Clinical exam questions

Breast
1) Pt with Breast reconstruction- breast exam (dr focus on how you describe things), if
pt comes back with new lump how you manage- triple assessment (must say this
first b4 you elaborate), usg finding (<35 yo just do usg no need mamogram) ,
advantage of core biopsy compared to fnac, what flap is this (LD flap because got
scar on the back lumbar area), what other flap is common (TRAM flap), what's the
main diff between TRAM vs LD flap (TRAM cannot do in physically active pt because
streneous activity causes increase intraabdominal pressure and later pt will get
incisional hernia)

1. 51 y/o, para 4, ul hpt and dyslipidemia, pw h/o lump at left breast for 1 year, firm, freely
mobile, non tender, increase from 1 to 4cm for 1 year. No any other positive findings. Pt
did mammogram and the result is not malignancy. Fibroadenoma
a. - Examination and presentation
b. - provisional & justify
c. - differentials and justify
d. - triple assessment and birads
e. - prognosis and Mx
f. - if pt want conservative tx, is it okay, what to do
g. - red flag for malignancy
2. Mx for this patient
3. Breast mass likely fibroadenoma,51 years old woman, parity 4
a. - demonstrate breast examination
b. - Describe mass
c. - Provisional
d. - Differential
e. - Investigation
f. - Malignant features of mammogram
g. - Why you think this patient is not malignant
h. - If malignant how to manage and follow up
i. - In this case how to manage

4.
5. Male patient with left breast lump, hard in consistency, an incision scar over it.
-ddx and supporting point
 Breast carcinoma with post wide local excision
 Recurrent breast fibroadenoma
-what examination other than breast
 Infraclaviucular, supraclavicular LN
 Resp examination – pleural effusion
 Abd – hepatomegaly
 Spine – bony tenderness/lumps
-purpose of the scar
-ix

6. female, dense breast, right breast abscess over inner upper quadrant besides nipple,
post op, wound packing, regular edge and shiny peripheral skin, edematous and
 erythematous, examine the axillary lymph nodes, examine the other side, cause of
abscess
cause of abscess – mastitis
bloody discharge – ductal ca, ductal papilloma
7. Examine breast.
● - One side breast got chemo port.
● - Got any finding?
● - what will you do to check for mets?
● - why there is no mass palpable?
8. Fibroadenoma
● Pdx
● Ddx
● What will you do next- ix, mx

diff between fnac and core biopsy

FNAC
cytologic examination
FNA is a simple
Ultrasound-guided FNA biopsy
using 23- to 27- gauge (commonly 25-gauge) needles
local anesthesia
FNA biopsy of the largest nodule

THYROID

Post thyroidectomy
1. How to do chvostek sign ? Where to tap
 Contraction of ipsilateral facial muscles by tapping facial nerve anterior to the
ear
 Trousseau sign – induction of carpal spasm (add of thumb, flexion of wrist)
by inflation of syhgnomanometer above sbp for 3 mins
2. Complication of thyroid surgery
 HITS
 Haematoma
 Hoarseness
 Hyperthyroidism (failed treatment)
 Hypoparathyroidism  hypocalcemia
 Hypothyroidism
 Infection
 Seroma
 Unilateral vs bilateral cord injury

Mx of hypocalcemia

 Look for cf of hypocalcemia (paresthesia around mouth, carpopedal spasm,

svosteck/troussoue sign)
 Ci – tetany ,laryngeal spasm, airway compromise
 Blood for serum calcium and albumin
 o Corrected calcium
o Serum calcium + 0.02 (40-albumin)
 Replace with 10ml 10% calcium gluconate if severe

3. How to manage the pt if you at kk?

4. Usg thyroid finding
 Malignant – hypoechoic, posterior acoustic shadowing, taller than wider,
absent of halo sign, microcalcification, increased vascularity, irregular border
5. Differential diagnosis of Solitary thyroid mass
 Prominent nodule of MNG
 colloid goiter
 Thyroid CA
 Follicular adenoma
 Thyroid cysts (systrunk procedure)
 Dermoid cysts
 Lymphoma
 Lymphadenopathy
6. Why do RAI?
7. What is the meaning thyroid suppression therapy?
8. investigation for this patient
 TFT – measurement of TSH ( in cA), fT4, T3
 Tumour markers - medullary (Serum calcitonin concentration), Tg
(differentiated thyroid CA)
 USG of neck – confirm origin of mass, tro features of malignancy, tro LN, look at
contralateral side
 Syncitography
 FNAC
o Extrathyroidal extension
o LN associated
o ≥1cm
o TIRADS 3&4
9. management of this patient

 Hemithyroidectomy – removal of one lobe of the gland, including the isthmus and the
pyramidal lobe; usually for suspicious thyroid nodules
 Total thyroidectomy – entire gland removed completely;
 RRA 6 monthly
 Chemotheraphy
 F/u
o Usg of neck – recurrence, LN
o TFT
o Tg aim <0.1
o Full body scan

10. pre-op preparation

 vocal cord assessment
 anaesthesia assessment
 suppression of TSH level
11. how to follow up pt.
12. where to ausculate

13. why not thyroglossal cyst cystic in consistency, moves with tongue portrusion
14. why check carotid A
15. elicit eye signs
A. lid retraction (can see sclera between upper limbus
B. exolpthamos (sclera between lower limbus and lower eyelid)
C. chemosys (edema and erythema of conjunctiva)
D. lid lag
E. proptosis (eye visible over supraorbital ridge)
16. management - when want to do surgery
A. Thy 3 / 4
17. follicular adenoma vs follicula CA
 adenoma –
 ca – capsular invasion

18. papillary ca-age, common (female)

papillary ca 20-40 years old. Bimorphic ca
1. Graves disease
● ix
● mx
● what to do for rhc pain (pt presented w rhc pain)

1. Neck scar horizontal with packing, superimposed scar

-describe the scar and wound, comment on warmth and tenderness
-what is purpose of scar
-why did u think its postthyroidectomy scar
-post thyroidectomy examination
-complication thyroidectomy and how u examine
- hypocalcemia (how to test, what to give)
- hypothyroidism symptom

2. MNG - Short case (nik, maher)

● DDX
● investigation
● management
● complication of thyroidectomy

3. Ant neck mass(lipoma?) - dr eugene

● give clinical findings for different types of neck mass
● what history to ask for specific mass
● DDX
● ix done before surgery - blood, imaging (US, CT scan)
● what are the features of malignancy clinically and in US,

2. Diffuse Goitre
● take hx and pe: present hx, dx, sign and symptom of the patient, ix,
management
● Approach triple assessment
 ● Ddx
● Hashimoto do surgery or not
● Thyroid storm and mx

● Hyperthyroidism symptoms
● -short hx
● -dx
● -ix
● -hyperthyroidism s&s
● -types of thyroid ca
● -spread of thyroid ca
● -mx
● -cx of thyroidectomy
● -thyroid storm presentation and mx

3. Post op thyroid (just a horizontal surgical scar at the anterior neck)

● -what is berry sign
i. Absence of carotid pulsation on the side of thyroid malignancy
● -where to listen to bruit
● -complication of thyroidectomy
● -how to elicit sign hypocalcemia
● -post op mx
● -ix to detect mets
● a. After neck exam proceed thyroid stat exam, what do u think the thyroid stat
for this patient (euthyroid)
● b. Scar - what possible op?
● c. Let's say patient post thyroidectomy 1 month come for follow up what u want
to check for?
● d. Action of parathyroid hormone
 i. calcitonin action in body
1. inhibits bone resoprtion, increase renal excretion of calcium
4. Thyroid nodule
● As a MO in district hospital, how you assess patient - TFT
● Physical signs of malignancy
● If FNAC shows follicular, what's ur next management

6. Grave disease in thyrotoxicosis state complicated with heart failure (PND & cardiomegaly)
- prof firdaus, prof aung mra, prof fairul (dr suru examine dpn dorang)
● Prov, Ddx for diffuse neck swelling
○ Graves disease, hashimoto thyroiditis
● Investigations, Management
● Do you think the dose is adequate (pt have tremors, palpitation, displaced apex beat,
pnd, 2x thyroid storm)
● Not respond to medical, wht other modalities? What first choice? What disadvantage
of RAI?
● What surgery?
● What preop preparation u want to do? (Euthyroid, GA assessment, refer ent to
exclude vocal cord palsy)
● Complications of total thyroidectomy and how to manage

7. THYROID
● ask how many times thyroid storm
● ask about eye dryness because dont have typical eye signs/thyroid acropachy
● from history elicit the cause ( living in iodine deficient area (hill area)
 ● patient have proximal muscle weakness (so ask about functional modification at
home like toilet)
● why this patient (grave’s) need for thyroidectomy- because symptoms uncontrolled
by medication
● investigation
● management

OBS JAUNDICE
9.Dr Edwin and Dr Fatimah

Post Op day 2
History of RUQ pain, with pale stool and tea coloured urine, LOW 17kg and LOA.
Ascending cholangitis with choledocholithiasis
1) differentials with justifications and provisional
a. ddx
i. peri ampullary CA (cholangio cA, head of pancreas CA, duodenal CA
ii. obstructed jaundice secondary to choledocholithiasis
iii. HCC
iv. Billiary Ascariasis
v. TB stricture of CBD
vi. Liver abscess secondary to malignancy
vii. Porta hepatis LN
viii. Primary sclerosing cholangitis (chronic inflammation/autoimmune)
ix. Hepatitis B C
x. Hemolytic anemia
xi. Thalassemia
xii. G6pd
xiii. Drug induced hepatotoxicity
2) Courvoisier’s law – palpable gallbladder, jaundice, unlikely due to gallstone
a. Periampullary CA
b. Double impaction
c. Oriental cholangiohepattitis
3) examination of patient see what
i. stigmata of CLD
ii. jaundice – pruritis, scratch marks,
iii. mass
iv. gallbladder
v. hepatomegaly
vi. temperature
vii. BP

2) investigations with expected results

 Blood
o FBC – leukocytosis, thrombocytopenia, anemia of chronic illness
o CRP – inflammatory marker 
o Serum amylase /lipase – acute pancreatitis
o LFT -  total & direct bilirubin, Nutritional status – pre albumin ,
transaminitis (ALT /AST) in obstructive jaundice ALP &GGT raised)
 o Coagulation profile – PT prolonged, INR prolonged
o Tumour marker (pancreatic /CRC/gastric - CA 19-9,CEA ,
HCC/ovarian/testis – AFP, cholangio – CA19-9)
o Hep B C, HIV serology
o RP – baseline before CECT
 Sepsis
o ABG – ascending cholangitis : sepsis
o Serum lactate - >4 sepsis
 Imaging
o USG of HBS
 Ascending cholangitis
 Dilated CBD >7mm
 Thickening of GB wall
 gallstone
o Endoscopy USG – view of tract
o CT scan for metastasis (CT TAP / pancreatic CT protocol - pancreas / 4
phase CT scan – liver)
o Or MRCP
o Chest X ray
o Bone scan – increased uptake

3)management before ercp (how to prepare the patient for ercp)

Severity assessment ascending cholangitis

one of the following organs/systems:

 Cardiovascular dysfunction – Hypotension requiring dopamine ≥5 micrograms/kg

per min, or any dose of norepinephrine
 Neurological dysfunction – Disturbance of consciousness
 Respiratory dysfunction – PaO2/FiO2 ratio <300
 Renal dysfunction – Oliguria, serum creatinine >2.0 mg/dl
 Hepatic dysfunction – Prothrombin time-international normalized ratio >1.5
 Hematological dysfunction – Platelet count <100,000/mm

Moderate acute

two of the following:

 Abnormal WBC count (>12,000/mm3, <4,000/mm3)

 Fever 39°C (102.2°F)
 Age (≥75 years)
 Hyperbilirubinemia (total bilirubin ≥5 mg/dl)
 Hypoalbuminemia

Mild acute
 1) Ensure patient clinically stable
2) Ensure patient is not allergic contrast, no cardiac implant
3) GA assesment
4) If patient undergoing anticoagulant  refer medical department if on warfarin
change to heparin

4) what to see in usg and cect in this case

Usg – stones in CBD, dilated CBD,
5) how to do ercp and what to do if the stone is too big or if there is multiple stones
that cannot be removed from ercp
billiary sphinctorotomy – cutting of sphincter of oddi + intraduodenal segment of
CBD

6) common organisms and what antibiotic to give

Gram + and gram negative anaerobes + microbials
3rd gen cephalosphorin + metrodinazole
obstructive jaundice
19. Murphy sign demonstrate
 On deep inspiration, pain when palpating the RUQ

1. types of gallstones
A. cholesterol
B. pigmented
C. mixed
2. what you see in usg?,
3. which gallstones can see in axr – pigmented stone as it contains caalcium which is
radioopaque - calcified
4. complication of obs jaundice
A. bile stasis  bacterial translocation  ascending cholangitis 
bacterimea  sepsis  septic shock
B. bile stasis  no lipid emulsification  no reabsorbtion of lipid
soluble vitamins  ADEK insufficiency  vit K  coagulopathy +
steatorrhoea
C. pruritus (retrograde bile salt into systemic circulation  bile salt
deposition )
D. gall stone pancreatitis
E. gall stone ilius
F. ascending cholangitis
G. gall bladder empyema  gall bladder perforation  liver abscess /
peritonitis
5. Obstructive jaundice 2 ca head of pancreas
Definitive mx
Whipples procedure ( 3 jejunostopy – gastrojejunstomy, pancreaticojejunostomy,
choledochojejunostomystomy)
PTBD – pylorus preserving pancreatico duodenctomy
Biopsy – percutaneous biopsy under USG guided/ CT guided
Endoscopic ultrasound guided biopsy
Courvoisier's law n exception
 1. Choledocholithiasis, underlying gastritis & thyroid enlargement - prov dx, d/dx, ix, mx,
How to manage at emergency & casualty

a. Burch wartofsky >45 thyroid storm

i. Temp
ii. CNS
iii. Cardio
iv. A FIB
v. cHF
vi. precipicipitating hx
b. block synthesis – high dose PTU/carbimazole
c. block release  lugols iodine
d. prevent peripheral conversion – propanolol
e. block conversion t4→43 – IV dexa
f. block enterohepatic circulation  cholesteromine
g. oxygen
h. iv fluid
i. anti pyrexia
j. treat precipitating event

2. antibiotics classification & eg

3. female jaundice and ascites, right eye unable to open (blind), obstructive jaundice
4. old man with deep jaundice, scratch mark..
dx obstructive jaundice due to malignancy
6. Gallstone pancreatitis
 Diagnosis, differentials, criteria for diagnosis, severity, blood investigations, usg features
of pancreatitis
management- do cholecystectomy first
8. Ascending cholangitis 2dary to choledocholithiasis with blocked stent (win tin)
- Dx
- Charcot's triad
 Fever, RUQ pain, jaundice

Reynolds pentad
 Charcot triad + AMS

- Calot's triangle
 Superior – inferior border liver, left – CHD, right – cystic duct,

courvoisier's

10. OJ secondary to ascending cholangitis (wintin)

Boas sign  hyperesthesia felt by the patient to light touch in the right lower
scapular region or the right upper quadrant of the abdomen. It is classically seen in
patients with acute cholecystitis

Ix management
15. Ascending cholangitis.
Dx, differentials and investigations
Causes of jaundice
Charcots triad
Mx- when to do cholecystectomy (current admission to prevent stop from dropping again)
Pre and post ercp mx
If toxic, how to manage (resus, ionotropes)
Sepsis
1. Initial resuscitation with ABC
a. Airway – ensure patent airway
b. Breathing - intubation + mechanical ventilation, give oxygen increase FiO2
c. C – 2 large bore IV line 16 gauge, IV fluid resus (fluid challege 30ml/kg/1/2hr) ,
blood for ix and C&S , broad spectrum antibiotic + anaerobic
d. Ix – serum lactate, ABG,platelet, calcitonin
e. Monitor vital signs
i. SBP >90
ii. CVP – central line 8-12mmHg
iii. MAP - >65mmHg
iv. FiO2
v. Urine output – at least 0.5ml/hr
vi. Normalised serum lactate <2 mmol/L
vii. If refractory to this give adrenaline
f. If ABG ph <7.1 give sodium bicarbonate

6. Dr Firdaus & Dr Win Tin

Post op Day 5 roof top incision
Hx of jaundice, epigastric pain for 5month with constitutional Sx.
1. Ddx.
2. Rooftop incision- what surgery?
3. How whipple procedure is done
4. Leak anastomosis and complication of whipple procedure
 Pancreatic fistula
 Delayed gastric emptying
 Diabetes (pancreatic insufficiency )
 Intraabdominal abscess  instraabdominal sepsis
 Leak anastomosis
 Haemorrhage
 Dumping syndrome
5. Intestinal obstruction 2° adhesion – management
a. NBM
b. IV hidration
c. Gastric decompression
d. IV antibiotic
e. Analgesia if abd
f. Supine abd x ray
g. Erect chest x ray
h. CT – site of obstruction

14.Mr Edwin and Dr Fatimah

Obstructive jaundice secondary to choledocholithiasis
-approach jaundice – surgical and medical  LFT (unconjugated – pre hepatic (medical
jaundice), conjugated – surgical jaundice
-medical and surgical jaundice
- DDx
-PE abdomen
-investigation
-Management
-complication ERCP
 Pneumobilia
  Post ERCP Pancreatitis
 Stricture
 Infection – cholangitis, cholecystitis
 GI Bleeding
 Duodenal /billiary perforation

Painless, Obstructive jaundice

Causes
Ix,mx,dormia basket technique, stone cant remove what to do, courvoisier law, types of
stone, radiolucent (cholesterol) or radio opaque (pigmented) and why, murphy sign
technique/landmark – midclavicular line, upper right tip of ICS joined with rectus margin,

58 yo, obstructive jaundice with underlying hcc with hepatitis, operated (2013- left
hepatectomy + cholecystectomy, 2018 - open segmentectomy for recurrent hcc) and TACE
5 times
Findings:
- CLD - jaundice, palmar erythema, clubbing, spider naevi, dilated veins
- RHC tenderness
- hepatomegaly
- scar previous hepatectomy
Questions:
- ddx obstructive jaundice in this case (PDX – hcc + porta hepatis LN)
Ddx – recurrent HCC, hepatitis,
- investigations (mrcp)
- management (ptbd
1. Sabperi, 45,male, p/w jaundice, fever, abd pain.
O/e : jaundice, others normal.

- obstructive jaundice ddx, ix, MX of acute cholangitis, other than ercp and
cholecystectomy want can we do, cx of ercp, cx of cholangitis, charcot triads,
Reynolds pentad, courvesiers law and exceptions, if obstruction due to periampullary
Ca how to confirm from hx, pe, ix.

- Dhoshini ques:
- Provisional, Ddx, Charcot’s triad, investigations, management – ERCP,
cholecystectomy.
- Complications of cholecystectomy. Bile duct leakage, bile injury, bleeding, bowel
injury
- Scenario: The next day after surgery, noted distended abdomen, what could be
cause?
- Ans: Bile leakage.
- Management: ERCP again and stenting
16. Jeffrey bin kalandak 57 yo (GB empyema)
- 2nd admission- for ercp procedure
- Initially well till 3wks ago, presented with epigastric pain for 1 days and worsen
became generalised abd pain. Claimed have jaundice and tea color urine.
Currently, having mild rhc pain and drainage.
- Provisional dx
- ERCP- why need to do in this patient, where to injectv the constrast – ampulla of
vater, if u see stone what u will do, complication
Prof Challa and Tun Aung
- different presentation between cholangitis (pentad triad) and pancreatic tumour
(courvoisoirs law)
- investigation for obstructive jaundice
- ercp indication, what dye – gadolinium (iodine based contrast media)
- PTBD/PTC - temporary relieve of obstructive jaundice
- laparoscopic cholecystectomy complication
- laparoscopic cholecystectomy – keyhole port placement *5mm at subshyphoid, medial
subcoastal, lateral subcoastal, periumbilical) initial retraction of gallbladder, clip and divide
cystic artery and duct, dissect gb from liver bed, extraction of gallbladder
- pringle maneuver

-complicated with stricture, what need to do – ERCP + stenting

Ascending cholangitis with cholecystectomy in 2016

- Differential diagnosis and why (given long list 😂), asked for ddx for medical
cause also
- Medical causes
o Heb b/c
o Drug induced ie rifampicin
o Malaria  Hemolytic anemia
o G6PD
o Hereditary spherocytosis
o Autoimmune hemolytic anemia

2. Post ercp choledocholithiasis

● - Why cxr not favourable for gallstone - only 10% and radioluscent
● - How does gallbladder empyema happen - chronic multiple untreated acute
cholecystitis  empyema
● - If you’re the attending at ED, what will you do (include ix)
● - List out ix
● - Why give antibiotics in this case bile stasis  translocation of bacteria 
bacterimea  sepsis, which antibiotics – . Why analgesics(bcoz this pt has
underlying gastritis) and which NSAIDs/ Opioid + PPI.
● - Calot’s triangle
59 yo gentleman, electively admitted for cholecystectomy.
- provisional diagnosis during the attack one year ago
- investigation
- operation that is gonna do
- explain how to do cholecystectomy
- one day after op, pt had generalized peritonitis, what happened? (Bile leak)
- where is the bile leaking from ?How do u manage?

2. OJ secondary to choledocholithiasis (challa)

- courvoisier law and exception of the law, and Charcot triad - why intermittent jaundice
- ix, what u can do with mrcp
- mx
 - prehepatic, hepatic, post hepatic
- portal venous system and postal hypertension

6. GSW3,74 female, malangoi, presented with abdominal pain for 1 yr, jaundice, tea colour
urine, pale stool, itchiness for 2 weeks, LOW 9kg in 2 mths, LOA
O/E jaundice, abdominal distension, scratch marks over abdomen, hard mass over
epigastrium, hepatomegaly 3 finger breath, positive shifting dullness
-differential diagnosis
-investigations
-management of gastric ca
-how to differentiate gastric mass and liver
4. Gastric Ca (Dr Chong & Dr Christopher)
1. Ddx,
2. ix plus finding
3. mx incld nutritional status
4. test( succussion splash)
5. How you classify jaundice

7. 79yrs old Male, jaundice, pale stool, tea colored urine 2 months. Pruritis, LOA LOW 20kg.
PE: deep jaundice. Scratch marks and blister. Otherwise no findings.
Impression: Obstructive Jaundice 2’ to Malignancy
-complications of obstructive jaundice
-how to differentiate head of pancreas ca and cholangioCa
-why ascending cholangitis have fluctuating jaundice? In stone case? In cancer case
- progressive?
-ALP produced from where?
8. Jaundice- Ddx, Ix, Management
9. RHC mass with jaundice, thyroid nodule, ileostomy at LIF Ms Roha & Dr Nik
- RHC mass , generalize jaundice. She ask me what mass is that? Some ddx.
- Ileostomy on the left illiac fossa. Why left? Explain with justification

10. Jaundice, pruritus with hepatomegaly.Dr Tun Aung & Dr Tofazzal

● - cause of hepatomegaly - HCC, liver mets, first stage of liver cirrhosis, viral
hepatitis,
● - cause of obstructive jaundice
● -type of CBD stone - pigmented and cholesterol(which is more common - cholesterol
and the prevalence, which one is radiopaque - pigmented and why? - because it
contains calcium)

Most common bacteria – ecoli, klebsiella , enterococcus

If ERCP fail – choledocotomy, ± choledochotomy
If missed/retained stone T tube using burhenne procedure

7. HCC- Differential, Ix, Mx, Child Pugh, common organism that can cause hcc, course of
hep B to become hcc.
8. HCC- Dd, Investigation, imaging.. support your diagnosis n why
20. (Dr Firdaus & Dr Win Tin)
Pt e/a for surgery. Presented 5 months ago with epigastric pain, fever, loa, low. PE no
significant findings.
-differentials? (pathology in the stomach, left lobe of liver, transverse colon, pancreas etc…)
-what investigations want to order? Justify why expected findings for each investigations?
-if hcc, what is the tumour marker?
-Management of hcc?
-hcc could be mets from where?
-significance of ct scan? Difference in management if involve 1 both vs involve both lobe?
could be liver abscess also.
-type of liver abscess? (pyogenic, amoebic)
-pathognomonic feature of amoebic liver abscess
11. Obstructive jaundice, no finding. Just jaundice lol - Dr Christopher
● - whats your dx
● - cause of obs jaundice
● - how to investigate (expected findings each, including usg) - LFT, USG, ERCP, MRCP

● Show me how to do abdominal examination

● - How do you know this is a liver?
● - Causes of liver enlargement with lost of weight and appetitie?
● - What do you mean shifting dullness positive?
● - Investigation of HCC?
● - Risk factor of HCC?
●

12. Acute cholescystitis - Dr Tun Aung+ Dr Challa

● - Differential diagnosis of Right hyperchondrium pain
● - Investigation of acute cholecystitis - FBC - leucocytosis, LFT- ALT mildly increased,
USG pericholecystic fluid, post. acoustic shadowing, thickened gb wall
● - Management of acute cholecystitis

Acutecholecystitis
- Present hx. Give dx.
- What is charcot triad, courvosier law
- Why intermittent jaundice
- Types of gallstones
- What is ercp. What procedure can you do. Can you do cholecystectomy same
admission with ercp
- What type of cholecystectomy you know. If laparascopic. What approach u can do to
remove the GB. How to remove gallbladder. What is calot tringle. Name of approach
to remove GB.
- What you want to counsel patient after ercp. Common complication of ercp. Besides
infection, cbd injury, haemorrhage

3. Acute cholecystitis waiting for cholecystectomy

● - Ddx
● - Differentiate (billary colic-acute cholecystitis- cholangitis)
● - How to mx all the 3
● - Complication of cholecystectomy and how to mx
4. 1.
 13. post op laparoscopic cholecystitis : how cholecystitis cause pancreatitis, what is ercp,
treatment modalities in ercp, laparoscopy vs endoscopy, couvoursier law and exceptions,
pre op prep for obs jaundice

2. Heldayah binti formin, 40y/o presented with epigastric pain and fever for
3days.Nausea n vomiting, LoA n LOW.
- ix for acute pancreatitis (usg finding)
- mx (what analgesia), cause
-severity, scoring, what systems, how to assess
- complication
-if pt condition suddenly deteriorate brabis, what happen? (necrotizing pancr, mx?)

14. Acute cholecystitis with multiple ep of choledocholithiasis

● d/dx, ix to support your prov dx
● management, broad spectrum antibiotic-ex
● aerob /anaerob - metronidazole
● function of ercp(full name?)/cx
● murphy sign,location,how to do n expected result if positive?
● why need cholecystectomy? to prevent recurrence
● laparotomy and laparoscopy?
● wht do you expect in u/s for choledo? dilated berapa >7mm?
● risk factor utk pt dpt cholecystitis (bsed on pt)-4F(explain fertile)
● type of gallstone n causes. - pigmented, cholesterol, mixed
● analgesic that you know? example.
● pt ada prev c sec. Wht type of scar?

APPENDICITIS
15. Acute appendicitis - all the signs, ix, mx, why lap better than open?
16. Acute Appendicitis (Christopher, Arif)
● Differentials
○ Acute appendicitis
○ Ureteric colic
○ Psoas muscle abscee
○ IO of iliocecal
○ TB abdomen
○ Inguinal hernia
○ Caecal CA
○ Endometriosis
○ Ovarian cysts
○ Ectopic pregnancy
○ Crhons disease
● ddx RIF pain
● What other signs? Psoas, obturator, rovsing, mc burney
● Investigations - Is USS can dx acute appendicitis
● Management
● Pathophysiology
● Obstruction  fecal lift  obstruction  lumen structure  inschaemia o
1. Acute perforated appendicitis- Ddx, Differences between tenderness and rebound
tenderness,
 Tenderness – visceral pain, rebound tenderness – parietal pain (peritoneal irritiation)
2. Cx of appendicitis surgery- injury to ilioinguinal nerve and cause hernia,
3. Stages of peritonitis & features
A. Stage
4. Sequele of acute appendicitis, Alvarado score (MANTRELS), Signs of appendicitis,
McBurney point, Positions of appendix (retrocecal 70%, pelvic 20% , pre/post ileal ,
subcaecal, paracaecal , subhepatic), Meckel's diverticulum- rule of 2 (2% of population ,
2 x more common in male, < 2 years of age, 2 ft proximan to illicecal valve, 2 inches in
length, 2% present with complication, 2 ectopic tissue (gastrc and pancreatic), ectopic
gastric tissue, Name of incision lenz follow langers line, Mcburney
MANTRELS

10.Dr Edwin and Dr Fatimah

Perforated appendicitis : Rif pain>whole abdomen and abdominal distention
Ddx, ix with expected result , causes of io, mx of this patient, types of abx given, causes of
bilateral limb edema post op

Post op day 1 appendicectomy for perforated appendicitis ( Dr Edwin)

- Provisional diagnosis and reason
- Differential diagnosis and reason and how to exclude each one (more than 5)
- Demonstrate PE
- Investigations and reasons
- Management
- How to check for dehydration
- How to give fluid resuscitation
- What organisms involved
- Name of antibiotics
- What are anaerobes
- Type of operation
 - Name of incision
- Post op complications
- What is paralytic ileus and it's causes
- Opstipation , intolerance of oral intake , due to non mechanical factor tht dysrupt the
normal coordinated propulsive motor activity of gi tract folowing abdominal
-
- Appendicitis, post op D2.
- 1.Scenario given posr op D2 present with fever, what u want to look for.
- 2. Intraop, noticed normal appendix, what u want to look for (merkel diverticulitis)
- 3. Ddx fo RIF pain
- 4. Anatomy for appendix, artery appendicular aetery from SMA (location-posterior),
site of appendicitis(commonest at which site)
- 5. Explain all the sign and reason
- 6. Pathophysiology of appendicitis
- 7. Management other than laporoscopic

3. Mr Adam Archel,15,M,Tuaran,DOA1d
u/l perforated appendicitis(post op open apendicectomy 2month) presented
epigastric pain 1 month nonradiating, colicky, intermittent p/s 3 with LOA, nausea,
worsening p/s 8 and vomiting 22x/1 night prior admission.

Q: Provisional Dx, Clinical dx, How to dif IO in small n large bowel, Cardinal
symptoms of IO unable to pass motion and flatus, vomitting, abdominal distension,
abdominal pain, Ix, What finding in x-ray, Mx, Why give antibiotics, How IO cause
sepsis, Patient already stable after initial mx and started with soft diet, suddenly
have recurrent nausea n vovimiting:Mx

4. Vino, 23 y.o
● Acute appendicitis
● Provisional and ddx
● Ix
● Difference btween x ray kub and axr
● Why do we need to ask abt urti in appendicitis

13. Rusia, 55y/o, female

- Acute Appendicitis, POD 6
- -Ddx and reasoning
- -Alvarado, Mc Burney’s point
- -Ix
- -Mx specific
- -scar? indication? if open, where?
- -Why patient still kept in hospital (infection)
- -if do PR what do you expect? (abscess, pus)

. Perforated appendicitis
- differential rif mass
 - diverticular complication and surgery
- ileostomy on the rif (indications, loop vs double barrel, stoma care)
- ddx most likely found in elderly (benign and malignant)
- in case of colorectal (how to approach)
- investigation, staging, management, follow up what to look for (CEA trending
etc), surveillance for crc

5. Mr Samri, 38 year old gentleman presented with lower abdominal pain, vomiting,
diarrhea and low grade fever for 2 days duration.

Differentials, investigations to TRO and confrim. Mx

- Provisional and ddx
- Ix
- Difference btween x ray kub and axr
- Why do we need to ask abt urti in appendicitis
- Ileocaecal TB, anti TB regime

9. Perforated appendicitis (wintin)

-appendiceal abscess pathophysiology & management
-peritonitis (everything)
-acute appendicitis management

PEPTIC ULCER DISEASE

dd
1. complicated chronic PUD with history of perforated duodenal ulcer, adhesion and
peritonitis, duodenal closure done with triple bypass (came in short case)
● a. This patient have multiple recurrent ulcers, what possible condition do you
think he might have - Zollinger-Ellison syndrome (hypergastrinoma)
● b. Ascites comes from? - anastomotic leak
● c. Layers of the abdominal wall
● d. Medical regime for PUD
● e. Surgical management of PUD
● f. Common place for an ulcer in the stomach (lesser curvature)
2. perforated peptic ulcer (tun aung)
3. - surgery for perforated ulcer
4. - types of drain
5. - complications and post op comp

. Perforated gastric ulcer done laparotomy with drain inserted (Dr Christopher)
Diff dx, ix, gastric or duodenal, how to diff, interpret cxr (gas under diaphragm), etiology
of ulcer, what to do when u see pt first time, what op, drain inserted for?, when to
discharge, what to give when discharge, when to follow up pt

6. GOO secondary to peptic ulcer/ gastric ca (Dr tun aung and Johnny)
- DDx
- Ix, monitoring of pt
 - management, indication of operation
Perforated duodenal ulcer
77 years old, male underlying hpt,dylipidemia, esrf, asthma,previous mi(aspirin-bila prlu jk).
Post op 8 days. Ada tapak dialysis dkt R groin.
C/o: melaena 2 days, upper central abd pain 1 days, low loa, anaemic symptom(pallor) 1
days
1. Midline vertical laparotomy(staple) necrotic ts(hitam2)
-granulation t/s content histologically(macrophage n fibroblast)
-dy/dx malaena (give ugib-causes)
-ix for perforated (cxr-air under diagram)
-basic ix smua
-what procedure kena buat dkt pt?(tya time ambik hx jak)
-aetiology of pud
-malignancy of liver:what ix?(afeto, lft, us of liver)
-mx pud (triple regime)
-dy/dx for epigastric abdominal pain.
Murphy's sign(how to do it) indicate?acute cholecystitis
Mcburney point (indicate ba…
Perforated gastric ulcer (Dr nik/ Dr Challa)
- ddx, ddx of acute conditions (PGU, MI, cholecystitis, appendicitis) , Ix for all causes, risk
factors PUD, AXR perforated viscous, how many percent will have air under diaphragm,
cholecystitis USG features, mx of PGU

6. Perforated gastric ulcer w upper gi bleed pre op.

● Ddx
● Ix- what should be expected in abd xray
● What should expect in drain
● Why whole abd resonance
● Relation ulcer and bleeding
● Relation ulcer and perforattion
● Why not do operation now

5. LGIB for Ix
D/dx
Diverticulitar D/s, anal fissure, angiodysplasia,
Ix, Mx, how to do proctoscope, Per rectal finding, mx of Diverticulitar D/s

43 yo gentleman presented with melena and hematemesis for 1 month, nkmi, chronic
smoker and alcoholic..on examination, no other findings except for pallor
Q:
how to diff. ugib n lgib
causes of ugib (discuss more on chronic liver disease, portosystemic shunt, blood supply of
liver, spider naevi)
how to ix
how to mx
GOO
d

6. GOO secondary to gastric adenocarcinoma (Christopher)

Ddx/ Ix/ Mx
6. Stomach CA
Ddx; midchest pain, vomiting, epigastric mass and pain (include TRO MI in hx; PTB)
PE: Mass epigastric ddx, how to differentiate with spleen
Ix: biopsy finding
Other ddx of GOO= stricture
Mx all
Transverse colon ca mx
79/M/ Advanced gastric adenoca with goo (mets to liver and porta hepatis)
*findings: on nasojejunotube feeding, no mass abdomen, nutritional edema, anemia,
slightly tachypneic and bibasal crepts
*question(prof AM, prof arif)
- differ btwn regurgitate n vomiting signs
-causes of post prandial vomiting
- differ ngt with nasojejunotube
-definitive ix
- how to mx, and what sugical procedure?
- interpret abd xray, describe the verterbra and pelvis, what are the features of bone mets
radiologically
68y/o Male. P/w upper abd pain, vomiting and abdominal distension for 1 month duration.
- -Prov dx: GOO secondary to gastric ca.
- differential diagnosis.
- why patient cachexic? What’s the evidences(loss of m/s bulk) name the muscles.
- investigations. What can be seen in ogds? Features of gastric ca in ogds.
- everything about h.pyrori.
- -how to solve the feeding problem ? TPN better or NJ tube feeding better?
- complications of TPN. (Refeeding synd), The content of TPN.
- pre-op preparation. How to increase nutritional status of pt for op.
- -palliative Care Mx., stenting. Chemo regime used for gastric ca.
- -If stage 1 gastric ca, no mets what surgery ?

STOMA

17. Midline laparotomy stapled wound with stoma on LIF & drainage bag in LIF & RIF
Examine pt’s abdomen
-describe what u see on the abdomen – describe everything, the wound, stoma and
drainage bag

18. male pt, with RIF pain and tenderness, on CBD and CVL.
dx perforated ca of sigmoid?

19. Prolapse of ileostomy at RIF, otherwise no other complications

- provisional diagnosis
- indication for the pt's stoma since no scar (for diversion)
- where is the obstruction
- indication colo and ileostomy
- complications of FAP
- types of inflammatory disease
- common type of crc
- causes of prolapse
- how to manage prolapse
 - midgut
- appendicitis initial pain is at midgut, why?
- differences ileostomy and colostomy
- APR and Hartmann

20. Stoma case ( sigmoid colostomy )

● - How many types of stoma
● - What stoma is patient having
● - What is the patient’s diagnosis most probably and why
● - Why don’t do transverse colostomy for this patient
● - Difference of lesion on right and left side of colon
● - What operation for right side tumour, what happen if it is unresectable - chemo
● - Why left side cause obstruction (narrower lumen)
● - What investigation best assess the tumour CT abd and pelvic
● - What tumour marker for colon (CEA)
● Simulated pt p/w epigastric pain and palpable mass at RHC - ascending colon ca
● Pdx, DDx (point for point against), Ix, Mx (before surgery, admit hosp, mx pt as a
whole (IV replacement, analgesia, nutrition - how to give?))

21. Regarding stoma on LIF, got dark green discharge.

● -describe everything abt the stoma.
● -it’s a colostomy but not really flushed to skin, mcm spout, but not spout.
● -does the stoma looks like a normal stoma?
● -do u think it’s normal to have this discharge in stoma?
● -type of stoma u know?
● -what stoma is pt having? End colostomy
● -what do u think pt has? I/O secondary to __
● Other problem pt is having?
● -dvt – ted stocking
● -cachexic – malnutrition, malignancy
● -ijc – on TPN?
● Stoma & abd exm
● -types
● -indication

22. Stoma
● - inspect stoma and comment
● - function of stoma
● - diff btn ileostomy & colostomy
● - what is dentate line
● - why anterior resection
● - premalignant lesion of crc
● - Duke's staging

23. Stoma
● -Describe everything
● -difference ileo and colostomy
● -tumor marker colon ca
● -CEA and...
 ● -why transverse colostomy
● -anterior resection
● -left hemicolectomy
● -complication stoma

24. Atypical features of this ileostomy, indications of this ileostomy - explain specifically

25. Stoma- transverse loop colostomy

● -why is it done in this pt,
● -what abd signs u want to see in this pt after stoma had been done (cx of the
stoma? mass? Distension? Sign of perforation?idk)
● -interpret xray (where is the mass? - distal to the dilated bowel, show it on the xray!)

26. Stoma
● - What is this stoma?
● - Difference btw colo and ileostomy
● - Tell me about colon polyp
● - what is the difference btw ant resection and APR

CRC
Advanced Rectal Ca:
Hx: 78, M, +ve FH Malign, C/c Altered bowel habit, tenesmus, bleeding per rectum loa. PE:
Mass at suprapubic, old suprapubic scar.
Q: ddx, premalignant cond for colon Ca (FAP, HNPCC, IBD), ileostomy vs colostomy, how to
mx(operable vs palliative), left hemicolectomy (colon involve and indication), ind permanent
ileostomy, why resection of colon more dangerous than small intestine.

42 year old gentleman, prev hx of colon ca 2 years ago. Current dx liver mets, presented
with jaundice, anemic symptoms due to UGIB, ascites and pedal edema present, liver
palpable 10cm below coastal margin.
-Ddx with supporting/ points against
-investigation with justifications
-management
7. Tiong chung ho, 58 yrs old, u/l rectal ca, electively admitted for transanal polyp
- Findings:midline laparotomy scar, transverse scars at RIF & LIF healed with 2
intention with keloid and incisional hernia.
o provisional dx - TRO recurrence of colon CA
o if post op already, and there is recurrence, usually tumour recur at which
side? (at anastomotic site)

o what do u call if there is CA at other site of the colon after 5 years, post op
(metachronous lesion)

o RF for this pt to hv incisional hernia (multiple op, SSI, poor wound heal 2 to
malnutrition, increase intrabdominal pressure)

o mx for this pt- follow up pt to look for recurrence and mets

 o ix during follow up (FBC, LFT, CEA, CXR, colonoscopy, CT scan)

- Sigmoid ca done hartmann procedure with end colostomy, completed chemotherapy

o 1. Side of colon tumor that can cause tenesmus: rectum and rectosigmoid
o 2. Do examination infront of them
o 3. Why do you think this is laparoscopic scars:size of scars and locations
o 4. What is flushing of stoma means
o 5. In apr, do u expect there is anus left
o 6. Tnm staging
o 7. Mode of spread colon ca: locally, hemato, lymph
o 8. What to do when first time u see this patient (w/o I/O symptoms):
colonoscopy, biopsy, staging
o 9. What is the name of chemotherapy after operation: adjuvant
chemotherapy
o 10. Name of liver and gb resection due to metastasis: metastasectomy

11.Dr Challa & Dr Ramu

Rectal Ca w/ RIF ileostomy
Mx in district hosp, imaging, chemoradiotherapy, chemo drugs, why ant resection, Cx of
stoma, mx of high output stoma, how to f/up stoma pt, how to f/up pt w/ rectal Ca (3
monthly for first 2 years, then 6 monthly for next 5 years), screening for CRC, premalignant
lesion of CRC, tumour markers of CRC
post op rectal ca complicated with anostomotic leak. (Mr Edwin)
Ddx, ileostomy, tell bout pus drainage from rif, ix, mx, explain about anterior resection,
staging, organs that are usually involved in mets, if stage 3, tell mx, s&s of peritonitis

5. Colorectal CA (Dr Christopher)

a) Pdx, ddx of lgib
b) Mx for rectal ca
c) Indication of chemo and radio neoadjuvant therapy in rectal ca
d) Concerns about fam history of colon ca
e) Diff btw fap and hnpcc
f) Ix for hnpcc
g) TCA plan for pt after discharge
h) Diff ileostomy and colonostomy
i) Ssx of colovesico fistula

IO Post APR with end colostomy secondary to Rectal Ca. (tun aung)
- he talk only I tak present pun😣

27. Intestinal obstruction, abd guarding and hyperactive bowel sound

- provisional diagnosis
- why
- investigation
- classification of i/o
- this patient has intramural, intraluminal or extramural

28. Hepatomegaly, ascites, dilated veins, jaundice

Ddx, CLD stigmata
/o, complaint of constipation: IO 2ndary to impacted stool - ddx, cxr, adhesion colic,
indications for surgery, mechanical and non mechanical obs, other causes of chronic
constipation(hypothyroidism, electrolyte imbalance), causes of abdominal distension in
normal person, investigation and justification,contraindication for colonoscopy.

17.Dr firdaus, dr wintin

Case: intestinal obstruction secondary to TB gut
-differential of IO
-how to investigate IO
-xray interpretation
-management

SCAR
29. Patient with kocher incision at RHC with t tube draining bile, previous scar ileostomy
Management and investigation

30. Regarding wound, features of SSI?

- erythematous, purulent discharge, wound breakdown at suprapubic area etc..

31. Pt with lap wound and also old lap scar. Indication for wound and old lap scar?
Complications of cholecystectomy? Procedure before op? Consent. How do you counsel
pt after surgery?
32. upraumbilical midline laparotomy scar, 2 small scar on both side iliac fossa (Dr Challa, Dr
Tun Aung )
● - What is Kucher’s incision
● - Zollinger Ellison syndrome
● - Charcot triad
● - Courvoisier’s Law, the exception

33. A young gentleman (in his 30s) had a midline laparotomy wound dressing and two small
dressings on the left (laparoscopic trocar incision) in pain. POD 1.
● Perform abd examination.
● What was done for him?
● Diff diag for RIF mass.

● Thalassemia - abd exam, hepatomegaly, post splenectomy, indication splenectomy,

complication, hypersplenism definition, causes of dull traube's space, cause of
hepatomegaly, why do you think this pt is thalassemia

34. B thalassemia post splenectomy

● - why u say this is splenectomy scar
● - indication of splenectony
● - complication of splenectomgastricy (why)
● - what do u think the pt have (B thalassemial
● - what other sign wud u like to look for in the abd (hepatomegaly, why.)
● - where can fe deposition happen, heart. What is that condition (cardiomyopathy)
● - in pancreas (pt will have DM, what else😢)

● 12.( Dr Johnny, Dr Tun Aung )

 ● E/A Splenectomy u/l B Thalassaemia major
● History: high drop rate since 11 years old, had medical therapy but still having high
drop rate.
● Examination : liver and spleen both very big.
● 1. Complication that can happen intra-op
● 2. NG tube after operation a must for this type of case, why.
● 3. Johnny: palmar pallor : see pallor on the palmar crease
● 4. Post splenectomy what complication you can expect, early and late. Why need to
give aspirin, why platelet will increase( mechanism )
● 5. Why this patient need splenectomy. What is the medical term?
● 6. Three vaccinations before splenectomy.

laparotomy scar -> splenectomy. cx post splenectomy, fast scan, c/i cheat tube insertion,
shock type & classify shock hypo, how clinically dx intra-abd iinjury. pneumo & hemothorax
interpret xray. how to know chest tube is function, pe finding of pneumothorax, mx, diff
btwn tension pneu & pneuthorax

- splenic rupture
Post exploratory laparotomy + open splenectomy
interpret xray (pneumothorax, rib fracture) (high or low velocity), possible cx of rib #, ddx in
mva (possible organ injury), solid vs hollow (why hollow viscus present late, why solid organ
present early), ix in emergency (fast scan and finding, ct scan) why need chest tube for the
pt (because pt need surgery-intubation), how to suspect intra-abdominal injury clinically,
post splenectomy cx- specific= OPSI- what organism= pneumococcal, meningiococcal,
hemophilus... and etc.

MVA – motorcycle with dog, fell on left side of body

p/w: Left sided chest pain + SOB + dizziness + altered consciousness
PE:
- Chest - Tenderness over left anterior chest, respi & CVS normal, not on chest tube
- Abdomen - Bruises over LIF and left thigh, not distended, tenderness over LIF, no
organomegaly, shifting dullness negative, normal bowel sound
- Neuro - normal
X ray shows left 2nd to 6th ribs fracture, No pneumothorax or pleural effusion
Questions:
- Provisional dx: blunt trauma to left chest with multiple rib fractures
- D/dx: pneumothorax, hemothorax, flail chest
- Cause of SOB in this case if no pneumothorax – pain?
- Investigations: FBC, RP, Coag profile, GXM, CXR, USG abdomen (extended FAST)
- Management: conservative with thorax brace? when to discharge patient?
- Cx of rib fracture, incentive spirometry and indication
- principles of fracture management
- clinical signs of splenic rupture, clinical signs of rib fracture

Post-splenectomy + hepatomegaly - method to elicit incisional hernia, surgical causes of

hepatomegaly
35. 26y/o lady, general look thin, with nasogastric aspuration, cbd, iv line and on abd exam,
upper midline lapartostomy wound extend below umbilicus, wrinkled skin over
periumbilicus, stretch marks. Mass in periumbilical region (omentum), what can give rise
to omental cake?
36. Midline laparotomy scar and laparoscopic scars (hx perforated bowel and intestinal
obstruction)
a. ask hx, do pe: present hx and how you know which part the anastomosis? Ix to
know
b. Short hx from pt
c. Layer of abd wall
d. Rectus sheath
e. What surgical incision u know
f. Hypertrophy and keloid different
g. -short hx
h. -layer of abd wall
i. -rectus sheath
j. -what surgical incision u know
k. -hypertrophy and keloid different
l. -semilunaris fascia
m. -incision for nephrectomy
8. Mr. Saiful 21y/o
Splenectomy. u/l Beta Thalassemia Major
● Why only give the three vaccination. Why not give vaccination for everything.
● If done total splenectomy but still hypersplenism..what is the cause.
● Pathophysiology and Ix of Hepatitis B
● Types of Jaundice
● Definition of Clean Surgery
● Complications of Beta Thalassemia Major
● What pre-op Ix or Preparation of Beta Thalassemia Major who is gonna undergo
Splenectomy

37. Stoma@lif with midline scar

a. Pdx
b. What op
c. Which part of colon affected
d. How to know if it is laparoscopic scar
e. Post op mxV

38. Abd mesenchymal tumour

● -ddx
● - diff between intra abdominal mass and extra abd mass
● - Ix
Dr Challa & Dr Eugene – MVA with splenic rupture, MVA with rib fractures, anterior neck
swelling, carbunble, post op laparoscopy

1.Splenic rupture due to mva- take brief history and describe on inspection. What type of
surgery? Indications? Why midline incision for splenectomy? Pre and post splenectomy care?
Causes of splenomegaly? Portal hypertension causes? Portosystemic collateral vessels?
- back carbuncle- brief hx and inspection, risk factors for carbuncles, define carbuncle,
management and what type of incision, what is it called if there was a punctum on cyst,
why more common at the back

2. Flail chest, definition, complications, discuss mx of comolications, types of pleural space

problems, how to manage, insertion of chest drain.how long do you keep a chest drain and
how u know patient is okay already to remove chest drain.

PROCEDURE?
1. Post MVA with skin traction and chest tube placement wound dressing.
Questions: what is the traction called, where to insert chest tube, interpret pt's cxr, on
cxr where is the scapula , how does a scapula look like, anatomical landmark for trachea
deviation, show lung parenchyma

2. Patient with PTBD at RHC, yellowish drainage, has gross ascites, in pain! Has few
laparoscopic wounds.
Questions: what is PTBD used for, bile collection at where, why u say its PTBD?

3. Regarding drainage bag, left bag has pinkish discharge, right bag has greenish
discharge.
-why different colour discharge? Is it worrying?
-what do u think is the discharge? (right greenish discharge is ___ from small bowel due to
small bowel injury. left pinkish discharge is seropurulent discharge from localized abscess)

2) A gentleman, 40+ y/o, had a PTBD tube.

Examine his abdomen.
Where is it inserted into? Indications of pigtail catheter?

HERNIA
1. Hernia (Left reducible indirect inguinal hernia)(Dr Firdaus & Mr Edwin)
● Examine pt’s groin area.
● -PE (must demonstrate while standing)
● -describe swelling on inspection
● -demonstrate palpation of testis
● -significance of deep ring occlusion test? Show anatomical landmark
● -differentials? Differentiating features?
● -what else examination u wanna do and why?

1. Indirect inguinal hernia

● Do examination
● Ddx of groin swelling
● Diagnosis how
 ● Content of inguinal canal
● Differentiate femoral n inguinal hernia
● Complications of hernia and hernioplasty
● How mesh strengthen the abd wall (fibrosis)
● If strangulation or io, how to mx
● Tapp or tep laparoscopic

2. Right complete indirect inguinal hernia (Dr Tun Aung & Dr Tofazzal) , containing
enterocele, how to show left side is not affected, show me the deep ring occlusion
test and the point, what is the content of hernia sac, type of inguinal hernia, cause
of this patient.

3. Direct inguinal hernia

● -how to find the Asis
● -what is positive cough impulse means
● -what location direct hernia usually happen
● -management

4. Rt inguinal hernia (not sure is direct or indirect, not mentioned)

● -how to diff from hydrocele
● -pre op mx
● -what surgery to do n type of hernioplasty
● -what other things need to ask in history + other PE

5. Indirect inguinal hernia

● - how to do deep ring occlusion test
● - Ix
● - Mx
● a. Demo deep ring occlusion test
● b. What kind of hernia (indirect)
● c. What other thing expected in an elderly male (hydrocele)
● d. What would u like to ask in the history (history of heavy lifting, prolonged
coughing, constipation
● - how to deep occlusion test, differential for scrotal swelling, ix , Mx

6. Ventral hernia at right iliac fossa with history of LSCS x 3 and 1 incisional hernia at
LSCS scar with repair done 2 years ago
● D/dx: incisional / spigelian / direct inguinal
● Examination: visible and palpable cough impulse, to look for defect opening
● Investigations and pre-op investigation
● Pre-op advice while waiting for repair, use binder or not?
● Surgical approach – open or laparoscopic? Laparoscopic to prevent recurrence
● Name of laparoscopic approach – intraperitoneal onlay mesh (IPOM), mesh below
abdominal wall for better strength
● When to ask patient to go hospital immediately

LUMPs & BUMPs

9. Carbuncle(post saucerization)
-differential
-management
5. Sebacous cyst
● -ddx & why
● -dont forget to do transillumination test
● - management:exisional biopsy
● - describe , differential , ix, Mx, how to differentiate lipoma and sebaceous cyst,
how to confirm lipoma

6. Lump (at the left back, not sure what cyst it is)
● - in what case transillumination test positive
● - in what case slip sign positive
● - Ddx
● - Mx
7. Lipoma - examine the forearm, prepare pen torch for transillumination test, how you
know the swelling is fixed to the muscle anot, give differential diagnosis and how to
differentiate them, investigation and management

DRE?
1. Fistula-in-ano with seton in-situ
● - other perianal condition
● - definition
● - types: high and low, explain
● - Goodsall's rule
● - definition of fissure-in-ano, treatment
● - definition of hemorrhoids
● - grading of hemorrhoids
● - treatment for hemorrhoids (botulinum toxin injection)

2. Fistula in ano (Dr challa and Dr win tin)

● -PE
● -Describe finding
● -Definition
● -types
● -difference between higher and lower fistula
● -different sites
● -significant of dentate line
● -investigation
● -mx
● -etiology

3. Fistula in AnoMs Hilal & Dr Firdaus

-PE (do inspection and palpation of fistula) decribe finding, location, ddx, goodsall rule, mx.

4. Fistula in ano (with seton done)

● - describe the perineum
● - dx
● - how does fistula occur
● - whr is perianal abcess from
● - anatomy of anal canal
 ● - classification of fistula in ano
● - goodsall rule
● - why seton procedure done
● - transphincteric what complication

Dr Firdaus + Dr Edwin
- Basically Dr Edwin will be the only one asking, he want precise examination only for the
patient base on the first look of that pt, he will guide you, but in a VERY HURRY way, so
just be prepared.
- He will ask you summarise ur finding and say the only important ix with expected finding
for this pt.

ACHALASIA
Long case: Achalasia
60y/o, dysphagia liuid first then solid. LOA, LOW. Deferential diagnosis. Do physical
examination in front dr (general, neck and abdomen)
Discussion on achalasia .
What is achalasia, Achalasia results from progressive degeneration of ganglion cells in the
myenteric plexus in the esophageal wall, leading to failure of relaxation of the lower
esophageal sphincter (LES), accompanied by a loss of peristalsis in the distal esophagus

pathophsio of achalasia,
clinical presentation of achalasia
(vomitus is non billous food particles and liquid, halothosis, LOW, heartburn),
Investigations including esophageal manometer. How to differentiate between dysphagia
and esophageal carcinoma in radiograph. Management (botox - how to administer botox ,
surgery-Heller myotomy, other surgical procedure if heller unsuccessful/cant do) Interpret
CXR (achalasia: showing widened mediastinum)

) achalasia
Dysphagia for 5 years(progress gradually from solid to liquid, loss of weight 10kg in one
month)
Provisional diagnosis and differential diagnosis
What is the clinical presentation particular for achalasia, how u differentiate it with other
differential diagnosis
Dysphagia to solids and liquids
●Heartburn unresponsive to a trial of proton pump inhibitor therapy
●Retained food in the esophagus on upper endoscopy
●Unusually increased resistance to passage of an endoscope through the esophagogastric
junction
How to look at nutritional status of the patient, how to feed?
Investigation (expected findings) and management