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National University Hospital (NUH), Singapore
National University of Singapore
Final Year (Year 5) Surgical Revision Posting
Class of 2001
Total Time: 1 hour
51 year old man presents with a sudden headache, and is comatose on admission.
His blood pressure is 220/140 mmHg. Discuss your management.
50 year old man has had gross haematuria with clots for 1 month.
On examination, he is pale and there is a left flank mass as well as a
Grade 3 varicocele on the left. How would you manage this patient?
Model Answer 1
2)ABCDE [Intubate, hyperventilate, i/v access, GCS score, focal neurological signs]
3)History and Physical
b)Assess etiology [Signs and symptoms of a bleed, Risk factors]
c)Assess severity [Signs of raised ICP (esp papilloedema), Cushing's reflex]
4)Working diagnosis - Intracranial bleed w/ raised ICP. Unlikely CSF obstruction, brain tumor.
a)Immediate: Treat ICP [Head up, hyperventilate (PC02=30-40), i/v mannitol]
b)Urgent CT Scan head [Looking for bleed, site, size, mass effect]
c)Urgent neurosurgical referal [Indications for op]
d)Future treatment [Rehabilitation, Prevention]
Model Answer 2
1)Resuscitate if unstable
a)Renal cell carcinoma of left kidney
b)Transitional cell carcinoma of left renal pelvis
c)Stone with hydronephrosis
3)Clinical examination (Hx and PE: Signs and symptoms, Risk factors)
a)RCC: Mass + pain + painless haematuria. Weight loss, loss of appetite, smoking.
b)TCC: Mass + pain + painless haematuria. Wt loss, anorexia, smoking, anilene dye exposure.
c)Stone: Past history, ureteric colic, obstructive symptoms.
d)Mention: Renal vein invasion causing varicocele. Clot colic.
a)For effect and severity: FBC, U/E/Cr, UFeme and cytology
b)Diagnostic: Ultrasound (U/S), IVU, Retrograde Pyelourethrogram (RPG) with biopsy
c)Staging: CT scan, U/S for IVC extension, Chest Xray
(i)RCC - Radical nephrectomy with lymph node dissection. (kiv partial nephrectomy)
(ii)TCC - Nephrouretectomy
b)Palliative:RCC - Radiotherapy, embolization
c)Stones: Percutaneous nephrostomy to relieve obstruction. Treat stones.
d)Follow up: UFeme, Cystoscopy, U/S.