'The Surgical Approach' Flashcards

Question 1

Q

viva-

Hx from pt:

I said ‘what operation have you had?’ I wasn’t allowed to ask that.

Symptoms*? He said he had urinated blood.
What happened*? He had gone to A&E.
Investigations*? Ultrasound.

(say what you KNOW!)

Answer

A

I note an atypical series of scars on the abdomen,

Desc; …largest being a veritcal scar of 15cm extending from the RUQ

Unlikely to be bladder surgery** as would expect a **Pfannenstiel/lower
midline.
Not a typical nephrectomy** scar, which was located on the **flanks.

Suggest; Due to the distribution of the main scar I thought it was atypical
surgery on the kidney or ureter, possibly with associated port scars.

Diagnosis: ?renal cell carcinoma.

Question 2

Q

What do you see?

What could this be?

Answer

A

Bilateral nephrostomy drains, draining urine into leg bags.

Asked what it could be?

obstruction at level of calyces, ureters or bladder. DDx bilateral obstruction; bilateral stones, extensive bladder malignancy, AAA, Retroperitoneal fibrosis

Question 3

Q

Bilateral urinary tract obstriction

Ix and Mx

Answer

A

Investigation

USS- identifies presence of hydronephrosis and can assess the kidneys
IVU (Intravenous urogram)- assess the position of the obstruction
Antegrade or retrograde pyelography- allows treatment
if suspect renal colic: CT scan (majority of stones are detected this way)

Management

Remove the obstruction and drainage of urine
Acute upper urinary tract obstruction: Nephrostomy tube
Chronic upper urinary tract obstruction: Ureteric stent or a pyeloplasty

Question 4

Q

Differentials for scar

and for scar with

With decreased air entry, dull percussion and decreased vocal resonance, in lower left base…

Answer

A

Midline Sternotomy enables access to the underlying structures; most commonly heart, also; pericardium, thoracic aorta, oestophagus, teachea, phrenic and cardiac nerves, thoracic duct, thymus and lymph nodes.

indications; cardiac (see table), Aortic aneurysm/disection, ?rarely as an alternative approach to resection of lung cancer/oestophagus (the latter with extension), thymectomy (MS)

‘findings atypical in a well patient in the absence of a pneumonectomy scar and could possible indicate a unilateral pleural effusion’ ….NOT AN EFFUSION

Given that the pt had had open heart surgery, damage could have been done to NAVY + surrounding structures. Phrenic nerve injury could have also lead to partial paralysis of the left hemi-diaphragm

With decreased air entry, dull percussion and decreased vocal resonance, in lower left base…

Question 5

Q

Differentials; What mass lies beneath the scar?

Question 6

Q

Shorts; present what you see

Answer

A

There is a stoma, not spouted and flush to the skin, located in the left lower quadrant/left iliac fossa. It is pink in colour, active, (producing reasonably well formed stool). On closer inspection, it does not appear herniated or retracted and there appears to be only one lumen.

This would be consistent with a colostomy.

The potential indications for this could include sigmoid cancer and diverticulitis, or less commonly inflammatory bowel disease.

Peripheral evidence for sigmoid cancer would include cachexia as evidenced by muscle wasting of the temporalis and triceps, peripheral sensory neuropathy, radiotherapy tattoos and/or PortaCath.’