Self-directed learning questions
Instructions: The following questions are intended to provide guidance on the
types of questions asked during evaluation of the surgical course. It is
suggested that students use the questions to define learning objectives for
themselves during clinical attachments and when reading about a specific
topic. Some students might like to write answers to the questions whilst others
can use the questions as a stimulus to further reading.
Describe the content categories of an admission history
What is the purpose of a progress note?
Resuscitation
1. Describe how the length and radius of an IV cannula influences the delivery rate.
2. What are the various placement sites for central venous access? What are the pros and cons
of each?
3. Differentiate between the following fluids and their use in resuscitation: Hartmann’s, normal
saline, hypertonic saline, colloids
4. Discuss the indications for the following blood products: packed red cells, fresh frozen
plasma, platelets, cryoprecipitate, factor VII
5. What are the daily fluid requirements for a 25 year old 70kg male? If he were NPO how
would provide his fluid requirements?(give specific type of fluid, volume and rate of
administration)
Surgical infections
1. List the factors which contribute to infection following a surgical procedure
2. List the types of surgical infections
3. What is necrotising fasciitis? How is it diagnosed and treated?
4. List the causes of postoperative pyrexia ad discuss the diagnostic evaluation
5. Identify the antibiotic of choice for acute cholecystitis, perforated sigmoid diverticulitis, lung
empyema, vascular graft infection.
6. What can be done pre and intra operatively to decrease the incidence of postoperative
infection in surgical patients?
7. How are human bites treated?
Nutrition
1. Which surgical patients need nutrition support?
2. List the advantages and disadvantages of enteral and parenteral nutrition
Preoperative assessment
1. Discuss aspects of the preoperative assessment of patients with respect to cardiovascular
fitness. Which investigations are likely to be of use?
2. How do the following variables impact on risk of surgery.: age, urgency of intervention, comorbidities (pregnancy, diabetes, COPD, ischaemic heart disease, valvular heart disease,
renal insufficiency)
3. Discuss the components of informed consent using a specific procedure as an example
4. Describe factors that might impair coagulation or increase risk of bleeding
Post-operative assessment
1. List the conditions necessary for discharge of patient to home or to the unit following a
general or spinal anaesthetic
2. Compare and contrast parenteral vs enteral analgesics.
3. Describe the role of epidural and nerve blocks in pain management
4. Enumerate the disease states and surgical interventions for patients at high risk for
nutritional impairment
5. List the forms of nutritional support
6. What are the advantages and disadvantages or enteral and parenteral support
Post-operative complications
1. Write short notes on wound infection, dehiscence, incisional hernia
2. List the 4 classes of surgical wounds and the frequency with which each type becomes
infected
3. What are the indications for prophylactic antibiotic use preoperatively? How are antibiotics
chosen? Give 5 examples with alternatives for patients with penicillin allergies
4. Which antibiotics would be prescribed for: acute appendicitis, acute perforated appendicitis,
perforated DU, compound fracture, central line infection, dog bite
5. For each of following postoperative scenarios discuss the clinical manifestations, appropriate
diagnostic work-up and management:
a. Fever
b. Wound dehiscence
c. Bleeding
d. Pain
e. Wound drainage
f.
Shock/hypotension
g. oliguria
6. For each of the following respiratory complications describe the aetiology, clinical
presentation, management, methods of prevention: atelectasis, pneumonia, aspiration
pulmonary oedema, ARDS, PE, fat embolus
7. What are the potential causes of hypotension in the post operative period?
8. Discuss the differential diagnosis of post op chest pain
9. Discuss the purpose of a nasogastric tube and list the risks, indications, and contraindications
for insertion and removal.
10. List the indications, contraindications, and possible complications of passage of a urethral
catheter.
11. Describe the types of surgical drains, including their advantages and disadvantages; describe
the indications for drain placement, advancement and removal, as well as possible
complications associated with their use. Define the differences between therapeutic and
prophylactic drainage.
12. List the indications, contraindications, and complications associated with the insertion of
central venous catheters, pulmonary artery catheters and peripheral arterial cannulae
13. List the indications, contraindications and complications associated with placement of chest
tubes; participate in the placement and removal of the same.
14. Name five major etiologic factors leading to bleeding disorders
15. Discuss common surgical condition leading to disseminated intravascular coagulation.
16. Discuss strategies to prevent the following complications post-operatively: surgical site
infection, respiratory complications, line sepsis, oliguria, hypotension, gastrointestinal
bleeding, hyperglycaemia, adrenal insufficiency
17. List the normal serum rage of the following electrolytes: K+, Na+, Cl-, HCO318. List symptoms or physical findings of dehydration
19. List and describe the objective ways of measuring fluid balance
20. Describe the possible causes of the following:
a. Hypernatraemia
b. Hyponatraemia
c. Hypokalaemia
d. Hyperkalaemia
21. List the electrolyte composition of the following solutions:
a. Normal saline,
b. solution 18
c. 5% dextrose
d. Hartmann’s
22. Indicate the mechanisms, methods of compensation, differential diagnosis and treatment of
the following:
a. Acute metabolic acidosis
b. Acute metabolic alkalosis
c. Acute respiratory acidosis
d. Acute respiratory alkalosis
Questions continue below
General surgery
Acute abdomen
1. List the major categories of disease which cause pain in the abdomen
2. Discuss the characteristics of the major types of acute abdominal pain especially character,
time course and location
3. Describe the clinical signs and significance of peritonitis
4. What are the common diagnostic tests (laboratory and radiologic) used to investigate the
acute abdomen.
5. Identify the common cause of severe abdominal pain that do not require surgery
6. Identify the common cause of severe abdominal pain that require surgery
7. Discuss the differential diagnosis of a patient who presents with shock and acute abdomen
8. How is the differential different in children, the elderly and pregnant patients
9. How does the embryology and pattern of nervous enervation of the abdominal structures
help analyse the cause of abdominal pain?
10. Write short notes on clinical signs used in the assessment of the acute abdomen – e.g.
guarding, obturator sign etc.
11. Explain the rationale for the various diagnostic modalities employed in the evaluation of the
acute abdomen: laboratory test, diagnostic imaging
12. Identify 6 groups of patients presenting with acute abdominal pain which require immediate
laparotomy (i.e. as soon as possible with no delay for resuscitation measures)
13. Discuss common non-surgical conditions that can present with abdominal pain
14. Discuss unique causes of abdominal pain in patients who are immunosuppressed
15. Discuss the approach to patients with postoperative abdominal pain
GI bleeding
1. Define haematemesis, haematochezia, melena, FOB+ stool. State their significance with
regard to level of bleeding source
2. Outline the resuscitation plan for a hypotensive patients with a massive Gi haemorrhage
3. In order of frequency list the most common cause of upper and lower GI bleeds in the
general adult population
4. Outline the work-up of an adult patients presenting with occult blood on rectal exam
5. List criteria for surgical intervention in a patient with gastrointestinal haemorrhage.
6. What diagnostic modalities are available for the work-up of lower GI bleeding?
7. Why is angiography considered both diagnostic and therapeutic?
8. What are the indications for surgery in patients presenting with diverticular bleeding?
Oesophageal disease
1. Describe the typical and atypical symptoms of oesophageal disease
2. Describe two important tests for diagnosing structural problems in the oesophagus and two
for functional disease
3. List the relative merits of medical and surgical treatment of common benign oesophageal
disease such as GORD, achalasia
4. Discuss the diagnostic work-up and treatment plan for a patient with Barrett’s oesophagus
5. How are oesophageal tumours staged?
6. What are the different histological types of oesophageal cancer? How are their aetiologies
different?
7. Describe surgical treatments for oesophageal cancer
8. What is the role of adjuvant therapy for oesophageal cancer?
9. Enumerate the palliative treatment options for oesophageal cancer
10. Define dysphagia and odynophagia
PUD
1. Describe the pathogenesis of gastric and duodenal ulcers
2. Discuss the role of helicobacter pylori in ulcer formation
3. Identify the pathophysiology of ulcers and discuss the significance of their location for
development of complications
4. List the main symptoms of PUD
5. What is the role of imaging in diagnosis of PID?
6. Outline the medical treatment of PUD
7. List clinical features of the Zollinger-Ellison syndrome
8. List the complications of PID that require surgical treatment
9. Classify the different histologic types of gastric neoplasms
10. List the general principles of curative and palliative surgical procedures for gastric neoplasms
and discuss the role of adjunctive treatments.
11. What is the difference in a truncal vagotomy and a highly selective vagotomy?
12. Why is pyloroplasty performed with a truncal vagotomy?
13. List the possible post-gastrectomy syndromes
Biliary disease
1. List the predisposing factors for gallstones
2. List the common types of gallstones and describe the pathophysiology involved in their
formation
3. Describe the signs and symptoms of biliary colic. Contrast these with the symptoms of acute
cholecystitis
4. List the tests commonly used to diagnose calculus biliary tract disease. Describe the
indications for, limitations of and potential complications of each.
5. Describe the likely natural history of a young patient with gallstones
6. List the potential complications of biliary calculi
7. Outline the medical and surgical management of a patient with acute cholecystitis
8. Describe the symptoms and signs of choledocholithiasis; describe the management of this
problem
9. Contrast the liver enzyme abnormalities in obstructive jaundice and viral hepatitis
10. List the most common bacteria that cause cholangitis
11. What is the differential diagnosis in the presentation of epigastric and/or RUQ pain, nausea
vomiting and fever?
12. How does diabetes affect the natural history of gallstones?
13. What are the advantages of laparoscopic cholecystectomy over open cholecystectomy? Are
there any disadvantages?
14. List the common complications of laparoscopic cholecystectomy.
15. What is the differential diagnosis of a patient with jaundice?
16. Discuss pre-hepatic, intra-hepatic and post-hepatic causes
Hepatic surgery
1. Define portal hypertension and classify its aetiology
2. What are the clinical manifestations of portal hypertension
3. List complications of portal hypertension
4. Outline the diagnostic methods appropriate for each complication of portal hypertension
5. Describe the medical and surgical treatment of a patient with ascites
6. Describe the prognosis of a patients with liver failure
7. What is the initial diagnostic radiologic test for a suspected liver mass?
8. Compare the aetiologies of the various types of cystic masses in the liver
9. What are the preferred methods for treated liver abscesses?
10. Describe the treatment modalities available for hepatic neoplasms
11. Discuss the indications for liver transplantation
12. List the causes of hepatomegaly
13. Discuss the clinical and radiological features to distinguish the different types of benign and
malignant hepatic lesions.
Pancreas
1. List the most common aetiologies of acute pancreatitis
2. Define acute and chronic pancreatitis
3. What are the complications of acute pancreatitis?
4. What are the complications of chronic pancreatitis?
5. Discuss the prognostic criteria for acute pancreatitis
6. What tests are performed for patients with suspected acute pancreatitis?
7. Define the role of Ct in assessing the severity of acute pancreatitis
8. Outline the management of pseudocysts
Spleen
1. Discuss management options for splenic trauma
2. Identify early and late complications following splenectomy
3. What are the indications for elective splenectomy?
4. Describe causes complications and treatment of splenic vein thrombosis
5. List the causes of splenomegaly
6. Define hypersplenism and contrast it with splenomegaly
Abdominal masses
1. Describe the most frequently encountered retroperitoneal masses
2. What are the most frequently encountered lymphomas?
3. Discuss the DDx of a mass in the inguinal region. How can they be distinguished – clinically
and radiologically?
4. Which condition predispose to the development of a hernia
5. What are the anatomic differences between inguinal (direct and indirect) and femoral
herniae?
6. Contrast incarcerated and strangulated hernia
7. Describe the potential sites of abdominal wall hernia
8. Describe the clinical factors contributing to the development of an incisional hernia
Vomiting
1. Discuss the differential diagnosis of a patient who presents with vomiting
2. Describe the clinical presentation and aetiologies of gastric outlet obstruction
3. Describe the signs and symptoms of small bowel obstruction. Contrast these with those of
large bowel obstruction
4. What is the aetiology of small bowel obstruction
5. Discuss the potential complications and management of sbo
6. Contrast the presentation and management of partial vs complete obstruction
Abdominal distension
1. List the differential diagnosis of intestinal obstruction
2.
Identify the signs and symptoms of large bowel obstruction
3. Identify the signs and symptoms of small bowel obstruction
4. Differentiate a small bowel from a large bowel obstruction
5. What is a closed loop obstruction? What are the implications for management?
6. Discuss the diagnostic studies available for a large bowel obstruction
7. List the known risk factors for colon carcinoma
8. Identify the common symptoms for carcinoma of the colon, rectum and anus
9. List the laboratory and radiologic studies for the diagnosis of colorectal carcinoma
10. Outline specific preoperative and postoperative management issues
11. Discuss the surgical treatment of colon carcinoma, particularly regarding anatomic
relationships
12. Discuss the indications for adjuvant treatment of colorectal cancer
13. Discuss the role of CEA in the management of colorectal carcinoma
14. Discuss the staging of colorectal carcinoma and their associated five-year survival
15. Discuss the effect of obstruction or perforation on the prognosis of colorectal carcinoma
16. What is the current status of colorectal cancer screening?
17. How are colorectal cancer patients followed?
18. What are the specific issues to be considered in post-operative management of patients post
bowel resection?
19. Discuss the treatment of liver metastases
20. What inherited conditions are associated with increased risk of colorectal cancer?
21. Discuss mechanical bowel preparation prior to surgery
Diverticular disease
1. Discuss the major aetiologies of diverticular disease including age, diet, and vascular
anatomy of the colon
2. Describe the clinical signs and symptoms of diverticular disease. Differentiate between the
signs and symptoms of diverticulitis and diverticulosis including signs of inflammation and
bleeding
3. Discuss the complications of diverticular disease including bleeding, obstruction, perforation
and fistula formation
4. Describe the management of symptomatic but uncomplicated diverticulosis. How does it
differ from the management of complicated diverticular disease?
5. When surgically managing diverticulitis, discuss when a two stage procedure versus a one
stage procedure is indicated.
6. What is the role of percutaneous catheter drainage for a diverticular abscess? How does the
patient benefit if this procedure is successful?
IBD
1. Differentiate ulcerative colitis and crohn’s disease in terms of history, pathology, radiology
findings, treatment and risk of cancer
2. Describe the presentation and potential complications of UC and Crohn’s
3. Discuss the role of surgery in the treatment of patients with UC who have the following
complications: intractability, toxic megacolon, cancer, perforation, bleeding
4. Discuss the role of surgery in the treatment of Crohn’s patients who have the following
complications: fistula, bleeding, stricture.
Benign perianal disease
1. Discuss the anatomy of haemorrhoids
2. Differentiate between internal and external haemorrhoids
3. Describe the role of the anal sphincters in maintaining faecal continence
4. Outline the principles of management of patients with symptomatic external haemorrhoids
5. Describe the symptoms and physical findings of patients with internal haemorrhoids
6. Outline the principles of management of patients with symptomatic internal haemorrhoids
7. Discuss the role of anal crypts in perianal infection
8. Describe the various types of perianal infections including perianal, perirectal ischiorectal
and pelvirectal.
9. Outline the symptoms and physical findings of patients with perianal infections
10. Outline the principles of managing patients with perianal infections
11. Define fissure-in-ano. Describe the symptoms and physical findings of patients with fissurein-ano and outline the principles of management.
12. Discuss the management of rectal prolapsed
13. What is the differential diagnosis of rectal masses?
Breast disease
1. Differentiate between benign and malignant disease of the breast; include their
presentation, physical examination findings and treatment.
2. Outline the diagnosis and management of a patient with nipple discharge.
3. List the major risk factors for breast cancer
4. Describe the current recommendations for screening mammography
5. Outline the fundamentals for diagnosing and managing a breast mass
6. List the diagnostic modalities and their sequence in working up a patient with a breast mass
7. Describe the categories of malignant breast disease and the difference in their management
8. Outline the presentation and management of patient with inflammatory breast cancer
9. Describe the staging for breast cancer
10. Outline current treatment options for a patient with non-invasive breast cancer
11. Outline current treatment options for a patient with invasive breast cancer
12. Outline the need for lymph node removal and its risks and benefit
13. Describe the rationale for adjuvant chemotherapy, hormonal therapy and radiation therapy
for breast cancer
Skin and soft tissue
1. Describe the gross morphologic and pathologic differences between benign and malignant
naevi and discuss the approach to diagnosis.
2. List the predisposing factors for malignant melanoma
3. Describe the major prognostic variables of melanoma.
4. Discuss methods of staging melanoma
5. Outline local, regional and systemic therapy for melanoma
6. Distinguish gross pathologic differences between basal and squamous cell carcinomas. List
predisposing causes and likely areas of occurrence. Discuss the prognosis of BCCs and SCCs
7. Describe the clinical features of a sarcoma presenting in the head, neck, trunk and extremity.
8. Describe the techniques to diagnose and adequately stage a soft tissue tumour of the
extremity.
9. List factors that are associated with a poorer prognosis for soft tissue sarcomas
Biopsy techniques
1. What are the different types of biopsy?
2. What is FNAC? What are the pros and cons of it?
3. What are the potential complications of biopsy?
Thyroid and parathyroid
1. Describe the common types of neck masses and how to distinguish them clinically
2. Describe the most common neoplastic neck masses and their origin
3. How should a neck mass suspicious for carcinoma be worked up?
4. Discuss the evaluation and treatment of a patient with a thyroid mass
5. Compare and contrast the different types of thyroid malignancy
6. What is MEN syndrome?
7. What are the complications of thyroid surgery?
8. What are the indications for parathyroidectomy?
9. What complications may occur after parathyroid surgery?
Adrenal gland
1. Describe the clinical features of Cushing’s syndrome. Distinguish Cushing’s syndrome and
disease.
2. What are the surgically treatable causes of hypertension?
Pneumothorax
1. Describe the principles governing the use of under-water seals in chest drains.
2. What are the indications for inserting a chest drain – as an emergency and electively?
Burns
1. How is the percentage burn surface area of a burn calculated? What is the significance of
BSA?
2. How do you differentiate 1st, 2nd and 3rd degree burns anatomically and clinically? What is
the significance of this?
3. What are the signs of inhalation injury?
4. List the indications for hospitalisation of a patient with burns
5. What are the indications for transfer of a patient to a burns centre?
6. What are the fluid requirements of a burns patient? How are they calculated?
7. What are the complications of burn injuries?
Soft tissue injury
1. What are the priorities in the management of a patient with a facial injury?
2. Discuss the treatment for the following injuries of the hand: lacerations, puncture wounds,
crush injuries, open fractures, extensor tendon injuries, flexor tendon injuries, finger
amputation.
Airway adjuncts and intubation
1. State three early and three late signs of hypoxaemia
2. State the indications, concentration/litre flow rate, advantages, disadvantages and nursing
considerations for each of the following oxygen delivery devices
a.
Nasal cannula
b. Oxygen mask
c. Venture mask
d. Non-rebreather mask
e. Bag-valve-mask
3. State the indications for insertion of the oropharyngeal and nasopharyngeal airway
4. State the various methods and their indications for opening the airway
5. State three indications for endotracheal intubation
6. State three complications associated with endotracheal intubation
Haemodynamic monitoring
1. Describe the purpose of the pulmonary artery catheter. What are complications associated
with its use?
2. Discuss the clinical manoeuvres to improve cardiac output
Mechanical ventilation
1. What are the goals of mechanical ventilation
2. Differentiate between volume cycled and pressure cycled ventilators
3. Distinguish between positive end expiratory pressure and pressure support
4. What are the benefits and potential complications of PEEP
5. Discuss weaning criteria from mechanical ventilation
6. What is oxygen toxicity?