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Surgery revision

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Surgery revision

  1. 1. OSCERevision ClassDr. Syed Asad AliFCPSDEPT:OF SURGERY
  2. 2. Q#1.What does OSCE stands for?• A)Objective Structured Clinical Examination• B)Over Stimulation and Crying Event• C)Opportunity for Showing your Competenceand Excellence• D)All• E)None
  3. 3. What is OSCE?The candidates rotate through a series ofstations at which they are asked to carry out avarious task(usually clinical)
  4. 4. OSCE includes several "stations"examinees are expected to performspecificclinical tasks within a specified timeperiod .students rotate through a series ofstations (as few as 2 or as many as 20).
  5. 5. TYPES OF OSCE STATIONS
  6. 6. Osce Stations• 1.INTERACTIVE• 2.STATIC• 3. INTERSTATION or TAG STATION
  7. 7. 1.Monitored station, where An EXAMINERscores the students performance,Encounters:patient history,performing a physical examinationdiagnostic procedure,teaching/counseling/advising a patient.A standardized checklist is used for markingof each station.INTERACTIVE STATIONS)
  8. 8. here the student answersquestions about the encounterWhat is your differentialdiagnosis?What investigations will youorder?What treatment will you advise?2. Interstation or tag station
  9. 9. a student is asked to answerquestions, about 1.Instruments2.interpret findings such aslab reportsx-rays,3.Clinical photographs(spotdiagnosis)4.Clinical Scenarios3.STATIC STATIONSare not observed
  10. 10. Osce StationsNO:16•1.INTERACTIVE -4.(1-INTERSTATION or TAG)•2.STATIC-12
  11. 11. REST STATIONS
  12. 12. COMMON QUESTIONS ASKED IN OSCE• INTERACTIVE STATIONS
  13. 13. INTRACTIVE-1• Simulated Patient (Hx taking)
  14. 14. HISTORY TAKING STATIONS• 1.Abdominal PAIN/MASS• -EPIGASTRIC• -HYPOCHONDRIAC REGION• -PERI-UMBILICAL /R I FOSSA•
  15. 15. HISTORY TAKING STATIONS• 2.DYSPHAGIA• 3.PAIN in the LOIN/FLANK• 4.HEMATURIA• 5.PAINFUL DEFECATION• 6.BLEEDING P/R• 7.HEMETEMESIS/MAELENA• 8.INGUINO-SCROTAL SWELLING• 9.BREAST LUMP• 10.GOITRE• 11.JAUNDICE(Surgical)
  16. 16. Station ProfileA) Instruction to students: .Mr.Mohammed is a 22-year-old, presentedwith sudden pain in periumblical regionassociated with nausea,vomiting and pyrexiafor the last one day.
  17. 17. Station Profile (cont)A) Instruction to students:(cont)• You have 4 minutes to assess this patient,by taking the proper and relevant history• An observer, using a checklist, will assessyour performance while you interact withthe patient• No questions will be asked by the examiner
  18. 18. Checklist• Student greeted the patient• Introduced her/himself• Asked the patient’s name• Site of pain/• Onset• Duration of pain• Nature of pain
  19. 19. ChecklistRadiation/ReferralAggravating/Alleviating factorsAssociated featuresChange in appetiteFever –typeBowel functions
  20. 20. INTERACTIVE-2(Tag Station)Here the student answers questionsabout the encounter on Interactive-1.1.What is your differential diagnosis?2.What investigations will you order?3.What treatment will you advise?
  21. 21. INTERACTIVE-3&4CLINICAL EXAMINATION
  22. 22. CLINICAL EXAMINATION• 1.Exam of a SWELLING• 2.Exam of ABDOMEN• 3.Exam of THYROID• 4.Exam of PAROTID• 5.Exam of an ULCER• 6.Exam of a BREAST LUMP• 7.Exam of VARICOSE VEINS• 8.Exam of INGUINAL HERNIA• 9.Exam of SCROTUM
  23. 23. Station ProfileA) Instruction to students: .Mr.Mohammed is a 22-year-old, presentedwith this Lump(Swelling) inNECK,BACK,SCALP,FACE etc
  24. 24. Station Profile (cont)A) Instruction to students:(cont)• You have 4 minutes to examine thispatient,• An observer, using a checklist, will assessyour performance while you examine thepatient
  25. 25. Check list; Examination of a LumpIntroduce self & consent• Position• Colour and texture ofoverlying skin• Temperature• Tenderness• Shape• Size• Surface• Edge• Hardness• Fluctuance• Fluid thrill• Translucency• Resonance• Pulsatility• Compressibility• Reducibility• Mobility
  26. 26. A FEW QUESTIONS• What are your findings• What is your dignosis?• D/D• Investigation• Treatment
  27. 27. BREAST EXAMINATION• Introduction and Consent• Inspection– With the patient sitting– With the patient leaning forward– Arms above head– Push hands into hips
  28. 28. BREAST EXAMINATION• Palpation– Start with the normal breast– Arm behind head– All 4 quadrants– Axillary tail• Examine lymph nodes– Axillary– Cervical
  29. 29. A few questions...• What is meant by triple assessment?– Clinical examination– Imaging – mammography and ultrasound– Cytology• What is the difference between cytology andhistology?• What are the risk factors for breast cancer?What is MRM? What are the risk factors forbreast cancer?
  30. 30. OSCE SPOTTERSTATION
  31. 31. Spotters• PAROTID LUMP• Jaundiced patient• Stomas• Cervicallymphadenopathy• Lipoma• Sebaceous cyst• TG cyst• Hemorrhoid/fistula/fissure/perianal abscess• Varicose veins• Multinodular goitre• Diabetic foot• Ulcer-bedsore• Basal cell cancer –face• Gangrene foot/toes• Tongue ulcer/Ranula• Abdominal trauma-liver/spleen/intestine• Appendix/Meckel`sdiverticulum• Ing:Hernia/Hydrocele
  32. 32. LOOK at this picture and answer thefollowing question:• 1.what is your diagnosis?• 2.justify• 3.what is the underlying pathology?• 4.Name 2or 3 investigations• 4.list 3 complications.• 5.mention treatment options.
  33. 33. Ostomy•Show a normal stoma Not painfulAlways red and moistRose Red Bud
  34. 34. Loop Colostomy
  35. 35. Stomas Continued• Complications– Early• Haemorrhage• Stoma Ischaemia• High Output• Obstruction (adhesions)• Stoma retraction– Delayed• Dermatitis,• Stoma Prolapsed• Parastomal hernia• Fistulae• ObstructionTypes of stoma– Temporary– Permanent– End– loop– Counselling– How to manage stomas– Stoma site avoided:• Bony areas, umbilicus,scars, waistline skin fold &creases
  36. 36. Look at this operative photographLook at this operative photograph-1- Dist = 1.30cm-2- Dist = 0.91cmLook at this operative photograph
  37. 37. QUESTIONS• Identify this organ• What is your diagnosis• List 3-4 clinical features• What complications occur if treatment isdelayed
  38. 38. Ranula9• Is a term used formucoceles that occurin the floor of themouth.• The name is derivedform the word rana,because the swellingmay resemble thetranslucent underbellyof the frog.
  39. 39. LOOK at this picture and answer thefollowing question:• 1.what is your diagnosis• 2.what is the underlying pathology?• 3.list 3 complications.• 4.mention treatment options.
  40. 40. Table 1 Classification of patients with renal cell carcinoma according to tumorthrombus levelKarnes RJ and Blute ML (2008) Surgery Insight: management of renal cell carcinoma with associated inferior vena cavathrombusNat Clin Pract Urol doi:10.1038/ncpuro1122
  41. 41. Scar
  42. 42. Figure 2Parotid lump –pleomorphicadenoma
  43. 43. Presentation• Swelling• Dragging pain• Features of complication• H/o increased abdominal• pressure
  44. 44. 48
  45. 45. 50
  46. 46. Primarysquamous cellcarcinoma of tonguetongue
  47. 47. CASE SCENARIOS
  48. 48. QUESTIONS• 1.What is this lesion.• 2.Name the commonest causes of thislesion in lower leg.• 3.What are the different parts of thislesion?• 4.How will you treat this lesion?
  49. 49. CASE 1.A 28-year-old man presents to the emergencydepartment complaining of anal and lower-back painfor the previous 36 h..The pain is progressively getting worse and he isuncomfortable to walk or sit down.ExaminationInspection of the anus reveals a 3cm 3 cm swelling atthe anal margin. The swelling is warm, exquisitelytender
  50. 50. Questions• What is the diagnosis?• What are the aetiological factorsassociated with this condition?• How are these lesions anatomicallyclassified?• What treatment is required
  51. 51. AETIOLOGY.in 90% of cases the abscesscommences as an infection of ananal gland.
  52. 52. classification of the perianalabscess:• Perianal• Ischiorectal• High intersphincteric• Submucous• Pelvirectal.
  53. 53. Treatment1. Incision and drainage may be done under localanesthesia. packing to keep skin edges open.2. Antibiotics .
  54. 54. Case Scenario I• 32 years old male, complaining of painlessbleeding per rectum and a palpable lumpwhile abluting. Pt sometimes has mucusdischarge and pruritis.
  55. 55. Scenario I• What is your provisional Diagnosis?• What are the investigations you need andwhy?• Mention 4 complication in such pt?
  56. 56. CASE SCENARIOA 60 years old man, presented to thesurgical OPD, complaining of left sidedloin pain, associated with occasionalhematuria.on examination his left kidney is palpableand U/S shows is mass in the upper poleleft kidney,
  57. 57. Q.#.1.What is your differential diagnosis?Q.#.2.What investigation is now required?Q.#.3.Name often relevant investigations forplanning management.Q.#.4.Mention treatment options.Questions:Keys:
  58. 58. Q.#.1. Renal CancerRenal calculusHydonephrosis/PyonephrosisQ.#.2. 1. CT Scan (Contrast)2. MRIQ.#.3. 1. Blood CP2. Lft3. X-Ray Chest4. CT Scan Cheat5. Renal Angiography6. I/V cavogram7. PET Scan8. Bone ScanQ.#.4. 1. Minimal Invasive procedure• NSS• RFA• Themal ablaTION1. Surgery• Radical Nephrectomy1. CHTH2. RT3. Throsine Knain Inlututor (TKI)4. Inter feron/Interleukin
  59. 59. 50 years male with mass epigastrium movingwith respiration, associated with vomiting, wtloss for two months .O/E : Left supraclavicular node palpableA Ba-meal –Ray is ordered which is shownbelowCASE
  60. 60. QuestionsQ.#.2.What is your likely diagnosis?Q.#.3.Which investigations is needed to cofirmdiagnosis?Q.#.4.Q#5.Name any 3investigationto stage the disease.List treatment optionsQ#1. Mention the finding on X-ray
  61. 61. ANSWERSQ.#.2. Cancer of StomachQ.#.3. Endoscopy/ BiopsyQ.#.4Q#5.1.CT SCAN 2.EUS 3.PET SCAN 4.StaggingLaparoscopy1.Surgery-Gastrectomy(subtotal/total)Palliative gastrojejunostomyLymphadenectomy.2.Radiotherapy3.aAdjuvant ChemotherapyQ#1. Apple core appearance-body of stomach
  62. 62. SCENARIOA 62 year-old woman with chief complainof neck mass.Physical exam reveals a thyroid nodule,2*2*2 cm.Clinically she is Euthyroid.
  63. 63. Questions:Q.#.1. What is your diagnosis.Q.#.2. Name any 3 causes of this lesion.Q.#.3.Q#4.Mention any 3 signs which suggest malignancy.List any 3 investigation which will help indiagnosis of this lesion.Keys:
  64. 64. Keys:Q.#.1. Solitary Thyroid noduleQ.#.2. 1.Thyroid cyst2.Thyroid Adenoma3.Thyroid cancerQ.#.3. 1,Firm to hard nodule2,Fixed nodule3.Rapid increase in size4. local invasion-Vocal cord paralysis-Dysphagia5.Cervica Lymphadenopathy1.T3,TSH 2. Thyroid scan3. FNA4. Thyroid uptake of I-1315. Ultrasound
  65. 65. INTERPRETING ABDOMINALRADIOGRAPHS
  66. 66. Some common X-rays• 1.PNEMOPERITONEUM• 2.INTESTINAL OBSTRUCTION• 3.APPEDICOLITH• 4.GALL STONESAXRs
  67. 67. Note theabsence ofbowel gas in theright upperquadrant due tothe presence ofthe liverS. Rizvi, 07.08.191027thAugust 2007; 15.14pm
  68. 68. Biliary treeMultiplegallstonesOnly 10% ofgallstones arevisible on plainfilm
  69. 69. PLAIN ABDO X RAY
  70. 70. “ERECTNote themultiplefluid levels
  71. 71. X-RAY Small Bowel Obstructionis suggested by a“ladder” pattern, whenobstruction occurs, bothfluid and gas collect inthe intestine. They produce acharacteristic patterncalled air-fluid levels.The air rises above thefluid and there is a flatsurface at the air-fluidinterface.
  72. 72. COLONOBSTRUCTIONDistension extends todistil descending colon.
  73. 73. SBO Vs LBOLarge bowel Small bowelPeripherally placed dilatedbowelCentrally placed loops dilatedbowelHaustra (do not cross wholediameter of colon; no morethan 1/3 of the way across)Valvulae conniventes extendacross whole bowel lumenFew loops Many loops
  74. 74. :Extra-luminal gas seen erect CXR.
  75. 75. KUB X-RAYs• 1.RENAL CALCULUS• 2.URETERIC CALCULUS• 3.VESICAL CALCULUS
  76. 76. KUB(KIDNEY- URETERS- BLADDER)THE KUB IS USED AS A SCOUT FILM FOR MANY ABDOMINAL IMAGING STUDIESRR
  77. 77. Kidneys
  78. 78. Bladder CalculusA large calculus shown in theA large calculus shown in thebladder.bladder.
  79. 79. CONTRAST X-RAYs of GIT• 1.BARIUM SWALLOW X-RAY• 2.BARIUM MEAL X-RAY• 3.BARIUM ENEMA X-RAY• 4.CHOLANGIOGRAM
  80. 80. ACHALASIA CARDIA
  81. 81. A- For diagnosis:(1) Barium swallow:(1) Barium swallow:a.a. Fungating and ulcerative massFungating and ulcerative mass: narrowed irregularfilling defect.b.b. Annular massAnnular mass:- If middle stricture: Apple core appearanceApple core appearance withevident shouldering- If lower stricture: Rat tail appearanceRat tail appearance.Apple core appearanceCancer lower 1/3Cancer lower 1/3Filling defect (ulcerativeFilling defect (ulcerativetype)type)Rate tail appearance
  82. 82. Radiographic appearances : Gastric cancerFocal constrictinglesion: localized infiltratingcarcinoma or localizedscirrhous carcinoma- circumferentialirregular narrowing ofthe lumen withrigidity (as figure;involved body andantrum)bodyantrumbulbfundus
  83. 83. Gastric cancer– No ability todistinguishbetweenmalignant andbenign ulcers.
  84. 84. HEPATICFLEXURESPLENICFLEXURETRANSVERSE COLONCECUMASCENDINGCOLONDESENDINGCOLONTERMINAL ILEUMNORMALCOLONNormal air contrastbarium enema showsfilling of colon with airand barium retrogradeto the cecum with refluxinto the terminal illeum
  85. 85. COLON CANCERBarium enema showingapple-core typeconstricting lesion withproximal dilation of colon—”APPLE -CORE”constricting lesion
  86. 86. Colonic Carcinoma• Annular Carcinoma(green arrow) with shelf-like margin (black arrow)
  87. 87. Ulcerative colitis
  88. 88. T-TUBE CHOLANGIOGRAPHY
  89. 89. T-TUBECholangiography : Stricture of common bileduct
  90. 90. MRCP
  91. 91. CHEST X-RAYs
  92. 92. Pleural Effusion
  93. 93. hemothorax
  94. 94. Simple Pneumothorax
  95. 95. Pneumothorax
  96. 96. XRAY CHEST
  97. 97. IVUs
  98. 98. IVP (URETERIC CALCULUS)Ureteric stoneUreteric stonecausing rightcausing righthydronephrosis.hydronephrosis.
  99. 99. OSCE-SURGICAL INSTRUMENTS
  100. 100. The standard questions tobe asked:•What is this instrument?•Name the parts.•What are its uses?•What complications canarise
  101. 101. Ryle`stube:•For gastricaspiration.•Afterlaparotomy• Intestinalobstruction• AfteranastomosisCatheterDistal (inner) endProximal (outer) end
  102. 102. 1. What is the use of this? For nasogastric feeding. To aspiration gastric secretions or contents beforeemergency surgeries & in bowel obstruction. Gastric empty because emergency surgery( Roadtraffic accident2. What are it`s different parts?
  103. 103. 1. What is the use of this object? Drainage of urine from bladder. Fluid management of patient. Measure urine output.2. What is the use of 2 channels? 1,Passage of distil water through x & inflate theballoon located at the end of the tube in order tokeep the catheter inside the bladder. So we call it“self retaining catheter.”2. For drainage of urine
  104. 104.  Used for irrigation of the bladder byusing normal saline after surgery Also used as gastrostomy tube
  105. 105. 3. What are the indications? Gastrostomy Pt, loss of Autonomic NS functions, incardiac failure.4. Disadvantages: - Connect the external and internal environment.Therefore infection can be spread to exterior to interior.
  106. 106.  What are the uses of this tube? To maintain Pt. air way in injured or unconscious Pts. To ventilate unconscious Pts. To give anesthetic drugs.e.g.:-halothane To ventilate pts. In intra oral surgeries. To prevention by use of cuff. What is the use of “a”? Inflation of “a” with air helps to keep the tube inposition & prevent aspiration. How does this tube an adult differ from that of ayoung child? In children’s endotracheal tube is a 3.5 mm area whichis radio opaque that help to detect the position of thetube in x-rays.
  107. 107. What are the uses of it? To depress the tongue preventing thetongue falls back To maintain a pts airway To keep air way pt until recoveringfrom anesthesia
  108. 108. 1. What are the indications? Acute airway obstruction.e.g.:-forging body. To ventilate Pts following surgeries including oral cavity. To protect the lower airwaye.g.:-aspiration of saliva in unconscious Pts. For Pt requiring artificial respiration – respiratoryinsufficiency. Who has dead space depression
  109. 109. 2. What are the advantages? Anatomical dead space is reduced. Work of breathing is reduced. Alveolar ventilation is increases. Level of sedation needed for Pts comfort, isreduced. No damage to the vocal cords
  110. 110. 3. What are the disadvantages? Loss of heat & moisture exchange performed in upperairway. Desiccation of tracheal epithelium. Loss of ciliated cells & metaplasia. Over production of mucous
  111. 111. 4. How do you manage tracheostomy postoperatively? Suction. Humidification. Change of the inner tube & remove mucousplugging. Physiotherapy.
  112. 112. VerticallimbHorizontal limbT- tube*Indications.*Time ofremoval.Therapeutic usesInsidecommonbile duct
  113. 113. Deaver Retractor• Common retractor used in major abdominalprocedures. Comes in several different widths. Mayalso be used during vaginal procedures.
  114. 114. Crile hemostatic forceps (curved andstraight)
  115. 115. Bard-Parker #3 scalpel handle
  116. 116. Needle holder:*Grasp the needlefor stitchingBladeShaftHandle
  117. 117. Kocher (Oschner)hemostatic forceps
  118. 118. Metzenbaum scissors
  119. 119. Allis tissue forceps
  120. 120. Babcock tissue (intestinal) holdingforceps
  121. 121. Straight or curvedDoyen Intestinal Forceps
  122. 122. Stoneforceps( Ureteric,biliary andBladder):•Used forStone extractionfrom the ureter,common bile ductand urinarybladder.Ureteric & Billiary BladderScope onbladeShaftHandle
  123. 123. Moynihan( Cholecystectomyforcep):•Used inGrasping the cystic vessels &cystic duct before their ligationduring cholecystectomyoperation.BladeShaftHandle
  124. 124. 156Above all
  125. 125. Any Questions ???
  126. 126. THANK YOU

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