You arrive with the ambulance crew to the scene of a high-energy road traffic accident involving a 30-year-old man. He has an open fracture of his right femur and is unconscious. He appears to be struggling to breathe. On initial observation, you see a large pool of blood gathered around his abdomen coming from a wide wound.
Which of the following is the first step in his immediate management?
You are asked to see a 78-year-old woman on the Surgical Assessment Unit who is complaining of abdominal pain.
Which of the following is not an indication for an abdominal X-ray?
A 38-year-old traveller returns from a long period of travelling in Indonesia. He complains of persistent fever and night sweats, has lost weight and now feels a dull right upper quadrant pain. On further questioning, he admits to having lived very cheaply during his trip and to eating meat from street vendors that may have been undercooked. On examination, he is mildly jaundiced.
Bloods:
Investigation Result Normal value
Bilirubin 98 μmol/l 2–17 µmol/l
Alanine aminotransferase (ALT) 57 IU/l 5–30 IU/l
Alkaline phosphatase 186 IU/l 30–130 IU/l
Haemoglobin 112g/l 135–175 g/l
White cell count (WCC) 12.1 × 109/l 4–11 × 109/l
Platelets 165 × 109/l 150–400 × 109/l
Erythrocyte sedimentation rate (ESR) 55 mm/hour 0–10mm in the 1st hour
An abdominal ultrasound scan shows a cystic mass within the right lobe of the liver.
Which of the following represents the most effective treatment for this man?
A 50-year-old woman presents with acute right upper quadrant abdominal pain and vomiting, which started earlier today.
On examination, the patient is not jaundiced and there is mild tenderness in the right upper quadrant and epigastrium. The blood results are as follows:
Investigation Result Normal value
Haemoglobin 130 g/l 115–155 g/l
White cell count (WCC) 14 × 109/l 4–11 × 109/l
Sodium (Na+) 138 mmol/l 135–145 mmol/l
Potassium (K+) 4.0 mmol/l 3.5–5.0 mmol/l
Urea 6.0 mmol/l 2.5–6.5 mmol/l
Creatinine 70 μmmol/l 50–120 μmol/l
Bilirubin 25 mmol/l 2–17 mmol/l
Alkaline phosphatase 120 IU/l 30–130 IU/l
Alanine aminotransferase (ALT) 40 IU/l 5–30 IU/l
Amylase 200 U/l < 200 U/l
Which of the following is the most appropriate management plan?
A 35-year-old yoga instructor presents to the General Practitioner (GP) with complaints of feeling constantly fatigued. During the consultation, she also mentions experiencing widespread, non-specific itching.
Upon examination, the GP observes generalised excoriation, but no other significant findings. Blood tests reveal an elevated alkaline phosphatase level, leading to a suspicion of primary biliary cholangitis.
What is the most specific symptom of primary biliary cholangitis?
A 44-year-old man with diagnosed primary sclerosing cholangitis (PSC) had been taking cholestyramine and vitamin supplementation for the last 3 years. He had ulcerative colitis which was in remission, and colonoscopic surveillance had not shown any dysplastic changes. His only significant history was two episodes of cholangitis for which he had to be hospitalised in the past year. On examination, he was mildly icteric with a body weight of 52 kg. At present, he had no complaints, except fatigue.
What is the next best treatment option?
A 23-year-old woman developed sudden-onset, severe epigastric pain 12 hours ago. She subsequently began having episodes of nausea and vomiting, especially after trying to eat or drink. The pain now feels more generalised, and even slight movement makes it worse. She has diminished bowel sounds and exquisite tenderness in the mid-epigastrium with rebound tenderness and board-like rigidity. Her pulse is 110 bpm and blood pressure 130/75. She reports taking ibuprofen for dysmenorrhoea. She had last taken ibuprofen the day before the pain began.
What is the most likely diagnosis?
A 38-year-old woman presents to the Emergency Department (ED) with chest and abdominal pain, following three days of severe vomiting secondary to gastroenteritis. She reports pain being worse on swallowing and feels short of breath. On examination, she looks unwell and has a heart rate of 105 bpm, a blood pressure of 110/90 mmHg, a respiratory rate of 22 breaths/minute and a temperature of 38 °C. Boerhaave syndrome is suspected.
What is the most appropriate initial investigation, given the suspected diagnosis?
A 67-year-old woman complains of epigastric pain, vomiting and weight loss. The surgeon suspects gastric cancer and sends her for endoscopy. Where is the cancer likely to be located?
A 50-year-old man presents to the Emergency Department with excruciating chest pain. He has had severe vomiting and retching over the last 24 hours after he ate some off-food at a restaurant. The last four episodes of vomiting have been bloody and he states that he has vomited too many times to count. The patient has a past medical history of type 2 diabetes mellitus and hypertension.
His observations are shown below:
Temperature 38.9 °C
Blood pressure 95/59 mmHg
Heart rate 115 beats per minute
Respiratory rate 24 breaths per minute
Sp(O2) 95% (room air)
Physical examination of the chest reveals subcutaneous emphysema over the chest wall. His electrocardiogram (ECG) is significant for sinus tachycardia without ischaemic changes and his blood tests results are shown below:
Investigation Result Normal value
White cell count 21.5 × 109/l 4–11 × 109/l
C-reactive protein 105.5 mgl 0–10 mg/l
Haemoglobin 103 g/l 135–175 g/l
Which of the following is the most likely diagnosis?