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

2. 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.

3.  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/ Povidone Iodine (Betadine)
- Leave open , partially insert a gauze wick

4. 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?

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

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

7. Tubes
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.

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

9. (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

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

11.  Needles
 14G- white - abscess drainage
 18G- Pink
 20G- Yellow
 21G- green – Blood culture
 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

12. 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
patient?

13.  A hyper dense, biconvex 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

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

15.  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.

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

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

18. GCS
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

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

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

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

24.  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

25. Intestinal obstruction
Small Bowel large Bowel

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

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

28. Colostomies

29.  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

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

31. Vascular
Arterial ulcers Venous ulcers
Hx of smoking, DM ,
lipids ,HT Hx of DVT, VV,
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

32. 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

33. Uses
 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

34. X ray – KUB IVU

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

36. Internal fixators
Indications
 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
Complications
 Infection
 Non-union
 Implant failure

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

38. fractures
 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

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

40. 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
burns
- requires Escharotomy

41.  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?

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

43. 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
infections
 D5-D7
- DVT , leaking bowel anastomosis
 >1 week
- Distant sepsis – hepatic,cerebral, deep seated
abscesses

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

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

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

47. LMA
Male – 4 cm
Female – 3 cm

48. 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
 Changes in 2005 ALS guidelines
 CPR rate – 30:2 ( not 15: 2)
 All 3 DC shocks – 360J each

51. 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

52. 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)
Polydiaxanone

53. Thank you