Revision [1] A 60-year-old man presents with 3 months’ duration of pain in right leg on walking. How would you elicit further details in his history?

He experiences pain in the Rt thight and calf after walking about 100 metres but this resolves after a short rest about 2 to 3 minutes.He has been smoking 30 cigarettes a day for last 15 years. He has type II diabetes and hypertension, but no angina or transient ischaemic attacks, no story suggestive of previous myocardial infarct or cerebrovascular accident. What relevant physical signs would you look for?

On examination, his pulse rate is 82/min and regular rhythm, BP is 160/90 mmHg. The Rt leg is colder than the Lt, and has scanty of hair and thin shiny skin. In the Rt leg, all peripheral pulses are not palpable. The Lt femoral pulse is normal to palpation but no distal pulses are palpable below this level. What is the most likely clinical diagnosis? What is the most important, non-invasive investigation to assess the severity for this patient?

Doppler examination reveals audible signals in both leg arteries but softer in the Rt. The ankle brachial pressure index (ABPI) is 0.6 on the Rt and 0.8 on the Lt. How can ABPI assess the severity of the disease clinically? How would you interpret on the clinical findings along with the mentioned ABPI? What other investigations would you suggest in this patient? (with your justification) The duplex arterial scan shows a short stenosis (70% narrowing) in the Rt common iliac artery and a further short occlusion in the Lt superficial femoral artery.Fasting sugar 130mg/dl; Lipid profile: S cholesterol 280mg/dl, S triglyceride 240mg/dl, HDL 120mg/dl, LDL 220mg/dl; ECG-Lt bundle branch block; CXR normal. Based on his history, clinical findings and the above results, what treatment will you suggest for him? The patient is instructed to carry out a regular exercise within his limitations. He is also strongly advised to stop smoking. His diabetic control and hypertension treatment are reviewed and monitored closely. Statins are commenced to treat hyperlipidaemia.

Why is any interventional treatment not considered in this condition? What are the indications to consider definitive limb revascularization procedures? Six months later, the patient is admitted urgently with discoloration of his Rt big toe and pain in the Rt foot which has kept him awake at night for 1 week. He has not stopped smoking. What is the next step of management?

REVISION- 2

A 68-year-old lady had an anterior resection for a rectal tumor 5 days ago. Her postoperative recovery has been unremarkable. On 6th post operative day, she develops low grade fever. You are asked to review the patient.Q1. What are the possible causes of postoperative fever in this lady?Q2. What are the relevant questions and physical findings that you must elicit in order to help you to narrow your differential diagnosis?

Upon enquiry, she complains of pain and swelling of the left leg. There is no history of trauma to the leg. On examination, her temperature is 38’C, pulse 99/min, O2 saturation 97%, chest is clear, abdomen is soft and non-tender, left calf feels warm, swollen and tender, the measurement of the calves shows a 6 cm difference in circumference. The pulses of lower limbs are normal.Q3. What is the most likely diagnosis? What are the differentials?Q4. What risks factors are associated with this condition in this patient? Q5. What relevant investigations would you do in this patient and justify your answer?

Hb 11.5g/dl, total WBC 16.7x10’9/L, Platelets 360x10’9/L, Na 143mmol/L, K 4.6mmol/L, Urea 9.5mmol/L, Creatinine 71umol/L, C-reactive protein 100 mg/LThe D-dimer assay is positive.An urgent duplex scan shows an adherent clot in the left femoral vein. Q5. How useful is a D-dimer assay in the diagnosis of DVT?Q6. How should this condition be treated? Q7.Could her DVT be predicted and prevented?How would you do DVT prophylaxis / thromboprophylaxis?

Q8. What are the long term sequelae of this condition? Q9. How would you detect and treat the pulmonary embolism?

REVISION [3]

A 49 year old male presents to an A&E with a 2-hour history of severe upper abdominal pain associated with persistent nausea and vomiting, that began after returning home from a party.Q1. List the differential diagnosis of acute upper abdominal pain associated with nausea and vomiting. (List the causes of acute abdominal pain.)Q2. What questions would you like to ask him? (with justification)

He describes the pain is sudden onset, located in the mid-epigastrium, constant, knife-like in character. Approximately 1 hour after onset of pain, he vomited a large

amount of undigested food, but the emesis did not relieve his pain.

Q3. What important histories are missing?

Pain radiates through to the back. It is not made worse by movement but he does seem more comfortable by leaning forward. He consumed pizza and eight beers at party.He denies any past surgical procedures but he has a history of peptic ulcer disease treated medically. He consumes alcohol 2 to 3 mixed drinks per day and 8 to 12 beers each weekend. Q4.What relevant physical findings would you look for?

Physical examination reveals he is in acute distress, temperature is 38.5’C, pulse 110/min,BP 96/60 mmHg without orthostatic changes, and respiratory rate 28/min with signs of dehydrationand breath smelling of alcohol.Abdomen is mildly distended. There is involuntary guarding and tenderness particularly in the epigastrium with rebound and no palpable mass. Bowel sounds are 2/min.On chest examination, diminished breath sounds at lower zone of Lt lung field and coarse crackles above it.Q5. What physical finding/s you want to know more to support P/Dx and exclude D/Dx? He has tinge of jaundice in sclera.Liver dullness is in 5th intercostal space at right mid clavicular line. Minimal fluid in the abdomen is demonstrated. Q6. What is the most likely diagnosis? (with reasons)Q7. Mention the specific investigations you like to do for the confirmation of the diagnosis (and to rule out D/Dx).

Q8. How would you rule out the peptic ulcer perforation?

Q9. How would you assess the severity of this patient’s disease? (What Laboratory and diagnostic studies do you need initially in acute pancreatitis?)Chest X-ray and Abdominal X-ray are done.Q10. Describe the findings in this chest X-ray.Q11. Describe the findings in these abdominal X-rays. Chest x-ray reveals obliteration of left costo-phrenic angle and no evidence of free gas under diaphragm. Abdominal x-ray shows:

-air in duodenal loop -sentinel loop (local ileus) -the lower abdomen shows “ground glass ” appearance. - dilated transverse colon, with colon “ cut off ” sign

Q12. In view of your diagnosis, explain these radiological features.

Laboratory results are as follows:

WBC 18,000/mm3, Hb 14.2 g/dl, Hct 48%,Serum amylase 4280 IU/L, Creatinine 140umol/L, BUN 25 mmol/L, electrolytes within normal limits, Glucose 13mmol/L, total bilirubin 3.2 mg/dl, AST 380 U/L , ALT 435 U/L, LDH 300 U/L, Albumin 35 g/L,

Q13. what significant lab data are missing to do severity assessment?

Ca 1.8 mmol/L, ABG studies (room air) pH 7.25, PaCO2 40mmHg, HCO3 16 meq/L, PaO2 60mmHg. He was admitted in ICU and resuscitation measures were started with central vein infusion of fluid, naso-gastric aspiration and monitoring of parameters. Bladder catheterization revealed oliguria.Q14. Describe the clinical status along with above parameters. Q15. How can his present metabolic abnormalities be rectified?

Q16. Name the scoring system that predicts the severity of acute pancreatitis.

Q17. What are the etiologic factors involved in acute pancreatitis? What is/are the possible etiology of acute pancreatitis in this patient?

Q18. How would you explain the hypotension, pleural effusion and jaundice in case of acute pancreatitis?

Q19. What is the pathophysiology of the development of adult respiratory distress syndrome (ARDS) in acute pancreatitis?

Q20. What are the other possible clinical manifestations in acute pancreatitis?

Q21. If this case proves to be severe, what early complications (first 3 days) and late complications(7-10 days) might develop?

Q22. What are other diagnostic tools in acute pancreatitis?

With 5 days of intensive medical treatment, the patient Apache scoring deteriorated and there was elevation of C-reactive protein levels to > 320mg/l.

Q23. What investigation can differentiate necrotizing from non-necrotizing pancreatitis? What abnormalities will be seen in necrotising pancreatitis by that investigation? Outline the principle of treatment of infective necrosis of the pancreas.

Q24. What is the role of ERCP in acute pancreatitis?

Q25. Give the outline of treatment for acute pancreatitis.

Q26. Is there a role for surgery in acute pancreatitis? What are the indications for surgery?

Q27. How do you understand the pseudocyst of pancreas and its management?

REVISION (4) A 52 yr old woman presents with several episodes of bright red blood per rectum over the past 8 weeks. Q1. List the common causes of bleeding per rectum in adult and in older-aged patients.Q2. What questions would you ask this patient? (Give your answer with justification.)Q3. What are the characters of bleeding (color of blood and its relation with the faeces, etc.) according to the causes of bleeding PR?

Upon inquiry about the character of blood, it is bright red and seen on the surface of the faeces.She also describes urgency with tenesmus as well as feelings of incomplete evacuation.There are no other complaints and family history is negative.Q4. What physical examination findings would you search for (with justification)?

Abdominal examination is normal. Rectal examination reveals ulcerated lesion at 7 cm from the anal verge on posterior rectal wall. Q5. What is your provisional diagnosis? Give the reasons to support your P/Dx. Q6. What are the next steps in evaluation and management?

Biopsy is taken and histology reveals adenocarcinoma of rectum. CT scan shows rectal wall thickening in distal third of rectum with irregularity of the mesorectal fat, otherwise unremarkable and liver is normal. Chest X-ray and blood works are normal. An endoanal ultrasound is performed. This demonstrates transmural extension with two hypo-echoic nodes in meso-rectum suspicious for metastases.

Q7. What important information in missing which is needed to consider the type of operation? Q8. What are the modes of spread in colorectal carcinoma? What are the staging systems? What is the stage in this patient?

Q9. What are the modalities of treatment in rectal carcinoma? What are the factors influencing the decision of type of surgery in carcinoma at lower rectum? What type of surgery would you choose in this patient?

Q10. If you decide to do abdominoperineal resection (APR), how would you explain the patient before obtaining informed consent? And what other procedure does this patient need before elective operation of APR?

Q11. How would you plan follow-up management in this patient? Q12. What are the roles of CEA in colorectal carcinoma?

REVISION [5]

۞ A 60 year-old male patient presents with a three-month history of difficulty in swallowing.Q1. List the common causes of dysphagia?Q2. What are your preliminary D/Dx in this patient?Q3. What questions would you ask this patient?

۞ On taking a history, he points out at the mid-sternum where he feels the foods are stuck. Initially only solid foods were getting stuck but now he has trouble swallowing even liquids. He also gives a previous history of dyspepsia and heartburn in last 5 years, which was associated with water brash (sour taste) and sometimes chest pain radiating up to the jaw and down to the arms. He smokes 20 cigarettes per day and is a heavy social alcohol drinker. He was overweight and now he has lost 15 kilos in 3 months.He looks pale otherwise physical examination is unremarkable.

Q4. What is the likely Dx? Give the reasons to support your Dx. Q5. How would you proceed with the work-up?۞ The complete work-up points to a carcinoma in the distal esophagus with no evidence of obvious metastasis.

Q6. What is the aetiology of carcinoma esophagus?Q7. What is the possible aetiology in this patient and likely cell type for carcinoma in this location?Q8. If you met this patient 3 year earlier (i.e. when he was having dyspepsia, heart burn and water- brash only), what other investigations would you recommend?

Q9. What are the factors preventing gastro-esophageal reflux in normal individual? What are the complications of GORD? What are the principles of treatment for GORD?

Q10. What is Barret’s esophagus? Describe diagnostic plan work-up and treatment for Barret’s esophagus?

Q11. What are the possible cell types of carcinoma according to the site of esophagus?Q12. What are the modes of spread of carcinoma esophagus? Describe the lymphatic spread.Q13. What are the therapeutic options available for esophageal carcinoma?Q14. What is the prognosis of carcinoma esophagus?

REVISION [6]

A 58-year old woman presents with a complaint of jaundice for 2 weeks and epigastric discomfort for 1 week.Q1. What questions would you ask her?

Upon inquiry, jaundice was initially noticed in her eyes by her husband 2 wks ago. It gradually increased last week and is now spreading to skin all over the body.

She has no specific pain but since last week she has noted post prandial epigastric discomfort which has not responded to antacids. Recently she has noticed that her urine has changed to the color of coca-cola. She also noted that stool color is getting pale and also developed generalized itchiness since last week.

She has lost 10 Kg over the past 3 months. She recently developed diabetes and is presently on insulin. Other than that, her past medical and surgical histories are non-contributory.She smokes one pack of cigarettes a day but does not consume alcohol.

Q2. What physical signs would you expect in this patient? Physical examination reveals an obviously icteric woman with slight pallor. Her temperature and vital signs are within normal limits.Abdomen is soft and non-tender. A globular mass is palpable in the right upper quadrant of abdomen which is not tender.Rectal examination reveals the presence of clay colored stool.

Q3. What is the most likely diagnosis?

Q4. What are the differential diagnoses of jaundice in this patient?

Q6. What are the causes of obstructive jaundice?

Q7. Explain the reasons for the change in urine and stool color, generalized itchiness, and palpable gallbladder in this patient. (Courvoisier’s Law)

Q 8. How would you confirm the diagnosis in this patient? (What further diagnostic work-up would you do for this patient?) (State one investigation that can confirm the diagnosis.) USG reveals 3.5cm mass in head of pancreas with dilated common bile duct and dilated gall bladder with no biliary stones. No free fluid seen in peritoneal cavity.

Q 9. What investigations would you order next?

Contrast-enhanced CT shows 3.5 cm mass in pancreatic head without vascular invasion and no enlarged lymph node. No evidence of metastasis to liver.

Q10. What diagnostic procedure can be done together with CT scan?

Q11. List the other investigations you would like to do?

Liver function test reveals total bilirubin 305 umol/l, direct bilirubin 273 umol/l, ALT 55 U/L, Alkaline phosphatase 364 U/L

Q12. Interpret the LFT results. Q13. What is the role of ERCP in this case?

Q14. What are the treatment priorities and options for this case?Q15. Discuss the management of a patient with localized pancreatic cancer and a patient with metastatic pancreatic cancer.

Q 16. What is prognosis of carcinoma pancreas?