CASES
FOR
PROBLEM
BASED
SEMINARS
Case #1: Dysphagia
-----------------------------------------------------------------------------------------------------------Assumptions:
Refer to the Objective manual. It is extremely important that the student refers to the
objectives prior to reading the following scenario and answering questions asked in it.
All students should read well in advance on this subject, before attending the problem based
seminar
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Problems based Scenarios
Scenario1
1. A 60 year old male presented with 3 month history of progressive dysphagia. The
dysphagia was initially to solids but now he could swallow only liquids. His appetite is
poor and he has lost 17kg since the onset of the illness. Nine months ago the patient was
admitted to the Intensive Care Unit with chronic obstructive airway disease and cor
pulmonale. He had to be ventilated and underwent tracheostomy. However, he made a
remarkable recovery and was discharged after three months. On examination he looked
weak and pale. His weight was 44kg. He had a barrel-shaped chest with diminished air
entry bilaterally plus a few basal crepitations. His abdominal examination was
unremarkable.
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What is the most probable diagnosis and what in the history is suggestive of the
diagnosis.
What further questions would you like to ask the patient?
What history would suggest that a patient has advanced carcinoma of esophagus
What history would you elicit that could be the contributing aetilogical factor and
aetilogical lesions for carcinoma of esophagus (squamous cell carcinoma and
adenocarcinoma).
How do you differentiate between dysphagia of benign and malignant esophageal
conditions. What are the common causes for dysphagia
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What abnormal findings would you look for on physical examination? (general
examination, chest and abdominal examination)
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What is odynophagia, water brash? What esophageal condition is associated with
them? What are other symptoms of esophageal disease and what condition is it
associated with
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What are the differential diagnoses for dysphagia with these various associated
symptoms?
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How would you evaluate this 60 year old patient who presented with dysphagia?
What investigation would you carry out to assess his respiratory status that will
differentiate between obstructive and restrictive lung disease.
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Discuss the diagnostic and staging investigations with abnormal findings in them
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What is the mode of spread of carcinoma of esophagus? What structures in chest are
involved by direct spread? What symptoms do they present with.
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Department of Surgery
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Which group of lymph nodes are involved in the abdomen/ chest and neck
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The patient underwent barium swallow followed by endoscopy. CT scan was then
carried out. Comment on the findings on images displayed
Barium swallow
Oesophagoscopy findings
The CT findings are displayed below. Comment on the adjoining structures to the
esophageal growth and note whether they are infiltrated. If infiltration to aorta and
trachea/bronchus is not clear on CT scan what investigation prior to definitive surgery
would help
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Department of Surgery
If the endoscopy biopsy is reported to be squamous cell carcinoma, what is the
probable site of the esophageal growth? What are the other histological types of
esophageal carcinoma?
What are the predisposing environmental factors / lesions for carcinoma of esophagus.
How are they different when the lesion is proximal (squamous cell carcinoma) and
distal (adenocarcinoma)?
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What are the treatment options for carcinoma of the esophagus?
What are the surgical options for carcinoma esophagus at different levels of growth?
(lower one third/ middle one third of esophagus).
What is the relevance of respiratory symptoms if this patient were to undergo
esophageal surgery?
What adjuvant therapy would the patient require after surgery. What is the role of
radiotherapy (indications / contraindication for radiotherapy and the potential
complications)
What is neoadjuvant therapy?
When is esophageal tumour considered inoperable?
What are the different options to palliate dysphagia in a patient with inoperable
growth and what are their advantages and potential complications
The following is an endoscopy finding of one such patient. He had undergone
placement of SEMS. What is SEMS? What are the complications of its insertion?
Endoscopy finding of a patient with insertion of stent
 If a patient with carcinoma of esophagus complains of cough after eating what is your
inference. How is this patient treated?
 What is the long term prognosis of a patient with carcinoma of esophagus and what
factors determine the outcome
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Department of Surgery
Scenario 2
A 32-year-old lady presents with a history of difficulty in swallowing for 2years. More
recently she is having increasing trouble swallowing, and has been regurgitating undigested
food. Her dysphagia is predominately to liquids and improves on carrying out Valsalva’s
maneouvre. She has lost 2 kgs in 2 years.
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What is the most likely diagnosis and what features in the presentation support the
diagnosis.
What is the aetiopathogenesis of this condition (aetiological factors/ physiological
changes in motility and lower esophageal sphincter pressure and pathological changes
in ganglia/nerve plexus)
How would you investigate this patient? (endoscopic / manometric study) and what
are the abnormal diagnostic findings
This patient undergoes chest x-ray and barium swallow, which is displayed. What is
the most likely diagnosis and what features support the diagnosis in these
investigations. How is it different in a patient with carcinoma of esophagus?
Chest Xray
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Department of Surgery
Barium swallow of the patient with dysphagia
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Discuss the management options for a patient with achalasia.
Discuss
the
advantage
and
disadvantage
of
medical,
endoscopic
(botilinium/pneumatic dilatation) and surgical treatment of achalasia cardia and the
potential complications of these treatment.
What complications patients can develop after Heller’s cardiomyotomy and how is
this avoided
What are the long term complications you may see in a patient with untreated
achalasia cardia
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Department of Surgery
Scenario 3
A 62 year old lady presents with 9 months history of retrosternal pain usually following a
meal. The pain gets better after taking H2 blockers
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What is the most likely diagnosis?
The patient undergoes barium swallow and the images are displayed below. What is
the diagnosis and what findings would support that
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What are the other types of hiatus hernia?
Differentiate between the three types in their incidence, presentation, complications,
investigations and treatment
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Senior Clerkship – Student Manual
Department of Surgery
Case #2 - Approach to a patient with vomiting/ epigastric pain and mass/loss of
weight and appetite
-----------------------------------------------------------------------------------------------------Assumptions:
Refer to the Objective manual. It is extremely important that the student refers to the
objectives prior to reading the following scenario and answering questions asked in it.
All students should read well in advance on this subject, before attending the problem
based seminar
Scenario 1
A 70 year old patient presents with 2 months history of upper abdominal pain and loss
of appetite. He has lost 10 kgs of weight during this time and has been vomiting for the
past 2 weeks.
What is the most likely diagnosis.
What features in history would support the diagnosis
What additional history would you ask in this patient.
On examination the patient is dehydrated. He has pallor. He has no jaundice. On
examination of the abdomen, there is an epigastric mass. Visible gastric peristalisis is
also noted.
What additional examination (general examination and abdominal examination) would
you carry out in this patient. What is the relevance of examining the supraclavicular
lymph node enlargement and how are they involved in carcinoma of stomach.
What features on clinical examination of the mass would differentiate it from pancreatic
mass, left lobe of liver mass and para-aortic lymph nodes
Should a per-rectal examination be carried out? If so why?
What are the features in history and examination of malignancy in proximal part/ body
and distal part (pyloric-antral region) of stomach?
What are the adjoining structures that carcinoma of stomach may infiltrate and what
symptoms would suggest that. What is the significance of persistent pain radiating to
back and feculent vomiting?
What investigation would you carry out in this patient? (hematological/ biochemicaldiagnostic and staging investigation)
The complete blood picture results of this patient is presented below
Hb- 8.6 gm%, MCV- 21fmol, MCHC 53gm%, WBC- 10x109/L
LFT- Bilirubin 22 umol/L, Alkaline phosphatase- 180 IU, ALAT 43, ASAT- 51 IU
Comment on the investigation results. What is the cause of anemia in this patient?
What electrolyte abnormality would you see in a patient with 2 weeks of vomiting?
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Senior Clerkship – Student Manual
Department of Surgery
The following are the findings on investigation of this patient
Barium meal
CT finding
Endoscopy finding
Comment on the abnormal findings. What is your diagnosis based on the investigation
How would you confirm the diagnosis? What is the most likely histological type of
carcinoma?
What investigation is most reliable in establishing the T stage of stomach carcinoma?
Following is the endoscopic ultrasound findings in a patient with carcinoma of stomach.
Familiarize with it
Endoscopic ultrasound showing 5 layers
Endoscopic ultrasound showing tumour
(T) and lymph node metastasis (LN)
Correlate the above findings with the diagrammatic picture of T stage displayed below
What is the role of CT scan and what lesions are likely to be missed in CT scan.
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Department of Surgery
What is the role of diagnostic laparoscopy in a patient with Carcinoma of stomach?
This is the laparoscopy finding in a patient with carcinoma of stomach. What abnormal findings do
you notice?
What is early gastric cancer? What are the endoscopic types? What percentage of these
patients has lymph node metastasis?
Which layer of stomach when involved is considered as advanced carcinoma of stomach?
What is Bormann’s classification of carcinoma of stomach?
What are the modes of spread of carcinoma of stomach?
Which are the major groups of lymph nodes that are involved in carcinoma of stomach.
Familiarize with the diagram below, which depicts the main lymphatic drainage
What are the predisposing environmental factors and what the predisposing lesions for
carcinoma of stomach. What is the role of H pylori induced gastritis
What are the differences between intestinal and diffuse type of gastric cancer in terms of
etiology, presentation, histopathology and prognosis?
What are the principles of management of carcinoma of stomach?
In a lesion which is operable, what surgical procedure is appropriate for a patient with
carcinoma of the pylorus, carcinoma of the body and carcinoma of cardiac and fundus region
of Stomach?
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Senior Clerkship – Student Manual
Department of Surgery
What are R0, R1 and R2 resection in carcinoma of stomach?
What is removed in radical (D2 gastrectomy)?
Identify the parts in the radical gastrectomy specimen displayed below
Gastrectomy Specimen
Vessels (encircled) and pancreas exposed
after radical gastrectomy
When the tumor is considered inoperable?
What important information would you seek in the histopathology report of gastrectomy
specimen that would determine the outcome in these patients?
Do these patients require adjuvant therapy? If so what
What is the long term outcome of patient with carcinoma of stomach?
What are the potential early and late complications of gastrectomy.
When are the following things carried out in a patient in the post-operative period following
gastrectomy: removal of NG tube, feeding, removal of sutures and discharge, assuming the
postoperative period was uneventful?
What are the non-epithelial tumours of stomach?
What is GIST?
Which cell do they arise from? What are the other sites of GIST? What receptors are
diagnostic of this condition?
How do you confirm the diagnosis and manage them
What medication can be used to control its growth?
What re the prognostic factors (clinical/ histological) that will determine the outcome
What is the presentation of patient with gastric lymphoma?
What is the common histological type? What is MALT?
The following are the findings of a patient with gastric lymphoma. Comment on it
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Senior Clerkship – Student Manual
Department of Surgery
Endoscopic finding of gastric Lymphoma
CT finding of gastric
How do you manage lymphoma of stomach?
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Senior Clerkship – Student Manual
Department of Surgery
Case #3: Obstructive Jaundice
Assumptions:
Refer to the Objective manual. It is extremely important that the student refers to the
objectives prior to reading the following scenario and answering questions asked in it.
All students should read well in advance on this subject, before attending the problem based
seminar
Case Scenarios:
Scenario 1
A general physician has referred to you a 65 years old male patient having yellowish
discoloration of his eyes for 2 months associated with vague upper abdominal discomfort. He
has poor appetite and has lost 15 kgs in the past one month. Patient also complains of clay
coloured stools and itching for the past 3 weeks. He is a smoker and consumes alcohol
regularly for the past 20 years and has been diagnosed to have chronic pancreatitis in the past.
1. What is the most likely diagnosis
2. What features in the history support the diagnosis of obstructive jaundice and the
possible cause for your diagnosis
3. What further information you would like to ask in the history?
4. What relevant examination would you carry out in this patient with the diagnosis you
have made? (general examination and abdominal examination)
On Physical Examination:
Patient looks emaciated, dehydrated and was clinically deeply jaundiced.
His Pulse rate is 88/min, Temperature is 37.3c, Blood Pressure is 120/80 and Respiratory rate
is 20/min. He had multiple scratch marks.
Chest Examination was unremarkable
Abdominal Examination: there was a palpable mass in the right hypochondrium and the gall
bladder was palpable.

How would you differentiate a distended gall bladder from liver and renal
mass?
 What are the causes of obstructive jaundice in patients when gall bladder is palpable
and in those when gall bladder is not palpable
 How do you clinically differentiate a pancreatic mass from liver mass and carcinoma
of stomach
 How would you investigate your patient? What abnormal findings would you expect
to see in these investigations to support your diagnosis? (investigations should
include- hematological, biochemistry, tumour markers and radiological investigations)
The patient underwent investigations and following are the results
His Laboratory results are:
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Senior Clerkship – Student Manual
Department of Surgery
Haematology resultsHb=7.8 g/dl, Hct 26/L, MCV 62 fmol, WBC= 13x109/l,
ANC=5X10^9/L. - Prothrombin time- 17 secs, INR- 1.8, APTT -52 secs
LFT results - Total Bilirubin=75 umol/L, direct 50 umol/L, ASAT=45 U/L, ALAT=65 U\L.
Alkaline Phosphatase= 850 U/L, Total Protein=35 Gm/L, Albumin- 22Gm/L
Electrolytes: Na=130
Creatinine=120umol/L.
mmol/L,
K=3.2
mmol/L,
Cl=105mmol/L,
Urea=10mmol/L,
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Analyze the results? What features in it support obstructive jaundice?
Comment on the Hb, albumin, coagulation profile and LFT results and discuss
why they are abnormal

Assuming the diagnosis is carcinoma head of pancreas, what radiological
investigations would you order? What features in it would suggest the
diagnosis and what features would suggest inoperability.
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The patient underwent MRI and the images are displayed. Comment on the
findings. What is “double duct sign” and its significance
MRI of the patient
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Department of Surgery
What features in the following MRI suggest inoperability?
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How would you like to proceed further? How do you relieve jaundice in a
patient who has inoperable carcinoma head of pancreas?
Is it necessary to establish histological diagnosis in carcinoma of pancreas
prior to surgery? If so how would you achieve it?
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Assuming that the pancreatic lesion was operable what is the definitive
surgical treatment for carcinoma of head of pancreas and periampullary
carcinoma
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Whipple resection specimen images are displayed below. Also displayed is a
diagrammatic representation of anastomosis in Whipple resection. Delineate
the parts in resected specimen and the anastomosis in the diagram. What are
the major complications of Whipple resection
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Senior Clerkship – Student Manual
Department of Surgery
Resected specimen
Diagrams of reconstruction
What is the difference between the two?
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What are the potential complications of a patient with obstructive jaundice
undergoing surgery? How would you optimize these patients prior to surgery?
What is the role of adjuvant therapy in patients following surgery in carcinoma of
pancreas? What chemotherapy are commonly used
What are the predisposing factors and lesions for carcinoma of pancreas
What is periampullary carcinoma
What is the mode of spread of carcinoma of pancreas
How is carcinoma of body and tail of pancreas different in its presentation from head
of pancreas? Which of them present early and why?
What are the malignant cystic lesions of pancreas? Mention the important differences
between them in terms of age of presentation, radiological findings, diagnostic
investigations, treatment and prognosis.
How do you differentiate them from benign cystic lesions of pancreas?
Following are the images of patients with cystic lesions on MRI. Differentiate
between them:
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Senior Clerkship – Student Manual
Department of Surgery
MRI T2 weighted images
Figure 1
Figure 2
Figure 3

What is the prognosis in patients with cancer of pancreas? What factors determine the
outcome
Scenario 2
A 53 year old lady has been complaining of fainting attacks usually in the morning after
waking up or after a bout of exercise. She feels better after intake fluids with glucose.
What is the most likely diagnosis?
What other clinical features are characteristic of this condition?
How do you biochemically establish the diagnosis?
How do you localize the lesion preoperatively?
What is the role of ultrasound/ contrast CT scan and nuclear study in these patients?
The following is the T2 weighted MRI scan of this patient. Comment on the finding
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Department of Surgery
The following is the angiogram of this patient.
Comment on it
What is the medical treatment of this condition?
How do you treat it surgically?
Mention the other types of endocrine tumours.
What are the clinical features of Zollinger Ellison syndrome? How do you diagnose this
condition?
Following is gastrinoma triangle.
What are its boundaries and its relevance?
How do you treat these patients? (medical/ surgical)
Discuss the important clinical features of Glucogonoma and VIPOMA and their management
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Department of Surgery
What is the following skin finding called and in which condition is it seen?
Scenario 3
A 62 year old man complains of progressive upper abdominal pain for the past 3 months. He
has recent history of loss of appetite and weight. He is known case of cirrhosis of liver due to
Hepatitis C infection following blood transfusion 10 years back. On examination his liver is
found to be nodular and there was large 5x6 cms mass in the right lobe.
What is the most likely diagnosis?
How do you differentiate clinically (history and examination) hepatoma (hepatocellular
carcinoma) from secondaries in liver ?
This is the laparotomy findings of patient with Hepatoma and secondaries in liver. Note the
difference
Hepatoma
Secondaries
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Senior Clerkship – Student Manual
Department of Surgery
What are the predisposing factors for hepatoma
Discuss the principle of investigations (CBC/ hepatitis profile/ tumour markers/ radiological
investigations) and management of hepatoma. (resection/ chemoembolization/ radiofrequency
ablation).
What is the role of adjuvant therapy. How would you follow up these patients
Following is the contrast CT scan of this patient. What are the likely diagnosis and the
abnormal findings to support it?
What are the common causes for secondaries in liver?
How do you investigate a patient who presents with secondaries in liver? (investigations to
look for primary) and investigations to confirm the diagnosis of metastasis
From which primary tumour are the metastatise to liver with better prognosis and which have
poor prognosis?
What is the role of hepatectomy in these patients?
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Senior Clerkship – Student Manual
Department of Surgery
Case #4 - Approach to patient altered bowel habits and bleeding per
rectum
--------------------------------------------------------------------------------------------------------------------Assumptions:
Refer to the Objective manual. It is extremely important that the student refers to the objectives
prior to reading the following scenario and answering questions asked in it.
All students should read well in advance on this subject, before attending the problem based
seminar
Scenario 1
A 47 year old lady presented with 2 months history of abdominal pain and easy fatigability. She
also complains of 6 weeks history of melena and in the past 2 weeks has altered bowel habits. She
has lost 8 kgs in the last 2 months. Ten years back she had undergone laparoscopic
cholecystectomy. There is no family history of carcinoma of the colon.
What is the most likely diagnosis?.
What additional history would you like to elicit?.
What are the main differences in presentation, in patient with right sided and left sided colon
cancer and what are the features of presentation of rectal cancer?
Why is intestinal obstruction common in left sided growth?
What is tenesmus and sense of incomplete evacuation in a patient with rectal cancer and what is
its significance?
What is the difference in the presentation, if patient was bleeding from carcinoma of caecum,
descending colon and rectal cancer?
What is the relevance of family history of carcinoma of colon in this patient? Family history of
carcinoma of which other primary site is of significance?
What examination (general /abdominal) would you carry out in this patient?
On examination there was mass felt in the right iliac fossa measuring 4x5 cms. It was hard in
consistency with restricted mobility.
What additional examination would you carry out in this patient?
What are the differential diagnoses of right iliac fossa mass in a female patient and what are the
salient features to differentiate them (history/ clinical features).
What investigation would you carry out that will help you in establishing the diagnosis?
Why is it important to see the entire colon on colonoscopy prior to carrying out colonic resection
in a patient with carcinoma of colon?
What is synchronous and what is metachronus tumour? How often are they seen in patients with
carcinoma of the colon?
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Following are the images of barium enema and endoscopy of this patient. Comment on the
findings and what features in them are suggestive of the diagnosis
What is the most likely histopathology report you would expect on biopsy?
What are the non-epithelial tumors of the colon?
What staging investigation would you order?
What are the sites of metastasis in carcinoma of the colon?
To which group of nodes the carcinoma in the right side of colon/ left side of colon/ rectum and
anal canal spread
To what adjoining structures can rectal cancer directly infiltrate and what will be the symptoms in
these patients
How do stage carcinoma of colon (Duke’s staging/ TNM staging
The following is the CT scan images of the patient. What abnormal findings do you notice?
Based on the above findings what is the appropriate surgical treatment?
How would you prepare this patient for surgery (general preparation and specific for patient
undergoing colonic surgery)?
In a patient undergoing right hemicolectomy what part of intestine is removed?
What is neoadjuvant therapy? What is its role in treatment of carcinoma of colon?
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Department of Surgery
When would you give patient adjuvant chemotherapy? What chemotherapy is usually
administered? What is FOLFOX regime?
How would you treat liver metastasis when it involves one lobe and when it involves both lobes?
How would you follow up patients with carcinoma of colon after resection?
What investigations would you carry out and how frequently?
What is the role of estimating CEA in post op period? Mention some benign conditions it may be
elevated in? What is the role of endoscopy during follow up and how often is it carried out
What are the predisposing environmental factors and what are predisposing pathological lesions
(conditions) for carcinoma of colon.
What genetic abnormalities are usually associated with sporadic carcinoma of the colon?
What are the acute manifestations of carcinoma of the colon?
What percentage of them present acutely
How would you manage a patient who presents with acute colonic obstruction due to carcinoma
at rectosigmoid junction?
Will the management differ if a patient is fit and haemodynamically normal and in a patient who
is elderly and has several co-morbidities?
What are abdomino perineal resection, anterior resection, Hartman’s procedure and mucous
fistula?
Indicate what surgeries would you recommend for patient with cancer in the descending colon/
sigmoid/ rectosigmoid junction, low rectum and anal canal?
In which of these surgeries the patient would require permanent colostomy and why?
What is the presentation of anal cancer?
What are its predisposing lesions /Factors?
What are the histological types of anal cancer?
Where does it normally spread?
What is the principal of treatment of anal cancer?
Scenario 2
A 71 year old patient undergoes abdomino perineal resection for a low rectal growth. He has a
colostomy fashioned. On inspection of the colostomy on the first postoperative day the following
finding is noted.
What is your conclusion?
What should be done for this patient?
What are the other complications of colostomy?
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Department of Surgery
Comment on the complications shown below
How do you classify colostomy based on location, appearance and function?
What is the ideal site to fashion a sigmoid and transverse colostomy
What are the indications for colostomy (permanent and temporary)?
What are the types of colostomy bags and what advice would you give the patient regarding its
care?
Scenario 3
A 22 year old patient, presented with bleeding per rectum for the past 6 weeks. On questioning, he
informed that his 28 years old brother and 32 year old sister were diagnosed to have carcinoma of
the colon.
What is the most likely diagnosis?
What additional history would you elicit?
What examination would you carry out in this patient?
What investigation would you carry out to establish the diagnosis?
The following is the finding on colonoscopy:
Comment on it
What are the features of this condition in terms of the following?
a. age at which these polyps appear and pattern of inheritance
b. what is the genetic abnormality
c. what are the common symptoms of presentation
d. what is the number, distribution and histological type of these polyps in Familial adenomatous
polyposis (FAP)
e. What are the extra-intestinal manifestation in these patients (eye/ soft tissue/ bone etc)
f. What is the major concern about these polyps?
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Department of Surgery
g. How do you screen for this complication and at what age do you start.
h. How do you treat these patients? What medication is used to slow the progress of these
polyps?
i. What are the surgical options in treating these patients and what are the advantage and
disadvantage of these options. When do you recommend the patient to undergo surgery
j. At what other sites are these patients likely to develop tumours (benign/malignant) during the
long term follow up (surveillance) after undergoing colectomy for colonic polyps
k. What are the features of the variants of familial adenomatous is (FAP)Attenuated
FAP, Turcot’s and Gardner’s syndrome
l. What is Hereditary Non polyposis colorectal cancer (HNPCC)? How do you manage them
m. What is Amsterdam’s criteria
n. What are the main differences between HNPCC and FAP
The following are patients with variants of FAP. Identify the pathology and the variants of
FAP they are associated with
Patient 1-clinical finding
Patient1- X-ray finding
Patient 2- CT – Abdomen
Patient 2- CT Abdomen
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Senior Clerkship – Student Manual
Department of Surgery
Patient 3- CT Brain
Patient 4- Retinoscopy finding
Scenario-4
These are the resected specimens of polyps in patients.
Comment on the gross appearance of the polyp in patient 1 and patient 2
Patient 1
Patient 2
What is the significance of these 2 types of polyps in terms of risk of malignancy?
What features on gross appearance in a polyp increase its risk of malignancy?
What are the presentations of a patient with polyp and what are its complications?
What are the types of benign/ premalignant and malignant polyps of colon?
What is the risk of malignancy among the 3 types of premalignant polyps?
How do you manage them?
What are hyperplastic/ metaplastic polyp?
What are the characteristic features of 2 types of Hamartamatous polyps (Juvenile and Peutz
Zegher's syndrome) in terms of pathology, presentation and management?
The following are the findings of a patient with familial polyposis. What is the diagnosis and
identify the abnormality in all the images displayed below that support the diagnosis.
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Department of Surgery
Clinical finding
Endoscopy finding
CT scan of the patient
laparotomy finding
How do you treat a 1cms sized sessile polyp found on colonoscopy? What is done during
colonoscopy that will facilitate the identification of site of polypectomy later on?
What should be the management, if the polyp is found to be malignant and the resection
margin is positive for malignancy post polypectomy?
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Department of Surgery
Case # 5 - Approach to a patient with intra-abdominal mass (right iliac
fossa / left hypochondrium / left iliac fossa)
---------------------------------------------------------------------------------------------------------------Assumptions:
Refer to the Objective manual. It is extremely important that the student refers to the
objectives prior to reading the following scenario and answering questions asked in it.
All students should read well in advance on this subject, before attending the problem based
seminar
Scenario 1
A 28 year old lady presents with a mass in left hypochondrium for the past 1 year. She is a
known sickler and complains of recurrent pain with enlargement of the left hypochondrium
mass.
What is the likely cause of this mass.
What features support your diagnosis on clinical examination? How do you differentiate it
from colonic, renal and tail of pancreas mass?
What are differential diagnoses for left hypochondriac mass (pathological diagnosis).
What are the common causes for splenomegaly (infective (viral- parasital- bacterial)/
haematological/ vascular/ metabolic/ tumours)?
In patients with sickle cell disease, the spleen generally undergo autosplenectomy and is not
palpable. Why are they generally palpable in Omani patients?
What are the indications for splenectomy?
Can it be done laparoscopically? In which haematological condition it is relatively easy and
why?
What are the indications for splenectomy in sickle cell disease, Thalassaemic and ITP
patients?
What preparations are required before patients undergoes splenectomy in general. What
vaccines need to be given and when do booster doses need to be given.
What precautions are required in a patient with sickle cell disease patient undergoing
surgery?
The following is the operative picture of a patient with sickle cell disease who has undergone
splenectomy and cholecystectomy. What are the gross changes noted in the spleen that is
reflective of the disease and why has this patient undergone cholecystectomy. What else is
displayed in this picture?
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What post-operative complications are seen in patients post Splenectomy?
What complications are seen specifically in patients with sickle cell disease undergoing
splenectomy and what measures are taken in post-operative period to reduce it?
This is the chest x-ray of a patient who had undergone splenectomy for sickle cell disease.
Comment on the complication you see and how would you treat it
What are the changes seen in blood post Splenectomy?
What is splenunculi? Where do you normally find them? Why should they be removed during
splenectomy for haematological disorder and in which haematological disorder failure to
remove them may lead to relapse of the condition. Splenuculi is shown below
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Scenario 2
A 51 year old female patient presents with right iliac fossa pain and mass of 3 weeks
duration. On examination the mass is measuring 4x5 cms , firm in consistency with restricted
mobility.
What are the differential diagnoses of right iliac fossa pain which are inflammatory/
infective/ tumours (benign/malignant)?
What additional differential diagnosis you will entertain which is seen exclusively in women
and exclusively in men
What clinical features will differentiate a mass arising from pelvis from non-pelvic intraabdominal mass?
Formulate a plan of investigation for a inflammatory / infective and malignant mass arising in
right iliac fossa.
What are the general principles of management of them?
Familiarize with the findings and diagnosis shown in following investigations for various
right iliac fossa mass. Also recollect the clinical features and principle of management of
these patients
--------------------------------------------------------------------------------------------------------------Barium enema- ca caecum
Apple core deformity
junction
Barium enema- Ileocaecal tuberculosis
contracted caecum/ fixity of ileocaecal
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CT Abdomen- Appendicular mass
Complex heterogenous mass/ faecolith
CT Abdomen- Intussusception
Sausage shaped mass
-------------------------------------------------------------------------------------------------------------CT abdomen- Mesenteric cyst
Smooth walled/ homogenous
CT abdomen- ovarian cyst
arising from pelvis- Smooth walled/ homogenous
Scenario 3
A 61 year old female patient presents with pain and left iliac fossa mass for the past 1 week.
She is febrile and complains of mild abdominal distension. She has history of constipation
and recurrent left iliac fossa pain for 2 years. On examination she is febrile (380 C) and has a
tender mass in left iliac fossa
What is the most likely diagnosis?
What predisposes them to this?
What investigations would you carry out to confirm the diagnosis?
How do you treat this condition when they present with diverticulitis, localized abscess and
when they present with peritonitis
What are the other complications of this condition?
Following is the radiological investigation of a patient with similar condition. What are the
abnormal findings?
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Barium enema
CT Abdomen of Diverticular abscess
Following is Hinchey’s classification for your reference used to guide in the management of these
Patients:
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Case #6 - Approach to patient with ischaemic limb
Assumptions:
Refer to the Objective manual. It is extremely important that the student refers to the
objectives prior to reading the following scenario and answering questions asked in it.
All students should read well in advance on this subject, before attending the problem based
seminar
Scenario 1:
A 73 years old lady brought by her family to the emergency department with sudden
onset severe right sided leg and foot pain for the last 3 hours duration. She is known to
have Diabetes, Hypertension and Coronary artery disease. She is on oral hypoglycemic
agents, antihypertensive medications and warfarin.
How do you approach this patient and what other history do you want to know?
You carried a systematic physical examination. Her pulse rate is 130 per minute which
is irregular, first and second heart sound are normal, there is equal air entry bilaterally,
abdomen is soft and there is no abdominal masses. The right leg is tender with absent
distal pulses compared to normal pulses on left leg.
What important examinations / signs you want to elicit in your general examination and local
examination of right leg?
-
List your differential diagnosis for acute lower limb pain?
-
List your differential diagnosis for acute lower limb ischemia?
-
What are the clinical manifestations of acute limb ischemia?
-
What is the most likely diagnosis in this patient?
-
What classification do you know for Acute limb Ischemia? What is the purpose of
using such classification(s)?
-
What is the difference between an embolus and a thrombus?
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-
What are the possible sources of arterial emboli? Familiarize with the figures below
-
Where are the common sites for embolic occlusions in the body?
-
What is your workup for this patient?
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-
Comment on the findings of investigations displayed below
-
What are the main components in the management of this patient?
-
What are your treatment options in managing this patient?
-
Familarize with figures given below for embolectomy and fasciotomies for
compartmental syndrome
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Femoral embolectomy
-
Is this patient at risk of developing acute renal failure? Why? And how to prevent
it?
-
What is compartment syndrome? How many compartments in the leg, and how do
you avoid leg compartment syndrome in this patient?
Compartments of the leg
Incisions for forearm fasciotomy
-
What is reperfusion injury?
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-
What is Trash foot/ Blue toe syndrome/ Cholesterol emboli?
CHRONIC LIMB ISCHEMIA
Scenario 2
A 60 years old man has been referred to surgical outpatient clinic with one year complaint of
both leg pain. His pain has worsened gradually. He is unable to walk without pain. As well he
has developed ulcers over his right sided 4th and 5th toes. Clinically, he is in pain. Both legs
showed signs of inadequate blood supply. There is no palpable abdominal mass; there is a
palpable thrill over his left femoral pulse which is felt with difficulty. His distal pulses are
absent.
- What is your differential diagnosis for chronic lower limb pain?
-
What is your differential diagnosis for chronic limb ischemia?
-
What is the most likely diagnosis in this patient?
-
What is the underlying pathology for most of chronic lower limb ischemia and what
is its pathophysiology?
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What is the relation between diabetes and atherosclerosis?
What are the clinical manifestations of chronic limb ischemia?
-
What is claudication? Claudication distance? Types of claudication(s)?
-
What is ABPI, how do you do it, what is its implications?
-
What is the use of Doppler and Duplex Ultrasound scanning in this patient?
-
What is your workup for this patient?
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-
What different types of angiography do you know about?
-
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How do you manage this patient?
-
What is meant by risk modification in treating chronic limb ischemia?
-
What are the existing treatment options for this patient?
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Case #7 - Approach to patient with suspected breast cancer
-----------------------------------------------------------------------------------Assumptions:
Refer to the Objective manual. It is extremely important that the student refers to the
objectives prior to reading the following scenario and answering questions asked in it.
All students should read well in advance on this subject, before attending the problem based
seminar
---------------------------------------------------------------------------------------------------------------Scenario1: Early (operable) breast cancer
A 56 years old female , presented w to breast clinic with history of painless right breast lump,
since 3 weeks duration, increasing in size, no nipple discharged , no family history of breast
cancer, no previous breast disease.
On examination normal left breast and axilla, right breast 2.5x1.8 cm, hard, ill-defined lump
in the upper outer quadrant, the axilla enlarged mobile lymph.
1. What are risk factors of breast cancer and what further questions would to ask the
patient?
2. What features on clinical examination suggest breast cancer in this patient?
3. What are the next steps to come to the diagnosis?
4. If the diagnosis is breast cancer, what is the T stage of the disease and discuss breast
cancer staging?
This is the mammogram of the patient.
1. Describe the different views of mammograms and discuss the findings?
2. What are the features of breast cancer on mammogram?
3. What are the different between multifocal and multicentric disease?
This is the breast Ultrasound of the patient, please discuss the finding. What features on US
suggest malignancy?
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1. Core biopsy and FNAC was done can you describe the finding on this slide.
2. What are the different between these 2 biopsies?
3. Discuss breast cancer prognosis based on immunohistochemistry.
Patient was diagnosed to have breast cancer, and histopathology showed invasive Ductal
carcinoma, grade I, Oestrogen receptors (ER) positive, progesterone receptors (PR) positive
and HER2 was negative and ki 67 proliferations was 30%.
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1.
2.
3.
4.
5.
6.
7.
What is the prognosis of this patient?
Discuss the histology of breast cancer.
What the best modality to treat this patient?
What are the indication of Breast Conservative(BCS)Surgery?
What are the indications for sentinel node biopsy?
What other axillary surgery you know?
What is the role of Multi-Disciplinary Meeting (MDT) is breast cancer?
---------------------------------------------------------------------------------------------------------------Scenario 2 case of locally advance breast cancer (LABC)
36 years old female notice left breast lump since 6 months, previously did not seek any
medical advice because she was reluctant to be exposed to male physician, now was
convinced by her family to come to get medical advised,
On examination: left breast oedematous ,huge mass occupying all the upper breast, hard, ill
defined, mobile but fixed, axilla multiple enlarged fixed lymph nodes.
1. whats are the clinical signs of locally advoanced breast cancer(LABC)?
2. How would you advise patients to seek medical advice at early stage when the disease
is curable and what public action would you advise?
3. What is the T stage of this patient?
4. What is the surgical role in this patient ?
5. Discuss this mamoogram finding, what are the fiding which suggest LABC.
6. When the tumour is fixed and mobile?
7. How further you investigate this patient for staging?
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1. CT chest/abdomen for staging of the patient, please discuss the abnormalities.
2. This patient was discussed in Multi-Disciplinary Meeting (MDT), why this patient
was discuss in MDT and what is the importance of this type of meeting?
3. What is the best modality in treating this patient?
Lung Nodule
Liver Nodule
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---------------------------------------------------------------------------------------------------------------Scenario 3: Inflammatory breast cancer
24 years old female, 34 weeks pregnant, presented to breast clinic with 5 weeks history of
left breast redness, no fever, was seen in local health centre, was treated with 2 weeks broad
spectrum antibiotics with no response, no further test was advise. No significant medical or
surgical history and no family h/o breast cancer.
On examination: erythematic left breast with retroareolare large mass, ill-defined and
enlarged fixed lymph nodes.
1. How would you assess this patient?
2. In view of poor response to broad spectrum antibiotic, what is the most common
diagnosis?
3. How would you differently do if you were the physician in the local health centre?
Patient had Breast ultrasound, please discuss the finding, and what features suggest of
malignancy of on this breast ultrasound?
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Core biopsy done showed invasive Ductal carcinoma, immunostains was triple negative.
1. What dose triple negative means from histology point and prognostic view?
2. What is the best treating modality for this patient?
3. Is chemotherapy safe for this pregnant patient?
4. When surgery is indicated in this patient?
---------------------------------------------------------------------------------------------------------------Scenario 4 : Paget’s disease
A 60 years old fema;le presented to breast clinic with 2 months histrory of spontanous
bleeding from the right nipple , associated with nipple distruction few weeks later, denies and
breast lum nor previous breast disease.
on examination :distructive roght breast with bleeding, no breats lumps and no palpable
axillary lymph nodes.
1. What is the commonest diagnosis?
2. What history would you ask to support your diagnosis?
3. How would you asseess this patient?
Mammogram and breast us done showed Intra Ductal growth which discharge from the
nipple was sent for cytology was suggestive of Paget’s disease. Patient was staged and was
discussed in multidisciplinary meeting,
1. Discuss Paget’s disease and what are the stages this disease may present?
2. If the disease is limited to the breast, what type of surgery would you advice this
patient to undergo?
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Case #8 - Approach to patient with chest/ head/ abdominal trauma
Assumptions:
Refer to the Objective manual. It is extremely important that the student refers to the
objectives prior to reading the following scenario and answering questions asked in it.
All students should read well in advance on this subject, before attending the problem based
seminar
HEAD TRAUMA PROBLEM BASED SEMINAR
Scenario 1:
A 25 year old male, involved in a motor vehicle collision. On arrival to the emergency
department, his airway is clear. He is breathing spontaneously without difficulty and he is
hemodynamicaly normal. He has a scalp contusion over the right side of his head. There is a
strong smell of alcohol on his breath but he is able to answer questions appropriately. His
eyes are open but he appears confused and pushes away the examiner’s hand when examined
for response to pain.
 What are the principles of management of this patient?
 Calculate his Glasgow coma scale score
He was thought to have a concussion and to have alcohol intoxication. He was kept in the
emergency department for observation. One hour later, the patient was more drowsy, briefly
open his eyes to painful stimuli, and demonstrates an abnormal flexion response to painful
stimuli on the right side and withdrawal on the left. His left pupil is now 2mm larger than his
right. Both pupils react sluggishly to light. His verbal response consists of incomprehensible
sounds.
 Re-calculate the Glasgow coma scale score
 Can alcohol account for the above mentioned findings?
 What are the next steps in managing this patient?
This is his CT scan


Describe the radiological findings
What structure is injured in this patient?
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


List the causes of the secondary brain injury and how can they be avoided.
What are the non-surgical components of managing this patient?
Compared to other types of intracranial hemorrhage, what is the prognosis of his
condition?
Scenario 2:
A 40 year old, non-helmeted, motorcyclist involved in an motor vehicle collision, is brought
to the emergency department.



What is the above finding and what is it suggestive of?
What other signs might this patient have with this condition?
What should be avoided in the management of this patient?
On examination, he has unequal pupil and response only to painful stimuli by abnormally
flexing his arm, opening his eyes, and speaking incomprehensively. When not stimulated, his
respirations are very noisy.
 How would you manage this patient?
 Calculate his Glasgow coma scale score
 What is Le Fort’s classification of facial fractures?
This is his CT scan



Describe the radiological findings
What structure is injured in this patient?
Is this injury more common in the young or the elderly and why?
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
In addition to a CT head, what other radiological investigations are needed in this
patient and why?
------------------------------------------------------------------------------------------------------THORACIC TRAUMA PROBLEM BASE SEMINAR:
Scenario 1:
A 26 year old male driver, unrestrained, involved in a head on collision with a large truck. He
is brought to your emergency department. On arrival, the patient is screaming in pain with the
following vital signs. BP 70/40 mmHg, Pulse 140 per minute, Respiratory rate 32 per minute,
SPO2 78%.



What are the principles of management of this patient?
Specify the steps that you will follow in assessing and managing this patient.
If this patient had the following findings on examination, what would be your
diagnosis and what intervention would you take?
o Deviated trachea to the left
o Distended neck veins
o Hyper resonance on percussion of the right hemi-thorax
o Absent breast sounds on the right hemi-thorax
o Decrease breast sounds on the left hemi-thorax
This is a chest X-ray of the above described patient
 Describe your findings
 What is the mechanism of injury that leads to above condition?
 Is the chest X-ray an appropriate investigation in this patient?
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Scenario 2:
A 27 year old male is brought to your emergency department after sustaining a gunshot injury
to the right side of his chest. His vital signs are: BP 80/50 mmHg, Pulse of 144 per minute,
Respiratory rate 28 per minute, SPO2 85%.
 If this patient had the following findings on examination, what would be your
diagnosis and what intervention would you take?
o Trachea is centrally located
o Collapsed neck veins
o Dullness on percussion of the right hemi-thorax
o Absent breast sounds on the right hemi-thorax



Describe your findings
Is the chest X-ray an appropriate investigation in this patient?
What are the life threatening conditions related to thoracic injury that need to be ruled
out in the primary survey assessment of a trauma patient?
This ECHO is of a 16 year old boy who was stabbed in the epigastric area
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

What is beck’s triad and what does it indicate?
How would you manage this patient?
This is the chest X-ray of a 28 year old male involved in a high speed motor vehicle collision.
The patient has normal vital signs and asymptomatic.
 Describe the chest X-ray findings.
 What other findings on a chest x-ray that might suggest this injury?
 Where is most likely location of this injury?
 What is the mechanism of injury that leads to his condition?
 How would you manage this patient?
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ABDOMINAL TRAUMA:
Scenario 1:
A 47 year old male driver, restrained, involved in a motor vehicle collision, is brought to your
emergency department. On arrival he is unconscious with the following vital signs, BP 90/50
mmHg, Pulse 120 per minute, Respiratory rate 22 per minute, SPO2 89% on room air.



What are the principles of management in this patient?
State in order of priorities of resuscitation
Looking at the picture above, list the possible structures that might be injured in this
patient.
After intubation, the patient saturation improves to 92% on a 100% FiO2. It was noted that
the patient had decrease air entry in the left side of the chest, with dullness on percussion.
 What is your suspected diagnosis?
 What would be your management?
A chest tube is inserted in the left 5th intercostal space. 300cc of blood drains. Multiple rib
fractures are noted clinically on the left side on insertion of the chest tube.
 How is this clinically relevant with regards to abdominal trauma?
 If this patient remains hemodynamically abnormal despite resuscitation, what are your
options of management?
After the infusion of 2 liters of normal saline intravenously, the patient has the following vital
signs: BP 105/85 mmHg, Pulse 105 per minute, SPO2 98%, Respiratory rate 14 per minute.
 After completion of the primary and secondary survey, what is your next step in
managing this patient?
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




Describe the findings in the image.
What is the clinical significance of the above findings?
What are your options of management?
If an operative intervention is chosen, what are the short term and long term possible
complications of your management?
How can these complications be avoided?
The passenger that was in the same vehicle is brought to your emergency department. He is
awake and alerts with the following vital signs, BP 110/80 mmHg, Pulse 110 per minute,
Respiratory rate 22 per minute, SPO2 92% on 100% oxygen mask. He’s complaining at left
side chest and abdominal pain. This is his chest X-ray



Describe the above findings.
What is the mechanism of injury that results in the above finding?
What is the management?
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Case #9 - Approach to patient with thyroid malignancy
Assumptions:
Refer to the Objective manual. It is extremely important that the student refers to the
objectives prior to reading the following scenario and answering questions asked in it.
All students should read well in advance on this subject, before attending the problem based
seminar
Scenario-1
A 49 year old male patient presented with a thyroid swelling of 9 months duration. It has
been gradually increasing in size and in the last 6 weeks it has been increasing more rapidly.
He has also noticed some hoarseness of voice in the past 1 month. There is no family history
of thyroid malignancy.
What is the most likely diagnosis?
What features in the history will support the diagnosis?
What additional history do you need to ask to support the diagnosis and possible predisposing
factors for malignancy?
What is the relevance of family history?
On examination there was 4x4cms thyroid nodule in the right lobe. It was hard in
consistency. There were multiple cervical nodes palpable in the right lateral group (111 and
1V), which are shown below
What additional examination would you carry out in this patient?
What is the likely diagnosis? What abnormal clinical findings would support your diagnosis?
Which type of thyroid malignancy generally spread to lymph nodes?
What sites would you look for blood borne metastasis?
What structures are commonly involved in direct infiltration? In which type of thyroid
malignancy is this commonly seen?
How would you establish the diagnosis?
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Appreciate the salient microscopic features of different thyroid malignancy shown below
Papillary ca with ground glass nuclei
and Psamoma body
Medullary carcinoma with Amyloid
Strauma
Follicular ca with follicular formation
Anaplastic carcinoma with poorly
differentiated cells
Which type of malignancy are not diagnosed by FNAC and why? What characteristic
features you see in papillary carcinoma of thyroid
What investigations would you order to stage thyroid malignancy in the neck and at distant
site?
Discuss the difference between Papillary, Follicular, Medullary, Anaplastic carcinoma and
lymphoma under the following features
1. predisposing factors including genetic predisposition if any
2. presentation- including age /sex/ symptoms and signs
3. cell of origin
4. propensity to spread to lymph nodes, blood and direct spread
5. difference in histological features
6. optimum treatment
7. prognosis
8. Post-operative follow up and screening for recurrence (tumour marker / radiological
investigations).
If the patient in scenario 1 is diagnosed to have papillary carcinoma of thyroid, how would
you manage the patient?
What preoperative investigations would you carry out to look for fitness of the patient and
investigations specific for patients undergoing thyroid surgery?
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What features in thyroid malignancy would categorise the patient to low risk and high risk
group of thyroid malignancy (AGES/ AMES/ MACIS/ TNM).
What is the optimum treatment of a patient with papillary carcinoma of thyroid? What is the
role of lymph node clearance? Which group of cervical nodes are usually cleared?
What is the post-operative management of this patient? When would you do a radioactive
iodine scan and what precautions are required prior to carrying it out. What is the role of
suppressive thyroxine dose and what are its long term complications.
How often do you follow up these patients and what investigations are carried out.
What is the long term outcome of this patient?
Comment on radiological investigations of 2 patients with follicular carcinoma of thyroid (in
terms of cause/ complications/ and findings).
How do you treat these patients?
Scenario 2
A 72 years old patient presented with 6 weeks history of rapidly increasing thyroid swelling.
He also complains of hoarseness of voice for the past 3 weeks and difficulty in swallowing
and occasional stridor. On examination the thyroid is enlarged and feels hard in consistency.
What is the most likely diagnosis?
What features in history support the diagnosis?
What additional history would you ask?
What further examination would you carry out?
How would you confirm the diagnosis?
What additional investigations need to be carried out?
The following is a patient with anaplastic carcinoma. What features in inspection is
supportive of the diagnosis. This patient undergoes a procedure. What procedure has he
undergone and why?
Comment of the CT scan of a patient with anaplastic carcinoma of thyroid
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How would you treat this patient?
Comment on the survival of patients with this condition
Scenario 3
A 37 year old lady presents with goiter of 6 months duration which has been progressively
increasing in size. She also has noticed multiple swellings in her tongue for the past 3 months
(figure shown below).On examination she has a goiter measuring 4x3 cms and cervical
lymph node enlargement (level 3 and 4 lymph nodes)
What is the diagnosis? What features support the diagnosis?
What biochemical investigation would you carry out?
Which MEN is this condition associated with it. What are the types of MEN and the
pathologies associated with them
What is the mode of spread of medullary carcinoma of thyroid? Which group of nodes do
they spread and what are the common sites of haematogenous spread of this tumour.
Which site in thyroid are parafollicular cells commonly found
What is the difference between sporadic and familial medullary thyroid cancer in terms of
age of presentation, genetic abnormality, site of lesion and prognosis
What investigation would you carry out in these patients to assess the primary tumour and
metastasis?
Following is the ultrasound finding of thyroid nodule with medullary carcinoma.
Familariase with the findings
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Arrow showing thyroid nodule (medullary ca) which is hypoechoic, irregular margin and
microcalcification
What is the optimum surgical treatment of this patient with reference to thyroid gland and
node clearance?
Total thyroidectomy specimen
Showing multifocal lesion in
Medullary thyroid cancer
Total thyroidectomy with lymph node
clearance
What are the potential complications of this surgery?
What are the factors that determine the prognosis in this condition?
How do you follow up his patient?
What is the role of estimation of calcitonin levels? Why is thyroid scan not carried out in
these patients in postoperative follow up?
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Case # 10 - Scrotal swellings
Objectives
At the end of the session students should be able to
1. Discuss differential diagnosis of acute and chronic scrotal swellings and understand
that proper history and focused clinical examination are key to differentiate between
them,
2. Discuss the management of different scrotal swellings,
3. Understand why trans scrotal biopsy of testis is avoided in suspected tumors,
4. Explain the value of tumor markers in the management of testicular mass,
5. Have an overview of the current management of testicular tumors,
Scenario 1
A 40 yr old man was seen in Urology OPD for left scrotal mass. Pt had first noticed the
swelling 6 months back while taking bath. There was no change in the size of swelling since
then. He denies any urinary symptoms, fever or weight loss. Clinical examination showed a
fluctuant and transilluminant mass behind the left testis which was non tender. Left testis is
palpable. Right testis and cord were also normal.
1. What is the most likely diagnosis?
2. What is the most appropriate investigation for this patient?
3. Discuss the findings of the following study?
4. What is the most appropriate treatment for this patient?
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Scenario 2
A 30 yr. old young man was referred to urology OPD for evaluation of right scrotal mass,
which was noticed one week back. There was no h/o trauma, fever or urinary symptoms.
Clinical examination showed enlarged Right testis without any fluctuation or
transillumination. Epididymis and cord were found to be normal.
1. What is the most likely diagnosis?
2. What is the most appropriate blood investigation?
3. Discuss the findings of the diagnostic imaging given below?
4. How will you confirm the diagnosis?
5. Given below is an intraoperative photograph from the surgical procedure that the
patient underwent. Discuss the procedure?
6. What is the most appropriate management?
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20 yr. old young man was referred to urology OPD for evaluation of right scrotal mass, which
was noticed one month back. There was no h/o trauma, fever or urinary symptoms. Clinical
examination showed a solid swelling arising from the right testis. S. AFP was very high.
S.HCG was WNL.
1. What is the most likely diagnosis?
2. How will you investigate him?
3. Discuss the findings of the below given investigation?
4. What is the most appropriate management for him?
5. Given below is image from another 30 yr old patient. Discuss the management?
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Case # 11 - Hematuria
Objectives
At the end of the session students should be able to
1. Discuss the common causes of hematuria,
2. Identify risk factors for bladder and renal cancers,
3. Understand the histological types of bladder and renal tumors,
4. Plan the diagnostic and staging work up of a patient with painless hematuria,
5. Discuss management principles of renal tumors,
6. Understand the difference in the management of muscle invasive and nonmuscle
invasive bladder tumors,
7. Have an overview of urinary diversion procedures,
8. Explain various metabolic complications of the use of bowel in bladder
reconstruction,
9. Take consent for radical cystectomy
Scenario 1
A 50 year old gentleman was referred to urology for painless haematuria. Pt noticed blood in
the urine towards the end of micturation on two occasions over the last 1 month. Urine
stream is good except when he pass clots. He is a heavy smoker for the last 20 yrs.
Abdominal examination was normal.
1. What is the most likely diagnosis?
2. How will you investigate this patient?
3. Discuss the finding from the image given below?
4. What staging investigations are needed for him?
5. How will you treat him?
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Scenario 2
A 60 yr. old male patient is referred to urology OPD with h/o blood in urine on and off for
the last 6 months. He has passed long ribbon like clots on two occasions associated with
Right flank pain radiating from loin to groin. He has loss of appetite and weight loss.
Investigations showed hypercalcemia.
1. What is the most likely diagnosis?
2. How will you make the diagnosis?
3. Discuss the findings in the image given below?
4. Is biopsy routinely indicated?
5. How will you treat him?
6. Given below is the image of another patient who is diabetic and hypertensive. Discuss
the management?
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Part 2
Scenario 1
A 50 yr old patient being investigated for painless hematuria was found to have a papillary
growth 1.5 cm in size in the bladder on Ultrasonography. Both kidneys were normal. Urine
microscopy showed RBCs but cytology was positive. Urine culture was sterile. S. Creatinine
was normal.
1. What is the most appropriate next step in the management of this lesion?
2. What is the implication of urine cytology remaining positive after your initial
management?
3. What is the further management, if this lesion turns out to be high grade TCC?
Scenario 2
A 60 yr old patient being investigated for painless hematuria was found to have a papillary
growth 3 cm in size near the left ureteric orifice on ultrasonography. S. Creatinine was
normal. He has no co-morbidities.
1. What is the next step in the management if this lesion is shown to be muscle invasive?
2. What all information do you seek from the investigation given below?
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3. What is the definitive treatment aimed at cure for such a patient?
4. Given below is the investigation from another patient. What will be your initial
intervention if his S. creatinine were to be found high?
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Case #12 - Bladder outlet obstruction
Objectives
At the end of the session students should be able to
1. Explain lower urinary tract symptoms ( LUTS)
2. Understand the difference between acute and chronic retention and its implications on
management,
3. Explain the mode of action of main classes of drugs used to treat BPH
4. Discuss the indication for surgical intervention in BPH and potential complications,
5. Discuss the clinical application of S. PSA.
6. Plan investigations for a suspected case of Carcinoma Prostate,
7. Discuss management of localized and metastatic Carcinoma prostate,
8. Discuss why screening for Carcinoma prostate is controversial,
Scenario 1
A 72 year old man complaining of progressive deterioration of urine stream inspite of being
on medical therapy for the last 2 yrs.
1. What is the likely diagnosis?
2. Plan the investigations and treatment for this man?
3. Interpret the investigation given below?
4. What information do you seek from the below investigation in him?
5. What is TURP syndrome?
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Scenario 2
A 60 year old female on insulin is seen in A@E with 3 weeks history of urinary incontinence
in spite of going frequently to the toilet and passing urine. Abdominal examination showed a
mass arising from the pelvis with suprapubic dullness. S. Creatinine is 244 umol/L. Patient is
eager to return home.
1. How will you manage this patient?
2. Discuss the potential complications of Foley catheterization in this patient?
Scenario 2
A 55 year old man is referred from local health centre with S.PSA of 6.4 ngm/ml. He has no
significant LUTS. DRE showed grade 1 smooth firm prostate.
1. What is the most likely diagnosis?
2. What is the most appropriate next step in the management?
3. Discuss the image given below?
4. Below is the schematic representation of the diagnostic procedure that this patient
underwent. Discuss the procedure?
5. What further investigations are needed if biopsy turns out to be positive?
6. What is the curative surgical treatment if his Prostate cancer is found to be organ
confined?
7. Are there any other options?
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Scenario 3
A 72 yr old man underwent TURP for acute retention of urine. His histopathology report
showed adenocarcinoma prostate with Gleason score 4+3 invoving 10% of chips.
1. What further investigations are needed?
2. How will you manage him?
Scenario 4
A 74 yr old man with retention of urine is found to have hard fixed prostate enlargement. His
PSA is 876 ngm/ml.
1. How will you investigate him?
2. Name the investigation given below and discuss the findings?
3. Which kidney is obstructed?
4. How will you manage him?
5. What is Hormone refractory Prostate cancer?
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Case #13 - Paediatric surgery
Assumptions
Refer to the Objective manual. It is extremely important that the student refers to the
objectives prior to reading the following scenario and answering questions asked in it.
All students should read well in advance on this subject, before attending the problem based
seminar
Case 1:
A 4 week old, term boy was evaluated at 3 weeks of age for a soft swelling in his right groin.
This was a reducible right inguinal hernia. An elective repair was scheduled for one week
later. However, the night before surgery, the infant became fussy and refused his feeds. He
became inconsolable and when the mother checked his diaper, she noted a firm, tender mass
in his right scrotum. On the way to see you for evaluation, the infant vomited stomach
content.
What are the management priorities for this child?
When is surgery indicated?
What are the sides of inguinal hernia?
Explain the embroyology of inguinal hernia?
Describe the steps of incarcirated inguinal hernia reduction?
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Case 2
A four week old, first born, white male infant fed well for the first 3 weeks of life. He then
had intermittent spitting of formula, which graduallybegan to occur at every feed. He was
seen by a local pediatrician and was diagnosed with formula intolerance. A soy formula was
prescribed. The vomiting persisted and occurred at every feed and became moreforceful with
the passage of time.
Two days later, Alimentum formula was prescribed. On re-evaluation by the pediatrician one
day later, gastro-esophageal reflux was diagnosed and recommendations were made for
smaller, more frequent feeds, rice cereal in the feeds and upright positioning. The vomiting
continued and increased in forcefulness.Two days later, the infant child is brought to youfor a
second opinion. He has not had a wet diaper or tears in 8 hours.
What is your diagnosis?
What are your management priorities?
How to confirm the diagnosis?
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The following are the finding on investigation. Comment on the findings:
1. Upper G I contrast study
2. Ultrasound
What is paradoxical aciduria?
When is surgery indicated?
What are different ways of surgery?
The patient had undergone surgical intervention. What surgery has been carried out
When should you start feeding post op?
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Case 3 :
A chubby, healthy 6 month old boy was noted byhis mother to have intermittent, severe, but
brief episodes of crampy abdominal pain that cause him to draw up his legs. These cramps
persisted for 24 hours with no other symptoms except for spitting up of a formula feed
once.He passed no stools. The next day he was extremely lethargic, but arousable. He went
for 6 hours without a wet diaper.
He passed red blood per rectum.
What is your diagnosis?
What is the significant of passing blood per rectum?
Explain the different between inttussuceptum and intussuccepient?
Explain the pathophysiology of inttussussception?
What is your next steps?
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What are the different types of reductions ?
What is the maximum pressure applied for pneumoreduction? why?
Reduction was successeful , what is your next step?
When you are going to discharge this child ?
When is your follow up?
If the same child the contrast study was not successeful reduction
What are your management priorities?
When is surgery indicated?
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Case 4
A term female infant fed well for the first 8 weeksof life. After a routine feed, she vomited
green material. She passed a normal stool 3 hours later. At the next feed,she vomited a large
amount of green material at the initiation of the feed. She was evaluated at an outside
hospital.
She was transferred for your evaluation. She vomited 30 cc of green material spontaneously
en route to the hospital. On exam, her abdomenis soft and non-tender.
What is your differential diagnosis?
What is the significant of bilious vomitting?
What are your management priorities?
If this child started to pass blood per rectum,What is this indicate?
What is whirlpool sign?
Explain the anatomy of intestinal rotation and malrotation?
When is surgery indicated?
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What is ladd’s procedure?
Case5 :
An 10 year old school boy felt nauseated and lost his appetite on Friday morning at school.
He developed peri-umbilical pain at lunch. He was seen by the school nurse and sent home
with presumed gastroenteritis. That evening, he vomited his dinner. He slept poorly through
the night and vomited his breakfast the next morning. The pain was now lower in his
abdomen and more to the right. He continued to eat poorly that weekend with little oral
intake, but on Sunday evening, he felt better. However, on Monday morning he had
atemperature to 101 F. He walked bent over like an old man. He hesitated to cough. He is
evaluated by you at this point, 54 hours after the onset of symptoms..
What is your diagnosis?
Indicate all the signs of acute appendicitis?
What are the spectrum of stages of appendicitis?
What are your management priorities?
Why did he feel better on Sunday night?
What are the investigations needed?
When should surgery be done?
What are the complications of acute appendicitis?
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