Last Minute CPS

8/12/2019 Last Minute CPS

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1PRINCIPLES OF

SURGERY-IN-GENERAL


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Principles of surgery-in-general questions 3

1 THEME: PREOPERATIVE FITNESS FOR SURGERY 1

A Electrocardiogram (ECG) aloneB ECG and urea and electrolytes (U&E)C ECG, U&E, and full blood count (FBC)D FBC, ECG, U&E and chest X-rayE FBC, ECG, U&E, chest X-ray and lung function testsF FBC and U&EsG No investigation requiredH Urea and electrolytes alone

From the list above pick the single most appropriate answer listing theobligatory tests required for the following clinical scenarios. The items may beused once, more than once or not at all.

1 A 4-year-old boy undergoing an elective repair of a ventriculoseptal defect, American Society of Anaesthesiologists (ASA) grade 1.

2 A 69-year-old woman booked for an elective total hip replacement with apast medical history of left ventricular failure, limiting her exercise toleranceto 180 metres (200 yards).

3 A 9-year-old boy with moderate asthma undergoing an elective tonsillec-tomy.

Q

PERIOPERATIVE CARE


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4 Principles of surgery-in-general answers

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1 PREOPERATIVE FITNESS FOR SURGERY 1

1** D FBC, ECG, U&E and chest X-ray

2 C ECG, U&E and FBC

3 G No investigations required

See ERN MRCS Book 1, Chapter 6, section 1 and the National Institute for Health and Clinical Excellence (NICE) guidelines CG3 Preoperative

tests (www.nice.org.uk/page.aspx?o=73376). All patients undergoing cardiovascular surgery require FBC, U&E, ECG

and chest X-ray, regardless of other risk factors.

Although commonly performed, chest X-ray is not a requirement for patients with limiting cardiovascular disease (ASA grade 3).

Children do not require any routine investigations unless they are likelyto have sickle cell disease, are undergoing neurological or cardiovascular surgery, or are known to have a life-threatening disease.


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2 THEME: PREOPERATIVE FITNESS FOR SURGERY 2

A ECG aloneB ECG and U&EC ECG, U&E and full blood countD FBC aloneE FBC and U&EF FBC, U&E, ECG and chest X-rayG FBC, U&E, ECG, chest X-ray and lung function testsH No investigation requiredI U&Es only

From the list above pick the single most appropriate answer containing theobligatory tests required for the following clinical scenarios. The items may beused once, more than once or not at all.

1 A 75-year-old man with chronic renal impairment (ASA grade 3) undergoingan elective hernia repair.

2 A 43-year-old woman undergoing elective right hemicolectomy for colorectal cancer. She is otherwise t and well.

3 A 56-year-old man with a past history of angina undergoing elective rightinguinal hernia repair (day case). He has no limitation to his exercisetolerance.

Q


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2 PREOPERATIVE FITNESS FOR SURGERY 2

1** B ECG and U&EHernia repair is intermediate surgery. FBC is not considered mandatory.

2 D FBC alone

3 A ECG aloneECG alone is the answer as this man is ASA grade 2 (cardiovascular) andundergoing intermediate surgery.

See ERN MRCS Book 1, Chapter 6, section 1 and the NICE guidelinesCG3 Preoperative tests (www.nice.org.uk/page.aspx?o=73376).

FBC is infrequently recommended for minor and intermediate surgery,although it is often listed as a test to be considered.

Group and save has not been explicitly dealt with in the NICEguidelines.


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3 THEME: PERIOPERATIVE MANAGEMENT OF ASSOCIATEDCARDIORESPIRATORY DISEASE

A Administration of of 2-agonist at inductionB Administration of -blockersC Administration of intravenous digoxinD Aggressive uid resuscitationE Avoidance of opioid analgesiaF Consideration of spinal anaesthesiaG Delay surgery for 3 months

H Diuretic therapyI Endocarditis prophylaxisJ Humidied oxygen therapyK Post-operative chest physiotherapyL Titration of intravenous uids to central venous pressure (CVP)

measurements

The following scenarios all refer to issues concerning the perioperativemanagement of cardiorespiratory disease. Select the single most appropriateaction from the list above. The items may be used once, more than once or notat all.

1 A 62-year-old man attends the preoperative assessment clinic 1 week prior to his scheduled laparoscopic cholecystectomy. The patient informs you thathe was only recently discharged from the hospital following an admission

for myocardial infarction.

2 A 53-year-old woman is due to undergo an emergency laparotomy for asuspected perforated duodenal ulcer. She has a body mass index (BMI) of 35, and her past medical history includes obstructive sleep apnoea.

3 A 74-year-old woman with a prosthetic aortic valve is admitted to thehospital ward 3 days prior to an elective anterior resection for rectalcarcinoma, as she needs to be on intravenous heparin while her warfarin isstopped.

4 You are on call and the ward sister asks you to review a 69-year-old manwith poor urine output. He has recently undergone an emergencyHartmanns procedure for a perforated sigmoid colon secondary todiverticular disease, and his past medical history includes ischaemic heartdisease. Examination reveals a pulse rate of 114 beats per minute (bpm),systolic blood pressure (BP) of 100 mmHg, gross peripheral oedema and 30

ml urine output over the past 3 hours. Serum albumin is 18 g/l.

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3 PERIOPERATIVE MANAGEMENT OF ASSOCIATEDCARDIORESPIRATORY DISEASE

1 G Delay surgery for 3 monthsThis is because there is a 46% risk of perioperative reinfarction.

2** E Avoidance of opioid analgesia

3 I Endocarditis prophylaxisIndicated in patients with prosthetic heart valves, previous endocarditis,mitral valve regurgitation and hypertrophic obstructive cardiomyopathy.

4** L Titration of intravenous uids to CVP measurements

Perioperative management of cardiovascular disease:

See ERN MRCS Book 1, Chapter 6, section 2.2.

Generally, cardiac medications should not be stopped before surgery.

Post-operative management of such patients includes adequateanalgesia, supplemental oxygen therapy, maintenance of euvolaemiawith or without intravenous CVP monitoring.

Perioperative management of respiratory disease:


Cessation of smoking, delaying surgery in the event of preoperativechest infection and adequate post-operative analgesia and chestphysiotherapy may reduce the risk of respiratory complications post-operatively.


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4 THEME: CESSATION OF MEDICATION

A Convert from intravenous to oral routeB Do not cease medicationC Gradual withdrawal of medicationD Immediate cessation of medicationE Stop for 1 week preoperativelyF Stop for 4 days preoperativelyG Stop for 4 days preoperatively, and replace with rapidly reversible equivalentH Stop for 48 hours preoperatively

The following scenarios all refer to issues concerning the cessation of medication prior to surgery. Select the single most appropriate answer from thelist above. The items may be used once, more than once or not at all.

1 A 62-year-old man is on warfarin, as part of the management of atrial brillation. He is on the waiting list for a laparoscopic cholecystectomy.

2 A 74-year-old woman is on clopidogrel, as part of the management of ischaemic heart disease. She is on the waiting list for a reversal of Hartmannsprocedure.

3 A 21-year-old man attends Accident and Emergency (A&E) with abdominalpain and the passage of bloody motions up to seven times per day. As partof his management, he is started on intravenous hydrocortisone. Following2 days of conservative management, the patients symptoms have onlymarginally improved, and stool cultures are positive for Escherichia coli O157:H7.

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4 CESSATION OF MEDICATION

1 F Stop for 4 days preoperativelyInvasive surgery is generally safe (from major haemorrhagiccomplications) when the international normalised ratio (INR) < 1.5.

2 E Stop for 1 week preoperatively Applies to other antiplatelet drugs as well.

3** D Immediate cessation of medicationThis patient has infective not ulcerative colitis.


Systemic corticosteroids can be stopped abruptly in those who areunlikely to relapse and who have received treatment for < 3 weeks,otherwise gradual withdrawal should be performed.

Metformin should be stopped 48 hours preoperatively as it can causelactic acidosis.


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5 THEME: CONSENT FOR SURGERY

A Advance refusalB BatteryC Best interests (treatment in) under common lawD Consent for medical researchE Implied consent (assent)F Informed consentG NegligenceH Parental consentI Treatment under the Mental Health ActJ Ward of court

The following scenarios all refer to issues concerning informed consent. Selectthe single most appropriate answer from the list above. The items may be usedonce, more than once or not at all.

1 A 20-year-old woman with severe right iliac fossa pain, but no signs of sepsis,underwent a diagnostic laparoscopy plus proceed to further surgery asrequired. At the time of the operation, no macroscopic organic pathologycould be identied, but the surgeon proceeded to remove the appendix viathe open approach in case of mucosal inammation. The pathology reportlater revealed the appendix to be normal. Legal action was taken by thepatient against the surgeon.

2 A 46-year-old man underwent proctoscopic injection sclerotherapy of gradeII haemorrhoids in the surgical clinic. He developed acute pelvic discomfortat the time of injection, followed by urgency, dysuria, fever, and aching inthe left testis. His symptoms settled with antibiotics and anti-inammatoryanalgesics, but he takes legal action, claiming he was not informed of therisks of the procedure.

3 An 18-year-old man is brought into A&E following an assault. He is uncon-scious and severely haemodynamically unstable with a stab wound to theright hypochondrium. Following intubation and ventilation, the patient isimmediately taken to the operating room for an emergency laparotomy.

Q


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5 CONSENT FOR SURGERY

1 B BatteryThis is violation of civil law that forbids intentionally touching another person without their consent. In this situation, harm can be construed asthe moral violation of the patients right to exercise autonomous controlover procedures performed on their body.

2** G Negligence

This is failure of the professional duty of the surgeon to adequatelyinform patients about a chosen procedures complications and anyappropriate alternatives. In this scenario, the patient could argue that hewould not of consented to the procedure had he known the risks.

3 C Best interests (treatment in) under common law

See ERN MRCS Book 1, Chapter 6, section 2.1; Department of Health,policy and guidance, Health and social care topics (www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics);General Medical Council, Seeking patients consent: the ethical considerations (www.gmc-uk.org/guidance/archivelibrary/consent.asp)

Informed consent is the process whereby a mentally competent patientagrees to undergo a procedure after discussion of the indications,alternatives, potential side effects and complications.


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