The document discusses various surgical cases and medical conditions, focusing on diagnosis, investigations, and management principles for different scenarios. It includes case studies involving abscesses, cellulitis, intercostal tube usage, and specific medical procedures like NG tubes and urinary catheters. Additionally, it highlights clinical assessments and treatment options for injuries and conditions such as carpal tunnel syndrome.

1. End of 4
End of 4th
th
year OSCE
year OSCE
- Surgery -
- Surgery -
20 – 03- 2007

2. A 50 yr old male presented with a
A 50 yr old male presented with a
5 days history of malaise, fever
5 days history of malaise, fever
with chills and rigors and this
with chills and rigors and this
tender lump over his left shin.
tender lump over his left shin.
(i)
(i) What is the likely diagnosis?
What is the likely diagnosis?
(ii)
(ii) What important investigation would
What important investigation would
you like to perform in this patient?
you like to perform in this patient?
(iii)
(iii) List the management principles.
List the management principles.

3.  Answer
Answer
(i)
(i) An abscess
An abscess
(ii)
(ii) Random/fasting blood sugar
Random/fasting blood sugar
(iii)
(iii) Mx
Mx
- adequate analgesia & antipyretics
- adequate analgesia & antipyretics
- broad spectrum IV antibiotics
- broad spectrum IV antibiotics
- Adequate incision & adequate drainage under
- Adequate incision & adequate drainage under GA
GA
- break into all loculi
- break into all loculi
- remove pyogenic membrane
- remove pyogenic membrane
- send pus for culture + ABST
- send pus for culture + ABST
- clean the cavity with
- clean the cavity with N.saline/ Povidone Iodine
N.saline/ Povidone Iodine (Betadine)
(Betadine)
- Leave open , partially insert a gauze wick
- Leave open , partially insert a gauze wick

4. This 35 yr old lady presented
This 35 yr old lady presented
with painful swelling of her
with painful swelling of her
leg for 2 days.
leg for 2 days.
(i)
(i) Name 2 likely diagnoses
Name 2 likely diagnoses
(ii)
(ii) Write 3 things you would
Write 3 things you would
ask in her history to
ask in her history to
differentiate between them.
differentiate between them.
(iii)
(iii) Name one investigation
Name one investigation
which enables you to come
which enables you to come
to a definitive diagnosis?
to a definitive diagnosis?

5. (i) Cellulitis , DVT
(i) Cellulitis , DVT
(ii)
(ii) Any preceding injury
Any preceding injury
history of DM
history of DM
prolonged immobilization
prolonged immobilization
Use of OCP
Use of OCP
Varicose veins
Varicose veins
(iii)
(iii) Duplex scan of LL
Duplex scan of LL

6. Mx of Cellulitis
Mx of Cellulitis
 REMAIN
REMAIN
R = Rest
R = Rest
E = elevation of the limb
E = elevation of the limb
M = mobilization
M = mobilization
A = Antibiotics, antipyretics, analgesia
A = Antibiotics, antipyretics, analgesia
I = Immunization against tetanus
I = Immunization against tetanus
N = Nutrition
N = Nutrition

7. Tubes
Tubes
An intercostal tube connected to an underwater
An intercostal tube connected to an underwater
seal drainage bottle given.
seal drainage bottle given.
(i)
(i) Write 2 indications of use.
Write 2 indications of use.
(ii)
(ii) Name 2 complications of this.
Name 2 complications of this.
(iii)
(iii) After inserting this to a patient, as the HO
After inserting this to a patient, as the HO
name 3 things you would assess in this patient.
name 3 things you would assess in this patient.

8. (i)
(i) Indications--- 1. therapeutic –
Indications--- 1. therapeutic – pneumo/haemothorax
pneumo/haemothorax
2. prophylactic –
2. prophylactic – post op in cardio-thoracic Sx
post op in cardio-thoracic Sx
(ii)
(ii) Complications--- 1. during insertion
Complications--- 1. during insertion
2. maintenance
2. maintenance
3. during removal
3. during removal

9. (iii)
(iii) Pt Assessment in the ward round.
Pt Assessment in the ward round.
S = Subjective
S = Subjective (ask from the pt about his complains)
(ask from the pt about his complains)
O= objective
O= objective (examine chest expansion, auscultation,
(examine chest expansion, auscultation,
resp rate, whether tube is functioning)
resp rate, whether tube is functioning)
A = Assessment
A = Assessment (overall condition of the pt)
(overall condition of the pt)
P= plan of management
P= plan of management

10.  Cannulas
Cannulas
 14G- Orange –
14G- Orange – in emergencies
in emergencies
 16G- grey
16G- grey
 17G- white
17G- white
 18G- Green
18G- Green
 20G- Pink
20G- Pink
 22G- Blue
22G- Blue
 24G- Yellow
24G- Yellow
 26G – Purple -
26G – Purple - paediatric
paediatric
Blood transfusion
Crystalloid infusion

11.  Needles
Needles
 14G- white -
14G- white - abscess drainage
abscess drainage
 18G- Pink
18G- Pink
 20G- Yellow
20G- Yellow
 21G- green –
21G- green – Blood culture
Blood culture
 22G- Black
22G- Black
 23G- blue -
23G- blue - IM injections/FNAC
IM injections/FNAC
 24G –Red -
24G –Red - SC injections
SC injections
 25G- orange –
25G- orange – VV sclerotherapy
VV sclerotherapy
 26G- Brown –
26G- Brown – Insulin SC/ Mantoux/ BCG (ID inj)
Insulin SC/ Mantoux/ BCG (ID inj)
 27G- Ash
27G- Ash
 29G- Dark orange
29G- Dark orange

12. Neuro surgery
Neuro surgery
 What’s the lesion?
What’s the lesion?
 Which condition
Which condition
produces this
produces this
characteristic lesion?
characteristic lesion?
 What’s the underlying
What’s the underlying
cause for this condition?
cause for this condition?
 How do you manage this
How do you manage this
patient?
patient?

13.  A hyper dense, biconvex shaped area in the right
A hyper dense, biconvex shaped area in the right
tempero-parietal region.
tempero-parietal region.
 Right sided
Right sided, Acute
, Acute Extra dural Haemorrhage
Extra dural Haemorrhage
 Damage to the middle meningeal artery. Parietal
Damage to the middle meningeal artery. Parietal
bone fracture maybe the cause for this injury but
bone fracture maybe the cause for this injury but
not always.
not always.
 Resuscitation, HIO, craniotomy
Resuscitation, HIO, craniotomy

14.  What is the lesion?
What is the lesion?
 What is the cause for this
What is the cause for this
lesion?
lesion?
 In which age group do
In which age group do
these occur commonly
these occur commonly
and why?
and why?

15.  Crescent shape, small hyper dense area in left
Crescent shape, small hyper dense area in left
tempero- parietal region.
tempero- parietal region.
 Left sided
Left sided Acute
Acute SDH
SDH
 In elderly because there subdural space is
In elderly because there subdural space is
enlarged in them due to brain atrophy.
enlarged in them due to brain atrophy.

16.  What’s the lesion?
What’s the lesion?
 What could be the
What could be the
underlying brain
underlying brain
condition?
condition?
 What are the causes?
What are the causes?

17.  Hypodense crescentic area in left temporal area.
Hypodense crescentic area in left temporal area.
 Left sided
Left sided Chronic
Chronic SDH
SDH
 - Alcoholics
- Alcoholics
- child abuse
- child abuse
- elderly following recurrent falls
- elderly following recurrent falls

18. GCS
GCS
1.
1. Eye opening
Eye opening spontaneous
spontaneous =4
=4
to speech
to speech = 3
= 3
to pain
to pain =2
=2
none
none =1
=1
2.
2. Best verbal response
Best verbal response oriented
oriented = 5
= 5
confused
confused = 4
= 4
inappropriate
inappropriate = 3
= 3
incomprehensible
incomprehensible = 2
= 2
None
None = 1
= 1
3.
3. Best motor response
Best motor response obeying
obeying = 6
= 6
localizing
localizing =5
=5
withdrawing
withdrawing =4
=4
flexing
flexing =3
=3
extending
extending =2
=2
none
none =1
=1

19. 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

20. 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

21. Audiograms
Audiograms
Sensorineural hearing loss
Causes
Acoustic neuroma
Meningitis
Ototoxic drugs
Noise induced

22. Conductive hearing loss
Wax impaction
Otitis media
Otosclerosis

23.  What’s the abnormality
What’s the abnormality
that you see in this CXR?
that you see in this CXR?
 What are the causes?
What are the causes?
 What could be the
What could be the
patient presentation?
patient presentation?

24.  There’s air under the diaphragm
There’s air under the diaphragm
 Perforation of a hollow viscus
Perforation of a hollow viscus
- bowel perforation
- bowel perforation
- perforated peptic ulcer
- perforated peptic ulcer
- ruptured appendix
- ruptured appendix
 Acute severe abdominal pain, guarding and
Acute severe abdominal pain, guarding and
board like rigidity
board like rigidity

25. Intestinal obstruction
Intestinal obstruction
Small Bowel large Bowel

26.  Small bowel
Central position
Many loops
Complete rings
(valvulae conniventes)
 Large bowel
Peripheral position
Few loops
Incomplete rings
(haustrations)

27. NG tubes
NG tubes
Measurement of the length & insertion
Measurement of the length & insertion
Uses
Uses
T
Therapeutic-
herapeutic-
- for NG feeding
- for NG feeding
- decompression of stomach contents in
- decompression of stomach contents in
emergency surgery
emergency surgery
- in gastric lavarge
- in gastric lavarge
- as a catheter in BPH pts
- as a catheter in BPH pts
Diagnostic
Diagnostic
- suspected oesophageal atresia
- suspected oesophageal atresia

28. Colostomies
Colostomies

29.  Colostomy
Colostomy loop & end
loop & end
temporary & permanent
temporary & permanent
 Indications
Indications
 Diversion – to protect a distal bowel anastomosis
Diversion – to protect a distal bowel anastomosis
 Decompression – to relieve a distal obstruction
Decompression – to relieve a distal obstruction
 In Rectal Ca following APR
In Rectal Ca following APR
 Complications
Complications
early
early – necrosis
– necrosis late
late - stenosis
- stenosis
- obstruction
- obstruction - parastomal hernia
- parastomal hernia
- retraction
- retraction - prolapse
- prolapse

30. Sclerosants
Sclerosants
 Haemorrhoids
Haemorrhoids
 Inject 5 % phenol in olive/almond oil using a
Inject 5 % phenol in olive/almond oil using a
Gabrielle syringe
Gabrielle syringe
 Varicose veins
Varicose veins
 1 % - STD ( sodium tetra decyl sulphate) inject IV
1 % - STD ( sodium tetra decyl sulphate) inject IV

31. Vascular
Vascular
Arterial ulcers
Hx of smoking, DM ,
lipids ,HT
Painful
Pressure areas
Regular , punched out
edge
Fx’s of ischemic limb
Venous ulcers
Hx of DVT, VV,
Majority Painless
Maleolar area
Irregular, sloping edge
Skin changes of venous
disease – venous eczema

32. Urinary Catheters
Urinary Catheters
 -- FG , Foley’s self retaining urinary catheter.
-- FG , Foley’s self retaining urinary catheter.
 2 way (normal) & 3way catheter.
2 way (normal) & 3way catheter.
 Paul’s tube (condom catheter)
Paul’s tube (condom catheter)
 Rubber Vs Silicone catheters
Rubber Vs Silicone catheters
 Males- 16 FG ; Females – 14 FG
Males- 16 FG ; Females – 14 FG

33. Uses
Uses
 2 way catheters,
2 way catheters,
 To measure the urine output
To measure the urine output
 investigations – MCUG
investigations – MCUG
 to relieve an acute retention of urine
to relieve an acute retention of urine
 Hydrostatic reduction of an intussuception in children
Hydrostatic reduction of an intussuception in children
 3 way,
3 way,
 For continuous irrigation of bladder following prostatectomy
For continuous irrigation of bladder following prostatectomy
 Paul’s tube (condom catheter)
Paul’s tube (condom catheter)
 In male pts with urinary incontinence
In male pts with urinary incontinence

34. X ray – KUB IVU

35. Double J stent
Double J stent
 Identify the instrument
Identify the instrument
 Uses;
Uses;
 To relieve obstruction of
To relieve obstruction of
the urinary tract
the urinary tract
 Prophylactically during
Prophylactically during
ESWL
ESWL
 To identify ureter in
To identify ureter in
certain surgeries
certain surgeries
eg:- Endometrial Ca
eg:- Endometrial Ca
 How long to be kept?
How long to be kept?
 < 3 months
< 3 months

36. Internal fixators
Internal fixators
Indications
Indications
 Intra-articular fractures - to stabilise anatomical reduction
Intra-articular fractures - to stabilise anatomical reduction
 Repair of blood vessels and nerves - to protect vascular and
Repair of blood vessels and nerves - to protect vascular and
nerve repair
nerve repair
 Multiple injuries
Multiple injuries
 Elderly patients - to allow early mobilisation
Elderly patients - to allow early mobilisation
 Long bone fractures - tibia, femur and humerus
Long bone fractures - tibia, femur and humerus
 Failure of conservative management
Failure of conservative management
 Pathological fractures
Pathological fractures
 Fractures that require open reduction
Fractures that require open reduction
 Unstable fractures
Unstable fractures
Complications
Complications
 Infection
Infection
 Non-union
Non-union
 Implant failure
Implant failure

37. External fixators
External fixators
Indications
Indications
 Acute trauma - open and unstable fractures
Acute trauma - open and unstable fractures
 Non union of fractures
Non union of fractures
 Correction of joint contracture
Correction of joint contracture
 Filling of segmental limb defects - trauma, tumour and
Filling of segmental limb defects - trauma, tumour and
osteomyelitis
osteomyelitis
 Limb lengthening
Limb lengthening
Complications
Complications
 Overdistraction
Overdistraction
 Pin-tract infection
Pin-tract infection

38. fractures
fractures
 Important fractures
Important fractures
 Colle’s – below elbow POP cast upto the metacarpal heads,
Colle’s – below elbow POP cast upto the metacarpal heads,
sparing the thumb
sparing the thumb
 Scaphoid – “ glass holding” position
Scaphoid – “ glass holding” position
 Know about;
Know about;
 Xray identification of Colle’s ,supracondylar, NOF
Xray identification of Colle’s ,supracondylar, NOF

39.  A patient with a POP cast to his Right
A patient with a POP cast to his Right
forearm in the A&E unit.
forearm in the A&E unit.
 During the ward round how to assess the
During the ward round how to assess the
cast?
cast?
Look for 6p’s of acute limb ischemia
Look for 6p’s of acute limb ischemia
- Pain
- Pain
- pallor
- pallor
- perishing cold
- perishing cold
- paraesthesia
- paraesthesia
- paralysis
- paralysis
- pulseless
- pulseless

40. The patient has pain on passive movements of the
The patient has pain on passive movements of the
fingers. What is your main worry?
fingers. What is your main worry?
Compartment syndrome
Compartment syndrome
What is the immediate management
What is the immediate management
Full thickness , full length splitting of the POP
Full thickness , full length splitting of the POP
elevation of the limb
elevation of the limb
immediate
immediate Fasciotomy.
Fasciotomy.
CS –can also occur in circumferential full thickness
CS –can also occur in circumferential full thickness
burns
burns
- requires
- requires Escharotomy
Escharotomy

41.  A 42 yr old school teacher presents with a 3
A 42 yr old school teacher presents with a 3
months history of tingling and numbness of
months history of tingling and numbness of
her Right hand which is worst at night.
her Right hand which is worst at night.
 What is the most likely diagnosis?
What is the most likely diagnosis?
 Write 2 possible causes
Write 2 possible causes
 What is the most important investigation you
What is the most important investigation you
would like to perform to confirm your diagnosis?
would like to perform to confirm your diagnosis?
 What are the management options?
What are the management options?

42.  Carpal tunnel syndrome
Carpal tunnel syndrome
 DM , hypothyroidism , obesity , Acromegaly,
DM , hypothyroidism , obesity , Acromegaly,
Amyloidosis
Amyloidosis
 Nerve conduction studies
Nerve conduction studies
 Weight reduction
Weight reduction
correct the underlying causes (DM, hypothyroid)
correct the underlying causes (DM, hypothyroid)
Diuretics
Diuretics
Decompression surgery if failing above
Decompression surgery if failing above

43. Post op fever
Post op fever
 1
1st
st
24 hrs of Sx
24 hrs of Sx
- Metobolic response to trauma
- Metobolic response to trauma
- Reactions to blood transfusions & anesthetic drugs
- Reactions to blood transfusions & anesthetic drugs
 D2
D2
-
- Lung atelectasis
Lung atelectasis
 D3-D5
D3-D5
- Local sepsis – cannula site , catheter, wound
Local sepsis – cannula site , catheter, wound
infections
infections
 D5-D7
D5-D7
- DVT , leaking bowel anastomosis
DVT , leaking bowel anastomosis
 >1 week
>1 week
- Distant sepsis – hepatic,cerebral, deep seated
- Distant sepsis – hepatic,cerebral, deep seated
abscesses
abscesses

44. ET tubes
ET tubes
 Cuffed & uncuffed
Cuffed & uncuffed
 Uncuffed – in children
Uncuffed – in children
 Size (internal diameter mm) = Age
Size (internal diameter mm) = Age + 4
+ 4
4
4
 Male – (8-9.5) ; female – (7-8)
Male – (8-9.5) ; female – (7-8)
 In place for <7 days – risk of tracheal stenosis
In place for <7 days – risk of tracheal stenosis
 Prevented by doing a tracheostomy
Prevented by doing a tracheostomy

45. Uses of ET tubes
Uses of ET tubes
 Maintain airway
Maintain airway
 For ventilation (IPPV)
For ventilation (IPPV)
 Prevent aspiration (cuffed)
Prevent aspiration (cuffed)
 Give drugs – adrenaline
Give drugs – adrenaline
- atropine
- atropine
- naloxone
- naloxone

46. Guedel(oral) airway
Guedel(oral) airway
How to select the appropriate size?

47. LMA
LMA
Male – 4 cm
Female – 3 cm

48. Tracheostomy tubes
Tracheostomy tubes

49. Cuffed plastic tube for tracheostomy
Indications
i. To relieve obstruction of upper airway
ii. Prolonged mechanical ventilation
iii.To remove retained secretions in LRT
complications
- Pneumothorax
- Haemorrage
- Surgical emphesema
- tube displacement

50. CPR
CPR
 Changes in 2005 ALS guidelines
Changes in 2005 ALS guidelines
 CPR rate – 30:2 ( not 15: 2)
CPR rate – 30:2 ( not 15: 2)
 All 3 DC shocks – 360J each
All 3 DC shocks – 360J each

51. Fitness for surgery
Fitness for surgery
 From the Hx
From the Hx
any co-morbidities (DM,BA,IHD) & their control
any co-morbidities (DM,BA,IHD) & their control
degree of dyspnoea if present (NYHA)
degree of dyspnoea if present (NYHA)
Drug history
Drug history
past hx of GA and recovery
past hx of GA and recovery
smoking , alcohol
smoking , alcohol
symptoms of anaemia
symptoms of anaemia

52. Suture material
Suture material
Absorbable
Absorbable Non- absorbable
Non- absorbable
Synthetic
Synthetic Natural
Natural Synthetic
Synthetic natural
natural
Polyglycolic
Polyglycolic
acid
acid
Catgut
Catgut Polypropylen
Polypropylen
e (prolene)
e (prolene)
Silk
Silk
Polyglactin 910
Polyglactin 910
(Vicryl)
(Vicryl)
Polyamide
Polyamide
(nylon)
(nylon)
Polyglecaprone
Polyglecaprone
25 (monocryl)
25 (monocryl)
Polyester
Polyester
Polydiaxanone
Polydiaxanone

53. Thank you
Thank you