SU9.1-3 | Surgical Investigations and Cancer Detection — Assignment

CLINICAL SCENARIO

Mr R, a 62-year-old man, presents to the surgical outpatient clinic with four weeks of progressive, painless yellowing of his eyes and skin, dark urine, pale stools and a 6 kg unintentional weight loss. Examination shows scleral icterus and a palpable, non-tender gallbladder. The consultant asks you to plan the investigations needed to reach a diagnosis and a stage, to interpret the results sensibly, and to prepare to communicate them to Mr R — who has already asked you, anxiously, 'Is it cancer, doctor?'

State your pretest probability for malignant versus benign obstructive jaundice based on the history and examination, and explain your reasoning. Then list the investigations you would order, and for EACH one name the specific clinical question it answers (diagnosis, staging, or fitness for surgery) and why you chose that modality over alternatives. Explicitly justify imaging choices by their purpose and risk.

Define sensitivity, specificity, PPV and NPV in your own words, and explain how Mr R's high pretest probability affects the predictive value of a positive result. Discuss the correct role of CA 19-9 here: explain why it is a monitoring rather than a screening test, and what a raised or normal value would and would not tell you.

Imaging confirms a mass in the head of the pancreas with no distant metastases. Explain how this result updates (rather than replaces) your clinical assessment, what the next steps are (including the role of the multidisciplinary team), and which result would or would not change the management plan.

Plan, step by step using the SPIKES protocol, how you would communicate this result to Mr R. For each letter (Setting, Perception, Invitation, Knowledge, Emotions, Strategy/Summary) write what you would actually do or say. Make clear how you would respond to emotion before moving to the management plan, and how you would protect confidentiality and consent.