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GENERAL SURGERY & PERI- OPERATIVE CARE SBA FINALS REVISION SESSION who are we? what we do? disclaimer: Theknowledge and expertise.hored by medical students and junior doctors to the best of their Cardiology Respiratory Gastroenterology Stroke Haematology Renal Endocrine Paediatrics ENT + General Surgery Musculoskeletal Ophthalmology online medical school finals Infections revision series & many more!easy medium hardBecome an ambassador of Crash Course Finals! Do you want to build your CV and portfolio? Represent our network and grow yours! Email us with 200 words. about why you’d be a great ambassador and what you’d bring to the role CrashCourseFinalsUK@gmail.comkeep up to date with all our teaching sessionsHouse rules go on mute questions in chat be respectfulROUND: 1 What is the most likely diagnosis? 1. A 52-year-old lady presents to the GP and reports a painless mass in the groin area. On examination, a mass is noted on coughing. It is below A Femoral hernia and lateral to the pubic tubercle. B Inguinal hernia C Umbilical hernia D Saphena varixFemoral hernia = inferior and lateral to pubic tubercle Inguinal hernia = superior and medial to pubic tubercle Umbilical hernia = around umbilicus What is the most likely diagnosis? Saphena varix = dilatation of the saphenous vein in the groin, often appearing as a lump A Femoral hernia B Inguinal hernia C Umbilical hernia D Saphena varies2. A 45 year old woman with a history of ulcerative What type of stoma does this patient have? colitis undergoes surgery and a stoma is created as part of the treatment plan. During the postoperative assessment, you observe that the End colostomy A stoma is in the right iliac fossa and is spouted from the skin. The stoma has a liquid output. B Loop colostomy C Mucous fistula D IleostomyStoma Types: (each of these types can be permanent or temporary) Colostomy - from the large bowel usually in the LIF, flush to the skin and has a solid or semisolid output flush to the skin as the enzymes present in large bowel contents are less alkali What type of stoma does this patient and, therefore, less irritating to the skin have? can be loop or end colostomy Ilesotomy - from the small bowel usually in the RIF, spouted from the skin and has a liquid output A End colostomy spouted to prevent the skin from coming into contact with the enzymes in the small intestine can be loop or end ileostomy B Loop colostomy Urostomy - urinary stoma C Urostomy Ileostomy D3. A 15 year old boy presents to the What is the most appropriate management for this patient? emergency department with sudden-onset severe left testicular pain. The pain started a few hours ago and he has also experienced A Urgent bilateral orchidopexy nausea and vomiting. On examination, the left B Perform scrotal doppler testicle is swollen and positioned higher than ultrasound the right. There is a loss of cremasteric reflex Consult urology for elective on the left side. C repair D Urgent unilateral L sided orchidopexy Testicular Torsion Treatment: urgent surgical exploration => if a torted testis is What is the most appropriate identified then both testis should be fixed as the condition is often management for this patient? bilateral ie bilateral orchidopexy (fixation of both testes to prevent torsion of the other testes) A Urgent bilateral orchidopexy Perform scrotal doppler B ultrasound Consult urology for elective C repair Urgent unilateral L sided D orchidopexy4. Mr. Jones, a 38-year-old male, presents to What is the most likely diagnosis for Mr. Jones's presentation? the emergency department with complaints of painful rectal bleeding. He reports experiencing intermittent episodes of bright red blood in his A Haemorrhoids stool for the past three weeks. He describes the pain as sharp and localized around the anal area. B Colorectal cancer He denies any recent changes in bowel habits or significant weight loss. On examination, there is C Anal fissure tenderness and induration around the anal verge. D Anal fistula Anal fissure vs Anal fistula Anal fissure = painful rectal bleeding What is the most likely diagnosis for Mr. Anal fistula = painless rectal bleeding Jones's presentation? A Haemorrhoids B Colorectal cancer C Anal fissure D Anal fistula5. Mrs. Adams, a 50-year-old woman, presents What is the most appropriate next step to the emergency department with severe in managing Mrs. Adams' suspected cholecystitis? right upper quadrant pain that radiates to her back. She reports nausea, vomiting, and A Administration of IV antibiotics intolerance to fatty foods. On physical examination, Murphy's sign is positive, and B Immediate cholecystectomy there is tenderness over the gallbladder area. C Perform ultrasound Conservative management with pain D control and bowel rest What is the most appropriate next step NICE Guidelines in managing Mrs. Adams' suspected cholecystitis? Administration of IV antibiotics A B Immediate cholecystectomy Perform ultrasound C Conservative management with pain D control and bowel rest What would be the most appropriate management approach? 6. Mr. Thompson, a 60-year-old man, has recently undergone a gastrectomy for the treatment of A IM Vitamin B12 supplementation gastric cancer. He now presents with symptoms suggestive of post-gastrectomy syndrome, B Oral Vitamin B12 supplementation including early satiety, bloating, and diarrhea Regular blood tests to monitor after meals. C vitamin B12 levels Dietary modifications to enhance D vitamin B12 absorptionGastrectomies can cause vitamin B12 deficiency Treatment: IM Vitamin B12 injections What would be the most appropriate management approach? IM Vitamin B12 supplementation A Oral Vitamin B12 supplementation NICE Guidelines: B Regular blood tests to monitor C vitamin B12 levels Dietary modifications to enhance D vitamin B12 absorptionROUND: 2 1. A 64 year old man presents to the emergency department with vomiting, abdominal pain and What is the most likely diagnosis? and distension for the past 24 hours. On examination, there is generalised abdominal tenderness with high pitched bowel sounds. A Ischaemic colitis BP 120/78, HR 115bpm, RR 19bpm, temp 37.1C, sats 98% B Diverticulitis A CT is performed and shown below: C Small bowel obstruction Large bowel obstruction D Small bowel obstruction What is the most likely diagnosis? Imaging findings: CT in the question is from a patient with small bowel obstruction secondary to adhesions. Dilated loops of small bowel. Presence of small amount of free fluid intracavity. Common reason for SBO in this age group: adhesions. Vomiting more likely to be A Ischaemic colitis small bowel obstruction Diverticulitis B C Small bowel obstruction D Large bowel obstruction2. A 48-year-old man is due to undergo a What method of airway management is most appropriate for this patient? laparotomy for small bowel obstruction. Endotracheal intubation A B Laryngeal mask C Tracheostomy Oropharyngeal airway D Patients who are due to undergo laparotomies for bowel obstruction have either been vomiting or at high risk of regurgitation of gastric contents on induction of anaesthesia. A rapid sequence induction with cricothyroid pressure applied to What method of airway management is most appropriate for this patient? occlude the oesophagus is performed. A cuffed endotracheal tube is then inserted. Once correct placement of the ET tube is confirmed the cricothyroid pressure can be removed. A Endotracheal intubation B Laryngeal mask Tracheostomy C D Oropharyngeal airway3. 62 year old woman presents to the emergency department with left lower abdominal pain and Considering the most likely diagnosis, altered bowel habits, including constipation and what is the most appropriate initial management for this patient? intermittent episodes of diarrhoea. She has also experienced two episodes of rectal bleeding. On examination, the patient is tender over the left A Broad-spectrum antibiotics liliac fossa and has no signs of peritonitis. Her B Immediate surgical resection observations are: BP 122/80, RR 16, oxygen sats 98%, temp 37.5. Her bloods are normal, expect from Colonscopy with biopsy a mildly elevated CRP. C D Increase dietary fibre intake Diverticular Disease 1st line: Increase dietary fibre intake Mild attacks of diverticulitis may be managed conservatively with Considering the most likely diagnosis, antibiotics. Peri colonic abscesses should be drained either surgically or what is the most appropriate initial management for this patient? radiologically. Recurrent episodes of acute diverticulitis requiring hospitalisation => relative indication for a segmental resection A Broad-spectrum antibiotics B Immediate surgical resection C Colonscopy with biopsy Increase dietary fibre intake D4. Ms. B, a 45-year-old woman, presents with a recent diagnosis of breast cancer. She noticed a painless lump in her right breast during a self-breast examination two months ago. She has no significant past medical What is the most appropriate next step history and takes no regular medications. She is a non- in the management of this patient? smoker and consumes alcohol occasionally. Family history is negative for breast cancer. A Mastectomy Investigations: Targeted therapy with Mammogram: Shows a 2.5 cm irregular mass in the B trastuzumab upper outer quadrant of the right breast. Ultrasound: Confirms a hypoechoic mass with Adjuvant radiotherapy irregular borders. C Core needle biopsy: Reveals invasive ductal Genetic counselling and testing carcinoma, estrogen receptor negative, D for BRCA1/2 mutations progesterone receptor negative, and HER2 positive. Breast Cancer Management What is the most appropriate next step Hormonal therapy -> for hormone receptor positive breast in the management of this patient? cancer (oestrogen and progesterone) eg. Tamoxifen Targeted biologic therapy -> for HER2 positive breast cancer A Mastectomy eg Trastuzumab Chemotherapy Targeted therapy with Radiotherapy B trastuzumab Surgery In this scenario: Targeted therapy can be given first to shrink the C Adjuvant radiotherapy tumour prior to surgery if appropriate Genetic counselling and testing D for BRCA1/2 mutations5. Ms. C, a 60-year-old female, is scheduled for an elective cholecystectomy due to symptomatic gallstones. She has a past medical history of well- controlled hypertension and type 2 diabetes What ASA score would be given to mellitus, both managed with medications. She denies this patient? any history of cardiac or pulmonary issues. Ms. C is a non-smoker and consumes alcohol occasionally. ASA I A Preoperative Assessment: 1.Blood pressure: 140/85 mmHg B ASA II 2.Heart rate: 72 beats per minute 3.Respiratory rate: 16 breaths per minute C ASA III 4.BMI: 32 kg/m² 5.Blood glucose: 150 mg/dL D ASA IV 6.ECG: Normal sinus rhythm 7.Chest X-ray: Clear lung fieldsWhat ASA score would be given to this patient? A ASA I B ASA II C ASA III ASA IV D6. Mr. Patel, a 55-year-old man, presents to What is the most appropriate next step the emergency department with severe in assessing and managing Mr. Patel's condition? epigastric pain radiating to his back. He reports nausea and vomiting over the past 24 Perform blood tests including A serum amylase and lipase levels hours. His medical history includes heavy alcohol consumption and recent binge drinking. B Abdominal ultrasound On examination, he appears jaundiced, and there is tenderness in the upper abdomen on C Calculate Glasgow-Imrie score palpation. D CT Abdo/pelvis with contrastWhat is the most appropriate next step in assessing and managing Mr. Patel's condition? Perform blood tests including A serum amylase and lipase levels Abdominal ultrasound B C Calculate Glasgow-Imrie score CT Abdo/pelvis with contrast Dround three 1.A 23 year old man presents to the emergency Which diagnostic investigation should be department after drinking heavily the night performed for the most likely diagnosis? before at a party. He has vomited multiple times and has reported that he saw fresh blood the last time that he vomited. He also A Chest x-ray has severe chest pain and on examination, his B Oesophagogastroduodenoscopy chest wall has a crackling feeling on palpation. (OGD) His observations are as follows: BP 120/70 C CT contrast swallow mmHg, HR 105 bpm, oxygen sats 96% on room air D Barium swallow and temperature of 37.0C Boerhaave’s syndrome => a spontaneous rupture of the oesophagus that often occurs as a result of repeated episodes of forceful vomiting Hx: sudden onset of severe chest pain that may occur after a period of severe vomiting. Subcutaneous emphysema may be Which diagnostic investigation should be performed for the most likely diagnosis? observed on the chest wall. Diagnosis: CT contrast swallow Treatment: Surgical management -> usually the standard of care Conservative management -> IV fluids, antibiotics etc A Chest x-ray Delays beyond 24 hours -> associated with a very high mortality rate Oesophagogastroduodenoscopy B (OGD) C CT contrast swallow D Barium swallow What long term feeding option should be used for this patient? A Nasogastric tube 2. A 56 year old man has undergone a potentially curative oesophagectomy for B Feeding jejunostomy carcinoma. Total parenteral nutrition (TPN) C Percutaneous endoscopic D gastrostomy (PEG) tubeWhat long term feeding option should be used for this patient? A Nasogastric tube Feeding jejunostomy B Total parenteral nutrition (TPN) C Percutaneous endoscopic D gastrostomy (PEG) tube What should happen with the patient’s diabetes medication in preparation for his surgery? 3. A 55 year old man with type 2 diabetes A Continue sitagliptin as normal mellitus is scheduled for elective surgery. His current medication regimen includes Withhold sitagliptin B sitagliptin. The surgery is planned for the Double dose of sitagliptin next day. C D Reduce dose of sitagliptin What should happen with the patient’s diabetes medication in preparation for NICE Guidelines: his surgery? Continue sitagliptin as normal A Withhold sitagliptin B Double dose of sitagliptin C Reduce dose of sitagliptin D When should Ms. Johnson discontinue unfractionated heparin therapy prior to 4. Ms. Johnson, a 65-year-old woman, is her surgery? scheduled to undergo surgery for a hip replacement . She currently has a metallic 6 hours before surgery A heart valve. 12 hours before surgery B C 24 hours before surgery D 48 hours befiore surgery When should Ms. Johnson discontinue Unfractionated heparin and surgery rules: unfractionated heparin therapy prior to her surgery? Stop 6 hours before surgery Unfractionated heparin is generally cleared from circulation A 6 hours before surgery within 2 hours so this allows plenty of time and is the method of choice in this elective setting Reversal agent for heparin => protamine sulfate (however, this B 12 hours before surgery is associated with risks of anaphylaxis and so is not generally used unless immediate reversal of anticoagulation is needed, eg. C 24 hours before surgery coming off bypass) D 48 hours befiore surgery What is the most appropriate next 5. During a dental procedure, Mr. Smith, a 50- step? year-old patient, begins to exhibit symptoms suggestive of local anesthesia toxicity. He A Administer a benzodiazepine for appears agitated, confused, and experiences sedation tremors. His heart rate and blood pressure IV lipid emulsion therapy B are elevated, and he complains of numbness around his mouth and tongue. Continue procedure and monitor C closely Discontinue procedure and D provide supplemental oxygenNICE Guidelines: What is the most appropriate next step? Administer a benzodiazepine for A sedation IV lipid emulsion therapy B Continue procedure and monitor C closely Discontinue procedure and D provide supplemental oxygen 6. Mr. Davis, a 35-year-old man, presents to What is the most appropriate next step? the emergency department with severe abdominal pain localized to the right lower Immediate administration of quadrant. He also reports nausea, vomiting, and A broad-spectrum antibiotics fever. On examination, there is rebound B Emergency surgical exploration and appendectomy tenderness and guarding in the right iliac fossa. Admission to the hospital for Imaging studies reveal signs consistent with a C observation and intravenous fluid resuscitation ruptured appendicitis. Discharge home with oral antibiotics D and outpatient follow-up Ruptured appendicitis: A burst/ruptured appendix => immediate surgery to remove the appendix and clean the abdominal cavity. This is an emergency as there is a risk of infection spreading throughout abdomen What is the most appropriate next (peritonitis) step? Immediate administration of A broad-spectrum antibiotics Emergency surgical exploration and B appendectomy Admission to the hospital for C observation and intravenous fluid resuscitation Discharge home with oral antibiotics D and outpatient follow-up Thank you very much for listening! Note: Certificates will be received once feedback is completed Obs & Gynae SBA next session Tuesday 12th March 7-8pm