{"id":37067,"date":"2026-06-17T07:11:16","date_gmt":"2026-06-17T01:41:16","guid":{"rendered":"https:\/\/atsixty.com\/?p=37067"},"modified":"2026-06-17T22:49:57","modified_gmt":"2026-06-17T17:19:57","slug":"oncology-neurosurgery-periop","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/clinical\/surgery\/oncology-neurosurgery-periop\/","title":{"rendered":"Oncology, Neurosurgery &amp; Periop"},"content":{"rendered":"\n\n\n<meta charset=\"UTF-8\">\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\">\n<title>Morning Rounds \u00b7 Oncology, Neurosurgery &amp; Periop<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&#038;family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&#038;display=swap\" rel=\"stylesheet\">\n<style>\n#surg07 *,#surg07 *::before,#surg07 *::after{box-sizing:border-box;margin:0;padding:0}\n#surg07{\n  --surg:#2C5F8A;--surg-light:#3A78A8;--surg-pale:#EBF2F8;--surg-dark:#1E4464;\n  --correct:#2D6B47;--correct-bg:#EAF6EF;--correct-border:#3A9960;\n  --wrong:#B83232;--wrong-bg:#FDF0F0;--wrong-border:#E53935;\n  --ink:#1A2A38;--ink-mid:#3A5A6A;--ink-soft:#7A98AD;\n  --line:#D6E5EE;--cream:#F4F8FB;--warm:#FAFCFE;\n  font-family:'Source Serif 4',Georgia,serif;font-size:16px;color:var(--ink);\n  background:var(--cream);line-height:1.7;padding:0 0 64px;\n}\n#surg07 .mr-header{background:var(--surg);color:#EEF5FA;padding:34px 24px 28px;text-align:center}\n#surg07 .mr-eyebrow{font-size:0.68rem;letter-spacing:0.18em;text-transform:uppercase;font-weight:600;opacity:0.65;margin-bottom:10px}\n#surg07 .mr-title{font-family:'Playfair Display',serif;font-size:1.75rem;font-weight:700;line-height:1.2;margin-bottom:4px}\n#surg07 .mr-title em{font-style:italic;font-weight:400;opacity:0.88}\n#surg07 .mr-subtitle{font-size:0.82rem;opacity:0.7;margin-top:8px;font-style:italic}\n#surg07 .mr-chips{display:flex;justify-content:center;gap:10px;margin-top:18px;flex-wrap:wrap}\n#surg07 .mr-chip{background:rgba(255,255,255,0.13);border:1px solid rgba(255,255,255,0.22);border-radius:20px;padding:4px 13px;font-size:0.73rem}\n#surg07 .mr-sentinel{height:1px}\n#surg07 .mr-progress{position:fixed;top:0;left:0;right:0;z-index:9999;background:var(--warm);border-bottom:1px solid var(--line);box-shadow:0 2px 12px rgba(26,42,56,0.08);padding:9px 16px;display:none}\n#surg07 .mr-progress.visible{display:block}\n#surg07 .mr-prog-inner{max-width:720px;margin:0 auto;display:flex;align-items:center;justify-content:center}\n#surg07 .mr-pips{display:flex;align-items:center;justify-content:center}\n#surg07 .mr-pip-wrap{display:flex;align-items:center}\n#surg07 .mr-pip-line{width:28px;height:2px;background:var(--line);transition:background 0.35s}\n#surg07 .mr-pip-line.done{background:var(--surg)}\n#surg07 .mr-pip{width:28px;height:28px;border-radius:50%;border:2px solid var(--line);background:var(--warm);display:flex;align-items:center;justify-content:center;font-size:0.63rem;font-weight:700;color:var(--ink-soft);transition:all 0.3s;flex-shrink:0}\n#surg07 .mr-pip.correct{background:var(--correct-border);border-color:var(--correct-border);color:#fff}\n#surg07 .mr-pip.wrong{background:var(--wrong-border);border-color:var(--wrong-border);color:#fff}\n#surg07 .mr-body{max-width:720px;margin:0 auto;padding:0 16px}\n#surg07 .mr-case{background:var(--warm);border:1px solid var(--line);border-left:4px solid var(--surg);border-radius:10px;margin:28px 0;overflow:hidden;box-shadow:0 1px 6px rgba(26,42,56,0.05)}\n#surg07 .mr-case-top{padding:16px 20px 14px;display:flex;gap:14px;align-items:flex-start}\n#surg07 .mr-num{font-family:'Playfair Display',serif;font-size:2.2rem;font-weight:700;color:var(--surg);opacity:0.16;line-height:1;margin-top:-2px;flex-shrink:0}\n#surg07 .mr-meta{flex:1}\n#surg07 .mr-tag{font-size:0.61rem;font-weight:700;letter-spacing:0.14em;text-transform:uppercase;color:var(--surg);opacity:0.75;margin-bottom:5px}\n#surg07 .mr-stem{font-size:0.94rem;color:var(--ink);line-height:1.72}\n#surg07 .mr-stem strong{font-weight:600}\n#surg07 .mr-stem em{font-style:italic}\n#surg07 .mr-rule{height:1px;background:var(--line);margin:0 20px}\n#surg07 .mr-opts{padding:12px 20px 16px;display:flex;flex-direction:column;gap:8px}\n#surg07 .mr-opt{display:flex;align-items:flex-start;gap:11px;padding:10px 14px;border:1.5px solid var(--line);border-radius:8px;cursor:pointer;background:var(--warm);transition:border-color 0.15s,background 0.15s;-webkit-tap-highlight-color:transparent}\n#surg07 .mr-opt:hover{border-color:var(--surg);background:var(--surg-pale)}\n#surg07 .mr-opt.locked{cursor:default}\n#surg07 .mr-opt.locked:hover{border-color:var(--line);background:var(--warm)}\n#surg07 .mr-opt.correct{border-color:var(--correct-border);background:var(--correct-bg);cursor:default}\n#surg07 .mr-opt.correct:hover{border-color:var(--correct-border);background:var(--correct-bg)}\n#surg07 .mr-opt.wrong{border-color:var(--wrong-border);background:var(--wrong-bg);cursor:default}\n#surg07 .mr-opt.wrong:hover{border-color:var(--wrong-border);background:var(--wrong-bg)}\n#surg07 .mr-opt.dimmed{opacity:0.35;cursor:default}\n#surg07 .mr-opt.dimmed:hover{border-color:var(--line);background:var(--warm)}\n#surg07 .mr-ltr{flex-shrink:0;width:20px;height:20px;border-radius:50%;border:1.5px solid var(--line);display:flex;align-items:center;justify-content:center;font-size:0.62rem;font-weight:700;color:var(--ink-soft);margin-top:2px;transition:all 0.15s}\n#surg07 .mr-opt.correct .mr-ltr{background:var(--correct-border);border-color:var(--correct-border);color:#fff}\n#surg07 .mr-opt.wrong .mr-ltr{background:var(--wrong-border);border-color:var(--wrong-border);color:#fff}\n#surg07 .mr-opt-text{font-size:0.9rem;color:var(--ink-mid);line-height:1.58}\n#surg07 .mr-opt.correct .mr-opt-text{color:var(--correct);font-weight:600}\n#surg07 .mr-opt.wrong .mr-opt-text{color:var(--wrong)}\n#surg07 .mr-exp{display:none;border-top:1px solid #b8d4e4;background:linear-gradient(180deg,#e4f0f7 0%,#f0f7fb 100%);padding:13px 20px 15px}\n#surg07 .mr-exp-lbl{font-size:0.61rem;font-weight:700;letter-spacing:0.12em;text-transform:uppercase;color:#1a5070;margin-bottom:6px}\n#surg07 .mr-exp-text{font-size:0.86rem;color:#12324A;line-height:1.68}\n#surg07 .mr-exp-text strong{font-weight:600}\n#surg07 .mr-exp-text em{font-style:italic}\n#surg07 .mr-img-wrap{margin-top:14px;background:var(--warm);border:1px solid var(--line);border-radius:8px;padding:14px;text-align:center}\n#surg07 .mr-img-wrap figcaption{font-size:0.73rem;color:var(--ink-soft);font-style:italic;margin-top:8px;line-height:1.4}\n#surg07 .mr-submit-wrap{text-align:center;padding:28px 16px 8px}\n#surg07 .mr-btn{background:var(--surg);color:#EEF5FA;border:none;border-radius:8px;padding:13px 44px;font-family:'Playfair Display',serif;font-size:1rem;font-weight:700;cursor:pointer;box-shadow:0 2px 8px rgba(44,95,138,0.28)}\n#surg07 .mr-btn:hover{background:var(--surg-dark)}\n#surg07 .mr-score{display:none;background:var(--warm);border:1px solid var(--line);border-top:4px solid var(--surg);border-radius:10px;margin:24px 0 0;box-shadow:0 2px 12px rgba(26,42,56,0.08);overflow:hidden}\n#surg07 .mr-score-in{padding:28px 24px;text-align:center}\n#surg07 .mr-score-ey{font-size:0.66rem;letter-spacing:0.14em;text-transform:uppercase;color:var(--ink-soft);margin-bottom:12px;font-weight:600}\n#surg07 .mr-ring{width:98px;height:98px;border-radius:50%;background:conic-gradient(var(--surg) 0%,var(--line) 0%);display:flex;align-items:center;justify-content:center;margin:0 auto 16px;position:relative}\n#surg07 .mr-ring::before{content:'';position:absolute;width:76px;height:76px;border-radius:50%;background:var(--warm)}\n#surg07 .mr-ring-in{position:relative;display:flex;flex-direction:column;align-items:center;line-height:1.2}\n#surg07 .mr-ring-pct{font-family:'Playfair Display',serif;font-size:1.3rem;font-weight:700;color:var(--surg)}\n#surg07 .mr-ring-sub{font-size:0.54rem;color:var(--ink-soft);text-transform:uppercase;letter-spacing:0.06em}\n#surg07 .mr-score-title{font-family:'Playfair Display',serif;font-size:1.15rem;font-weight:700;color:var(--ink);margin-bottom:4px}\n#surg07 .mr-score-net{font-size:0.9rem;color:var(--surg);font-weight:600;margin-bottom:4px}\n#surg07 .mr-verdict{font-size:0.83rem;color:var(--ink-soft);font-style:italic;margin-bottom:18px;padding:0 12px}\n#surg07 .mr-bands{display:flex;justify-content:center;gap:10px;flex-wrap:wrap}\n#surg07 .mr-band{padding:5px 13px;border-radius:16px;font-size:0.78rem;font-weight:600}\n#surg07 .mr-band-c{background:var(--correct-bg);color:var(--correct)}\n#surg07 .mr-band-w{background:var(--wrong-bg);color:var(--wrong)}\n#surg07 .mr-band-s{background:var(--surg-pale);color:var(--surg)}\n#surg07 .mr-retry{display:block;margin:18px auto 4px;background:transparent;border:2px solid var(--surg);color:var(--surg);border-radius:8px;padding:9px 28px;font-family:'Playfair Display',serif;font-size:0.92rem;font-weight:700;cursor:pointer}\n#surg07 .mr-retry:hover{background:var(--surg);color:#EEF5FA}\n@media(max-width:480px){#surg07 .mr-title{font-size:1.4rem}#surg07 .mr-num{font-size:1.7rem}#surg07 .mr-stem{font-size:0.9rem}#surg07 .mr-opt-text{font-size:0.86rem}}\n<\/style>\n\n<!-- SVG Q1: EDH vs SDH -->\n<div id=\"surg07-img1\" style=\"display:none\">\n  <figure class=\"mr-img-wrap\">\n    <svg viewBox=\"0 0 560 185\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:560px;display:block;margin:0 auto\">\n      <rect x=\"0\" y=\"0\" width=\"560\" height=\"185\" rx=\"8\" fill=\"#f0f5f9\"\/>\n      <text x=\"14\" y=\"18\" fill=\"#1A2A38\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Extradural vs Subdural Haematoma \u2014 Key Differentiators<\/text>\n      <rect x=\"10\" y=\"24\" width=\"150\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"165\" y=\"24\" width=\"185\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"355\" y=\"24\" width=\"195\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <text x=\"85\"  y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Feature<\/text>\n      <text x=\"257\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Extradural (EDH)<\/text>\n      <text x=\"452\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Subdural (SDH)<\/text>\n      <!-- Source -->\n      <rect x=\"10\" y=\"48\" width=\"150\" height=\"26\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"85\"  y=\"65\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Source of bleeding<\/text>\n      <rect x=\"165\" y=\"48\" width=\"185\" height=\"26\" rx=\"2\" fill=\"#fdf3e0\"\/>\n      <text x=\"257\" y=\"59\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Middle meningeal artery<\/text>\n      <text x=\"257\" y=\"70\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">(arterial \u2014 rapid accumulation)<\/text>\n      <rect x=\"355\" y=\"48\" width=\"195\" height=\"26\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"452\" y=\"59\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Bridging cortical veins<\/text>\n      <text x=\"452\" y=\"70\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">(venous \u2014 slower, can be chronic)<\/text>\n      <!-- CT shape -->\n      <rect x=\"10\" y=\"76\" width=\"150\" height=\"26\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"85\"  y=\"93\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">CT appearance<\/text>\n      <rect x=\"165\" y=\"76\" width=\"185\" height=\"26\" rx=\"2\" fill=\"#fdf3e0\"\/>\n      <text x=\"257\" y=\"87\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Biconvex (lens-shaped)<\/text>\n      <text x=\"257\" y=\"98\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">Does NOT cross suture lines<\/text>\n      <rect x=\"355\" y=\"76\" width=\"195\" height=\"26\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"452\" y=\"87\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Crescent-shaped<\/text>\n      <text x=\"452\" y=\"98\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Crosses suture lines freely<\/text>\n      <!-- Location -->\n      <rect x=\"10\" y=\"104\" width=\"150\" height=\"26\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"85\"  y=\"121\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Typical location<\/text>\n      <rect x=\"165\" y=\"104\" width=\"185\" height=\"26\" rx=\"2\" fill=\"#fdf3e0\"\/>\n      <text x=\"257\" y=\"115\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">Temporal \/ temporoparietal<\/text>\n      <text x=\"257\" y=\"126\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">(pterion fracture \u2014 thinnest bone)<\/text>\n      <rect x=\"355\" y=\"104\" width=\"195\" height=\"26\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"452\" y=\"115\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Frontoparietal (acute)<\/text>\n      <text x=\"452\" y=\"126\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Bilateral in chronic SDH<\/text>\n      <!-- Classic history -->\n      <rect x=\"10\" y=\"132\" width=\"150\" height=\"26\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"85\"  y=\"149\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Classic history<\/text>\n      <rect x=\"165\" y=\"132\" width=\"185\" height=\"26\" rx=\"2\" fill=\"#fdf3e0\"\/>\n      <text x=\"257\" y=\"143\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Lucid interval<\/text>\n      <text x=\"257\" y=\"154\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">KO \u2192 recovery \u2192 rapid decline<\/text>\n      <rect x=\"355\" y=\"132\" width=\"195\" height=\"26\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"452\" y=\"143\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Acute: severe head injury<\/text>\n      <text x=\"452\" y=\"154\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Chronic: elderly, minor trauma\/anticoag<\/text>\n      <!-- Treatment -->\n      <rect x=\"10\" y=\"160\" width=\"540\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\" opacity=\"0.10\"\/>\n      <text x=\"280\" y=\"171\" text-anchor=\"middle\" fill=\"#1E4464\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">EDH: emergency burr hole \/ craniotomy \u00b7 SDH acute: craniotomy \u00b7 SDH chronic: burr hole drainage<\/text>\n      <text x=\"280\" y=\"182\" text-anchor=\"middle\" fill=\"#2C5F8A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Kernohan's notch = ipsilateral hemiplegia from contralateral peduncle compression \u2014 a false localising sign<\/text>\n    <\/svg>\n    <figcaption>\n      <strong>The lucid interval is pathognomonic of EDH<\/strong> \u2014 arterial bleeding accumulates rapidly, compressing the brain after an initial lucid period. EDH does not cross suture lines (dura is tightly attached at sutures). SDH is crescent-shaped and crosses sutures freely. <strong>Pterion<\/strong> \u2014 thinnest part of the skull, overlies the middle meningeal artery groove; fractures here cause EDH.\n    <\/figcaption>\n  <\/figure>\n<\/div>\n\n<!-- SVG Q4: Post-splenectomy \u2014 OPSI and vaccination -->\n<div id=\"surg07-img4\" style=\"display:none\">\n  <figure class=\"mr-img-wrap\">\n    <svg viewBox=\"0 0 560 155\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:560px;display:block;margin:0 auto\">\n      <rect x=\"0\" y=\"0\" width=\"560\" height=\"155\" rx=\"8\" fill=\"#f0f5f9\"\/>\n      <text x=\"14\" y=\"18\" fill=\"#1A2A38\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Post-Splenectomy \u2014 OPSI Prevention Protocol<\/text>\n      <!-- Headers -->\n      <rect x=\"10\" y=\"24\" width=\"160\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"175\" y=\"24\" width=\"180\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"360\" y=\"24\" width=\"190\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <text x=\"85\"  y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Vaccine<\/text>\n      <text x=\"265\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Organism covered<\/text>\n      <text x=\"455\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Timing<\/text>\n      <!-- Pneumococcal -->\n      <rect x=\"10\" y=\"48\" width=\"160\" height=\"26\" rx=\"2\" fill=\"#fdf3e0\"\/>\n      <text x=\"85\"  y=\"59\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Pneumococcal<\/text>\n      <text x=\"85\"  y=\"70\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7\" font-family=\"Georgia,serif\">(PPV23 \/ PCV13)<\/text>\n      <rect x=\"175\" y=\"48\" width=\"180\" height=\"26\" rx=\"2\" fill=\"#fdf3e0\"\/>\n      <text x=\"265\" y=\"59\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Strep. pneumoniae<\/text>\n      <text x=\"265\" y=\"70\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7\" font-family=\"Georgia,serif\">(MC organism in OPSI)<\/text>\n      <rect x=\"360\" y=\"48\" width=\"190\" height=\"26\" rx=\"2\" fill=\"#fdf3e0\"\/>\n      <text x=\"455\" y=\"59\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">\u22652 weeks pre-op (elective)<\/text>\n      <text x=\"455\" y=\"70\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7\" font-family=\"Georgia,serif\">or 2 weeks post-op (emergency)<\/text>\n      <!-- Meningococcal -->\n      <rect x=\"10\" y=\"76\" width=\"160\" height=\"24\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"85\"  y=\"92\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Meningococcal ACWY<\/text>\n      <rect x=\"175\" y=\"76\" width=\"180\" height=\"24\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"265\" y=\"92\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Neisseria meningitidis<\/text>\n      <rect x=\"360\" y=\"76\" width=\"190\" height=\"24\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"455\" y=\"92\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Same timing as pneumococcal<\/text>\n      <!-- Hib -->\n      <rect x=\"10\" y=\"102\" width=\"160\" height=\"24\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"85\"  y=\"118\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Haemophilus influenzae b<\/text>\n      <rect x=\"175\" y=\"102\" width=\"180\" height=\"24\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"265\" y=\"118\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">H. influenzae type b<\/text>\n      <rect x=\"360\" y=\"102\" width=\"190\" height=\"24\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"455\" y=\"118\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Same timing as pneumococcal<\/text>\n      <!-- Antibiotic prophylaxis -->\n      <rect x=\"10\" y=\"128\" width=\"540\" height=\"24\" rx=\"3\" fill=\"#fdf0f0\"\/>\n      <text x=\"280\" y=\"139\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Lifelong prophylactic antibiotics: Phenoxymethylpenicillin (penicillin V) 250\u2013500 mg BD \u00b7 Amoxicillin alternative<\/text>\n      <text x=\"280\" y=\"150\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7\" font-family=\"Georgia,serif\">OPSI: sudden onset fever \u2192 sepsis \u2192 DIC \u2192 death within hours \u00b7 Risk highest in first 2 years, persists lifelong \u00b7 Mortality 50\u201370% once established<\/text>\n    <\/svg>\n    <figcaption>\n      <strong>OPSI (Overwhelming Post-Splenectomy Infection)<\/strong> \u2014 fulminant bacteraemia with encapsulated organisms. Lifetime risk ~5%; highest in first 2 years. <strong>Encapsulated organisms<\/strong> (SHiN mnemonic: <em>Streptococcus pneumoniae<\/em> [MC], <em>Haemophilus influenzae<\/em>, <em>Neisseria meningitidis<\/em>) escape opsonisation without splenic macrophages. Patient must carry an emergency antibiotic card and take prophylaxis lifelong.\n    <\/figcaption>\n  <\/figure>\n<\/div>\n\n<!-- SVG Q5: Wound classification -->\n<div id=\"surg07-img5\" style=\"display:none\">\n  <figure class=\"mr-img-wrap\">\n    <svg viewBox=\"0 0 560 162\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:560px;display:block;margin:0 auto\">\n      <rect x=\"0\" y=\"0\" width=\"560\" height=\"162\" rx=\"8\" fill=\"#f0f5f9\"\/>\n      <text x=\"14\" y=\"18\" fill=\"#1A2A38\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Wound Classification &amp; SSI Risk<\/text>\n      <rect x=\"10\" y=\"24\" width=\"110\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"125\" y=\"24\" width=\"175\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"305\" y=\"24\" width=\"115\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"425\" y=\"24\" width=\"125\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <text x=\"65\"  y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Class<\/text>\n      <text x=\"212\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Definition<\/text>\n      <text x=\"362\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">SSI risk<\/text>\n      <text x=\"487\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Example<\/text>\n      <!-- Clean -->\n      <rect x=\"10\" y=\"48\" width=\"110\" height=\"24\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"65\"  y=\"64\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">I \u2014 Clean<\/text>\n      <rect x=\"125\" y=\"48\" width=\"175\" height=\"24\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"212\" y=\"57\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7\" font-family=\"Georgia,serif\">No inflammation; GI\/GU\/resp not<\/text>\n      <text x=\"212\" y=\"68\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7\" font-family=\"Georgia,serif\">entered; no break in technique<\/text>\n      <rect x=\"305\" y=\"48\" width=\"115\" height=\"24\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"362\" y=\"64\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">&lt;2%<\/text>\n      <rect x=\"425\" y=\"48\" width=\"125\" height=\"24\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"487\" y=\"64\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">Hernia repair, thyroidectomy<\/text>\n      <!-- Clean-contaminated -->\n      <rect x=\"10\" y=\"74\" width=\"110\" height=\"28\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"65\"  y=\"86\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7\" font-family=\"Georgia,serif\" font-weight=\"bold\">II \u2014 Clean-<\/text>\n      <text x=\"65\"  y=\"97\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7\" font-family=\"Georgia,serif\" font-weight=\"bold\">contaminated<\/text>\n      <rect x=\"125\" y=\"74\" width=\"175\" height=\"28\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"212\" y=\"83\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7\" font-family=\"Georgia,serif\">GI\/GU\/resp entered under<\/text>\n      <text x=\"212\" y=\"94\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7\" font-family=\"Georgia,serif\">controlled conditions; minor<\/text>\n      <text x=\"212\" y=\"105\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7\" font-family=\"Georgia,serif\">technique break<\/text>\n      <rect x=\"305\" y=\"74\" width=\"115\" height=\"28\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"362\" y=\"92\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">5\u201310%<\/text>\n      <rect x=\"425\" y=\"74\" width=\"125\" height=\"28\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"487\" y=\"83\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Elective cholecystectomy,<\/text>\n      <text x=\"487\" y=\"94\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">appendicectomy (no perf)<\/text>\n      <!-- Contaminated -->\n      <rect x=\"10\" y=\"104\" width=\"110\" height=\"24\" rx=\"2\" fill=\"#fdf3e0\"\/>\n      <text x=\"65\"  y=\"116\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7\" font-family=\"Georgia,serif\" font-weight=\"bold\">III \u2014<\/text>\n      <text x=\"65\"  y=\"127\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7\" font-family=\"Georgia,serif\" font-weight=\"bold\">Contaminated<\/text>\n      <rect x=\"125\" y=\"104\" width=\"175\" height=\"24\" rx=\"2\" fill=\"#fdf3e0\"\/>\n      <text x=\"212\" y=\"115\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7\" font-family=\"Georgia,serif\">Open fresh traumatic wound;<\/text>\n      <text x=\"212\" y=\"126\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7\" font-family=\"Georgia,serif\">major technique break; acute inflam<\/text>\n      <rect x=\"305\" y=\"104\" width=\"115\" height=\"24\" rx=\"2\" fill=\"#fdf3e0\"\/>\n      <text x=\"362\" y=\"120\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">~20%<\/text>\n      <rect x=\"425\" y=\"104\" width=\"125\" height=\"24\" rx=\"2\" fill=\"#fdf3e0\"\/>\n      <text x=\"487\" y=\"115\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">Perforated appendix,<\/text>\n      <text x=\"487\" y=\"126\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">traumatic laceration<\/text>\n      <!-- Dirty -->\n      <rect x=\"10\" y=\"130\" width=\"110\" height=\"24\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"65\"  y=\"142\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7\" font-family=\"Georgia,serif\" font-weight=\"bold\">IV \u2014 Dirty \/<\/text>\n      <text x=\"65\"  y=\"153\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7\" font-family=\"Georgia,serif\" font-weight=\"bold\">Infected<\/text>\n      <rect x=\"125\" y=\"130\" width=\"175\" height=\"24\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"212\" y=\"141\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7\" font-family=\"Georgia,serif\">Old traumatic wound; established<\/text>\n      <text x=\"212\" y=\"152\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7\" font-family=\"Georgia,serif\">infection; perforated viscus<\/text>\n      <rect x=\"305\" y=\"130\" width=\"115\" height=\"24\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"362\" y=\"146\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">&gt;30\u201340%<\/text>\n      <rect x=\"425\" y=\"130\" width=\"125\" height=\"24\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"487\" y=\"141\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">Faecal peritonitis,<\/text>\n      <text x=\"487\" y=\"152\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">gangrenous bowel<\/text>\n    <\/svg>\n    <figcaption>\n      <strong>Antibiotic prophylaxis<\/strong> is given for Class II and above; for Class I, only if implant is used. Prophylaxis is given <strong>30\u201360 minutes before skin incision<\/strong> (not on call to theatre, not post-op). Cefazolin is first-line for most clean and clean-contaminated surgery. <strong>SSI timing:<\/strong> superficial incisional (&lt;30 days); deep incisional or organ\/space (&lt;30 days, or &lt;1 year if implant).\n    <\/figcaption>\n  <\/figure>\n<\/div>\n\n<div id=\"surg07\">\n  <div class=\"mr-header\">\n    <div class=\"mr-eyebrow\">Morning Rounds &middot; Surgery Series &middot; Round 07<\/div>\n    <div class=\"mr-title\">Oncology, Neurosurgery &amp; Periop<br><em>The Final Round<\/em><\/div>\n    <div class=\"mr-subtitle\">Five cases &middot; Read carefully &middot; Trust your instinct<\/div>\n    <div class=\"mr-chips\">\n      <span class=\"mr-chip\">5 Cases<\/span>\n      <span class=\"mr-chip\">+4 \/ &minus;1 scoring<\/span>\n      <span class=\"mr-chip\">Options reshuffled<\/span>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-sentinel\" id=\"surg07-sentinel\"><\/div>\n  <div class=\"mr-progress\" id=\"surg07-progress\">\n    <div class=\"mr-prog-inner\">\n      <div class=\"mr-pips\" id=\"surg07-pips\"><\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-body\">\n    <div id=\"surg07-cases\"><\/div>\n    <div class=\"mr-submit-wrap\">\n      <button class=\"mr-btn\" id=\"surg07-submit\">Submit for Debrief<\/button>\n    <\/div>\n    <div class=\"mr-score\" id=\"surg07-score\">\n      <div class=\"mr-score-in\">\n        <div class=\"mr-score-ey\">Series Complete<\/div>\n        <div class=\"mr-ring\" id=\"surg07-ring\">\n          <div class=\"mr-ring-in\">\n            <span class=\"mr-ring-pct\" id=\"surg07-pct\">0%<\/span>\n            <span class=\"mr-ring-sub\">net<\/span>\n          <\/div>\n        <\/div>\n        <div class=\"mr-score-title\">Your Debrief<\/div>\n        <div class=\"mr-score-net\" id=\"surg07-net\"><\/div>\n        <div class=\"mr-verdict\" id=\"surg07-verdict\"><\/div>\n        <div class=\"mr-bands\">\n          <span class=\"mr-band mr-band-c\" id=\"surg07-ct-c\"><\/span>\n          <span class=\"mr-band mr-band-w\" id=\"surg07-ct-w\"><\/span>\n          <span class=\"mr-band mr-band-s\" id=\"surg07-ct-s\"><\/span>\n        <\/div>\n        <button class=\"mr-retry\" id=\"surg07-retry\">&#8635; New Round<\/button>\n      <\/div>\n    <\/div>\n  <\/div>\n<\/div>\n\n<script>\n(function () {\n  'use strict';\n\n  var NS    = 'surg07';\n  var TOTAL = 5;\n  var MAX   = 20;\n  var LTRS  = ['A','B','C','D'];\n\n  var QS = [\n\n    {\n      id:    1,\n      tag:   'Neurosurgery &mdash; Extradural Haematoma',\n      stem:  'A <strong>22-year-old man<\/strong> is brought to the emergency department after being struck on the right side of his head by a cricket ball. He was briefly <strong>knocked unconscious for 2 minutes<\/strong>, then became fully alert and conversed normally with bystanders (<em>lucid interval<\/em>). Forty minutes later he developed a <strong>sudden severe headache, became progressively drowsy, and collapsed<\/strong>. On arrival: GCS 9\/15, right pupil dilated and unreactive, left hemiplegia. Non-contrast CT head shows a <strong>hyperdense biconvex collection in the right temporal region<\/strong> with midline shift. What is the most likely diagnosis and immediate management?',\n      correct: 'Extradural haematoma from middle meningeal artery rupture; emergency craniotomy and clot evacuation',\n      opts: [\n        'Extradural haematoma from middle meningeal artery rupture; emergency craniotomy and clot evacuation',\n        'Acute subdural haematoma from bridging vein rupture; IV mannitol and observation in ICU',\n        'Intracerebral haemorrhage; conservative management with BP control and reversal of coagulopathy',\n        'Cerebral contusion; immediate intubation and hyperventilation to reduce ICP as definitive treatment'\n      ],\n      exp:   'The <strong>lucid interval<\/strong> \u2014 brief LOC, full recovery, then rapid neurological deterioration \u2014 is the classical hallmark of <strong>extradural haematoma (EDH)<\/strong>. The biconvex (lens-shaped) hyperdense collection on CT, confined to the right temporal region and not crossing the suture lines, confirms it. <br><br><strong>Mechanism:<\/strong> a blow to the temporal region fractures the pterion (thinnest part of the skull) \u2192 lacerates the <strong>middle meningeal artery<\/strong> in the epidural space \u2192 rapid arterial haemorrhage accumulates \u2192 rising ICP \u2192 transtentorial herniation \u2192 ipsilateral pupil dilatation (CN III compression) + contralateral hemiplegia (corticospinal tract compression). <br><br><strong>Kernohan\\'s notch phenomenon:<\/strong> if uncal herniation pushes the brainstem against the opposite tentorial edge, the contralateral cerebral peduncle is compressed \u2192 <em>ipsilateral<\/em> hemiplegia (a false localising sign). Here the left hemiplegia is a true localising sign of the right-sided lesion. <br><br><strong>Immediate management:<\/strong> <br>&bull; Airway, breathing, circulation + rapid sequence intubation (GCS \u22648) <br>&bull; IV mannitol 20% (0.5\u20131 g\/kg) as a temporising measure to reduce ICP while preparing for theatre <br>&bull; <strong>Emergency craniotomy + clot evacuation + coagulation of MMA<\/strong> \u2014 definitive treatment; must not be delayed <br>&bull; Burr hole at bedside if patient is deteriorating too rapidly to reach theatre <br><br><strong>Prognosis:<\/strong> excellent if operated promptly (mortality &lt;5%); dismal if delayed (mortality rises to &gt;50% with coning).',\n      imgId: 'surg07-img1'\n    },\n\n    {\n      id:    2,\n      tag:   'Oncology &mdash; Soft Tissue Sarcoma',\n      stem:  'A <strong>34-year-old woman<\/strong> presents with a <strong>4-month history of a painless, slowly enlarging mass in her right thigh<\/strong>. On examination the mass is <strong>deep to the deep fascia, firm, non-tender, and measures 8 cm<\/strong>. It does not transilluminate. USS shows a solid heterogeneous mass; MRI confirms a deep intramuscular lesion with areas of necrosis. Core needle biopsy reports: <strong>high-grade spindle cell sarcoma<\/strong>. CT thorax shows no pulmonary metastases. Which statement most accurately describes the management principle?',\n      correct: 'Wide local excision with clear histological margins (R0 resection) + post-operative radiotherapy; amputation is not routinely required',\n      opts: [\n        'Wide local excision with clear histological margins (R0 resection) + post-operative radiotherapy; amputation is not routinely required',\n        'Amputation of the right lower limb; the only curative option for a high-grade deep sarcoma &gt;5 cm is radical amputation',\n        'Excision biopsy (marginal excision through the pseudocapsule) followed by chemotherapy; radiotherapy is not indicated for extremity sarcomas',\n        'Incisional biopsy along the long axis of the limb, followed by observation; high-grade sarcomas rarely metastasise to the lung'\n      ],\n      exp:   '<strong>Soft tissue sarcoma (STS)<\/strong> \u2014 rare, heterogeneous group of mesenchymal malignancies. <strong>Features suggesting malignancy:<\/strong> size &gt;5 cm, deep to deep fascia, hard consistency, rapid growth, heterogeneous on imaging (areas of necrosis\/haemorrhage), non-transilluminable. This lesion has all of these \u2014 it is a sarcoma until proven otherwise. <br><br><strong>Biopsy:<\/strong> always <strong>core needle biopsy<\/strong> (or incisional biopsy aligned along the long axis of the limb so the biopsy tract can be excised en bloc with the tumour). <em>Never<\/em> excisional biopsy for a suspected sarcoma \u2014 cutting through the pseudocapsule seeds tumour cells locally. <br><br><strong>The pseudocapsule danger:<\/strong> sarcomas have a false capsule of compressed tumour cells \u2014 \"shelling out\" through the pseudocapsule (marginal excision) leaves microscopic disease behind and results in high local recurrence. <br><br><strong>Definitive management:<\/strong> <br>&bull; <strong>Wide local excision (WLE)<\/strong> with \u22651 cm clear margins (R0 resection) \u2014 limb-salvage surgery in ~90% of cases <br>&bull; <strong>Post-operative radiotherapy<\/strong> to the tumour bed \u2014 reduces local recurrence from ~30% to ~10% for high-grade tumours <br>&bull; Adjuvant chemotherapy (ifosfamide\/doxorubicin) \u2014 limited evidence in localised STS; used for high-risk cases <br>&bull; <strong>Amputation<\/strong> is reserved for tumours involving major neurovascular structures where R0 resection is impossible with limb preservation <br><br><strong>Metastasis pattern:<\/strong> sarcomas spread <em>haematogenously<\/em> \u2014 lungs are the MC site (hence CT thorax). Lymph node metastasis is rare (except synovial sarcoma, rhabdomyosarcoma, epithelioid sarcoma).',\n      imgId: null\n    },\n\n    {\n      id:    3,\n      tag:   'Oncology &mdash; Carcinoma of the Lip',\n      stem:  'A <strong>65-year-old male farmer<\/strong> presents with a <strong>non-healing ulcer on the lower lip<\/strong> of 4 months\\' duration. He has a history of heavy pipe smoking and significant sun exposure. On examination: a <strong>2 cm indurated ulcer with everted edges on the vermilion border of the lower lip<\/strong>. There is a <strong>single, firm, non-tender 1.5 cm lymph node<\/strong> in the right submandibular region. Biopsy confirms <strong>well-differentiated squamous cell carcinoma<\/strong>. CT neck shows the single submandibular node, no distant disease. What is the correct TNM stage and the appropriate management?',\n      correct: 'T2N1M0 (Stage III); surgical excision of the lip lesion with V- or W-plasty reconstruction + ipsilateral supraomohyoid neck dissection',\n      opts: [\n        'T2N1M0 (Stage III); surgical excision of the lip lesion with V- or W-plasty reconstruction + ipsilateral supraomohyoid neck dissection',\n        'T1N1M0 (Stage II); radiotherapy alone is curative and avoids cosmetic deformity of the lip',\n        'T2N0M0 (Stage II); surgery is not indicated as SCC of the lip responds completely to radiotherapy',\n        'T3N1M0 (Stage IVA); total lower lip excision (lip-shave) + bilateral radical neck dissection is mandatory'\n      ],\n      exp:   '<strong>Carcinoma of the lip<\/strong> \u2014 95% are SCC; lower lip affected in ~90% (sun-exposed, pipe smoking). Risk factors: UV exposure, smoking, pipe smoking, immunosuppression, leukoplakia. <br><br><strong>TNM staging (lip SCC):<\/strong> <br>&bull; T1: \u22642 cm; T2: &gt;2\u20134 cm; T3: &gt;4 cm; T4: invades adjacent structures <br>&bull; N1: single ipsilateral node \u22643 cm <br>&bull; This patient: 2 cm lesion = <strong>T2<\/strong>; single submandibular node = <strong>N1<\/strong>; no distant mets = <strong>M0 \u2192 T2N1M0 = Stage III<\/strong> <br><br><strong>Management:<\/strong> <br>&bull; <strong>Primary tumour:<\/strong> wide excision with adequate margins. Lower lip defects &lt;30% of lip width: primary closure. 30\u201360%: local flap (Abbe flap from upper lip, Karapandzic flap). &gt;60%: free flap. V-excision (V-plasty) or W-excision gives good cosmetic result for &lt;1\/3 width lesions; step-ladder repair for larger. <br>&bull; <strong>Neck (N1 disease):<\/strong> <strong>ipsilateral supraomohyoid neck dissection<\/strong> (levels I\u2013III) \u2014 the submandibular node is in level I. N1 disease without extracapsular spread does not require post-op radiotherapy alone; adjuvant RT added for ECS, close margins, or multiple nodes. <br>&bull; <strong>N0 neck<\/strong> for T2 lip SCC: elective neck dissection or radiotherapy is recommended given ~30% occult nodal rate <br><br><strong>Sentinel lymph node biopsy<\/strong> has an emerging role in cN0 oral cavity SCC to guide elective neck management. <br><br><strong>Prognosis:<\/strong> lower lip SCC has a better prognosis than other oral cavity sites \u2014 well-differentiated, slow-growing, detected early. 5-year survival ~90% for node-negative disease.',\n      imgId: null\n    },\n\n    {\n      id:    4,\n      tag:   'Perioperative &mdash; Post-Splenectomy',\n      stem:  'A <strong>24-year-old man<\/strong> undergoes <strong>emergency splenectomy<\/strong> following blunt abdominal trauma with splenic laceration (Grade IV) and haemodynamic instability. The operation is successful. On post-operative day 5 he develops a <strong>temperature of 39.8&deg;C, rigors, and confusion<\/strong>. Blood cultures grow <em>Streptococcus pneumoniae<\/em>. He deteriorates rapidly despite IV ceftriaxone, developing DIC and requiring ICU admission. In retrospect, which single preventive measure was most critical and was missed in the peri-operative period?',\n      correct: 'Post-operative pneumococcal vaccination (and Hib + meningococcal vaccines) with lifelong prophylactic penicillin \u2014 not given after emergency splenectomy',\n      opts: [\n        'Post-operative pneumococcal vaccination (and Hib + meningococcal vaccines) with lifelong prophylactic penicillin \u2014 not given after emergency splenectomy',\n        'Prophylactic low molecular weight heparin; post-splenectomy thrombocytosis causes PE which mimics sepsis',\n        'Prolonged post-operative IV antibiotics for 4 weeks; all splenectomy patients require this regardless of vaccination',\n        'Partial splenectomy should have been performed; total splenectomy is contraindicated in trauma patients under 30'\n      ],\n      exp:   'This is <strong>OPSI \u2014 Overwhelming Post-Splenectomy Infection<\/strong> \u2014 a life-threatening emergency with mortality of 50\u201370% once established. It can develop months to years after splenectomy, but risk is highest in the first 2 years. <br><br><strong>Why:<\/strong> the spleen removes encapsulated bacteria (especially <em>Streptococcus pneumoniae<\/em>, <em>Haemophilus influenzae<\/em> type b, <em>Neisseria meningitidis<\/em>) via opsonisation + phagocytosis by splenic macrophages. Without the spleen, these organisms cause fulminant bacteraemia \u2192 septic shock \u2192 DIC \u2192 death within hours. <br><br><strong>Prevention protocol (what was missed):<\/strong> <br>&bull; <strong>Vaccination:<\/strong> in <em>emergency<\/em> splenectomy, vaccines should be given <strong>at least 2 weeks post-operatively<\/strong> (immune response is blunted if given acutely when immunosuppressed from surgery\/blood loss). Three vaccines: pneumococcal (PPV23\/PCV13) + meningococcal ACWY + Hib. <br>&bull; <strong>Lifelong prophylactic antibiotics:<\/strong> phenoxymethylpenicillin (penicillin V) 250\u2013500 mg BD \u2014 continued lifelong (risk never fully disappears). Erythromycin if penicillin-allergic. <br>&bull; <strong>Patient education:<\/strong> emergency antibiotic card carried at all times; seek medical attention immediately for any fever; avoid travel to high-risk malaria endemic areas (spleen normally destroys parasitised RBCs). <br><br><strong>Post-splenectomy haematological changes:<\/strong> Howell-Jolly bodies (nuclear remnants in RBCs \u2014 normally removed by spleen), target cells, thrombocytosis (platelet count may exceed 1,000,000 \u2192 thrombosis risk if &gt;800 \u2014 antiplatelet therapy). <br><br><strong>Partial splenectomy<\/strong> preserves some splenic function and is preferred for benign disease (haemolytic anaemias, cysts) but in Grade IV trauma with instability, total splenectomy is the correct decision.',\n      imgId: 'surg07-img4'\n    },\n\n    {\n      id:    5,\n      tag:   'Perioperative &mdash; Surgical Site Infection',\n      stem:  'A <strong>55-year-old woman<\/strong> undergoes elective <strong>open right hemicolectomy<\/strong> for carcinoma of the caecum. On post-operative <strong>day 6<\/strong>, she develops a <strong>temperature of 38.4&deg;C<\/strong> and the wound is found to be <strong>erythematous, warm, indurated, and discharging green-yellow purulent fluid<\/strong> from the lower end of the incision. WBC is 16,200\/mm\u00b3. She is haemodynamically stable. The wound is opened at the bedside: there is no fascial dehiscence. Which wound class was this operation, and what is the most appropriate management of the SSI?',\n      correct: 'Class II (clean-contaminated); open the wound, send wound swab for culture, dress with saline-moistened gauze, and allow healing by secondary intention',\n      opts: [\n        'Class II (clean-contaminated); open the wound, send wound swab for culture, dress with saline-moistened gauze, and allow healing by secondary intention',\n        'Class I (clean); IV antibiotics alone are sufficient as the bowel is resected under controlled conditions in elective surgery',\n        'Class III (contaminated); immediate return to theatre for wound debridement and vacuum-assisted closure (VAC) therapy as first-line',\n        'Class IV (dirty); aggressive IV antibiotics for 6 weeks are mandatory before any attempt at wound closure'\n      ],\n      exp:   'An <strong>elective right hemicolectomy<\/strong> enters the colon under controlled conditions with bowel preparation, no spillage, and no established infection \u2014 this is a <strong>Class II (clean-contaminated)<\/strong> wound. SSI rate for Class II is approximately 5\u201310%. <br><br><strong>SSI classification (CDC):<\/strong> <br>&bull; Superficial incisional: involves skin and subcutaneous tissue only \u2014 within 30 days <br>&bull; Deep incisional: involves fascial and muscle layers \u2014 within 30 days <br>&bull; Organ\/space: involves any part of the anatomy opened or manipulated during the procedure <br><br>This patient has a <strong>superficial incisional SSI<\/strong> \u2014 purulent discharge + erythema + warmth, no fascial dehiscence confirmed. <br><br><strong>Management of superficial SSI:<\/strong> <br>&bull; <strong>Open the wound<\/strong> (remove sutures\/staples over the infected segment) \u2014 allows drainage of pus <br>&bull; <strong>Wound swab<\/strong> for culture and sensitivity <br>&bull; <strong>Saline-moistened gauze dressings<\/strong> (wet-to-dry) twice daily \u2014 allows healing by <strong>secondary intention<\/strong> <br>&bull; <strong>Antibiotics<\/strong> are <em>NOT<\/em> routinely required for superficial SSI that is adequately drained \u2014 reserve for systemic signs (fever, cellulitis extending &gt;2 cm, immunocompromised, haemodynamic instability) <br><br><strong>VAC (vacuum-assisted closure \/ negative pressure wound therapy)<\/strong> is used for large, complex, or deep wound defects \u2014 not first-line for a simple superficial SSI. <br><br><strong>SSI prevention:<\/strong> antibiotic prophylaxis 30\u201360 min before incision (cefazolin for Class I\/II); maintain normothermia, normoglycaemia, adequate oxygenation intra-operatively; chlorhexidine skin prep; minimise hair removal (clip, do not shave); theatre discipline (scrub technique, gown changes).',\n      imgId: 'surg07-img5'\n    }\n\n  ];\n\n  var answers  = {};\n  var answered = 0;\n  var shuffled = {};\n  var done     = false;\n\n  function byId(id) { return document.getElementById(id); }\n  function gid(s)   { return byId(NS + '-' + s); }\n\n  function shuffleArr(arr) {\n    var a = arr.slice(), i, j, t;\n    for (i = a.length - 1; i > 0; i--) {\n      j = Math.floor(Math.random() * (i + 1));\n      t = a[i]; a[i] = a[j]; a[j] = t;\n    }\n    return a;\n  }\n\n  function countVal(v) {\n    var k, n = 0;\n    for (k in answers) { if (answers.hasOwnProperty(k) && answers[k] === v) n++; }\n    return n;\n  }\n\n  function buildPips() {\n    var cont = gid('pips'), i, q, wl, wp, l, p;\n    cont.innerHTML = '';\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      if (i > 0) {\n        wl = document.createElement('div'); wl.className = 'mr-pip-wrap';\n        l  = document.createElement('div'); l.className  = 'mr-pip-line'; l.id = NS + '-pl' + q.id;\n        wl.appendChild(l); cont.appendChild(wl);\n      }\n      wp = document.createElement('div'); wp.className = 'mr-pip-wrap';\n      p  = document.createElement('div'); p.className  = 'mr-pip'; p.id = NS + '-pip' + q.id;\n      p.textContent = String(q.id);\n      wp.appendChild(p); cont.appendChild(wp);\n    }\n  }\n\n  function build() {\n    var cont, i, q, opts, card, top, num, meta, tag, stem,\n        rule, od, exp, lbl, txt, imgDiv, imgSrc, j, opt, ls, ts;\n    cont = gid('cases'); cont.innerHTML = '';\n    answers = {}; answered = 0; shuffled = {}; done = false;\n    gid('score').style.display = 'none';\n    buildPips();\n\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      opts = shuffleArr(q.opts);\n      shuffled[q.id] = opts;\n\n      card = document.createElement('div'); card.className = 'mr-case';\n      top  = document.createElement('div'); top.className  = 'mr-case-top';\n      num  = document.createElement('div'); num.className  = 'mr-num';\n      num.textContent = q.id < 10 ? 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