End of 4End of 4thth year year OSCEOSCE

- Surgery -- Surgery -

20 – 03- 2007

A 50 yr old male presented with a A 50 yr old male presented with a

5 days history of malaise, fever 5 days history of malaise, fever

with chills and rigors and this with chills and rigors and this

tender lump over his left shin.tender lump over his left shin.

(i)(i) What is the likely diagnosis?What is the likely diagnosis?

(ii)(ii) What important investigation What important investigation would you like to perform in would you like to perform in this patient?this patient?

(iii)(iii) List the management List the management principles.principles.

AnswerAnswer(i)(i) An abscessAn abscess(ii)(ii) Random/fasting blood sugarRandom/fasting blood sugar(iii)(iii) MxMx

- adequate analgesia & antipyretics- adequate analgesia & antipyretics- broad spectrum IV antibiotics - broad spectrum IV antibiotics - Adequate incision & adequate drainage - Adequate incision & adequate drainage under under GAGA- break into all loculi- break into all loculi- remove pyogenic membrane- remove pyogenic membrane

- send pus for culture + ABST- send pus for culture + ABST- clean the cavity with - clean the cavity with N.saline/ Povidone N.saline/ Povidone Iodine Iodine (Betadine)(Betadine)

- Leave open , partially insert a gauze wick - Leave open , partially insert a gauze wick

This 35 yr old lady This 35 yr old lady presented presented

with painful swelling of her with painful swelling of her leg for 2 days.leg for 2 days.(i)(i) Name 2 likely diagnosesName 2 likely diagnoses(ii)(ii) Write 3 things you would Write 3 things you would

ask in her history to ask in her history to differentiate between differentiate between them.them.

(iii)(iii) Name one investigation Name one investigation which enables you to which enables you to come to a definitive come to a definitive diagnosis?diagnosis?

(i) Cellulitis , DVT(i) Cellulitis , DVT(ii)(ii) Any preceding injuryAny preceding injury

history of DMhistory of DM prolonged immobilizationprolonged immobilization

Use of OCPUse of OCP

Varicose veinsVaricose veins

(iii)(iii) Duplex scan of LL Duplex scan of LL

Mx of CellulitisMx of Cellulitis

REMAINREMAIN

R = RestR = Rest

E = elevation of the limbE = elevation of the limb

M = mobilizationM = mobilization

A = Antibiotics, antipyretics, A = Antibiotics, antipyretics, analgesiaanalgesia

I = Immunization against tetanusI = Immunization against tetanus

N = NutritionN = Nutrition

TubesTubes

An intercostal tube connected to an An intercostal tube connected to an underwater seal drainage bottle underwater seal drainage bottle given.given.

(i)(i) Write 2 indications of use.Write 2 indications of use.

(ii)(ii) Name 2 complications of this.Name 2 complications of this.

(iii)(iii) After inserting this to a patient, as After inserting this to a patient, as the HO name 3 things you would the HO name 3 things you would assess in this patient.assess in this patient.

(i)(i) Indications--- 1. therapeutic – Indications--- 1. therapeutic – pneumo/haemothoraxpneumo/haemothorax

2. prophylactic – 2. prophylactic – post op in post op in cardio-thoracic Sxcardio-thoracic Sx

(ii)(ii) Complications--- 1. during insertionComplications--- 1. during insertion

2. maintenance2. maintenance

3. during removal3. during removal

(iii)(iii) Pt Assessment in the ward round.Pt Assessment in the ward round.

S = Subjective S = Subjective (ask from the pt about his (ask from the pt about his complains)complains)

O= objective O= objective (examine chest expansion, (examine chest expansion, auscultation, auscultation, resp rate, whether resp rate, whether tube is functioning)tube is functioning)

A = Assessment A = Assessment (overall condition of the pt)(overall condition of the pt)

P= plan of managementP= plan of management

CannulasCannulas

14G- Orange – 14G- Orange – in emergencies in emergencies

16G- grey 16G- grey 17G- white17G- white 18G- Green18G- Green 20G- Pink20G- Pink 22G- Blue22G- Blue 24G- Yellow24G- Yellow 26G – Purple - 26G – Purple - paediatricpaediatric

Blood transfusion

Crystalloid infusion

NeedlesNeedles

14G- white - 14G- white - abscess drainageabscess drainage 18G- Pink 18G- Pink 20G- Yellow20G- Yellow 21G- green – 21G- green – Blood cultureBlood culture 22G- Black22G- Black 23G- blue - 23G- blue - IM injections/FNACIM injections/FNAC 24G –Red - 24G –Red - SC injectionsSC injections 25G- orange – 25G- orange – VV sclerotherapyVV sclerotherapy 26G- Brown – 26G- Brown – Insulin SC/ Mantoux/ BCG Insulin SC/ Mantoux/ BCG

(ID inj)(ID inj) 27G- Ash27G- Ash 29G- Dark orange29G- Dark orange

Neuro surgeryNeuro surgery

What’s the lesion?What’s the lesion? Which condition Which condition

produces this produces this characteristic characteristic lesion?lesion?

What’s the What’s the underlying cause underlying cause for this condition?for this condition?

How do you manage How do you manage this patient?this patient?

A hyper dense, biconvex shaped area A hyper dense, biconvex shaped area in the right tempero-parietal region.in the right tempero-parietal region.

Right sidedRight sided, Acute , Acute Extra dural Extra dural HaemorrhageHaemorrhage

Damage to the middle meningeal Damage to the middle meningeal artery. Parietal bone fracture maybe artery. Parietal bone fracture maybe the cause for this injury but not the cause for this injury but not always.always.

Resuscitation, HIO, craniotomyResuscitation, HIO, craniotomy

What is the lesion?What is the lesion? What is the cause What is the cause

for this lesion?for this lesion? In which age group In which age group

do these occur do these occur commonly and commonly and why?why?

Crescent shape, small hyper dense Crescent shape, small hyper dense area in left tempero- parietal region.area in left tempero- parietal region.

Left sidedLeft sided Acute Acute SDH SDH In elderly because there subdural In elderly because there subdural

space is enlarged in them due to space is enlarged in them due to brain atrophy.brain atrophy.

What’s the lesion?What’s the lesion? What could be the What could be the

underlying brain underlying brain condition?condition?

What are the What are the causes?causes?

Hypodense crescentic area in left Hypodense crescentic area in left temporal area.temporal area.

Left sided Left sided ChronicChronic SDH SDH - Alcoholics- Alcoholics

- child abuse- child abuse

- elderly following recurrent falls- elderly following recurrent falls

GCSGCS1. 1. Eye openingEye opening spontaneousspontaneous =4=4

to speech to speech = 3= 3to painto pain =2=2nonenone =1=1

2. 2. Best verbal responseBest verbal response oriented oriented = 5= 5confusedconfused = 4= 4inappropriateinappropriate = 3= 3incomprehensible incomprehensible = 2= 2None None = 1= 1

3. 3. Best motor responseBest motor response obeying obeying = 6= 6localizing localizing =5=5withdrawingwithdrawing =4=4flexing flexing =3=3extending extending =2=2none none =1=1

Criteria for admission after head injury

o Altered level of consciousness o Skull fracture o Neurological symptoms or signs o Difficult assessment - drugs, alcohol o No responsible carer

Indications for CT scan

GCS less than 13 at any point since the injury Suspected open or depressed skull fracture Any sign of basal skull fracture Post-traumatic seizure Focal neurological deficit

If GCS ≤ 8 , Req intubation & ventilation

AudiogramsAudiograms

Sensorineural hearing loss

CausesAcoustic neuroma

Meningitis

Ototoxic drugs

Noise induced

Conductive hearing loss

Wax impaction

Otitis media

Otosclerosis

What’s the What’s the abnormality that abnormality that you see in this you see in this CXR?CXR?

What are the What are the causes?causes?

What could be the What could be the patient patient presentation?presentation?

There’s air under the diaphragmThere’s air under the diaphragm Perforation of a hollow viscusPerforation of a hollow viscus

- bowel perforation- bowel perforation

- perforated peptic ulcer- perforated peptic ulcer

- ruptured appendix- ruptured appendix Acute severe abdominal pain, Acute severe abdominal pain,

guarding and board like rigidityguarding and board like rigidity

Intestinal obstructionIntestinal obstruction

Small Bowel

large Bowel

Small bowel

Central positionMany loopsComplete rings (valvulae

conniventes)

Large bowel

Peripheral position

Few loopsIncomplete

rings(haustrations)

NG tubesNG tubes

Measurement of the length & insertionMeasurement of the length & insertionUsesUses

TTherapeutic-herapeutic-- for NG feeding- for NG feeding- decompression of stomach contents - decompression of stomach contents

in in emergency surgeryemergency surgery- in gastric lavarge- in gastric lavarge- as a catheter in BPH pts- as a catheter in BPH pts

DiagnosticDiagnostic- suspected oesophageal atresia- suspected oesophageal atresia

ColostomiesColostomies

ColostomyColostomy loop & endloop & endtemporary & permanenttemporary & permanent

IndicationsIndications Diversion – to protect a distal bowel Diversion – to protect a distal bowel

anastomosisanastomosis Decompression – to relieve a distal obstructionDecompression – to relieve a distal obstruction In Rectal Ca following APRIn Rectal Ca following APR

ComplicationsComplicationsearlyearly – necrosis – necrosis latelate - stenosis - stenosis

- obstruction- obstruction - parastomal hernia - parastomal hernia

- retraction- retraction - prolapse - prolapse

Sclerosants Sclerosants

Haemorrhoids Haemorrhoids Inject 5 % phenol in olive/almond oil Inject 5 % phenol in olive/almond oil

using a using a Gabrielle syringeGabrielle syringe

Varicose veinsVaricose veins 1 % - STD ( sodium tetra decyl 1 % - STD ( sodium tetra decyl

sulphate) inject IV sulphate) inject IV

VascularVascularArterial ulcers

Hx of smoking, DM , lipids ,HT

Painful

Pressure areas

Regular , punched out edge

Fx’s of ischemic limb

Venous ulcers

Hx of DVT, VV,

Majority Painless

Maleolar area

Irregular, sloping edge

Skin changes of venous disease – venous eczema

Urinary CathetersUrinary Catheters

-- FG , Foley’s self retaining urinary -- FG , Foley’s self retaining urinary catheter.catheter.

2 way (normal) & 3way catheter.2 way (normal) & 3way catheter. Paul’s tube (condom catheter)Paul’s tube (condom catheter) Rubber Vs Silicone catheters Rubber Vs Silicone catheters Males- 16 FG ; Females – 14 FGMales- 16 FG ; Females – 14 FG

UsesUses 2 way catheters,2 way catheters,

To measure the urine outputTo measure the urine output investigations – MCUGinvestigations – MCUG to relieve an acute retention of urineto relieve an acute retention of urine Hydrostatic reduction of an intussuception in Hydrostatic reduction of an intussuception in

childrenchildren 3 way,3 way,

For continuous irrigation of bladder following For continuous irrigation of bladder following prostatectomyprostatectomy

Paul’s tube (condom catheter)Paul’s tube (condom catheter) In male pts with urinary incontinenceIn male pts with urinary incontinence

X ray – KUB IVU

Double J stentDouble J stent Identify the Identify the

instrumentinstrument Uses;Uses;

To relieve obstruction To relieve obstruction of the urinary tractof the urinary tract

Prophylactically Prophylactically during ESWLduring ESWL

To identify ureter in To identify ureter in certain surgeries certain surgeries

eg:- Endometrial Caeg:- Endometrial Ca

How long to be kept?How long to be kept? < 3 months< 3 months

Internal fixatorsInternal fixatorsIndicationsIndications Intra-articular fractures - to stabilise anatomical Intra-articular fractures - to stabilise anatomical

reduction reduction Repair of blood vessels and nerves - to protect Repair of blood vessels and nerves - to protect

vascular and nerve repair vascular and nerve repair Multiple injuries Multiple injuries Elderly patients - to allow early mobilisation Elderly patients - to allow early mobilisation Long bone fractures - tibia, femur and humerus Long bone fractures - tibia, femur and humerus Failure of conservative management Failure of conservative management Pathological fractures Pathological fractures Fractures that require open reduction Fractures that require open reduction Unstable fractures Unstable fractures

ComplicationsComplications Infection Infection Non-union Non-union Implant failure Implant failure

External fixatorsExternal fixators

Indications Indications Acute trauma - open and unstable fractures Acute trauma - open and unstable fractures Non union of fractures Non union of fractures Correction of joint contracture Correction of joint contracture Filling of segmental limb defects - trauma, Filling of segmental limb defects - trauma,

tumour and osteomyelitis tumour and osteomyelitis Limb lengthening Limb lengthening

ComplicationsComplications Overdistraction Overdistraction Pin-tract infection Pin-tract infection

fracturesfractures

Important fracturesImportant fractures Colle’s – below elbow POP cast upto the Colle’s – below elbow POP cast upto the

metacarpal heads, sparing the thumbmetacarpal heads, sparing the thumb Scaphoid – “ glass holding” positionScaphoid – “ glass holding” position

Know about;Know about; Xray identification of Colle’s ,supracondylar, Xray identification of Colle’s ,supracondylar,

NOFNOF

A patient with a POP cast to his Right A patient with a POP cast to his Right forearm in the A&E unit.forearm in the A&E unit.

During the ward round how to assess the During the ward round how to assess the cast?cast?Look for 6p’s of acute limb ischemiaLook for 6p’s of acute limb ischemia

- Pain- Pain- pallor- pallor- perishing cold- perishing cold- paraesthesia- paraesthesia- paralysis- paralysis- pulseless- pulseless

The patient has pain on passive The patient has pain on passive movements of the fingers. What is your movements of the fingers. What is your main worry?main worry?

Compartment syndromeCompartment syndrome

What is the immediate managementWhat is the immediate management

Full thickness , full length splitting Full thickness , full length splitting of the POPof the POP

elevation of the limbelevation of the limbimmediate immediate Fasciotomy.Fasciotomy.

CS –can also occur in circumferential CS –can also occur in circumferential full thickness burnsfull thickness burns

- requires - requires EscharotomyEscharotomy

A 42 yr old school teacher presents A 42 yr old school teacher presents with a 3 months history of tingling with a 3 months history of tingling and numbness of her Right hand and numbness of her Right hand which is worst at night.which is worst at night.

What is the most likely diagnosis?What is the most likely diagnosis? Write 2 possible causes Write 2 possible causes What is the most important What is the most important

investigation you would like to investigation you would like to perform to confirm your diagnosis?perform to confirm your diagnosis?

What are the management options?What are the management options?

Carpal tunnel syndromeCarpal tunnel syndrome DM , hypothyroidism , obesity , DM , hypothyroidism , obesity ,

Acromegaly, Acromegaly, AmyloidosisAmyloidosis Nerve conduction studiesNerve conduction studies Weight reductionWeight reduction correct the underlying causes (DM, correct the underlying causes (DM,

hypothyroid)hypothyroid)DiureticsDiureticsDecompression surgery if failing aboveDecompression surgery if failing above

Post op feverPost op fever 11stst 24 hrs of Sx 24 hrs of Sx

- Metobolic response to trauma- Metobolic response to trauma- Reactions to blood transfusions & anesthetic drugs - Reactions to blood transfusions & anesthetic drugs

D2D2 - - Lung atelectasisLung atelectasis

D3-D5D3-D5- Local sepsis – cannula site , catheter, wound infections Local sepsis – cannula site , catheter, wound infections

D5-D7D5-D7- DVT , leaking bowel anastomosisDVT , leaking bowel anastomosis

>1 week>1 week- Distant sepsis – hepatic,cerebral, deep seated abscesses- Distant sepsis – hepatic,cerebral, deep seated abscesses

ET tubesET tubes

Cuffed & uncuffed Cuffed & uncuffed Uncuffed – in childrenUncuffed – in children

Size (internal diameter mm) = Age Size (internal diameter mm) = Age + 4+ 4

44 Male – (8-9.5) ; female – (7-8) Male – (8-9.5) ; female – (7-8) In place for <7 days – risk of tracheal In place for <7 days – risk of tracheal

stenosisstenosis Prevented by doing a tracheostomyPrevented by doing a tracheostomy

Uses of ET tubesUses of ET tubes

Maintain airwayMaintain airway For ventilation (IPPV)For ventilation (IPPV) Prevent aspiration (cuffed)Prevent aspiration (cuffed) Give drugs – adrenalineGive drugs – adrenaline

- atropine- atropine

- naloxone- naloxone

Guedel(oral) airwayGuedel(oral) airway

How to select the appropriate size?

LMALMA

Male – 4 cm

Female – 3 cm

Tracheostomy tubesTracheostomy tubes

Cuffed plastic tube for tracheostomy

Indications

i. To relieve obstruction of upper airway

ii.Prolonged mechanical ventilation

iii.To remove retained secretions in LRT

complications

- Pneumothorax

- Haemorrage

- Surgical emphesema

- tube displacement

CPRCPR

Changes in 2005 ALS guidelinesChanges in 2005 ALS guidelines

CPR rate – 30:2 ( not 15: 2)CPR rate – 30:2 ( not 15: 2)

All 3 DC shocks – 360J each All 3 DC shocks – 360J each

Fitness for surgeryFitness for surgery

From the HxFrom the Hx

any co-morbidities (DM,BA,IHD) & any co-morbidities (DM,BA,IHD) & their controltheir control

degree of dyspnoea if present (NYHA)degree of dyspnoea if present (NYHA)

Drug historyDrug history

past hx of GA and recoverypast hx of GA and recovery

smoking , alcoholsmoking , alcohol

symptoms of anaemia symptoms of anaemia

Suture materialSuture materialAbsorbableAbsorbable Non- absorbableNon- absorbable

SyntheticSynthetic NaturalNatural SynthetiSyntheticc

naturalnatural

PolyglycoliPolyglycolic acidc acid

CatgutCatgut PolypropyPolypropylene lene (prolene)(prolene)

SilkSilk

Polyglactin Polyglactin 910 910 (Vicryl)(Vicryl)

PolyamidePolyamide

(nylon)(nylon)

PolyglecapPolyglecaprone 25 rone 25 (monocryl)(monocryl)

PolyesterPolyester

PolydiaxanPolydiaxanoneone

Thank youThank you