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End of 4th year OSCE surgery

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									End of4th year OSCE
     - Surgery -

               20 – 03- 2007
A 50 yr old male presented with a
5 days history of malaise, fever
with chills and rigors and this
tender lump over his left shin.

(i)     What is the likely diagnosis?
(ii)    What important investigation would
        you like to perform in this patient?
(iii)   List the management principles.
       Answer
(i)     An abscess
(ii)    Random/fasting blood sugar
(iii)   Mx
        - adequate analgesia & antipyretics
        - broad spectrum IV antibiotics
        - Adequate incision & adequate drainage under GA
        - break into all loculi
        - remove pyogenic membrane
        - send pus for culture + ABST
        - clean the cavity with N.saline/ Betadine
        - Leave open , partially insert a gauze wick
This 35 yr old lady presented
with painful swelling of her
leg for 2 days.
(i)   Name 2 likely diagnoses
(ii) Write 3 things you would
      ask in her history to
      differentiate between them.
(iii) Name one investigation
      which enables you to come
      to a definitive diagnosis?
(i) Cellulitis , DVT
(ii)      Any preceding injury
          history of DM
          prolonged immobilization
          Use of OCP
          Varicose veins

(iii) Duplex scan of LL
                Mx of Cellulitis
    R = Rest
    E = elevation of the limb
    M = mobilization
    A = Antibiotics, antipyretics, analgesia
    I = Immunization against tetanus
    N = Nutrition
An intercostal tube connected to an underwater
    seal drainage bottle given.

(i)     Write 2 indications of use.
(ii)    Name 2 complications of this.
(iii)   After inserting this to a patient, as the HO
        name 3 things you would assess in this patient.
(i)    indications----- 1. therapeutic
                        2. prophylactic

(ii)   Complications----- 1. during insertion
                          2. maintenance
                          3. during removal
(iii)   Pt Assessment in the ward round.

S = Subjective (ask from the pt about his complains)
O= objective (examine chest expansion, auscultation,
                   resp rate, whether tube is functioning)
A = Assessment (overall condition of the pt)
P= plan of management
   Cannulas

       14G- Orange
       16G- grey
       17G- white
       18G- Green
       20G- Pink
       22G- Blue
       24G- Yellow
       26G - Purple
   Needles
       14G- white - abscess drainage
       18G- Pink
       20G- Yellow
       21G- green
       22G- Black
       23G- blue - IM injections/FNAC
       24G –Red - SC injections
       25G- orange – VV sclerotherapy
       26G- Brown – Insulin SC/ Mantoux/ BCG (ID inj)
       27G- Ash
       29G- Dark orange
Neuro surgery
          What’s the lesion?
          Which condition
           produces this
           characteristic lesion?
          What’s the underlying
           cause for this condition?
          How do you manage this
   A hyper dense, biconcave shaped area in the
    right tempero-parietal region.
   Right sided, Acute Extra dural Haemorrhage
   Damage to the middle meningeal artery. Parietal
    bone fracture maybe the cause for this injury but
    not always.
   Resuscitation, HIO, craniotomy
   What is the lesion?
   What is the cause for this
   In which age group do
    these occur commonly
    and why?
   Crescent shape, small hyper dense area in left
    tempero- parietal region.
   Left sided Acute SDH
   In elderly because there subdural space is
    enlarged in them due to brain atrophy.
   What’s the lesion?
   What could be the
    underlying brain
   What are the causes?
   Hypodense crescentic area in left temporal area.
   Left sided Chronic SDH
   - Alcoholics
    - child abuse
    - elderly following recurrent falls
1. Eye opening    spontaneous   =4
                  to speech     =3
                  to pain       =2
                  none          =1

2. Best verbal response   oriented           =5
                          confused           =4
                          inappropriate      =3
                          incomprehensible   =2
                          None               =1

3. Best motor response     obeying      =6
                          localizing    =5
                          withdrawing   =4
                          flexing       =3
                          extending     =2
                          none          =1
   Criteria for admission after head injury

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

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

      If GCS ≤ 8 ,
      Req intubation & ventilation
                             Acoustic neuroma
                             Ototoxic drugs
                             Noise induced

Sensorineural hearing loss
Conductive hearing loss
Wax impaction
Otitis media
   What’s the abnormality
    that you see in this CXR?
   What are the causes?
   What could be the
    patient presentation?
   There’s air under the diaphragm
   Perforation of a hollow viscus
    - bowel perforation
    - perforated peptic ulcer
    - ruptured appendix
   Acute severe abdominal pain, guarding and
    board like rigidity
 Intestinal obstruction

Small Bowel     large Bowel
   Small bowel             Large bowel

Central position         Peripheral position
Many loops               Few loops
Complete rings           Incomplete rings
(valvulae conniventes)   (haustrations)
                   NG tubes
Measurement of the length & insertion
     - for enteral feeding
     - decompression of stomach contents in
     emergency surgery
     - as a catheter in BPH pts
     - suspected oesophageal atresia
   Colostomy                 loop & end
                              temporary & permanent
   Indications
         Diversion – to protect a distal bowel anastomosis
         Decompression – to relieve a distal obstruction
         In Rectal Ca following APR

   Complications
    early – necrosis          late - stenosis
         - obstruction             - parastomal hernia
         - retraction              - prolapse
   Haemorrhoids
       Inject 5 % phenol in olive/almond oil using a
        Gabrielle syringe

   Varicose veins
       1 % - STD ( sodium tetra decyl sulphate) inject IV
Arterial ulcers          Venous ulcers
Hx of smoking, DM ,
                         Hx of DVT, VV,
lipids ,HT
Painful                 Majority Painless

Pressure areas          Maleolar area

Regular , punched out   Irregular, sloping edge
edge                     Skin changes of venous
Fx’s of ischemic limb   disease – venous eczema
                 Urinary Catheters

    -- FG , Foley’s self retaining urinary catheter.
   2 way (normal) & 3way catheter.
   Paul’s tube (condom catheter)
   Rubber Vs Silicone catheters
   Males- 16 FG ; Females – 14 FG
   2 way catheters,
       To measure the urine output
       investigations – MCUG
       to relieve an acute retention of urine
       Hydrostatic reduction of an intussuception in children
   3 way,
       For continuous irrigation of bladder following prostatectomy
   Paul’s tube (condom catheter)
       In male pts with urinary incontinence
X ray – KUB   IVU
Double J stent
          Identify the instrument
          Uses;
              To relieve obstruction of
               the urinary tract
              Prophylactically during
              To identify ureter in
               certain surgeries
                  eg:- Endometrial Ca
          How long to be kept?
              < 3 months
                    Internal fixators
 Intra-articular fractures - to stabilise anatomical reduction
 Repair of blood vessels and nerves - to protect vascular and
   nerve repair
 Multiple injuries
 Elderly patients - to allow early mobilisation
 Long bone fractures - tibia, femur and humerus
 Failure of conservative management
 Pathological fractures
 Fractures that require open reduction
 Unstable fractures

 Infection
 Non-union
 Implant failure
                 External fixators
 Acute trauma - open and unstable fractures
 Non union of fractures
 Correction of joint contracture
 Filling of segmental limb defects - trauma, tumour and
 Limb lengthening

 Overdistraction
 Pin-tract infection
   Important fractures
       Colle’s – below elbow POP cast upto the metacarpal heads,
        sparing the thumb
       Scaphoid – “ glass holding” position

   Know about;
       Xray identification of Colle’s ,supracondylar, NOF
   A patient with a POP cast to his Right
    forearm in the A&E unit.

     During   the ward round how to assess the
      Look for 6p’s of acute limb ischemia
            - Pain
            - pallor
            - perishing cold
            - paraesthesia
            - paralysis
            - pulseless
The patient has pain on passive movements of the
fingers. What is your main worry?

   Compartment syndrome

What is the immediate management

   Full thickness , full length splitting of the POP
   elevation of the limb
   immediate Fasciotomy.

CS –can also occur in circumferential full thickness
   - requires Escharotomy
   A 42 yr old school teacher presents with a 3
    months history of tingling and numbness of
    her Right hand which is worst at night.

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

     What is the most important investigation you
      would like to perform to confirm your diagnosis?
     What are the management options?
   Carpal tunnel syndrome
    DM , hypothyroidism , obesity , Acromegaly,
   Nerve conduction studies
   Weight reduction
    correct the underlying causes (DM, hypothyroid)
    Decompression surgery if failing above
                    Post op fever
   1st 24 hrs of Sx
     - Metobolic response to trauma
     - Reactions to blood transfusions & anesthetic drugs
   D2
      - Lung atelectasis
   D3-D5
     - Local sepsis – cannula site , catheter, wound
   D5-D7
     - DVT , leaking bowel anastomosis
   >1 week
     - Distant sepsis – hepatic,cerebral, deep seated
                       ET tubes
   Cuffed & uncuffed
   Uncuffed – in children

       Size (internal diameter mm) =   Age   +4
   Male – (8-9.5) ; female – (7-8)
   In place for <7 days – risk of tracheal stenosis
   Prevented by doing a tracheostomy
              Uses of ET tubes

   Maintain airway
   For ventilation (IPPV)
   Prevent aspiration (cuffed)
   Give drugs – adrenaline
                - atropine
                - naloxone
        Guedel(oral) airway

How to select the appropriate size?

 Male – 4 cm
 Female – 3 cm
Tracheostomy tubes
Cuffed plastic tube for tracheostomy
i. To relieve obstruction of upper airway
ii. Prolonged mechanical ventilation
iii. To remove retained secretions in LRT
- Pneumothorax
- Haemorrage
- Surgical emphesema
- tube displacement

   Changes in 2005 ALS guidelines

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

        All   3 DC shocks – 360J each
             Fitness for surgery
   From the Hx
       any co-morbidities (DM,BA,IHD) & their control
       degree of dyspnoea if present (NYHA)
       Drug history
       past hx of GA and recovery
       smoking , alcohol
       symptoms of anaemia
                 Suture material
     Absorbable               Non- absorbable
Synthetic        Natural   Synthetic    natural

Polyglycolic    Catgut     Polypropylen Silk
acid                       e (prolene)
Polyglactin 910            Polyamide
(Vicryl)                   (nylon)
Polyglecaprone             Polyester
25 (monocryl)
Thank you

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