Core Clinical Cases in Surgery and Surgical Specialties

Janesh Gupta

• Publisher: CRC Press
• Year: 2014
• Print ISBN: 9781138471283
• eBook ISBN: 9780429586620
• Edition: 2
• Topic: Medicine
• Subtopic: Surgery & Surgical Medicine

You've read your textbook and your course notes. Now you need to apply your knowledge to real-life clinical situations.The problem-solving approach of Core Clinical Cases guides you to think of the patient as a whole, rather than as a sequence of unconnected symptoms. With its emphasis on everyday practice strongly linked to underlying theory, the

1	General surgery Matthew Clark, Jevan Taylor, Steven Thrush

KEY CONCEPTS

Landmarks for post-operative care and complications

Late complications of surgery

The five Bs

HERNIAS

Questions

Clinical cases

OSCE Counselling cases

Key concepts

Answers

Clinical cases

OSCE Counselling cases

Revision panel

GALLSTONES

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OSCE Counselling cases

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Clinical cases

OSCE Counselling cases

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APPENDICITIS

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Clinical cases

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COLON AND RECTAL CANCER

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OSCE Counselling cases

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OSCE Counselling cases

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SURGICAL EMERGENCIES

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VASCULAR: ABDOMINAL AORTIC ANEURYSM

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OSCE Counselling cases

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OSCE Counselling cases

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PERIPHERAL VASCULAR DISEASE (PVD)

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Clinical cases

VASCULAR: CAROTID

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VENOUS DISEASE

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Clinical cases

BREAST

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OSCE Counselling cases

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KEY CONCEPTS

Complications can occur early or late in the post-operative period, and can be specific to the surgery performed, or more general, occurring after almost all operations.

Landmarks for post-operative care and complications

FIRST 24 HOURS

Primary haemorrhage is the most common feature presenting as tachycardia. Initially a fit young patient will have a stable blood pressure (BP) because the cardiovascular system is able to compensate. As circulating volume falls further (> 20–40 per cent), hypotension develops. Resuscitation with colloid plus blood and stopping the haemorrhage is essential before decompensation occurs.

A raised temperature (<37.9°C) in the first 24-hour period is usually a reactive post-operative pyrexia, but a rise > 38°C is suspicious of a urinary tract infection (UTI) that was pre-existing but flared up after urinary catheterization.

24 TO 72 HOURS

Infection of the urinary tract, chest, surgical wounds and legs (deep vein thrombosis) must be checked for causes of pyrexia during this time period.

After abdominal surgery, a pyrexia in this time period should also raise suspicion of direct injury to the bowel that was missed during surgery and has caused peritonitis.

7 TO 10 DAYS

• Secondary haemorrhage caused by infection

• Thrombosis (deep vein thrombosis or pulmonary embolus)

• Bowel anastomotic leak

• Infected post-operative collection

• Fistula formation from avascular necrosis (diathermy burns) presenting as late complications (e.g. ureteric fistula, vesicovaginal fistula, rectovaginal fistula or bowel perforation causing peritonitis)

• Pressure sores

Late complications of surgery

• Incisional hernia

• Adhesions

• False aneurysm

• Infected prosthesis

The five Bs

Who needs emergency out-of-hours surgery? Remember the five ‘B’s:

Block (e.g. bowel obstruction)

Bleed (e.g. peptic ulcer)

Burst (e.g. ectopic pregnancy, perforated bowel)

Break (e.g. open fractures)

Burn (e.g. skin burns)

HERNIAS

Questions

Clinical cases

For each of the clinical case scenarios given

Q1: What is the likely differential diagnosis?

Q2: What features of the given history support the diagnosis?

Q3: What additional features in the history would you seek to support a particular diagnosis?

Q4: What clinical examination would you perform and why?

Q5: What investigations would be most useful and why?

Q6: What treatment options are appropriate?

CASE 1.1 – ‘I’ve developed a lump in my groin’

A 25-year-old builder suddenly develops a golf-ball-sized, slightly tender lump in his right groin after lifting a 20-kg bag of sand. He states that he felt a tearing sensation as it happened. He attends the accident and emergency department.

CASE 1.2 – ‘I can’t push my lump back in anymore’

A 70-year-old retired man presents to surgical outpatient clinic with a slightly tender lump in his left groin. He has had the lump for many months, but previously it would disappear overnight, or if necessary he could gently push it back inside. His health is fine, other than a cough from years of smoking. Over the last 2 weeks he has not been able to reduce the lump.

CASE 1.3 – ‘My hernia is sore and I’ve started to vomit’

A slim 73-year-old woman has had a groin lump for some time which she ignored. Over the last 3 days it has become progressively more painful, with redness of the overlying skin. She has not opened her bowels during this time (which is unusual for her), and yesterday she started to vomit.

OSCE Counselling cases

OSCE COUNSELLING CASE 1.1 – ‘Should I have my hernia repaired?’

A 47-year-old man presents, via his general practitioner (GP), with an intermittent left groin mass, causing only moderate symptoms. Examination confirms an easily reducible inguinal hernia.

Q1: If an operation is offered, what specific risks should the patient be warned about?

OSCE COUNSELLING CASE 1.2 – ‘Why did my surgeon suggest I see a urologist first?’

An otherwise well 74-year-old man has a right inguinal hernia and chooses to proceed with hernia repair. In his history he reveals that he has slight difficulty initiating urination, poor stream and nocturia. The surgeon suggests that he is seen by a urologist before proceeding with the operation.

Q1: What factors might the surgeon be thinking about in deferring the operation?

Q2: What will the urologist do?

Key concepts

In order to work through the core clinical cases in this section you will need to understand the following key concepts.

WHAT IS A HERNIA?

‘An abnormal protrusion of a viscus through the wall of the cavity that usually contains it.’

WHERE DO THEY OCCUR?

Hernias may occur anywhere in the body. Groin hernias are the most common, usually occurring through the inguinal or femoral canals. Other sites for hernias are where musculofascial weaknesses may develop (umbilicus, diaphragm, edge of rectus abdominis, lumbar triangle), when abnormally raised pressure develops (cerebral tumours causing ‘coning’) or as a complication of wound healing (incisional hernias).

WHAT CAN THEY CONTAIN?

Just about anything. Omentum and small bowel are the most common contents of abdominal wall hernias, but most organs (including the pregnant uterus) have been described in hernias. Sometimes ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Contributors
• Abbreviations
• Chapter 1 General surgery
• Chapter 2 Ear, nose and throat (ENT)
• Chapter 3 Ophthalmology
• Chapter 4 Trauma and orthopaedic surgery
• Chapter 5 Urology