isurg

Communication

COPD + perforated viscus + ARF + metabolic acidosis.

Prep station, 73 y old brought by daughter. Hx of COPD on steroids / relievers, seen in ED (Emergency) for being "under the weather", unremarkable until ate some food and suddenly had pain in abdomen. Assessment revealed suspected perforated viscus. Urgent Laparotomy was required.

Call ICU Registrar for Preoperative advice and request for ITU bed. (Remember to write down his advice because he will make you repeat them at the end). Pick up the phone and start speaking.

Introduction

• Introduce yourself
• Summary of the question you are calling about.
• SBAR approach

Escalation

Hello, I am Dr Z, one of the general surgery SHOs working with Mr X, can I please confirm that I am speaking with the ITU registrar.

I am calling you from Surgical ward A regarding an acutely unwell patient with query bowel perforation/pancreatitis who needs an ITU.

Mr A is a 73-year old, presented off legs with sudden onset abdominal pain, peritonitic abdomen, hypotensive and tachycardiac. His most recent results show lactic acidosis, hypokalaemia of 2.1, raised amylase and AKI. His chest XR shows air under the diaphragm, and the U?S shows free intra-abdominal fluid.

He has a background of COPD and is on salbutamol and steroids.

Due to his current state, he is likely to need laparotomy for the bowel perforation with I ITU bed pre/post and I was wondering if you are able to come assess and let me know about the availability of beds at the moment.

spotter7.html

STEM:
You are the general surgical SHO on call in a district general hospital with no gastroenterology service and have been asked to attend A&E to review a patient who had profuse haematemesis and was becoming haemodynamically unstable.

The patient is known to consume excessive amounts of alcohol and make use of other substances. On arrival in A&E, you find a patient with a BP of 100/70, HR 120, RR 30, Temperature 37.4°C and SpO₂ of 91%.

What are your differentials?

Spoiler

Bleeding oesophageal varices due to portal HTN caused by cirrhotic liver
Mallory–Weiss tear
Boerhaave's syndrome
Bleeding peptic ulcer

What are your concerns regarding this patient?

Spoiler

Ongoing bleeding resulting in hypovolaemia, as the patient has cirrhosis and clotting abnormalities.
Likelihood of complications such as:
Hepatic encephalopathy
AKI
Hepatorenal syndrome

How will you manage this patient?

Spoiler

I will treat the patient according to CCrISP protocol and admit this patient to HDU.
Active resuscitation, reduction of portal venous pressure and measures to avoid hepatic encephalopathy:
High flow oxygen
Venous access
Immediate cross-matching, 2–4 units of blood after discussing with haematologists
Fresh blood transfusion, FFP, platelets after consultation with haematologist
Close monitoring (pulse, blood pressure, hourly urine output, central venous pressure)
Assessment of coagulation status
Prothrombin time
Platelet count

Control of bleeding

Spoiler

Tamponade (Minnesota tube) if bleeding uncontrolled
Pharmacological measures (e.g. vasopressin / octreotide)
Urgent endoscopy. Banding or injection sclerotherapy

checklist3.html

Pain since this morning. LMP 3 weeks ago

Introduce yourself and confirm the patient’s name and age.

Confirm the patient is comfortable and not in severe pain.

Ask an open question about the presenting complaint (e.g. “What brought you in today?”).

Ask the patient to point to the site of the abdominal pain.

Ask about onset (sudden or gradual).

Ask about the character of the pain (sharp, dull, cramping, burning).

Ask about radiation of pain (e.g. to back, groin, shoulder).

Ask about the severity of pain (0–10 scale).

Ask about the timing and duration (constant or intermittent).

Ask about exacerbating or relieving factors (movement, food, position, analgesia).

Ask about associated gastrointestinal symptoms (nausea, vomiting, diarrhoea, constipation, bloating).

Ask about red flag symptoms (fever, weight loss, rectal bleeding, syncope).

Ask about urinary symptoms (dysuria, frequency, haematuria).

Ask about gynaecological history (last menstrual period, cycle regularity).

Ask about possibility of pregnancy and contraception use.

Ask about vaginal bleeding or discharge.

Ask about past medical and surgical history, especially previous abdominal or gynaecological surgery.

Ask about drug history and allergies, including analgesics and contraceptive medications.

Ask about family history, particularly gastrointestinal or gynaecological disease.

Ask about social history and close (smoking, alcohol, occupation; summarise and ask if anything has

Follow-up Question 2 (2 marks):
"This patient works in a dye manufacturing factory. Name two specific chemical groups that are occupational carcinogens for bladder cancer, and explain why smoking significantly increases his risk."**

Two chemical groups (1 mark):

Spoiler

Aromatic amines (0.5 marks)
Polycyclic aromatic hydrocarbons/PAHs (0.5 marks)
Acceptable alternatives: benzidine, 2-naphthylamine, 4-aminobiphenyl
Smoking mechanism (1 mark):
Carcinogenic metabolites concentrated and excreted in urine, causing direct contact with urothelium/bladder lining (1 mark)

LAY OBSERVER ASSESSMENT (4 MARKS)
COMMUNICATION SKILLS (2 MARKS)
Introduction and Rapport (1 mark)
Introduces self appropriately and establishes good rapport with patient
Clear Communication (1 mark)
Uses appropriate language, avoids excessive medical jargon, checks understanding

PROFESSIONALISM (2 MARKS)
Empathy and Sensitivity (1 mark)
Shows appropriate concern for patient's symptoms and anxiety about potential diagnosis

Structure and Time Management (1 mark)

Maintains good structure throughout consultation and uses time effectively

KEY TEACHING POINTS
Painless visible haematuria in a male >50 years is bladder cancer until proven otherwise
Smoking is the most significant modifiable risk factor for bladder cancer
Occupational exposure to aromatic amines (dye industry) is a well-established risk factor
Urgent 2-week wait referral criteria are met in this case
Constitutional symptoms may indicate advanced disease

COMMON CANDIDATE ERRORS

Failing to quantify smoking history adequately
Not exploring occupational exposure risks
Inadequate assessment of constitutional symptoms
Poor time management leading to incomplete history
Not demonstrating understanding of red flag symptoms

1. What are the common causes of gastric outlet obstruction in adults?

Spoiler

The causes can be divided into benign and malignant.
Benign
Peptic ulcer disease causing pyloric stenosis
Chronic pancreatitis
Caustic ingestion
Post-surgical strictures
Crohn’s disease
Malignant
Distal gastric cancer (most common modern cause)
Pancreatic head cancer
Duodenal carcinoma
Periampullary tumours
Historically peptic ulcer disease was the commonest cause, but malignancy is now more common.

2. Why does gastric outlet obstruction cause vomiting of undigested food?

Spoiler

The obstruction occurs at the pylorus or proximal duodenum, preventing gastric emptying.
Food therefore remains in the stomach for prolonged periods and is vomited before reaching the small intestine, so it appears undigested.

3. What electrolyte and acid–base abnormalities are classically seen?

Spoiler

The classical abnormality is:
Hypochloraemic
Hypokalaemic
Metabolic alkalosis
Often associated with hyponatraemia and volume depletion.

4. Why does vomiting lead to metabolic alkalosis?

Spoiler

Gastric secretions contain hydrochloric acid (HCl).
Vomiting causes loss of:
Hydrogen ions
Chloride ions
Loss of hydrogen ions leads to metabolic alkalosis, and loss of chloride contributes to hypochloraemia, which also impairs renal bicarbonate excretion and worsens the alkalosis.

5. Why does hypokalaemia occur in gastric outlet obstruction?

Spoiler

Hypokalaemia occurs due to:
Renal potassium loss from activation of the renin–angiotensin–aldosterone system due to dehydration.
Hydrogen–potassium exchange in the kidney during metabolic alkalosis, where potassium is excreted to retain hydrogen ions.

6. What clinical signs might you find on examination?

Spoiler

Possible signs include:
Epigastric distension
Succussion splash (if stomach contains retained fluid)
Visible gastric peristalsis
Signs of dehydration (tachycardia, hypotension)
Possible weight loss if chronic

7. What investigations would you perform to confirm the diagnosis?

Spoiler

Investigations include:
Blood tests: FBC, U&E, LFTs, ABG
Nasogastric aspiration (large residual volume)
Upper GI endoscopy (OGD) – confirms obstruction and allows biopsy
CT abdomen – helps identify malignancy or extrinsic compression
OGD is the key diagnostic test.

8. How would you manage this patient initially?

Spoiler

Initial management is resuscitation and decompression:
Nil by mouth
Nasogastric tube for gastric decompression
IV fluids to correct dehydration
Correct electrolyte abnormalities
IV proton pump inhibitor
Arrange urgent endoscopy
Definitive treatment depends on the cause (e.g., endoscopic dilation, surgery, or oncological treatment).

Stations

1. Chest Drain Insertion
2. Blood Culture
3. Prepping + Draping
4. Scrubbing
5. Removal of a Skin Lesion (1)
6. Removal of a Skin Lesion (2)
7. Catheterisation
8. Incision + Drainage
9. Ordering a List (1)
10. Ordering a List (2)
11. Surgical Principles
12. Pre-operative Management
13. Wound Debridement

Link: https://drive.google.com/file/d/16I0ieZxZrqM_qC-Ec_DWPYWrY_dbefYj/view?usp=sharing

https://drive.google.com/file/d/13BSA5vPEBL1K8tUammuFnYImChg2HCbV/view?usp=sharing
https://drive.google.com/file/d/1xq-WFQx4Qu4ndB8TRoEM3vPfg5T6UYmk/view?usp=sharing
https://drive.google.com/file/d/1HgR5e7u-mKZyjjYwk9OEUG8xuECi7aT_/view?usp=sharing
https://drive.google.com/file/d/170D_EHE4IPxlU_RQxKMdBOEers6qSxb5/view?usp=sharing
https://drive.google.com/file/d/1j10G4nUi_vLguq2T8EPNIEex1wt-ZprY/view?usp=sharing

1: "Anterior circumflex humeral artery and musculocutaneous nerve",
2: "Axillary lymph nodes (enlarged)",
3: "Axillary vein",
4: "Branches of medial pectoral nerve",
5: "Branches of lateral pectoral nerve",
6: "Cephalic vein",
7: "Clavicle",
8: "Coracobrachialis",
9: "Coracoid process and acromial branch of thoracoacromial artery",
10: "Deltoid",
11: "First rib",
12: "Inferior belly of omohyoid (displaced upwards)",
13: "Intercostobrachial nerve",
14: "Internal jugular vein",
15: "Lateral thoracic artery",
16: "Long thoracic nerve (to serratus anterior)",
17: "Median nerve",
18: "Nerve to sternothyroid",
19: "Pectoral branch of thoracoacromial artery",
20: "Pectoralis major",
21: "Pectoralis minor",
22: "Phrenic nerve overlying scalenus anterior",
23: "Scalenus medius",
24: "Short head of biceps",
25: "Sternohyoid",
26: "Sternothyroid",
27: "Subclavian vein",
28: "Subclavius",
29: "Subscapularis",
30: "Suprascapular nerve",
31: "Tendon of long head of biceps",
32: "Trapezius",
33: "Trunks of brachial plexus"