NL Examination Part I

General Surgery

1.AAA
66 1 emergency repair of rupture of aortic aneurysm urine output 35/4hr Foley catheter 4 U
BT 37.3C , BP 104/68mmHg , PR 126/min diffuse peripheral edema CVS, RS, Abdomen : normal A:Heart failure Lab : Hct 27%, Na 143, K 5 B.Hypovolemia Oliguria

C.Occluded foley cath D.Renal a. thrombosis E.Tranfusion reaction

AAA Sx complication
1. 2. 3. 4. MI or arrhythmia most common morbidity Acute renal failure ruptured > elective Ischemic colitis Prosthetic graft infection

Renal failure s/p AAA Sx

1. 2. 3. 4. 5. Perioperative hypotension Atheromatous embolization Injury to the ureter Preoperative contrast-induced nephropathy Suprarenal aortic clamping

2.Urinary retention
A 70 year old man comes to the physician because of urinary frequency , hesitancy and slow stream for 18 mo. Rectal examination shows a firm slightly enlarged prostate. After he voids, A Foley catheter is inserted and Yields 500 ml of urine. Urinalysis is within normal limits. Which of the following is the most likely diagnosis?

A.Acute prostatitis B.BPH C.Neurogenic bladder D.Prostate cancer E.Urethral stricture

Lower urinary tract symptoms (LUTS)

Bladder Outlet Obstruction (BOO)

Complication of BOO 1.Acute retention 2.Chronic retention 3.Impaired bladder emptying 4.Hematuria 5.Pain

3.Breast mass
A previously healthy 22 year old woman come to the
physician 3 months after discovering a mass in the lower outer quadrant of her right breast. Examination shows a 2 cm oval firm, smooth, mobile mass. No axillary masses are present. Excision biopsy is most likely to show which of the following?

A. Fat necrosis B. Fibroadenoma C. Fibrocystic chage of the breast D. Intraductal carcinoma E. Intraductal papillma

Approach Breast mass

Aberrations of Normal Development and Involution (ANDI)

4.Benign breast mass

17 Left breast mass 3 cm. well circumscribe, rubbery, movable, axillary LN-negative
A. Subcutaneous mastectomy ?Management B. Estrogen antagonize C. Core needle biopsy D. Incisional biopsy E. Excision

5.Dysphagia 1
50 4 Barium swallowing dilatation of distal
esophagus and loss of peristalsis at distal two-thirds.

6.Dysphagia 2
62 4.5 . 1 2 40 Barium swallowing distal esophageal lumen partial obstruction

7.Dysphagia 3
68 7 Barium swallowing generally dilated esophageal with loss of peristalsis.

Barium swallowing

Barium swallowing

Barium swallowing

Achalasia

8.Trauma
A 21 yr old man is brought to the emergency department 45 min after a head on motor vehicle collision in which he was the unrestrained driver. On arrival he is alert and coherent, he is breathing 100% O2. Examination shows bruising over the central portion of the chest extending to both sides. Neck vein are not distended. His trachea is deviate to the right. Breath sounds are present on the right and absent on the left. Following administration of 2 L of lactated Ringers solution, his systolic blood pressure is 80 mmHg. A. Intubation
Which of the following is the most appropriate next step in Tx?

B. Peritoneal lavage C. Blood transfusion D. ICD Insertion E. Pericardiocentesis

Primary survey

Secondary survey

Trauma Management

9.Inguinal Hernia
47 3 5
A) Analgesic B) Try reducing C) Observe D) Surgery E) Analgesic + Try reducing

Approach

Type of Hernia

Strangulated Hernia

Golden period = 6 hours

Urgent Treatment

10.Colorectal polyp
56 ca colon colonoscopy polyps at descending colon polypectomy
A) Villous adenoma B) Tubulovillous adenoma C) Tubulous adenoma

Colorectal polyp
Neoplastic polyp (Adenomatous polyps) Harmatomatous polyp Risk of ca Inflammatory polyp - Type of polyp Hyperplastic polyp - Size of polyp Villous adenoma - 40% Tubulovillous - 20% Tubular adenoma - 5% Serrated polyp-ca 10%

Colorectal polyp

Colorectal polyp

11.Gross hematuria
60 1 PR = prostate gland grade II, smooth surface
A. Vesicle stone B. CA prostate C. CA bladder D. Chronic pyelonephritis E. Chronic glomerulonephritis

Approach

Painless ? Malignancy Hematuria upper tract

Hematuria at beginning lower tract Terminal haematuria severe bladder irritation (stone or infection)

12.BPH
prostate gland gr. IV, smooth, ruberry, PSA investigation ?
A. Tranabdominal U/S B. Urine C/S C. Cr D. Cystoscope E. Prostate Bx

Investigation of men with LUTS

Investigation of men with LUTS

13.Gut obstruction
40 4 10 BT 37.5 PR 96 RR 20 BP 130/70
Mild abdominal distension, inc bowel sound with high pitch no tender, PR plain abdomen air rectum colon A. B. C. NG tube IV fluid D. Rectal tube E. Emergency laparotomy

14.Head injury
20 2 GCS 8, pupil 3 mm RTL 5 mm SRTL Rt. Hemiparesis
A. Observe neuro sign B. ET tube + hyperventilation C. Furosemide D. Mannitol IV E. Craniotomy

GCS
Mild HI : 14-15/15 +LOC Mod HI : 9-13 Severe HI : 3-8

15.CA breast
50 5 cm upper outer quadrant Axillary node=fix FNA malignant
A. Radiation B. Simple mastectomy C. Radical mastectomy D. Hormanal therapy E. Neoadjuvant therapy

CA breast staging
T1=2cm T2=2-5cm T3=>5cm T4=local invade N1=1-3 N2=4-9 N3=>=10
N1=moveable ipsilat axillary LN N2 N2a=fix/matted axillary LN N2b=ipsilat IM LN N3 N3a=ipsilat infraclavicular LN N3b=ipsilat IM LN and axillary LN N3c=ipsilat supraclavicular LN

Locally advanced CA = T3 or N2

CA breast Treatment
Locally advanced Breast cancer
Work up distant metastasis Neoadjuvant CMT reassess
Response = Surgery No response = step up CMT / XRT

Surgery
MRM vs BCT ALND vs SLNBx

16.Peptic ulcer
35 10 3 upper GI studies 0.5 . duodenal bulb
A. H.pylori eradication B. Antisecretory agent C. High selective vagotomy D. Mucosal protective agent E. Antisecretory agent+giving up smoking

Peptic ulcer

? H.pylori

? Cancer

H.pylori work up
Histology (biopsy) = Gold std Rapid urease test (CLO test) = Simplest method Urea breath test = Confirm eradication Serologic test = Not confirm eradication Culture = Failure of ATB

17.Ischiorectal abscess
45 3 tender over Rt.Ischiorectal space PR: warm and tender along Rt. Side
A. Lateral sphincterectomy B. I&D C. Debridement D. Excision

Ischiorectal abscess

18.UGIB
60 2 1 .. V/S BP 90/60 mmHg PR 140/min RR 25/min
A. omeprazole IV B. Fluid resuscitation C. Retain NG Tube D. Esophagogastroscopy E.

Melena & Hematemesis

Elderly GU > DU

Varice vs Non varice

GIB treatment
1st = resuscitation

19.Pancreas
60 1 anorexia 1 wk PTA epigastrium N/V
A. pancreatic pseudocyst B. retroperitoneal lymphoma C. pancreatic cystadenoma D. pancreatic adenocarcinoma E. pancreatic cystadenocarcinoma

Chronic pancreatitis

Chronic pancreatitis
S&S 1. Pain 2. Malabsorption + wt loss 3. Apancreatic DM (type 3 DM)
Complication 1. Pseudocyst most common complication 2. Pancreatic ascitis 3. Pancreatic enteric fistula 4. Pancreatic head mass 5. PV/SV thrombosis

Pseudocyst
50% can resolve spontaneously (<6 cm)

Asymptomatic Conservative Treatment

Symptomatic or failed conservative Sx (Internal drain > external drain) ? Infected FNA +ve Sx

Pseudocyst
1. Percutaneous drainage 2. Endoscopic drainage 3. Open drainage
Cystogastrostomy Cystoduodenostomy Cystojejunostomy (Roux En Y)

4. Resection Distal pancreatectomy 5. ERCP Communicating duct

20.Acute Epididymo-Orchitis
55 5 cm
A. CT scan B. Ultrasound C. morphine and try reduction D. ATB E. Immediate surgery

Acute Epididymo-Orchitis
Mode of infection 1 infection of urethra, seminal vesicle, prostate 2 infection : outflow obstruction/ Foley catheter
Organism Chlamydia Gonococcus Mumps infertile

Clinical feature
UTI Painful & edema Abscess

Tx
ATB 2 wk (STD Doxycyclin) +/- drainage

Chronic Epididymo-Orchitis
Organism Tuberculous Sarcoidosis

2/3 =Renal Tuberculosis Lesion Lower pole of the epididymis Tx Tx primary lesion Anti TB Not resolved Sx

Investigation Urine/semen AFB IVP CXR

21.Acute cholecystits
40 12 PE BT 38.9 RUQ pain U/S gall stone, GB wall Management
thickening, pericholecystic fluid

1. IV ATB 2. IV ATB + 3. IV ATB + percu.cholecystectomy 4. IV ATB + LC 48-72 hr 5. IV ATB+ ERCP

Acute cholecystits Tx

22.Liver Cyst
50 U/S well-defined anechoic mass, strongly posterior enhancement, 4 cm left lobe liver
a. Hepatocellular carcinoma b. Calcified granuloma c. Liver abscess d. Hepatic cyst

23.Blunt abdominal injury

35 5 5 BP 110/70 PR 88 generalized mild tender
1. DPL 2. FAST 3. CT abdomen 4. general abdominal exam 5. Explore lap

DPL

Blunt abdominal injury

24.Head injury
36 CT brain (CT:cresent shape hemorrhage, midline shift)

a. Cerebral contusion b. EDH c. SDH d. SAH

25.Acute urinary retention

72 1 2 admit 3 5-6
1. retain foley catheter and off 2. intermittent catheter and refer for Sx 3. retain foley cathteter and alpha blocker 4. alpha blocker 5. intermittent catheter , off and alpha blocker

26.Acute pancreatitis
40 6 1-2 hr 1 .
PE: moderate tenderness at epigastrium decrease BS TB 0.5 AST/ALT 400/550 ALP 140 serum amylase 1500 investigation A. CT abdomen B. Serum lipase C. Blood culture D. Plain film E. U/S abdomen

Severity assessment
Early prognosis score
1. Ranson criteria (>=3 : severe pancreatitis) 2. APACHE II score (>=7 : severe pancreatitis)

CT severity Index (CTSI) (>=4 : severe pancreatitis)

Barthaza score + necrosis (Gold std for severity assessment)

The End

part I