Professional Documents
Culture Documents
Osce Impo
Osce Impo
Osce Impo
POINTS TO BE ASKED
Age:
Children infections (usually), cystic hygroma, congenital dermoid cyst.
1
Young adult Branchial cyst, carotid body tumour (˃ 30 Y/O)
Older Adults pharyngeal pouch (˃ 50 y/o), malignant LN (pharyngeal/laryngeal CA).
Work:
2 Those worked abroad TB ()عملت خارج البلد, health worker (radiation) CA
Asbestose, nickel exposure [industrial plant (alloys, batteries)] Laryngo-Pharyngeal CA.
Duration (onset)
3 < 3 wk LAP.
Since birth Congenital → if yes ask if diagnosed intra-nataly by U/S.
4 First Time / Recurrent (Previous Similar condition).
Number:
5 How many lumps have you noticed (Single)/ (multipleLN, Lipomata, Sebaceous cysts).
6 Unilateral or (bilateral Parotitis, Mumps, Sjogren/mikulicz syndrome).
7 any other site lump(s) →axilla, groin, abdomen (LN metastasis)
Size change:
8 Any change in size (smaller, bigger or remaining the same).
9 Continuous or intermittent Salivary stone →Ask about precipitate factors like food.
Pharyngeal pouch → size (bulge) on swallowing.
10 Color change melanoma
11 Trauma / Insect Bite [pyogenic granuloma; after minor trauma / bite].
Painful or painless (if yes → pain features → severity, radiation, precipitating & alleviating
12
factors) [e.g. Salivary gland stone] any other region Pain (Neck, Chest, Abdomen)
13 Temperature change / sweeting at night
14 Travelling Infectious (recent travel), EBV (China/Hong Kong)
ENT:
15 Dental problem dental sepsis
16 Voice Change (hoarseness) Bronchus, Esophagus, Thyroid (all with/without LN
metastasis).
17 Sore throat ( )احتقان في الحلق Pharyngeal pouch, oropharyngeal CA.
18 Halitosis ( )رائحة فم كريھة Pharyngeal pouch.
19 Otalgia (ear pain) Pharyngeal/Laryngeal CA → Hoarse voice + Painful ear.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
1 HEAD & NECK OSCE ‐ Stasions
Respiratory:
20 Difficult breath.
21 Cough (dry or productive).
22 Hemoptysis (Blood) CA, infection (TB).
23 Chest infections (single or frequent) Pharyngeal pouch, CA.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 2
1 HEAD & NECK OSCE ‐ Stasions
Great and Introduce yourself to the patient, and ask his/her permission.
Positioning and exposure.
Wash/Gel your hands.
Ask (Is it Painful or not? Any other pain region?).
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 3
1 HEAD & NECK OSCE ‐ Stasions
ASOCIATETED EXAM
22 Palpate Carotid A
23 Thyroid gland anteriorly
24 Cervical lymph nodes ( all groups) from behind
Mouth examination:
Tongue.
Teeth.
25 Floor of the mouth.
Waldeyer's tonsillar ring.
Parotid Duct Orifice.
Bimanual examination.
I Finished My Exam with:
1. Other lymphoid tissues:
Axilla.
26 Groin.
2. Abdomen for HSM.
3. ENT exam (laryngoscopy, bronchoscopy)
4. Chest examination
THANKING the patient.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 4
1 HEAD & NECK OSCE ‐ Stasions
CERVICAL LN (EXAMINATION)
Great and Introduce yourself to the patient, and ask his/her permission.
Positioning and exposure.
Wash/Gel your hands.
Ask (Is it Painful or not? Any other pain region?).
INSPECTION
1 General look, Swelling , Scars ,Dilated veins
2 Asking the patient to swallow
PALPATION
3 Palpate Carotid A
4 Thyroid gland anteriorly
5 Cervical lymph nodes ( all groups) from behind
Mouth examination:
6 Tongue.
7 Teeth.
8 Floor of the mouth.
9 Waldeyer's tonsillar ring.
10 Parotid Duct Orifice.
11 Bimanual examination.
I Finished My Exam with:
12 1. Other lymphoid tissues:
Axilla.
Groin.
13 2. Abdomen for HSM.
14 3. ENT exam (laryngoscopy, bronchoscopy)
15 4. Chest examination
THANKING the patient.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 5
1 HEAD & NECK OSCE ‐ Stasions
1. Chest X-ray:
Chest radiology is important in young adults, when lymphoma is the possibility.
TB
Primary or secondary lung neoplasms.
2. Ultrasound
Can differentiate between solid and cystic masses
Can indicate whether or not there are multiple enlarged lymph nodes or the presence of
multiple nodules in the thyroid gland.
Ultrasound, however, rarely assists in clarifying the diagnosis.
4. Excision biopsy:
If a diagnosis cannot be confirmed on fine-needle aspiration biopsy, an excision biopsy may
be necessary to confirm or exclude malignancy.
6. Angiography
The gold standard in carotid body tumor (Lyre’s Sign).
7. Barium swallow:
In pharyngeal pouch.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 6
1 HEAD & NECK OSCE ‐ Stasions
Lateral Structures
Superficial MIDLINE
ANTERIOR POSTERIOR
- - Submental LN - Lymph Node (levels II, - Lymph Node (level V and
Sebaceous - Sublingual dermoid III, IV). supraclavicular lymph node
cyst cyst - Submandibular Gland groups)
- Abscess - Thyroglossal cyst mass - Cervical rib
- Lipoma - Plunging ranula - Carotid body Tumor - Brachial plexus
- Dermoid (retention cyst of the (Chemodectoma) or neuroma/schwannoma
sublingual) Aneurysm. - Cystic Hygroma.
- Rarely, hyoid pathology - Branchial cyst (+ - Aberrant thyroid (2ry
e.g. bursa Fistula) deposit of Papillary thyroid
- Thyroid nodule in the - Cold Abscess (TB) CA).
isthmus - Thyroid Nodule. - Subclavian A aneurysm.
- Pharyngeal pouch
(Zenker’s
diverticulum)
- Laryngocoele (rare; an
air-filled, compressible
structure seen in glass-
blowers)
Notes:
If SCC → Panendoscopy
If Adenocarcinoma → Breast Stomach, Pharynx
Lymph node → Biopsy.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 7
1 HEAD & NECK OSCE ‐ Stasions
THYROID (HISTORY)
THYROID (EXAMINATION)
Great and Introduce yourself to the patient, and ask his/her permission.
Positioning and exposure.
Wash/Gel your hands.
Ask (Is it Painful or not? Any other pain region?).
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 9
1 HEAD & NECK OSCE ‐ Stasions
EYE SIGNS
Joffroy's sing: absence of forehead wrinkling on eye brows elevation, thyrotoxicosis.
Hair loss of lateral third of the eyebrow [Hypoth].
Stellwag's sign: infrequent & incomplete blinking
Chemosis [hyperth].
Exophthalmos (sclera visible all around the iris) (normally only 1/5).
Proptosis (Front, Lteral & Behind the patient).
Lid retraction (Dalrymple’s sign)
lid lag (Von Graefe's sign)
opthalmoplegia (ocular movement; superior recti & inf oblique) leads to diplopia when
looking up and out
LEGS SIGNS
Pretibial myxoedema
Reflexes (ankle reflex delayed in hypothyroidism)
proximal myopathy (ask the patient to stand up with arms across the chest).
FINISHING
Vocal cord by flexible laryngoscopy.
THANKING the patient
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 10
1 HEAD & NECK OSCE ‐ Stasions
Serum Thyroglobulin
Tg is only made by normal or abnormal thyroid tissue. It normally is not released into the circulation
in large amounts but increases dramatically in destructive processes of the thyroid gland, such as
thyroiditis, or overactive states such as Graves' disease and toxic multinodular goiter. The most
important use for serum Tg levels is in monitoring patients with differentiated thyroid cancer for
recurrence, particularly after total thyroidectomy and RAI ablation.
B. Ultrasound
o An excellent noninvasive
o Distinguishing solid from cystic ones.
o Providing information about size and multicentricity.
o Cervical lymphadenopathy.
o To guide FNAB. An experienced ultrasonographer is necessary for the best results
C. FNA
These incidentally discovered nodules should be worked up by ultrasound and fine-needle aspiration
biopsy (FNAB).
D. Chest X-ray
E. Radionuclide Imaging
Both iodine 123 (123I) and iodine 131 (131I) are used to image the thyroid gland. The former emits
low-dose radiation, has a half-life of 12 to 14 hours, and is used to image lingual thyroids or goiters.
In contrast, 131I has a half-life of 8 to 10 days and leads to higher-dose radiation exposure.
Therefore, this isotope is used to screen and treat patients with differentiated thyroid cancers for
metastatic disease.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 11
1 PAROTID GLAND-FACIAL NERVE OSCE ‐ Stasions
Great and Introduce yourself to the patient, and ask his/her permission.
Positioning and exposure.
Wash/Gel your hands.
Ask (Is it Painful or not? Any other pain region?).
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
2 BREAST OSCE ‐ Stasions
BREAST:
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
2 BREAST OSCE ‐ Stasions
A. LAB Tests:
1. Urine Pregnancy Test (Quantitative Serum Beta hCG).
2. Serum Prolactin Level (Delay measurement until at least 30 minutes or more after vigorous
Exercise or Breast Exam or stimulation)
3. Thyroid Stimulating Hormone (TSH) Level.
4. Serum Creatinine.
5. Sex hormones (if Hypogonadism suspected) Serum Estrogen, Testosterone, FSH & LH.
(NOTE) Culture and sensitivity are not useful. Usually grows skin contaminant
2. Serous
Fibrocystic disease
C. Discharge from a single duct Duct ectasia
1. Blood-stained Carcinoma
Intraduct papilloma
Intraduct carcinoma 3. Black or green
Duct ectasia Duct ectasia
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 2
2 BREAST OSCE ‐ Stasions
POINTS TO BE ASKED
1 Age.
2 Duration.
3 First Time / Recurrent (Previous Similar condition).
4 Site.
5 Single / multiple.
6 Unilateral / Bilateral.
7 Any other site lump(s) →axilla, groin, abdomen (LN metastasis).
8 Change size (bigger, smaller, same size) is it variation with menstrual cycle?
9 Continuous or intermittent.
10 pain (cyclical or not)
11 Breast size & shape change Skin.
12 Nipple change or Discharge.
13 Arm swelling
14 Hx of Trauma (Cyst or Fat necrosis).
15 Fever
16 Weight loss
17 Jaundice, Bone pain, Breathing problems Metastasis.
18 Breast feeding
19 Contraceptive pills
20 Menstrual history (menarche, menopause) & Childrens
Past medical:
Chronic disease (DM, HT, HF, RF, thyroid, liver diseases).
21 Drugs (regular medications) or medication for this problem
Allergies.
Previous hospital admission, investigation (especially U/S, FNA).
Past surgical:
Previous operation.
22
Radiotherapy.
Chemotherapy.
Family Social History:
23 Similar family condition, Family history of malignancies (Breast & Ovaries).
Smoking & Alcohol.
THANKING the patient.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 3
2 BREAST OSCE ‐ Stasions
BREAST (EXAMINATION)
Great and Introduce yourself to the patient, and ask his/her permission.
Positioning and exposure 45 degree.
Wash/Gel your hands.
Ask (Is it Painful or not? Any other pain region?).
Feel axilla of both sides [non palpated hand support elbow at shoulder level]
Lateral, medial, anterior, posterior & apex
Supraclavicular fossa (both sides)
Complete:
chest [Percussion & auscultation to(effusion, consolidation)].
Abdomen palpation for hepatomegaly.
Axil spine Percussion for tenderness.
THANKING the patient.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 5
2 BREAST OSCE ‐ Stasions
Gynecomastia Causes:
1) Physiological
2) Pathological
3) Drug-induced
4) Idiopathic - especially in the elderly
1) physiological:
Newborns
Adolescence or puberty associated
Elderly
2) pathological:
A) Increased oestrogen production:
Increased availability of androstenedione for extraglandular conversion, for example:
liver disease especially cirrhosis - reduced hepatic extraction of androstenedione
thyrotoxicosis - gynaecomastia occurs in about one third of men with thyrotoxicosis
adrenal carcinoma - also, rarely, adrenal tumours may secrete oestrogen directly
congenital adrenal hyperplasia
starvation and refeeding - by a similar mechanism to that in liver disease
3) Drug-induced:
ketoconazole, metronidazole, spironolactone
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 6
2 BREAST OSCE ‐ Stasions
Gail Model
1) Age at menarche (years)
2) Number of biopsies/history of benign breast disease, age <50 y and those ˃ 50 y
3) Age at first live birth (years)
4) Number of first-degree relatives with history of breast cancer
Risk management strategies for BRCA1 and BRCA2 mutation carriers include the following:
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 7
2 BREAST OSCE ‐ Stasions
Foote and Stewart originally proposed the following classification for invasive breast cancer:
1. Paget's disease of the nipple
2. Invasive ductal carcinoma
3. Adenocarcinoma with productive fibrosis (scirrhous, simplex, NST), 80%
4. Medullary carcinoma, 4%
5. Mucinous (colloid) carcinoma, 2%
6. Papillary carcinoma, 2%
7. Tubular carcinoma, 2%
8. Invasive lobular carcinoma, 10%
9. Rare cancers (adenoid cystic, squamous cell, apocrine)
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 8
2 BREAST OSCE ‐ Stasions
Surgery:
Breast Conservative Surgery (BCT):
This is aimed at removing the tumour plus a rim of at least 1 cm of normal breast tissue. This is
commonly referred to as a wide local excision:
For Stage 0, I, or II invasive breast cancer (less than 3-4 cm), breast-conserving therapy (BCT) is
preferable to total mastectomy because BCT produces survival rates equivalent to those after total
mastectomy
Women with DCIS require only resection of the primary cancer and adjuvant radiation therapy
without assessment of regional lymph nodes
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 9
2 BREAST OSCE ‐ Stasions
INDICATIONS OF MASTECTOMY
Therapeutic:
1. One or more tumors in separate areas of the breast.
2. Widespread DCIS.
3. Sub-areolar tumor.
4. Large size tumor relatively to breast size (small breast).
5. Risk tumor of further disease (BRCA 1/2 +ve).
6. Previous radiation.
7. Risk from radiation (pregnancy).
Prophylactic mastectomy:
1. Strong family history of breast ca.
2. To obtain optimal symmetry to contralateral breast.
3. For peace of mind following mastectomy for carcinoma of contralateral breast.
10 yr survival
10 yr survival
NPI Prognostic group (surgery & adjuvant
(surgery alone) %
therapy)
< 2.4 excellent 95 95
2.4-3.4 good 85 90
3.41-4.4 Moderate 1 70 79
4.41-5.4 Moderate 2 50 71
> 5.4 poor 20 41
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 10
2 BREAST OSCE ‐ Stasions
1. Lumpectomy: Surgery to remove a tumor (lump) and a small amount of normal tissue around it.
2. A quadrantectomy: which is more often used outside of North America, refers to removal of the
tumor and about one-fourth of the breast tissue on that side.
3. Partial mastectomy (segmental mastectomy): Surgery to remove the part of the breast that has
cancer and some normal tissue around it. The lining over the chest muscles below the cancer may
also be removed.
4. Subcutaneous: all breast tissue removed but sparing overlying shin, nipple and areola.
5. Skin-sparing mastectomy: all breast tissue and nipple/areola complex, the skin around the
biopsy site, and the skin within 1 to 2 cm of the tumor margin. It usually sacrifices only 5% to
10% of the breast skin.
Include:
Those with multicentric disease.
Invasive carcinoma associated with an extensive intraductal component.
T2 tumors with a difficult-to-interpret mammograms.
Central tumors that would require removal of the nipple/areola complex.
6. Nipple sparing mastectomy (NSM) and areola-sparing mastectomy (ASM): As with the skin-
sparing mastectomy, these are done in conjunction with immediate reconstruction with a plastic
surgeon.
7. Total mastectomy (simple mastectomy): remove the whole breast that has cancer. Some of the
lymph nodes under the arm may be removed for biopsy at the same time as the breast surgery or
after. This is done through a separate incision.
8. Modified radical mastectomy (Patey surgery): Surgery to remove the whole breast that has
cancer, many of the lymph nodes under the arm, the lining over the chest muscles, and
sometimes, part of the chest wall muscles.
9. Radical mastectomy (Halsted): removal of the breast, muscles (including pectoralis major and
pectoralis minor), and axillary lymph nodes.
10. Extended radical mastectomy - as for radical proceudure but also removing internal mammary nodes
(between 2-4th anterior intercostal spaces).
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 11
2 BREAST OSCE ‐ Stasions
No skin edema, ulceration, or solid fixation of the tumor to the chest wall. Axillary
Stage A
nodes are not involved clinically
No skin edema, ulceration, or solid fixation of the tumor to the chest wall. Clinically
Stage B involved nodes, but less than 2.5 cm in transverse diameter and not fixed to overlying
skin or deeper structures of the axilla
Any one of the five grave signs of advanced breast carcinoma:
(1) Edema of the skin of limited extent (involving less than one-third of the skin over
the breast)
(2) Skin ulceration
Stage C
(3) Solid fixation of the tumor to the chest wall
(4) Massive involvement of axillary lymph nodes (measuring 2.5 cm or more in
transverse diameter)
(5) Fixation of the axillary nodes to overlying skin or deeper structures of the axilla
All other patients with more advanced breast carcinoma, including:
(1) A combination of any two or more of the five grave signs listed under stage C
(2) Extensive edema of the skin (involving more than one-third of the skin over the
breast)
(3) Satellite skin nodules
Stage D
(4) The inflammatory type of carcinoma
(5) Clinically involved supraclavicular lymph nodes
(6) Internal mammary metastases as evidenced by a parasternal tumor
(7) Edema of the arm
(8) Distant metastases
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 12
2 BREAST OSCE ‐ Stasions
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 14
2 BREAST OSCE ‐ Stasions
T4, Any N, M0
Stage IIIB
Any T, N3, M0
Stage IV Any T, Any N, M1
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 15
3 ENDOCRINE OSCE ‐ Stasions
A. Head:
Thinning of scalp hair (Baldness).
Increase the facial hair (Hirsutism).
Greasy or dry skin with Acne.
Thinning of skin (cracks, splits & bruises easily) (Telangiectasia) Visible vessels on the
cheeks.
Excessive sweating.
Moon face (rounded facial appearance).
Mood change (irritability, Euphoria or depression) (Sleep disturbances/ Insomnia) (Memory
and attention dysfunction).
Visual problem (bitemporal hemianopia) (pituitary tumor pressure on optic chiasm)
Changes in voice? (New deepening of the voice is suggestive of an adrenal virilising
tumour).
Buccal pigmentation.
C. Abdomen:
Rapid weight gain with Central obesity (sparing of limbs).
Stretch marks (red striae around abdomen, hips).
Bruising.
D. Reproductive System:
Menstrual disorders such as amenorrhea in women and decreased fertility in men
E. Legs:
Edema
Ulceration
Bruising
F. Musculoskeletal:
Muscle weakness/ posture (proximal myopathy).
Limbs or Spine pain/fracture (Osteoporosis).
G. Others:
Poor wound healing (Immune suppression).
Diabetes mellitus (recent).
Hypertension (recent).
Hypercholesterolemia.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
3 ENDOCRINE OSCE ‐ Stasions
A. General Inspection:
The patient as a whole (for the 'gestalt' picture of Cushing's syndrome):
For central obesity.
For stooped posture (due to osteoporotic damage)
Generalised changes over the body, including:
Easy bruising
Striae
Thin skin
Classical central fat distribution
B. Systemic Examination:
1. Hands and arms for...
Bruising
Thin arms
Ask to measure blood pressure (would be raised)
Shoulder abduction power - reduced in proximal myopathy
Rheumatoid arthritis (suggesting an iatrogenic cause of the Cushingoid features)
2. Face for...
Rounded face (moon face)
Visible vessels on the cheeks suggesting thin skin
Greasy skin
Acne
Hirsutism
At this point you may wish to test Visual fields (looking for a bitemporal hemianopia that may be
the result of an ACTH producing pituitary tumour pressing on the optic chiasm)
Buccal pigmentation.
3. Shoulders for...
Supra-clavicular fat pads
Buffalo hump
4. Abdomen for...
Central obesity
Striae
Bruising
Renal transplant scars (patient may be on long term steroids which is causing the Cushing's
syndrome)
5. Legs for...
Skin ulceration
Ask patient to get up from a sitting position without using hands to test for proximal myopathy
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 2
3 ENDOCRINE OSCE ‐ Stasions
6. Spine for...
Spinal tenderness (may occur with osteoporosis if vertebral fractures)
If urinary excretion. UFC is elevated (> 4 times the upper limit of normal) between 100 and 150
µg/24h (276 and 414 nmol/24h), then a dexamethasone suppression test may be done to determine
the cause
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 3
4 ABDOMEN OSCE ‐ Stasions
1 Duration
2 Onset (sudden, gradual)
Bleed or not (if yes or already came with bleeding)
Nature (fresh blood, Melena, clots)
3 [bright; fissure or hemorrhoids] [dark; carcinoma, IBD, angiodysplasia, diverticular
disease]
Relation to defecation (before, after or mixed)
change of bowel habits, nature & consistency (diarrhoea; > 3times watery,
constipation or mix of them)
4
[diarrhoea; carcinoma, IBD, diverticular disease, food poisning]
[Constipation; fissure, hemorrhoids, carcinoma, crohn’s stricture]
5 Presence of mucus [rectal carcinoma, IBD]
Abdominal Pain/ Tenesmus during defecation [if yes SIROD CASP3]or
6
abdominal distension
7 Anal pain [anal fissure] or feeling of swelling or tag [hemorrhoid, anal fissure]
8 Sense of incomplete emptying
9 GI symptoms (nausea, vomiting, loss of appetite)
10 Swallowing difficulty, heartburn, indigestion
11 Weight loss [Carcinoma, IBD]
12 Associated symptoms (Jaundice, fever)
13 History of recent foreign travel [infective cause]
14 Anyone in the home have the same problem [food poisoning]
Drug allergy and anti-coagulant (aspirin, warfarin)
Past medical and past surgical (chronic disease, previous operation, radiotherapy,
15
chemotherapy, previous hospital admission, investigation or medication for this
problem)
Past social (Smoking, alcohol) if yes, amount and duration
16
Similar family condition
Thanking
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
4 ABDOMEN OSCE ‐ Stasions
ABDOMINAL (EXAMINATION)
Great and Introduce yourself to the patient, and ask his/her permission.
Positioning and exposure.
Wash/Gel your hands.
Ask (Is it Painful or not? Any other pain region?).
INSPECTION
General inspection: JACCOL + Cachexia
1 From the end of bed see abdominal symmetry, movement with breathing & type of breathing
From right side of patient
contour (scaphoid or distended)
any scar
any dilated veins
2 umbilicus ( position, inverted or everted or flat)
pigmentation
pulsation
cough impulse (hernial orifice & scar)
stomas, drains & catheters
Palpation
1 Asking the patient if there is any painful area and starting away from it
2 Superficial palpation (tenderness , guarding or rigidity and masses
3 Deep palpation of 9 areas for masses
4 Examine liver, spleen & kidney
5 Cough impulse at hernial orifices & aortic aneurysm (expansile pulse & epigastric mass)
Percussion
1 Percussion tenderness (peritonitis)
2 Ascites shifting dullness & transmitted thrill
3 Organ span (liver & spleen)
Auscultation
1 Bowel sound
2 aorta, renal & femoral arteries
3 Over liver for bruit
Extra tests
1 Groin
2 gentalia
3 DRE
4 The back
5 Left supra clavicular lymph nodes
6 Ankle oedema
Finishing Thanking, covering the patient & washing hands
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
4 ABDOMEN OSCE ‐ Stasions
site
margins
shape
Can get above / bellow it
surface
consistency
temperature
tenderness
Pinch the skin over it
Head raising test (to establish the depth of the mass)
reducible
compressible
Thrill or pulsation
Percussion
Percussion over the mass
Auscultation
Over the mass
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 2
4 ABDOMEN OSCE ‐ Stasions
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 3
4 ABDOMEN OSCE ‐ Stasions
DYSPHAGIA (HISTORY)
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
4 ABDOMEN OSCE ‐ Stasions
JAUNDICE (HISTORY)
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
4 ABDOMEN OSCE ‐ Stasions
JUINDCE PREPARATION
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 2
4 ABDOMEN OSCE ‐ Stasions
Occupation
Site (where is)
For how long (onset)
sudden or gradual
Duration (how long does the pain last)
Intermittent or constant
Intensity (from 1-10), activity limitation, wake him at night
Character (sharp, heavy, dull, burning or colicky)
Radiation
Aggravating factors (work, food directly after food or few hrs later, fatty meal)
relieving factors
Similar previous attacks of pain, is it periodic (more in certain time or weather)
ASSOCIATED SYMPTOMS
Nausea & Vomitting, heart burn
Hematemesis
Changes in bowel habit
Blood in the stool (malena)
Loss of appetite
Weight loss
sweeting, fever,
Jaundice
palpitation, SOB, cough,
loss of conscious
Urinary symptoms
Vaginal discharge (if the patient is female)
Last period and Possibility of being pregnant
Past medical:
Chronic disease (DM, HT, HF, liver diseases).
Drugs (NSAIDs), or medication for this problem
Allergies.
Previous hospital admission, investigation (especially ENDOSCOPY).
Past surgical:
Previous operation.
Radiotherapy.
Chemotherapy.
Family Social History:
Similar family condition, Family history of malignancies.
Smoking & Alcohol.
THANKING the patient.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
4 ABDOMEN OSCE ‐ Stasions
Present Illness:
1 Duration
2 Quantity
3 Appearance (blood + bile)
4 Any clots
5 Any abdominal pain
6 Bowel symptoms
7 Stool colour
8 Any syncope/ any chest pain/ any sweating
9 Need for blood transfusion?
10 Any weight loss
11 Jaundice
12 Fever
Past Medical History:
13 Peptic ulcer
14 Liver disease (Abdominal distension, dilated veins, hand palms erythema)
15 Any cancers
16 Prior bleeding
17 Cad
18 Previous surgeries
19 Medications: use of NSAIDS/Aspirin
20 Family History
21 Social History (particularly alcohol use)
THANKs the patient
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
4 ABDOMEN OSCE ‐ Stasions
inspection
Assess level of consciousness
Look for signs of chronic liver disease (palmer erythema, clubbing, spider
angioma, gynecomastia, jaundice, testicular atrophy, ascitis,
hepatosplenomegaly)
palpation
Vital signs
Examine abdomen: inspection, palpation (light/deep), percussion,
auscultation
Ensure that the patient is properly draped
Intend to perform DRE
Finishing
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 2
4 ABDOMEN OSCE ‐ Stasions
1 Duration
2 Loss of weight in Kg
3 Loss of appetite, weakness & easy fatigability
GI symptoms
4 dysphagia
5 vomiting
6 diarrhea & constipation
7 change of bowel habits
BLEEDING
8 GIT Hematemesis, melena
9 URINARY Hematuria
10 RESPIRATORY hemoptysis
11 GYNECOLOGY vaginal bleeding
THYROTOXICOSIS SYMPTOMS
12 Intolerance to heat
13 sweating
14 Tachycardia, palpitation
15 nervousness
16 PSYCHOLOGICAL STATUS
17 Past medical history (DM, chronic illness)
18 Past surgical history (previous surgery, Tumor, chemotherapy, radiotherapy)
19 Family Hx and Smoking, Alcohol Hx
THANKS the patient
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
4 ABDOMEN OSCE ‐ Stasions
STOMA (HISTORY)
1 Duration
2 Elective or emergency
3 Cause of surgery (permanent or temporary)
4 Site
5 Colostomy bag (content, blood, amount)
6 Change of colostomy bag
7 Abdominal pain
8 nausea, vomiting
9 bleeding
10 diarrhea
11 prolapsed
12 Skin condition
13 wound infection
14 Fever
15 weight loss
Past medical
16 past surgical (chronic disease, previous operation, radiotherapy, chemotherapy,
previous hospital admission, investigation or medication for this problem)
17 Family hx
18 Smoking, alcohol
THANKS the patient
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
4 ABDOMEN OSCE ‐ Stasions
STOMA (EXAMINATION)
Great and Introduce yourself to the patient, and ask his/her permission.
Positioning and exposure.
Wash/Gel your hands.
Ask (Is it Painful or not? Any other pain region?).
INSPECTION
ABDOMEN (distended, scar, erythema….etc)
Scar (medical prescription)
No midline scar (defunctioning, or laparoscopy)
Ask the patient to cough or raise his legs (parastomal hernia)
Site (RIF, LIF, epigastric, transverse…etc.)
Covering (with bag or had been removed) & comment on the bag content [urine,
formed stool, liquid stool]
Caliber shape: spout (ileostomy) or flush colostomy
Lumen number [spout, end; one opening, loop; with a common opening or 2 separate
openings (double-barrelled)]
Maybe a colostomy with a urinary diversion [pelvic clearance]
State of stoma (Healthy well-constructed, ischemic, retracted, prolapsed) any mucosal
inflammation or polyps
Surrounding skins (excoriations)
Palpation (Digital stomal examination) begin with distal opening
Any stenosis
Confirming weather single or double lumen
I would like to complete by examining:
The rest of the abdomen.
Perineum (patent anal canal or closed perineum).
Asses stoma position during sitting, lying & standing
Assess the patient's fluid status (hydration; high output stmoa).
THANKING and COVER the patient.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 2
4 ABDOMEN OSCE ‐ Stasions
Indications
Complications
Specific/ technical:
1. Ischemic/gangrene.
2. Obstruction.
3. Haemorrhage.
4. Retraction.
5. Prolapse/intussusception.
6. Stenosis.
7. Parastomal hernia.
8. Skin excoriation.
9. Odour & flatus.
General:
1. Diarrhoea (water and electrolyte imbalance, especially hypokalemia)
2. Nutritional disorders (VB12 deficiency; megaloblastic anemia, microcytic
normochromic anemia).
3. Stones (gallstones, renal stone) loss of terminal ileum and bile salt absorption, also
excessive water loss.
4. Residual disease (crohn’s; parastomal fistula).
5. short gut syndrome: fluid/electrolyte loss
6. Psychosexual.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 3
5 POST‐OPERATIVE OSCE ‐ Stasions
POST-LAPAROTOMY (EXAMINATION)
Great and Introduce yourself to the patient, and ask his/her permission.
Positioning and exposure.
Wash/Gel your hands.
Ask (Is it Painful or not? Any other pain region?).
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
5 POST‐OPERATIVE OSCE ‐ Stasions
POST-THYROIDECTOMY (EXAMINATION)
Great and Introduce yourself to the patient, and ask his/her permission.
Positioning and exposure.
Wash/Gel your hands.
Ask (Is it Painful or not? Any other pain region?).
General Examination
General appearance ( conscious or not , well or tired , pallor , jaundice , cyanosis
1
and respiratory state)
2 Pulse examination (rate,rhythm,volume)
3 Blood pressure and trousses sign
4 Hydration state
5 Checking for pallor
6 Checking for jaundice
7 Auscultation of the chest anteriorly
8 Auscultation of the chest posteriorly (lung bases)
Specific examination
9 Removal of dressing and wound inspection ( checking for any heamatoma
10 Patient voice
11 Chvosticks sign
12 Ask the patient to cough
Tube checking
13 Intravenous access examination
14 Drains
Thanking and covering the patient
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 2
5 POST‐OPERATIVE OSCE ‐ Stasions
What are the causes of post-operative fever? Give the likely post-operative days related to the
cause.
6W
(Wonder drug, Wings (veins), Wind, Wound, Walking, Water)
Same time: (Wonder drug)
1 Transfusion reactions
2 Drug reactions
Day 1:
3 Inflammatory response to surgical trauma
4 Thrombophlebitis (at any day) (Weins/Wings)
Day 2: (Wind)
5 Atelectasis of the lung
Day 3:
6 Systemic bacteremia/fungemia/viremia
Day 5: (Wound)
7 Superficial and deep wound infection
After day 5:
8 Intra-abdominal abscess
Day 7 & on:
Deep vein thrombosis (DVT) (Walking)
Urinary tract infection (Water)
9 Leaking anastomosis
Clostridium difficile diarrhea
Deep wound infection
Abscess
Others
Infected prosthetic material
10 Collagen/Vascular disease
Occult bacteremia
Neoplasm
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 3
5 POST‐OPERATIVE OSCE ‐ Stasions
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 4
5 POST‐OPERATIVE OSCE ‐ Stasions
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 5
6 INGUINAL OSCE ‐ Stasions
Duration
1
Onset (gradual) (sudden; is it related with lifting)
2
Occupation or leisure involves a lot of lifting?
3
Increase in size (with muscular efforts, cough, straining)
4
Reducible or not? When lie down or by yourself [hernia, saphena varix]
5
Previous lumps or swelling similar [recurrent hernia]
6
Painful [incarcerated hernia, abscess]
7
Discharge [abscess, infected LN]
8
Fever, night sweeting, weight loss [lymphoma, TB]
9
GI symptoms; abdominal pain, Fullness, bloating or dyspeptic symptoms. Nausea or
10
vomiting
11 Chronic constipation
12 Chronic cough
13 Urinary symptoms
Past medical; diabetes, jaundice, tuberculosis, ascitis, hypertension. Drug history;
14 steroids, cytotoxic drugs
previous hospital admission, investigation or medication for this problem
15 Social history; smoking, alcohol
THANKING the patient
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
6 INGUINAL OSCE ‐ Stasions
INGUINAL (EXAMINATION)
Great and Introduce yourself to the patient, and ask his/her permission.
Positioning and exposure.
Wash/Gel your hands.
Ask (Is it Painful or not? Any other pain region?).
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 2
6 INGUINAL OSCE ‐ Stasions
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 3
7 DRE OSCE ‐ Stasions
1 Great & introduce yourself to the patient & EXPLAIN the procedure
Take consent (Verbal consent only for DRE, but do document in the notes that you gained
2
consent from the appropriate person)
Ensure privacy with assistance nurse (chaperone) (private room, curtains good enough)
3
Keep as much of the patient covered as possible
Positions:
Left lateral (bring their knees right up to their chest)
4 Knee elbow position (jack-knife)
Modified lithotomy (patient on back, knees flexed)
Leaning forward on bench.
5 Glove both hands (non-sterile gloves)
Gently separate the buttocks for inspection of the perineum:
6 External skin lesion (e.g. warts, candidiasis, herpes simplex.)
prolapsed piles, rectal prolapse (ask patient to strain), abscess, sentinel piles, fissure, fistula
Digital examination;
Ask about tenderness (if yes complete under GA)
7
Generously lubricate the gloved index finger, inform the patient that you are going to insert
your finger.
8
Any lubricant can be used (lidocaine used for slight pain and should wait to 5 minutes) (severe
pain need GA)
Left hand on the patient back (stabilize the patient) right hand index down natal cleft with
slight pressure on the anal verge (to relax puborectalis muscle, before insertion) insert your
9 index finger into the anus.
10 Perform a full 360 ° sweep assessing Sweep the anterior, lateral & posterior walls of the
rectum
you need to turn away from the patient and pronate your wrist
Sweep your finger over the prostate gland (anteriorly through the rectal wall)
11 Identify the two lobes, and the longitudinal groove (median sulcus)
Note the size, nodularity, consistency and tenderness of the prostate (prostatitis)
Finding:
Rectal mucosa: Normal mucosa feels uniformly smooth and
pliable to palpate
12
prostate: (normal) Prominent median sulcus Smooth, rubbery consistency
(Ca) Asymmetric shape, Hard consistency, Discrete nodule may be palpable, Median sulcus
often obscure
Withdrawal your index and inspect the colour of any soiling on your glove (faeces, mucous,
13
blood)
Ending:
Offer the patient a tissue
14 Allow the patient to get dressed, sit down and
prepare themselves for discussing results
Explain your findings to the patient
15
Negotiate a follow up plan / tests /investigations like Proctoscopy, or Sigmoidoscopy
Address the patients concerns
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
7 DRE OSCE ‐ Stasions
1. Suspected Appendicitis
2. Change in bowel habit
3. PR bleeding
4. As a part of abdominal exam
5. Pelvic or spinal trauma
6. Genitourinary problems
PROCTOHEAL composition:
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 2
8 LIMB OSCE ‐ Stasions
6 Ps
Pain:
Onset
Duration
Location
Radiation
Alleviating factors
Provoking factors
Paresthesias
Pallor
Paralysis
Pulseless
Poikilothermic (temperature change, cold)
Past Medical History: (risk factors)
Diabetes mellitus
Coronary artery disease
Hypertension
Dyslipidemia
Family History: CAD, HTN, Stroke, DM
Social History:
Smoking
Alcohol
Cocaine / heroine abuse
Diet
Activity
THANKING the patient.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
8 LIMB OSCE ‐ Stasions
PAD (EXAMINATION)
Also for DIABETIC FOOT
Great and Introduce yourself to the patient, and ask his/her permission.
Positioning and exposure.
Wash/Gel your hands.
Ask (Is it Painful or not? Any other pain region?).
Inspection
General:
1 Look around bed for aids, O2, GTN
Look for pt as a whole; unwell, on pain, shortness of breath, cyanosis, obesity
2 Nails changes
Skin changes ( Color, Ulcer , Gangrene, digital amputation) if found ULCER:
3
Site, Size, Shape, Edge, Floor, Surrounding skin.
4 Trophic Changes ( Loss of hair , Muscle wasting )
5 Don’t forget examine between toes, pressure areas & bilaterally
Palpation
6 Tenderness
7 Temperature
8 Pitting edema
9 Base of the ulcer ( induration and fixity to deep structures)
10 Capillary Refilling Time
pulses examination(Abdominal Aorta, Femoral, Popliteal, Posterior Tibial & Dorsalis
11
Pedis)
Auscultation (bruit)
12 Aorta, renal & iliac aa
13 Femoral
14 Adductor hiatus
Special examination
15 ABPI
16 Buerger’s test
17 DeWeese test (disappearance of previously palpable pulse after walking exercise)
Nerve functions
18 Temperature sensation
19 Touch sensation
20 Motor
Finishing Thanking the patient , cover pt & washing hands
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 2
8 LIMB OSCE ‐ Stasions
Inspection
General:
Look around bed for aids & support stocking
Look for pt as a whole; unwell, on pain, shortness of breath, cyanosis, obesity
Ask the pt to stand with one leg in front the other, you must inspect from the front, side &
behind.
Skin (scar, edema, eczema, ulcer, hair loss, hemosiderosis, lipodermatosclerosis) due to
venous HT … especial around med malleolus
Asses varicose vein distribution & location
Asses Sapheno-varix
Site and size include saphena varix (SFJ; inguinal medial to femora A pulse), LSV front
and lateral & behind for SSV (below knee)
Palpation (Ask pt if there is pain)
Tenderness
Temperature
Pitting oedema
Palpate the course of long & short saphenous veins
palpate the groin for regional LN
Palpate for Sapheno-varix
Perform cough test by asking pt to cough while your index finger on the sapheno-femoral
junction
Percussion Test (Chevrier,s Sign)
Tap proximal & palpate distally, to identify venous valvular incompetency
Tap distally & palpate proximally, to identify venous lumen patency
Auscultation (bruit)
Listen for bruit (A-V fistula)
Special test
Tourniquet test: also known as Brodie-Trendelenburg test (if the finger is used instead of
tourniquet over SFJ). Place pt in supine position, elevate leg, empty the leg veins & put
tourniquet on mid thigh. Ask pt to stand, if incompetence is above it, the various V will be
controlled & if it is bellow the V will be refilled. The test can be repeated using multiple
positions.
Perthes test: place the tourniquet on the thigh & ask pt to stand on their toes. If the veins
enlarged or pt experience pain, the deep vein likely to be involved.
Hand held Doppler ultrasound
Further considerations
ABPI
Abdominal examination
Duplex US
Thanking the patient , cover pt
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 3
8 LIMB OSCE ‐ Stasions
DVT (HISTORY)
Begin by general look General: for aids, O2, GTN, unwell, on pain, shortness of breath,
cyanosis, and obesity.
Inspection
Palpation (tenderness, temperature, vascular, neurology) + Hoffman sign (calf pain with
dorsiflexion of right foot)
Chest exam (Listen to the lungs in four places)
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 4
8 LIMB OSCE ‐ Stasions
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 5
8 LIMB OSCE ‐ Stasions
HEPARIN
Dosing:
1. Give heparin and warfarin jointly for 5-7 days.
2. 5000 units IV one time as a bolus dose followed by 1300 units/hour by continuous IV
infusion. Alternatively, a bolus dose of 80 units/kg IV one time followed by 18
units/kg/hour by continuous IV infusion may be used.
3. Obtain APTT at 4-6 hrs and keep APTT in a range that corresponds to a plasma
heparin level of 0.2-0.4 u/ml.
4. Start warfarin on day one at 5 mg and dose daily with the estimated daily maintenance
dose or start the estimated daily maintenance dose (2-5 mg.)
5. Obtain platelet count every 3-5 days of heparin therapy up to 21 days.
6. Stop heparin thereafter when PT gives an INR of 2.0-3.0.
7. Continue warfarin at an INR of 2.0-3.0.
Complication:
1. Bleeding
2. Heparine induced thrombocytopenia
3. Intra-arterial thrombosis.
4. Osteoporosis.
5. Skin necrosis.
1. Average molecular weight: heparin is about 15 kDa and LMWH is about 4.5 kDa.
2. Less frequent subcutaneous dosing than for heparin.
3. No need for monitoring of the APTT coagulation parameter as required for high dose
heparin.
4. Possibly a smaller risk of bleeding.
5. Smaller risk of osteoporosis in long-term use.
6. Smaller risk of heparin-induced thrombocytopenia, a potential side effect of heparin.
7. The anticoagulant effects of heparin are typically reversible with protamine sulfate,
while protamine's effect on LMWH is limited.
8. Has less of an effect on thrombin compared to heparin, but about the same effect on
Factor Xa.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 6
8 LIMB OSCE ‐ Stasions
RISK FACTORS:
1. Age: 60-80
2. Male
3. Indo-Asians and African-Americans
4. Familial history of PAD, myocardial infarction, coronary heart disease, or stroke
5. Diabetes
6. HT
7. Hyperlipidemia
8. Obesity
9. Systemic atherosclerosis
10. Myocardial infarction
11. Coronary heart disease
12. Stroke
13. Renal artery stenosis
14. Leriche syndrome
15. Cardiac arrhythmias, including atrial fibrillation, with emboli to the extremities
16. Hypercoagulable states due to elevation of several coagulation factors
Stage I: Asymptomatic.
Stage II: Mild claudication pain in limb
IIA: Claudication at a distance of greater than 200 metres.
IIB: Claudication distance of less than 200 metres
Stage III: Rest pain, mostly in the feet
Stage IV: Necrosis and/or gangrene of the limb
A more recent classification by (RUTHERFORD) consists of three grades and six categories:
Category 0: Asymptomatic
Category 1: Mild claudication
Category 2: Moderate claudication
Category 3: Severe claudication
Category 4: Rest pain
Category 5: Minor tissue loss; Ischemic ulceration not exceeding ulcer of the digits of the foot
Category 6: Major tissue loss; Severe ischemic ulcers or frank gangrene
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 7
8 LIMB OSCE ‐ Stasions
Sudden decrease in limb perfusion that causes a potential threat to limb viability (manifested by
ischemic rest pain, ischemic ulcers, and/or gangrene)
In patients who present within two weeks of the acute event (if >2 weeks, it is considered chronic
ischaemia).
CAUSES:
1. Arterial embolism
Most common cause of acute limb ischaemia (60-80% of the time)
The most likely source of embolus is the heart (80%), of which 70% is due to atrial fibrillation, 20%
to AMI with left ventricular mural thrombus, and a small proportion to prosthetic heart valves
2. Acute thrombosis
Thrombosis of a previously stenotic but patent artery (atherosclerotic vessel)
Other less common causes of acute thrombosis include the arteritides (usually affecting medium-
sized arteries), ergotism, and hypercoagulable states (notably antiphospholipid syndrome).
3. Arterial trauma
4. Dissecting aneurysm
Classification of severity
Viable: No immediate threat of tissue loss
Threatened: Salvageable if re-vascularized promptly
Non-viable: Limb cannot be salvaged and has to be amputated, no emergency to operate
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 8
8 LIMB OSCE ‐ Stasions
a. Critical:- a potential threat to limb viability (manifested by ischemic rest pain, ischemic
ulcers, and/or gangrene) in patients who present more than two weeks after the acute event
(the converse of the definition of acute limb ischaemia).
b. non-critical limb ischaemia:-
symptomatic (usually claudication)
asymptomatic.
Neurogenic claudication
Vascular intermittent claudication needs to be differentiated from neurogenic claudication which can
also present as pain in the lower limb on exertion
The characteristic of neurogenic claudication is “park bench to park bench” where the patient
has to sit down and flex the spine to relieve the pain (pain results from compression of the
cord and spinal nerves in spinal stenosis; extension of the spine further narrows the spinal
canal while flexion widens it)
“Claudication distance” of neurogenic claudication is more variable
Pulses will be absent/diminished in vascular but not in neurogenic claudication
IMAGING
1) Ankle-brachial pressure index:
Brachial pressure is measured with a blood pressure cuff around the arm and a Doppler probe at the
brachial artery – cuff is inflated until the arterial signal is obliterated, then slowly deflated until the
signal just starts being detected, at which the pressure is recorded
Ankle pressures are measured in a similar manner, with the cuff around the calf and the Doppler at
the dorsalis pedis and posterior tibial arteries – one reading for each artery
The ankle pressure to be used for each leg is the higher of the two taken
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 9
8 LIMB OSCE ‐ Stasions
This ankle pressure is then divided by the brachial pressure (the higher of the two brachial pressures
for both upper limbs) to get the ankle-brachial pressure index
6) Angiography:
Determines details about the anatomy, including the level of occlusion, stenosis, and collateral flow
Useful where the diagnosis of acute ischemia is uncertain or before emergent bypass grafting.
7) CT angiogram:
CT is useful for diagnosis of occlusive aortic disease or dissection.
Rapidly available and reliable
may not be 1st line for patients with renal insufficiency
8) MRI:
Disadvantages are that MRI is time-consuming and expensive.
DIFFERENTIAL DIAGNOSIS:
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 10
8 LIMB OSCE ‐ Stasions
Surgical Endovascular
Embolectomy
Endarterectomy Thrombolysis
Bypass grafting Angioplasty
Fasciotomy Stenting
Primary amputation
In general, embolectomy is done for embolic occlusion, while thrombolysis is done for thrombotic
occlusion.
1. Embolectomy
Can be done under LA but still require anaesthetist to monitor patient as he may be quite sick
(e.g. AMI), and hyperkalaemia with cardiac arrhythmia can occur after reperfusion
Need to convert to full warfarin anticoagulation, uptitrating dose until INR 2-2.5 before stopping
heparin (patient at risk of further embolic events)
2. Thrombolysis
Angiogram done before thrombolysis to locate occlusion
Thrombolysis catheter inserted into the clot, and the thrombolytic agent is infused.
Patient will be in high-dependency with thrombolytic infusion for 6 hours (~1000-4000 units
per minute).
After 6 hours, redo angiogram to check for residual clot; if some clot remains, adjust catheter
into the clot and infuse for 6 more hours.
After complete lysis of the clot, can do angioplasty
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 11
8 LIMB OSCE ‐ Stasions
Thrombolysis may be preferred for embolism in a diseased artery, since it may be difficult to trawl
out the clot in a diffusely stenosed vessel – the clot may get caught on a proximal stenosed segment
Results:
Embolectomy has a 20% mortality, almost full success rate
Thrombolysis has a 10% mortality, only 35% successful
1. Conservative
Smoking cessation.
Exercise training
Exercise at least half to one hour every day
Walk until pain comes, rest 2-3 minutes, and walk again.
Podiatrist to teach foot care.
Aggressive management of hyperlipidemia, HTN, diabetes.
Antiplatelets e.g. aspirin
New method: subintimal angioplasty – if lumen is so occluded that guide wire cannot pass through,
the guidewire is threaded into the subintimal space to create a dissection around the occluded
segment, and this space is then angioplastied to create a channel parallel to the actual lumen for
blood to flow through
3. Bypass grafting
Consider bypass when lesions cannot be treated by angioplasty i.e. lesion extends for long distance
through the vessel and/or no lumen for guide wire to pass through (complete occlusion)
4. Amputation
Indications (3 D’s)
1. Dead (Necrotic tissue).
2. Dangerous (Gangrene, ascending sepsis).
3. Damn nuisance (Non-functional limb; bad smell; pain; constant need to dress wound).
o Level of amputation depends on vascularity of the limb and the indication (e.g. if infected,
need to amputate above level of infection)
o As far as possible try to preserve function of the lower limb
o May require revascularisation interventions before amputation to ensure good healing, or to
enable lower amputation
o Do not simply amputate without ensuring good vascular supply to the surgical site, otherwise
the wound will not heal
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 12
8 LIMB OSCE ‐ Stasions
Types of Amputations:
1. Toe: most common; usually through proximal phalanx. Must not be performed through the
joint; exposes avascular cartilage and won’t heal.
2. Ray: excision of toe through the metatarsal bone.
3. Transmetatarsal: divided at mid-shaft level. Indicated for infection or gangrene.
4. Midfoot: consider only in patients with correctable or absent ischaemia. Types:
Lisfranc (disarticulation between metatarsal and tarsal bones)
Chopart (disarticulation of the talonavicular and calcaneocuboid joints).
5. Ankle level (Syme and Pirogoff): rarely indicated in vascular practice today.
6. Below-knee (Burgess long posterior flap and skew flap).
7. Through-knee, e.g. Gritti–Stokes: useful if orthopaedic metalware in the femur.
8. Above-knee.
9. Hip disarticulation and hindquarter:
malignant disease
extensive trauma
infection or gangrene
non-healing high above-knee amputation.
Early
1. Stump haematoma
2. Flap necrosis, infection.
3. Stump trauma from falls.
4. Wound-related pain
Late
1. Neuroma formation.
2. Osteomyelitis.
3. Bony erosion.
4. Ulceration.
5. Ongoing ischaemia.
6. Phantom limb pain.
7. Joint contractures.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 13
9 TRAUMA OSCE ‐ Stasions
TRAUMA (HISTORY)
At accident site
The exact time of accident ( history in hours)
How the accident happen (passenger, in the front seat )
Where the patient was hit (which part of the body) – left side of the body –side
collision
Other passengers or pedestrians condition –fine
The condition of patient immediately after accident
Transportation
How the patient was transported
The condition of the patient during transportation
In the hospital ( ER, OR , ward)
The condition of the patient in ER
Over the last night what treatment he received and investigation done-cxr, abdominal
us and blood investigation and received iv fluid
Symptoms of the patient at time of history taking
Any loss of consciousness
Respiratory distress
Abdominal pain
Vomiting and the type of vomitus
The color of the urine
Asking about bowel motion and color of feces
Related history (AMPL)
Allergy
any Medications
Past medical, past surgical (Any Systemic illness?)
Last meal
THANKING the patient.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
9 TRAUMA OSCE ‐ Stasions
Great and Introduce yourself to the patient, and ask his/her permission.
Positioning and exposure.
Wash/Gel your hands.
Ask (Is it Painful or not? Any other pain region?).
inspection
Site of insertion of chest tube
Tissue surrounding the insertion site ( infection ?)
Under water seal position to the patient
Checking the function of chest tube
Type and amount of fluid drained
Auscultation ( both sides)
Anterior auscultation
Lateral auscultation
Posterior auscultation
Indication for removal
Clinical (stable, breath comfortable)
radiological
THANKING the patient.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 2
9 TRAUMA OSCE ‐ Stasions
HEAD INJURY
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 3
10 COMMUNICATION SKILLS OSCE ‐ Stasions
CONSENT
Greet with (use patient name) & Introduce yourself. Ask his/her permission.
Quiet & calm environment.
Invite to sit, alone or someone else.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
10 COMMUNICATION SKILLS OSCE ‐ Stasions
S; SETTING:
Great and Introduce yourself to the patient, and ask his/her permission.
Privacy
Ask for presence of family members or friends Sit down
P; PERCEPTION:
Ask pt what he know about his condition
I; INVETITION:
Respect pt right to know or not to know other
K; KNOWLEDGE:
Give the bad news in small digestible pieces, give a warning that bad news are coming,
avoiding technical & scientific language.
E; EMPATHY:
Downplay the sensitivity of situation or give more helpful prognosis
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 2
10 COMMUNICATION SKILLS OSCE ‐ Stasions
CONSULTATION (HT)
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 3
11 ORTHO OSCE ‐ Stasions
Great and Introduce yourself to the patient, and ask his/her permission.
Positioning and exposure.
Wash/Gel your hands.
Ask (Is it Painful or not? Any other pain region?).
LOOK (inspection)
with comparison of both Elbow joints
The arms by the body side and arms fully extended
Look for any swelling or deformity
Compare the carrying angles of both sides
FELL (palpation)
Temp
tenderness over:
Medial & lateral epicondyle.
olecranon process
MOVE
Full flextion
( normally the medial, lateral epicondyles and olecranon form equilateral triangle )
Full extension
( normally the medial , lateral epicondyles and olecranon are in one line )
Pronation and suppination
( during which fell the radial head just distal to the lateral epicindyle)
SPECIAL TESTS
Cozen's test for tennis elbow
(clinched hand, pronated forearm, the patient extend his clinched hand while the
examiner try to flex the hand , pain in the common extensors origin)
Mills's test for tennis elbow
(suppinated forearm , flextion of the wrist ,,, pain in the common extensors origin )
THANKING the patient.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
11 ORTHO OSCE ‐ Stasions
Great and Introduce yourself to the patient, and ask his/her permission.
Positioning and exposure.
Wash/Gel your hands.
Ask (Is it Painful or not? Any other pain region?).
LOOK (inspection)
( start with the patient standing and exposure of both knees)
Standing patient (any skin or joint shape changes or muscle wasting)
Scar: (injury, arthroscope, meniscectomy)
Popliteal swelling (baker cyst) (popliteal aneurysm)
Ask the patient to walk
Ask the patient to squat
Supine patient (for effusion –horseshoe swelling of the suprapatellar pouch)
FELL (palpation)
Measure the Quadriceps circumference at a set distance (fixed bony point; e.g. 15cm above tibial
tuberosity)
Temperature (septic arthritis, inflammatory arthritis).
Tenderness: Patella:
Knee extension (around patella)
Grind test (move patella up & down)
Clarke’s test (push patella against femur & then extension knee)
Both testes for patellofemoral osteoarthritis (PFOA) & painfull
Palpation of the joint line for local tenderness while knee is flexed 45 degree:
Tibial tuberosity (flat foot, 90° flexed knee)
Patellar ligament
Medial and lateral joint lines.
Popliteal fossa
Effusion:
Patellar hollow test [very small fluid] appear with slight flexion at the medial aspect & disappear with
further flexion
Bulge/Swipe test [small fluid] empty one side and sharply swipe the other and observe the bulge in
side you try to empty it
Cross-fluctuation [moderate fluid] one hand empty the suprapatellar space & other hand empty the
medial aspect and sharply swipe to lateral to observe fluid transmission in the medial
Cruciate ligaments:
Posterior Sag and Posterior drawer (PCL)
Anterior drawer (ACL)
Lachman test (sensitive for ACL)
Collateral ligaments: Standard & Modified tests
MOVE
Asking the patient to extend knees
Asking the patient to flex knees
Passive flexion and extension while palpating the knee for clicking
SPECIAL TESTS
Menisci: McMurray’s test
Complete by examining:
Hip (above) & Ankle (below)
Neurovascular state
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 2
11 ORTHO OSCE ‐ Stasions
Great and Introduce yourself to the patient, and ask his/her permission.
Positioning and exposure.
Wash/Gel your hands.
Ask (Is it Painful or not? Any other pain region?).
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 3
11 ORTHO OSCE ‐ Stasions
Great and Introduce yourself to the patient, and ask his/her permission.
Positioning and exposure.
Wash/Gel your hands.
Ask (Is it Painful or not? Any other pain region?).
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 4
12 PEDIATRIC OSCE ‐ Stasions
Duration
Progression during this time (better, worse)
Related to stool
How many times open bowel per week
When he pass motion Stool Amount:
Few
Large (that can block the toilet)
Nature:
Hard large stool (firm).
thick
very loose (watery)
Stool passed without sensation? If yes → Can also be thick and sticky or dry and flaky
Spontaneously pass motion?.
Straining.
need stimulation (PR, medication)
Weakness in legs, locomotor delay (such as falling over in a child/young person older
than 1 year).
Changes in infant formula, weaning, insufficient fluid intake
Poor diet and/or insufficient fluid intake.
Relevant Hx
Previous attack
fears and phobias, major change in family,
taking medicines
DDx:
Hirschsprung's disease.
Meconium ileus.
Cystic Fibrosis
Perianal streptococcal infection.
Coeliac disease.
Hypothyroidism.
Idiopathic constipation.
EXAMINATION:
1. Appearance of the skin and anatomical structures of lumbosacral, gluteal, Anal regions
Anal position, patency, Fistulae, bruising, multiple fissures.
Flattening of the gluteal muscles, evidence of sacral agenesis, discoloured skin, naevi
or sinus, hairy patch, lipoma, central pit (dimple that you can't see the bottom of),
scoliosis
2. Abdominal examination (distention, mass, organomegaly).
3. A digital rectal examination.
4. Lower limb neuromuscular examination including tone, strength and Reflexes.
INVESTIGATIONS:
1. Blood Tests for coeliac disease and hypothyroidism (T4, TSH, Ca, IRT, Coeliac Ab)
2. Plain abdominal radiograph
3. Ultrasound
4. Barium enema
5. Endoscopy.
6. Manometry
7. Transit studies.
8. Rectal biopsy
TREATMENT:
Conservative: Surgical:
1. Education (bad toilet habit) for bowel training.
4. Stenosis.
2. Diet
5. Hirschsprung's disease.
3. Medication (laxative)
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 2
12 PEDIATRIC OSCE ‐ Stasions
Delayed growth
Failure to gain weight normally during childhood
No bowel movements in first 24 to 48 hours of life
Salty-tasting skin
1. Immunoreactive trypsinogen (IRT) test is a standard newborn screening test for CF.
A high level of IRT suggests possible CF and requires further testing.
2. Sweat chloride test is the standard diagnostic test for CF. A high salt level in the
patient's sweat is a sign of the disease.
Other tests that identify problems that can be related to cystic fibrosis include:
1. Chest x-ray or CT scan
2. Fecal fat test
3. Lung function tests
4. Measurement of pancreatic function
5. Secretin stimulation test
6. Trypsin and chymotrypsin in stool
7. Upper GI and small bowel series
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 3
12 PEDIATRIC OSCE ‐ Stasions
Treatment:
A) for lung problems includes:
1. Antibiotics to prevent and treat lung and sinus infections.
2. Inhaled medicines to help open the airways
3. DNAse enzyme therapy to thin mucus and make it easier to cough up
4. High concentration of salt solutions (hypertonic saline)
5. Flu vaccine and pneumococcal polysaccharide vaccine (PPV) yearly (ask your health
care provider).
6. Lung transplant is an option in some cases.
7. Oxygen therapy may be needed as lung disease gets worse.
B) Lung problems are also treated with aerobic exercise or other therapies to thin the
mucous and make it easier to cough up out of the lungs. These include a Percussion
Vest, manual chest percussion, A-capella, or TheraPEP device.
Possible Complications
1. The most common complication is chronic respiratory infection.
2. Bowel problems, such as gallstones, intestinal obstruction, and rectal prolapse
3. Coughing up blood
4. Chronic respiratory failure
5. Diabetes
6. Infertility
7. Liver disease or liver failure, pancreatitis, biliary cirrhosis
8. Malnutrition
9. Nasal polyps and sinusitis
10. Osteoporosis and arthritis
11. Pneumonia, recurrent
12. Pneumothorax
13. Right-sided heart failure (cor pulmonale)
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 4
12 PEDIATRIC OSCE ‐ Stasions
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 5
12 PEDIATRIC OSCE ‐ Stasions
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 6
12 PATINET SAFETY OSCE ‐ Stasions
Risk Factors:
1. Patient with high BMI
2. Emergence surgery
3. Unplanned change in procedure plan
4. Multiple surgeons involved in the same patient
5. Multiple procedure in the same patient
6. Multiple operation room nurse/staff members.
7. Multiple nurse shift
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
14 DAY CASE SURGERY OSCE ‐ Stasions
a patient who is admitted for investigation or operation on a planned non-resident basis and who
nonetheless requires facilities for recovery
'out-patient cases': These are minor procedures performed under a local anaesthetic which do not
generally require postoperative recovery time.
Type of surgery:
About 50% of all elective procedures were best done on a day case basis:
general surgery:
o hernia repair, e.g. inguinal, femoral, epigastric
o varicose vein surgery
o breast lump excision
o anal stretch
o pilonidal sinus
orthopaedic surgery:
o carpal tunnel release
o release of trigger finger
o Dupuytren's contracture surgery
o arthroscopy
o amputation of finger or toe
o ingrowing toe nails
urological surgery:
o circumcision
o cystoscopy with or without biopsy
o hydrocoele surgery
o excision of epididymal cyst
o reversal of vasectomy
paediatric surgery:
o circumcision
o inguinal herniotomy
o hydrocoele surgery
gynaecological surgery:
o D&C
o termination of pregnancy
o laparoscopy
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
14 DAY CASE SURGERY OSCE ‐ Stasions
ENT surgery:
o myringotomy & insertion of grommets
o direct larygoscopy & pharyngoscopy
o submucous resection
plastic surgery: blepharoplasty, breast augmentation, insertion of tissue expanders
Advantages:
patients:
o know when operation will be, little risk of cancellation
o minimal time away from home which is particularly beneficial for paediatric patients
surgeons:
o less risk of cancellation permits better scheduling of operating lists
o greater turnover of cases
o less delay between cases, usually because less preparation is required
o release of in-patient beds that would have been occupied by day case patients
general practitioners:
o happier patient
o financial saving ranging from 19% to 70% compared to in-patient treatment
hospital management:
o cost-effective treatment, still attaining clinical goals
o facilitates less demand for in-patient beds
disadvantages
the need for a responsible person to oversee the day case patient at home for the first 24-48
hours
the restriction of day case surgery to experienced senior staff; little opportunity for junior
staff to practise
extra work for the general practitioner in the postoperative period; patients often ring them
for advice or treatment
the cost-effectiveness of the unit is reduced when less complex cases are dealt with on a day
basis
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 2
14 DAY CASE SURGERY OSCE ‐ Stasions
contraindications:
medical:
o angina at rest } all ischaemic
o myocardial infarct in last six months } heart disease is controversial
o hypertensives - diastolic greater than 105 mmHg
o cardiac failure
o acute respiratory infection
o asthma - moderate to severe require increased observation
o chronic bronchitis
o emphysema
o gross obesity: body mass index > 35
o insulin dependent diabetics
o coagulation defects
o anticoagulation therapy
o deformity or anatomical problems in jaw or neck
o extent of pathology, e.g. large scrotal hernia
o operation longer than one hour
o painful operations - need an increase in analgesia
psychological:
o psychologically unstable, e.g. psychosis
o concept of day surgery unacceptable to patient
social:
o lives over one hour away from unit
o no reliable person to drive patient home after surgery and look after them for the first
24-48 hours postoperatively
o at home, no access to a lift, telephone or indoor toilet and bathroom
explaining to the patient the exact nature of the problem and the surgery to be undertaken
the protocol of the day unit
fasting
need for an accompanying person
transport
postoperative restrictions on driving and the use of heavy machinery, HGVs in the
succeeding days
avoidance of alcohol
drug requirements
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 3
14 DAY CASE SURGERY OSCE ‐ Stasions
Analgesia:
opiates are used less extensively; fentanil and alfentanil are used because of their rapid
metabolism
long-acting local anaesthetic, e.g. bupivacaine, is added to block the region of surgery, e.g.
wound infiltration
mild-to-moderate pain is controlled with paracetamol or dextropropoxyphene
moderate-to-severe pain is countered with NSAID's, e.g. diclofenac, or slow-release
morphine
The following should be considered before discharging patients from day surgery:
Complications:
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 4
15 NUTRITIONAL STATUS OSCE ‐ Stasions
Wash hands
Introduce self
Permission - ask to examine patient
Expose down to underwear
Reposition lying flat
A) GENERAL INSPECTION:
Around the patient for:
Nutritional supplements.
'Nil by mouth' (NBM) signs.
Patient as a whole
Comfortable?
Is there food at the bedside? Are meals unfinished?
Do they have nutrition supplements on their table?
Do they have a naso-gastric (NG) tube in situ
Do they have 'Total Parenteral Nutrition' (TPN) running - usually a covered plastic bag on a
drip stand, running through a long line (PICC line/Hickman line/central line).
Do they have intravenous fluids running?
B) SPECIFIC INSPECTION:
1. Hands: Nails, for:
Clubbing (could be in keeping with Cystic Fibrosis, Crohns Disease, or causes of cachexia
such as malignancy or tuberculosis).
Koilonychia (iron deficiency).
Leukonychia (low albumin).
Xanthomata (hypercholesterolaemia).
2. Arms, for: Loose skin over upper arms suggestive of rapid weight loss?
3. Face, for:
Hair (Rough and wirey?)
Eyes, for:
- Corneal arcus (hypercholesterolaemia).
- Xanthelasma (hypercholesterolaemia).
- Xerophthalmia - reduced tear formation. May be due to vitamin A deficiency.
4. Mouth:
Angular stomatitis (vitamin deficiency).
Glossitis (vitamin/mineral deficiency).
Apthous ulcers (in keeping with Crohns Disease).
Gums (Gingivitis?)
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
15 NUTRITIONAL STATUS OSCE ‐ Stasions
D) If there is evidence of a specific nutritional deficiency then you could offer to further
investigate as appropriate:
1. Full blood count and haematinic blood tests (Iron, Vitamin B12, Folate).
2. Iron deficiency (depending on other factors): oesophagogastroduodenoscopy (OGD) and
colonoscopy.
3. Vitamin B12 deficiency: Shilling test.
4. Mixed deficiency: Coeliac serology.
5. Bone radiographs or DEXA scan for osteomalacia.
Enteral nutrition:
Conditions:
(1) At least 100 cm of small intestine.
(2) an intact ileocecal valve.
(3) adequate airway protection.
Contraindications:
(1) Gastroparesis.
(2) Intestinal obstruction.
(3) Paralytic ileus.
(4) high-output enteric fistula.
(5) short bowel syndrome.
(6) Severe gastrointestinal bleeding.
(7) No access to the gastrointestinal tract.
(8) Aggressive nutrition not wanted by the patient.
(9) Short-term need for enteral nutrition (<5 to 7 days), 10. Severe malabsorption.
(10) Hemodynamic instability.
Types:
Nasogastric tubes are preferred for short-term feedings (<4 weeks) and can be inserted in the
stomach, duodenum, or jejunum.
Long-term feedings (>4 to 6 weeks) require the placement of a more permanent
gastrointestinal access device: (1) a percutaneous enteral device, (2) a laparoscopically placed
tube (gastrostomy or jejunostomy), or (3) a surgically placed tube (gastrostomy or
jejunostomy).
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 2
15 NUTRITIONAL STATUS OSCE ‐ Stasions
Complications:
(1) metabolic (e.g., overhydration or underhydration).
(2) gastrointestinal (e.g., diarrhea, nausea, vomiting, delayed gastric emptying, constipation, or
abdominal distention).
(3) mechanical; (e.g., the wrong tube size or a cracked tube)
Note that the typical tube feeding regimen requires additional water to ensure adequate hydration.
Types of formulas:
(1) Slandered
(2) Elemental
(3) Concentrated
(4) High protein nitrogen formula
(5) Fiber containing formula
(6) Special formula
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 3
16 ORGAN DONATION & TRANSPLANT OSCE ‐ Stasions
1. GCS= 3 + Apnea + Exclude (Hs & Ts) reversible cause of cardiac arrest
2. Confirm death:
Lack of pupil reaction
Lack of corneal reflex
Caloric testing
Lack of gag reflex
Lack of cough reflex
Lack of respiratory effort when taking off a ventillator
Two other senior doctor confirm death (same manner) each alone, or both together.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1
16 ORGAN DONATION & TRANSPLANT OSCE ‐ Stasions
Indications for a liver transplant in patients with acute liver failure (sch/rush):
A) Acetaminophen toxicity
PH ˂ 7.30
Prothrombin time > 100 s (INR > 6.5)
Serum creatinine >300 mmol/l (> 3.4 mg/dl)
B) No acetaminophen toxicity
Prothrombin time> 100s (INR > 6.5)
age <10 or >40 y
Non A non B hepatitis
Duration of Jaundice before onset of encephalopathy >7 d
Serum creatinine >300 mm/L (>3.4 mg/dl).
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 2
17 OTHERS OSCE ‐ Stasions
Gastrointestinal causes:
1. Gastroenteritis
2. Constipation
3. Diverticulitis
4. Volvulus
5. Left inguinal/femoral hernia.
6. Appendicitis: rarely, this can present as LIF pain, particularly in patients with
redundant and loosely attached caecum.
7. Irritable bowel syndrome
8. Carcinoma of rectum or descending colon
9. Crohn's disease and ulcerative colitis (inflammatory bowel disease)
Gynaecological causes
1. Ectopic pregnancy in the left Fallopian tube.
2. Threatened or complete abortion:
3. Causes of LIF pain in later pregnancy: premature labour, placental abruption, uterine
rupture.
4. Pelvic inflammatory disease (PID)/salpingitis/pelvic abscess
5. Mittelschmerz: this is a sudden onset of mid-cycle pain.
6. Ovarian torsion:
7. Fibroid degeneration.
8. Pelvic tumour.
9. Endometriosis
Urological causes
1. Testicular torsion or epididymo-orchitis:
2. Ureteric colic.
3. UTI:
Other causes
1. Abdominal aortic aneurysm (AAA):
2. Situs inversus:
3. Herpes zoster:
4. Pelvic vein thrombosis.
5. Hip pathology.
POST‐GRADUATE GENERAL SURGERY OSCE (By Ali M J) 1