SURGERY

PROBLEM CARDS

BY SANTANU DAS

FINAL YEAR MBBS

BURDWAN MEDICAL COLLEGE
PC:1) A 45 YEAR OLD MALE PATIENT ATTENDED EMERGENCY WITH SEVERE PAIN IN THE RIGHT
INGUINAL [Link] EXAMINATION THERE IS SWELLING ON RIGHT INGUINAL REGION.

I. WHAT IS YOUR PROVISIONAL DIAGNOSIS?

II. HOW WILL YOU MANAGE THE CASE?
ANSWER-
Here presenting features are-
i. severe pain in right inguinal region,
ii. On examination, swelling in right inguinal region.

Provisional Diagnosis- IRREDUCIBLE HERNIA.(IN REDUCIBLE HERNIA,THERE IS NO PAIN

GENERALLY).
Differential Diagnosis-
i. Strangulated hernia (Gangrenous changes+ Toxemia present),
ii. Obstructed hernia (Intestinal obstruction),
iii. Lipoma of cord that got infected (excised during herniotomy),
iv. Rt. Inguinal lymphadenopathy (Mx- Conservative Treatment),
v. Parietal wall abscess (Presents with fever) (Mx- INCISION AND DRAINAGE).

Management-HERNIORRHAPHY (Mesh is not inserted in emergency as it can lead to

infections).

STRANGULATED HERNIA-
✓ Occurs when blood supply of content of sac is seriously impaired.
✓ Formation of gangrene.
✓ Common bacteria- E. coli, Anaerobic streptococci, Klebsiella.
✓ Indirect>direct (D/t narrow neck in indirect hernia).
✓ Causes of strangulation are- narrow neck, adhesions, irreducibility, long time,
large hernia with adhesions.
✓ C/F- sudden severe pain, persistent vomiting, severely tender, tense hernia
irreducible without any expansile impulse on coughing, rebound
tenderness(diagnostic), features of toxicity and dehydration, electrolyte
imbalance, abdominal distension with guarding rigidity.
✓ Investigations- X-RAY ABDOMEN-Erect posture-multiple air fluid levels (may
be in stepladder pattern suggesting small bowel obstruction).
✓ Treatment- ADMISSION>RYLES’S TUBE ASPIRATION>IV fluid to correct
dehydration and electrolyte imbalance>Antibiotics>Catheterization to
maintain adequate urine output>Emergency surgery.
✓ Emergency surgery- Viability of gut is checked by color, peristalsis, pulsation
and bleeding: If not viable (gangrenous) resection and anastomosis is done
and drain is placed. Bassini’s repair is done by placing interrupted non-
absorbable sutures. IV fluid and antibiotics continued, drain removed in 4-5
days. Once bowel movement starts, oral diet is started. Mesh is not used.
 PC:2) A 60 YEARS OLD MALE PATIENT ATTENDED YOUR SOPD WITH A MASS IN RIGHT SIDE OF
THE ABDOMEN.
I. WHAT IS YOUR DIFFERENTIAL DIAGNOSIS?
II. WHAT INVESTIGATIONS WOULD YOU LIKE TO DO FOR CONFIRMATION OF YOUR
DIAGNOSIS?
III. HOW WILL YOU MANAGE THE CASE?

ANSWER:-

Here presenting feature- 60 yo male pt. with right sided abdominal mass.
DIFFERENTIAL DIAGNOSIS- (both upper and lower quadrant need to be considered.)
i. CA caecum (aged patient more prone to develop cancer)
ii. CA ascending colon
iii. Appendicular lump (first d/d in case of young patient)
iv. Mesenteric cyst
v. CA gallbladder
vi. Hepatomegaly
vii. Hernias
viii. Rt. Sided lipoma of cord
ix. Rt. Sided inguinal lymphadenopathy
INVESTIGATIONS-
i. USG whole abdomen,
ii. Depending upon the reports on USG , CECT whole abdomen is done. CECT is the
IOC.
iii. Confirmation of any mass by HISTOPATHOLOGICAL EXAMINATIONS.
MANAGEMENT-

i. CA caecum and CA colon- Rt. HEMICOLECTOMY

ii. Appendicular lump- INTERVAL APPENDICECTOMY (Conservative t/t for first 6
weeks, then APPENDICECTOMY).
iii. CA Gallbladder- EXTENDED CHOLECYSTECTOMY
iv. Hepatomegaly- FIND THE CAUSE,MANAGE ACCORDINGLY-CONSERVATIVE
TREATMENT.
HOW TO APPROACH (ACCORDING TO CURRENT GUIDELINES) –
CECT WHOLE ABDOMEN-→ if malignancy suspected→ COLONOSCOPY guided BIOPSY→HPE.
If any malignancy- ASSESS THE SPREAD:

I. GREAT SPREAD- 1ST CHEMOTHERAPY THEN SURGERY

II. NOT SO GREAT SPREAD- 1ST SURGERY THEN CHEMOTHERAPY.
WHAT STRUCTURES ARE REMOVED IN RIGHT HEMICOLECTOMY-
i. Caecum,
ii. Ascending colon,
iii. Hepatic flexure and first third of transverse colon,
iv. Parts of terminal ileum, along with fat and LN.
PC:3) A 20 YEARS OLD FEMALE PATIENT ATTENDED YOUR EMERGENCY WITH SEVERE PAIN IN
RIGHT LOWER ABDOMEN.
I. WHAT ARE YOUR DIFFERENTIAL DIAGNOSIS?
II. HOW WILL YOU MANAGE THE CASE?

ANSWER:-
As there is only pain and no swelling, it is probably due to any intra-abdominal pathology.

PROVISIONAL DIAGNOSIS-
Acute appendicitis- As the patient is young, it is most probable cause of rt. sided lower
abdominal pain.
DIFFERENTIAL DIAGNOSIS AND MANAGEMENT-

DIFFERENTIAL DIAGNOSIS MANAGEMENT

1. ACUTE APPENDICITIS APPENDICECTOMY

2. OVARIAN TORSION OOPHERECTOMY

3. RUPTURED OVARIAN CYST CYSTECTOMY

4. MESENTERIC LYMPHADENOPATHY DETERMINE THE CAUSE, AND MANAGE

ACCORDINGLY (CONSERVATIVE TREATMENT)

INVESTIGATIONS-
I. USG Whole abdomen- IOC IN ACUTE APPENDICITIS.
II. CT SCAN IS GOLD STANDARD THOUGH.

PC:4) A 40 YEAR OLD FEMALE FATTY PATIENT ATTENDED YOUR EMERGENCY WITH SEVERE
PAIN IN RIGHT UPPER ABDOMEN.
I. WHAT WILL BE YOUR PROBABLE DIAGNOSIS?
II. WHAT INVESTIGATIONS WOULD YOU LIKE TO DO FOR THIS PATIENT?
III. HOW WILL YOU MANAGE THE CASE?
ANSWER:-

PROBABLE DIAGNOSIS- Acute cholecystitis (pain is the presenting complaint, hence acute).
DIFFERENTIAL DIAGNOSIS-
i. Acute appendicitis (If the appendix is subhepatic) (M/C position – Retrocecal).
ii. Cholangitis (d/t worm infestation).
iii. Infected hydatid cyst.
iv. Mucocele of GB.
v. Empyema of GB (Associated with fever).
INVESTIGATIONS-
1ST Investigation- USG Whole abdomen.
IOC- CECT Whole abdomen.

MANAGEMENT-

DIAGNOSIS MANAGEMENT
1. Acute cholecystitis Laparoscopic or Open Cholecystectomy
2. Worm infestation Albendazole→Cholecystectomy/CBD
Exploration
3. Infected hydatid cyst (Hepatic) 6 weeks antibiotics→ PAIR Therapy
4. Acute appendicitis Interval Appendicectomy
5. Mucocele of GB Cholecystectomy
6. Empyema of GB Cholecystectomy

PAIR THERAPY-
Cut open abdomen→Visualize the cyst→Using a 20G needle, puncture the cyst→Sclerosing agents
(3% NaCl, Savlon, Cetrimide) are pushed in and the needle is kept as it is for 10 minutes→ The
sclerosing agent kill the organisms→Then nick the cyst and take everything out→Go for
CYSTECTOMY.
[If we cut the cyst without administering sclerosing agents, the organism enters the abdominal
cavity and leads to anaphylactic shock.]
EMPYEMA GALLBLADDER-
GENERAL FEATURE CLINICAL FEATURES INVESTIGATIONS TREATMENT
Type of acute Fever, Toxicity USG ABDOMEN Cholecystectomy-
cholecystitis where GB Pain in rt. emergency
is filled with pus. hypochondrium
Commonly seen in- Tender, smooth, RADIOISOTOPE SCAN Antibiotics-
impacted stone, Globular GB is Ceftriaxone,
diabetic individuals, palpable in rt. Cefotaxime,
immunocompromised hypochondrium Quinolones
patients-HIV

Can perforate COMPLICATIONS TC,PT-↑

Can cause peritonitis Septicemia HAEMATOCRIT- ↑
High mortality rates Rupture, peritonitis LFT-↑
MUCOCELE OF THE GALL BLADDER-
GENERAL C/F- COMPLICATIONS- TREATMENT-
CONSIDERATIONS- ✓ Dyspepsia with ✓ Empyema GB ✓ Cholecystectomy
✓ Overdistension painless ✓ Perforation -open or lap.
of GB swelling in the ✓ Biliary ✓ Occasionally
✓ Containing right peritonitis needs initial
mucoid or clear hypochondrium, ✓ Pseudomyxoma percutaneous
fluid, ✓ Nontender, peritonei (rare) guided needle
✓ Results from- smooth, INVESTIGATIONS- decompression
cystic duct globular ✓ USG ABDOMEN or
obstruction due palpable GB, (AP diameter>5cm) cholecystostomy
to- impacted ✓ Often GB ✓ LFT prior to
stone, polyp, reaches up to ✓ CT Scan cholecystectomy.
carcinoma, pelvis ✓ MRCP
extrinsic D/D-
compression, ✓ Choledochal
congenital cyst
narrowing of the ✓ Mesenteric cyst,
cystic duct, ✓ Hydatid cyst,
parasitic block or ✓ Pseudocyst of
prolonged TPN; pancreas
✓ This causes
absorption of all
the bile and
secretion of
mucous into
gallbladder
allowing it to
distend,
✓ Contents are
usually sterile
PC:5) A 40 YEARS OLD MALE PATIENT PRESENTED WITH ACUTE PAIN IN EPIGASTRIUM WHICH LATER
BECAME [Link] EXAMINATION THERE IS CARD-BOARD LIKE RIGIDITY AND OBLITERATION OF
LIVER DULLNESS.
I. WHAT IS YOUR PROBABLE DIAGNOSIS?
II. WHAT ARE THE INVESTIGATIONS OF CHOICE TO CONFIRM DIAGNOSIS?
III. HOW WILL YOU MANAGE THE CASE?
ANSWER:-
PROBABLE DIAGNOSIS-
POINTS FROM PRESENTING FEATURES AND IMPORTANCE IN DIAGNOSIS

PRESENTING FEATURES IMPORTANCE IN DIAGNOSIS

1. Card-board like rigidity Indicative of peritonitis
2. Obliteration of liver dullness Air is present (Tympanic)→suggesting
hollow viscus perforation
So, probable diagnosis is hollow viscus perforation with features of peritonitis. It can be d/t-
✓ Peptic ulcer perforation (Includes both gastric and duodenal ulcers; peptic part=gastric
antrum+pylorus+D1)
✓ Intestinal perforation (small or large)
✓ GB perforation
✓ Appendicular perforation (very small to show gas under right dome of diaphragm)
INVESTIGATIONS-
✓ Digital X-RAY of whole abdomen in Erect posture:- Gas under right dome of
diaphragm AND GROUND-GLASS appearance. It is the IOC.
✓ CECT- Gold standard.
MANAGEMENT- Admission of patient
↓
IV Fluids (Ringer lactate, NS, Dextrose saline); Antibiotics: cefotaxime, metronidazole, amikacin

↓
Catheterization; Ryle’s tube aspiration
↓
Emergency laparotomy through upper midline incision; all infected fluids are sucked out

↓
Perforation is identified and closed with interrupted, horizontal sutures: silk or vicryl
↓
 Closure of the perforation using omental patch- GRAHAM’S PATCH REPAIR
↓
3 sutures are given-

1st suture 2nd suture 3rd suture

Most tightly tied→ to keep Looser than 1st suture Loosest → because blood
omentum in place supply goes from down to up
for omentum.
So to omentum to remain
healthy, it needs blood
supply.
In modified Graham’s technique- Before omentum placement tie once and again after it is
placed.
↓

Peritoneal toilet- 5-10 lt. of NS ; Drain is placed→ Abdomen is closed→Drain removed after 3-5
days→ Discharge with advice of avoiding alcohol and to take PPI or H 2 blocker for 6-12
weeks→After 12 weeks follow up gastroscopy must be done.

PC:6) A 30 YEAR OLD FEMALE PATIENT ATTENDED EMERGENCY OF YOUR HOSPITAL WITH 40%
BURN [Link] OF THE PATIENT IS 50KG.

HOW WILL YOU MANAGE THE CASE?

ANSWER-

Clothing removed→cooling of the part by running water for 20 minutes (avoid cold water-
causes hypothermia)→cleaning the part to remove dust, mud if
present→CHEMOPROPHYLAXIS WITH TETANUS TOXOID; ATG-500 UNITS,IM; ANTIBIOTICS;
LOCAL ANTISEPTICS→ Maintain ABC[emergency endotracheal intubation]→clean and cool
environment→sedation and proper analgesia→Fluid Resuscitation→Dressing at regular
interval→silver sulfadiazine ointment+ supportive treatment→when infection subsides, post
burn contractures are seen and plastic surgery is done for wound coverage using split skin graft
(SSG)→ If eschar has formed, escharotomy is required to prevent compression of vessels.

FLUID RESUSCITATION-
✓ FLUIDS USED- Ringer lactate (fluid of choice), Hartmann fluid, plasma.
✓ FORMULAS-
• PARKLAND REGIME- 3-4ml/kg body wt./% burn in 24 hours.
Half the volume in first 8 hours and other half in last 16 hours.
• Other regimes are- Galveston regime (pediatrics), Modified Brooke formula,
Evan’s formula
 • ATLS PROTOCOL- 2ml/kg/%burn in 24 hours( adult), 3ml/kg/%burn in 24 hours
(children). Currently followed.
• For first 24 hours, crystalloids are used and thereafter colloids can be used.
• After 24 hours colloids are given to compensate plasma loos. Some colloids are-
plasma, hemacel, dextrans, hetastarch. Human albumin is ideal colloid.
• Amount of colloid is calculated by MUIR AND BURCLAY REGIME.
• MUIR AND BURCLAY REGIME- %BURN* KG BODY WT./2= 1 RATION; 3 RATION
IS GIVEN IN FIRST 12 HOURS (AFTER FIRST 24HOURS), 2 RATIONS IN 2ND 12
HOURS AND 1 RATION IN 3RD 12 HOURS.
• MODIFIED BROOKE FORMULA- First 24 h. -RL 4ml/%burns/kg body wt.(half in 1st 8
hours, then remaining in 16 hours); Second 24H.—colloid- 0.3-0.5ml/kg/%burn in
24 hours + crystalloid (to maintain urine output).[Albumin in RL solution].
• Urinary catheterization must be done to monitor urine output- 30-50ml/hour
should be ideal.
• Hourly monitoring of vitals
• Ryle’s tube insertion- initially for aspiration later for feeding. Total parenteral
nutrition is required for quick recovery.
• Culture of the discharge on regular intervals to check bacterial load, antibiotics to
be given- aminoglycosides, cephalosporins, metronidazole etc.
• In burn injury → relative more loss of K+ as it is more in ECF→Causes electrolyte
imbalance. RL contains K+, Na+, lactate and Cl- .So all losses are made up.
Concentration of electrolytes are much less in RL than NS → No hyperosmolarity.
• NS is hyperosmolar and thus attracts more fluids from tissue causing further
dehydration.

PC:7) A 65 YEARS OLD MALE PATIENT PRESENTED WITH PAIN IN ABDOMEN,VOMITING,

ABDOMINAL DISTENSION AND ABSOLUTE CONSTIPATION.

HOW WILL YOU PROCEED TO MANAGE?

ANSWER:-
PRESENTING FEATURES-
Absolute constipation(AKA obstipation )-Most indicative of intestinal obstruction.
Causes of intestinal obstruction are as follows-

CONGENITAL ACQUIRED
✓ Duodenal atresia ✓ Hernia
✓ Bands and adhesions ✓ Carcinoma
✓ Congenital megacolon ✓ Crohn’s disease
✓ Anorectal malformations ✓ Tuberculosis of gut
✓ Volvulus neonatorum ✓ Intussusception
✓ Malrotation ✓ Roundworm infestation
✓ Gallstones
✓ Stercolith
✓ Foreign body
✓ Bezoars

Patient complaints of – vomiting, abdominal distension- so patient may be hemodynamically

unstable, dehydrated and may have ion imbalance.
APPROACH-
Initial Resuscitation if the patient is not stable and dehydrated –

Give Fluids and assess for dehydration corrected or not by catheterization and urine output
↓
Check for pulse ,BP and other vitals and correct them if they are not under proper limits
↓
Provide supportive treatment with PPI, analgesics, and prevention of vomiting

↓
If the patient is stable, now determine the cause of obstruction by:
✓ X-RAY erect posture- Multiple air fluid levels, often in
stepladder pattern
✓ If patient is stable, go for CT Scan
↙ ↘
PATIENT IS STABLE PATIENT DID NOT RESPOND TO TREATMENT
↓ ↓

WAIT FOR 24 HOURS GO FOR EXPLORATIVE LAPAROTOMY

 XRAY FINDINGS IN XRAY FINDINGS IN
LARGE INTESTINE OBSTRUCTION SMALL INTESTINAL OBSTRUCTION
✓ Haustrations can be seen as ✓ Complete ring-like structures can be
incomplete ring visualized- valvulae connivantes
✓ Air – Fluid levels are seen peripherally ✓ Air-Fluid levels are seen centrally

After explorative laparotomy the case is managed according to its causes.

CECT IS DONE TO DIFFERENTIATE BETWEEN MALIGNACY, CYST, STRICTURES ETC, ie, to

differentiate it causes

PC:8) A PERSON SUSTAINED CHEST INJURY FOLLOWING RTA AND DEVELOPED SEVERE
RESPIRATORY DISTRESS.

HOW WILL YOU MANAGE THE CASE?

ANSWER:-
✓ Maintain ABC.
✓ Here respiratory distress may be due to rib fracture following a RTA.
✓ Rib fracture causes→ Pneumothorax.
✓ It can be of three types- Open, closed and tension.
✓ Give O2 if patient can breathe.
✓ If he can not breath, look for accessory muscle utilization for breathing- SCM & Alar
nasi→Working→ Indicative of severe respiratory distress→Tension pneumothorax→Do
not wait for investigation→Wide-bore needle is inserted in the 2nd intercostal
space→Add into water seal drainage→if bubble present→Air is coming out.
✓ If no accessory muscles working→ Send for digital CXR→
PNEUMOTHORAX/HYDROTHORAX/PLEURAL EFFUSION/EMPYEMA THORACIS.
✓ TREATMENT- INTERCOSTAL TUBE DRAINAGE(ICT) for 3-4 days in 5th or 6th intercostal
space along anterior axillary line through the upper border of ribs without damaging
intercostal nerves which runs through lower border of ribs.
 ✓ If flail chest present- manage accordingly- Applying clips to fracture ribs and fixing
above and below normal ribs; antibiotics (penicillin, cefotaxime); bronchodilators;
steroids ; ventilator support with IPPV (TREATMENT OF CHOICE) UNTIL chest wall
stabilizes. If ventilator support is required for more than 10days, then tracheostomy is
done to prevent laryngeal stenosis which can occur d/t prolonged endotracheal
intubation.

PC:9) A 20 YEAR OLD MALE PATIENT SUSTAINED PELVIC INJURIES FOLLOWING A [Link]
HAS BEEN UNABLE TO PASS URINE SINCE THE ACCIDENT.

HOW WILL YOU PROCEED TO MANAGE THE CASE?

ANSWER:-
Possible causes of the condition are-

✓ Urethral rupture
✓ Sacral plexus injury which may result d/t vertebral injury following an RTA.
INVESTIGATIONS-
✓ XRAY PELVIS- To see for any fracture→any injury in vertebra suggesting sacral plexus
injury,
✓ USG KUBP- 1ST CHOICE in emergency condition.
✓ NCCT(KBP) – Investigation of choice.
TREATMENT-

We don’t know where is the rupture in urethra→ So for that, supra-pubic catheterization (SPC)
is done→ Incision is given just above pubic symphysis→Go deep→Shiny glossy surface is
seen→It is the urinary bladder→Small nick→Insert the Foley’s catheter→Inflate the balloon (so
that it won’t come out)→suture→ Plan OT→URETHRAL RECONSTRUCTION by transection and
anastomosis.
 PC:10) A 65 YEARS OLD MALE PATIENT PRESENTED WITH PAINLESS GROSS HEMATURIA.

WHAT IS YOUR DIFFERENTIAL DIAGNOSIS?

HOW WILL YOU MANAGE THE CASE?

ANSWER:-

PAINLESS HEMATURIA PAINFUL HEMATURIA

1. Malignant lesions in bladder, 1. Calculi
urethra, urinary tree 2. Malignancy in later stages
2. Coagulopathy of the patient
3. Parasite Schistosoma in bladder
4. Glomerulonephritis

INVESTIGATIONS-

✓ Routine and microscopic urine examination

✓ USG KUBP
✓ NCCT KUBP-Investigation of choice
✓ Brain and kidney NCCT
✓ All other system- CECT
TREATMENT-
Treatment according to cause of hematuria-
✓ For malignancies- downstaging with chemotherapy followed by surgical procedure.
✓ Calculus – Surgical removal of the calculi.

PC:11) A 45 YEARS OLD MALE ATTENDED EMERGENCY WITH [Link] WILL YOU
MANAGE THE CASE?
ANSWER:-

✓ Inability to retract the prepuce over glans penis.

PHIMOSIS ✓ Balanitis and balanoposthitis are common causes apart from
congenital phimosis-especially in diabetics.
✓ More prone CA penis and recurrent infections.
✓ Treatment- circumcision.
✓ Inability to place back the retracted prepucial skin over glans.
PARAPHIMOSIS ✓ Causes ring like constriction proximal to the corona and prepuceal
skin.
✓ Glans will be swollen, edematous with severe pain and
tenderness.
✓ Often glans undergoes necrosis & become gangrenous.
✓ May be iatrogenic- post catheterization or after sexual intercourse.
✓ Emergency condition as it constricts the blood supply.
MANAGEMENT-
Manual reduction of prepuceal skin→Not possible→Initial dorsal slit to relieve
edema→antibiotics + analgesics→Circumcision done after 3 weeks.

Sedation and hyaluronidase inj. In 10ml NS into constriction ring or multiple needle
punctures over edematous part → Reduces edema and paraphimosis→Later circumcision is
done.

CIRCUMCISION-
✓ ANASTHESIA- CHILDREN- GA, ADULT- LA( 1% LIDOCAINE CIRCUMFERENTIALLY NEAR THE
ROOF OF PENIS- RING BLOCK.
✓ PROCEDURE-
• Dorsal skin cut upto corona and later circumferentially and ventrally→Skin is cut
with inner layer→Less skin is cut ventrally to prevent chordee →Frenular artery
transfixed & ligated using chromic catgut (2-0 or 3-0)→ Skin is apposed to the cut
edge of corona using interrupted chromic catgut sutures.
• Postoperative antibiotics and analgesics.
✓ INDICATIONS-
➢ Religious
➢ Phimosis
➢ Paraphimosis
➢ Recurrent balanitis and balanoposthitis
➢ Early CA of prepuce or glans penis- diagnostic as well as therapeutic value
➢ Certain STDs- Herpes infection
✓ COMPLICATIONS-
➢ Reactionary hemorrhage d/t slipping of ligature from frenular artery and dorsal
vein
➢ Infection
➢ Stricture urethra near external meatus in children
➢ Chordee
➢ Priapism – rarely.
PC:12) A 5 YEAR OLD MALE PATIENT ATTENDED EMERGENCY WITH RETENTION OF [Link]
EXAMINATION,IT IS NOTED THAT PREPUCIAL SKIN CAN NOT BE RETRACTED BEYOND CORONA
GLANDIS.
WHAT IS YOUR PROVISIONAL DIAGNOSIS?
HOW WILL YOU MANAGE THE CASE?
ANSWER:-
✓ DIAGNOSIS- Phimosis
✓ MANAGEMENT- Circumcision

PC:13) A 60 YEARS OLD MALE PATIENT PRESENTED WITH ACUTE RETENTION OF URINE IN
EMERGENCY.
WHAT ARE THE CAUSES OF URINE RETENTION?
HOW WILL YOU MANAGE THE CASE?

ANSWER:-
PROBABLE CAUSES-

✓ BPH
✓ Neuropathy (D/t sacral plexus injury , poliomyelitis)
✓ Cystitis
✓ Obstructive uropathy (D/t malignancies, calculi)
INVESTIGATIONS-

✓ USG- Foley’s catheterization ( for passage of urine otherwise can cause rupture of
bladder) → send for USG KUBP.
✓ NCCT- KUBP.
MANAGEMENT-

According to the cause-

BPH- first medical treatment → surgery

✓ Tamsulosin- 0.4mg ODHS( ONCE DAILY AT BED TIME)
It is an alpha 1A Blocker→sympathetic stimulation inhibited→inhibits contraction
of smooth muscle of prostate→Hence prostate won’t compress urethra.
✓ Dutasteride
✓ Tamsulosin+ dutasteride- drug of choice.
✓ Sx- 1. TURP (Transurethral resection of prostate) or 2. Open Prostatectomy
CYSTITIS- Antibiotic nitrofurantoin 100mg TDS for 7 days and send for culture sensitivity; if
found sensitive→ change antibiotic accordingly.
NEUROPATHY- Physiotherapy
OBSTRUCTED UROPATHY- Malignancy→ Downstaging→surgery; calculi→surgical removal
PC:14) A 40YEARS OLD FEMALE PATIENT PRESENTED WITH ABNORMAL NIPPLE DISCHARGE.

HOW WILL YOU MANAGE THE CASE?

ANSWER:-
INVESTIGATIONS-
➢ Triple Assessment-
It includes-
✓ History and clinical examination
✓ Radiological imaging- USG/MRI/MAMMOGRAPHY
✓ Cytological or histopathological examination- FNAC/ Core cut BIOPSY.
➢ Discharge is sent for routine examination.
TYPE OF DISCHARGE UNDERLYING PATHOLOGY
1. Red colored CA Breast
2. Pus Breast abscess
3. Greenish Duct ectasia
4. Black Duct ectasia, duct papilloma

TREATMENT-

PATHOLOGY TREATMENT
1. CA Breast MRM OR TM.
2. Breast abscess Antibiotics- cephalosporins, flucloxacillin
and amoxicillin;
Repeated US guided aspirations (using 18
gauge needle with saline lavage)-Ideal and
standard now.
Incision and drainage under GA.
3. Duct ectasia Adair- Hadfield operation- cone excision of
involved major ducts,
Melhem Novel modified breast ductal
system excision.
4. Duct papilloma Microdochectomy- probed lactiferous ducts
are opened and papilloma is excised using
tennis racquet incision.