomy, general anaesthetic risks) it is the generally recommended option.
Open repair is preferred by NICE because:
It is more cost effective
Has better long-term survival and fewer complications/ lower rate of re-intervention
The evidence around this is a little mixed, but generally the consensus is that EVAR has a short term advantage in that it has a shorter hospital stay and operative mortality associated. However this advantage is lost after 1-3 years because of the increase in aneurysm-related mortality.
There is even evidence that using EVAR in patients too frail to undergo open repair does not actually improve lifespan when accounting for perioperative mortality and complications.
The European guidelines has a very good section summarising the evidence (p31):
https://www.esvs.org/wp-content/uploads/2018/12/Wanhainen-A-et-al-ESVS-AAA-GL-2019-epublished-041218.pdf
51
Which of the following features would give the worst prognosis in a case of acute limb ischaemia?
A. No sensation from the mid-shin distally
B. Undetectable arterial doppler signal
C. Weakness of movements of the foot
D. Non-palpable pedal pulses
E. Blanching mottled appearance of the skin
A. No sensation from the mid-shin distally
This is a question about the Rutherford classification of acute limb ischaemia which assess limb viability based on sensory deficit, motor deficit, and results of venous and arterial Doppler scan. A profound sensory deficit is an indicator of a non-viable limb.
Mottling is not part of the Rutherford classification but is an important sign of ishcaemia: it indicates non-viability when it becomes non-blanching (fixed mottling).
European guidelines on acute limb ischaemia:
https://www.esvs.org/wp-content/uploads/2020/02/Acute-Limb-Ischaemia-Feb-2020.pdf
52
A 70 year old man is due to undergo surgery for a NOF#. He has a signficant past medical history and is on a range of medications:
Metformin for T2DM
Bisoprolol and low-dose aspirin after a STEMI 3 weeks ago for which he had PCI and stenting
Perindopril for hypertension
Sodium valproate for generalised epileptic seizures
Which of his medications should be stopped prior to surgery?
```
A. Metformin
B. Bisoprolol
C. Perindopril
D. Sodium valproate
E. Low dose aspirin
```
C. Perindopril
Many medications can be continued as normal in the run up to surgery and after. Some notable exceptions are:
The oral contraceptive pill - stop 4 weeks prior to immoblising surgery, and resume 2 weeks after fully mobile again
ACEi, ARBs, and potassium sparing diuretics - risk of hyperkalaemia and hypotension
Aspirin unless they are at high thrombotic risk (previous stenting, recent ACS, or previous stroke)
Lithium
BNF summary of long-term medications in surgery:
https://bnf.nice.org.uk/treatment-summary/surgery-and-long-term-medication.html
53
A 24 year old woman presents with severe on-off sharp pain that radiates from her flank to her groin. She has also been passing some blood in her urine. A urine dip confirms the presence of blood but there are no nitrites or leukocytes. She is afebrile with a BP of 123/85.
How should this patient be managed?
A. Order an USS and initiate the sepsis 6
B. Give I.M. diclofenac +/- paracetamol, I.V. fluids, and perform an USS
C. Order a CTKUB, give I.V. antibiotics and fluids
D. Order a CTKUB and make an urgent referral to urology
E. Give oral tramadol and refer for ureteroscopy
B. Give I.M. diclofenac +/- paracetamol, I.V. fluids, and perform an USS
Though a non-contrast CTKUB is the gold standard investigation for renal colic, it it preferable to avoid radiation in children and young people, especially young women of child bearing age. Accordingly an USS should be done first, and in the meantime she should receive pain relief and fluids as she is probably dehydrated.
NB: this women should receive a pregnancy test before being exposed to ionising radiation
54
A 68 year old woman is due to undergo an elective AAA repair. She has a background of rheumatoid arthritis for which she has been taking 10mg prednisolone daily for 4 weeks.
Which of the following is an appropriate steroid regime for her?
A. Give steroids at induction, and a post-op infusion until able to take orally
B. Take double her usual dose of steroids on the day of surgery, and in the week following the operation
C. Wean the steroids over the 4 weeks before surgery
D. Omit steroids on the day of surgery, take blood gas and U&Es post-op to assess need for top-up dose
E. Continue to take her steroids as normal up to, and after the operation
A. Give steroids at induction, and a post-op infusion until able to take orally
She should be given 100mg hydrocortisone I.V. at induction, then a 200mg/24h hydrocortisone infusion until she is able to take double her usual dose orally. This is then weaned back to her usual steroid dose over 48 hours (may need longer with major surgery).
Association of Anaesthetists Guidelines:
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.14963
55
A 72 year old woman is due to have a total hip replacement following a fall and NOF#. She has stage 1 hypertension controlled with lisinopril and had a STEMI 2 years ago since which she has been taking bisoprolol, atorvastatin, and aspirin. She underwent angioplasty and has been managing well, and denies any symptoms of heart failure.
Which preoperative tests should she receive?
A. CXR, urine dip, bloods (FBC, VBG, clotting)
B. CXR, ECG, bloods (FBC, LFTs, U&Es, Hba1c)
C. ECG, bloods (FBC, U&Es)
D. CXR, ECG, bloods (FBC, U&Es, clotting, LFTs)
E. Spirometry, CXR, ECG, bloods (FBC, U&Es, clotting, LFTs)
C. ECG, bloods (FBC, U&Es)
NICE determines which preoperative tests are needed based on the patient's ASA (fit status) and the scale of the surgery. Given this patient would be ASA 3 and a total joint replacement counts as major surgery, she will need the following tests:
ECG
FBC
U&Es
Clotting would be done if she had liver impairment or was taking anticoagulants
Spirometry +/- an ABG would be considered if she had serious lung disease
Chest x-rays are not routinely done as part of a preoperative assessment, and there isn't a good reason to do one here. Similarly Hba1c and LFTs are not routinely done without an indication (the exception being diabetics who have not had an Hba1c within the last 3 months - they need one).
Echocardiograms may be indicated if there is evidence of impaired LVEF.
NICE poster summary of preoperative tests:
https://www.nice.org.uk/guidance/ng45/resources/colour-poster-pdf-2423836189
56
How should you classify complications of any surgery?
They should be classified according to timing (immediate, early, late) and location (systemic and local):
Immediate Local:
Injury to adjaceant structures (vessels, nerves, muscles, tendons, ligaments, organs)
Immediate Systemic:
Bleeding +/- shock
Anaesthetic complications
```
Early Local:
Wound site infection
Wound dehiscence
Implanted material infection
Anastamotic leak
Post-op ileus
```
```
Early Systemic:
Pain
Nausea
Delirium
Sepsis
Bed sores
UTI
HAP
VTE
Muscle atrophy
```
```
Late Local:
Healing failure/ malunion
Scarring
Adhesions
Operative failure
Stricture
```
Late Systemic?
57
A 72 year old presents to his GP with bilateral calf pain. The pain started about a year ago and is worse on exertion but relieves with rest. however he has recently noticed pain at rest, and the pain has started to wake him from sleep though it improves if he stands up for a bit.
What has this patient recently developed?
```
A. Lumbar spinal canal stenosis
B. Critical limb ischaemia
C. Peripheral arterial disease
D. Acute on chronic limb ischaemia
E. Intermittent claudication
```
B. Critical limb ischaemia
Critical limb ischaemia refers to peripheral arterial disease that has progressed so far as to threaten the limb. The key feature of critical limb ischaemia is pain at rest, often worse at night as elevation of the limb removes the assistance of gravity in perfusing the limb, and BP drops during sleep.
Treatment of peripheral arterial disease centres on reducing other cardiovascular risk factors (smoking, diet, exercise, lipid modification, hypertension, diabetes, antiplatelet therapy) and encouraging exercise as this promotes formation of collateral vessels to improve perfusion. Pain should be managed with paracetamol or weak opiods.
Once critical limb ischaemia develops, treatment should address wound care, footwear modification, good glycaemic control, and potentially revascularisation.
ESC guidelines:
https://academic.oup.com/eurheartj/article/39/9/763/4095038
58
A 53 year old woman presents to A&E with rapid onset epigastric pain. Her blood tests show a very high amylase in-keeping with pancreatitis, though there is no evidence of gallstones on USS, and she is admitted.
Which of the following steps should be taken at this point?
A. Give broad spectrum antibiotics
B. Start enteral feeding as soon as tolerable
C. MRCP
D. ERCP
E. Consider endoscopic or percutaneous pancreatic debridement
B. Start enteral feeding as soon as tolerable
Early enteral (either oral or via NG/ NJ tube) feeding is encouraged in acute pancreatitis if tolerable. This is because it is safer than parenteral nutrition and there is some evidence it improves recovery time and limits gut inflammation (though this is disputed).
Antibiotics are not routinely recommended in pancreatitis, there is some evidence showing efficacy but not enough for the UK guidelines to recommend it, and NICE explicitly advises against it.
ERCP and MRCP would not be helpful given the USS findings, and debridement is not a consideration till later on as their is unlikely to be any necrosis yet.
Link to UK guidelines on acute pancreatiits:
https://gut.bmj.com/content/54/suppl_3/iii1
NICE guidelines:
https://www.bsg.org.uk/wp-content/uploads/2019/12/NICE-Guideline-Pancreatitis-September-2018.pdf
59
What is an acceptable post-void residual urine volume?
There is little consensus, but above 200ml is abnormal, and above 100ml may be.
60
A 65 year old man presents to his GP with pain in his buttocks and the back of his legs down to his feet. The pain has been progressively worsening over the last month and is exacerbated by standing or walking, but relieved by sitting down. The pain is accompanied by numbness and a feeling of heaviness in his legs. On examination power is 5/5 in all leg muscle groups, sensation is normal, and there is no muscle wasting. His pedal pulses are palpable and strong, and his feet are warm. He is otherwise generally well and not taking any medication.
What is the most likely diagnosis?
```
A. Multiple sclerosis
B. Spondylolisthesis
C. Lumbar spinal stenosis
D. Critical limb ischaemia
E. Peripheral arterial disease
```
C. Lumbar spinal stenosis
Differentiating between peripheral arterial disease and lumbar spinal canal stenosis is difficult as both present with pain and weakness on walking. The key features in this history are: the pain is relieved by sitting down, the examination shows the feet are well perfused, and he has no significant PMHx.
The pain in spinal stenosis is relieved by sitting and leaning forward because the flexion of the spin opens up the space for the spinal cord, whereas standing and walking restores the lordosis of the lumbar spine and compresses the cord. The well perfused feet on examination make peripheral arteriasl disease less likely, and the lack of PMHx is suspicious too as someone with peripheral arterial disease will often have concomitant diabetes or hypertension or heart disease.
Since the compression of the cord in stenosis is transient, there should not be any neurological deficits on examination, save in very advanced and serious cases.
61
Briefly outline management of acute cholecystitis
History and exam/ A-E assessment
Bloods: FBC, CRP, LFTs (ALP may be raised but other LFTs usually aren't), amylase, VBG, U&Es
USS 1st line imaging, hepatobiliary iminodiacetic acid (HIDA) scan is very accurate but rarely available
I.V. antibiotics, fluids, analgesia
Laparoscopic cholecystectomy within 1 week
Preoperative imagine e.g. with MRCP or endoscopic ultrasound
Here is a good recent set of guidelines with an analysis of the evidence:
https://wjes.biomedcentral.com/articles/10.1186/s13017-020-00336-x#Abs1
62
Why might an extended right hemicolectomy by preferable to a left hemicolectomy in tumours of the splenic flexure?
Anastomosing the transverse colon with the sigmoid is practically difficult because the transverse colon is fixed in place by the middle colic artery. It is therefore more practical to perform an extended right hemicolectomy (taking the right, middle, and left colic arteries) and make an ileo-sigmoid anastomosis. Small bowel has a better blood supply so this anastomosis is also more likely to heal well.
63
Describe the TNM tumour calssification system for bowel cancer
REVIEW*
T1: into (but not through) submucosa
T2: into (but not through) muscularis propria
T3: through muscularis propria into subserosa, or
into non-peritonealised pericolic/perirectal tissues
T4a: penetration of the visceral peritoneal layer
T4b: penetration or adhesion to adjacent organs
```
N0: no evidence of nodal involvement
N1a: involvement of one regional nodes
N1b: involvement of 2-3 regional nodes
N1c: deposits involving serosa or non-peritonealised pericolic/perirectal tissues without regional nodal metastasis
N2a: involvement of 4-6 nodes
N2b: involvement of ≥7 nodes
```
M0: no evidence of metastases
M1a: distant metastases confined to one organ (e.g. liver, lung, ovary, non-regional node)
M1b: distant metastases confined to more than one organ or to the peritoneum
64
Colorectal questions
```
When to stent
When to adjuvant and neoadjuvant
Why MRI for rectal
What is the clearance needed for ant res instaed of aper
What are the pallaitive options
Is stenting only for use in palliative
```
https: //onlinelibrary.wiley.com/doi/full/10.1111/codi.13703
https: //onlinelibrary.wiley.com/doi/full/10.1111/codi.13704
https: //teachmesurgery.com/general/large-bowel/colorectal-cancer/
65
The general surgery F1 is bleeped to see a 68 year old patient who is 5 hours post bowel resection + anastomosis and has developed a fever. When the F1 arrives the patient is a little drowsy and his obs are as follows:
```
RR: 15
SO2: 98% RA
HR: 71
BP: 132/79
Temp: 37.8
```
What is the most likely cause of his fever?
```
A. Normal post-op fever
B. Atelectasis
C. Pneumonia
D. UTI
E. Anastamotic leak
```
A. Normal post-op fever
After a large operation, it is normal for the patient to be slightly febrile as such a major insult will trigger an inflammatory reaction. It is also not too surprising he is drowsy as he has recently had a general anaesthetic.
Though it is frequently cited as a cause of early post-op fever, there is essentially no evidence that atelectasis is associated with fever, and it's likely that it actually isn't.
It is too early in this patient's admission for them to be devloping either a UTI or pneumonia (usually 3-5 days post-op). Similarly it would be unusual to see fever from an anastomotic leak a few hours after an operation (this usually presents 5-7 days post-op).
66
Summarise the causes of post-operative pyrexia
The causes of post-operative pyrexia can be classified by time course:
0-2 days post-op:
General post-op fever
Malignant hyperthermia anaesthetic reaction
Febrile reaction to intraoperative blood transfusion
Potentially pneumonia secondary to atelectasis
Drug reaction
```
3-5 days post-op:
UTI
Pneumonia
Sepsis
VTE
Drug reaction
```
```
5-7 days post-op:
Anastomotic leak
Wound site/ surgical material infection/ abscess
UTI
Pneumonia
Sepsis
VTE
Drug reaction
```
67
Which of the following is NOT an indication for referral of varicos veins to specialist services?
```
A.
B.
C.
D.
E.
```
https://cks.nice.org.uk/topics/varicose-veins/management/varicose-veins/
68
Describe the 'A FROGMAN' risk factors for breast cancer
These just seemed quite useful to learn
```
A - age
F - family history
R - radiation
O - OCP/HRT and obesity
G - genetics (e.g. known BRCA mutation)
M - menarche (early) or menopause (late)
A - alcohol
N - nullparity
```
69
An 80 year old woman presents to her GP with 4 weeks of constipation. She was seen 2 weeks prior and had her Amlodipine switched to Losartan, but the constipation persists. She also mentions some recent progressive fatigue and 3kg of unintentional weight loss in the past month.
Which test result would support the likely diagnosis?
```
A. A normocytic anaemia on FBC
B. Presence of Bence-Jones proteins in the urine
C. The 'apple core sign' on CT
D. Positive faceal calprotectin test
E. Positive anti-ttg antibody test
```
C. The 'apple core sign' on CT
This history is suspicious for bowel cancer, specifically a left-sided malignancy. Left-sided colon cancer presents ealrier than right-sided and is more likely to disrupt bowel habit (e.g. by causing constipation). Left sided cancers may stenose the bowel lumen if they involve the full circumference of the bowel wall, leading to an 'aple core' sign on CT scan.
The second best option here would be 'B', because there are systemic symptoms, a potential sign of anaemia, and the constipation could be due to hypercalcaemia.
70
Briefly summarise the diagnosis, staging, and management of a colorectal cancer:
Diagnosis is ideally with colonoscopy + biopsy, but ct colongraphy can be used as an alternative (more comfortable, more tolerable bowel prep)
Biopsy is ideal but not essential for colonic cancer, but is essential for rectal cancer
Staging for colonic cancer is done using a CTCAP
Rectal cancer also requires an MRI - better for visualising the safe margin which is important when trying to save the sphincter
MRI and PET scan may be used for better visualisation of lesions
Curative treatment can be achieved via resection
Radiotherapy is generally not used for colonic tumours due to the risk of small bowel damage, but is used for rectal tumours to shrink the mass before surgery
The margin for a rectal cancer is contentious, with a figure of 5cm classically quoted: this is often reduced to 2cm and may even be reduced to 1cm in cases of low-risk early tumours
Trans-anal resection for T1/T2 rectal tumours
Adjuvant chemotherapy advised for many colorectal cancers to increase survival - oxiplatin-based regime
Palliative options:
Stenting
Defunctioning colostomy
Radiotherapy
CEA is used to monitor treatment response, but not for diagnosis
71
Briefly summarise the diagnosis, staging, and management of oesophageal cancer
Symptoms - 2 week wait referral
Endoscopy + biopsy
CTCAP for staging
PET scan for radical treatment
USS or laparoscopy (gastric cancer) where indicated?
72
A 72 year old man attends A&E with sudden onset severe back pain. He is rapidly assessed and found to have a BP of 95/67mmHg. He is known to have a 5.7cm AAA.
What is the most appropriate next step?
```
A. Compress the pulsatile abdominal mass
B. Immediate transfer to theatres
C. 500ml saline bolus given over 15 minutes
D. Urgent CT angiogram
E. Perform a DRE
```
REVIEW
D. Urgent CT angiogram
This is a history of ruptured AAA. In cases where a AAA ruptures an approach of 'permissive hypotension' is taken. This means the systolic pressure is purposely kept low (generally 80-100mmHg) in order to avoid dislodging any clots that have formed to stem the bleeding. Accordingly this patient's BP does not need bolstering with a saline bolus.
Instead it is important to urgently assess the AAA with a CT angiogram. This patient is not so unstable that they don't have time to be imaged, but if the systolic pressure was lower then it may be more appropriate to transfuse packed RBCs, FFP, and platelets in accordance witht the major haemorrhage protocol, and take them urgently to theatres.
Rupture of a AAA is a very serious event, and still carries a mortality of ~40%
The European guidelines (p33):
https://www.esvs.org/wp-content/uploads/2018/12/Wanhainen-A-et-al-ESVS-AAA-GL-2019-epublished-041218.pdf
73
2 week wait criteria for bowel cancer screening
Refer if:
They are aged 40 years and over with unexplained weight loss and abdominal pain
They are aged 50 years and over with unexplained rectal bleeding
They are aged 60 years and over with:
Iron-deficiency anaemia, or
Changes in their bowel habit
Tests show occult blood in their faeces
Consider referral if there is rectal bleeding with one of:
Abdominal pain
Change in bowel habit
Weight loss
Iron-deficiency anaemia
Or if there is a rectal mass with or without bleeding
74
A 58 year old man presents to A&E with sudden painless loss of vision in his left eye. He has a PMHx of hypertension, diabetes, and peripheral arterial disease. Describe the likely findings on fundoscopy if this were a arterial retinal occlusion, and if it were a venous retinal occlusion:
```
Retinal artery occlusion:
Pale retina
Cherry red spot where fovea is because it has a different circulation
There may be a non-ischaemic superior macular segment due to collateral cilioretinal circulation (present in 15-
30% of people
Arterial sequestering (box-carring)
Visible retinal embolus
Afferent pupillary defect
```
Retinal vein occlusion:
Tortuous dilated vessels
Haemorrhage
Whether it is branched or retinal can be determined by whether it affects the entire eye or just one quadrant
https: //www.aao.org/eyenet/article/diagnosis-and-management-of-crao
https: //www.asrs.org/patients/retinal-diseases/32/retinal-artery-occlusion
https: //www.asrs.org/patients/retinal-diseases/22/central-retinal-vein-occlusion#:~:text=Central%20retinal%20vein%20occlusion%2C%20also,other%20problems%20with%20the%20eye.
75
A 58 year old woman presents to A&E with an 8 hour history of headache accompanied by nausea. She also describes blurred vision in her left eye and an appearance of halos around lights. She has a PMHx of hypertension controlled with perindopril and is farsighted. On examination her left eye is red with a fixed dilated pupil and fundoscopy reveals optic disk cupping.
Given the likely diagnosis, what would be the most appropriate management?
A. S.C. Sumitriptan + high flow oxygen, Paracetamol, and NSAIDs
B. Oral Acetazolamide +/- I.V. Mannitol
C. 100mg Prednisolone and immediate opthalmology referral
D. Latanoprost eye drops
E. I.V. Mannitol and urgent referral to neurosurgeons
B. Oral Acetazolamide +/- I.V. Mannitol
This is a case history of angle-closure glaucoma: where the narrow passage between the anterior and posterior chambers of the eye becomes closed off. This prevents flow of the aqueous humour from the anterior chamber where it is made to the posterior chamber. The pressure in the eye builds, impairs vision, and damages the optic nerve. Treatment centres on trying to bring down the intraocular pressure initially with drugs, but with paracentesis of fluid if needed.
76
An 81 year old lady attends her GP with a 2 week history of blurred vision in her left eye. She denies pain, flashing lights, or nausea. She has smoked 20 cigarettes a day for 50 years. On examination the eye looks normal, but on testing with an Amsler grid there is loss of central vision with preservation of peripheral vision.
What is the most likely diagnosis?
```
A. Central retinal artery occlusion
B. Retinal detachment
C. Open angle glaucoma
D. Angle-closure glaucoma
E. Macular degeneration
```
E. Macular degeneration
Macular degeneration is an age-related condition involving damage to the retina from years of metabolic stress. This leads to a progressive loss of central vision which may present as sudden-onset visual loss. This is because the disease is insidious in its early stages so may not be noticed for a while, at which time it may seem like a sudden onset to the patient.
Treatment is complex and depends on the sub-type of degeneration - suffice it to say it is managed by a specialist.
77
A 71 year old man is brought to A&E by his daughter following sudden, painless loss of vision in his left eye. This was preceded by floaters in his vision and flashing lights. He normally wears glasses for high degree short-sightedness and has had previous cataract surgery on the affected eye. He also has type II diabetes for which he takes Metformin and Sitagliptin.
What is the most likely cause of the vision loss?
```
A. Posterior vitreous detachment
B. Retinal detachment
C. Amaurosis fugax
D. Temporal arteritis
E. Angle-closure glaucoma
```
B. Retinal detachment
This is a history of retinal detachment from the choroid layer. Retinal detachment causes painless loss of vision which may be sudden or progressive depending on the type and cause, and will usually present with loss of central vision but may affect peripheral.
The floaters and flashing lights described are actually features of posterior vitreous detachment - where the vitreous gel loses its shape and pulls away from the retina. This condition is not concerning in of itself, but as has happened here may cause a retinal tear which then progresses to retinal detachment which causes the loss of vision. Retinal detachment will generally require surgical or minimally invasive intervention to fix the retina.
Key features in the history: elderly, diabetic, sudden loss of vision, previous cataract, very short-sighted, painless, preceded by flashing lights and floaters.
78
A 69 year old woman presents to A&E with 2 weeks of progressive loss of vision in her right eye. There was no associated pain, but she has been having intermittent headaches for the past month. She has not visited her GP for at least 10 years, but describes recent issues with pain and sitffness in her shoulders and pain in her jaw when chewing. On fundoscopy her optic disk appears pale and swollen.
How should this patient be managed?
A. Oral Acetazolamide +/- I.V. Mannitol infusion
B. I.V. Mannitol infusion
C. Anterior chamber paracentesis
D. Intravenous Acetazolamide
E. 80mg prednisolone and urgent opthalmology review
E. 80mg prednisolone and urgent opthalmology review
This is a history of progressive vision loss on a background of symptoms suspicious for polymyalgia rheumatica and giant cell arteritis. The vision loss here is due to inflammation of the retinal artery interfering with blood supply to the retina. The pale swollen apperance of the optic disk is due to retinal ischaemia and oedema.
Given this is giant cell arteritis with eye involvement, this woman should be given a very high dose of steroids (60-100mg) and seen same-day by an opthalmologist, after which biopsy of the temporal artery may be arranged. The standard treatment of temporal arteritis without eye involvement would be 40-60mg prednisolone and urgent rheumatology referral (ideally same day but up to 3 weeks).
79
A 62 year old woman is scheduled to undergo a total knee replacement in 24 hours. She has a mechanical heart valve and usually takes warfarin but this has been witheld for the previous 4 days. Her INR is currently 2.3.
What should be done regarding her INR?
```
A. Give a platelet infusion
B. Nothing, her INR is acceptable
C. Give I.V. phytomenadione (vitamin K)
D. Give I.V. prothrombin complex concentrate
E. Give FFP
```
C. Give I.V. phytomenadione (vitamin K)
Management of a high INR due to warfarin is a common question but is fairly simple:
If there is major bleeding or a need for urgent surgery, give prothrombin complex concentrate to rapidly reverse the effects of warfarin.
If neither condition is met but the INR is >8, stop warfarin and give vitamin k
If INR is 5-8 with minor bleeding, stop warfarin and give vitamin k
If INR is 5-8 with no bleeding withold 1-2 doses of warfarin
INR should be 1.5 or less for surgery, which should be achieved by witholding warfarin for 5 days before surgery and giving vitamin k the day before if INR is above 1.5.
80
A 53 year old man presents to A&E with 1 hour of severe intermittent right flank pain. The pain is 10/10 when present but fades to a 2/10 background ache between episodes. He has also passed blood in his urine. His observations are normal, and a non-contrast CTKUB shows an 18mm stone in the mid-ureter.
How should this stone be managed?
```
A. Ureteric stenting
B. Shock-wave lithotripsy
C. Percutaneous nephrolithotomy
D. Ureteroscopy and basket extraction
E. Percutaneous nephrostomy
```
D. Ureteroscopy and basket extraction
If asymptomatic:
Stones less than 5mm can just be allowed to pass
Stones 5-10mm may just be allowed to pass
Consider alpha blockers for distal ureteric stones <10mm
The following rules of thumb are based on the NICE guidelines, but in reality there are more factors and more complex decisions urologists will have to consider and make
```
Renal stones:
<10mm - shock wave lithotripsy
10-20mm - shock-wave lithotripsy OR ureteroscopy
>20mm - percutaneous nephrolithotomy
+ signs of infection
```
Ureteric stones:
<10mm - shock wave lithotripsy
10-20mm - ureteroscopy
Stones greater than 20mm will generally not be able to enter the ureter
NB: ureteroscopy can be used to stent the ureter in cases where there is co-existent infection to relieve the obstruction, but may also be used
BAUS guidelines:
https://www.baus.org.uk/_userfiles/pages/files/Publications/Acute%20ureteric%20colic%202018.pdf
NICE guidelines:
https://www.nice.org.uk/guidance/ng118/chapter/Recommendations
81
Summarise the treatment of anal fissures:
```
Conservative:
Gradually increase dietary fibre
Increase fluid intake
Keep area clean and dry
Avoid stool witholding or excessive straining
```
Medical:
Bulk-forming laxative - e.g. Ispaghula husk
Paracetamol and NSAIDs
Rectal GTN
Topical Lidocaine - short course for extreme pain persisting after defecation
Surgical:
Sphincterotomy
82
A 33 year old woman presents with a breast lump to her GP. She has not noticed any skin changes or systemic symptoms. The lump is located in the upper outer quadrant, is firm to touch, smooth, and mobile. She has no lymphadenopathy.
How should she be managed?
A. Discharge with safety netting and follow-up in 4 weeks
B. Make a routine referral for mammogram and specialist review
C. Make a 2 week wait referral for USS and biopsy
D. Make a 48 hour referral for mammogram and biopsy
E. Make a Make a 48 hour referral for USS and biopsy
C. Make a 2 week wait referral for USS and biopsy
With breast lumps, the referral process is designed to be over-cautious. From the description this lump is non-worrying, but because it is an unexplained lump in a woman over 30, it should be triple assessed (history/ exam, imaging, cytology/ histology). USS is more appropriate than mammogram for this woman because she is 35 and therefore likely to have denser breast tissue which is visualised best with an USS.
The NICE guidelines on referring patients with suspected breast cancer are:
Aged 30 years and over and have an unexplained breast lump with or without pain, or
They are aged 50 years and over with any of the following symptoms in one nipple only:
Discharge.
Retraction.
Other changes of concern.
Consider a 2 week wait referral in people:
With skin changes that suggest breast cancer, or
Aged 30 years and over with an unexplained lump in the axilla.
Consider non-urgent referral in people aged under 30 years with an unexplained breast lump with or without pain.
83
What is the most common form of breast cancer?
Invasive ductal carcinoma
84
Briefly describe the UK breast cancer screening program:
Offered a mammogram every 3 years from 50-70
| May request further mammograms after
85
Summarise the treatment of breast cancer:
Triple assessment
USS for axillary lymphadenopathy if not palpable
Surgery is the mainstay and can be divided into breast-conserving (wide local excision) and mastectomy:
Tumour <4cm, peripheral tumour, comparatively large breast, and non-diffuse unifocal disease are all indications for WLE.
Sentinel lymph node biopsy if no axillary lymphadenopathy, axillary node clearance if there is
Deep inspiration radiotherapy is used post-WLE to reduce the risk of recurrence
Chemotherapy is used either to reduce tumour size prior to breast-conserving surgery or as an adjunct after surgery in axillary node positive disease
Endocrine:
Tamoxifen adjuvant for pre-menopausal women, or post-menopausal at low risk of recurrence
Aromatase inhibitors adjuvant for post-menopausal women
Aromatase inhibitor therapy >5 years improves recurrence rates
Herceptin is useful in HER2 positive cases
86
A 68 year old man presents to A&E with abdominal pain. He is given a CT which reveals faecal impaction, but incidentally the reporting radiologist notices a mass in the left kidney. The CT is repeated pre and post contrast and the mass is diagnosed as a 6cm renal cell carcinoma.
How should this cancer be managed?
```
A. Tyrosine kinase inhibitors
B. Radical nephrectomy
C. Radical nephrectomy + cisplatin-based regime
D. Partial nephrectomy
E. Percutaneous radiofrequency ablation
```
D. Partial nephrectomy
Renal cell carcinoma (RCC) is the most common cancer of the kidney. It is most often an incidental finding, but when it does present the most common presentation is with painless haematuria. Only ~15% present with the classic triad of flank pain, and abdominal mass, and haematuria. Given the insidious development of the disease, around 1 in 4 patients present with metastases.
Risk factors include smoking, industrial exposure to toxins (e.g. aromatic hydrocarbons - found in fossil fuels, dyes, and mothballs), hypertension, obesity, abnormal renal anatomy, and dialysis.
Treatment is surgical resection of the tumour: if it is T1 (7cm or less at its widest point) a partial nephrectomy is indicated, and if it is T2 or above (>7cm) then radical nephrectomy is indicated. RCC is generally considered insensitive to chemotherapy.
Systemic therapies such as tyrosine kinase inhibitors and immune checkpoint inhibitors may be used in metastatic disease.
ESMO RCC guidelines:
https://www.sciencedirect.com/science/article/pii/S0923753419311573?via%3Dihub
EAU RCC guidelines:
https://uroweb.org/guideline/renal-cell-carcinoma/#1
87
An 82 year old man presents to his GP with 2 weeks of intermittent painless haemturia. He is given a 2 week wait referral, and flexible cystoscopy identifies a suspicious lesion. CT staging reveals a T1 tumour within the bladder which is identified as intermediate-risk.
Intermediate-risk non muscle invading
```
A. Resection + intravesical BCG vaccine
B. Resection + intravesical mitomycin C
C. Cisplatin chemotherapy
D. Radical cystectomy
E. Radical cystectomy + neoadjuvant cisplatin
```
B. Resection + intravesical mitomycin C
This is a history of bladder cancer, the most common type being transitional cell carcinoma. The risk factors are similar to those for renal cell carcinoma (aromatic hydrocarbon exposure, smoking). In the developing world a very important risk factor is schistosomiasis as the associated chronic inflammation causes squamous cell carcinoma of the bladder.
Bladder cancer classically presents with painless haematuria, though may cause recurrent UTIs, urinary retention, or lower uriniary tract symptoms if the cancer obstructs the bladder outflow.
Urinanalysis is important in part to rule out other causes of haematuria. Bladder cancer will require CT staging of the tumour itself, as well as potential scans of the thorax and abdomen to assess for spread. A urogram may be performed to look for upper urinary tract involvement.
Treatment depends on whether the tumour has invaded the muscle (T2) or not (T1):
T1 - transurethral resection +:
Low risk - 1 dose of mitomycin C
Intermediate risk - 6 doses of mitomycin C
High risk - either intravesical BCG vaccine or radical cystectomy
All these tumours require regular follow up due to a very high risk of recurrence within 3 years
T2:
Usually radical cystectomy with formation of a urostomy and ileal conduit
Radical radiotherapy may also be used
Neoadjuvant cisplatin chemotherapy (or adjuvant if not given before)
Metastatic:
Cisplatin-based chemotherapy regime
Radiotherapy may help alleviate urinary symptoms for palliative patients
88
Which of the following is LEAST likely to be associated with a renal cell carcinoma?
```
A. Hypercalcaemia
B. Hypertension
C. Polycythaemia
D. SIADH
E. Cannonball lung metastases
```
D. SIADH
Renal cell carcinoma (RCC) is seemingly one of the few conditions not associated with SIADH. All the other features may occur as complications of RCC:
Hypercalcaemia results from PTH-related peptide production
Hypertension is a risk factor for developing RCC but may also result from tumour renin production
Polycythaemia results from tumour production of erythropoietin
Cannonball lung metastases are classic of RCC or choriocarcinoma
89
Match each vignette to the most likely diagnosis:
1. 52 year old man with 1 month of recurrent attacks of hearing loss, tinnitus, and vertigo lasting 30 minutes each
2. 28 y/o man with sudden onset disabling vertigo and vomiting, had a cold 1 week ago, O/E has horizontal nystagmus
3. 32 y/o woman with 1 week of vertigo and fatigue, visited GP 6 months ago for blurred vision which self-resolved
4. 62 y/o man visits GP for episodes of vertigo associated with nausea and vomiting lasting a few seconds each, noticed when getting up or rolling over in bed
5. 72 y/o woman with sudden onset ataxia, vertigo, and dysarthria
```
A. Vestibular neuritis
B. Posterior circulation stroke
C. Ménière's disease
D. BPPV
E. Multiple sclerosis
```
1. 52 year old man with 1 month of recurrent attacks of hearing loss, tinnitus, and vertigo lasting 30 minutes each - C. Ménière's disease
2. 28 y/o man with sudden onset disabling vertigo and vomiting, had a cold 1 week ago, O/E has horizontal nystagmus - A. Vestibular neuritis
3. 32 y/o woman with 1 week of vertigo and fatigue, visited GP 6 months ago for blurred vision which self-resolved - E. Multiple sclerosis
4. 62 y/o man visits GP for episodes of vertigo associated with nausea and vomiting lasting a few seconds each, noticed when getting up or rolling over in bed - D. BPPV
5. 72 y/o woman with sudden onset ataxia, vertigo, and dysarthria - B. Posterior circulation stroke
90
A 63 year old man presents to his GP with 4 months of urinary hesitancy and poor stream; he had been putting it down to age but is concerned that it seems to be progressing. He is otherwise generally well. DRE reveals a hard, irregular prostate. His PSA is 31ng/ml and a trans-perineal biopsy reveals a localised Gleason 9 prostate cancer
What is the most appropriate treatment plan?
```
A. Watchful waiting
B. Brachytherapy
C. External beam radiotherapy + goserelin
D. Docetaxel + goserelin
E. Docetaxel + prednisolone
```
C. External beam radiotherapy + goserelin
Prostate cancer is divided into localised and metastatic. Localised disease is further divided into low, intermediate, and high risk. Risk is stratified by Gleason score and PSA level. The Gleason score is based on biopsy: the biopsy is scored with a number corresponding to the most common cell pattern in the biopsy (1-5 from least to most malignant), which is added to the number for the second most common pattern in the biopsy. These added together give the Gleason score which should accurately reflect the degree of malignant change within the prostate biopsy.
Low risk (Gleason 2-6, PSA <10ng/ml):
Watchful waiting
Patient may choose radical radiotherapy (+androgen deprivation therapy) or radical prostatectomy
```
Intermediate risk (Gleason 7, PSA 10-20ng/ml):
Radical radiotherapy (+androgen deprivation therapy) or radical prostatectomy
Brachytherapy may be added to radiotherapy
```
High risk (Gleason 8-10, PSA >20ng/ml):
Radical radiotherapy (+androgen deprivation therapy) or radical prostatectomy
Offer Docetaxel chemotherapy
Brachytherapy may be added to radiotherapy
Metastatic:
Docetaxel chemotherapy
Androgen deprivation therapy or orchidectomy
Bisphosphonates and radiotherapy are useful in palliating symptoms of bone metastases
https: //www.nice.org.uk/guidance/ng131/chapter/Recommendations
https: //teachmesurgery.com/urology/prostate/prostate-cancer/
https: //cks.nice.org.uk/topics/prostate-cancer/
91
Which questions are most important to ask somebody who is being taken urgently for surgery?
```
A - allergies
M - medications currently taking
P - past medical history (surgeries, anaesthetics)
L - last ate and drank
E - events leading up to surgery
```
92
Septic arthritis
50% cases not picked up on Gram stain
https://bestpractice.bmj.com/topics/en-gb/3000116/investigations
93
A 35 year old man presents to his GP with a testicular swelling. The swelling is indistinguishable from the testis, soft, fluctant, non-tender, and trans-illuminates.
Given the likely diagnosis, what is the most appropriate next step?
A. Refer to urology for excision
B. Reassure and follow-up in 3 months
C. Refer for urgent USS
D. Prescribe a 7 day course of amoxicillin
E. Give a 1mg intramuscular dose of ceftriaxone
C. Refer for urgent USS
A hydrocele is a collection of fluid between two layers ofthe tunica vaginalis. The reason this man needs an urgent USS is because a possible cause of hydrocele is testicular cancer, so an urgent USS is important in any man between 20-40 years old or in whom the testis cannot be palpated.
Hydroceles don't often cause problems and many can be left alone. If they are symptomatic or bothering the patient, they may be treated with excision, aspiration, or sclerotherapy.
94
A 64 year old woman presents to A&E with epistaxis. Her left nostril has been bleeding for 30 minutes depsite pinching the nostrils shut and applying a cold pack. On nasal speculum examination the bleeding point cannot be visualised.
How should this patient be managed?
```
A. Intra-nasal adrenaline spray
B. Anterior pack
C. Silver nitrate cautery
D. Posterior pack
E. Intra-nasal cold pack
```
B. Nasal packing
95
Summarise the treatment of haemorrhoids:
Conservative:
Gradually increase dietary fibre content
Ensure good fluid intake
Keep anus dry and clean and avoid straining or witholding stool
Refer if conservative management does not work
```
Non-surgical:
Topical creams (steroid, local anaesthetic, lubricant etc.)
Rubber band ligation
Injection sclerotherapy
Infrared coagulation
Diathermy
```
Surgical:
Haemorrhoidectomy
Stapled haemorrhoidectomy
Haemorrhoidal artery ligation
