Tiêu đề SURGICAL BASED PBQ PRO II COMPILATION ✅

SURGICAL BASED BATCH 9 1 S Acute Limb Ischaemia A 35 years old with underlying Rheumatic Heart Disease and Atrial Fibrillation come with a history of sudden severe pain of left lower limb, cold and numbness. On examination, absent of pulse over left popliteal artery and left dorsalis pedis. Other pulses were palpable. NO ANSWER SOURCE A Most likely diagnosis (1m) ● Acute limb ischemia of left lower limb secondary to cardiac emboli Points for: ❖ clinical features: sudden severe pain, paraesthesia, perishingly cold, pulselessness (other features : pallor & paralysis) ❖ source of emboli from atrial fibrillation & underlying rheumatic heart disease ❖ no previous history of claudication Principle & practice of Surgery , 7 th Ed pages 389 -391 Oxford handbook of clinical surgery 4 th Ed pages 642- 643 Bailey & Love’s Short Practice of Surgery 27th edition pages 954 Med bear pages 198 - 200 B Risk factors enquiry from the above (2m) ● rheumatic heart disease ● atrial fibrillation C Specific diagnostic investigation to confirm the diagnosis (1m) ● CT Angiography - confirm an occlusion, level of occlusion & cause of occlusion (thrombotic/emboli)

2 S Cholangitis A 57 years old man presented with progressive jaundice one week associated with tea coloured urine and pale stool. Had a similar episode previously and was admitted to the surgical ward. No constitutional symptoms, no trauma On physical examination, pale, dehydrated, febrile. Liver palpable 2 finger breadth below costal margin and tender. Ultrasound done revealed dilated cbd and intrahepatic duct. Filling defect distal common bile duct probably calculi NO ANSWER SOURCE A Provisional diagnosis ● ascending cholangitis secondary to choledocholithiasis Oxford handbook of clinical surgery 4 th Ed pages 312 - 313, 318 - 319 Clinical key : choledocholithiasis & ascending cholangitis B 4 possible causes of jaundice in this patient ● biliary stricture secondary to gallstone/post-surgical ● periampullary tumor : cancer head of pancreas, cholangiocarcinoma, carcinoma ampulla of Vater ● hepatocellular carcinoma ● hepatitis ● primary biliary cirrhosis/ primary biliary cholangitis (PBC) C 2 blood investigation and reason ● full blood count : to look for evidence of infection - high white cell count ● liver function test : confirm obstructive jaundice - increase conjugated bilirubin/ ALP/ GGT ● BUSEC : dehydration & electrolyte imbalance ● blood C&S : isolation of causative agents ● clotting study : coagulopathy (vitamin K) ● amylase : pancreatitis
D 2 imaging modalities and reason ● Ultrasound HBS : look for common bile duct & intrahepatic duct dilation, presence of gallstone in common bile duct and gallbladder, liver consistency ● ERCP : diagnostic & therapeutic procedure ● Magnetic resonance cholangiopancreatography (MRCP) : non invasive, avoid radiation exposure ● Endoscopic ultrasound (EUS) E 2 treatment modalities for this condition ● Endoscopic retrograde cholangiopancreatography (ERCP) - endoscopic sphincterotomy, cbd stone extraction or biliary stenting ● Percutaneous transhepatic biliary drainage (PTBD)/ percutaneous transhepatic cholangiography (PTC) ● Surgical drainage F 2 complications of this condition if not treated early complication of choledocholithiasis ● ascending cholangitis ● acute pancreatitis complication acute cholangitis ● sepsis, shock, multiple organ failure ● coagulopathy ● liver abscess