Consultant General Surgery oral assessment prep

Knowledge: Any discrete lump in a woman of this age requires formal triple assessment, and I would not discuss any surgical option until I have a tissue diagnosis. Clinically and sonographically this is suspicious, and the family history of early breast cancer plus ovarian cancer in a second-degree relative on the same side raises the possibility of a BRCA1 or BRCA2 pathogenic variant, which would change surgical decision making, systemic therapy options and family screening.

Management: I would perform bilateral mammography with tomosynthesis and targeted ultrasound of the breast and axilla, and take an ultrasound-guided core biopsy of the mass plus a fine needle aspirate or core of the indeterminate node, with clip placement in the tumour and in the node if it is positive.

Ethics and communication: Her request for bilateral mastectomy is driven by fear, and my professional duty is neither to dismiss it nor to accede to it, but to slow the process down, name the fear, and provide the information she needs to make an autonomous decision once the diagnosis and genetic status are known.

Reference: NICE Guideline NG101, Early and Locally Advanced Breast Cancer: Diagnosis and Management, 2018 updated 2023; NCCN Clinical Practice Guidelines in Oncology, Breast Cancer and Genetic/Familial High-Risk Assessment, 2024

Knowledge: This is a transient responder with a high grade splenic injury and active contrast extravasation, and the central question is not the CT grade but the physiology and the resources available. Haemodynamic instability that does not respond to resuscitation is an absolute indication for laparotomy regardless of grade, whereas a stabilising patient with an isolated splenic injury and a blush is exactly the population in whom angioembolisation converts a likely splenectomy into splenic preservation.

Management: I would complete the ATLS primary survey with tranexamic acid within three hours, activate the massive haemorrhage protocol if he needs further transfusion, keep him warm and correct coagulopathy guided by viscoelastic testing. Given the transient response, I would take him directly for angiography with the operating theatre on standby and a surgeon accompanying him, and ask for proximal splenic artery embolisation for a high grade injury with a blush.

Ethics and communication: Consent here is layered, because he is alert and has capacity, and he is entitled to understand that non-operative management carries a real chance of needing emergency surgery later, that embolisation may cause splenic infarction, abscess or post-embolisation syndrome, and that splenectomy carries lifelong infection risk; I would take him through both pathways and record his agreement.

Reference: Coccolini et al, WSES Splenic Trauma Classification and Guidelines for Adult and Pediatric Patients, World Journal of Emergency Surgery 2017; ATLS Advanced Trauma Life Support Student Course Manual, 10th edition, American College of Surgeons 2018

Knowledge: New atrial fibrillation, tachycardia, oliguria and a rising CRP on day five after a low rectal anastomosis is an anastomotic leak until proven otherwise, and the patient feeling well is a well-recognised trap because the systemic inflammatory response often precedes clinical peritonism, particularly in a pelvic leak walled off from the general cavity. This anastomosis carries high risk because it is low, the patient has had neoadjuvant radiotherapy, and no defunctioning stoma was made.

Management: I would review him myself, take a full set of observations, arterial blood gas, lactate, blood cultures and repeat bloods, start sepsis management including fluids, oxygen and broad-spectrum antibiotics, and involve intensive care early for the atrial fibrillation and oliguria. The definitive investigation is a contrast-enhanced CT of the abdomen and pelvis with rectal contrast where the protocol allows, understanding that a negative CT does not exclude a leak in a patient with this physiology.

Ethics and communication: He wants to go home and I must explain clearly and without alarm-mongering why that would be dangerous, checking his understanding, because a discharge against advice at this point could be fatal; if he still insists after a capacity-appropriate discussion, I would document capacity, the risks explained and the alternatives offered.

Reference: ERAS Society Guidelines for Perioperative Care in Elective Colorectal Surgery, World Journal of Surgery 2019; Association of Coloproctology of Great Britain and Ireland guidance on the management of anastomotic leak, Colorectal Disease 2021

Knowledge: A competent adult has the right to refuse any treatment, including life-saving transfusion, and that refusal is valid even if others consider it unwise; transfusing her against a clear, current, informed refusal would be an assault regardless of her husband consenting. My first duty is therefore a proper capacity assessment: can she understand, retain, weigh and communicate the decision, and is she making it free from coercion, which I would confirm by speaking to her alone without her husband or any hospital liaison committee representative present.

Management: I would confirm capacity and document it in detail with a witness, record precisely which products and techniques she accepts and refuses on the hospital form, and then plan a bloodless strategy.

Ethics and communication: Her autonomy governs, and I would tell her husband gently, privately and unambiguously that I cannot act on his request, that his wife has made a valid decision with capacity, and that no relative can consent on behalf of a competent adult; I would acknowledge his distress and offer him chaplaincy or the hospital family support service rather than dismiss him.

Reference: Association of Anaesthetists of Great Britain and Ireland, Management of Anaesthesia for Jehovah's Witnesses, 3rd edition 2018; General Medical Council, Decision Making and Consent 2020; UAE Federal Law No. 4 of 2016 on Medical Liability and its Executive Regulations