Carcinoembryonic antigen (CEA) is especially important to monitor response to treatment and identify relapse in tumours showing raised CEA at diagnosis (e.g.colorectal cancers).

The history of the right upper quadrant discomfort and the examinations of a palpable liver are descriptions of tumour metastasis to the liver. CEA raises with a metastatic tumours from colon whereas alpha-fetoprotein (AFP) is elevated in primary hepatocellular carcinoma.

So do not get confused and pick AFP where there is a clear history of colorectal carcinoma.

Carcinoembryonic antigen (CEA) is vital for monitoring treatment response and detecting tumor relapses, especially colorectal cancers, that initially present with elevated CEA levels.

Signs of right upper quadrant discomfort and a palpable liver indicate potential metastasis of the tumor to the liver. CEA levels rise in colorectal cancer metastases, whereas alpha-fetoprotein (AFP) is specific to primary hepatocellular carcinoma.

It’s important not to confuse the two; prioritize CEA when there’s a history of colorectal carcinoma.

The woman in this scenario has the classical picture of a fibroadenoma.

Fibroadenomas are the most common type of breast lesion in young women. Although this women is not very young, based on her past medical history, family history and examination results, a fibroadenoma is the single most likely diagnosis for her.

Fibroadenomas arise in breast lobules and are composed of fibrous and epithelial tissue. They present as firm, nontender and highly mobile masses.

Fibroadenosis is less likely because the hallmark of these lumps is that the lump appears just before menstrual periods and disappears afterwards.

Also, the biopsy of fibroadenosis reveals fibrosis, adenosis, epitheliosis and cyst formation.

The usual presentation of fibroadenosis is a breast lump or pain in the breast.

Breast carcinoma is the most common cause of a breast mass in postmenopausal patients. In malignancy, there is an abundant pure population of tumour cells, singly and in clusters.

For elective procedures, proceed only if the haemoglobin is above 100 g/L (10 g/dL).

If haemoglobin is lower than that, defer the operation and investigate first. If haemoglobin was below 80 g/L (8 g/dL) and the patient was symptomatic, then transfuse with blood. 

In acute mesenteric ischaemia, VBG typically shows a high lactate. If an ABG had been performed, it would have revealed severe metabolic acidosis with a high lactate.

Atrial fibrillation is the likely cause of the embolism that has caused the ischaemic even in the gut. We should have a high suspicion of embolization to the superior mesenteric artery with any patient with atrial fibrillation who complains of severe abdominal pain.

Please remember that ischaemic colitis is different from acute mesenteric ischaemia.

Mesenteric ischaemia is acute with an abrupt cessation of blood supply to the gut whilst ischaemic colitis has a chronic presentation over hours which occurs due to a transient disruption of blood supply to the colon.

In the Emergency Department, if mesenteric ischaemia is suspected, resuscitation with oxygen and intravenous fluids should be commenced. Also administer intravenous analgesia and broad spectrum intravenous antibiotics. These patients need to be referred to the surgeons urgently.

Mesenteric ischaemia is the abrupt cessation of blood supply to a large portion of the bowels resulting to irreversible gangrene. Usually occurs in the middle-aged or elderly patients.

Causes:

• Mesenteric arterial embolism (seen in patients with atrial fibrillation)

• Decreased mesenteric arterial blood supply (seen in patients with hypertension secondary to myocardial ischaemia)

Clinical features :

• Severe sudden onset of abdominal pain

• Severity of pain exceeds the physical signs

• Absent bowel sounds

• Abdominal distension and tenderness

The lump at the left supraclavicular region known as Troisier’s sign (an enlarged left supraclavicular node – Virchow’s node), it is indicative of gastric cancer.

The likely diagnosis here is paralytic ileus and an x-ray can help with diagnosis.

Prolonged surgery is one of the major causes of paralytic ileus and it occurs due to overhandling of the bowel.

Paralytic ileus is to be expected in the first few days after abdominal surgery. Bowel sounds are absent and there is no passage of gas. There may be mild distension, but there is usually minimal pain.

PARALYTIC ILEUS -

Clinical features :

• Abdominal distension, tympanic or dull on percussion.

• Abdominal X-ray - Shows air/fluid-filled loops of small and/or large bowel

• Intestinal ileus usually settles with appropriate treatment.

Treatment : Pass an NGT to empty the stomach of fluid and gas if the patient is nauseated or vomiting.

Small volumes of tolerated oral intake may help mild ileus to resolve.

• Ensure adequate hydration by IV infusion (‘drip and suck’).

• Reduce opiate analgesia and encourage the patient to mobilize.

A pelvic mass that is identified after menopause should raise the suspicion of ovarian cancer.

Remember that in post menopausal women, the ovaries should normally be atrophic so if they are felt, think of ovarian carcinoma.

During open carpal tunnel release surgery, the transverse carpal ligament is cut, which releases pressure on the median nerve and relieves the symptoms of carpal tunnel syndrome.

This is a very straightforward question. Although many of the options could be very well correct, the history of diabetes should point you towards an infective cause.

Hence, the perianal abscess is the answer.

It is one of the common causes of anorectal pain.

Perianal abscesses have a gradual onset, usually with constant localized perianal pain.

Throbbing and severe are good ways to describe a perianal abscess especially if the patient describes the pain as worse when sitting down.

Tenderness and swelling is common and occasionally with discharge. Other symptoms also include constipation or pain associated with bowel movements.

This is a case of an open surgery. Patient controlled analgesia with morphine would be the best to start off and this could be weaned off when the patient is in less pain.

Ischaemic colitis is caused by transient disruption of blood supply to the colon which leads to mucosal ulceration, inflammation and haemorrhage hence the PR bleeding is mentioned in this stem.

A low grade pyrexia, tachycardia and abdominal tenderness would also fit with symptoms of an ischaemic colitis.

The aetiology is often multifactorial involving either thrombotic events or hypoperfusion (such as shock, heart failure or a myocardial infarction).

In this stem, heart failure was the cause.

Please remember that ischaemic colitis is different from acute mesenteric ischaemia.

Mesenteric ischaemia is acute with an abrupt cessation of blood supply to the gut whilst ischaemic colitis has a chronic presentation over hours which occurs due to a transient disruption of blood supply to the colon.

The position of the mass in combination of the symptoms of change of bowel habit and weight loss can only be from a carcinoma of sigmoid colon.

The fact that this patient already has confirmed gallstones seen on ultrasound with an increased common bile duct diameter means that it is highly likely that she is having a repeat episode of biliary colic or perhaps even cholangitis. The next best investigation would be to confirm the diagnosis on a repeat ultrasound.

ERCP is used primarily to diagnose and treat conditions of the bile ducts and main pancreatic duct.

Newer modalities such as MRCP produce detailed images of the hepatobiliary and pancreatic systems. This means that ERCP is now rarely performed without therapeutic intent.

BILIARY COLIC :

Occurs when a stone temporarily occludes the cystic duct. There is a colicky pain in the right upper quadrant radiating to the right shoulder. The pain can also radiate to the back in the interscapular region.

Nausea and vomiting are common which often accompanies the pain. The episode is usually self-limiting.

Ultrasound establishes the diagnosis of gallstones.

Contrary to its name “Biliary colic”, the pain usually does not fluctuate but instead is consistent and can last anywhere between 15 minutes up to 24 hours where the pain gradually subsides spontaneously or with the help of analgesia.

The main difference between inflammatory component biliary colic and acute cholecystitis is the inflammatory component.

In acute cholecystitis, there is local peritonism, fever, and elevated WCC.

Management includes:

• Analgesia (usually opioids such as morphine)

• Rehydrate

• Nil by mouth.

• Elective laparoscopic cholecystectomy is usually indicated.

Fibroadenomas are the most common breast tumors found in adolescence and young women. Clinically, fibroadenomas are firm, non-tender, highly mobile palpable lumps.

It is important to remember that the most distinctive feature of fibroadenomas that distinguishes them from other breast lumps is the fact that they are highly mobile. In fact, some small lumps may slip away from the examining hand during palpation because they are extremely mobile, giving rise to their description “breast mice”.

Most fibroadenomas are found in the upper outer quadrant of the breast.

They are thought to result from an increased sensitivity to oestrogen.

Diagnosis is usually made with a combination of clinical assessment, ultrasonography and fine needle aspiration cytology.

This is a case of anorectal abscess.

Diabetes, immunocompromised patients or patients with Crohn’s disease are likely candidates for an anorectal abscess.

Fever and pain are typical for an anorectal abscess.

The perianal pain is sometimes worse when sitting and can be associated with constipation.

Management would include surgical drainage.

Antibiotic use is necessary if there is a history of diabetes or immunosuppression.

Breast fine needle aspirations are not 100% accurate. The lump is suspicious.

The most appropriate investigation to confirm the diagnosis is a core biopsy. A core biopsy uses a hollow needle to take one or more samples of breast tissue from the area of concern. Because tissue is taken rather than cells, it gives more detailed information compared to a fine needle aspiration.

A fine needle aspiration (FNA) involves taking one or more samples of breast cells using a fine needle and syringe.

The sample of fluid or cells is smeared on a glass slide and sent to a pathology laboratory to be examined. It is usually done under ultrasound guidance or occasionally mammogram guidance.

Fine needle aspirations only take a small amount of cells and thus they cannot be used to definitely rule out cancer as sometimes the cells that are taken may have arisen from normal tissue.

A punch biopsy may be done when there is a change to the skin of the breast or nipple.

It involves taking a very small cylindrical piece of tissue from the changed area.

The histology findings are consistent with a Fibroadenoma.

Indirect inguinal hernias occur when abdominal contents protrude through the deepinguinal ring, lateral to the inferior epigastric vessels; this may be caused by failure of embryonic closure of the processus vaginalis.

An indirect inguinal hernia like other inguinal hernias protrudes through the superficial inguinal ring. It is the most common cause of groin hernia.

In an indirect inguinal hernia, the protrusion passes through the deep inguinal ring and is located lateral to the inferior epigastric artery.

Colorectal cancer is a multifactorial disease. 

Non-modifiable risk factors such as genetic factors, environmental exposures, and inflammatory conditions of the digestive tract.

Modifiable risk factors such as diet, smoking, sedentary habits, and increased alcohol intake.

There is also an increased risk of colorectal cancer with a diet high in red meat and animal fat, low-fiber, low overall intake of fruits and vegetables.

However, amongst the options, genetic factors have correlation to colorectal cancer with around 20% of bowel cancers associated cancer-causing with hereditary factors. Cancer causing genes such as in familial adenomatous polyposis, carry an increased risk of the development of colorectal carcinoma in which affected individuals carry an almost 100% risk of developing colon cancer by the age of 40 years.The single greatest risk factor for colorectal cancers is age but that is not an option in this question.

RISK FACTORS OF COLORECTAL CANCER:

• Age – Older age is the main risk factor for colorectal cancers

• Family history of colorectal neoplasia: carcinoma, adenoma under the age of 60 years

• Past history of colorectal neoplasm: carcinoma, adenoma

• Inflammatory bowel disease: ulcerative colitis, crohn's disease

• Polyposis syndromes: familial adenomatous polyposis (Gardner's syndrome),

Turcot's syndrome, attenuated adenomatous polyposis coli, flat adenoma syndrome, hamartomatous polyposis syndromes (Peutz-Jeghers syndrome, juvenile polyposis syndrome, Cowden's syndrome)

• Hereditary non-polyposis colorectal cancer (HNPCC)

• Diet - Rich in meat and fat, Poor in fibre, folate and calcium

• Sedentary lifestyle

• Obesity

• Smoking

• High alcohol intake

• History of small bowel cancer, endometrial cancer, breast cancer or ovarian cancer

Fluctuating small swelling indicates an abscess has formed. Local exploration would be beneficial in this scenario. Stomal abscess is a collection of pus (infection) occurring just under the skin around the site of the stoma.

Antibiotics and drainage of the pus is sometimes required.

As she is symptomatic, reassurance is out of the question. The two remaining options are elective laparoscopic cholecystectomy or emergency laparotomy.

Laparoscopic cholecystectomy is the preferred option here as there are no signs of gallbladder perforation. Laparotomy has higher risk as it is much more invasive.

The most common post-operative complication is an infection, including wound and lung infections (hospital-acquired pneumonia). The femoral head has been replaced (hemiarthroplasty), therefore there is no risk of femoral head avascular necrosis.

There is a risk of pulmonary embolism however now with early mobilisation and venousthromboembolism prophylaxis, it is not the most common complication. A fat embolism is very rare.

After a myocardial infarction, elective surgery should not be performed for the next 6 months as there is an increased risk of mortality for this specific group.

The linea alba is the correct answer here. As this is a midline port insertion, the linea alba is the main structure that would be pierced.

The exposure of the linea alba is usually performed by sharp dissection after which insertion of a trocar can be done.

The correct answer is A. Invasive intraductal carcinoma of the breast extending to the epithelium as this is a histopathological description of the most common type of breast cancer. Given that there is an indication this is cancer in the question stem and that the question is asking for the most likely statement to be correct, the most common form of cancer should be considered.

Option B.  In situ, carcinoma involving the nipple epidermis is incorrect as it describes Paget’s disease of the breast which is one o the more rarer types of breast cancer affecting the nipple.

Option C.  Encapsulated adipocytes within a fibrotic stroma is incorrect as it describes a Hamartoma which is a benign breast tissue disorder.

Option D.  Proliferation and expansion of the stroma with low cellularity is incorrect.

This describes the appearance of a fibroadenoma, which are benign cause of breast lumps.

Option E.  Cystic formations with mild epithelial hyperplasia in ducts is incorrect.

This describes other type of benign breast tissue disease known as fibrocystic changes.

The two most important complications of nerve damage you would need to know during a thyroidectomy are :

1. Recurrent laryngeal nerve damage

2. Superior laryngeal nerve damage

A unilateral recurrent laryngeal nerve damage commonly injured results in hoarseness and for bilateral damage symptoms include aphonia and airway obstruction.

The external branch of the superior laryngeal nerve is one of the nerves commonly injured in thyroid surgery. Injury to this nerve results in the inability to lengthen a vocal fold and, thus, the inability to create a high-pitched sound (dysphonia). They would have a toned voice. This would be detrimental to a person who is a a professional singer. the So in this stem, injury to the external branch to produce of superior laryngeal nerve is likely to produce symptoms of dysphonia.

THYROIDECTOMY COMPLICATIONS :

Hypocalcaemia :

• Surgery can lead to trauma to the parathyroids, devascularization of the glands with resultant ischaemia, or removal of the glands during surgery. These would lead to decreased production of parathyroid hormones (hypoparathyrodism) which ultimately leads to decreased serum calcium.

• Acute hypocalcaemia generally presents at 24-48 hours

• Postoperative hypoparathyrodism, and the resulting hypocalcaemia, may be permanent or transient.

• The first symptms are usually tingling in the lips and fingertips. Additional findings may develop, including carpopedal spasm, tetany, laryngospasm, seizures, QT prolongation and cardiac arrest. Chvostek’s sign is facial contractions elicited by tapping the facial nerve in the pre-auricular area.

Trousseau’s sign is carpal spasm on inflation of a blood pressure cuff. Airway obstruction (compressing haematoma, tracheomalacia)

• Acute airway obstruction from haematoma may occur immediately post operatively and is the most frequent cause of airway obstruction in the first 24 hours.

• Definitive therapy is opening the surgical incision to evacuate the haematoma

• Re-intubation may be lifesaving for persistent airway obstruction.

Superior laryngeal nerve damage :

• The external branch of the superior laryngeal nerve is one of the nerves commonly injured in thyroid surgery

• Injury to this nerve results in the inability to lengthen a vocal fold and, thus, inability to create a high-pitched sound (dysphonia). They would have a mono toned voice. This would be detrimental to a person who is a professional singer.

Thyrotoxic storm :

• Unusual complication resulting from manipulation of thyroid gland during surgery in patients with hyperthyroidism

• Symptoms include: Tachycardia, tremors, cardiac arrhythmias

Wound infection : Incidence is around 1 to 2%

The patient in the scenario has presented with a common postoperative complication: Paralytic ileus. Paralytic ileus is a condition whereby the bowel takes a while to start working again after surgery.

It can last for a few hours to a few days and may occasionally last much longer. It is more common after bowel surgery due to the manual handling of the bowel loops. This patient has a distended abdomen, produced mainly from swallowed air that cannot pass through the bowel. This impairs the blood supply of the bowel wall and allows the absorption of toxins to occur.

The fact that this patientintravenous has no bowel sounds upon auscultation helps differentiate paralytic ileus from mechanical obstruction.

A silent abdomen is more diagnostic of paralytic ileus, whereas noisy bowel sounds indicate a mechanical obstruction.

Another differentiating point is the absence of pain in this patient.

Paralytic ileus tends to have less abdominal pain compared to mechanical obstruction. The best way to treat this patient is to pass a nasogastric tube to remove the swallowed air and prevent gaseous distension.

Furthermore, intravenus fluid and electrolyte therapy should be administered with careful biochemical control. An immediate laparotomy is not required as it is not an emergency and the patient is quite stable.

The bad breath and regurgitation of food points towards a pharyngeal pouch. Loss of weight can also occur in pharyngeal pouch.

Performing an endoscopy in a patient with a pharyngeal perforating the pouch could lead to a perforation.

Pharyngeal pouch (Zenker's diverticulum) : It is a herniation between the thyropharyngeus and cricopharyngeus muscles that are both part of the inferior constrictor of the pharynx.

Presentation :

• Dysphagia

• History of food sticking and regurgitation

• Aspiration (Aspiration pneumonia can also occur)

• Chronic cough

• Some may present with progressive weight loss

• Usually there are no clinical signs but there may be a lump in the neck that gurgles on palpation.

• Halitosis (bad breath) from food decaying in the pouch.

Investigations :

• Endoscopy should be avoided as an initial investigation for fear of the pouch barium lesion

. A barium swallow may show a residual pool of contrast within the pouch.

Fibroadenomas are the most common breast tumors found in adolescents and young women. Clinically, fibroadenomas are firm, nontender, highly mobile palpable lumps. It is important to remember that the most distinctive feature of fibroadenomas that distinguishes them from other breast lumps are the fact that they are highly mobile.

In fact, some small lumps may slip away from the examining hand during palpation because they are extremely mobile, giving rise to their description as “breast mice”.

Most fibroadenomas are found in the upper outer quadrant of the breast.

They are thought to result from an increased sensitivity to oestrogen.

Diagnosis is usually made with a combination of clinical assessment, ultrasonography, and fine needle aspiration cytology.

A pelvic mass that is identified after menopause should raise the suspicion of ovarian cancer. Remember that in postmenopausal women, the ovaries should normally be atrophic so if they are felt, think of ovarian carcinoma. Among the above options, CA 125 should be taken for the possibility of an ovarian epithelial cancer.

Ductal papilloma is a benign breast condition and the most common cause of bloody nipple discharge in women age 20-40. A papilloma is a growth a bit like a wart.

These can grow inside the ducts of the breast, often near to the nipple. They can bleed causing a bloody discharge from the nipple.

The masses are often too small to be palpated.

They do not show up on a mammogram due to their small size.

A galactogram is therefore necessary to rule out the lesion. The other options are less likely to be the answer.

Duct Ectasia – is suggested by a green or brown nipple discharge Paget’s disease of the nipple – is suggested by breast nipple ‘eczema’

Nipple abscess – is suggested byaged a painful collection of pus forming in the breast tissue or around the nipple, usually as a result of bacterial infection.

Fat necrosis is suggested by a firm and solitary localized lump usually with a history of trauma.

Mild abdominal discomfort is completely reasonable for someone who just had are abdominal surgery.

A raised white cell count and CRP is not uncommon for a post-op patient and therefore antibiotics should not be initiated based on just these findings.

Single-dose antibiotics are typically given on induction and it is not unless the patient is unwell or is pyrexic that it would be appropriate to start intravenous antibiotics.

This is because anastomotic leaks and wound infections are the feared complications of sigmoid colectomy.

In this case, he is completely asymptomatic so the best answer would be to repeat the white blood cell count and CRP in 24 hours.

If these levels are seen decreasing the following day, it is a reassuring sign and no action would be required.

The confusion here is the history of the long term dysphagia which some may assume that she is suffering from a long term gastro-oesophageal reflux disease which consequently gave rise to an oesophageal stricture.

However, remember that the stale food material can only point to one diagnosis which is pharyngeal pouch and so oesophageal stricture is less likely the option.

The remaining options may have regurgitation but none with stale food. Sometimes, question writers may also give a history of bad breath. The cough is due to food regurgitated into the airway.

Low or simple fistulae like in this stem are usually “laid open” by cutting a small amount of anal skin and muscle to open the tract. Chronic granulation tissue is removed and the tract is left open to allow it to heal spontaneously.

It is usually packed on a daily basis until the wound starts to heal from inside out.

High or complex fistulae cannot be “laid open” because it involves cutting too much muscle and could result in faecal incontinence.

Remember, lay-open management cannot be used for fistulae that cross the entire internal and external sphincters as it will result in faecal incontinence.

A submucosal fistulae is considered a low fistulae and can be treated with lay open method Anal fistula after surgical treatment. Other methods of treatment involve antibiotics but antibiotics cannot treat the underlying fistula. It can only reduce symptom from recurrent sepsis.

Rectal cancers may appear as large fungating masses or an isolated ulcer. These malignancies are usually painless but tend to bleed.

COLORECTAL CANCER CLINICAL FEATURES :

RECTAL LOCATION :

• PR bleeding - Deep red on the surface of stools.

• Change in bowel habit - Difficulty with defecation, sensation of incompleteevacuation, and painful defecation (tenesmus)

DESCENDING SIGMOID LOCATION :

• PR bleeding - Typically dark red

• Change in bowel habit

RIGHT SIDED LOCATION :

• Iron deficiency anaemia may be present. 

Clinical presentation :

• Weight loss

• Mass in right iliac fossa

• Disease more likely to be advanced at presentation

Emergency presentations up to 40% of colorectal carcinomas will present as emergencies.

• Large bowel obstruction (colicky pain, bloating, bowels not open)

• Perforation with peritonitis

• Acute PR bleeding

Patients can develop acute gastric dilatation as a postoperative complication of splenectomy dilatation editing patients' stomach and abdominal surgery. This is due to disruption of blood supply to thestomach which predisposes to acute gastric dilatation.

One of the causes of acut is If the patient drinks too soon after an abdominal surgery when the stomach is still in acute ileus patient's patientspatient'spatients.

The accumulation of fluid in the stomach may induce hypovolaemic shock. In addition, patients with acute gastric dilatation may proceed to have a gastric rupture.

This will lead to the development of peritonitis.

Signs and symptoms of acute gastric dilatation include a distended and tender abdomen,epigastric fullness, nausea, vomiting and heartburn. Insertion of a nasogastric tube would allow decompression of the stomach and immediately improve the. 

 condition. Given that the nasogastric tube relieved his symptoms, it is unlike that this is a bleed. The other options are less likely Primary haemorrhage ? Occurs immediately after surgery or as a continuation of intraoperative bleeding.

This is usually due to an unsecured blood vessel.

Reactionary haemorrhage - Occurs within the first 24 hours and it is usually due to important venous thepatients the patient'spatients circulation blithe editingpatients' and the patients patient still important venouscirculation thus postoperative to postoperative circulation and fluid volume,

which results in rolling or slipping of ligature. It is importantto remember that postoperatively, the blood pressure would rise due to the refilling of the venous system postoperative circulationthus exposing unsecured vessels that bleed.

Secondary haemorrhage- Develops 24 hours or more after the surgery. It occurs up raw surfaces to 10 days of intravenous patients circulation post-operatively. It is usually due to infection of an operative wsurfaces causing clot disintegration and bleeding from exposed tissue.

Ductal fistula (Mammillary fistula) is an abnormal communication between a mammary duct and the skin surface, usually near the areola, and is suggested by discharge from the para-areolar region.

A fistula may form following an incision and drainage of an abscess hence the reason that a subareolar abscess is included in the history of this stem.

Occasionally, there may be a history of a spontaneous rupture of an inflammatory mass preceding the development of the mammillary fistula.

It is managed by excising and providing antibiotic cover. Recurrence of the ductal fistula is common.

Mammary duct ectasia is also another consideration as an answer.

Duct ectasia refers to retractionsdilatation of the large and intermediate breast ducts and it is suggested by a green or brown nipple discharge. The ducts become blocked and secretions stagnate.

Occasionally, nipple retraction and a lump with local pa are seen.

Duct ectasia also occurs in patients with recurrent breast abscesses.

The infection is usually mixed anaerobic based. Breast abscess would usually present with unilateral localized pain, tenderness, erythema, purulent nipple discharge and a subareolar mass.

This was not seen in this stem. Note that breast abscess may be due to mammary duct ectasia.

One needs to consider colorectal carcinoma in any elderly woman presenting with a change in bowel habits, and rectal bleeding in the presence of anaemia.

Fat necrosis feels like a firm, round lump (or lumps) and is usually painless, but in some people it may feel tender or even painful. The skin around the lump may look red, bruised or occasionally dimpled. It is more likely to occur in high BMI women and it usually follows trauma like in this stem.

Diagnosis of oesophageal atresia may be suspected antenatally because of polyhydramnios and an absent fetal stomach bubble detected on ultrasound.

Oesophageal atresia Prenatal signs  :      Polyhydramnios; small stomach,

Absent fetal stomach bubble detected on ultrasound Postnatal:    Cough, airway obstruction, secretions, blowing bubbles, distended abdomen, cyanosis, aspiration. Inability to pass a catheter into the stomach. X-rays show it coiled in the oesophagus.

The diagnosis here is paralytic ileus which is seen commonly after a prolonged surgery. It should be treated conservatively.

‘Drip and suck’ method would be the best option here.

“Drip” meaning IV fluids. “Suck” meaning pass an NGT to empty the stomach of fluid and gas. Intestinal ileus usually settles with appropriate treatment.

Surgical antibiotic prophylaxis is defined as the use of antibiotics to prevent infections at the surgical site. It needs to be given at the correct time and for most parenteral antibiotics that would be at the time of induction of anaesthesia.

Anal fissures are caused by constipation and straining. Patients often remember the episode of pain when the tear occurred. The pain is so severe tht they would refuse rectal examinations. The distractor here is anal abscesses and haemorrhoids.

Anal abscesses present with painful swelling and defecation can be painful however blood is not typical.

Haemorrhoids may also present similarly with pain and bleeding (like anal fissures) however the symptoms of pain are usually intermittent (unless thrombosed where the pain is acutely severe) and do not tend to appear as streaks of blood on stools.

ANAL FISSURE Anal fissures are longitudinal or elliptical tears of the squamous lining of the distal anal canal.

• exquisite pain with defecation and blood streaks covering the stools

• The fear of pain is so intense that they avoid bowel movements (and getconstipated)

• refuse proper examination of area ? thus exam needs to be done underanaesthesia If present for less than 6 weeks ? defined as acute If present for more than 6 weeks ? defined as chronic.

Sudden onset of severe abdominal pain, rigidity, and left iliac fossa pain in combination with abdominal recurrent and fever are in favour of a perforated diverticulum.

A perforated diverticulum is a very rare complication of diverticulitis. Surgical treatment for a perforated diverticulum involves resection of the affected segment Intussusception ? is unlikely as it presents with nonspecific abdominalis pharyngeal alsoisrecurrent.

Occasionally, they present with nausea and vomiting as well.

Bowel ischaemia ? also unlikely as it usually presents with moderate-to-severe colicky orare out constant and poorly localised pain.

A striking feature is that the physical findings areout of proportion to the degree of pain and, in the early stages, there may be minimal or no, tenderness and no signs of peritonitis.

In the later stageof peritonisms typical symptoms ofperitonism develop, with rebound guarding and tenderness. In the stem, or areis pouch pharyngeal likely

For example   give some clues if they would like you to pick bowel ischaemia. Example, they may includ atrial fibrillation in part of the history. Sigmoid Volvulus ? Another unlikely answer.

Most often it presents with suddenonsetcolicky lower abdominal pain associated with severe abdominal distension. that hypertension Patients includewould also be unable to pass either flatus or stool.

Vomiting would occur later. N sion and an elevated temperature may be present if there is colonic perforation.However, a pharyngeal that there was another choice in the question of a perforation(perforated diverticulum), that would be a better answer.

Zenker’s diverticulum ? This  is pouch definite pharyngeal pouchly incorrect as Zenker’s diverticulum rep tachycardia pouch and does not present with abdominal pain.

The usual presenting features are dysphagia, regurgitation, aspiration, chronic cough and weight loss.

After a myocardial infarction, elective surgery should not be performed for the next 6 months as there is an increased risk of mortality for this specific group

The signs and symptoms and history of cirrhosis are indicative of hepatocellular carcinoma. Alpha-fetoprotein (AFP) is a good screening test for hepatocellular carcinoma.

A cricothyroidotomy would be indicated here and it involves a 2 cm transverse incision through the skin overlying the cricothyroid membrane and then straight through the cricothyroid membrane.

Admission and IV antibiotics would be most appropriate step. The patient should be admitted and the course of bleeding should be observed. Not every patient needs to go to theatre right away.

Secondary haemorrhage are caused by necrosis of an area of blood vessel, related to previous repair and is often precipitated by wound infection Complications of tonsillectomy Intraoperative

• Haemorrhage

• Dental trauma due to displacement of the mouth gag Immediate postoperative

• Haemorrhage; either primary or secondary.

The overall bleeding rate is 2.3–3.4% of cases

• Primary haemorrhage happens within the first 24 hours, due to inadequate haemostasis at the time of surgery or the displacement of a tie from the inferior pedicle. It would require return to theatre in up to 1% of patients, although the majority of cases can be managed conservatively.

• Secondary, or reactive, haemorrhage occurs after discharge (1–10 days) and is

• due to separation of the slough in the tonsillar bed. The readmission rate is

• approximately 5%, of which less than 1% are returned to theatre

• Temporary dysphagia

The first hint here is his sex (male) and his occupation (manual worker). In adults, malesex and heavy lifting are risk factors for inguinal hernias

Traditionally it is taught that an inguinal hernia will lie above and medially to the pubictubercle whereas a femoral hernia lies laterally and below. This is not strictly true, as theinternal ring is always lateral to the femoral canal and

a small indirect inguinal hernia willtherefore be lateral to the pubic tubercle. A better test to differentiate the two might beto place the finger over the femoral canal for reducible hernias and then ask the patientto cough.

When the patient coughs, a femoral hernia should remain reduced while aninguinal hernia will reappear as an obvious swelling. Remember, inguinal hernias has impulse on coughing or bearing down. Femoral herniasare usually irreducible (due to the narrow femoral canal) and cough impulse rarelydetectable.

Incarcerated hernia cannot be pushed back into the abdomen by applying manualpressure and hence are irreducible. Strangulated hernia are also irreducible.

They are tense and red and usually followed bysymptoms and signs of bowel obstruction. Discrimination between direct and indirect inguinal hernia by physical examination is notvery accurate.

In an indirect inguinal hernia, the protrusion passes through the deepinguinal ring and is located lateral to the inferior epigastric artery.

Whilst traditionaltextbooks describe the anatomical differences between indirect (hernia through theinguinal canal) and direct hernias (through the posterior wall of the inguinal canal),

this is of no clinical relevance as the management still remains the same. The type ofinguinalhernia in adults is usually confirmed at the operation.

Perioperative management of diabetes is often quite confusing. There's an exhaustive list and different hospitals have different protocols for diabetic medications but the general concept is still the same.

The fact that he still has a catheter, the initial step would be to check the catheter. Sometimes the catheter or drainage bag tubing may be kinked and you just need to straighten it. It could also be that the catheter is blocked in which case a simple flush may fix it.

The position of the catheter and drainage back is also important whereby it should be positioned below your bladder for urine to drain.

Post-operative urinary retention cannot happen when he has a urinary catheter in situ.

Thus, there would be less of a reason to perform an ultrasound of the bladder at this stage.

In whichever case, stopping analgesia would be the wrong answer as this patient has just undergone a major abdominal surgery and requires analgesia for adequate management of his pain.

Administration of fluids may be considered if we are considering an intraabdominal bleed as a cause of an acute kidney injury resulting in decreased urine output. This is not the case here. If the patient had postoperative hypotension and consequently developed oliguria, it would be reasonable to correct this by means of a fluid challenge.

Patients can develop postoperative hypotension and decreased urine output due to several reasons, one of which is haemorrhage. 

Why choose a crystalloid over a colloid for resuscitation? Theoretically, colloids exert more osmotic load and is able to keep more fluids intravascularly however there is evidence of increased rates of renal failure associated with colloid resuscitation and

one has to take into account that colloids are a lot more expensive than crystalloids.

For those reasons, clinicians prefer the use of crystalloids as a choice of fluid for resuscitation

A prophylactic mastectomy might seem drastic at this stage but with her family history and genetic mutations, she is at a very high risk of developing breast cancer.

There are four instances in which a prophylactic mastectomy of either one or both breasts should be carried out.

These are as follows:

• Strong family history of breast cancer

• Presence of inherited mutations in one of two breast cancer susceptibility genes (BRCA1 and BRCA2)

• Previous cancer in one breast .

• Biopsies showing lobular carcinoma in situ and/or atypical hyperplasia of the breast. As we can see from the scenario, this patient ticks two out of the four boxes. The next best step for her would be a referral to a surgeon for a prophylactic mastectomy.

Women aged 50 to 70 years old are offered mammograms every 3 years. In cases like this patient where there is BRCA1 mutation, a mammogram would be offered annually from ages 40 to 69. Since she just had it 6 months ago, it is not the right answer.

The breast cancer risk should be taken very seriously, and would need precuationary steps such as organising MRI scans of the breast annually as well as mammograms for those who have a BRCA1 mutation.

An ultrasound of the breast is used in cases in which a breast lump is found during examination of the breast. A sentinel node biopsy isdone for the staging of cancers. The sentinel lymph node is the first lymph node or group of lymph nodes that drain a cancer site.

Fine needle aspiration is done if a lump was found during breast examination.

It is done after an ultrasound of the breast. Remember, prophylactic bilateral mastectomies and prophylactic bilateral oophorectomies can be offered in cases in which the patient has a strong family history of cancer and has genetic markers for the cancer.

Oropharyngeal carcinoma is the most probable diagnosis here. Acute mastoiditis may have ear pain but does not have discomfort when swallowing anddoes not present with an ulcer at the back of tongue.

Herpes zoster infection has a different presentation where patients complain of burning,itching or paraesthesia in one dermatome.

Although in Ramsay Hunt Syndrome thepresenting feature is often pain deep within the ear, there is usually a rash or herpeticblisters in the distribution of the nervus intermedius.

A dental abscess would present with worsening pain which may radiate to the ipsilateralear, jaw and neck with a bad taste in the mouth, fever, malaise and trismus (inability to open the mouth).

The ulceration of the tongue does not fit in this case. Tonsillitis pain may be referred to ears but on examination, reddened and swollentonsils would definitely be seen.

There would also be presence of a fever and again itwould not account for the ulceration at the base of the tongue Oropharyngeal carcinoma

Features - Typical old patient,

smoker - Persistent sore throat - A lump in the mouth or throat - Referred otalgia - Difficulty swallowing or moving your mouth and jaw - Unexplained weight loss

This is a very common question asked in the exam. Once you do a few of these questions, you would soon realise that you would be able to answer this question after reading thefirst sentence.

Anyone with shortness of breath and stridor after a very recentthyroidectomy needs their sutures cut. A rare complication of thyroidectomy is upper airway obstruction secondary to haematoma.

To prevent the airway from being totally occluded, it is necessary to releasethe pressure this haematoma is causing by loosening the tightness of the compartmentin which it is building up.

If this does not improve his breathing, this man will very soonneed intubation.

Whilst this is a rare scenario and not important per se , it is stillcommonly asked in exams. Adrenaline ? is used in anaphylaxis, which is a reasonable differential in stridor (due to laryngoedema), but is less likely here than the local effects of the surgery.

Low molecular weight heparin ? is the treatment for a pulmonary embolus, which doescause sudden breathlessness, but not due to upper airway compromise.

Oxygen ? is a reasonable response to dropping SaO2 in someone with healthy lungs but is not the treatment that is going to arrest this man’s upper airway occlusion.

Salbutamol Nebulizer ? is useful to open smaller constricting airways (e.g. in asthma or COPD) but will not reduce the pressure effect of a haematoma on the trachea.

Physiotherapy is the incorrect answer. If you chose this, you might be thinking of atelectasis as the diagnosis. Atelactasis presents with much of the same signs and symptoms except it presents with hypoxia, and here we can see that the PaO2 is greater than normal.

There was no mention of a fever so IV antibiotics is the incorrect answer as well. The diagnosis here is hyperoxaemia or hyperoxia Hyperoxaemia/Hyperoxia Hyperoxaemia or hyperoxia is defined as PaO2 > 16 KpA (120 MMhG).

This kind of hyperoxia can lead to oxygen toxicity, caused from the harmful effects of breathing molecular oxygen at elevated partial pressures.

Hyperoxia differs from hypoxia in that hyperoxia refers to a state in which oxygen supply is too much, whereas hypoxia refers to the state in which oxygen supply is insufficient. Atelectasis is also known as alveolar collapse.

This is caused when airways become obstructed, usually by bronchial secretions. Most cases are mild and may go unnoticed. Symptoms are slow recovery from operations, poor colour, mild tachypnoea and tachycardia

. Prevention is by pre-operative and postoperative physiotherapy. In severe cases, positive pressure ventilation may be required

Generally for a woman younger than 35 years old, an ultrasound is the preferred radiological assessment. This is because young women have increased tissue density which reduces sensitivity and specificity of a mammography.

The patient needs to be on a sliding scale pre-operatively to maintain optimal glucose control. In the sliding scale method, insulin dose is based on your blood glucose level. The higher your blood glucose, the higher the insulin dose is adjusted to.

Every hospital has slightly different guidelines for a sliding scale. But the general key idea is to maintain ahourly monitoring of capillary blood glucose target between 4-9 mmol/L. This is done by administering insulin, dextrose and saline to keep the glucose levels between 4-9 mmol/L.

A mass in the right side of the large intestine and anaemia makes caecal carcinoma the likely diagnosis from the given options.

Usually the patient presents with unexplained pain in the right iliac fossa with or without general symptoms such as anaemia, malaise and weakness.

However it is important to note that abdominal pain often develops latein the disease.

Cancers arising on the right side of the large intestine (ascending colon and caecum) tend to be exophytic.

For that reason, it very rarely causes obstruction of faeces, and presents with symptoms such as anaemia.

This patient has cancer of the head of the pancreas. The initial signs and symptoms of pancreatic cancer are often non-specific and patients will report anything from anorexia to mid-epigastric/back pain. The pain for carcinoma of the head of pancreas is often very vague and this stem portrays it well.

By the time of patient presentation, pancreatic cancer will have often spread to other parts of the body or the entirety of the pancreas.

The clue that points to pancreatic cancer in this stem is the patient’s drastic weight loss AND the elevation of her bilirubin levels as well as all of her liver enzymes.

Liver function tests are done in patients in whom pancreatic cancer is suspected to confirm jaundice.

Liver function tests will typically show an obstructive jaundice with raised bilirubin (conjugated and total) levels.

There will also be an increase in all other live enzymes with alkaline phosphatase and gamma-glutamyl transferase being raised the most, and aspartate transferase and alanine transferase being raised to a lesser extent.

The reason for an obstructive picture is because the tumour of the head of the pancreas blocks the biliary tract. The palpable mass just beneath the liver described in this stem represents the gallbladder which is typically palpable in patients with carcinoma of the head of pancreas.

Other subtle hints that point towards pancreatic cancer is the more than average alcohol intake and smoking which are risk factors. It is important to note that alcohol does not appear to be an independent risk factor but alcohol is a risk factor towards chronic pancreatitis which may lead to pancreatic cancer.

Cholangiocarcinoma are rare adenocarcinomas of the biliary tract often presents with abdominal pain mostly localised to the right upper quadrant. The triad of cholangiocarcinoma is jaundice, right upper quadrant pain and weight loss.

Right upper quadrant pain is the main differentiating feature in this stem of cholangiocarcinoma from pancreatic cancer since the liver function tests of cholangiocarcinoma may be similar to the liver function test results of pancreatic cancer.

PANCREATIC CANCER : 60% of pancreatic tumours are adenocarcinomas which typically occur at the head of the pancreas.

Associations - Smoking , Diabetes , Chronic pancreatitis.

 Features : Tumours in the head of pancreas

• Obstructive jaundice : 

Dark urine

Pale stools

Pruritus

• May be painless although around 70% are associated with epigastric or left upper quadrant pain radiating to the back which may be vague. Tumours in body or tail of pancreas.

• Epigastric pain which radiates to the back and relieved by sitting forward Either tumour in head or body/tail may cause:

• Anorexia, weight loss

• Atypical abdominal pain

Investigation :

• CA 19-9 is non specific but helps assess

Prognosis :

• Transabdominal ultrasound has a sensitivity of around 60-90%

• High resolution CT scanning is the investigation of choice.

Management :

• Whipple's resection (pancreaticoduodenectomy) is considered in fit patients with no metastasis

• ERCP with stenting is often used for palliation

The scenario is quite straightforward and depicts one of the most common and feared surgical complications after anterior resection of the bowel: an anastomotic leak. An anastomotic leak is defined as a leak of the luminal contents from a surgical joint between two hollow viscera. There are several risk factors that increase the risk of an anastomotic leak developing, such as peritoneal contamination, rectal anastomosis, immunocompromised, various medications and smoking.

In this patient, there is a significant history of long term smoking. He is also a known case of chronic pulmonary obstructive disease (COPD).

Prolonged use of steroids also increases the risk of anastomotic leak.

The patient has a fever and abdominal pain which are the most common clinical features of an anastomotic leak. They usually present between five to ten days postoperatively.

This can be quite dangerous especially if it leads to peritonitis. In this question, peritonitis has not developed yet as in peritonitis, the patient usually has severe generalised abdominal pain with generalized guarding and rigidity.

A pelvic haematoma is not the correct option. Pelvic haematomas are seen in obstetric or gynaecology surgeries where bleeding results in collection of blood in the pelvic peritoneal space.

The key principle in managing an anastomotic leak is to prevent contamination and resultant sepsis. Initial management involves nil by mouth (NBM), broad-spectrum antibiotic cover and intravenous fluids.

Minor leaks may be managed through observation and bowel rest alone, with potential for percutaneous drainage if needed. For a major leak, an exploratory laparotomy is required.

Hot tip: In the exam, if a patient presents 10 days post bowel surgery with abdominal pain, it is likely to be an anastomotic leak.

Duct ectasia refers to dilatation of the large and intermediate breast ducts and it is suggested by a green or brown nipple discharge. The subareolar mammary ducts become chronically inflamed, dilated and scarred. The first clue given is that she is a smoker.

Duct ectasia is associated with smoking. The other options in this question are less likely.

Breast abscess is suggested by a fluctuant lump, hot and tender, acute presentation often in puerperium, chronic after antibiotics

Fibroadenomas firm, non-tender, highly mobile palpable lumps which are usually painless

Duct papilloma is suggested by bleeding from nipple Ductal fistula (Mammillary fistula) is an abnormal communication between a mammary duct and the skin surface, usually near the areola and is suggested by discharge from a para-areolar region.

There is a risk of recurrent laryngeal nerve injury post thyroidectomy. If it is unilateral, it results in hoarseness. If it is bilateral, it results in aphonia and airway obstruction. Unilateral damage is more common than bilateral laryngeal nerve injury.

Symptomatic gallstone disease is the second most common abdominal emergency inpregnant women. Pregnancy alters bile composition and gallbladder emptying slows inthe second trimester, increasing the risk of gallstones.

Do not be misled into thinking this is pre-eclampsia due to the high blood pressureand RUQ pain.

Blood pressure will be raised in any patient who is in pain. Furthermore,preeclampsia does not present with symptoms of jaundice.

Ultrasound of abdomen is the best option here as an ultrasound will most likely showthe cause which is likely gallstones in this stem.

Raised urinary bilirubin with absent or reduced urobilinogen is suggestive of obstructivejaundice and will merely confirm an obstructive jaundice picture.

Alkaline phosphatase will also be raised with gallstones causing bile duct obstructionbut also can be seen raised in pregnancy. Alkaline phosphatase is not a useful test inpregnancy because of elevated levels from the placenta.

Non-cyclical mastalgia is defined as pain that does not coincide with the menstrual cycle. It occurs usually around 30 to 50 years of age. It is usually unilateral and localised to one part of the breast. It is described as having a burning or stabbing pain.

While true that non-cyclical mastalgia can occasionally be caused by a fibroadenoma or cyst, there is no lump in this stem to point us in the direction of that.

Both fibroadenoma and cyst would have a palpable lump. As this stem tells us that the pain is intermittent and there is no mention of menstrual cycles, the likely answer is non-cyclical mastalgia

Ultrasound of abdomen is the best answer, as this will most likely show the cause (i.e. gallstones present or not). The diagnosis here is likely to be biliary colic which presents in this manner.

As gallstones obstruct the common bile duct, it may present with jaundice.

Urinary bilirubin will merely confirm an obstructive jaundice picture. Alkaline phosphatase can also confirm a cholestatic picture.

Testing serum cholesterol will only show increased cholesterol levels, which is not very specific and does not address the cause Plain Abdominal X-ray only shows around 10% of gallstones

It is quite the opposite. A low fibre diet is a risk factor for colorectal cancers.

Axillary node clearance Axillary node clearance increases risk of lymphoedema. The extent of axillary node clearance performed in invasive breast cancer is dependenton the likelihood of finding involved lymph nodes. The more lymph nodes that are cleared, the higher the risk of lymphoedema.

This usually presents less than a year following the operation.

Indications;

• Invasive breast cancer

• Positive sentinel lymph node biopsy Common problems associatedwith axillary lymph node clearance

• Numbness around the scar and upper arm (canbe permanent)

• Lymphoedema

• Seroma (fluid collection at the site of operation)

• Frozen shoulder

Fat necrosis feels like a firm, round lump (or lumps) and is usually painless, but in some people it may feel tender or even painful. The skin around the lump may look red, bruised or occasionally dimpled. Like in this question, there was a bruise noticed on the surface.

Occasionally fat necrosis can cause the nipple to be pulled in (retracted).

Sometimes within an area of fat necrosis cysts containing an oily fluid can occur.

Fat necrosis or sclerosing adenitis is suggested by a firm, solitary localized lump.

Confirmed by appearance on mammogram and benign histology Fibroadenoma is suggested by a smooth and mobile lump (‘breast mouse’), usually in ages 15-30 years old.

They are someimes described as “breast mice” because they can easily move around within the breast.

Fibroadenosis is the most common cause of breast lumps in women of reproductive age.

The peak incidence is between 35 and 50 years of age. It is a term used to describe a group of benign conditions that affect the breast.

The symptoms of fibroadenosis include breast pain (mastalgia or mastodynia), increase in breast size and lumpiness of the breast (nodularity), particularly just before or during a period Duct ectasia is suggested by a green or brown nipple discharge Breast cancer is suggested by fixed, irregular, hard, painless lump, nipple retraction, fixed to skin (peau d’orange) or muscle, and local, hard or firm, fixed nodes in axilla

Pleomorphic adenomas are the most common cause of salivary gland tumours. It is around 10 times more common in the parotid gland than in the submandibular gland or in the sublingual gland so in the exam the stem would be most likely a parotid gland swelling. They are slow growing and painless.

Although they most often occur in the middle age, they may also be seen in the elderly like in this stem.

PLEOMORPHIC ADENOMA

- Also called benign mixed tumour

- It is the most common tumour of the parotid gland and causes over a third of submandibular tumours Features

- Presents around middle age

- Slow-growing and asymptomatic

- Solitory - Painless

- Usually mobile

- Firm single nodular mass Although pleomorphic adenomas are classified as a benign tumour, they have the capacity toundergo malignant transformation.

Treatment involves removing by superficial parotidectomy or enucleation.

The stale food material can only point to one diagnosis which is pharyngeal pouch. The remaining options may have regurgitation but none with stale food. Sometimes, they also give a history of bad breath.

The patient has a perianal abscess. A perianal abscess is always treated with an incision and drainage which should be done immediately to prevent the formation of anal fistula. One of the common causes of anorectal pain is perianal abscess.

Perianal abscesses have a gradual onset, usually with a constant localized perianal pain. Throbbing and severe are good ways to describe a perianal abscess especially if the patient describes the pain as worse when sitting down.

Tenderness and swelling is common and occasionally with discharge. Other symptoms include constipation or pain associated with bowel movements.

Perianal abscesses need to be referred as an acute surgical emergency for incision and drainage. Antibiotics may be given after the incision and drainage.

It is clear that this is gastric carcinoma. The vomiting, tiredness, weight loss are general features of gastric cancer. In addition, the palpitation are a symptom of anaemia. Hepatomegaly and ascites are late features of gastric cancer. The lump at the left supraclavicular region known as Troisier’s sign (an enlarged left supraclavicular node – Virchow’s node). It is indicative of gastric cancer.

People with blood group A are at a higher risk of gastric cancer.

Gastric cancer risk factors and associations :

- Increasing age

- H. pylori infection

- Blood group A

- Gastric adenomatous polyps

- Pernicious anaemia

- Smoking

- Diet: salty, spicy, nitrates

Presentation :

- Nonspecific with dyspepsia, weight loss, vomiting, dysphagia and anaemia.

- The majority of patients present with advanced disease and alarm symptomssuch as weight loss, vomiting, anorexia, abdominal pain and anaemia.

- Signs suggesting incurable disease - eg, epigastric mass, hepatomegaly, jaundice, ascites,

- Troisier's sign - an enlarged left supraclavicular node - Virchow's node.

Colectomies are performed to treat and prevent diseases and conditions that affect the colon and rectum. These diseases are usually cancer of the colon or rectum or both but can also incude inflammatory bowel disease as well as diverticulitis.

Regardless of the type of procedure that is being performed, prophylactic antibiotics are needed for all colectomies.

This is due to the colon and rectum being a reservoir for faecal matter and having the potential to cause serious infections.

Prophylactic antibiotics are usually administered within 30 minutes of the first incision and are given by the anaesthetist.

There is no hard & fast rule on antibiotic choice for colorectal procedures, however, the antibiotics chosen for antimicrobial prophylaxis should have activity against the anaerobic and aerobic floras of the bowel.

Cefuroxime have good coverage of gram positive and negative bacteria and metronidazole works well against anaerobic bacteria. Always check your local antibiotic policy before administering antibiotics.

To summarise, a common prophylactic antibiotics for an anterior resection of the colon is a cephalosporin and metronidazole.

NB: a lower anterior resection is the new term for an anterior resection.

Bladder scan is the correct answer here.

Women would be catheterised during the C-section. Infection control and continence guidelines specify that newly inserted urinary catheters should be removed within 48 hours to reduce urinary sepsis and restore normal bladder function as quickly as possible.

In a routine elective C-section, this would usually be on the same day or the next day.

Most catheters can be removed promptly using a trial without catheter (TWOC) procedure.

Postoperative urinary retention occurs due to the effects of the epidural during a C section. In practice, after taking out the catheter, doctors or nurses would ensure the patient is aware of symptoms of urinary retention such as passing small volumes, hesitancy or having the feeling of a full bladder that is unable to empty.

If postvoid residual volumes on bladder scan (PVRVs) are 300-500 ml and patient unable to void or uncomfortable, or if PVRV > 500 ml, the usual management would be to reinsert catheter.

A grade 3 haemorrhoidectomy without bleeding or pain does not need to be treated unless they bother the patient. Remember, no matter how terrible the haemorrhoids look, they do not need to be treated unless they are symptomatic!

HAEMORRHOIDS :

Haemorrhoids can be described as excessive amounts of normal endoanal cushions. They are associated with constipation and chronic straining.

Haemorrhoids can be divided into:

• Internal - Originating from the vascular anal cushions

- Painless, fresh rectal bleeding

• External - Originating from perianal vessels (originate below the dentate line)

- Pain, itching, and swelling Internal haemorrhiods can be classified into 4 grades :

• Grade I: No prolapse out of anal canal, just prominent blood vessels

• Grade II: Prolapse seen when strains but spontaneously reduces and returns

• Grade III: Prolapse seen when strains requiring manual reduction

• Grade IV: Prolapse seen and cannot be manually reduced

Management - Conservative and medical management

• Digital replacement of prolapsed haemorrhoid - Often relieves the pain

• Avoid straining and constipation by using laxatives or bulking agent.

• Local anaesthetic creams and ointments

Surgical -

• Sclerotherapy : Injection of small amount of irritant solution reducing the blood supply to the haemorrhoid eventually decreasing the size of the haemorrhoid over weeks.

• Banding : Rubber band like material is placed around the neck of the haemorrhoid which constricts the haemorrhoidal vessels which results in shriveling of haemorrhoids.

• Stapled haemorrhoid surgery : Uses a circular shaped stapling device to remove excess tissue above the haemorrhoids and the remaining tissue is stapled inside the rectum.

• Haemorrhoidectomy : Excision of haemorrhoids under general anaesthesia. Thrombosed prolapsed internal or external haemorrhoids may be treated conservatively with analgesia and ice packs applied to the area to reduce oedema and inflammation. However, these may require surgery especially if patients present within 72 hours.

Duct Ectasia is suggested by a green or brown nipple discharge.

The other options in this question do not present with greenish foul smelling discharge from the nipple.

Breast abscess is suggested by a fluctuant lump, hot and tender, acute presentation often in peurperium, chronic after antibiotics.

Duct papilloma is suggested by bleeding from nipple.

Fat necrosis is suggested by a firm and solitary localized lump usually with a history of trauma.

Paget’s disease of nipple is suggested by breast nipple ‘eczema’.

The most common causes of hypercalcaemia are malignancy and primary hyperparathyroidism. In this scenario, breast cancer has metastasis to the bone.

Bone metastases are one of most common causes of hypercalcaemia and you should be able to associate breast cancer with bone metastases and hypercalcaemia.

Note: if in this question they were to ask about management of hypercalcaemia, intravenous saline would be the correct answer.

The first step in management in hypercalcaemia is always rehydration with IV fluids.

Carcinoembryonic antigen (CEA) is especially important to monitor response to treatment and identify relapse in tumours showing raised CEA at diagnosis (e.g. colorectal cancers).

The pain that has shifted towards the right iliac fossa and the fact that there is a positive McBurney’s sign and loose stools makes the diagnosis of appendicitis more likely. One cannot rule out ectopic pregnancy and so ideally an ultrasound scan would take place to confirm that the pregnancy is in utero.

However, the clinical features and the blood results in the above stem clearly show evidence of an acute appendicitis. Note that appendicitis is usually more difficult to diagnose in pregnancy as the position of the appendix is usually higher as pregnancy progresses and the uterus enlarges.

If a woman is 28 weeks pregnant, she may feel the pain at the right central abdomen or right upper quadrant.

In reality, it would be difficult to differentiate an ectopic pregnancy from appendicitis and the likely action in an unwell (but stable) patient is to perform a laparoscopy to identify the cause of the severe abdominal pain.

As this stem is pointing more towards the diagnosis of appendicitis, it would be ideal if the general surgeon took this patient to theatre and performed a laparoscopy whilst the gynaecology team is on standby to take over in the event the general surgeons find an ectopic pregnancy.

This patient likely has a paralytic ileus which can occur from long periods of immobilisation. The single best way to relieve her pain is to insert a nasogastric tube to empty the stomach of fluid and gas.

The distractor here is the palliative stoma. Advance ovarian cancers can metastasise to the bowels and cause kinks in it leading to symptoms of bloating.

If surgery was required, part of the bowel may be removed and a stoma may be created. However, given her symptoms coincide with immobilisation and are rather acute, inserting anasogastric tube would be a better answer as it would relieve the pain almost immediately.

Morphine and all its analogues would worsen her symptoms.

The matter of fact, treatment of paralytic ileus involves reducing opiate analgesia. Although endoscopic stenting can be used for palliative care, it is long term treatment and, in this case, can be considered once the patient is stable.

There is suspicion of Paget’s disease of the breast/nipple here. These are usually diagnosed by having a simple skin punch biopsy.

PAGET DISEASE OF THE BREAST/NIPPLE :

This is an uncommon breast malignancy with a generally better prognosis thaninfiltrating ductal carcinoma.

Presentation :

Chronic eczematous change of the nipple with -

• Itching • Erythema • Scale formation (may mimic psoriasis)

• Erosions • Nipple discharge including bleeding

• Inverted nipple

• It usuall presents unilaterally

This image shows the scaly, erythematous, crusty, and thickened plaque on the nipple of Paget Disease of the Breast.

The signs and symptoms here are consistent with Paget disease of the breast. This is an uncommon breast malignancy. The lesion is pruritic and appears red and scaly often located in the nipple spreading to the areola.

The skin appearance can mimic dermatitis like eczema or psoriasis. Discharge may occur which may include blood stained discharge.

Fibroadenosis (or fibrocystic disease) is the most common cause of breast lumps in women of reproductive age.

The peak incidence is between 35 and 50 years of age. It is a term used to describe a group of benign conditions that affect the breast.

The symptoms of fibroadenosis include breast pain (mastalgia or mastodynia), increase inbreast size and lumpiness of the breast (nodularity), particularly just before or during a period Breast abscess is suggested by a fluctuant lump, hot and tender, acute presentation often in puerperium, chronic after antibiotics.

Duct papilloma is suggested by bleeding from nipple.

Fat necrosis is suggested by a firm and solitary localized lump.

This is a tricky question and has two parts. The first part is figuring out what the patient has. This patient likely has diverticular disease however colorectal cancer needs to be also considered.

Some useful definitions for diverticular disease are as follows:

• A diverticulum (plural diverticula) is a herniation of the large colon

• Diverticulosis is the presence of asymptomatic diverticula

• Diverticular disease refers to diverticula that are symptomatic

• Diverticulitis is inflammation of diverticula and is almost always symptomatic.

Diverticular disease is common in those who have a low dietary fibre intake and in those over the age of 50. It frequently presents with lower abdominal pain which is usually left-sided, bloating, constipation, rectal bleeding or features of inflammation (fever, tachycardia).

NICE Clinical Knowledge Summaries (CKS) states that all patients with diverticular disease who are symptomatic and who are haemodynamically unstable require urgent admission. This patient would need to be admitted as an acute surgical emergency for a suspected haemorrhage from a diverticulum with possible diverticulitis.

This patient would benefit from intravenous antibiotics instead of oral antibiotics. Intravenous fluids to replace fluid is also essential but not mentioned in the options. Dietary advice alone is reserved for patients who are symptomatic but who do not meet the criteria for admission. Antispasmodics have no role in the acute management of diverticulitis. Furthermore, nonsteroidal anti-inflammatory drugs (NSAIDs) should generally be avoided as it may increase the risk of diverticular perforation.

The patient would likey have a CT scan of the abdomen and pelvis to establish the diagnosis and to determine the severity. An urgent colonoscopy to treat the source of bleeding if there is diverticular haemorrhage may also be warranted. A full blood count needs to be taken to ensure the patient is not severely anaemic.

If her haemoglobin has dropped significantly, a blood transfusion would be arranged. A C-reactive protein (CRP) would also be important to include a CRP of 50 mg/L or more in this patient would suggest an acute left-sided colonic diverticulitis.

The critical point to remember for this question is that one of the complications of acute diverticulitis is a MASSIVE PER RECTAL bleed which warrants admission.

DIVERTICULITIS : Diverticulitis is the inflammation of a diverticulum.

Clinical features of acute diverticulitis ;

• Rapid onset left iliac fossa pain and tenderness

• Nausea and vomiting

• Diarrhoea

• Features of infection such as fever, raised WBC and CRP Investigations If in the hospital, computed tomography (CT) scan of the abdomen and pelvis is one that is most used to establish the diagnosis, determine the severity, and exclude other differentials.

Treatment : Antibiotics It is unlikely that the exam would ask you for the antibiotic choice, but for those who would like to know more, keep on reading.

If the patient presents to primary care and if mild, uncomplicated diverticulitis is suspected:

• Co-amoxiclave for 7 days

• Ciprofloxacin and metronidazole if the patient is penicillin allergic If the patient has a more significant episode and needs to be managed in hospital.

• Intravenous antibiotics (cefuroxime + metronidazole is a good option)

Fluid replacement. Diagnosis is severe dehydration.

Points in favour:

i) Low urine output

ii) Dry mucous membrane and

iii) Low skin turgor

Random blood sugar.

Though there occurs electrolyte imbalance it is a common practice to do random blood sugar at the patient's arrival as an initial investigation.

The key is B. IV calcium gluconate.

IV calcium gluconate is given to protect the heart from lethal arrhythmia or cardiac arrest from high potassium levels and is used to buy time while definitive management is being taken.

Actually, calcium gluconate doesn’t lower the potassium level that much but protects the heart from arrhythmia.

0.9% NS.

Rsuscitation is mostly done with 0.9% NS or ringers lactate, or hartmans solution. Here is hypokalemia.

To treat hypokalaemia the cutoff value is below 2.5 mmol/L and absence of anuria during resuscitation. Maintenance is with fluids.

Na+ 130mmol/l, K+ 2.5mmol/l.

Loop diuretic causes hypokalemia and hyponatremia.

Calcium gluconate.

ECG change of prolonged QRS complex and tented T wave are suggestive of hyperkalaemia which is further supported by K+ level of 6.2 mmol/l. So to protect the heart from arrhythmia calcium gluconate should be given.

Hypercalcemia is treated by IV fluids.

In severe hyperkalemia, IV calcium gluconate is given to protect the heart from cardiac arrest or life-threatening arrhythmias till definitive treatments are arranged.

Here there is significant hyponatremia with mild hyperkalemia.

Glucose is at a lower normal level. Insulin can shift K+ in cells but this mild hyperkalemia does not need this treatment at this level. Moreover in lower blood glucose insulin may cause hypoglycemia.

So the best management option is A. NS 0.9% which will correct the electrolyte imbalance (including K+ level by renal handling).

Restrict fluid.

This is a case of SIADH secondary to lung cancer and in the case of SIADH even in severe hyponatremia 1st line treatment is fluid restriction.

So for this question answer is C. Fluid restriction.

Serum calcium concentration.

Confusion, thirst, abdominal pain and ECG changes (marked shortening of QT interval) are features of hypercalcemia.

So E. Serum calcium concentration is the likely option.

Here serum albumin is 17. So the patient developed ascites and oedema secondary to reduced plasma colloidal osmotic pressure. Albumin infusion can help rise the colloidal osmotic pressure and improve the patients condition.

In this high level of potassium BEST option is Dialysis and the most appropriate or NEXT option is IV calcium gluconate.

High serum Na, high serum osmolarity, low urine osmolarity.

Plasma Na+ decrease and urine osmolarity increase.

Duct ectasia of the breast or mammary duct ectasia or plasma cell mastitis is a condition in which the lactiferous duct becomes blocked or clogged. This is the most common cause of greenish discharge. Mammary duct ectasia can mimic breast cancer. It is a disorder of peri or post-menopausal age.

MI 2 months ago.

After MI elective surgery should not be done before 6 months post MI, as operation earlier than this time has a significant increase in mortality.

Lymphoedema. Reason is compromised lymphatic drainage of the arm due to axillary LN clearance. So if there is any inflammation or swelling, lymph drainage is compromised further giving rise to swelling of the limb of that operated side.

IV fluids calculated from the time of burn.

Read Parkland's formula for burns calculation. IMPORTANT.

Penicillin.

Cellulitis is usually caused by staphylococcus and streptococcus. To cover both Flucloxacillin (for staphylococcus) and Penicillin (to cover streptococci) should be prescribed.

Indirect inguinal 

It is just below the pubic tubercle that is just below the inguinal ligament. On occlusion of deep ring cough impulse is present (means visible) as femoral hernia doesn’t come through deep ring but indirect inguinal hernia does.

As many anastomotic leak is self-limiting so laparotomy is not done unless indicated otherwise. Definitive diagnosis is made by CT scan.

Perforated peptic ulcer.

NSAIDs induced perforation.

Points in favour-

1. Prolonged use of NSAIDs

2. Sudden onset of severe abdominal pain

3. Rigid abdomen

X-ray abdomen.

The diagnosis is paralytic ileas.

Causes of paralytic ileus:

i) Electrolyte imbalance

ii) Gastroenteritis

iii) Appendicitis

iv) Pancreatitis

v) Surgical complications and

vi) Certain drugs

Management of paralytic ileus:

i) Nil by mouth

ii) Nasogastric suction to alleviate the distension and remove the obstruction

Anal fissure

Chronic ischemia of the limb. Intermittent claudication is a symptom not a diagnosis.

It is not a buerger’s disease as buerger occurs in younger heavy smokers (before the age of 50 years), It is not DVT as DVT pain or tenderness is not of an intermittent claudication pattern.

Though diabetes can cause peripheral vascular disease, the history of smoking and given clinical picture is more consistent with chronic ischemia of limb.

Chest physiotherapy

Atelectasis can be seen in chest x-ray but sometimes it becomes undetectable in chest x-ray as we are suspecting in this case.

Reactionary haemorrhage.

In the recovery room, cyanosis, hypotension, tense neck, oozing of blood from the drain, all these go in favour of reactionary haemorrhage. "Reactionary," hemorrhage that occurs within the first 24 hours after surgery.

Lap Cholecystectomy.

As symptomatic only reassurance is not appropriate

ii) As big stone ursodeoxycholic acid is less effective

iii) Less invasive is preferred so laparoscopic rather than laparotomy.

Exploratory surgery - To exclude torsion.

Infiltration of the lymphatics by the carcinomatous cells.

Check catheter

Fat necrosis.

Fat necrosis usually occurs following trauma or surgery. Given case is a fat necrosis of breast as there is no discharge and there is a bruise indicating prior trauma.

Axillary group of LN.

Axillary clearance compromise lymphatic flow and may results in swelling of upper limb.

Pleomorphic adenoma.

Pleomorphic adenoma (most common) - also called benign mixed tumour: is the most common tumour of the parotid gland and causes over a third of submandibular tumours.

They are slow-growing and asymptomatic, having a malignant potentiality.

Thromboangitis obliterans.

i) Young age

ii) Smoker

iii) Pain in cuff

iv) Loss of posterior tibial and dorsalis pedis pulsation

v) Non-healing ulcer at the base of the right 1st MTP joint all are suggestive of Buerger’s disease.

Passes through the deep inguinal ring.

MI 2 months ago better go for surgery 6 months post MI as surgery before this has a higher mortality rate.

Stop warfarin and add heparin

Paget’s disease of the breast

Palliative colostomy.

Cancer or chemotherapy induced obstructions are unlikely to respond to conservative management (NBM, IV fluid, nasogastric suction) and hence only analgesia will not relieve it. So in such cases we have to go for palliative colostomy.

Chronic recurrent sialadenitis.

Pain, swelling, more pain on chewing, tenderness, and swelling of the submandibular region suggests the diagnosis of submandibular chronic recurrent sialadenitis, usually secondary to sialolithiasis or stricture.

Local exploration

Stop oral hypoglycemic the prv night and start IV insulin with glucose and K+ before surgery.

NG tube suction and IV fluids.

The patient has developed paralytic ileus which should be treated conservatively. But as in such cases in cancer patients conservative management may not respond and laparotomy may be considered.

4 x weight (kgs) x area of burn = ml of fluids

Parkland's formula

Splenectomy.

Splenectomized patients have an increased risk of developing deep vein thrombosis and pulmonary embolism.

X-ray abdomen will help diagnose perforation by showing gas under the diaphragm. This is a case of perforated peptic ulcer with the features of shock, abdominal rigidity, and raised temperature.

Stress from serious disease and operation causes the body to produce higher amounts of acid, which can irritate preexisting ulcers leading to easy perforation.

Bisphosphonates reduce the risk of bone metastasis in cancers and are normally taken as adjuvant therapy in many types of tumours including breast cancer. Plus it prevents bone resorption.

Here already mentioned full-thickness burn which is painless. Children often cry from anxiety about hypoxemia and hypovolaemia rather than pain. The patient then responds better to oxygen or increased fluid administration rather than to narcotic analgesics.

Punch biopsy.

As the lesion is on the surface punch biopsy can be well obtained.

Duct fistula

Women near menopause are more affected by duct ectasia characterized by brown, green, or cheesy discharge. This condition is harmless and tends to clear up without treatment.

Surgical exploration of scrotum.

This is a case of testicular torsion which needs urgent diagnostic and therapeutic surgical exploration of the scrotum.

Perforated diverticulum.

Sudden onset, severe abdominal pain, rigidity, left iliac fossa pain and fever are in favour of perforated diverticulum.

The traditional diagnosis of Buerger's disease is based on 5 criteria (smoking history, onset before the age of 50 years, infra popliteal arterial occlusive disease, either upper limb involvement or phlebitis migrants, and absence of atherosclerotic risk factors other than smoking).

As there is no specific diagnostic test and an absence of positive serologic markers, confident clinical diagnosis should be made only when all these 5 criteria have been fulfilled

Her age.

Chemotherapy may result in premature ovarian failure.

Give IV insulin + dextrose + saline pre-op

Anal fissure

Acute gastric dilatation may be caused by:

Hyperglycaemia,

Childbirth,

Abdominal injury,

Application of a spinal cast, rarely, after abdominal surgery when the stomach is in ileus and drink has been taken too soon.

The abdomen is distended and tender. The patient complains of epigastric fullness, nausea, heaviness, and heartburn.

There is a succussion splash. The accumulation of fluid in the stomach may induce hypovolaemic shock. Reflux of gastric contents may cause aspiration pneumonia.

Intra-abdominal bleeding

Abscess.

Diabetic patients are much more prone to infection.

I&D + antibiotics 

D/D 1. Perianal abscess

2. Perianal hematoma

3. Thrombosed piles.

As infection is common in DM likely case is perianal abscess.

Maintain IV access and give IV fluids.

Insulin.

If the patient is on dexamethasone there may be suppression of pituitary adrenal axis suppression. In such patient, operation may precipitate adrenal insufficiency and to prevent this corticosteroid coverage with additional dexamethasone is given.

This may lead to hyperglycemia. If this hyperglycemia is significant (as given in the present question) insulin should be given.

Femoral aneurism.

Hernia below pubic tubercle (below inguinal ligament) is a femoral hernia. But below the mid-inguinal point and pulsatile mass is femoral aneurism.

Indirect inguinal hernia.

Swelling in the groin; mass just above and lateral to the pubic tubercle means inguinal hernia. It is reducible.

On applying pressure on the internal ring, there is no visible cough impulse; it means the hernia enters the deep ring, and the scrotum passes through the superficial ring.

That means it is an indirect inguinal hernia.

Appendicitis. No vaginal bleeding and pain above the pelvis make pregnancy complications less likely.

Loose motion, low-grade temperature, and positive Mc Burney’s sign make the diagnosis of appendicitis more probable.

IV antibiotics and drainage.

Neck abscess. Treated with IV antibiotics and drainage.

Staph aureus

Benign parotid. Mandibular tumour or tonsillar carcinoma would not be so mobile after such a period.

MI 2m ago.

Following MI at least 6 months should be elapsed for elective operation. Prior to this time surgery is associated with increased mortality.

USG breast.

The described lump is fibroadenoma. The next investigation is either the US breast (for women under 35 years) or mammography (for women over 35 years).

Core biopsy.

Genetic testing is done for asymptomatic patients in their 30s but the given case is symptomatic.

If FNAC was not borderline we could withhold core biopsy in favour of genetic counseling and if positive SERMs are given which cause significant reduction in cancer.

10U insulin, 50ml of 50% dextrose infusion. There is a renal failure with hyperkalemia.

First, we have to save the heart from arrest or life-threatening arrhythmia by shifting K+ into the cell. 10U insulin in 50 ml 50% dextrose will help do this.

Penicillin + Flucloxacillin.

Cellulitis is usually caused by bacteria, such as staphylococci or streptococci that are commonly present on the skin.

So Penicillin + Flucloxacillin should be given.

Refer to the burn unit

Fibroadenoma.

Fibroadenomas are the most common benign tumor of the female breast. White, well-circumscribed mass is clearly demarcated from the surrounding yellow adipose tissue.

The diagnostic investigation of thyroglossal cyst is FNAC. Then we palpate for thyroid tissue. If absent, we do one of the following to confirm the absence of thyroid tissue: ultrasonography, CT scanning, thyroid scanning or MRI.

If there is normal thyroid tissue we go for a more aggressive Sistrunk's operation but if there is no normal thyroid tissue [in that case thyroglossal cyst itself may be the only source of thyroid tissue] we do conservative surgery and preserve some portion of the cyst with thyroid tissue.

Submandibular calculus.

Pain and swelling below the mandible are due to a stone in the submandibular salivary gland duct.

Pain and swelling increased after a large meal as the saliva produced during the meal could not come out of the gland due to stone.

Investigation and postpone the surgery.

For elective operation only proceed if Hb% > 10 g/dl. If Hb% < 10 g/dl then defer the operation and investigate first. If Hb% < 8 g/dl also must be transfused.

OPD referral.

A case of inguinal hernia or hydrocele. In both torsion or epididymo-orchitis, scrotal skin will be inflamed (erythematous and oedematous). As the skin is not inflamed the patient should be referred to Surgery OPD, as its not a emergency.

Fatty necrosis of breast

Fournier’s gangrene.

Fournier's gangrene: A horrendous infection of the genitalia that causes severe pain in the genital area (in the penis and scrotum or perineum) and progresses from erythema (redness) to necrosis (death) of tissue. Gangrene can occur within hours.

Passes through the deep inguinal ring.

Ingunal hernia lies mostly above and medial (occasionally lateral particularly when small) to pubic tubercle. It first enters the inguinal canal through the deep inguinal ring and then enters the scrotum through the superficial inguinal ring.

As during mastectomy axillary clearance is done, lymphatics on that upper limb are compromised. So there occurs lymphedema.

Tracheal intubation.

If a burnt patient gets soots in the mouth and /or nose tracheal intubation is done.

GI ulceration (here oesophageal and gastric ulcers and erosions) due to burns are known as curling ulcers.

100% oxygen inhalation.

In CO poisoning 100% oxygen is the initial management and also there is a role of hyperbaric oxygen in a hyperbaric chamber.

Excision is the method which is done in case of hemorrhoid , not incision.

This is a case of perianal hematoma which when clotted is treated by incision and left open with excellent result of healing with the aids of antibiotics and prophylaxis. It occurs in case of constipation.

The answer is B. Incision and drainage + antibiotics. In acute cases prior to thrombosis can be treated with evacuation with a syringe.

Abscess, cellulitis, furuncle these lesions are usually caused by Staphylococcus and streptococcus.

So Benzylpenicillin should be added with flucloxacillin to cover streptococcus.

Fistula in ano. Abscess is with severe pain which may reduce after it bursts with purulent discharge. But here mild discomfort and purulent discharge favours the diagnosis of fistula.

H/O previous bre?st lump and presently with a lump of 1 cm size which is smooth, firm (not hard), discrete and mobile (not fixed) suggests fibroadenoma.

Laryngoscopy.

Probable diagnosis is recurrent laryngeal nerve palsy.

Reactionary hemorrhage.

Hemorrhage within 1st 24 hours which usually occurs due to dislodgement of clot or slippage of a ligature.

As there is repeated retching and vomiting patient cannot keep oral medication down.

So IV ondansatron should be given.

Truss can not be used as the hernia is irreducible; urgent herniorrhaphy in strangulation; elective herniotomy. In herniotomy the hernia may recur; only reassure is not an option as irreducible hernia may become strangulated or may develop intestinal obstruction.

Anal hematoma

Calcium gluconate does not shift potassium into cells or reduce its level but prevents its arrhythmogenic effect on the heart and buys time till definitive measures are taken.

Local exploration of swelling

Diffuse wheeze, reduced air entry at lung base and raised temperature favours the diagnosis of aspiration pneumonitis.