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Answers to Set 1: 7/1/13

1.

A 72 years old man was admitted with colicky abdominal pain and vomiting for 2 days.
An Abdominal Xray was taken and shown below:

QUESTION 1:
Describe what you see

Answer: Dilated loops of small bowel suggestive of small bowel obstruction

Question 2:

What are the distinguishing features of distended small bowel from large bowel in plain
AXR?

Answer:
a. Valvulae conniventes which completely across the bowel wall (unlike the taeniae
coli of the large bowel which are incomplete )
b. Relatively central in position
c. Relatively small in diameter 4-5cm in small bowel distension as oppose to 10cm in
severe large bowel obstruction

Question 3:
What do you expect to see in erect AXR of this patient?

Answer:
Loops of distended bowel with fluid levels
Question 4:
What are the common causes of small bowel obstruction in elderly? What should you
look for in your physical examination?

Answer:
Bowel adhesions, hernia, food bolus, neoplasia
Physical signs to look for :
Previous surgical scar causing adhesions
A mass anywhere in the abdomen
Hernia in the groin and previous surgical site

Question 5:
What do you understand by the term conservative (non-operative) treatment in
managing patients with small bowel obstruction?

Answer:
a. proximal decompression by a nasogastric tube
b. intravenous fluids to replace water and electrolytes loss
c. repeated evaluation of patients development of abdominal tenderness,
tachycardia, abdominal girdle, changes of bowel sounds

Question 6
When should you stop conservative treatment / operative management is indicated in
small bowel obstruction?

Answer:
a. Established or suspected strangulation including those with irreducible
external hernia
b. Failure of resolution after a period (usually 5 days) of non-operative
management

Question 7
What are the clinical signs of bowel strangulation?

Answer:
Tachycardia, pyrexia, abdominal guarding and tenderness, decrease of bowel sounds

2. A 35years of male motorcycle rider was involved in a motor vehicle accident. He


was unconscious, cysnosed, dyspnoea with pulse rate of 122 per min. A urgent portable
CXR was taken and shown below.
Question 1:
What is the diagnosis here? Give your reasons

Answer:
Right tension pneumothrax deviation of trachea to the left, shifting of mediastinum

Question 2:
What physical signs do you expect to find in this patient?

Answer:
Inspection:
Severe dyspnoea with rapid respiratory rate, cysnosis, engorged neck veins,
tachycardia, hypotension, decrease of movement of right chest

Palpation:
Trachea deviated to the left, shifting of apex beat to laterally
Percussion:
Hyper-resonant over the right chest
Auscultation:
Absent breath sounds over the right chest

Question 3:
How do you manage a patient with tension pneumothorax?
Answer:
Insertion of a wide bore needle through the 2nd intercostals space in the midclavicular line
followed by formal insertion of an intercostal drain with an underwater seal

Question 4:
Please refer to your notes on minor procedure
Data Interpretation, Practical HO Points and Surgical Therapeutics

Set 2: 14/01/13 Data Interpretation: Haematology

Answers:

Red cell count (RCC)

is an estimation of the number of red blood cells per litre of blood.

Abnormally low numbers of red blood cells may indicate anaemia as a result of blood
loss, bone marrow failure, malnutrition such as iron deficiency, over-hydration, or
mechanical damage to red blood cells.

Abnormally high numbers of red blood cells may indicate congenital heart disease, some
lung diseases, dehydration, kidney disease or polycythaemia vera.

Packed cell volume (PCV) or haematocrit (Hct)

is a measure of the percentage of red blood cells to the total blood volume.

A low haematocrit may indicate anaemia, blood loss, bone marrow failure, leukaemia,
multiple myeloma, nutritional deficiency, over-hydration or rheumatoid arthritis.

A high haematocrit may indicate dehydration (for example, due to burns or diarrhoea),
eclampsia (a serious condition that can occur during pregnancy) or polycythaemia vera.

Mean cell volume or mean corpuscular volume (MCV)

is an estimate of the volume of red blood cells. It is useful for determining the type of
anaemia a person might have.

A low MCV may indicate iron deficiency, chronic disease, pregnancy, anaemia due to
blood cell destruction or bone marrow disorders.

A high MCV may indicate anaemia due to nutritional deficiencies, bone marrow
abnormalities, liver disease, alcoholism, chronic lung disease, or therapy with certain
medications.
Mean cell haemoglobin (MCH) and mean cell haemoglobin concentration (MCHC)

also known as mean corpuscular haemoglobin and mean corpuscular haemoglobin


concentration, are further guides to the investigation of anaemia.

The MCH is the haemoglobin content of the average red cell. The MCHC is the average
haemoglobin concentration in a given volume of packed red cells.

The MCH may be low in types of anaemia where the red blood cells are abnormally
small, or high in other types of anaemia where the red blood cells are enlarged (for
example, as a result of folic acid or vitamin B12 deficiency).

The MCHC is low in iron deficiency, blood loss, pregnancy and anaemias caused by
chronic disease.

White cell (leucocyte) count

estimates the total number of white blood cells per litre of blood.

An abnormal high or low white cell count can indicate many possible medical conditions
and a leucocyte differential count, which provides numbers of the different types of white
cells, is usually needed to help make any diagnosis.

Abnormally low numbers of white blood cells may indicate liver or spleen disorders,
bone marrow disorders, or exposure to radiation or toxic substances.

Abnormally high levels of white blood cells may indicate infection, tissue damage,
leukaemia, or inflammatory diseases.

Leucocyte (white cell) differential count

provides an estimate of the numbers of the 5 main types of white blood cells. These are:
neutrophils; monocytes; lymphocytes; eosinophils; and basophils.

Each of the 5 types has a specific role in the body.

Neutrophils and monocytes protect the body against bacteria and eat up small particles of
foreign matter.
Lymphocytes are involved in the immune process, producing antibodies against foreign
organisms, protecting against viruses and fighting cancer.

Eosinophils kill parasites and are involved in allergic responses. High numbers of
eosinophils may be associated with worm infections or exposure to substances that cause
allergic reactions.

Basophils also take part in allergic responses and increased basophil production may be
associated with bone marrow disorders or viral infection.

Platelet count

is an estimation of the number of platelets per litre of blood. Abnormally low numbers of
platelets is known as thrombocytopenia, while an abnormally high level of platelets is
known as thrombocytosis.

Platelet counts are often used to monitor medications such as heparin, which may cause
low numbers of platelets, as well as medications that can have toxic effects on bone
marrow. They may also be used to help diagnose problems associated with abnormal
bleeding or bruising.

Patient 1:

1. The low Hb, MCV, MCH + MCHC this patient indicates microcytic hypochromic
anaemia. The mild thrombocytosis suggests active bleeding.

2. Commonest cause of microcytic anaemia is iron deficiency. The blood smear of a


patient with iron deficiency shows many hypochromatic and rather small RBCs, and may
also show poikilocytosis (variation in shape) and anisocytosis (variation in size), and a
few target cells.

The diagnosis of iron deficiency anemia will be suggested by such diagnostic tests as a
low serum ferritin, a low serum iron level, an elevated serum transferrin and a high total
iron binding capacity (TIBC). Serum ferritin is the most sensitive lab test for iron
deficiency anemia.

3. Blood smear and iron studies to confirm iron deficiency anaemia. In an elderly male
with iron deficiency anaemia, investigations should be carried out to exclude a sinister
cause in particular occult GI malignancy. Therefore, further investigations of a elderly
patient with iron deficiency anaemia usually involves upper and lower endoscopy or
barium studies

Patient 2.

In a patient with acute blood loss, the initial haemoglobin level, MCV and MCH may
be normal. However, the haematocrit (PCV) is low. The low platelet count also
suggestive of acute blood loss. The low haematocrit level, abdominal pain,
tachycardia and hypotension point to intraabdominal injury with active bleeding.
Further investigation will include crossmatching (if not yet done) and CT scan of
abdomen (after resuscitate and stabilize the patient).
Data Interpretation, Practical HO Points and Surgical Therapeutics

Set 3: 21/01/13: Data Interpretation: Practical HO points

Answers: Perioperative care:


You are a surgical house officer at Hospital PMC. Mr. M, a 60 years old chronic smoker
with history of hypertension is admitted for a right hemicolectomy for colon cancer
tomorrow morning. You are requested to write up a preoperative management plan
for this patient.

You assist your Consultant to perform the operation. Post-operatively, he asks you to
write up the post-operative orders for this patient.

Answers

Preoperative management

Investigations:
o General:
Biochemical: U&E, liver function test
Haematology: FBC
CXR
ECG
o Specific:
Blood group and save / cross match
CEA
Respiratory function test & ABG (only if this patient has COPD)
Bowel preparation as Departments protocol

DVT prophylaxis

Chest physiotherapy

Medications

o Usual medications ( ? need to be continued, stopped temporarily, changed


to IV form) the antihypertensive medications in this patient should be
continued
o Pre-Med as ordered by the Anaesthesist
o Prophylactic antibiotics

Fasting from midnight

Consent
Postoperative Care

- Hourly BP,PR & UO ( if a foley catheter is present)


- IV fluids: Dextrose/saline 1 litre 8 hourly
- Nil by mouth except medications
- Resume normal antihypertensive
- 4 hourly nasogastric aspirate ( if present)
- Daily chest physiotherapy
- 24 hourly charting of drain output
- Medications:
o Anagesia
o Antibiotics
o Heparin
Postoperative Check list - Go through the post operative patient from hand to
head to write your postoperative orders!

?need any oxygen -


? nasal or mask?
? how much GCS head injury
patient, neurosurgical
patient
? Allow oral intake
If so, ?liquid or If has nasogastric
solid, how much, tube free drainage
how often or 4 hrly aspirate

Medications
Incentive - ? need to continue
spirometry & usual medications
chest physio - Prophylactic
? any chest drain antibiotics
- Special medications
? require any
IV fluid if
so, what type
of fluid, how ? any blood
often test
Glucostix
Pain relief in DM
?prn, ? round patient
the clock

?Any drain
PR, BP how often ? what type
- major operation Charting drain
hourly output - ? how
- minor operation - 4 often
hrly

? need to chart
UO ? how
often hrly or 4
hrly
DVT prophylaxis
- heparin, elastic
stocking
Data Interpretation, Practical HO Points and Surgical Therapeutics

Answer to EXERCISE 4, 28/01/13

Patient 1

1. Gas under the diaphragm bilaterally indicating pneumoperitoneum

Gas in stomach

Gas under diaphragm

2. Perforated peptic ulcer disease. ( Hx of chronic knee pain, likely to have taken
NSAIDs + sudden onset of severe epigastric pain)
3. Other causes of extraluminal gas
Post abdominal surgery or ERCP
Perforated of other abdominal viscus ( bowel)
Gall stone ileus
Chalangitis
Abscess

Patient 2.

1. Barium swallow
a. QUIZ : What is the difference among barium swallow, barium meal and
barium follow through?

2. Shouldering and persistent stricture at the upper 1/3 of esophagus

3. Cancer of the esophagus


4. Upper endoscopy (oesophago-gastro-duodenoscopy) and biopsy

Answer to Quiz 1.

Ba swallow:
performs to visualize abnormality of esophagus and OGJ like hiatus hernia
is performed with patient in erect position after drinking the barium

Ba meal:
performs to look for abnormality in the stomach and duodenum like peptic
ulcers or ca stomach
the barium is thicker
Patient has to take a gas producing tablets (CO2 effervescent) to help to
distend the stomach
Is performed with patient in supine and patient is asked to turn around in
various positions for the barium to fully coat the wall of the stomach

Ba follow through:
Performs to look for abnormality in the small bowel
The barium is dilute ( abut 10x less than that used in Ba meal)
Data Interpretation, Practical HO Points and Surgical Therapeutics

4: 28/01/13: Data Interpretation

Patient 1

A 60 years old gentleman with chronic knee pain presents with sudden onset of severe
epigastric pain. A chest X-ray is ordered and shown below.

Q1. What do you see in the CXR?


Q2. What is the likely diagnosis in this patient?
Q3. List other causes that might give rise to similar appearance?
Patient 2

A 72 years old Chinese man presents with progressive dysphagia for the last 2 months.
The following Xray is ordered.
Questions:
1. What type of Xray is this?
2. What does it show?
3. What is your diagnosis?
4. How do you confirm your diagnosis?
Data Interpretation, Practical HO Points and Surgical Therapeutics 2013

Exercise 5 04/02/13: Data Interpretation

Answers:
Pateint 1

Q1: 3 abnormalities can be seen in the results: Hyponatraemia, hypokalaemia and high
urea. The low sodium and potassium levels are a consequence of a prolonged period of
vomiting. The raised in urea without creatinine level suggests of dehydration.

Q2: The low sodium and potassium need to be replaced. Initially I will give
1. Normal saline 0.9% 1 litre with potassium 40mmol infused over 2 hours
2. Normal saline 0.9% 1 litre with potassium 40mmol/l 8 hourly

The exact rate of the IVF has to be given according to the urine output of the patient.
The electrolytes need to be checked daily until the values are normalized.

Patient 2.

1. The raised urea and creatinine indicate that this patient has renal failure. The
potassium level is dangerously high as a result of the renal failure.

2. the immediate treatment will be to relieve the urinary retention with insertion of a
foley catheter and correction of the hyperkalaemia as it will cause cardiac
arrhythmias. Treatment of hyperkalaemia include:

a. giving glucose, insulin, and bicarbonate (BIG) and


b. doing a ECG

One of the regime is as follow:


8.4% sodium bicarbonate 50mls
Insulin 10units
10% glucose solution 50mls

If there is severe ECG changes, give 10% calcium gluconate 20mls over 5
minutes. Remember: sodium bicarbonate and calcium gluconate should not be given at
the IV site at same time .
Patient 3:

Write the IV fluids order for a 56 years old lady (weight 46kg) who just has a total
gastrectomy for ca stomach.

As a response to stress and trauma of surgery, there is an increase in secretion of cortisol,


aldosterone and ADH in the first 24 48 hours. This will cause sodium and water
retention with excretion of potassium.

For a patient of 46kg, the daily maintenance requirements


Water: 2 l per day (1.5 2mls/kg/hr)
Sodium: 1.5mmol/kg/day
Potassium: 1 mmol/kg/day

So the fluids order will be as below:

1litre lDextrose (4%) Saline (0.18%) + 20mmol KCl over 12 hours

(that will give 2l of water, 60mmol Na and 40mmol of K per day)


Data Interpretation, Practical HO Points and Surgical Therapeutics

Exercise 6: 18/02/13: Surgical Therapeutics

ANSWERS:

Prescribed the followings:

1. A patient with Helicobacter pylori positive gastritis


a. Omeprazole 40mg daily, clarithromycin 500mg bd & metronidazole
400mg bd for 7 days or
b. Omeprazole 40mg daily, amoxicillin 500mg tds & metrodidazole
400mg tds for 7 days or
c. Omeprazole 40mg daily, amoxicillin 1g bd & clarithromycin 500mg
bd for 7 days
Note: Alternatively can replace Omeprazole with Lansoprazole 30mg bd

2. H2 receptor blockers for a patient with duodenal ulcer


a. Ranitidine 150mg bd or 300mg nocte for 4 weeks or
b. Famotidine 40mg nocte for 4 weeks

3. Octreotide for a patient who has a pancreatic fistula


a. Octreotide 0.1mg 8 hourly subcutaneously for 7 days

4. Ocleotide for a patient with bleeding esophageal varices


a. Ocleotide 0.025mg (25ug) per hour IV infusion for 5 days
Data Interpretation, Practical HO Points and Surgical Therapeutics

No 7: 25/02/13 : Practical HO points: perioperative care

ANSWERS

General management:

a. Adequate glucose monitoring by glucostix during hospital admission. At


least twice a day.

b. Assessment of blood pressure and cardiac function

c. Place the patient first on the operative list preferably in am and inform the
anaesthesist that there is a diabetic patient requires surgery.

1. Perioperative management of a 50 yeas old IDDM patient admitted for an


elective right hemicolectomy. His is on Humulin N 20am and 10u pm.

Preop:
a. The insulin should be stopped on the morning of the operation. (If patient is
on long acting insulin e.g. monotard HM, Insultard HM amd Humulin N the
dose of the insulin should be decreased by one third on the evening before
surgery)
b. After the patient is kept nil by mouth, monitor the blood sugar level 2 hourly
and set up a GKI infusion.

Postop:
c. The GKI infusion should be continued until the patient can resume oral
intake
d. Check blood glucose 2 hourly and adjust the infusion rate of the GKI
accordingly

2. Perioperative management of a 50 years old NIDDM patient admitted for an


elective right hemicolectomy. His usual medications are: Metformin 500mg bd
and Daonil 5mg bd.

Preop:
a. The oral hypoglycaemic agents should be discontinued on the day of surgery.
(Note: For those patient taking chlorpropramide, it should be stopped 3 days
before OT and substituted with twice daily short acting insulin)
b. 4 hourly glucostix to check the blood glucose level after the patient is kept nil
by mouth. If BSL is > 14mmol/l, start a sliding scale insulin or a GKI drip

Post op:
a. Continue to check the blood glucose level at 4 hourly until the patient is
eating and drinking. If BSL is > 14mmol/l, start a sliding scale insulin or a
GKI drip
b. When the patient is eating and the BSL is >8mmol/l, start the
hypoglycaemic agent

3. Write a example of a GKI (glucose potassium insulin) infusion

500mls 10% dextrose + 20mol KCL + 16u soluble insulin at 6 hourly

Aim to keep the blood sugar level between 4-10mmol/l

Increase the amount of insulin in the drip according to the 2 hourly blood
glucose level

4. Write a sliding scale insulin.

Glucometer reading Soluble insulin Soluble insuin IV infusion


subcutaneously in unit u/h
(10unit in 100mls normal
saline via an infusion
pump)
0-8 0 0
>8 12 4 2
>12 16 8 3
>16 - 20 12 4
>20 16 6
Data Interpretation, Practical HO Points and Surgical Therapeutics

No8: 04/03/13 Data Interpretation A series of surgical X rays Part 1

Answers
X ray 1:

Q1: What does the arrow indicate?

A double-J ureteric stent

Q2: What potential complications may arise?

Complications associated with ureteral stenting include:

haematuria
catheter migration or dislodgement
reflux of urine to kidney causing flank pain during micturation
bladder irritation causing urgency, bladder pain
introduction or worsening of infection
penetration of adjacent organs during insertion (e.g., bowel, gallbladder,
lungs or vessels)
forgotten stent causing calcification and stone formation. Potential
litigation. Its the responsibility of the doctor who put the stent to take it out
X ray 2: Pelvic X ray of a 55 years old lady with history of right mastectomy
complaining of pelvic pain.

What does the Xray show?

Multiple osteolytic lesions of pelvic bone suggesting of bone metastasis from her
breast cancer
Xray 3: Xray of a 76 years old man with abdominal pain and distension.

Q1: What type of Xray is this and what does it show?

Barium enema. There is an apple core lesion at the descending colon consistent with
colon cancer. The proximal bowel is dilated suggesting the lesion is causing bowel
obstruction and the need for urgent surgical intervention
Xray 4: Xray of a new born child with Down Syndrome who has bile stained vomiting

Gas in stomach

Gas in 1st
part of
duodenum

Q1: What does the Xray show and what is the diagnosis?

Double bubbles sign of duodenal atresia.


X ray 5: AXR of a 83 years old man presents with vomiting, abdominal distension and
absolute constipation. He lives in a nursing home with history of chronic constipation

Q1; What does the Xray show and what is the diagnosis?:

Sigmoid volvulus. The sigmoid colon is grossly dilated with loss of haustration and
take the form of an inverted "U" with a centre line that points to the left iliac fossa
(Omega sign). A metal pin over the left hip.
Data Interpretation, Practical HO Points and Surgical Therapeutics

9: 11/03/13 : Data Interpretation A series of surgical X rays 2

Answers

Xray6: Supine AXR of a 70 years old lady with persistent abdominal distension and
vomiting 5 days after right hemicolectomy.

Q1: What does the X-ray show and what is the diagnosis?

Answer: The Xray shows dilated small and large bowels with gas in the rectum. In
a post-operative patient, the likely diagnosis is post-operative ileus.
X-ray 7: A 45 years old man with past history of appendectomy presents colicky
abdominal pain and vomiting

Q: What does the X-ray show and what is the diagnosis?

Answer:
The Xray shows dilated small bowels. With a history of appendectomy, the
diagnosis is likely to be subacute small bowel obstruction secondary to adhesions
Xray 8: KUB Xray of a 43 years old man with severe left sided abdominal pain and
vomiting.

Q1: What does the Xray show and what is the likely diagnosis?

Answer:
There is an oval shape opacity over the left renal area. Its likely to be a left renal
stone

Q2: What investigation will you order to confirm your diagnosis?

Answer:
CTUrogram ( Non contrast spiral CT) or ultrasound or IVUrogram
Xray -9: Xray of a 60 years old lady with recurrent urinary tract infection.

Q1: What type of Xray is this?

Plain AXR / KUB

Q2: What is the diagnosis?

Right staghorn stone and a left renal stone


Xray 10: AXR of a 35 years old man with history of ulcerative colitis presents with
abdominal pain, vomiting and abdominal distension.

Q1: Describe the Xray.

Answer:
Dilated small and large bowel. The transverse colon is grossly dilated (a feature of
toxic megacolon)

Q2: What is the diagnosis?

Answer:
Toxic megacolon
Data Interpretation, Practical HO Points and Surgical Therapeutics

No 10: 18/03/13 : Surgical Therapeutics

Answers:
1. DVT prophylaxis
Low dose unfractionated heparin (LDUH) or Low molecular weight heparin
(LMWH) is given 1-2 hours before the operation until the patient is fully
ambulatory.

Heparin 5000u subcutanoesly q8h or


Enoxaprin (CLEXANE) 4000u subcutaneously per day or
Nadroparin (FRAXIPARIN) 2850u subcutaneously per day or
Tinzaparin (INNOHEP) 3500u subcutaneously per day

Other non pharmaceutical measures for DVT prophylaxis should also be given.

2. Management of patient who is on warfarin going for an elective open operation


a. Check the prothrobin time ratio / INR
To check whether the warfarin therapy is at the right level,
non-existent or excessive
b. If the INR is below 1.5, warfarin is stopped, SC heparin is started
and operation can be carried out.
c. If the INR is above 1.5, the warfarin should be stopped and the
INR is recheck until the ratio is below 1.5 before the operation
can be carried out.
d. The wafarin is normally recommenced 2 days after the surgery
until the desirable level (usually bt 2.5 to 3.5 in patient with
valvular heart disease) is achieved. SC heparin should be
continued until the desirable of warfarin is attained.

Notes on DVTprophylaxis:

Risk factors for developing short-term (30-day) postoperative risk for DVT have been
examined in a prospective cohort of 21,903 consecutive surgical patients:

Age older than 50 years


History of varicose veins
History of myocardial infarction
History of cancer
History of atrial fibrillation
History of ischemic stroke
History of diabetes mellitus

Other additional factors included previous DVT, heart failure, obesity, paralysis, or the
presence of an inhibitor deficiency state. Among inherited conditions, factor V Leiden
accounts for 40-50% of cases; other causes include prothrombin gene mutation, protein S
deficiency, protein C deficiency, and antithrombin deficiency.

Management
Goals of therapy

Perioperative (or primary) prophylactic therapy in patients with risk factors for DVT or
PE requires prevention of both the occurrence of DVT or PE and the consequences of
DVT or PE. The 2 main strategies are (1) nonpharmacologic interventions and (2)
pharmacologic interventions. Based on published data, the Seventh American College of
Chest Physicians (ACCP) Consensus Conference on Antithrombotic Therapy
recommend that patients are classified as having low, moderate, high, and very high risks
for the development of DVT or PE and that the prophylactic regimens are used according
to this risk stratification, as described in the Table.

Classification of Risk Levels*

Table

Thromboembolic Event, %
Risk Proximal
Surgical Parameters Calf Vein Clinical Fatal
level Vein
Thrombosis PE PE
Thrombosis
Uncomplicated minor surgery in
patients younger than 40 years
Low with no clinical risk factors; 2 0.4 0.2 0.002
require general anesthesia less
than 30 minutes
Any surgery in patients aged 40-
60 years with no additional risk
factors
Major surgery in patients
younger than 40 years with no 0.1-
Moderate 10-20 2-4 1-2
additional risk factors; require 0.4
general anesthesia longer than 30
minutes
Minor surgery in patients with
risk factors
Major surgery in patients older
High 20-40 4-8 2-4 0.4-1
than 60 years without additional
risk factors or patients aged 40-
60 years with additional risk
factors
Patients with myocardial
infarction (MI)
Medical patients with risk factors
Major surgery in patients older
than 40 years with prior venous
thromboembolism, malignant
disease, or hypercoagulable state
Highest Patients with elective major 40-80 10-20 4-10 0.2-5
lower extremity orthopedic
surgery, hip fracture, stroke,
multiple trauma, or spinal cord
injury
Thromboembolic Event, %
Risk Proximal
Surgical Parameters Calf Vein Clinical Fatal
level Vein
Thrombosis PE PE
Thrombosis
Uncomplicated minor surgery in
patients younger than 40 years
Low with no clinical risk factors; 2 0.4 0.2 0.002
require general anesthesia less
than 30 minutes
Any surgery in patients aged 40-
60 years with no additional risk
factors
Major surgery in patients
younger than 40 years with no 0.1-
Moderate 10-20 2-4 1-2
additional risk factors; require 0.4
general anesthesia longer than 30
minutes
Minor surgery in patients with
risk factors
Major surgery in patients older
than 60 years without additional
risk factors or patients aged 40-
60 years with additional risk
High 20-40 4-8 2-4 0.4-1
factors
Patients with myocardial
infarction (MI)
Medical patients with risk factors
Major surgery in patients older
Highest than 40 years with prior venous 40-80 10-20 4-10 0.2-5
thromboembolism, malignant
disease, or hypercoagulable state
Patients with elective major
lower extremity orthopedic
surgery, hip fracture, stroke,
multiple trauma, or spinal cord
injury

*Adapted from 2004 ACCP Consensus Conference

Absolute contraindications to antithrombotic or anticoagulant therapy include active


bleeding, severe bleeding diathesis or platelet count less than 20,000/L, neurosurgery,
ocular surgery, or intracranial bleeding within the past 10 days. Relative
contraindications include mild-to-moderate bleeding diathesis or platelet count 20,000-
100,000/L, brain metastases or recent major trauma, major abdominal surgery within
past 2 days, gastrointestinal or genitourinary bleeding within past 14 days, infective
endocarditis, or malignant hypertension.

Low-dose unfractionated heparin (LDUH) is usually given at 5,000 U, administered


SC q8h (high risk) to SC q12h (moderate risk), usually starting 1-2 h preoperatively.
Adjusted dose heparin is no longer recommended.

Lowmolecular-weight heparin is widely used in the perioperative setting for DVT


prophylaxis. Overall, heparin and LMWH are equivalent in preventing DVT, although
LMWH has greater bioavailability, longer duration of anticoagulant effect in fixed doses,
and little requirement for laboratory monitoring (thus is more cost-effective).
Preoperative prophylaxis with LMWH leads to a lower frequency of bleeding
complications (0.9% vs 3.5%) and a lower incidence of DVT (10% vs 15.3%) than with
postoperative unfractionated heparin. Postoperative use of LMWH (up to 2-3 wk after
hospital discharge) results in a lower frequency of DVT; however, use LMWH with
caution in patients with spinal punctures or epidural catheters because of the risk of
neurologic impairment and paralysis resulting from an expanding hematoma (especially
at sites of traumatic or repeated epidural or spinal puncture). Also, use caution in patients
in whom severe liver and kidney dysfunction can produce delayed drug elimination.

Obese patients may be difficult to dose appropriately.

Enoxaparin (Lovenox)
o General surgery (moderate risk) - 2,000 U (20 mg) SC 1-2 h
preoperatively, then SC qd postoperatively
o General surgery (high risk) - 4,000 U (40 mg) SC 1-2 h preoperatively,
then SC qd postoperatively or 3,000 U (30 mg) SC q12h starting 8-12 h
postoperatively
o Orthopedic surgery - 3,000 U (30 mg) SC q12h starting 12-24 h
postoperatively, or 4,000 U/d (40 mg/d) SC starting 10-12 h
preoperatively
o Acute spinal injury - 3,000 U (30 mg) SC q12h if hemodynamically stable
o Major trauma - 3,000 U (30 mg) SC q12h starting 12-36 h postinjury
o Epidural anesthesia - Last dose 12 h prior to pulling catheter; restart more
than 2 h afterwards
Dalteparin (Fragmin)
o General surgery (moderate risk) - 2,500 U SC 1-2 h preoperatively, then
SC qd postoperatively
o General surgery (high risk) - 5,000 U SC 8-12 h preoperatively, then SC
qd postoperatively
o Orthopedic surgery - 5,000 U SC 8-12 h preoperatively, then SC qd
starting 12-24 h postoperatively
Danaparoid (Orgaran)
o General surgery (high risk)/orthopedic surgery - 750 U SC 1-4 h
preoperatively, SC q12h postoperatively
Nadroparin (Fraxiparine)
o General surgery (moderate risk) - 2,850 U SC 2-4 h preoperatively, then
SC qd postoperatively
o Orthopedic surgery - 38 U/kg SC 12 h preoperatively, then SC qd for 3 d,
then 57 U/kg/d SC
Tinzaparin (Innohep)
o General surgery (moderate risk) - 3,500 U SC 2 h preoperatively, then SC
qd postoperatively
o Orthopedic surgery - 75 U/kg/d SC starting 12-24 h postoperatively or
4500 U SC 12 h preoperatively, then SC qd postoperatively
Ardeparin (Normiflo)
o Knee surgery - 50 IU/kg SC bid postoperatively for 14 d or until
ambulatory

Other antithrombotic agents

Warfarin, either a fixed or adjusted dose, has an effective but cumbersome DVT
prophylaxis regimen, and it is reserved for very high-risk patients who are undergoing
general surgery (if the international normalized ratio [INR] is kept at 2-3 with target at
2.5). Direct comparison between warfarin (Coumadin) and other antithrombotic agents
has yielded mixed results; however, warfarin is certainly more effective than aspirin or
external pneumatic compression.

Antiplatelet agents are generally considered ineffective in preventing PE. Current


guidelines advise against the use of aspirin alone in DVT prophylaxis.

Although earlier studies suggest comparable efficacy of dextran in PE prevention, with


bleeding risks equivalent to those of heparin, dextran is generally considered less
effective than heparin in preventing DVT; furthermore, it can lead to anaphylactoid
reactions in 0.1-0.25% of patients. There has been little mention of using dextran in the
recent guidelines.

Nonpharmacologic measures
Nonpharmacologic prophylaxis is recommended for low-risk patients throughout the
perioperative period until they are ambulatory. These measures are especially useful
when heparin therapy is contraindicated. Graduated compression stockings (GCS) and
early ambulation have few, if any, complications and are effective for patients who
undergo low-risk procedures.

Intermittent pneumatic compression (IPC) is a commonly applied method used to reduce


stasis and improve venous return from the lower extremities. IPC has demonstrable
efficacy even in patients with moderately high risk; however, if a patient has been at bed
rest or immobilized for more than 72 hours, exercise caution in the use of these devices
because of the risk of disrupting newly formed clots. These devices are not suitable for
patients with injuries or surgical sites in the lower extremities. Newer device designs,
such as foot pumps (arteriovenous impulse system), have the same recommendations as
those for the IPCs.

Early ambulation remains the most important nonpharmacologic approach to prevention


of perioperative DVT and PE. Inferior vena cava filters are no longer recommended in
primary prevention for perioperative DVT and PE.

Secondary prevention

Secondary prevention involves the early detection and treatment of subclinical DVT by
screening high-risk postoperative patients, particularly those in whom primary
prophylaxis is either contraindicated or ineffective. However, the use of routine
ultrasonography screening at discharge or during outpatient follow-up is not
recommended in asymptomatic patients.

Special Considerations
The recommended therapies for prevention of venous thromboembolism based on patient
characteristics are as follows, adapted from Seventh ACCP Consensus Conference on
Antithrombotic Therapy (for LMWH, low-dose <3,400 anti-Xa units; high-dose >/=
3,400 anti-Xa units):

Low-risk patients undergoing general surgery, benign gynecologic surgery,


transurethral surgery, or laparoscopic surgery: Recommendation includes early
and persistent ambulation without any specific prophylaxis.
Moderate-risk patients undergoing general surgery: Recommendations include
LDUH (5,000 U bid), LMWH (low-dose), and GCS/IPC.
Higher-risk patients undergoing general surgery; patients undergoing major open
urologic procedures: Recommendations include LDUH (5,000 U bid), LMWH
(high-dose), or IPC.
Higher-risk patients undergoing general surgery who are prone to wound
complications (eg, hematomas) and infection: Recommendation includes
GCS/IPC initially.
Very high-risk patients undergoing general surgery who have multiple risk factors,
including extensive gynecologic surgery for malignancy or high-risk urologic
surgery: Recommendations include LMWH (high-dose), fondaparinux, warfarin
(goal INR, 2.5; range, 2-3), or LDUH (5,000 U tid)/LMWH (high-dose) combined
with GCS/IPC. Postoperative discharge with LMWH after major cancer surgery.
Patients undergoing elective total hip replacement surgery: The optimal duration
of prophylaxis is uncertain; 7-10 days is recommended with LMWH or warfarin,
and 29-35 days with LMWH may offer additional protection. Recommendation
includes LMWH, with the full dose started 12 hours preoperatively or a half dose
started 4-6 hours preoperatively, then 12-24 hours postoperatively. Alternatively,
warfarin can be started before or immediately after surgery (goal INR, 2.5; range,
2-3) or adjusted-dose heparin can be started preoperatively. Adjuvant use of ES or
IPC may be helpful. LDH, aspirin, dextran, and IPC reduce the overall incidence
of venous thromboembolism but are less effective.
Patients undergoing elective total hip arthroplasty or total knee arthroplasty: The
optimal duration of prophylaxis is uncertain; at least 10 days is recommended
with LMWH, fondaparinux or warfarin; extending to 27-35 days with LMWH
may offer additional protection. Recommendation includes LMWH (high-dose),
with the full dose started 12 hours preoperatively or a half dose started 4-6 hours
preoperatively, then 12-24 hours postoperatively. Alternatively, half-dose LMWH
2-6 hours postoperatively followed by usual high-dose LMWH the following day
can be used. Fondaparinux (2.5 mg daily, 6-8 hours postoperatively) warfarin can
be started before or immediately after surgery (goal INR, 2.5; range, 2-3) or
adjusted-dose heparin can be started preoperatively. Adjuvant use of GCS or IPC
may be helpful. LDUH, aspirin, dextran, and IPC reduce the overall incidence of
venous thromboembolism but are less effective.
Higher-risk patients undergoing knee arthroscopy, with risk factors or following a
prolonged or complicated procedure: LMWH for at least 10 days.
Patients undergoing hip fracture surgery: Recommendations include LMWH
(high-dose) or adjusted-dose warfarin (goal INR, 2.5; range, 2-3) started
preoperatively or immediately after surgery; LDUH is an alternative.
Anticoagulation should continue during the time between hospitalization and
surgery.
High-risk patients undergoing orthopedic surgery: Inferior vena cava filter
placement is recommended only if other forms of anticoagulant-based
prophylaxis are not feasible because of active bleeding; this is rarely necessary.
Patients undergoing intracranial neurosurgery: Recommendation includes IPC
with or without GCS. LMWH and LDUH may be acceptable alternatives.
Consider IPC or GCC, with LMWH or LDUH, for high-risk patients.
Patients with acute spinal cord injury: Recommendation includes LMWH once
primary hemostasis is evident. Although GCS and IPC appear ineffective when
used alone, GCS and IPC may be of benefit when used with LMWH or if
anticoagulants are contraindicated. During rehabilitation, consider continuing
LMWH or converting to full-dose oral anticoagulation therapy.
Patients with elective spine surgery with advanced age, known malignancy,
neurologic deficit, prior DVT, or anterior surgical approach: LDUH, LMWH, or
IPC.
Trauma patients with an identifiable risk factor for thromboembolism:
Recommendations include LMWH as soon as it is considered safe. Consider
initial prophylaxis with IPC or GCS if the administration of LMWH is delayed or
contraindicated. In high-risk patients (eg, spinal cord injury, lower extremity or
pelvic fracture, major head injury, indwelling femoral venous lines) or with
suboptimal prophylaxis, consider screening with duplex ultrasonography, and
postdischarge LMWH or warfarin, especially in patients with major impaired
mobility.
Patients with MI: Recommendations include LDUH or full-dose therapeutic
intravenous heparin or LMWH. IPC and possibly GCS may be useful when
heparin is contraindicated.
Patients with ischemic stroke and lower extremity paralysis: Recommendations
include LDUH or LMWH. IPC with GCS is probably effective.
General medical patients with clinical risk factors for venous thromboembolism,
particularly those with heart failure, cancer, or severe lung disease or on bed rest:
Recommendations include LDUH or LMWH.
Patients with long-term indwelling central vein catheters: Recommendations
include warfarin (1 mg/d) or LMWH (low-dose) to prevent axillary-subclavian
venous thrombosis.
Patients having spinal puncture or epidural catheters placed for regional
anesthesia or analgesia: Recommendation includes LMWH, with last dose 12
hours prior to pulling catheter. Do not administer a dose until at least 2 hours after
the catheter is pulled.

Types of surgery

A pooled analysis of trials suggests that the rate of DVT following total hip replacement
declines from 51% to 11% with the use of LDUH, to 15% with LMWH, and to 22% with
IPC or GCS. With LMWH as the prophylactic regimen, the rate of DVT is reduced
similarly, from 61% to 31% after total knee replacement and from 48% to 24% after hip
fracture surgery.

A smaller number of studies have examined the efficacy of DVT prophylactic regimens
for other forms of surgery. Overall, heparin and IPC or GCS are recommended,
especially during open prostatectomy (untreated, DVT rate of 31-51%), neurosurgery
(untreated, DVT rate of 19-34%), and gynecologic malignancy surgery (untreated, DVT
rate of 12-35%).

Comorbidity

The risk of DVT in patients who are untreated after acute MI (25%) is comparable to that
following general surgery, and prophylaxis is recommended either in the form of LDUH
or full-dose anticoagulation (or IPC or GCS if heparin is contraindicated). In patients
with ischemic stroke, pooled data show a reduction in the rate of DVT from 63% to 16%,
and to 47% when using unfractionated heparin.

The treatment of patients who present with an established DVT or PE prior to surgery is
somewhat different. The risk of thromboembolic complications may increase if the
antithrombotic regimen is halted perioperatively. If surgery is elective, patients should
undergo a complete course of treatment for DVT or PE before undergoing surgery.
Conversely, if surgery is urgent, minimize the duration of antithrombotic cessation and
consider placement of a vena cava filter to prevent potential embolization. Switching to a
shorter-acting antithrombotic regimen (eg, LDUH) is a frequently used strategy in
patients with indications for lifelong anticoagulation (eg, in patients with prosthetic
valves).

Hypercoagulability states

The presence of hypercoagulable states (eg, factor V Leiden mutation, protein S or C


deficiency, antiphospholipid syndrome) is an indication for the institution of an
aggressive perioperative DVT prophylactic regimen. Conduct a diagnostic evaluation
preoperatively in patients with a personal or family history of recurrent thromboembolic
events. Although the frequency of heparin-induced thrombocytopenia seems to be lower
with LMWH than with unfractionated heparin, avoid both regimens in patients with
documented heparin sensitivity of this type.
Data Interpretation, Practical HO Points and Surgical Therapeutics

11: 25/03/13 : Data Interpretation

Patient 1

A 60 years old Chinese gentleman admitted with 3 months history of progressive


dysphagia. He has a blood test done and shown below:

Chemistry
Test Result Unit Reference
Electrolytes
Sodium 146 mmol/l 136.0 145.0
Potassium 4.2 mmol/l 3.5 5.1
Urea 11.6 mmol/l 3.0 9.2
Chlorides 107.0 mmol/l 98 - 107
Creatinine 110 umol/l 62 115
Calcium 1.97 mmol/l 2.20 2.50

Questions:
1. How would you interpret the result?

A: hypocalcaemia

2. From the history, what may be the cause of the low calcium level? What blood test
are you going to order?

A: From the history, its likely that this patient will have a low albumin level due
to his dysphagia. Low albumin level can lower the total serum calcium level as
most of the calcium is bound to albumin. So, the albumin level must be checked
in order to know the actual total calcium level

3. How do you calculate the corrected calcium level?


A: Corrected Calcium level = Serum calcium level + 0.1 X (40 albumin level)

4
Patient 2:

A 76 years old lady with history of mastectomy 5 years ago is admitted with generalized
aches and pains.

Chemistry
Test Result Unit Reference
Electrolytes
Sodium 138 mmol/l 136.0 145.0
Potassium 4.3 mmol/l 3.5 5.1
Urea 8.2 mmol/l 3.0 9.2
Chlorides 99 mmol/l 98 - 107
Creatinine 113 umol/l 62 115
Calcium 3.10 mmol/l 2.20 2.50
Phosphate 1.50 mmol/l 1.00 1.50
Total protein 60 g/l 60 83
Albumin 33 g/l 34 48
Total Bilirubin 18 umol/l 0 22
ALT (SGPT) 23 U/l 0 40
Alk. Phos 215 U/l 53 128
GGT 44 U/l 12 - 64
Questions:

1. What is wrong with this patient?


A: the patient has hypercalcaemia ( corrected Ca level= 3.28) and isolated
increased in ALP. It is likely that the patient has bone metastases in view of
her PHx of Ca breast.

Bone diseases Calcium Phosphate ALP


Osteoporosis N N N
Osteomalacia N/
Pagets disease N N
Bone metastases / N N/
Primary
hyperparathyroidism
Secondary N
hyperparathyroidism
Tertiary
hyperparathyrodism
2. How do you treat her hypercalcaemia?

Treatment depends on the severity of symptoms and the underlying cause.

Volume expansion and saline diuresis


o Volume depletion results from uncontrolled symptoms leading to
decreased intake and enhanced renal sodium loss. This tends to
exacerbate or perpetuate the hypercalcemia by increasing Na+
reabsorption in the thick ascending limb of the loop of Henle (TALH).
Thus, appropriate volume repletion with isotonic sodium chloride
solution is an effective short-term treatment for hypercalcemia.
o Once volume is restored, simultaneous administration of loop
diuretics blocks Na+ and calcium reabsorption in the TALH.
o Replacing ongoing sodium, potassium, chloride, and magnesium
losses is important if prolonged sodium chloride and loop diuretic
therapy is contemplated.
Inhibition of bone resorption
o Bisphosphonates inhibit osteoclastic bone resorption and are effective
in the treatment of hypercalcemia due to conditions causing increased
bone resorption and malignancy-related hypercalcemia.
o Pamidronate and etidronate can be given intravenously, while
risedronate and alendronate may be effective as oral therapy.
o Calcitonin can be given intramuscularly or subcutaneously, but it
becomes less effective after several days of use.
o Mithramycin blocks osteoclastic function and can be given for severe
malignancy-related hypercalcemia. It has significant hepatic, renal,
and marrow toxicity.
Dialysis: Peritoneal or hemodialysis against calcium-free or lower calcium
concentration dialysate solution is highly effective in lowering plasma
calcium levels.

SUMMARY: The first therapy for symptomatic hypercalcemia is volume repletion.


More severe cases require saline infusion with concomitant loop diuretics (eg,
furosemide) to increase calcium excretion and lower levels rapidly. Other therapies,
outlined below, are for longer-term management.

Clodronate (BONOFOS) can be given either PO at a dose 1600 - 3200mg/d or IV


300mg /d.

Pamidronate IV 30-90mg

Zoledronic acid is 100-850 times more potent than pamidronate and given as 4mg
IV over 15 minutes.
Data Interpretation, Practical HO Points and Surgical Therapeutics

12: 01/04/13 : Surgical Therapeutics - Answers

Patient 1

Mr.P a 70 years old man is scheduled for an anterior resection for Ca rectum. Write a
regime for bowel preparation for him.

Bowel prep:
Basic principles: always checked with your seniors about the bowel prep regime in
your department. Nowadays, majority of bowel prep regimes involve the use of
polyethylene glycol (Klean-prep, Golytely) or purgatives like Fleet Phospho-Soda

Golytely or Klean-prep:
1. Start the bowel prep at least 3 to 4 hours after last solid meal
2. Dissolve one sachet in 4l of water. Patient to take 250mls of the solution
every 10 minutes until 4l are consumed or the rectal effluent is clear. For
patients who are unable to take the solution orally, it is administered through
a nasogastric tube at a rate of 25mls/min
3. Patients are kept on fluid diet after starting of bowel prep
4. The first bowel movement should occur about one hour after the start of the
administration.

Fleet Phosphos Soda (FPS)


1. administer 45mls pf FPS 6pm the night before surgery
2. Fluid diet after starting FPS
3. Another 45mls of FPS 6am on the day of surgery

Contraindications for bowel prep:


1. pregnancy
2. any evidence of IO including gastric outlet obstruction
3. inflammatory bowel disease
4. bowel perforation
5. peritonitis
6. Body weight < 20kg

PROPHYLACTIC ANTIBIOTICS:

Write the type of antibiotics you will prescribed for the following:

1. Laparotomy for acute abdomen


2. Elective right inguinal hernia repair
3. Appendectomy for acute appendicitis
4. Elective laparoscopic cholecystectomy for gallstones
5. Anterior resection for Ca rectum
6. Total knee replacement
7. Hemithyroidectomy for a solitary nodule
8. Radical right mastectomy for ca breast
9. TURP
10. Craniotomy for brain tumour

Answer:

Prophylactic antibiotics

Usually 3 doses of antibiotics are given starting from the time of induction of anaesthesia.

Operation Organisms Antibiotics


Hepatobiliary G-ve & G+ve Aminoglycosides + 2nd generation cephalosporin
like cefuroxime
Colorectl surgery G ve + 2nd G cephalosporin + metrodinazole
anaerobes
Appendectomy G ve aminoglycosides
Vascular surgery G+ve esp Flucloxacillin + cephalosporin
staphylococcus
+ G -ve
Orthopaedic G+ & G-ve Flucloxacillin + cephalosporin
Neurosurgery G + & -ve 3rd generation cephalosporin
Urological G -ve 2nd ngeneration cephlosporin or quinolones
procedure

Clean surgery like inguinal hernia repair, thyroid and breast in healthy patients do not
require prophylactic antibiotics
Data Interpretation, Practical HO Points and Surgical Therapeutics

13: 08/04/13: Data Interpretation

Below are the arterial blood gases, taken at room air of 4 surgical patients:

pH pCO2 (kPa) pO2 (kPa) HCO3 BE


(mmol/l)
Patient 1 7.39 5.1 11.9 25.1 +1
Patient 2 7.33 8.77 7.8 37.5 +9.2
Patient 3 7.25 3.9 12.8 12.4 -14.3
Patient 4 7.51 5.0 13.3 33 -1

Normal values: pH 7.35-7.45


PCO2 4.3 6 kPa
PO2 10.5 14 kPa
HCO3 22 28 mmol/L
BE +/- 2

Patient 1:

A 45 years old alcoholic male admitted with epigastric pain and suspicious of having
acute pancreatitis.

Q: What is the abnormality of his blood gas?

Normal

Patient 2:

A 70 years old male, chronic smokers, admitted for an elective inguinal hernia repair. He
complained of having several years history of SOBOE and productive cough.

Q: What is the abnormality of his blood gas?


Q: What is the likely diagnosis ?
Respiratory Acidosis with metabolic compensation
Type I respiratory failure

Patient 3:

A 75 years old female is admitted with fever, colicky abdominal pain, abdominal
distension and vomiting for 5 days. Examination shows generalized tendernass of her
abdomen. AXR shows dilated small bowel. She had a history of right hemicolectomy for
Ca colon 4 years ago.

Q: What is the abnormality of her blood gas?


Q: From her history and examination, AXR and the result of the blood gas, what
complication might the patient have?

Metabolic acidosis with some degree of respiratory compensation


Bowel ischaemia secondary to stranguation

Patient 4

A 43 years old gentleman with severe epigastric pain and vomiting for one week. He has
a past history of peptic ulcer disease. Clinically he is dehydrated.

Q: Interpret his blood gas.


Q: What is likely diagnosis in this man ?

Metabolic alkalosis
Gastric outlet obstruction

Interpretation of ABGS

1. Look at the pH
a. Normal 7.35 7.45
b. Acidosis <7.35
c. Alkalosis > 7.45

2. Look at the PaCO2


a. High : Respiratory acidosis, then assess HCO3, if
i. High: respiratory acidosis with metabolic compensation or
predominant respiratory acidosis and co-existent metabolic
alkalosis
ii. Normal: uncompensated respiratory acidosis
iii. Low: mixed acidosis
b. Low : Respiratory alkalosis, then assess HCO, if
i. High: mixed alkalosis
ii. Normal: uncompensated respiratory alkalosis
iii. Low: Respiratory alkalosis With metabolic compensation or
predominant respiratory alkalosis with co-exixtent metabolic
acidosis

3. Look at the HCO3


a. High: Alkalosis
b. Low: Acisdosis
Data Interpretation, Practical HO Points and Surgical Therapeutics

14a: 15 April 2013 : Data Interpretation: Xrays 1 ANSWERS

1. Contrast CT abdomen of a 35 years old man with severe abdominal pain. What is the
diagnosis?

Acute necrotizing pancreatitis


CT shows that the pancreas is oedematous with air inside

2. Contrast abdominal CT of a 70 years old men with history of IHD with sudden
onset of abdominal and back pain. What is the diagnosis?

Leaking AAA
3. Plain CT brain. What is the diagnosis?

Subdural haematoma ( concave )

4. Another pain CT brain. What is the diagnosis?

Epidural haematoma (convex)

5. A 70 years old lady with change of bowel habits for 3 months. Her CEA is elevated.
Based on the CT abdomen, what is the like diagnosis?

Ca colon with hepatic secondaries


Data Interpretation, Practical HO Points and Surgical Therapeutics

15 : 22/04/13 Data Interpretation: Xrays 2

6. Mammogram of a 50 years old lady. What is the diagnosis?

7. A 56 years old man with obstructive jaundice. Based on the CT abdomen, what is the
diagnosis?

8. A 56 years old man with microscopic haematuria. What is the diagnosis?


9. A 35 years old man with severe right loin pain. What does his plain CT abdomen
show?

10. A 70 years old gentleman with lower urinary tract symptoms a d boe pain. What
type of investigation is this? What is the likely diagnosis?