Surgery revision

OSCE
Revision Class
Dr. Syed Asad Ali
FCPS
DEPT:OF SURGERY

Q#1.What does OSCE stands for?
• A)Objective Structured Clinical Examination
• B)Over Stimulation and Crying Event
• C)Opportunity for Showing your Competence
and Excellence
• D)All
• E)None

What is OSCE?
The candidates rotate through a series of
stations at which they are asked to carry out a
various task(usually clinical)

OSCE includes several "stations"
examinees are expected to perform
specific
clinical tasks within a specified time
period .
students rotate through a series of
stations (as few as 2 or as many as 20).

Osce Stations
• 1.INTERACTIVE
• 2.STATIC
• 3. INTERSTATION or TAG STATION

1.Monitored station, where An EXAMINER
scores the student's performance,
Encounters:
patient history,
performing a physical examination
diagnostic procedure,
teaching/counseling/advising a patient.
A standardized checklist is used for marking
of each station.
INTERACTIVE STATIONS)

here the student answers
questions about the encounter
What is your differential
diagnosis?
What investigations will you
order?
What treatment will you advise?
2. Interstation or tag station

a student is asked to answer
questions, about 1.Instruments
2.interpret findings such as
lab reports
x-rays,
3.Clinical photographs(spot
diagnosis)
4.Clinical Scenarios
3.STATIC STATIONS
are not observed

Osce Stations
NO:16
•1.INTERACTIVE -4.(1-
INTERSTATION or TAG)
•2.STATIC-12

COMMON QUESTIONS ASKED IN OSCE
• INTERACTIVE STATIONS

INTRACTIVE-1
• Simulated Patient (Hx taking)

HISTORY TAKING STATIONS
• 1.Abdominal PAIN/MASS
• -EPIGASTRIC
• -HYPOCHONDRIAC REGION
• -PERI-UMBILICAL /R I FOSSA
•

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)

Station Profile
A) Instruction to students: .
Mr.Mohammed is a 22-year-old, presented
with sudden pain in periumblical region
associated with nausea,vomiting and pyrexia
for the last one day.

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 assess
your performance while you interact with
the patient
• No questions will be asked by the examiner

Checklist
• Student greeted the patient
• Introduced her/himself
• Asked the patient’s name
• Site of pain/
• Onset
• Duration of pain
• Nature of pain

Checklist
Radiation/Referral
Aggravating/Alleviating factors
Associated features
Change in appetite
Fever –type
Bowel functions

INTERACTIVE-2
(Tag Station)
Here the student answers questions
about the encounter on Interactive-1.
1.What is your differential diagnosis?
2.What investigations will you order?
3.What treatment will you advise?

INTERACTIVE-3&4
CLINICAL EXAMINATION

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

Station Profile
A) Instruction to students: .
Mr.Mohammed is a 22-year-old, presented
with this Lump(Swelling) in
NECK,BACK,SCALP,FACE etc

Station Profile (cont)
A) Instruction to students:(cont)
• You have 4 minutes to examine this
patient,
• An observer, using a checklist, will assess
your performance while you examine the
patient

Check list; Examination of a Lump
Introduce self & consent
• Position
• Colour and texture of
overlying skin
• Temperature
• Tenderness
• Shape
• Size
• Surface
• Edge
• Hardness
• Fluctuance
• Fluid thrill
• Translucency
• Resonance
• Pulsatility
• Compressibility
• Reducibility
• Mobility

A FEW QUESTIONS
• What are your findings
• What is your dignosis?
• D/D
• Investigation
• Treatment

BREAST EXAMINATION
• Introduction and Consent
• Inspection
– With the patient sitting
– With the patient leaning forward
– Arms above head
– Push hands into hips

BREAST EXAMINATION
• Palpation
– Start with the normal breast
– Arm behind head
– All 4 quadrants
– Axillary tail
• Examine lymph nodes
– Axillary
– Cervical

A few questions...
• What is meant by triple assessment?
– Clinical examination
– Imaging – mammography and ultrasound
– Cytology
• What is the difference between cytology and
histology?
• What are the risk factors for breast cancer?
What is MRM? What are the risk factors for
breast cancer?

Spotters
• PAROTID LUMP
• Jaundiced patient
• Stomas
• Cervical
lymphadenopathy
• Lipoma
• Sebaceous cyst
• TG cyst
• Hemorrhoid/fistula/fiss
ure/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`s
diverticulum
• Ing:Hernia/Hydrocele

LOOK at this picture and answer the
following 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.

Ostomy
•Show a normal stoma

Not painful
Always red and moist
Rose Red Bud

Stomas Continued
• Complications
– Early
• Haemorrhage
• Stoma Ischaemia
• High Output
• Obstruction (adhesions)
• Stoma retraction
– Delayed
• Dermatitis,
• Stoma Prolapsed
• Parastomal hernia
• Fistulae
• Obstruction
Types of stoma
– Temporary
– Permanent
– End
– loop
– Counselling
– How to manage stomas
– Stoma site avoided:
• Bony areas, umbilicus,
scars, waistline skin fold &
creases

Look at this operative photographLook at this operative photograph
-1- Dist = 1.30cm
-2- Dist = 0.91cm
Look at this operative photograph

QUESTIONS
• Identify this organ
• What is your diagnosis
• List 3-4 clinical features
• What complications occur if treatment is
delayed

Ranula9
• Is a term used for
mucoceles that occur
in the floor of the
mouth.
• The name is derived
form the word rana,
because the swelling
may resemble the
translucent underbelly
of the frog.

LOOK at this picture and answer the
following question:
• 1.what is your diagnosis
• 2.what is the underlying pathology?
• 3.list 3 complications.
• 4.mention treatment options.

Table 1 Classification of patients with renal cell carcinoma according to tumor
thrombus level
Karnes RJ and Blute ML (2008) Surgery Insight: management of renal cell carcinoma with associated inferior vena cava
thrombus
Nat Clin Pract Urol doi:10.1038/ncpuro1122

Figure 2
Parotid lump –
pleomorphic
adenoma

Presentation
• Swelling
• Dragging pain
• Features of complication
• H/o increased abdominal
• pressure

Primary
squamous cell
carcinoma of tongue
tongue

QUESTIONS
• 1.What is this lesion.
• 2.Name the commonest causes of this
lesion in lower leg.
• 3.What are the different parts of this
lesion?
• 4.How will you treat this lesion?

CASE 1.
A 28-year-old man presents to the emergency
department complaining of anal and lower-back pain
for the previous 36 h..
The pain is progressively getting worse and he is
uncomfortable to walk or sit down.
Examination
Inspection of the anus reveals a 3cm 3 cm swelling at
the anal margin. The swelling is warm, exquisitely
tender

Questions
• What is the diagnosis?
• What are the aetiological factors
associated with this condition?
• How are these lesions anatomically
classified?
• What treatment is required

AETIOLOGY
.in 90% of cases the abscess
commences as an infection of an
anal gland.

classification of the perianal
abscess:
• Perianal
• Ischiorectal
• High intersphincteric
• Submucous
• Pelvirectal.

Treatment
1. Incision and drainage may be done under local
anesthesia. packing to keep skin edges open.
2. Antibiotics .

Case Scenario I
• 32 years old male, complaining of painless
bleeding per rectum and a palpable lump
while abluting. Pt sometimes has mucus
discharge and pruritis.

Scenario I
• What is your provisional Diagnosis?
• What are the investigations you need and
why?
• Mention 4 complication in such pt?

CASE SCENARIO
A 60 years old man, presented to the
surgical OPD, complaining of left sided
loin pain, associated with occasional
hematuria.
on examination his left kidney is palpable
and U/S shows is mass in the upper pole
left kidney,

Q.#.1
.
What is your differential diagnosis?
Q.#.2
.
What investigation is now required?
Q.#.3
.
Name often relevant investigations for
planning management.
Q.#.4
.
Mention treatment options.
Questions:Keys:

Q.#.1. Renal Cancer
Renal calculus
Hydonephrosis/Pyonephrosis
Q.#.2. 1. CT Scan (Contrast)
2. MRI
Q.#.3. 1. Blood CP
2. Lft
3. X-Ray Chest
4. CT Scan Cheat
5. Renal Angiography
6. I/V cavogram
7. PET Scan
8. Bone Scan
Q.#.4. 1. Minimal Invasive procedure
• NSS
• RFA
• Themal ablaTION
1. Surgery
• Radical Nephrectomy
1. CHTH
2. RT
3. Throsine Knain Inlututor (TKI)
4. Inter feron/Interleukin

50 years male with mass epigastrium moving
with respiration, associated with vomiting, wt
loss for two months .
O/E : Left supraclavicular node palpable
A Ba-meal –Ray is ordered which is shown
below
CASE

Questions
Q.#.2
.
What is your likely diagnosis?
Q.#.3
.
Which investigations is needed to cofirm
diagnosis?
Q.#.4
.
Q#5.
Name any 3investigationto stage the disease.
List treatment options
Q#1. Mention the finding on X-ray

ANSWERS
Q.#.2. Cancer of Stomach
Q.#.3. Endoscopy/ Biopsy
Q.#.4
Q#5.
1.CT SCAN 2.EUS 3.PET SCAN 4.Stagging
Laparoscopy
1.Surgery-Gastrectomy(subtotal/total)
Palliative gastrojejunostomy
Lymphadenectomy.
2.Radiotherapy
3.aAdjuvant Chemotherapy
Q#1. Apple core appearance-body of stomach

SCENARIO
A 62 year-old woman with chief complain
of neck mass.
Physical exam reveals a thyroid nodule,
2*2*2 cm.
Clinically she is Euthyroid.

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 in
diagnosis of this lesion.
Keys:

Keys:
Q.#.1. Solitary Thyroid nodule
Q.#.2. 1.Thyroid cyst
2.Thyroid Adenoma
3.Thyroid cancer
Q.#.3. 1,Firm to hard nodule
2,Fixed nodule
3.Rapid increase in size
4. local invasion
-Vocal cord paralysis
-Dysphagia
5.Cervica Lymphadenopathy
1.T3,TSH 2. Thyroid scan
3. FNA
4. Thyroid uptake of I-131
5. Ultrasound

INTERPRETING ABDOMINAL
RADIOGRAPHS

Some common X-rays
• 1.PNEMOPERITONEUM
• 2.INTESTINAL OBSTRUCTION
• 3.APPEDICOLITH
• 4.GALL STONES
AXRs

Note the
absence of
bowel gas in the
right upper
quadrant due to
the presence of
the liver
S. Rizvi, 07.08.1910
27th
August 2007; 15.14pm

Biliary tree
Multiple
gallstones
Only 10% of
gallstones are
visible on plain
film

“
ERECT
Note the
multiple
fluid levels

X-RAY
 Small Bowel Obstruction
is suggested by a
“ladder” pattern, when
obstruction occurs, both
fluid and gas collect in
the intestine.
 They produce a
characteristic pattern
called air-fluid levels.
The air rises above the
fluid and there is a flat
surface at the air-fluid
interface.

COLON
OBSTRUCTION
Distension extends to
distil descending colon.

SBO Vs LBO
Large bowel Small bowel
Peripherally placed dilated
bowel
Centrally placed loops dilated
bowel
Haustra (do not cross whole
diameter of colon; no more
than 1/3 of the way across)
Valvulae conniventes extend
across whole bowel lumen
Few loops Many loops

:Extra-luminal gas seen erect CXR.

KUB X-RAYs
• 1.RENAL CALCULUS
• 2.URETERIC CALCULUS
• 3.VESICAL CALCULUS

KUB
(KIDNEY- URETERS- BLADDER)
THE KUB IS USED AS A SCOUT FILM FOR MANY ABDOMINAL IMAGING STUDIES
R
R

Bladder Calculus
A large calculus shown in theA large calculus shown in the
bladder.bladder.

CONTRAST X-RAYs of GIT
• 1.BARIUM SWALLOW X-RAY
• 2.BARIUM MEAL X-RAY
• 3.BARIUM ENEMA X-RAY
• 4.CHOLANGIOGRAM

A- For diagnosis:
(1) Barium swallow:(1) Barium swallow:
a.a. Fungating and ulcerative massFungating and ulcerative mass: narrowed irregular
filling defect.
b.b. Annular massAnnular mass:
- If middle stricture: Apple core appearanceApple core appearance with
evident shouldering
- If lower stricture: Rat tail appearanceRat tail appearance.
Apple core appearance
Cancer lower 1/3Cancer lower 1/3
Filling defect (ulcerativeFilling defect (ulcerative
type)type)
Rate tail appearance

Radiographic appearances : Gastric cancer
Focal constricting
lesion
: localized infiltrating
carcinoma or localized
scirrhous carcinoma
- circumferential
irregular narrowing of
the lumen with
rigidity (as figure;
involved body and
antrum)
body
antrumbulb
fundus

Gastric cancer
– No ability to
distinguish
between
malignant and
benign ulcers.

HEPATIC
FLEXURE
SPLENIC
FLEXURE
TRANSVERSE COLON
CECUM
ASCENDING
COLON
DESENDINGCOLON
TERMINAL ILEUM
NORMAL
COLON
Normal air contrast
barium enema shows
filling of colon with air
and barium retrograde
to the cecum with reflux
into the terminal illeum

COLON CANCER
Barium enema showing
apple-core type
constricting lesion with
proximal dilation of colon
—”APPLE -CORE”
constricting lesion

Colonic Carcinoma
• Annular Carcinoma
(green arrow) with s
helf-like margin (blac
k arrow)

T-TUBECholangiography : Stricture of common bile
duct

IVP (URETERIC CALCULUS)
Ureteric stoneUreteric stone
causing rightcausing right
hydronephrosis.hydronephrosis.

The standard questions to
be asked:
•What is this instrument?
•Name the parts.
•What are its uses?
•What complications can
arise

Ryle`s
tube:
•For gastric
aspiration.
•After
laparotomy
• Intestinal
obstruction
• After
anastomosi
s
Catheter
Distal (inner) end
Proximal (outer) end

1. What is the use of this?
 For nasogastric feeding.
 To aspiration gastric secretions or contents before
emergency surgeries & in bowel obstruction.
 Gastric empty because emergency surgery( Road
traffic accident
2. What are it`s different parts?

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 the
balloon located at the end of the tube in order to
keep the catheter inside the bladder. So we call it
“self retaining catheter.”
2. For drainage of urine

 Used for irrigation of the bladder by
using normal saline after surgery
 Also used as gastrostomy tube

3. What are the indications?
 Gastrostomy Pt, loss of Autonomic NS functions, in
cardiac failure.
4. Disadvantages: -
 Connect the external and internal environment.
Therefore infection can be spread to exterior to interior.

 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 in
position & prevent aspiration.
 How does this tube an adult differ from that of a
young child?
 In children’s endotracheal tube is a 3.5 mm area which
is radio opaque that help to detect the position of the
tube in x-rays.

What are the uses of it?
 To depress the tongue preventing the
tongue falls back
 To maintain a pts airway
 To keep air way pt until recovering
from anesthesia

1. What are the indications?
 Acute airway obstruction.
e.g.:-forging body.
 To ventilate Pts following surgeries including oral cavity.
 To protect the lower airway
e.g.:-aspiration of saliva in unconscious Pts.
 For Pt requiring artificial respiration – respiratory
insufficiency.
 Who has dead space depression

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, is
reduced.
 No damage to the vocal cords

3. What are the disadvantages?
 Loss of heat & moisture exchange performed in upper
airway.
 Desiccation of tracheal epithelium.
 Loss of ciliated cells & metaplasia.
 Over production of mucous

4. How do you manage tracheostomy post
operatively?
 Suction.
 Humidification.
 Change of the inner tube & remove mucous
plugging.
 Physiotherapy.

Vertical
limb
Horizont
al limb
T- tube
*Indication
s.
*Time of
removal.
Therapeuti
c uses
Inside
common
bile duct

Deaver Retractor
• Common retractor used in major abdominal
procedures. Comes in several different widths. May
also be used during vaginal procedures.

Crile hemostatic forceps (curved and
straight)

Needle holder:
*Grasp the needle
for stitching
Blade
Shaft
Handle

Kocher (Oschner)
hemostatic forceps

Babcock tissue (intestinal) holding
forceps

Straight or curved
Doyen Intestinal Forceps

Stone
forceps
( Ureteric,
biliary and
Bladder):
•Used for
Stone extraction
from the ureter,
common bile duct
and urinary
bladder.
Ureteric & Billiary Bladder
Scope on
blade
Shaft
Handle

Moynihan
( Cholecystectomy
forcep):
•Used in
Grasping the cystic vessels &
cystic duct before their ligation
during cholecystectomy
operation.
Blade
Shaft
Handle

Surgery revision

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Editor's Notes