Wednesday, October 22, 2014

End Surgery Posting Examination Sept-Oct 2014

Yesss!! We have finished our exam!! Alhamdullilah, hopefully all of us will pass!! Here's a review on what came out during the exam.

MONDAY, 20/10/14


Surprisingly, there were not many repeated MCQ questions from previous years. Sometimes, even very simple and basic stuff I forgot! Or I have read it before, but forgot! What the heck Nurul Ain! Some of the questions that I can remember:

1. Stomach cancer is the second most cancer worldwide - FALSE
Gastric cancer is the fourth most common cancer in the world. Source : US National Cancer Institute

2. Familial Adenomatosis Polyposis is an autosomal recessive inherited disease - TRUE
Familial adenomatous polyposis can have different inheritance patterns. When familial adenomatous polyposis results from mutations in the APC gene, it is inherited in an autosomal dominant pattern. When familial adenomatous polyposis results from mutations in the MUTYH gene, it is inherited in an autosomal recessive pattern. Source : Genetics Home Reference

3. Alcohol cannot kill bacterial spores - TRUE
Endospores are resistant to heat (>100 °C), radiation, many chemicals (i.e. acids, bases, alcohol, chloroform), and desiccation. Source : The Microbial World 

4. Bacterial spores can be killed during sterilization - TRUE 
Sterilization is necessary for the complete destruction or removal of all microorganisms (including spore-forming and non-spore-forming bacteria, viruses, fungi, and protozoa). Source : WHO Pharmacopoeia Library

5. Orphan Annie eye nuclear inclusion is found in papillary thyroid cancer.
Characteristic Orphan Annie eye nuclear inclusions (nuclei with uniform staining, which appear empty) and psammoma bodies on light microscopy. The former is useful in identifying the follicular variant of papillary thyroid carcinomas. Source : Wikipedia

PMP 1 - Carcinoma of caecum

The most difficult questions were:

1. Pathology of colon carcinoma
Write about adenoma-carcinoma sequence and microsatellite instability pathway. The mutation of KRAS, APC and p53 as well as loss of 18q. Progress from normal => early adenoma => late adenoma => carcinoma. The MSI, MSH2, PMS2 etc.

Also write about adenocarcinoma (mucinous, colloid), polyps (adenomatous, hyperplastic), the tubular, tubulovillous or villous adenomas, sessile and pedunculated etc. I did not manage to write about them all though, not enough time =..='' 

2. Principle of management in this patient
If you have upper rectum carcinoma and above - the principle is resection! Only when you have rectal carcinoma and below, you give neo-adjuvant first. After resect, give adjuvant chemotherapy and long-term follow-up. Elaborate.

PMP 2 - Carcinoma of bladder

The most terrifying questions:

1. Pathology of bladder carcinoma
The most common type is transitional cell carcinoma. 90% of them develop from papillary tumour that projects into bladder lumen and if untreated => penetrate basement membrane, invade lamina propria and muscle => metastasize. 10% of them develop from CIS, the flat, noninvasive, high-grade urothelial carcinoma that spreads along the bladder surface and over time => invasive.

Other type is squamous cell carcinoma, develops from urothelium of bladder, purely squamous type. Adenocarcinoma is only 2%, mostly in congenital problem (exstrophic bladder, persistent urachal remnant). Other rare forms are leiomyosarcoma (most common bladder sarcoma), rhabdosarcoma (in children), carcinosarcoma (mesenchymal and epithelial), lymphoma (arise in submucosa), and small cell carcinoma (poorly differentiated, same morphology like in lung). All rare carcinomas have poor prognosis, except lymphoma. Source : Medscape

Pftt. If only I can answer this well in the exam =..=''

2. Principle of management of bladder carcinoma
You do cystoscopy, transurethral resection of tumour (TURT), intravesicle BCG/Mitomycin, review HPE and decide from there - either non-invasive or invasive. Don't forget staging of tumour. Cystectomy is an option. Elaborate. 


5 stations altogether, 2 minutes for each. Not enough time to think!! >..<''

The pictures were about thyroid swelling, Chest XRay (air under diaphragm?), an instrument used for vein stripping (Mr.Fadel told us that), CT brain (ring-enhancing lesion) and one more picture I cant remember.

TUESDAY, 22/10/14

LONG CASE (Mr. Islah & Mr. Hisham)
Obstructive Jaundice secondary to choledocholithiasis

29-year-old Malay man from Pekan with history of cholelithiasis and mitral valve replacement was admitted 3 days ago, presented with 4 months' history of yellowish discolouration of sclera associated with tea-coloured urine, pale-coloured stool and epigastric pain. He is on warfarin for 4 years. He has history of multiple blood transfusions. His Hepatitis B, C and HIV results were non-reactive. He does not smoke, not consume alcohol and no history of high-risk behaviour. Currently admitted for laparoscopic cholecystectomy tomorrow.

On examination, patient was on heparin infusion 1.4ml/h. He was alert, comfortable and afebrile. He had mild jaundice of sclerae. There was no stigmata of chronic liver disease. Tenderness at epigastric and right hypochondriac region. Hepatomegaly 2-finger-breadth noted. There was no splenomegaly, ascites or pedal edema. Per rectal examination was not done due to patient's refusal. On cardiovascular examination, a 21 cm of midline scar from mitral valve surgery noted on chest, well-healed with no keloid or hyperthrophy. Prosthetic click heard on auscultation, mostly prominent at mitral valve area.

Questions asked by Mr.Islah:

1. Why the patient is on heparin infusion? Why not continue oral warfarin?

The most common indications for long-term oral anticoagulation with warfarin are venous thromboembolism, mechanical cardiac valves (like in this patient) and atrial fibrillation. Source : Australian Prescriber

The approach options for patients on long-term anticoagulants can be one of the following: 
a. Continue warfarin therapy 
b. Withhold warfarin therapy for a period of time before and after the procedure (like in most cases we see in the ward, withhold warfarin 4-5 days pre-op, these patients have low risk of developing thromboembolism)
c. Temporarily withhold warfarin therapy and also provide a "heparin bridge" during the perioperative period (like in this patient)

Which management option to follow is primarily determined by the characteristics of the patient and by the nature of the procedure. 

Do you know half-life of heparin is how many days? It's only ONE and A HALF HOUR!! Thats why in this patient, you stop warfarin and start heparin!! Before surgery, you need 5 days to get warfarin out of your system (warfarin half life is 5 days), but you cannot leave the patient without anticoagulant (he has mechanical heart valve for god's sake! it will increase the risk of thromboembolism!), so you start on heparin infusion because of its short half life!! Now I understandd!! :D 

It has been suggested that patients on long-term warfarin therapy (including those with mechanical heart valves or atrial fibrillation) who are undergoing minor elective invasive outpatient procedures (eg, colonoscopy, dental procedures) may have a slightly increased risk of perioperative bleeding if placed in some form of heparin therapy (eg, heparin bridge) than those who have their oral anticoagulation withheld for 4-5 days (major hemorrhage 3.7% vs 0.2% and significant nonmajor hemorrhage 9% vs 0.6%, respectively). The perioperative risk of bleeding when using a heparin bridge appears to be higher and the risk of thromboembolic events appears to be lower when Coumadin is stopped than what is reported elsewhere in the literature. Source : Medscape

2. Differential diagnosis of obstructive jaundice:

- Choledocholithiasis
- CBD stricture
- Cancer of pancreas, peri-ampullary, cholangiocarcinoma
- Parasitic infestation
- Mirizzi syndrome

3. What is Mirizzi syndrome? 

Gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of CBD or common hepatic duct. Obstructive jaundice can result from direct extrinsic compression by the stone or from fibrosis caused by chronic cholecystitis. Source : Wikipedia.

4. Management of this patient

As usual, start with rescucitation. Since he came with abdominal pain, give analgesia. Put on CBD, monitor urine output and vital signs. Do investigations like FBC, PT/APTT, GSH, RP, LFT as baseline, pre-op assessment and to investigate cause. Do HBS US, ERCP and later get date for cholecystectomy.

5. How ERCP is done? Uses of ERCP?

Ask consent from patient to undergo endoscopic retrograde cholangiopancreatography. Review blood investigations. Bring patient to endoscopy room. Insert scope through mouth until duodenum level 2 (because thats where your ampulla of vater is). Then, inject contrast. View the biliary tree on the screen.

ERCP can be diagnostic (you want to look if there is stone, tumour, stricture or any abnormalities in the biliary tree) or therapeutic (stones can be removed, stents inserted, cut the sphincters or dilate the stricture using balloon).

6. Indications of cholecystectomy. How cholecystectomy is done?

Cholecystectomy is indicated in the presence of gallbladder trauma, gallbladder cancer, acute cholecystitis, and other complications of gallstonesMore controversial are the indications for elective cholecystectomy. Cholecystectomy is done in symptomatic patients with cholelithiasis escpecially with non-functioning gallbladder. Source : PubMed

Other indications are porcelain gallbladder, if gallstones are big (>5cm), gallbladder polyp (>1cm) and multiple recurrence of gallbladder stones because we are afraid of GB stones go into CBD causing obstruction. 

Cholecystectomy can be done in open surgery or laparoscopic. In open surgery, you do Kocher incision (right subcostal region).

30 MINUTES'S UP!!! Thank you Mr.Islah! :)

SHORT CASE (Mr. Nazli)
Non-toxic multinodular goitre

Patient is a middle-aged woman, sitting comfortable on a chair. She looks well with good hydration and nutritional status.

There are multiple nodules noted at anterior neck region. It moves with swallowing but not move during tongue protrusion. There is no dilated veins noted, no surgical scar and no colour changes on skin.

The swelling is not warm on touch. It is located at anterior neck, multinodular with a dominant nodule (measured 7x4cm), has regular margin, firm in consistency, not attached to skin or muscles. There is no lymphadenopathy. Trachea cannot be assessed due to the swelling.

There is no retrosternal extension of the swelling.

There is no carotid bruit heard.

General examination:
Patient's hands are dry and warm, not sweaty. Pulse is regular in rhythm and volume, no atrial fibrillation. There is no ophthalmopathy.

Questions asked by Mr. Nazli:

1. What is Pemberton's sign? How to test?

You ask the patient to elevate both arms until they touch the sides of face. Pemberton's sign positive when you see the patient's face become cyanosed and congested, and patient develops respiratory distress after one minute. This is because of substernal goitre in the mediastinum, causing superior vena cava syndrome. Source : Wikipedia

2. What is Berry's sign? How to test?

Berry's sign is the absence of carotid pulse. It results from the tumour encasing thyroid artery and muffling the pulsation. It indicates a malignant thyroid tumour!! Source : Emergency Medical Paramedic

3. What is your diagnosis for this patient?

Non-toxic mutinodular goitre

4. What is the common cause of MNG?

Patient with long-standing multinodular goitre is usually due to deficiency in iodine, it is called colloid goitre.

5. How do you manage this patient?

I would like to take blood for investigations such as FBC (check for anemia and neutrophilia), TFT (check for high T4), RP, PT/APTT (as baseline for surgery) and GSH. I would like to do ultrasound of thyroid to see if the mass is cystic or solid. Then, I would like to send the patient for surgery.

6. What surgery do you want to do? Complications of the surgery?

I would like to do total thyroidectomy. The complications of surgery can be divided into early and late complications. Early complications include haemorrhage and haematoma formation causing stridor, external laryngeal nerve injury causing weak voice and left recurrent laryngeal nerve injury causing hoearseness of voice. Late complication is patient will develop hypocalcemia and hypothyroidism (I forgot this last one that's why I felt that something was missing ughhh what were you thinking Nurul Ainn!!)

7. What are the signs in hypocalcemic patient? How do you test them?

Patient will have positive Chovstek sign and Trosseau sign. For Chovstek sign, you tap patient's facial nerve (perioral area) and patient will develop facial spasm. For Trosseau sign, you inflate blood pressure cuff on patient's arm, and the patient will develop contracture (wrist and MCP joints flex, DIP and PIP extend, fingers adduct).

TIME'S UPP!! Thank you Mr. Nazli! :) posting done - FOUR more to go!!  


Hello PSYCHIATRY!! Hehehe

Have a good dayy people!! :D

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