Surgical problems

DR. SUHAS DAS

ASSISTANT PROFESSOR
DEPARTMENT OF GENERAL SURGERY
MEDICAL COLLEGE, KOLKATA
 PROBLEM

A 25year old boy was brought to E.R with a history of being run over by a motorcycle/RTA
and progressive pain in abdomen since then. How will you assess and subsequently manage
the patient?
OR
An elderly male was brought to E.R with blunt trauma injury of the abdomen. How will you
manage this patient?
OR
A middle aged man was rescued from the side of a road traffic accident and was brought to
E.R in an unconscious state. What should be the line of management?
 Frequently Asked Questions

1. Glasgow coma scale ?

2. Trauma score ?
3. How will you provide prehospital care ?
4. What will you see in secondary survey ?
5. What is FAST/ eFAST ? Advantage and disadvantage ?
6. What is DPL ? Advantage and disadvantage ?
7. What are the organs most commonly injured during blunt trauma abdomen ?
8. Investigations in blunt trauma abdomen ?
9. Indications for exploratory laparotomy ?
PRIMARY SURVEY
 CIRCULATION

Circulation and control of bleeding Assessment BY three critical clinical

observations:
 1. Conscious level
 2 . Skin colour
 3 . Pulse
DISABILITY assessment
SECONDARY SURVEY
 SECONDARY SURVEY

Secondary survey physical examination

 Head and face
 Neck.
 Chest.
 Neurological. Examine the GCS regularly.
 Abdomen and pelvis.
 Extremities.
 Log roll.
Blunt Trauma X-Ray

the big three films :-

 chest
 pelvic radiographs
 lateral cervical spine

Investigation of choice ??
DIAGNOSTIC PERITONEAL LAVAGE
Death following major trauma
 ‘trimodal distribution of death’.
 The three ‘peaks’ as follows:
1 Immediate
 50 % of all deaths.
 not possible to save.
 massive head injury
 severe cardio-pulmonary insult.
2 Early, within the first few hours.
 failure of oxygenation of tissue (airway or breathing problem)
 circulatory failure
3 Late, 20 per cent of deaths.
 multiple organ failure and sepsis
 influenced by inadequate early resuscitation and care
 The ATLS principles are aimed primarily at the ‘early’ group of patients.
Other Topics Asked Frequently……..

 Penetrating abdominal trauma

 Head injury- EDH/SDH
 Chest trauma, indication for emergency thoracotomy
 Triage
 Tension pneumothorax, flail chest
 Splenic trauma, Hepatic trauma
 Burn injury
 PROBLEM

A 60 year old male came to E.R with history of painless

haematuria for last 2 weeks. How will you investigate the
patient?
 Frequently Asked Questions

• What is hematuria?
• Is that hematuria significant?
• Is it a true hematuria or something else?
• What are the DDx and MCC of Hematuria?
• What are the urological malignancies presenting with hematuria?
• When should you investigate a patient with hematuria?
• What investigation should you consider?
• When to admit a patient with hematuria and when to refer to a Urologist?
 HEMATURIA definition

 The American Urologic Association (AUA) guideline panel defined

hematuria as three or more RBCs/HPF.
Hematuria types and Classification
According to the amount of RBC in the urine

 Gross
 Microscopic

According to Timing (when it occurs during urination)

 Early (initial) hematuria: Urethral origin, distal to external Sphincter.

 Terminal hematuria: Bladder neck or prostate origin.

 Diffuse (total) hematuria: Source is in the bladder or upper urinary tract.
Hematuria types and Classification,
cont.
According to its site of Origin
 Nephrologic: arising from the kidney.
 Urologic: arising from the urinary drainage system.

Pseudohematuria: arising from outside the urinary system (E.g. menstruation, inflammation
from phimosis or balantitis)
 Classification of Hematuria

 Painful or Painless.

 Gross or Microscopic.

 Initial, Terminal or Total.

 Transient/lntermittent or Persistent.

 Isolated or associated with proteinuria and other urinary abnormalities.

 Glomerular or Non-Glomerular
 Etiologies

Major Diagnosis Groups:

• Cancer

• Infection

• Stones

• Benign prostatic hyperplasia

• Renal parenchymal lesions

• Trauma

• Benign idiopathic hematuria

Narrowing down the Differentials
 Bright red gross, or macroscopic hematuria  lower urinary tract
 Renal parenchymal bleeding is usually smoky, hazy, or reddish brown owing to the formation of acid
hematin in urine of low pH.
 Proteinuria  renal parenchymal origin (e.g., glomerulonephritis).
 An active urine sediment (e.g., red cell casts or granular casts) also suggests a renal parenchymal origin
 Silent or painless hematuria suggests tumor, vascular causes or renal parenchymal disease.
 Irritative voiding symptoms (e.g., frequency, urgency, and dysuria
suggest infection; however, a bladder tumor should be suspected if cultures are negative.
Cont…

 Colicky pain suggests stone passage or sloughed renal papillae

 Brown or Smokey-colored urine usually has a renal source.
 Initial hematuria  anterior urethral bleeding
 Terminal hematuria  posterior urethral bleeding (e.g., prostate or bladder neck).
 Total hematuria  bleeding occurring at the level of the bladder or above.
 Cyclic hematuria occurring with menses in females suggests endometriosis
 Information regarding exercise, menstruation, recent bladder catheterization, intake of certain drugs or toxic
substances, or passage of a calculus may also assist in the differential diagnosis.
 A family history that is suggestive of Alport syndrome, collagen vascular diseases, urolithiasis, or polycystic kidney
disease is important
Common Risk Factors for Urinary Tract Malignancy in Patients
With Microscopic Hematuria
Is that hematuria significant?

 A single urine analysis with hematuria is common and can result from
menstruation, recent heavy exercise, recent urologic procedure, sexual activity, and
the use of agents that can produce red urine without blood.

A single urinalysis with >IOO RBCs or gross hematuria is SIGNIFICANT.

hematuria
hematuria
hematuria
 PROBLEM

A 26 year old female came to you with history of fever,

anorexia and pain right iliac fossa for last 2 days. How will
you manage the patient?
OR

A 26 year old male came to you with history of fever,

anorexia and pain right iliac fossa for last 2 days. On
examination there is a lump in right iliac fossa. How will
you manage the patient?
Frequently Asked Questions from
Appendix
 Etiology and Pathophysiology
 PRESENTATION
 PHYSICAL EXAMINATION
 SYMPTOMS AND SIGNS OF PERFORATED APPENDICITIS
 DIAGNOSTIC SCORES
 IMAGING STUDIES
 DIFFERENTIAL DIAGNOSIS
 Management
 Ochsner-sherren regime
ALVARADO SCORING SYSTEM FOR
ACUTE APPENDICITIS
ALVARADO SCORING SYSTEM FOR ACUTE
APPENDICITIS
Appendicitis
Lump in right iliac fossa

 Appendicular lump
 Ileocecal tuberculosis
 Crohn’s ileitis
 Tubo ovarian mass
 Carcinoma cecum or ascending colon
 Lymph node mass—Koch’s or lymphoma
 Hydronephrosis or tumor in an unascended or dropped kidney
 Retroperitoneal sarcoma
 Iliopsoas abscess
 Tumor in an undescended right testis
 Ileocecal intussusception
 PROBLEM

A 36 year old male came to you with a history of fall astride in a

manhole. Since then he is not able to pass urine. On examination you
find blood at the tip of penile meatus. How will you manage the
patient?
 Injuries to the male urethra

Rupture of the bulbar urethra Rupture of the membranous urethra

 PROBLEM

A 35 year female patient has come to emergency with acute pain in right upper
quadrant of abdomen. How will you proceed in this case?
OR
A 40 year old male came with pain in the right hypochondrium and vomiting after
attending last night party. How will you proceed to manage this patient?
OR
A 40 Year old alcoholic male reported to E.R with complaints of severe abdominal
pain and repeated bouts of vomiting for last 36 hours. What is the most likely cause
and how will you confirm that? How will you make a day to day evaluation of the
disease process?
Epigastric pain –D/D

 Acute cholecystitis
 Acute pancreatitis
 Peptic ulcer disease
 Acute gastritis
 Biliary colic
 Liver abscess
 Acute myocardial infarction
 Basal pneumonia
 Dissecting aneurysm of aorta
 PROBLEM

 A 6o year old male patient came to E.R with sudden onset severe pain in
epigastric region which diffuses gradually to whole abdomen. He gave history
of frequent analgesic intake. On examination of abdomen you find cardboard
rigidity. How will you investigate and manage the patient?
 PROBLEM

A seventy two year old male presented with acute retention of urine
for last 6 hours. How will you manage the patient?
 PROBLEM

A 68 year old female came to you with painless fresh bleeding per rectum for last
2 weeks. How will you come to a diagnosis?
 PROBLEM

A 35 year old lady (weight 50kg) sustained burn injury of a significant portion (40%) of her
body surface. How will you manage the patient?
 PROBLEM

Q. A 36 year old male was stabbed to his left side of chest. He was brought to E.R
with respiratory distress. How will you manage the patient?
 PROBLEM

Q. A 45 year old smoker came to you with severe pain in right foot. On examination you find
gangrenous changes in right great toe and absent pulsation of arteria dorsalis pedis artery of
the same side. How will you manage the patient?
 PROBLEM

 Q. A middle aged male brought to hospital with a history of fall from a coconut
tree. What injuries he might sustain and how to confirm them?
 PROBLEM

 How will you manage a patient with massive non variceal upper Gastro-
intestinal tract haemorrhage?
 PROBLEM

1. Q. Preoperative preparation of a 46 years old male patient with obstructive

jaundice.
2. Q. Preoperative preparation of a 70 year old male patient with gastric outlet
obstruction.
3. Q. Preoperative preparation of a patient with thyrotoxicosis.
4. Q. Preoperative preparation of a patient with carcinoma colon.