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OSCE STATIONS

OF SURGERY
Dr. ABDULHUSSEIN AL-JABERI

Aljaberi3ra@yahoo.com

History

ABDOMINAL PAIN
Greet the patient by last/first name; introduce
self and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the
visit
1-Present illness onset and duration
2-Location of pain and severity
3-Radiation
4-Timing related to food
5-Aggravating and Relieving factor
6-Associated fever and rigors
7-Nausea/Vomiting
8-Change in bowel motion, blood in the stool
9- Weight loss
10-Past history of previous episodes
11-Past surgical and medical history
12-Drugs history
13-Jaundice
14-Social history, alcohol, smoking

WRITING AN OPERATION NOTE


1-Demographic details (name,age, hospital No.)
2-Staff details (you, your assistant, and the
anaesthetist)
3-Date and location of operation
4-Operation title
5-Indication
6-Incision
7-Findings
8-Procedure
9-Closure
10-Post-operative instructions

WEIGHT LOSS
Greet the patient by last/first name; introduce
self and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the
visit

1-Duration
2-How many Kgs/week or month was lost
3-Loss of appetite ,weakness and easy fatigability
4-GI symptoms(dysphagia, vomiting, diarrhea and
constipation, change of bowel habits
5-Chronic bleeding(hematemesis, malena,
hematuria, vaginal bleeding, hemoptysis
6-Thyrotoxicosis symptoms(intolerance to hot
weather, sweating, tachycardia, palpitation,
nervousness)
7-Past surgical history (previous surgery, tumour,
chemotherapy, radiotherapy)
8-Past medical history(DM ,chronic illness)
9-Psychological status

VOMITING
1-Greet patient, introduce yourself, establish a plan
2-Duration
3-Frequency
4-Vomitus.(volume, content, character)
5-Regurgitation
6-Bile stained
7-Blood, clots
8-Relation to meal
9-Abdominal pain (radiation)
10-Bowel motion (diarrhea, constipation)
11-Jaundice
12-Fever,rigor
13-Weight loss
14-Past history(peptic ulcer, gall stone, endoscopy)
15-Drugs history
16-Social history(smoking, alcohol)

THYROID SWELLING
1-Greet patient, introduce yourself ,establish a plan
2-Location
3-Duration
4-Change in size
5- Pain
6-Intllerance to hot Vs cold whether
7-Anxiety, sleep disturbances
8-Palpitations
9-Diarrhea
10-Menstrual disturbances
11-Miscarriages and infertility
12-Fever
13-Sweaty palms and skin Vs dry scaly skin
14-Change in voice and speech pattern
15-Respiratort obstruction
16-Drugs,antithyroids
17-Irradiation exposure
18-Past medical history ,cardiac troubles
19-Family history of goiter

THYROID STATUS
Greet the patient by last/first name; introduce
self and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the
visit
1-Age
2-Occupation
3-Do you prefer cold or warm room
4-Gained or lost weight recently: How much and
over how long
5-Appetite
6-Bowel habit
7-Changed of mood
8-Palpitations or chest pain
9-Change in your periods(female)
10-Change in your appearance
11- Change in your vision
12-Have notice alump in your neck ?Does it cause
any problems
13-Past medical and surgical history
14- Any medical conditions
15-Operation on thyroid gland or radiotherapy on
neck in the past
16-Medications and allergies
8

17-Any thyroid drugs


)18-Pressure symptoms(dysphagia, stridor
SPIKES
)Settings (s
Privacy

:



Involve significant others


Sit down



Look attentive and calm
)
(



Listening mode
:



:
:
:

10

Availability





Perception (P) ICE

:
:








)Invitation (I

:





)Knowledge (K
11


:

... ... ) ...

(
Avoid scientific and technical language


:




)Empathy (E



:
.1
:


.2 :

.3
:
-

12



:


Validation



)Strategy and summary (S





.

13

S-P-I-K-E-S
S=SETTING
*privacy
*ask for presence of family members or friends
*sit dowen
P=PERCEPTION
*ask patient what he knows about his condition
I=INVITATION
*obtaining overt permission
*respect patients right to know or not to know
K=KNOWLEDGE
*give your patient a warning that bad news are
coming
*avoid technical and scientific language
E=EMPATHY
*downplay the severity of the situation or give a
more hopeful prognosis
S=STRATEGY AND SUMMERY
*summarize the information in your discussion

14

PYLORIC STENOSIS
Greet the patient by last/first name; introduce
self and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the
visit

1-When did the vomiting start


2-How many episodes per day
3-Any relation to feeds
4- Character of the vomits and volume
5-Number of wet diapers
6-Number and character of stool, any blood
7-Weight gain in relation to birth weight
8-Birth history
9-Family history

15

PEPTIC ULCER / GALL STONE / CHOLECYSTITIS


/ DU / PANCREATITIS
Greet the patient by last/first name; introduce
self and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the
visit
1-Site,onset ,duration,severity,course
2-Quality,quantity
3-Aggravating and relieving factor
4-Radiation
5-Dizziness
6-Bleeding P/R, malena, haematemesis
7-Bowel movement ,flatus
8-Urinary symptoms
9-Previous episodes
10-Medication-NSAID
11-Past medical and surgical history, endoscopy,
12-Nausea,vomiting,fever,chills
13-Weight loss
14-Chest pain, SOB,DOE, cough, IHD
15-Social history, smoking, alcohol
16-Family history
16

17

NIPPLE DISCHARGE
Greet the patient by last/first name; introduce
self and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the
visit
1-Nature of the discharge
2-Association with mass
3-Unilateral or bilateral
4-Single or multiple duct discharge
5-The use of contraceptive pills
6-Association with pain, tenderness
7- Association with fever
8-History of trauma
9- Family history
10- Age of patient

18

NECK MASS
Greet the patient by last/first name; introduce
self and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the
visit
1-Onset
2-Rate of growth
3-Associated pain
4- Associated fever, sweating, rigor
5-Smoking
6-Sun exposure
7-Alcohol
8-Otalgia
9-Hoarsness
10-Trismus
11-Dysphagia
12-Wt loss

19

JAUNDICE
Greet the patient by last/first name; introduce
self and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the
visit

1-Onset
2-Pain
3-Fluctuation
4-Progression
5-Duration
6-Fever and chills
7-Loss of appetite
8-Loss of weight
9-Pruritus
10-Change in stool colour
11-Change in urin colour
12-Past medical history
13-Past surgical history
14-Drugs and blood transfusion
15-Family history
16-Alcohol and smoking
20

17-Foreign travel
INTESTINAL OBSTRUCTION
Greet the patient by last/first name; introduce
self and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the
visit
1-Pain :character, severity, location, periodicity
2-Distention:rapid,sudden,degree
3-Bowel habit and flatus
4-Wt loss
5-Previous obstruction
6- Previous abdomen or pelvic operation
7- Previous abdominal CA
8- Previous intra abdominal inflammation
9-Immediat post operative state
10-Exposure to radiation
11-Past medical history

21

INFORMED CONSENTS
Greet the patient by last/first name; introduce
self and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the
visit

C= explanation of the condition and natural history


and prognosis
O= explanation of the therapeutic options,
conservative, surgical treatment
N= the name of the procedure
S= side effect and complication(anesthetic,
infection, bleeding)
E= extra procedure(drain, NG tube, Foley catheter
stoma information)
N= name of the operating person and assistant
T= if the procedure under TRIAL the patient must
be informed
S= second opinion of the other family members
may be obtained prior to surgery

22

INCISIONAL HERNIA / HYPERTENSIVE


WRITE MEDICAL CONSULTATION
1-Patients name and Age
2-Clear consultation destination
3- Greeting the consultant doctor
4-Duration of HT
5-The drug/drugs used by the patient
6-The doses of the drugs used
7-Recording the BP
8-Any chest pain
9-Any kind of dyspnoea
10-Clear and direct aims of the consultation
11- Greeting the consultant doctor
12-Name and position of the consultation writer
13-Signature of the consultation writer
14-Date of the consultation

23

HYPOTHYROIDISM
Greet the patient by last/first name; introduce
self and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the
visit

1-How long has she been fatigued


2-Has there been a weight gain
3-Any swelling in the lower legs
4-Notice any change in her hair or skin, any rashes
5-Any history of thyroid disease in the family
6-Any joint pain or intolerance to cold
7-Any excessive intake of water
8-Do you suffer from constipation
9-Past medical/family history
10-Any history of thyroid disease in the family
11-Any previous medical conditions
12-On you on any other medication

24

GROIN LUMP
Greet the patient by last/first name; introduce self
and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the visit
1-Age-occupation
2-How long have you noticed the lump?
3-Were you doing anything in particular when you
first noticed the lump?
4-Is it painful?
5-Has it increased in size since you first noticed it?
6-Does it disappear if you lie down/ can you push it
back inside?
7-Have you had any previous lump or swellings
similar to this?
8-Does it discharge?
9-Has the lump ever become red, painful or difficult
to reduce ? did you have associated episodes of
vomiting or your bowel not opening?
10-Do you have any urinary symptoms?
11-Do you suffer from constipation?
12- Do you suffer from cough?
13-Does your work/leisure time involve a lot of
lifting ?
14-Do you ever inject drugs in your groin?
15-Have you had any recent night sweats/weight
loss?
25

16-Past medical and surgical history


17-Have you had any tests to investigate the
lump?
18- Have you had any treatment for it?
GI BLEEDING
Greet the patient by last/first name; introduce self
and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the visit
1-Duration
2-Quantity
3-Appearance
4-Any clots
5-Any abdominal pain
6-Bowel symptoms
7-Stool
8-Any chest pain/Any syncope/Any sweating
9-Weight loss
10-Past medical history:
11-Peptic ulcer
12-liver disease
13-Any cancer
14-Prior bleeding
15-Cardiac disease
26

16-Previous surgeries
17-Medications/NSAIDS/Aspirin
18-Family history
19-Social history: smoking, alcohol
DYSPHAGIA
Greet the patient by last/first name; introduce self
and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the visit
1-Hematemesis/malena
2-Weight loss
3-Difficulty initially with solids and later liquids
4-Painful dysphagia or painless
5-Diarrhea or Constipation
6-Anemia
7-Fever,chills,night sweats
8-Abdominal pain/mass
9-Heart burn
10-Nausea/vomiting
11-Chest pain
12-Medication use
13-Cough
14-Hoarse voice
27

15-Pneumonia
16-Past medical and surgical history
17-Family history
18-Social history: work, family, smoking, alcohol,
eating habits, life style
DVT (POST OPRATIVE LEG PAIN)
Greet the patient by last/first name; introduce
self and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the
visit
1-Onset
2-Trauma
3-Fever
4-Chest pain
5-SOB
6-Pregnancy
7-Recent immobilization(airplane tripe)
8-Occupation
9-Past medical and surgical history
10-Medications
11-Smoking and alcohol
12-Drug use
28

13-Family history of blood clots

29

DIABETIC FOOT
Greet the patient by last/first name; introduce
self and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the
visit
1-Greet patient ,introduce yourself, establish a plan
2-Do you have diabetes
3-When diabetes diagnosed
4-How it had been diagnosed as a diabetes
5-What is treatment he/she was on
6- What is treatment he/she was on now
7-Any incident of hypoglycemia
8- Any incident of hyperglycemia
9-Is he /she on regular follow up program (diabetic
clinic )
10-How he/she started the foot problem
11-Does he/she feel his/her foot
12-What kind of treatment he/she received

30

CUSHINGS
Greet the patient by last/first name; introduce
self and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the
visit
1-Weight gain
2-Truncal obesity
3-Muscle weakness
4-Depression
5-Thin skin
6-Bruising
7-Hyperglycaemia
8-Hypertention
9-Headach
10-Amenorrhoea
11-Impotance(male)
12-Pathological Fractures
13-Cogestive heart failure

31

CLAUDICATION/ISCHEMIC LIMB
Greet the patient by last/first name; introduce self
and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the visit
1-Onset
2-Duration
3-Location
4-Radiation
5-Alleviating factor
6-Provoking factor
7-Paresthesias
8-Pallor
9-Paralysis
10-Deformity,swelling,stiffness
11-Amputation and ulceration
12-Walking distance
13-Effects on function
14-Reduced range of movement
15-Rest pain and night pain
16-One or both legs
17-Calf, buttock, thigh
18-Past medical history(DM,HT,CAD, Dyslipidemia)
19-Family history(CAR,HTN,DM,STROKE)
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20-Social history(smoking, alcohol, diet, activity,


cocaine/heroine abuse)
CHANGE OF BOWEL HABIT
Greet the patient by last/first name; introduce
self and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the
visit
1-Nature of bowel habit (diarrhea, constipation)
2-Duration
3-Onset (sudden, gradual)
4-Tenessmus
5-Mucus
6-Wight loss
7-Nausea /vomiting
8-Blood in the stool(bright red, mixed with stool,
dark)
9-Past history of previous episodes
10-Past surgical history
11-Drugs history
12-Social history(smoking, alcohol)

33

BREAST PAIN
Greet the patient by last/first name; introduce
self and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the
visit
1-Relation to M. cycle
2-Previous trauma
3-Any nipple discharge
4-Any abnormality in breast
5-Nipple retraction
6-Nodularity of breast
7-One or both breast
8-Any musculoskeletal disorder
9-Previous biopsy and result
10-Marital status,children,lactating, menarch,1st
child
11-Family history of CA breast
12-History of CA breast

34

BREAST LUMP
Greet the patient by last/first name; introduce self
and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the visit
1-Age
2-Lump site ,single, multiple
3-Lump onset, growth rate, variations with
menstrual cycle
4-Presence or absence of pain
5-Change in breast size or shape
6-Skin and nipple changes
7-Discharge (serous, serosanguinous, green,
bloody, milky)
8-Temperature/fever
9-Wieght loss
10-Bone or abdominal pain
11-Arm swelling (lymphoedema)
12-Previous radiation or surgery
13-Menstrual history(menarche, menopause,
contraceptive pill, hormone replacement)
14-Obstetric history (breast feeding and
complication, parity, previous mammograms,
screening)
15-Family history(breast, bowel, ovarian
carcinoma)
35

16-Symptoms of possible metastatic disease ,other


lump (axilla), breathlessness, backache, headache,
tiredness, anorexia, weight loss ,jaundice

36

Assess fitness for surgery patient


with GROIN HERNIA
Greet the patient by last/first name; introduce
self and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the
visit
1-Age
2-Have you had much trouble with your groin
3-Has it ever got stuck out and become painful
4-Vomiting , constipation, abdominal pain
5-Is it always reducible
6-Medical problems
7-Heart ,lung trouble
8-Shortness of breath and chest pain
9-How far can you walk on the flat without
stopping
10-Can you climb a flight of stairs
11-Can you dress yourself without getting
SOB/chest pain
12-Have you had an anaesthetic before: general,
local, regional,
13-Do you take any regular medication: warfarin,
antiplatelet agent
37

38

ANAL PAIN
Greet the patient by last/first name; introduce
self and role; shake hands
Identify and confirm problem list
Negotiate an agenda; establish a plan for the
visit
1-Duration and onset of pain and time
2-Associated discharge and color
3-Is the pain periodic
4-Previous attacks of such pain
5-Any associated mass
6-Change in bowel habit
7-Pain increase by defecation
8-Any bleeding on defecation
9-Fever,malass,lethargy
10- Wt loss
11-Constipation

39

Examination
&
Management

40

ABDOMINAL EXAMINATION
1-Greet patient ,introduce yourself, establish a plan
2- Expose from nipple to mid-thigh
INSPECTION
3-Stand at the foot of patient and observe:
( movement with respiration, symmetry of the
abdomen)
4- Stand at the right side of the patient and
observe : (movement with respiration, contour ,any
scar, any dilated veins, umbilicuse inverted*
everted or flat, pigmentation, pulsation , cough
impulse, any stoma)
PALPATION
5-Ask if there is any tenderness point
6-Superficial palpation looking for any mass or
tenderness (look at the face of the patient)
7-Deep palpation:
SPLEEN
*Right hand on the right iliac fossa of the patient
and the left hand placed on the lateral aspect of
the costal margin of the patient with compression
towards right hand. The patient instructed to take
deep breath
* Right hand on the left iliac fossa of the patient
and the left hand placed on the lateral aspect of
the costal margin of the patient with compression
41

towards right hand. The patient instructed to take


deep breath
LIVER
*Hand in the RIF with fingers pointing towards the
left axilla
*With expiration, slide the hand nearer the right
costal margin
*The edge of the liver strikes the hand as the
patient inspire
KIDNEYS
*Bimanual
8-Cough implse at the hernia orifice
PERCUSSION
9-Splenic size
10-Liver span: percussion of the right side of the
chest ,start at fourth intercostals space to obtain
resonant note, then work downwards to determine
liver dullness
11-Look for the ascites: (shifting dullness,
transmitted thrill)
AUSCULTATION
12-Bowel sounds
13-Renal bruits
14-Dont forget (external genitalia, supraclavicular
LN, back, PR, hernia orifice)
42

43

THYROID EXAMINATION
1-Greet patient ,introduce yourself, establish a plan
2-Inspection
3-Asked patient to swallow
4- Asked patient to protrude the tongue
5-Observed for restlessness, agitation, sitting
unstill
6-Observed for lethargy, hypotonia, speech and
voice
7-Body build and temperature
8-Moist palms, skin
9-Fine tremor
10-PR and BP
11-Eye sings:(lid lag, lid retraction, exophthalmos,
ophthalmoplagia, chemosis)
12-Palpation from the front
13- Palpation from the back
14-Size
15-Shape
16-Surface
17-Consistency
18-Mobility Vs fixity
19-Tenderness
20-Position of the trachea
21-Carotid pulsation
22-Examined for possible retrosternal extension
23-Cervical LN including suraclavicular LN
44

24-Auscultate for bruit ,vascular goiter


25-Looked for Horners syndrome
SUBMANDIBULAR GLAND EXAMINATION
1-Ask patient to suck lemon
2-Inspection of the floor of the mouth
3-Ask patient to open mouth widely and raise the
tip of the tongue towards roof of mouth
4- Bimanual palpation of the gland using gloves
5-Patients head flexed and inclined to the affected
side
6-Index fingers inserted in the mouth and fingers
of the other hand beneath the jaw
7-Examine other side for comparison

45

SMALL BOWEL OBSTRUCTION MANAGEMENT


1-A-B-C-D-and fluid resuscitation
2-History and physical examination
3-N.P.O. and N.G.T
4-Catheterise
5-IV fluid(RL,NS,K)
6-Analgesia and antiemetic

46

RTA MANAGEMENT
1-Introduce yourself ,Greet, Establish a plan
2-Ask for C-spine precaution
3- Ask for 2 large bore IV line
4- Ask for O2,monitors, appropriate fluid
boluses
5-Check airways ,cyanosis
6-Inspect chest
7-Palpate chest for subcutaneous emphysema,
# ribs
8-Auscultate chest for air entry
9-Feel for tracheal position
10- Vital signs
11-Look for external sources of blood loss
12-Recognize hemo-pnemothorax
13-Check the abdomen for possible abdominal
hemorrhage
14-Examine pelvis ,long bones, for #

47

Pyloric Stenosis counseling


Brief overview of the findings
Information of diagnosis
Natural history of condition
Investigation if required
Treatment and prognosis

48

PREOPERATIVE ASSESSMENT
(SURGERY FITNESS)
1-HISTORY :previous surgery / anaesthetic ,ICU
admission, exercise tolerance , medication,
smoking, respiratory symptoms.
2-PHYSICAL EXAMINATION: cardiorespiratory signs
(wheeze, cough, dyspnoea, heart murmur,
dysrhythmia)
3-ECG,CXR
4-BLOOD PROFILE: Hb, LFT,RFT,SE, coagulation,
blood sugar, ABG, ECHO

49

PERIPHERAL VASCULAR SYSTEM (ISCHEMIC


LIMB) EXAMINATION
1-Introduce yourself ,Greet, Establish a plan
2-GENERAL(look around bed for aids ,oxygen
or medication {GTN spray} look at the patient
as a whole : well / unwell, pain/ pain-free, SOB,
cyanosis ,obesity
3-Skin and Nails: colour, ulceration, gangrene,
digital amputation/ tissue loss, oedema, hair
loss, venous guttering, scar, muscle wasting,
4-Looked for pressure points and between the
toes(web spaces)
5-Palpation: temperature ,pitting oedema,
capillary refill time .PULSES : aortic-femoralpopliteal-DP-PT
6-Burger test
7- Numbness, paresthesia and absent
sensation
8-Auscultation (aortic-renal-iliac-femoral)
9-ABPI-CARDIOVASCULAR-NEUROLOGICALABDOMINAL EXAMINATIN

50

Peptic Ulcer: MANAGEMENT and physical


examination and COUNSELING
MANAGEMENT
Level of consciousness
Airways
Breathing
Circulation
Vitals: pulse, BP, Temp, RR
NPO
PHYSICAL EXAMINATION
Wash hands
Solicit consent for examination
Ensure that the patient is properly draped
Relevant general hydration, pulse
Inspection
Auscultation
Percussion
Peritoneal signs
Palpation
Rectal exam (not actually performed but the
intention voiced)
Give attention to patients physical comfort
Verbalize the maneuvers on the examination
COUNSELING
Explain seriousness of the condition
Willing to explain the matter to the girlfriend
Explain PEPTIC ULCER and complications
Inform about endoscopy and admission to
hospital
Stating H.pylori as a probable cause and
cigarette-smoking as an aggravating factor
Counsel on smoking cessation

51

52

PANCREATITIS MANAGEMENT
1-A-B-C-D-E- and fluid resuscitation
2-History( establish cause: gallstone, alcohol,
trauma, steroids, mumps, autoimmunity,
hyperlipidaemia, hypercalcaemia , ERCP, drugs,
scorpion venom)
3-Physical examination
4- Arterial blood gases :assess PH,PO2
5- Blood profile : CBC, LFT, SE, UREA,
ALBUMIN,GLUCOSE
5-U/S CT scan at 5-7 days

53

MVA Trauma: EXAMINATION AND


MANAGEMENT
Greet the patient by last/first name; introduce self
and role
Identify and confirm problem list
Ask for vital signs
Wash hands
Solicit consent for examination
Explain about the procedures to be performed
Ask for C-spine precautions
Ask for :
2 large bore IVs
Oxygen
Monitors
Appropriate fluid boluses
Check airways
Recognize cyanosis
Inspect chest
Palpate chest-left subcut emphysema
Auscultate chest-no air entry on the right
Feel for tracheal position-midline
Recognize PTX
Treat correctly PTX
Reassess chest after CT or needle decompression
Reassess the vital signs
Look for external sources of blood loss
Check the abdomen for possible abdominal
hemorrhage
Examine pelvis
Examine long bones for fractures
Assess the GCS
Exposed the patient and log roll and DRE
Indicate options to determine intra-abdominal
hemorrhage (DPL, FAST, CT)
Asked AMPLE Hx ( at least 3 )
Demonstrate competent approach to the ABCDE
54

primary survey
Verbalize the maneuvers on the examination
Give attention to patients comfort and modesty
MANAGEMENT OF GASTROINTESTINAL
HAEMORRHAGE
1-Use the ABC approach ,ensure airway, breathing
and circulation
2-Wide- bore cannulae or central venous catheter
3-Rapid infusion of colloid to correct hypotension
4-Estimation of Hb and clotting status and blood
for crossmatching
5-Monitoring of BP ,PR,UOP/h, and oxygen
saturations
6- Pass NG Tube
7-Commence infusion of PPI or antacids
8-Give FFP if PT is abnormal, and give platelets if
thrombocytopaenia is present
9-Give blood when available if BP is not
maintained by clear fluids
10-Give unmatced blood O-ve if necessary if the
bleeding is massive
11-Correct coagulopathies
12-Intervene early in cases with chronic disease or
atherosclerosis , as these patients dont tolerate
hypotension well
13- Endoscopy after patient stabilize

55

56

GI Bleeding MANAGEMENT and PHYSICAL


EXAMINATION
MANAGEMENT
Safety precautions
Airway management
Breathing- give oxygen
Circulation:
Ask for vital signs
2 large bore IV lines
State to give IV fluids (normal saline/ Ringer
lactate)
Draw blood for CBC, lytes, Cr, Ur, PT/PTT,
glucose, cross-match 4-6 units
Cardiac monitor/12 lead EKG
Intend to insert Foley catheter to monitor urine
output
Stabilize patient
Keep NPO/NG tube
PHYSICAL EXAMINATION
Wash hands
Solicit consent for examination
Assess level of consciousness
VS
Examine extremities
Oral exam
Look for signs of chronic liver disease (palmer
erythema, clubbing, spider angioma,
gynecomastia, jaundice, testicular atrophy,
ascitis, hepatosplenomegaly)
Examine abdomen:
inspection
auscultation
palpation (light/deep)
percussion
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Give attention to patients physical comfort


Ensure that the patient is properly draped
Verbalize the maneuvers on the examination
Intend to perform DRE
Gall Stone. Provide initial management and
perform a focused examination
Level of consciousness
Airways
Breathing
Circulation ( IV line)
Vitals: pulse, BP, Temp, RR
NPO
Wash hands
Solicit consent for examination
Ensure that the patient is properly draped
Relevant general hydration, pulse
Inspection
Auscultation
Percussion
Peritoneal signs
Palpation
Rectal exam (not actually performed but the
intention voiced)
Give attention to patients physical comfort
Verbalize the maneuvers on the examination
Key Points: COUNSELING
Explain seriousness of the condition
Discussed helping with note to be off work
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Explain gall bladder stone and complications


Inform about U/S and admission to hospital
Advised may need surgery if the duct or gallbladder
is infected
FOOT ULCER EXAMINATION
1-Introduce yourself ,Greet, Establish a plan
2-Inspection/general/gait, shoes, heels
3-Any foot ulcer or deformity
4-Inspection/skin/vascular insufficienyhairlessness ,pallor
5-Rubor at pressure points
6-Skin breakdown (portal for infection)
7-Diabetic dermopathy (brown macules )over
shins
8-Infection, cellulites( erythema, swelling)
9-Gangrene
10-Web space, cracked, infected, ulcer,
maceration
11-Toe nails, dystrophic, in-grown , paronychia,
onychomycosis
12-Palpation pulses: femoral-popliteal PT-DP
13-Temp-capillary refill
14-Ausculation/bruits, femoral, popliteal

59

60

Dysphagia PHYSICAL EXAMINATION


Washing hands
Soliciting consent for examination
Check mouth for loss of enamel
Check throat
Check cervical lymph nodes
ABD: looks for epigastric tenderness/mass,
liver
Auscultate chest
Verbalize the maneuvers on the examination
Give attention to patients physical comfort
Ensure that the patient is draped properly

61

DVT perform a focused physical examination

Wash hands
Solicit consent for examination
Explain the procedures to be performed
Check leg for tenderness and swelling and
colour (patients leg will be red and warm to
simulate a deep vein thrombosis or cellulitis; if
the leg is touched by examinee, the patient will
complain of severe pain)
Check the pulse of foot to confirm good arterial
circulation
Check for Hoffmans sign (calf pain with
dorsiflexion of right foot)
Listen to the lungs in four places
Verbalize the maneuvers on the examination
Give attention to patients physical comfort

62

Claudication: physical examination


Wash hands
Solicit consent for examination
Ensure that the patient is properly draped
Ask for blood pressure
Comment on changes in skin color, or
temperature
Comment on loss of hair or dystrophic nails
Abdominal aortic area
Bilateral Femoral, popliteal, dorsalis pedis and
posterior tibial arteries.
To be confident that the pulse you cannot feel is
truly absent, you must know the arterial
anatomical landmarks. (Posterior tibial at the
infero-posterior border of the medial malleolus,
dorsalis pedis at the upper third of the dorsal foot
just lateral to the extensor halluses longus,
popliteal artery in the infero-lateral portion of the
popliteal fossa, femoral artery mid-point between
the anterior superior iliac spine and the
symphysis pubis bone).
Ask for the ankle brachial index (ABI)
Auscultate abdominal aortic and femoral arteries.
Buergers test (blanching of skin of feet noted
upon raising legs to 30-45o for 1 min)
Mention DeWeese test (disappearance of
63

previously palpable pulse after walking exrecise)


Give attention to patients physical comfort
Verbalize the maneuvers on the examination

64

CERVICAL L.N EXAMINATION


1- Examination of cervical L.N. from behind
2- Flexion of the head for exam. of submandibular
and supraclavicular L.N.
3- Put the hand on the head to adjust the degree of
flexion
4- Palpate supraclavicular fossa from infront
5- Did he turn the face to one side in examining the
jugular L.N.
6- Palpate supraclavicular fossa from behind with
patient elevating and hunching forward his
shoulders
7- Palpation of submental L.N. group
8- Palpation of submandibular L.N. group
9- Palpation of jugular L.N. group
10- Palpation of supraclavicular L.N. group
11- Palpation of posterior triangular L.N. group
12- Palpation of postauricular and preauricular L.N.
group
13- Palpation of suboccipital L.N. group
14- Palpation of L.N. group along the posterior
border of the sternomastoid muscle
15-Make the sternomastoid muscle tense ,turn the
head to one side (to determine the relation of L.N.
to it)
16-Examination of the mouth and looking for any
cause of the enlargement of L.N.
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66

BREAST LUMP , NIPPL DISCHARGE


INSPECTION
1-Inspection both breasts for size
2-Symmetry
3-Skin changes
4-Congenital anomalies
5-Nipple and areola, presence or absence
6-Colour, symmetry
7-Discharge, nature from which duct
8-Retraction, Distraction, Deviation of nipple
9-Peu de orange
10-Inspection,Breasts
11- Inspection axilla and supraclavicular fossa and
arms swellings
12-Enlargement, Distended veins, Wasted muscles
13-Raising arms above head for mass
14-Press arms against hips for mass

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ABDOMINAL MASS EXAMINATION


1-Introduce yourself to the patient
2-Ask for a nurse chaperone
3-Obtain consent
4-Ensure adequate privacy comfort and exposure
5-Ask the patient whether they have any pain
6-Wash hand
7-INSPECTION-PALPATION- PERCUSSION AND
AUSCULTATION-of the abdomen
8-MASS:( site, scar, size, shape, surface-regular /
irregular,
edge,
tenderness,
temperature,
consistency, can you get above / below it ?, pinch
skin over it, lift head off the bed (tense the rectus
sheath) to determine mobility / fixity of mass,
cough impulse, reducibility / compressibility,
fluctuance, pulsatility, expansibility, does it move
with respiration, can it be balloted, percuss the
lump, auscultate over the lump, palpate for
regional LN (inguinal and axillary).
9-THANK THE PATIENT

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OSCE OF ARAB BOARD


IN FINAL EXAM.
2009-2010-2011

69

SLIDS IN
ARAB BOARD OSCE

70

2009 - slides
1- History, Mammograph, Ca breast, (finding,
prognosis)
2- History, CT scan, plan x-ray,(Dx, treatment,
prognosis)= chronic calcified pancreatitis
3- History, Abd. x-ray, barium, (finding, Dx) =
sigmoid valvulus
4- History, Cross pathology, operative view
(finding, Dx,) = Ca stomach
5- History, Isotop scan (describe, Dx, treatment)=
GRAVES
6- History, CT scan(describe, Dx,) pancreatic
pseudocyst
7- History, abd x-ray,(finding, Dx, treatment) =
duodenal atresia
8- History ,MRCP,ERCP, (describe, Dx) = CBD injury
9- History ,Barium swallow (describe, Dx , causes,
treatment)= zenker diverticulum
10- History, CT scan, (describe , Dx, treatment)=
adrenal tumor
11- History, CT scan ,angiogram,(describe, Dx,
treatment)
12- History , lower limb ulcer( describe, causes,
treatment)
13- History , face tumor(describe, DDx,
treatment)=SCC
14- History , stoma (describe, Dx, treatment)=
parastomal hernia

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15- History , barium swallow (finding, Dx,


treatment ,causes)= achalasia
16- History , CXR (describe, treatment, DDx)=
plural effusion ? Ca ? fistula ?
17- History , CT scan, ERCP( describe ,Dx,
treatment)=ca head of pancreas
18- History, X-ray, cross pathology, (finding, Dx,
treatment)= small bowel obstruction
19- History, CT scan, operative,( describe, Dx,
treatment)= liver H. cyst
20-History,CTscan, operative,(describe, Dx,
prognosis, treatment) = Ca gallbladder

72

2010 - slides
1-Hydrocoele
2-CBD injury
3-artriovenus fistula
4-Ca breast
5-Esophagal atresia
6-Megacolon
7-Appendicular abscess
8- diverticulosis and fistula
9-sigmoid valvulus
10-paroted tumor
11-splenectomy
12-DIC
13-Prolaps pills
14-klatskin tumor
15-A.P resection
16-Gastrostomy feeding tube
17-treachiostomy
18-Necrotizing fasciitis
19-Wound dehisces
20-H.cyst liver and spleen

73

2011 - slides
1-leomyosarcoma
2-lung abscess
3-forign body
4- splenic abscess
5-perforated DU
6-sebaceous cyst
7-lymphedema
8-Burn
9-cleft lip and palate
10-BCC
11-D.foot
12-Ca gallbladder
13-fascial wound
14- venous ulcer
15-ovarian teratoma
16-dermoid cyst
17-adrenal mass
18-melanoma
19-hairy nevus
20-poplital artery aneurysm

74

6 / 2011 (stations)
1- EXAM. THE NECK WHAT YOUR DX AND
INVESTIGATION(RETROSTERNAL GOITER)
2- JAUNDICE TAKE HISTORY WHAT IS THE Dx
(OBST.JAUND. CBD STONE)
3- CUSHING TAKE HISTORY AND WHAT ARE THE
INVESTIGATION
4- RED COLOR NIPPL DISCHARAGR TAKE HISTORY
AND WHAT IS THE INVESTIGATION
5- PATIENT WITH CA CAECUM (PHYSICAL EXAM.)
6- HEPATOMEGALY ABDOMINAL EXAM.
7- RTA GCS 3 HOW TO CONFIM AND LEGALLY TAKE
ANY ORGAN AND WHAT ARE CONTRAINDICATION
FOR TAKE ANY ORGAN
8- PATIENT OPERATED FOR PEPTIC ULCER THEN
DEVELOP GASTROCOLIC FISTULA WHAT ARE THE
CAUSES AND HOW TO PREPAIR FOR OPERATION
9- 70 YEAR OLD PATIENT DM AND HAD 2 VASCULAR
STENT AND ILIOFEMORAL DVT DEVELPED ACUT
CHOLECYSTITIS WHAT ARE OPTION OF TREATMENT
AND PREPERATION
10- BOTH LOWER LIMBS PAIN FOR 2MONTHS TAKE
HISTORY AND DISCRIB THE X-RAY(ANGIOGRAM)

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5 / 2010 (stations)
1- THYROID EXAMINATION
2- 2nd POSTOPRATIVE DAY PERFORATED DU
MANAGEMENT
3- UPPER GI BLEEDING MANAGEMENT
4- POSTERIOR NECK MASS HISTORY AND
EXAMINATION
5- PATIENT ON T.P.N (PHYSICAL EXAM. AND
MANAGEMENT)
6- LOWER LIMB ISCHEMIA AND ANGIOGRAM
HISTORY AND DISCRIB ANGIOGRAM
7- CT (PANCREATIC PSEDOCYST) HISTORY AND DX
AND CAUSES
8- MELANOMA (EXAM THIS PATIENT LEG)
9- LOWER GI BLEEDING HISTORY AND
INVESTIGATION
10- ABDOMINAL EXAMINATION
(ASCITES,HEPATOSPLENOMEGALY)

76

12 / 2009 (stations)
1- THYROID EXAMINATION
2- ABDOMINAL EXAMINATION (HEPATOMEGALY)
3- CXR HISTORY-TREATMENT
(SPONT.PNEMOTHORAX)
4- PERFORATED DU (X-RAY) OPERATION AND
COMPLICATION
5- CT SPLENIC INJURY (COUNSELING)
6- DYSHPAGIA HISTORY
7- LOWER LIMB VASCULAR EXAMINATION
8- JAUNDICE HISTORY
9- DDX OF APPENDICITIS IN FEMALE
10- BAD NEWS(SPIKES) CA LUNG

77

12 / 2010 (stations)
1- ABDOMINAL EXAMINATION (ABD.MASS)
2- THYROID EXAMINATION INVESTIGATION-AND
DX.
3- VIDIO BREAST EXAMINATION TWO
HPOTO.WHAT IS MISTAKE IN EXAM. DISCRIB THE 2
PHOTO(ON LABTOP)
4- DYSPHAGIA HISTORY
5- CA COLON RECURRENT OPERATION COPDSUDDEN CHEST PAIN SOB-(DX AND
MANAGEMENT) PUL.EMBOLISM
6- CA RECTUM 6cmFROM ANAL VERGE OPTIONS OF
TREATMENT ADVANTAGE AND DISADVANTAGE OF
EACH
7- 140 kg 175cm DM (PREPERATION AND
TREATMENT AND WHAT IS BMI)
8- AMPULA OF VATER TUMOR OBST. JAUNDICEDM-WHAT IS THE CURABLE TREATMENT AND
PREPERATION
9- ABDOMINAL PAIN 2MONTH HISTORY OF
CHOLECYSTECTOMY TAKE HISTORY AND WHAT IS
THE Dx FROM HISTORY AND INVESTIGATION(DX
PANCREATIC PSEDOCYST)
10- 2nd DAY POSTOPERATIVE (HYSTERECTOMY)WBC
1600 BP 90/60 PR 105 CXR? (AIR
UNDERDIAPHRAGM) DISCRIB CXR , MANAGEMENT,
WHAT YOU TALL TO HER AND TO GYNECOLOGEST?

78

Slides (Yemen exam)


1-DM PT WITH MASS IN TRUNK (MAY BE SOFT
TISSUE TUMOUR)
2- NEUROFIBROMATOSIS
3- DIVERTICULOSIS +COLORECTAL CANCER
BARUIM ENEMA
4- TRAUMA TO HAND WITH LOSS OF DISTAL
PHALANGES
5- BURN -2ND DEGREE
6- CLEFT PALATE AND LIP
7- RTA WITH LIVER INJURY - CT SCAN
8- 2 CASES OF ERCP X-RAY
9- PHEOCHROMOCYTOMA -CT SCAN
10- AIR UNDER DIAPHRAGM X-RAY

79

Stations (Yemen exam)


1-ABDOMINAL EXAMINATION (ABOUT 2 CASES ABD
MASS & INCISIONAL HERNIA)
2- HYDATID CYST LUNG
3- CHILD FOR ORCHIPEXY --->TALK TO HIS MOTHER
ABOUT OPERATION
4- INVESTIGATIONS AND PREPARATION OF PT WITH
OBSTRUCTIVE JAUNDICE FOR OPERATION
5- COMPLICATION OF ILEOANAL POUCH OPERATION
IN PT WITH UC.
6- TALK TO FAMILY OF PT WITH EXTENSIVE
PANCREATIC TUMOUR
7- PT WITH POSTERIOR NECK MASS
8- HX OF PT WITH OBSTRUCTIVE JAUNDICE
9- HX OF PT WITH NECK MASS

80


OSCE
:
:
o . Stations
.
:
Slides Show
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o 6 10
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o .6/10
o 10 Slides Show . 20
o Slide Show 5 .10
o 6/10 Stations
.Slide Show
o .

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References
1- SCHWATRZ
2- SHORT PRACTICE
3- MRCS PART B OSCEs
4- BAILEY AND LOVE OSCE FOR MRCS
5- CLINICAL CASES AND OSCEs in surgery
6- NORMAN L. BROWSE
7- CRACKING THE MRCS VIVA

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