Question 1

Describe how you would approach this scenario?

Accepted Answer

This is a situation requiring emergent attention and you should quickly make your way to the ward.

The patient should be assessed in a safe, logical manner using an A, B, C, D, E approach to quickly identify problems. I would wash my hands, introduce myself and then quickly assess A and B as, from the history, C is of most concern.

Airway
If the patient is alert and communicative a maintained airway can be assumed.

Breathing
I would assess respiratory rate, oxygen sats from the sats probe and listen to the patient’s chest for equal air entry and breath sounds.

Circulation
I would ascertain the precise volume of blood produced and whether this is ongoing. I would check the pulse, blood pressure and capillary refill time of the gentleman to assess his current circulation. I would check his urine output if catheterised.

I would insert two large-bore venflons into both antecubital fossae for venous access and take blood at the same time for crossmatch, baseline bloods, coagulation screen and lactate. Depending on the BP I would start a 250-500ml fluid challenge.

I would examine the abdomen, looking for epigastric tenderness, peritonitis or the fullness of a tumour.

D and E
I would assess the patient’s cognitive state and ensure that he/she was not losing blood from his/her back passage or anywhere else.

If I felt I needed help at any stage I would ask the nursing staff to call for assistance.

Question 2

The patient has vomited around 500ml of fresh blood and a further 250ml since you assessed him. He is slightly tachycardic with a slightly low BP but otherwise ok at present. How will you resuscitate him?

Accepted Answer

The patient is actively losing his circulatory volume and, given the above information, is in type II circulatory shock (15-30% loss).

I would continue to give fluid challenges to assess whether his blood pressure responds. I would also ensure that blood is available should his haematemesis continue.

Question 3

The patient’s haemoglobin comes back as 11.5. Is this an accurate reflection of his current blood volume?

Accepted Answer

Both haemoglobin and haematocrit will remain normal when taken immediately following acute blood loss. This is because during acute blood loss, both red blood cells and plasma are lost in a similar ratio.

Laboratory values are not helpful in acute haemorrhage because values do not change from normal until redistribution of interstitial fluid into the blood plasma occurs after 8-12 hours.

Question 4

Give some potential causes for the above patient’s symptoms

Accepted Answer

Haematemesis with fresh, red blood is indicative of an upper GI bleed. Causes of upper GI bleeding can be remembered by their location:

Oesophagus: oesophageal ulcer (aspirin, NSAIDs), oesophageal varices (secondary to portal hypertension), malignancy, Mallory-Weiss tear

Stomach: gastric ulcer (H.pylori / aspirin / NSAIDs / malignancy), gastric adenocarcinoma, gastric varices (secondary to portal hypertension), angiodysplasia

Duodenum: duodenal ulcer (H.pylori / aspirin / NSAIDs / malignancy), duodenal varices (secondary to portal hypertension), malignancy, angiodysplasia

Question 5

How will you manage this gentleman?

Accepted Answer

I would treat this man according to ALS guidance. If an AMPLE history was available I would get this from the nurses or paramedics who had already looked after the patient. I would assess his airway and ensure he receives oxygen from a non re-breath mask set at 100%. I would listen to his chest to ensure equal air entry and the heart for murmurs or irregularities. I would get an ECG and place two large bore antecubital fossa cannulae and start IV fluids. Analgesia would be given as required. A full set of bloods plus a group and save would be sent and an ABG/VBG could be done to check immediate gases and Hb’s in ED. I would check his BM and ensure he was catheterised if required. Once stabilisation had been performed a full history and examination would be appropriate.

Question 6

What is your differential diagnosis?

Accepted Answer

Differentials are multiple and include pneumonia, MI, epigastric irritation or GI bleed.

Question 7

Is this patient in hypovolaemic shock?

Accepted Answer

This patient is exhibiting signs of stage 3 shock. This would indicate that there was occult blood loss if there were no signs of external haemorrhage.

Question 8

How would you proceed?

Accepted Answer

A FAST scan could be used in ED to establish internal bleeding looking at the heart, spleen, kidneys and pelvis. If this was not available and the patient was stable a CT would be helpful. It is likely this patient with no history of trauma may have an upper GI bleed which with his grade three shock would be a candidate for surgery. I would inform my senior colleagues, anaesthetist and the CEPOD list and prepare the patient for theatre.

Question 9

How would you manage this gentleman?

Accepted Answer

This man is clearly in shock and requires simultaneous assessment and resuscitation. I would assess him using an A, B, C, D approach to identify the most serious problems first. He will be managed according to the CCrISP algorithm and IV fluids shall be given with high flow oxygen via a non re-breath mask. A blood gas would provide information regarding his acid-base balance, electrolytes, Hb and lactate which is a direct indicator of shock. The most likely cause in this scenario is intra-abdominal sepsis and he may well require a laparotomy. I would seek help from my senior colleagues and prepare this man for surgery once stabilised on the ward. I would also inform ITU of this patient and the potential need for a bed following his operation.

Question 10

What is metabolic acidosis?

Accepted Answer

Metabolic acidosis occurs when the kidneys are unable to excrete hydrogen ions or increased levels of lactate thus driving the acid-base equation to the right causing an increased respiratory rate to help remove CO2 and reduce the acidity in the body.

Question 11

The gentleman has a low urine output. Name some causes of acute renal failure.

Accepted Answer

Pre-renal causes: hypovolaemia, sepsis or low cardiac output Intrinsic renal causes: ATN, hypoxia and hypoperfusion, toxin and drug related nephropathy, hepatorenal and abdominal compartment syndrome Post-renal causes: bladder or ureteric obstruction or blocked catheter

Question 12

On a further set of bloods the gentleman was noted to be hyperkalaemic. How would you treat this?

Accepted Answer

An ECG should be performed and a second sample should be sent to the lab while treatment for hyperkalaemia is started to ensure the initial result was not haemolysed or anomalous. Calcium gluconate 10-30mls of 10% solution should be given IV to protect the heart and allow for membrane stabilisation. 10 units of Actrapid should be given in 100mls of 50% dextrose to help drive the potassium into the cells and this can be additionally helped with a 5mg salbutamol nebuliser. When the potassium is driven into the cells it is exchanged for hydrogen ions so it is important to be aware that the patient will become acidotic and sodium bicarbonate should be on standby to overcome this metabolic imbalance.

FREE CORE SURGERY INTERVIEW QUESTIONS

Core Surgery Interview Questions Online

Sample Clinical Question 1