Tiêu đề Excellence ASSCC.pdf ✅

Excellence for MRCS OSCE By Dr. Rifat & Dr. Hasnat 1 APPLIED SURGICAL SKILLS AND CRITICAL CARE (ASSCC) TABLE OF CONTENTS S/L No Topic Page No 01 Esophageal varices and haematemesis 02 02 Perforated PUD 07 03 Gastric outlet obstruction 10 04 Obstructive jaundice 13 05 Gallbladder stone 16 06 Diverticular abscess and septic shock 19 07 Bloody diarrhea 22 08 Intestinal obstruction 24 09 Enterocutaneous fistula 27 10 Sigmoid volvulus 29 11 Postoperative fluid management 32 12 Burn and ARDS 36 13 Acute pancreatitis 42 14 Hypothermia and ruptured AAA 48 15 Postoperative pain management 52 16 Epidural analgesia 57 17 TAP block and local anaesthetics 59 18 Malignant Hyperthermia 61 19 Nutrition and surgical feeding options 62 20 Head injury (Extradural haematoma) 67 21 Subdural haematoma 72 22 Polytrauma with liver tear 74 23 Polytrauma with cervical spine fracture 78 24 Polytrauma with lumbar spine fracture 83 25 Polytrauma with pelvic fracture 86 26 Crush injury and compartment syndrome 89 27 Steroids 92 28 Calcium homeostasis 95 29 Diabetes mellitus 98 30 Hypothyroidism 100 31 Hyperthyroidism 103 32 TURP syndrome 106 33 Post-tonsillectomy bleeding 109 34 Post-thyroidectomy bleeding 111 35 Pulmonary embolism 116 36 SIADH and hyponatraemtia 119 37 Hypotension in a pregnant lady 122 38 Atrial fibrillation and ruptured viscus 125 39 Preoperative aortic stenosis 128 40 Pulmonary edema 132 41 Pneumothorax and CV line insertion 134 42 Renal failure and hyperkalaemia 137 43 Respiratory failure and respiratory acidosis 140

Excellence for MRCS OSCE By Dr. Rifat & Dr. Hasnat 3 New lab findings with low Hb and elevated FDP. What is your diagnosis? DIC What is the mechanism of ascites formation in this case? ê Obstructed lymphatic drainage: ↓ ability of the lymphatic system to drain the peritoneal space ê Increased formation of hepatic and splanchnic lymph ê Hypoalbuminemia due to liver cirrhosis and liver failure ê ↑ RAAS → salt and water retention → ↑ blood volume: the extra fluid will pass from the mesenteric vessels to peritoneal cavity due to: → Increased hydrostatic pressure → Increased vascular wall permeability. What could be the cause of thrombocytopenia in this case? ê Hypersplenism ê DIC ê Hemodilution ê Chronic low platelet production ê Decreased hepatic production of thrombopoietin What are the indications for platelet transfusion? ê Ongoing coagulopathy with continued bleeding ê As a part of massive blood transfusion, after consultation with hematologists Which varices are usually bleeding? Varices in the submucosa of the lower esophagus are the common source of major bleeding. Blood findings in alcoholic patients? Features of FBC to suggest ETOH abuse? ê Low platelets due to toxic effect on bone marrow, impaired hematopoiesis (also affect RBCs and WBCs) ê Raised mean corpuscular volume (MCV), anemia (megaloblastic and hemolytic) ê Elevated liver enzymes (Increased PT and INR, GGT, AST, ALT and ferritin) Explain the pathogenesis of portal HTN in chronic alcoholism. Pathogenesis of portal HTN in chronic alcoholism: ê Cirrhosis resulting from chronic liver disease and is characterized by liver cell damage, fibrosis and nodular regeneration. The fibrosis obstructs portal venous return and portal hypertension develops. ê In cirrhosis, portal vascular resistance is increased. As we know, Pressure = Flow x Resistance. So proportionately pressure is increased. Sites of portosystemic anastomosis
Excellence for MRCS OSCE By Dr. Rifat & Dr. Hasnat 4 Other than drugs, what are the surgical treatment options / Therapeutic maneuvers to reduce portal venous pressure? ê Portosystemic shunts (lienorenal shunts - TIPSS: a metal stent is inserted via the trans jugular route using a guidewire passed through the hepatic vein to the intrahepatic branches of the portal vein.) ê Stapled esophageal transection: The gastric vein and short gastric veins are ligated, and the distal esophagus is transected and re-anastomose just above the cardia using a stapling gun. ê Orthotopic liver transplantation (OLT) - Treatment of choice in patients with advanced liver disease. What is TIPSS? The Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure is a medical treatment for complications related to liver disease. 1. Purpose: TIPS is used to relieve high blood pressure in the portal vein (called portal hypertension), which often occurs in the context of liver cirrhosis. 2. Mechanism: During the TIPS procedure, a radiologist inserts a stent through a jugular vein in the neck and directs it into the liver. The stent creates a small passageway inside the liver, allowing blood to flow directly from the portal vein into the hepatic vein. This bypasses the liver and reduces pressure in the portal system. What are the indications of TIPSS? ê Ascites: When fluid accumulates in the abdomen (ascites) and cannot be managed with dietary sodium restriction and diuretics, TIPS may be considered. It can also help with a condition called hepatic hydrothorax, where ascites crosses the diaphragm muscle and fills the space around the lung. ê Bleeding Varices: TIPSS is often needed when bleeding from swollen veins (varices) in the esophagus, stomach, rectum, or elsewhere cannot be controlled with endoscopic treatments. How does alcohol cause liver cirrhosis? ê Changes in lipid metabolism ê Cell injury caused by reactive oxygen species and cytokines. ê These induce inflammation and causes liver cell damage, fibrosis and nodular regeneration. Over time, this process turns normal liver into a cirrhotic liver. What is the cause of confusion in this patient? Hepatic encephalopathy What are the hepatic changes as a consequence of excessive alcohol consumption? ê Hepatic steatosis (Fatty changes): Enhanced lipid synthesis à ̄ hepatic lipid metabolism à ̄ export of VLDL à accumulation within hepatocytes à Converting the liver from a lipid-burning to a lipid-storing organ. ê Steatohepatitis (Alcoholic hepatitis with liver cell damage): Ballooning degeneration of Hepatocytes with infiltration of neutrophils and macrophages and fibrosis are characteristic pathologic findings indicative of hepatitis Release of ROS and cytokines (TNF) ê Hepatic fibrosis: Hepatic stellate cells secrete copious amounts of the scar-forming extracellular matrix proteins which characterize fibrosis, Fibrosis is a transient and reversible. ê Hepatic Cirrhosis: Formation of regenerative nodules of hepatic parenchyma surrounded by fibrous septa. that severely compromises the liver’s vascular architecture ê Hepatocellular carcinoma: Chronic alcohol consumption interferes with several host anti-tumor mechanisms, thereby facilitating hepatocyte proliferation and tumorigenesis.