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AMorning in SAU 17th May 2025, Dr Ololade Tijani, Dr Yi SimLearningOutcomes ● Triage of surgical patients ● Acute surgical emergencies: Appendicitis, cholecystitis, bowel obstruction ● Preoperative assessment: ○ Key considerations for urgent surgery ○ Could also include preoperative investigations ○ Medications - antidiabetic medications, anticoagulants etc. ○ Fluids, NBM etc ● Postoperative complications: Fever, wound infection, anastomotic leak ○ Fluid management and nutritional support ○ Pain management in surgical patientsQuestion 1 A 45 year old man presented to SAU with chest pain and vomiting. He smells strongly of alcohol. On examination, you notice some crepitations as you palpate his chest. You request an ECG which shows widespread ST elevation. You also request bloods including troponin and a portable chest x-ray. Which of these chest x-ray findings would most likely be present for the suspected most probable diagnosis? A Pneumothorax B Pleural effusion C Pneumomediastinum D Pneumonia E Pulmonary embolismQuestion 1 A 45 year old man presented to SAU with chest pain and vomiting. He smells strongly of alcohol. On examination, you notice some crepitations as you palpate his chest. You request an ECG which shows widespread ST elevation. You also request bloods including troponin and a portable chest x-ray. Which of these chest x-ray findings would most likely be present for the suspected most probable diagnosis? A Pneumothorax B Pleural effusion C Pneumomediastinum D Pneumonia E Pulmonary embolismBoerhaave’s SyndromeExplanation Boerhaave’s syndrome : Oesophageal rupture - Stomach contents into mediastinum + pleural cavity - Subcutaneous emphysema Question 2 A 50 year old lady presents due to a groin lump which she was unable to push back in. She is not in pain and her observation are normal. PMHx: chronic constipation, T2DM, HTN, 3x previous vaginal births. On examination, you palpate a lump infero-lateral to the pubic tubercle. What is the best course of action? A Discharge and reassure B Consent for immediate urgent operation C Explain that she has an inguinal hernia which needs to be repaired D Explain that she has a femoral hernia which will require urgent surgical intervention E Push it back in under conscious sedation Question 2 A 50 year old lady presents due to a groin lump which she was unable to push back in. She is not in pain and her observation are normal. PMHx: chronic constipation, T2DM, HTN, 3x previous vaginal births. On examination, you palpate a lump infero-lateral to the pubic tubercle. What is the best course of action? A Discharge and reassure B Consent for immediate urgent operation C Explain that she has an inguinal hernia which needs to be repaired D Explain that she has a femoral hernia which will require urgent surgical intervention E Push it back in under conscious sedationFemoral hernia Explanation Femoral hernias: - Infero-lateral to the pubic tubercle Risk factors: - Females - Increasing age - Pregnancy/multiparity - Raised intra-abdominal pressure: heavy lifting, chronic constipationQuestion 3 You receive a phone call from one of the nurses to clarify the plan for a 50 year old type 2 diabetic on Lantus who is first on the list for theatre today. The patient self administers their insulin and wanted to check if any modifications needed to be made to their regular dose as they can’t remember the advice from the pre-op clinic. What do you tell them? A Switch to short acting and stop long acting insulin B Half the dose C Skip the dose as they are first on the list and will be on VRII D Take 80% of their usual dose E Switch to oral hypoglycaemicsQuestion 3 You receive a phone call from one of the nurses to clarify the plan for a 50 year old type 2 diabetic on Lantus who is first on the list for theatre today. The patient self administers their insulin and wanted to check if any modifications needed to be made to their regular dose as they can’t remember the advice from the pre-op clinic. What do you tell them? A Switch to short acting and stop long acting insulin B Half the dose C Skip the dose as they are first on the list and will be on VRII D Take 80% of their usual dose E Switch to oral hypoglycaemicsPre/peri-operative management of diabetesExplanation Text body Don’t stop long acting insulin while on VRIIQuestion 4 70 y/o M presents to SAU from his GP because his wife reported she was concerned about yellow discolouration of his skin. He has had previous pancreatitis and has a 30 pack year smoking history. She also reports his clothes being more loose on his body. On examination, his gallbladder is palpable but he is not in significant pain when you palpate his abdomen. Which of these blood tests results would be in keeping with the suspected diagnosis? A Bilirubin - high ALP - high Gamma-GT - high Ca 19-9 - high B Bilirubin - high ALP - low Gamma-GT - high Ca 19-9 - low C Bilirubin - low ALP - high Gamma-GT - high Ca 19-9 - high D Bilirubin - low ALP - low Gamma-GT - low CEA - high E Bilirubin - high ALP - high Gamma-GT - high CEA - highQuestion 4 70 y/o M presents to SAU from his GP because his wife reported she was concerned about yellow discolouration of his skin. He has had previous pancreatitis and has a 30 pack year smoking history. She also reports his clothes being more loose on his body. On examination, his gallbladder is palpable but he is not in significant pain when you palpate his abdomen. Which of these blood tests results would be in keeping with the suspected diagnosis? A Bilirubin - high ALP - high Gamma-GT - high Ca 19-9 - high B Bilirubin - high ALP - low Gamma-GT - high Ca 19-9 - low C Bilirubin - low ALP - high Gamma-GT - high Ca 19-9 - high D Bilirubin - low ALP - low Gamma-GT - low CEA - high E Bilirubin - high ALP - high Gamma-GT - high CEA - highPancreaticCancerExplanation Risk factors: ● Male ● Smoking ● Older age ● Obesity ● Chronic pancreatitis ● Diabetes Presentation: Jaundice, weight loss, abdominal painExplanation LFTs: Cholestatic/obstructive - Raised bilirubin - Raised ALP - Raised GGTQuestion 5 A 24 year old presents with severe lower abdominal pain. Further history reveals she has recently had an IUD inserted and she complains of pain during sexual intercourse and has noticed some post-coital bleeding. Her obs show BP: 100/60, HR: 90 RR 20 Temp 38 degrees O2 sats 98% on room air. On examination, you notice adnexal tenderness and you notice a mucopurulent discharge. Her pregnancy test is negative. What is the most likely diagnosis? A Endometriosis B Appendicitis C Ectopic pregnancy D Ovarian cyst E Pelvic inflammatory diseaseQuestion 5 A 24 year old presents with severe lower abdominal pain. Further history reveals she has recently had an IUD inserted and she complains of pain during sexual intercourse and has noticed some post-coital bleeding. Her obs show BP: 100/60, HR: 90 RR 20 Temp 38 degrees O2 sats 98% on room air. On examination, you notice adnexal tenderness and you notice a mucopurulent discharge. Her pregnancy test is negative. What is the most likely diagnosis? A Endometriosis B Appendicitis C Ectopic pregnancy D Ovarian cyst E Pelvic inflammatory diseasePelvicInflammatory Disease Explanation Infection of the female upper genital tract in Signs/Symptoms: females: uterus, fallopian tubes and ovaries ● Pyrexia affected ● Cervical excitation, Risk factors uterine/adnexal tenderness - Sexually active ● Lower abdominal pain - Cervical instrumentation ● Deep dyspareunia - Younger age 15-24 ● Menstrual abnormalities - Recent partner change ● Post-coital bleeding - Intercourse without barrier contraceptive ● Dysuria protection ● Vaginal discharge - History of STIs - Personal history of pelvic inflammatory disease Explanation Investigations: Management: STI screen Doxycycline, ceftriaxone + metronidazole 14 days Endocervical swabs - Gonorrhea + chlamydia Sexual partner should be tested and treated High vaginal swab - trichomonas + BV Complications: Pregnancy test ● Fitz-Hugh Curtis syndrome TVUS ● Infertility ● Tubo-ovarian abscess Laparoscopy ● Ectopic pregnancyQuestion 6 A 20 year old male presents with pain in his right iliac fossa. He is nauseous and complains of loss of appetite. PMHx: nil. Social Hx: minimal alcohol. His obs are: BP 100/59 HR 98 Temp 37.7 O2 100% on room air RR 20. You request bloods which shows raised WCC and CRP. Which of the following signs would you expect on examination of this patient? A Pain in the left iliac fossa on palpation of the right iliac fossa B Pain that starts in the RIF and migrates to the umbilicus C RUQ tenderness radiating to the back D Tenderness between the PSIS and umbilicus E Pain in the right iliac fossa on palpation of the left iliac fossaQuestion 6 A 20 year old male presents with pain in his right iliac fossa. He is nauseous and complains of loss of appetite. PMHx: nil. Social Hx: minimal alcohol. His obs are: BP 100/59 HR 98 Temp 37.7 O2 100% on room air RR 20. You request bloods which shows raised WCC and CRP. Which of the following signs would you expect on examination of this patient? A Pain in the left iliac fossa on palpation of the right iliac fossa B Pain that starts in the RIF and migrates to the umbilicus C RUQ tenderness radiating to the back D Tenderness between the PSIS and umbilicus E Pain in the right iliac fossa on palpation of the left iliac fossaAppendicitisExplanation Rovsing sign Text body Question 7 A 30 year old presents with severe abdominal pain and vomiting. She has not opened her bowels or passed flatus. PMHx/surgical hx: appendicectomy, 2x previous c-sections, myomectomy. On examination, her abdomen is distended with evidence of guarding and rebound tenderness. She has an empty rectum on PR exam. What is the most appropriate initial plan? A NBM, IV fluids, Bloods including G&S, Clotting and a VBG, ECG, IV analgesia B IV fluids and NG tube insertion “Drip and suck” C NBM, IV fluids, Bloods including G&S, Clotting and a VBG, ECG, PO antiemetics D Laparotomy + adhesiolysis E Laparoscopy + bowel resection Question 7 A 30 year old presents with severe abdominal pain and vomiting. She has not opened her bowels or passed flatus. PMHx/surgical hx: appendicectomy, 2x previous c-sections, myomectomy. On examination, her abdomen is distended with evidence of guarding and rebound tenderness. She has an empty rectum on PR exam. What is the most appropriate initial plan? A NBM, IV fluids, Bloods including G&S, Clotting and a VBG, ECG, IV analgesia B IV fluids and NG tube insertion “Drip and suck” C NBM, IV fluids, Bloods including G&S, Clotting and a VBG, ECG, PO antiemetics D Laparotomy + adhesiolysis E Laparoscopy + bowel resectionBowel ObstructionExplanation Top 3 causes: ● Hernia ● Adhesion ● Malignancy Initial management: A to E (perforation and ischaemia can lead to haemodynamic instability) Conservative vs Surgery Question 8 A 19 year old male presents after having sudden onset left scrotal pain yesterday evening. It was the final day of his university field trip so he self medicated till he returned today and has vomited 2x due to the the pain. On examination, the pain persists when you elevate the testicle and the cremasteric reflex is absent. He has a TWIST score of 5. What is the best course of action? A USS testes to assess the viability as it has been more than 6 hours B Provide analgesia and watch and wait C Urgent scrotal exploration +/- orchidopexy/orchidectomy D Urgent orchidectomy E Delayed orchidectomy as the testis is non-viable Question 8 A 19 year old male presents after having sudden onset left scrotal pain yesterday evening. It was the final day of his university field trip so he self medicated till he returned today and has vomited 2x due to the the pain. On examination, the pain persists when you elevate the testicle and the cremasteric reflex is absent. He has a TWIST score of 5. What is the best course of action? A USS testes to assess the viability as it has been more than 6 hours B Provide analgesia and watch and wait C Urgent scrotal exploration +/- orchidopexy or orchidectomy D Urgent orchidectomy E Delayed orchidectomy as the testis is non-viableTesticular torsionExplanation Question 9 During your SAU shift, your FY1 friend working in ED calls you because the patient he is about to clerk presented following a netball injury and triage notes show that she came to ED due to worsening ankle pain. He can’t remember the guidelines on whether or not she will need an ankle xray. Which of the following findings will result in you advising your friend to request an ankle xray: A Bimalleolar tenderness but able to weight bear since the injury B Pain around the midfoot and unable to weight bear since the injury C Pain around medial malleolus and unable to weight bear at time of injury but now tolerating weight bearing D Bone tenderness distal 6cm of the tibia and unable to weight bear 3 steps while in ED E Unable to weight bear 4 steps at time of injury & weightbearing now limited to 100m Question 9 During your SAU shift, your FY1 friend working in ED calls you because the patient he is about to clerk presented following a netball injury and triage notes show that she came to ED due to worsening pain. He can’t remember the guidelines on whether or not she will need an ankle xray. Which of the following findings will result in you advising your friend to request an ankle xray: A Bimalleolar tenderness but able to weight bear since the injury B Pain around the midfoot and unable to weight bear since the injury C Pain around medial malleolus and unable to weight bear at time of injury but now tolerating weight bearing D Bone tenderness distal 6cm of the tibia and unable to weight bear 3 steps while in ED E Unable to weight bear 4 steps at time of injury & weightbearing now limited to 100mOttawaAnkle RulesExplanationQuestion 10 A 52 year old male presents with a fluctuant mass in his upper back which requires excision. Your registrar plans to excise this under local anaesthetic and the patient understands, retains, weighs up and communicates the plan which he is happy with. The reg asks you to please bring a consent form so he can formally consent the patient. Which consent form is most appropriate? A Consent form 1 B Consent form 2 C Consent form 3 D Consent form 4 E Consent form 5Question 10 A 52 year old male presents with a fluctuant mass in his upper back which requires excision. Your registrar plans to excise this under local anaesthetic and the patient understands, retains, weighs up and communicates the plan which he is happy with. The reg asks you to please bring a consent form so he can formally consent the patient. Which consent form is most appropriate? A Consent form 1 B Consent form 2 C Consent form 3 D Consent form 4 E Consent form 5Consent formsExplanation Text bodyBreaktime! Question 11 A 19 year old female is brought up to SAU for abdominal pain. She states it started around the sides of the right side of the abdomen, and has slowly spread towards her vagina. She also states it stings when she passes urine, and it has become more of a maroon colour over the past 24 hours. 3 days ago she mentions she ran the London Marathon. A non contrast CT-KUB was done with the following report conclusion: 13 mm Radio-opaque stone identified in the Right pelvico-ureteric junction. Nil stones identified along the ureter and kidney on the left side. No Hydronephrosis bilaterally. Which of the below would be the most indicated management? A) Extracorporeal Shockwave Lithotripsy B) Percutaneous Nephrolithotomy C) Analgesia + Hydration D) Ureteroscopy E) Right unilateral Nephrostomy insertion Question 11 A 19 year old female is brought up to SAU for abdominal pain. She states it started around the sides of the right side of the abdomen, and has slowly spread towards her vagina. She also states it stings when she passes urine, and it has become more of a maroon colour over the past 24 hours. 3 days ago she mentions she ran the London Marathon. A non contrast CT-KUB was done with the following report conclusion: 13 mm Radio-opaque stone identified in the Right pelvico-ureteric junction. Nil stones identified along the ureter and kidney on the left side. No Hydronephrosis bilaterally. Which of the below would be the most indicated management? A) Extracorporeal Shockwave Lithotripsy B) Percutaneous Nephrolithotomy C) Analgesia + Hydration D) Ureteroscopy E) Right unilateral Nephrostomy insertionRenal StonesMineral deposits that morph Symptoms: into stones and lodging into ● Loin to groin pain ● Haematuria; areas of the kidney, ureter or bladder visible/microscopic ● Burning sensation when Risk Factors: passing urine ● Dehydration Investigations: ● Obesity Non Contrast CT KUB ● UTIs ● Diuretics Abdominal USS ● Diet (uric acid) Urine dip Bloods ● Genetics e.g Horse Shoe Kidney, HomocystinuriaStone composition pH Radio-lucency Associations Calcium Oxalate Variable Radio-opaque Hypercalcaemia, Idiopathic (most common) Calcium Phosphate Normal - Radio-opaque Renal Tubular Acidosis Types I Alkali and III Struvite Alkali Radio-opaque Horseshoe Kidney, Proteus mirabilis Xanthine Alkali Radiolucent Lesch Nyhan Syndrome Uric Acid Acid Radiolucent Gout Cystine Normal Semi-Opaque; Homocystinuria Ground glass appearanceQuestion 12 A 78 year old lady attends SAU after A&E referred her to the unit for haematuria. She has stated she has no pain, but her urine has started to show a “red tinge”. She also states symptoms of incomplete bladder emptying, 3 stone (20kg) weight loss over a month, and night sweats. You suspect Bladder Cancer. Which of the below is not a risk factor for Bladder Cancer A) Schistosomiasis B) Cyclophosphamide therapy C) Aromatic Amines D) Isocyanates E) PioglitazoneQuestion 12 A 78 year old lady attends SAU after A&E referred her to the unit for haematuria. She has stated she has no pain, but her urine has started to show a “red tinge”. She also states symptoms of incomplete bladder emptying, 3 stone (20kg) weight loss over a month, and night sweats. You suspect Bladder Cancer. Which of the below is not a risk factor for Bladder Cancer A) Schistosomiasis B) Cyclophosphamide therapy C) Aromatic Amines D) Isocyanates: Occupational Asthma E) PioglitazoneBladder CancerTumours of the Bladder Investigations: Types: ● Transitional Cell Carcinoma: Most common ● Bloods ● Squamous Cell Carcinoma ● Urine sample ● Flexible Cystoscopy Risk Factors: ● CT Urogram ● Exposure to dyes and paints ● Smoking ● Biopsy ● Schistosomiasis haematobium; Lake Malawi (SCC) ● Staging PET/CT ● Medications e.g Cyclophosphamide (Haemorrhagic Cystitis), Pioglitazone ● Recurrent UTIs ● Long term catheters ● Male ● Radiotherapy Management 1) BCG: reduce progression 2) Mitomycin: reduce recurrence Stage I: TURBT Stage II or higher: Total Cystectomy Chemotherapy and Radiotherapy ● For those unsuitable for surgery pelvic lymph nodes, ● For advanced disease external iliac, internal iliac, and common iliac nodesQuestion 13 A 13 year old boy with a known background of sickle cell anaemia is referred urgently from Paediatrics ED to SAU at 17:00 for groin pain. On examination you noted an erection with a swollen glans penis. The boy states it has been there “for a while”, while his father says it has been the case since 09:00. The boy has not had any previous crises, surgery or other PMHx. He is up to date with his vaccinations and there are no developmental concerns. What is the next best step? A) Start Hydroxycarbamide B) Aspiration of Corpus Cavernosum C) Aspiration of Corpus Spongiosum D) Aspiration of Superficial Dorsal Vein E) Penectomy + OrchiectomyQuestion 13 A 13 year old boy with a known background of sickle cell anaemia is referred urgently from Paediatrics ED to SAU at 17:00 for groin pain. On examination you noted an erection with a swollen glans penis. The boy states it has been there “for a while”, while his father says it has been the case since 09:00. The boy has not had any previous crises, surgery or other PMHx. He is up to date with his vaccinations and there are no developmental concerns. What is the next best step? A) Start Hydroxycarbamide B) Aspiration of Corpus Cavernosum C) Aspiration of Corpus Spongiosum D) Aspiration of Superficial Dorsal Vein E) Penectomy + OrchiectomyPriapismA persistent erection lasting >4 hours + absence of sexual stimulation Types: ● Low flow (Veno-occlusive): Most common, painful ● High flow (Arterial obstruction): less painful, mid erection ● Recurrent: Sickle Cell Disease, Leukemia Management ● Low flow: Intracavernosal alpha adrenergic agonists or Corpus Cavernosum aspiration ● High Flow: Ice packs + penile compression. If fails then surgeryQuestion 14 A 55 year old male presents to SAU with suprapubic pain. During the history he notes the last time he passed urine was 8 hours ago. He always has LUT symptoms due to having BPH. He currently takes Tamsulosin, Atorvastatin, Amlodipine and Salbutamol inhaler PRN Abdominal Examination notes suprapubic tenderness but no guarding or peritonism. A bladder scan measures 850ml. What is the next best step? A) Insert an 18 Fr Catheter B) Insert a 14 Fr Catheter C) Insert an 18 Fr curved tipped Catheter D) Escalate to Urology SpR for Suprapubic Catheter insertion E) Escalate to Urology SpR for Guide Wire Catheter insertionQuestion 14 A 55 year old male presents to SAU with suprapubic pain. During the history he notes the last time he passed urine was 8 hours ago. He always has LUT symptoms due to having BPH. He currently takes Tamsulosin, Atorvastatin, Amlodipine and Salbutamol inhaler PRN Abdominal Examination notes suprapubic tenderness but no guarding or peritonism. A bladder scan measures 850ml. What is the next best step? A) Insert an 18 Fr Catheter B) Insert a 14 Fr Catheter C) Insert an 18 Fr curved tipped Catheter D) Escalate to Urology SpR for Suprapubic Catheter insertion E) Escalate to Urology SpR for Guide Wire Catheter insertionAcute Urinary RetentionAn acute cessation of urinary flow. It results in a painful distension of the bladder Investigations ● Bloods Causes: ● Bladder Scan ● Acute on Chronic: BPH, Prostate Carcinoma ● +/- PR exam ● Post Op ● Trauma: Urethral injuries and Bladder rupture are associatManagement with Pelvic injuries! ● Fluid Overload 1) Conservative: Privacy + ● Blocked catheter/urethra e.g clots mobilising ● Constipation 2) Analgesia ● Phimosis ● Urethral Strictures ● Pregnancy Catheterise!! ● Extra-Urethral Malignancy ● Urethral; Note curved tip ● Bladder stones better for prostate problems The patient is anuric, in great discomfort and has an intense desire tounsuccessful: Suprapubic or micturate. Guide wire The bladder is palpable and there is suprapubic dullness to ● If clots: Wash out and Irrigation percussion. (higher Fr number = wider diameter to remove clots!)Question 15 A 45‑year‑old man presents to the urology clinic with a 4‑month history of a painless swelling in his right hemiscrotum. He first noticed it after lifting some heavy boxes at work. The swelling has slowly increased in size but does not disturb his sleep or sexual function. On examination: There is a smooth, non‑tender right hemiscrotal swelling that feels fluctuant. It extends to the upper pole of the scrotum but does not reduce into the inguinal canal. Transillumination of the swelling is positive, with a uniform red glow. The right testis can be palpated separately at the lower pole. There is no cough impulse and no associated erythema or warmth. Which of the following is the most likely diagnosis? A) Varicocele B) Hydrocele C) Inguinal hernia D) Epididymo‑orchitis E) Testicular tumourQuestion 15 A 45‑year‑old man presents to the urology clinic with a 4‑month history of a painless swelling in his right hemiscrotum. He first noticed it after lifting some heavy boxes at work. The swelling has slowly increased in size but does not disturb his sleep or sexual function. On examination: There is a smooth, non‑tender right hemiscrotal swelling that feels fluctuant. It extends to the upper pole of the scrotum but does not reduce into the inguinal canal. Transillumination of the swelling is positive, with a uniform red glow. The right testis can be palpated separately at the lower pole. There is no cough impulse and no associated erythema or warmth. Which of the following is the most likely diagnosis? A) Varicocele B) Hydrocele C) Inguinal hernia D) Epididymo‑orchitis E) Testicular tumour A hydrocoele is the result of excessive fluid in the tunica remnant of processus vaginalis and embryology of testesa formation (gubernaculum) HydrocoeleCondition Examination findings Investigations Management Hydrocoele: Paeds + adults Unilateral swelling USS Testes Paediatrics: <1 years observe; if still present then Get above lump Adults: CTAP (rule out surgery after 1 years old Painless malignancy) Adults: Conservative +/- surgery Transilluminates Inguino-Scrotal Hernia Unilateral swelling CTAP Inguinal Hernia repair Get above lump May be reducible Cough impulse may be present Transilluminates Epididymo-orchitis Prehn’s sign positive Clinical Abx and monitor symptoms Unilateral swelling STI screening Dysuria +/- Urethral discharge Epididymal cysts Unilateral swelling USS Testes Get above lump Varicocoele Unilateral “bag of worms” Clinical If Left side: think RCC!! CTAP: Rule out RCC Testicular Cancer: Males <40 years!! Discrete hard nodule separate to testes AFP + Beta HCG Orchidectomy +/- Chemotherapy + RadiotherapyQuestion 16 A 45 year old woman was admitted into SAU for review of swallowing difficulties. A Barium swallow arranged for her reported a bird’s beak sign. As a result a diagnosis of Achalasia was made. Since he is clinically stable the General Surgery consultant arranges her for an Elective Heller’s Cardiomyotomy for her in a future date. Her medications include Lansoprazole (GORD), COCP, and Amitriptyline (Migraine prophylaxis). Advice to stop COCP has been provided for her. How long should this duration be prior to the date of the operation? A) 24 hours B) 48 hours C) 1 week D) 2 weeks E) 4 weeksQuestion 16 A 45 year old woman was admitted into SAU for review of swallowing difficulties. A Barium swallow arranged for her reported a bird’s beak sign. As a result a diagnosis of Achalasia was made. Since he is clinically stable the General Surgery consultant arranges her for an Elective Heller’s Cardiomyotomy for her in a future date. Her medications include Lansoprazole (GORD), COCP, and Amitriptyline (Migraine prophylaxis). Advice to stop COCP has been provided for her. How long should this duration be prior to the date of the operation? A) 24 hours B) 48 hours C) 1 week D) 2 weeks E) 4 weeksPre Op management of Medications Explanation Medication Period to Omit Before Surgery When to go back on it COCP or HRT 4 weeks 2 weeks post-op NSAIDs (e.g Clopidogrel, Aspirin) 7 days (if for prophylaxis e.g MI, TIA/Stroke,risk benefit If patient has a cardiac stent or other high risk indication, decision) liaise with cardiology and surgeon to make decision regarding stopping Warfarin 5 days + Bridging (temporary) prescription of Bridge with LMWH post op until target INR Therapeutic-dose LMWH OR Unfractionated Heparin (e.g Mechanical Heart Valve) DOACs 48 hrs: Major Operation Discuss with Haematology/Med SpR 24 hrs: Minor Operation Therapeutic Dose LMWH 1 day Immediately Lithium 1 day Immediately Unfractionated Heparin Infusion 4 hours Restart Post-Op ACEi/Diuretics (especially K sparing e.g Spironolactone) Day of Operation 2 days post-opQuestion 17 A 56 year old woman is currently confirmed to have Acute Cholecystitis. She has a history of well controlled type 2 diabetes, hypertension with compliance to medication, and Asthma. She is independent in activities of daily living with a BMI of 41. She has been consented for surgery and is awaiting Anaesthetics review. Based on her clinical background, how would you classify her ASA (American Society of Anesthesiologists) score? A) ASA I B) ASA II C) ASA III D) ASA IV E) ASA VQuestion 17 A 56 year old woman is currently confirmed to have Acute Cholecystitis. She has a history of well controlled type 2 diabetes, hypertension with compliance to medication, and Asthma. She is independent in activities of daily living with a BMI of 41. She has been consented for surgery and is awaiting Anaesthetics review. Based on her clinical background, how would you classify her ASA (American Society of Anesthesiologists) score? A) ASA I B) ASA II C) ASA III D) ASA IV E) ASA VASAExplanationQuestion 18 A 76 year old woman who previously had a Hysterectomy presents to SAU with N+V. After history, examination and a CTAP, she is found to have SBO secondary to Adhesions. She is admitted to the General Surgery ward for initial management with a Ryle’s tube, IV fluids, and observation. However 4 days into her admission she unfortunately doesn’t pass Gastrografin testing, and is sent to theatre for Laparotomy + Adhesiolysis. She is currently recovering post op but still feels nauseous. Which of these Anti-emetics would be most appropriate to start her on? A) Metoclopramide B) Ondansetron C) Haloperidol D) Cyclizine E) DexamethasoneQuestion 18 A 76 year old woman who previously had a Hysterectomy presents to SAU with N+V. After history, examination and a CTAP, she is found to have SBO secondary to Adhesions. She is admitted to the General Surgery ward for initial management with a Ryle’s tube, IV fluids, and observation. However 4 days into her admission she unfortunately doesn’t pass Gastrografin testing, and is sent to theatre for Laparotomy + Adhesiolysis. She is currently recovering post op but still feels nauseous. Which of these Anti-emetics would be most appropriate to start her on? A) Metoclopramide B) Ondansetron C) Haloperidol D) Cyclizine E) DexamethasonePost Op Nausea + VomitingExplanation Ondansetron: ● PONV ● Post ChemotherapyQuestion 19 A 21-year-old man attends the SAU 3 days after fracturing his left tibia in a football injury. He was initially treated with a below-knee plaster cast. Over the past 12 hours, he has developed increasing pain in his lower leg that is severe and not relieved by oral analgesia. He describes the pain as deep and throbbing, and it is worse with passive movement of the toes. On examination, the leg appears tense and swollen beneath the cast. His toes are warm with capillary refill measuring 6s. He has reduced sensation between the first and second toes and complains that the pain is unbearable when you attempt to dorsiflex the big toe. Dorsalis Pedis pulses are absent on the site of the cast. What will be the most appropriate next steps? A) Remove the cast B) Urgent Fasciotomy C) Urgent T&O referral D) Start Therapeutic Apixaban E) Start IV AmoxicillinQuestion 19 A 21-year-old man attends the SAU 3 days after fracturing his left tibia in a football injury. He was initially treated with a below-knee plaster cast. Over the past 12 hours, he has developed increasing pain in his lower leg that is severe and not relieved by oral analgesia. He describes the pain as deep and throbbing, and it is worse with passive movement of the toes. On examination, the leg appears tense and swollen beneath the cast. His toes are warm with capillary refill measuring 6s. He has reduced sensation between the first and second toes and complains that the pain is unbearable when you attempt to dorsiflex the big toe. Dorsalis Pedis pulses are absent on the site of the cast. What will be the most appropriate next steps? A) Remove the cast B) Urgent Fasciotomy C) Urgent T&O referral D) Start Therapeutic Apixaban E) Start IV AmoxicillinCompartment Syndrome Explanation Causes: ● Trauma: Crush injuries, burns ● Burns; Superficial for heat/flame, Deep with electrical ● Iatrogenic: Tight casts, bandages etc ● Prolonged periods of pressure ● Reperfusion Injurry: Free radical release causes acute oedema and ischaemia ● Vigorous exercise (rare) 6Ps of Compartment Syndrome ● Pain: Passive stretch/extension as well. Un improving with analgesia ● Pallor: Reduced CRT ● Paraesthesia ● Pulselessness ● Perishing ColdInvestigations FBC, U+Es, CK, CRP, D-DIMER Intra-Compartmental Pressure Monitor System Radiographs Wound is left open. Wound closure with suture Mainly clinical diagnosis approximation is expected Management: You have 6 hours!!! to occur within 5 days to 3 weeks ● A to E Close U+E monitoring ● FLUIDS ● Trauma: Urgent T&O/Plastics referral for theatre;eded Fasciotomy ● Iatrogenic: Remove bandages/cast, Fasciotomy ● Burns: Plastics referral for Escharotomy + burns managementQuestion 20 A 29-year-old woman presents to SAU with a 3-week history of rectal bleeding. She describes bright red blood on toilet paper, and has occasionally seen dripping into the toilet bowl after defecation. The bleeding is associated with a sharp, severe pain during bowel movements which lingers for several minutes afterward. She has no weight loss, change in bowel habit, or family history of bowel cancer. She reports some constipation and straining during bowel movements, which she attributes to a recent change in diet. On examination, she appears well. Abdominal examination is unremarkable. When you try to do a PR exam she screams in pain and asks not to continue. What is the most likely cause of her symptoms? A) Internal haemorrhoids B) Anal fissure C) Colorectal cancer D) Ulcerative colitis E) Infective proctitisQuestion 20 A 29-year-old woman presents to SAU with a 3-week history of rectal bleeding. She describes bright red blood on toilet paper, and has occasionally seen dripping into the toilet bowl after defecation. The bleeding is associated with a sharp, severe pain during bowel movements which lingers for several minutes afterward. She has no weight loss, change in bowel habit, or family history of bowel cancer. She reports some constipation and straining during bowel movements, which she attributes to a recent change in diet. On examination, she appears well. Abdominal examination is unremarkable. When you try to do a PR exam she screams in pain and asks not to continue. What is the most likely cause of her symptoms? A) Internal haemorrhoids B) Anal fissure C) Colorectal cancer D) Ulcerative colitis E) Infective proctitisAnal Fissure Diagnosis: Clinical + Hx of A crack in the wall of the anal mucosa aggravating during defecation + fresh so that the circular muscle layer is exposed. red PR bleeding ● Unable to tolerate PR Exam The tear usually occurs directly ● If really need to, would need to posteriorly and in the midline. be EUA (Examined Under Anaesthesia) Risk factors: ● Chronic Constipation Management ● Excessive straining ● Warm baths ● Crohn’s Disease ● Analgesia ● Diet changes + Hydration ● Sexual Abuse in Children!! ● Topical GTN/Diltiazem ● Botulinum toxinBreaktime!Question 21 A 45-year-old woman with a history of asthma undergoes a laparoscopic cholecystectomy. On postoperative day 1, she complains of mild shoulder and upper abdominal pain, which worsens with deep breathing. She is afebrile and her vital signs are stable. On examination, her lungs are clear, and the surgical site appears clean. What is the most appropriate initial step in managing her pain? A. Start oral opioids as needed B. Encourage ambulation and administer oral paracetamol C. Order a chest X-ray to rule out pneumonia D. Begin intravenous ketorolac for stronger pain relief E. Administer nebulized bronchodilators for suspected asthma exacerbationQuestion 21 A 45-year-old woman with a history of asthma undergoes a laparoscopic cholecystectomy. On postoperative day 1, she complains of mild shoulder and upper abdominal pain, which worsens with deep breathing. She is afebrile and her vital signs are stable. On examination, her lungs are clear, and the surgical site appears clean. What is the most appropriate initial step in managing her pain? A. Start oral opioids as needed B. Encourage ambulation and administer oral paracetamol C. Order a chest X-ray to rule out pneumonia D. Begin intravenous ketorolac for stronger pain relief E. Administer nebulized bronchodilators for suspected asthma exacerbationAnalgesiaWHOpain ladderOpioids choices Renal impairment ● Tramadol - reduced dose in severe impairment ● Codeine - avoid ● Morphine - avoid ● Oxycodone - reduced dose in severe impairment ● Fentanyl - generally safe ● Transdermal buprenorphine - safeQuestion 22 A 65-year-old man undergoes an elective open right hemicolectomy for colon cancer. Pre-operatively, he is otherwise healthy with no significant past medical history. The surgery is uneventful, lasting 3 hours. On the first post-operative day, he is noted to have a urine output of 20 mL/hour over the past 6 hours. His vital signs are: BP 111/70, HR 90 bpm, RR 18, oxygen sats 98% on RA. On examination, his mucous membranes are dry, and capillary refill time is 3 seconds. His laboratory results are: - Sodium: 145 mmol/L (135-145) - Potassium: 4.5 mmol/L (3.5-5.0) - Urea: 8 mmol/L (2.5-7.8) - Creatinine: 120 µmol/L (60-110) - Haemoglobin: 12.5 g/dL (13.5-17.5) Which of the following is the most appropriate fluid to administer at this time? A. 1 litre of 0.9% sodium chloride over 2 hours B. 1 litre of Hartmann's solution over 2 hours C. 500 mL of 5% dextrose over 4 hours D. 250 mL of colloid over 15 minutes E. No intravenous fluids; encourage oral intakeQuestion 22 A 65-year-old man undergoes an elective open right hemicolectomy for colon cancer. Pre-operatively, he is otherwise healthy with no significant past medical history. The surgery is uneventful, lasting 3 hours. On the first post-operative day, he is noted to have a urine output of 20 mL/hour over the past 6 hours. His vital signs are: BP 111/70, HR 90 bpm, RR 18, oxygen sats 98% on RA. On examination, his mucous membranes are dry, and capillary refill time is 3 seconds. His laboratory results are: - Sodium: 145 mmol/L (135-145) - Potassium: 4.5 mmol/L (3.5-5.0) - Urea: 8 mmol/L (2.5-7.8) - Creatinine: 120 µmol/L (60-110) - Haemoglobin: 12.5 g/dL (13.5-17.5) Which of the following is the most appropriate fluid to administer at this time? A. 1 litre of 0.9% sodium chloride over 2 hours B. 1 litre of Hartmann's solution over 2 hours C. 500 mL of 5% dextrose over 4 hours D. 250 mL of colloid over 15 minutes E. No intravenous fluids; encourage oral intakeFluid managementFluid assessment Fluid-depletion Fluid chart Dry mucous membranes, reduced Weights skin turgor U&Es Decreased urine output (<0.5ml/kg/hr) Orthostatic hypotension Fluid-overload Raised JVP Peripheral oedema Pulmonary oedemaFluid management Key points: 1. Restart oral fluids as soon as possible 2. Hartman’s >> Saline (in adults) ->hyperchloraemic acidosis 3. Avoid dextrose in surgical patients ->hyponatraemia 4. Review electrolytes and replace where necessaryQuestion 23 A 65-year-old man undergoes elective abdominal surgery for colon cancer. Post-operatively, he is resuscitated with 2 litres of 5% dextrose over 12 hours due to low urine output. The next day, he is noted to be confused and drowsy. His observations are within normal limits. Blood tests reveal: - Sodium: 127 mmol/L (135-145 mmol/L) - Potassium: 4.2 mmol/L (3.5-5.0 mmol/L) - Urea: 4.5 mmol/L (2.5-7.8 mmol/L) - Creatinine: 90 µmol/L (60-110 µmol/L) Which of the following is the most appropriate next step in management? A. Administer hypertonic saline B. Restrict fluid intake C. Administer 0.9% normal saline D. Administer Hartmann's solution E. Continue current fluid regimenQuestion 23 A 65-year-old man undergoes elective abdominal surgery for colon cancer. Post-operatively, he is resuscitated with 2 litres of 5% dextrose over 12 hours due to low urine output. The next day, he is noted to be confused and drowsy. His observations are within normal limits. Blood tests reveal: - Sodium: 127 mmol/L (135-145 mmol/L) - Potassium: 4.2 mmol/L (3.5-5.0 mmol/L) - Urea: 4.5 mmol/L (2.5-7.8 mmol/L) - Creatinine: 90 µmol/L (60-110 µmol/L) Which of the following is the most appropriate next step in management? A. Administer hypertonic saline B. Restrict fluid intake C. Administer 0.9% normal saline D. Administer Hartmann's solution E. Continue current fluid regimenFluid managementFluid management-replacement Hyponatraemia secondary to dilatation due to over-use of dextrose ->correct with saline ->hypertonic saline may be used in critical situationsQuestion 24 A 67-year-old man undergoes a carotid endarterectomy for symptomatic carotid artery stenosis. The surgery proceeds without intraoperative complications. On postoperative Day 1, during your morning round, you notice that when the patient protrudes his tongue, it deviates to the right side. He also reports difficulty swallowing and mild slurring of speech. His vital signs are stable, and there is no evidence of haematoma or airway compromise. What is the most likely nerve that has been injured during surgery? A. Hypoglossal nerve B. Glossopharyngeal nerve C. Vagus nerve D. Mandibular branch of the facial nerve E. Accessory nerveQuestion 24 A 67-year-old man undergoes a carotid endarterectomy for symptomatic carotid artery stenosis. The surgery proceeds without intraoperative complications. On postoperative Day 1, during your morning round, you notice that when the patient protrudes his tongue, it deviates to the right side. He also reports difficulty swallowing and mild slurring of speech. His vital signs are stable, and there is no evidence of haematoma or airway compromise. What is the most likely nerve that has been injured during surgery? A. Hypoglossal nerve B. Glossopharyngeal nerve C. Vagus nerve D. Mandibular branch of the facial nerve E. Accessory nerveNerve damage Surgical Procedure Nerve(s) at Risk Posterior triangle lymph node Accessory nerve (CN XI) biopsy Lloyd-Davies stirrups positioning Common peroneal nerve Thyroidectomy Recurrent laryngeal nerve (also external branch of SLN) Anterior resection of the rectum Hypogastric autonomic nerves Axillary lymph node clearance Long thoracic, thoracodorsal, intercostobrachial nerves Inguinal hernia repair Ilioinguinal nerve Varicose vein surgery Saphenous and sural nerves Posterior approach to the hip Sciatic nerve Carotid endarterectomy Hypoglossal nerve (CN XII)Question 25 A 70-year-old woman underwent an uneventful right hemicolectomy for colon cancer. On postoperative day 3, she becomes increasingly lethargic and experiences episodes of dizziness when mobilising. Her blood pressure is 90/60 mmHg (down from 130/80 mmHg preoperatively), heart rate is 105 beats per minute, and her temperature is 37.0°C. Physical examination reveals abdominal distension with absent bowel sounds but no tenderness. Her surgical wound is clean and dry. She has minimal urine output over the past 12 hours. Laboratory investigations show: - Sodium: 130 mmol/L (135-145 mmol/L) - Potassium: 3.0 mmol/L (3.5-5.0 mmol/L) - Urea: 10 mmol/L (2.5-7.8 mmol/L) - Creatinine: 150 μmol/L (60-110 μmol/L) What is the most likely cause of her hypotension? A. Hypovolaemia due to postoperative ileus B. Sepsis from surgical site infection C. Acute myocardial infarction D. Pulmonary embolism E. Acute kidney injury due to nephrotoxic drugsQuestion 25 A 70-year-old woman underwent an uneventful right hemicolectomy for colon cancer. On postoperative day 3, she becomes increasingly lethargic and experiences episodes of dizziness when mobilising. Her blood pressure is 90/60 mmHg (down from 130/80 mmHg preoperatively), heart rate is 105 beats per minute, and her temperature is 37.0°C. Physical examination reveals abdominal distension with absent bowel sounds but no tenderness. Her surgical wound is clean and dry. She has minimal urine output over the past 12 hours. Laboratory investigations show: - Sodium: 130 mmol/L (135-145 mmol/L) - Potassium: 3.0 mmol/L (3.5-5.0 mmol/L) - Urea: 10 mmol/L (2.5-7.8 mmol/L) - Creatinine: 150 μmol/L (60-110 μmol/L) What is the most likely cause of her hypotension? A. Hypovolaemia due to postoperative ileus B. Sepsis from surgical site infection C. Acute myocardial infarction D. Pulmonary embolism E. Acute kidney injury due to nephrotoxic drugsPostoperative ileusPostoperative ileus Common complication after bowel surgery ➔ Temporary cessation of bowel motility ➔ Accumulation of fluids & electrolytes in intestines ➔ Third-space fluid losses Features: 1. Abdominal distension, abdominal pain, nausea/vomiting, inability to pass flatus, inability to tolerate oral intake 2. hypovolaemia, hypokalaemia, hyponatraemia, hypophosphataemia Management: 1. Supportive 2. nil -by-mouth initially 3. NG tube if vomiting, 4. IV fluids & electrolyte replacement 5. Total parenteral nutritionPostoperative ileus Common complication after bowel surgery ➔ Temporary cessation of bowel motility ➔ Accumulation of fluids & electrolytes in intestines ➔ Third-space fluid losses Features: 1. Abdominal distension, abdominal pain, nausea/vomiting, inability to pass flatus, inability to tolerate oral intake 2. hypovolaemia, hypokalaemia, hyponatraemia, hypophosphataemia Management: 1. Supportive 2. nil -by-mouth initially 3. NG tube if vomiting, 4. IV fluids & electrolyte replacement 5. Total parenteral nutritionQuestion 26 A 65-year-old man undergoes an open right hemicolectomy for colon carcinoma. On post-operative day 6, he develops a fever of 38.5°C. He complains of increasing abdominal pain near the surgical site. On examination, his abdomen is tender around the incision, which appears erythematous and slightly swollen. Laboratory investigations show: - White blood cell count: 15 ×10^9/L (4–11 ×10^9/L) - C-reactive protein (CRP): 200 mg/L (<5 mg/L) What is the most appropriate next step in his management? A. Start intravenous broad-spectrum antibiotics and arrange wound swab for culture B. Order a chest X-ray to rule out pneumonia C. Request a Doppler ultrasound of the lower limbs to assess for deep vein thrombosis D. Begin physiotherapy with deep breathing exercises E. Observe without intervention as this is likely a normal post-operative findingQuestion 26 A 65-year-old man undergoes an open right hemicolectomy for colon carcinoma. On post-operative day 6, he develops a fever of 38.5°C. He complains of increasing abdominal pain near the surgical site. On examination, his abdomen is tender around the incision, which appears erythematous and slightly swollen. Laboratory investigations show: - White blood cell count: 15 ×10^9/L (4–11 ×10^9/L) - C-reactive protein (CRP): 200 mg/L (<5 mg/L) What is the most appropriate next step in his management? A. Start intravenous broad-spectrum antibiotics and arrange wound swab for culture B. Order a chest X-ray to rule out pneumonia C. Request a Doppler ultrasound of the lower limbs to assess for deep vein thrombosis D. Begin physiotherapy with deep breathing exercises E. Observe without intervention as this is likely a normal post-operative findingSurgical site infectionSurgical site infection Infection around surgical incision up to 30 days post-op Risk factors: ● diabetes, obesity, smoking, immunosuppression ● Poor surgical technique, emergency surgery, long surgery Features: erythema, swelling, pain around site, purulent discharge, fever Investigations: wound swab, inflammatory markers, imaging Management: Abx, fluids, analgesia, surgical drainage/ debridementSurgical site infection Infection around surgical incision up to 30 days post-op Risk factors: ● diabetes, obesity, smoking, immunosuppression ● Poor surgical technique, emergency surgery, long surgery Features: erythema, swelling, pain around site, purulent discharge, fever Investigations: wound swab, inflammatory markers, imaging Management: Abx, fluids, analgesia, surgical drainage/ debridementQuestion 27 A 72-year-old man is recovering from a right hemicolectomy performed 6 days ago for colon cancer. His postoperative course was initially uneventful. Today, he develops a fever of 38.5°C, increasing abdominal pain, and feels generally unwell. On examination, he is tachycardic, hypotensive, and his abdomen is distended with generalised tenderness and guarding. Blood tests reveal: - White cell count: 18 x10^9/L (4-11 x10^9/L) - C-reactive protein: 200 mg/L (<5 mg/L) What is the most likely cause of his pyrexia? A. Wound infection B. Urinary tract infection C. Anastomotic leak D. Hospital-acquired pneumonia E. Deep vein thrombosisQuestion 27 A 72-year-old man is recovering from a right hemicolectomy performed 6 days ago for colon cancer. His postoperative course was initially uneventful. Today, he develops a fever of 38.5°C, increasing abdominal pain, and feels generally unwell. On examination, he is tachycardic, hypotensive, and his abdomen is distended with generalised tenderness and guarding. Blood tests reveal: - White cell count: 18 x10^9/L (4-11 x10^9/L) - C-reactive protein: 200 mg/L (<5 mg/L) What is the most likely cause of his pyrexia? A. Wound infection B. Urinary tract infection C. Anastomotic leak D. Hospital-acquired pneumonia E. Deep vein thrombosisAnastomoticLeakAnastomoticleak Faecal matter enters peritoneal cavity Features: abdominal pain, peritonitis, pyrexia, prolonged ileus, purulent drainage Investigations: CT abdomen and pelvis Management: IV fluids, IV abx, conservative vs surgical managementAnastomoticleak Faecal matter enters peritoneal cavity Features: abdominal pain, peritonitis, pyrexia, prolonged ileus, purulent drainage Investigations: CT abdomen and pelvis Management: IV fluids, IV abx, conservative vs surgical managementQuestion 28 A 65-year-old man undergoes elective open hernia repair under general anaesthesia. Two days post-operatively, he develops a fever of 38.5°C, tachypnoea, and a productive cough with purulent sputum. On examination, his chest expansion is reduced on the right side, and auscultation reveals coarse crackles at the right lung base. His oxygen saturation on room air is 92%. His postoperative pain management has been limited to as-needed analgesia, and he reports severe pain at the surgical site, especially during movement or deep breathing. A chest X-ray shows right lower lobe consolidation suggestive of pneumonia. Which of the following is the most likely contributing factor to his current condition? A. Aspiration during surgery B. Poor postoperative pain management leading to hypoventilation C. Nosocomial infection from contaminated equipment D. Exacerbation of underlying chronic lung disease E. Pulmonary embolismQuestion 28 A 65-year-old man undergoes elective open hernia repair under general anaesthesia. Two days post-operatively, he develops a fever of 38.5°C, tachypnoea, and a productive cough with purulent sputum. On examination, his chest expansion is reduced on the right side, and auscultation reveals coarse crackles at the right lung base. His oxygen saturation on room air is 92%. His postoperative pain management has been limited to as-needed analgesia, and he reports severe pain at the surgical site, especially during movement or deep breathing. A chest X-ray shows right lower lobe consolidation suggestive of pneumonia. Which of the following is the most likely contributing factor to his current condition? A. Aspiration during surgery B. Poor postoperative pain management leading to hypoventilation C. Nosocomial infection from contaminated equipment D. Exacerbation of underlying chronic lung disease E. Pulmonary embolismPneumoniaPneumonia Risk factors: ● old age, lung conditions, immunosuppression ● abdominal/ thoracic surgery, GA, inadequate analgesia, intubation Features: fever, cough +/- sputum, dyspnoea, chest pain O/E: crackles, reduced air entry, dullness to percussion Investigations: CXR, inflammatory markers, sputum culture, blood cultures Management: O2, IV fluids, Abx, analgesiaPneumonia Risk factors: ● old age, lung conditions, immunosuppression ● abdominal/ thoracic surgery, GA, inadequate analgesia, intubation Features: fever, cough +/- sputum, dyspnoea, chest pain O/E: crackles, reduced air entry, dullness to percussion Investigations: CXR, inflammatory markers, sputum culture, blood cultures Management: O2, IV fluids, Abx, analgesiaQuestion 29 A 45-year-old woman undergoes an elective total abdominal hysterectomy for symptomatic uterine fibroids. On the sixth post-operative day, she develops a fever of 38.2°C and complains of abdominal cramping and diarrhoea. She has had six watery bowel movements over the past 24 hours, which are foul-smelling and contain mucus but no blood. Her surgical wound appears clean with no signs of infection. She was given prophylactic antibiotics during surgery and has been taking codeine phosphate for post-operative pain. On examination, her abdomen is mildly distended with diffuse tenderness but no guarding or rebound tenderness. Bowel sounds are increased. Laboratory investigations show: - White blood cell count: 18 x10⁹/L (reference range 4-11 x10⁹/L) - C-reactive protein: 200 mg/L (reference range <5 mg/L) What is the most likely cause of her pyrexia? A. Clostridioides difficile infection B. Urinary tract infection C. Anastomotic leak D. Wound infection E. Physiological response to surgeryQuestion 29 A 45-year-old woman undergoes an elective total abdominal hysterectomy for symptomatic uterine fibroids. On the sixth post-operative day, she develops a fever of 38.2°C and complains of abdominal cramping and diarrhoea. She has had six watery bowel movements over the past 24 hours, which are foul-smelling and contain mucus but no blood. Her surgical wound appears clean with no signs of infection. She was given prophylactic antibiotics during surgery and has been taking codeine phosphate for post-operative pain. On examination, her abdomen is mildly distended with diffuse tenderness but no guarding or rebound tenderness. Bowel sounds are increased. Laboratory investigations show: - White blood cell count: 18 x10⁹/L (reference range 4-11 x10⁹/L) - C-reactive protein: 200 mg/L (reference range <5 mg/L) What is the most likely cause of her pyrexia? A. Clostridioides difficile infection B. Urinary tract infection C. Anastomotic leak D. Wound infection E. Physiological response to surgeryClostridioides difficileClostridioides difficile Risk factors: antibiotics (cephalosporins), PPIs Features: diarrhoea, abdominal pain, raised WCC Investigations: c.difficile toxin +ve Management: ● 1st episode: ○ 1st line: 10-day oral vancomycin ○ 2nd line: Oral fidaxomicin ○ 3rd line: Oral vancomycin +/- IV metronidazole ● Recurrent episode ○ <12 weeks: oral fidaxomicin ○ >12 weeks: oral vancomycin ● Life-threatening: oral vancomycin + IV metronidazoleClostridioides difficile Risk factors: antibiotics (cephalosporins), PPIs Features: diarrhoea, abdominal pain, raised WCC Investigations: c.difficile toxin +ve Management: ● 1st episode: ○ 1st line: 10-day oral vancomycin ○ 2nd line: Oral fidaxomicin ○ 3rd line: Oral vancomycin +/- IV metronidazole ● Recurrent episode ○ <12 weeks: oral fidaxomicin ○ >12 weeks: oral vancomycin ● Life-threatening: oral vancomycin + IV metronidazolePost-operative pyrexia Early (<5 days) Late (>5 days) ● Blood transfusion reaction ● Venous thromboembolism (e.g. DVT, PE) ● Cellulitis ● Hospital-acquired pneumonia ● Urinary tract infection ● Surgical site (wound) infection ● Physiological systemic inflammatory ● Anastomotic leak response (typically within 24 hours ● Deep/organ-space infections (e.g. post-op) intra-abdominal abscess, pelvic ● Pulmonary atelectasis collection) ● Drug-induced fever – e.g. antibiotics, ● Clostridioides difficile colitis – heparin particularly in patients who received ● Line-associated infection – especially antibiotics with central venous access ● Endocarditis – consider in high-risk ● Infected haematoma or seroma patients with prolonged unexplained feverPost-operative pyrexia Early (<5 days) Late (>5 days) ● Blood transfusion reaction ● Venous thromboembolism (e.g. DVT, PE) ● Cellulitis ● Hospital-acquired pneumonia ● Urinary tract infection ● Surgical site (wound) infection ● Physiological systemic inflammatory ● Anastomotic leak response (typically within 24 hours ● Deep/organ-space infections (e.g. post-op) intra-abdominal abscess, pelvic ● Pulmonary atelectasis collection) ● Drug-induced fever – e.g. antibiotics, ● Clostridioides difficile colitis – heparin particularly in patients who received ● Line-associated infection – especially antibiotics with central venous access ● Endocarditis – consider in high-risk ● Infected haematoma or seroma patients with prolonged unexplained feverPost-operative pyrexia Pneumonia UTI VTE Wound Drugs/ antibiotic fever IV line infection Transfusion infection reactionQuestion 30 A 65-year-old man is admitted to hospital for surgical management of a neck of femur fracture. He has a history of stage 4 chronic kidney disease (CKD), hypertension, and type 2 diabetes mellitus. He is expected to have significantly reduced mobility for the next few days. Laboratory results: - Urea: 15 mmol/L (2.5–7.8) - Creatinine: 190 µmol/L (64–104) - Estimated glomerular filtration rate (eGFR): 25 mL/min/1.73 m² (>90) - Haemoglobin: 110 g/L (130–180) - Platelets: 150 × 10⁹/L (150–400) What is the most appropriate venous thromboembolism (VTE) prophylaxis for this patient? A. Low molecular weight heparin (LMWH) at standard dosing B. Unfractionated heparin (UFH) C. Fondaparinux sodium D. Anti-embolism compression stockings E. No prophylaxis needed due to bleeding riskQuestion 30 A 65-year-old man is admitted to hospital for surgical management of a neck of femur fracture. He has a history of stage 4 chronic kidney disease (CKD), hypertension, and type 2 diabetes mellitus. He is expected to have significantly reduced mobility for the next few days. Laboratory results: - Urea: 15 mmol/L (2.5–7.8) - Creatinine: 190 µmol/L (64–104) - Estimated glomerular filtration rate (eGFR): 25 mL/min/1.73 m² (>90) - Haemoglobin: 110 g/L (130–180) - Platelets: 150 × 10⁹/L (150–400) What is the most appropriate venous thromboembolism (VTE) prophylaxis for this patient? A. Low molecular weight heparin (LMWH) at standard dosing B. Unfractionated heparin (UFH) C. Fondaparinux sodium D. Anti-embolism compression stockings E. No prophylaxis needed due to bleeding riskVTE prophylaxisVTE prophylaxis Indications (in consideration of bleeding risk: ● Surgical time >90 mins (or >60 mins for pelvic/ lower limb surgery) ● Reduced mobility post-surgery ● Additional VTE risk factors Pharmacology: ● LMWH (enoxaparin) ● Fondaparinux (alternative) ● Unfractionated heparin OR reduced dose LMWH (renal impairment) ○ Duration: start 12h before or 12 hours after surgery depending on bleeding risk ○ Until fully mobileVTE prophylaxis Indications (in consideration of bleeding risk: ● Surgical time >90 mins (or >60 mins for pelvic/ lower limb surgery) ● Reduced mobility post-surgery ● Additional VTE risk factors Pharmacology: ● LMWH (enoxaparin) ● Fondaparinux (alternative) ● Unfractionated heparin OR reduced dose LMWH (renal impairment) ○ Duration: start 12h before or 12 hours after surgery depending on bleeding risk ○ Until fully mobileTitle Column textFigure slideTransition slideSection slide Figure/TextCaption SEEYOUNEXT https://linktr.ee/medtic.teaching THURSDAY! 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