STATION 1

(a) Look at the x-rays below and tell me the abnormality that you see in these x-ray
(b) What are the causes of the abnormality?
© What could be the patient presentation?
(d) Why you do not find free gas under diaphragm in appendicular perforation?
(e) What operation will you plan for this patient?

Answers:

(a) The abnormality on the CXR is air under the diaphragm (pneumoperitoneum)
(b) Causes of air the diaphragm are perforation of hollow viscus such as:
 Bowel perforation
 Perforated peptic ulcer
 Ruptured appendix
 Penetrating injury abdomen causing peritoneal penetration, with or without underlying
visceral injury.
 Bullet injury abdomen—with peritoneal penetration and with or without underlying
hollow viscus injury.
 Following laparoscopic procedure or following abdominal operation—due to
entrapment of carbon dioxide gas or air
(c) The patient will present with acute severe abdominal pain, guarding and board like rigidity
(d) The lumen of appendix contains very little amount of gas. So there is no free gas under
diaphragm in appendicular perforation. However, if there is perforation at the base of the
appendix involving the cecal wall, there may be free gas under both domes of diaphragm.
(e) I will do exploratory laparotomy.
 The diagnosis of peptic ulcer perforation is confirmed.
 Simple closure of perforation with interrupted polyglactin suture with an omental patch
(Graham’s patch).
 Thorough peritoneal lavage.
  If it is a perforated gastric ulcer a biopsy is to be taken from the ulcer margin to exclude
malignancy.

STATION 2
(a) Look at the patient below and state the type of injury it?
(b)What methods are used to assess the percentage of burns and what percentage does this
patient have?
(c) How to do you classify burns and what class does this patient belong to?
(d) How are going to manage this patient
(e) Tell us how you are going to administer fluid therapy in this patient?
(f) What are the complications of burns?
(g) What is the criteria for admitting patients with burns and when do you give blood?
(h) what are the different methods for treating burns?
(i) What is the pathophysiology?

Answers:

(a) This is a burn injury

(b) The methods used are Wallace rule of nine(adults), rule of seven(children), rule of palm and the
most accurate is the lund and browder. This child has about 15% burns
(c) (i) Superficial burn-First degree burn
 Involves epidermis only, No blisters, Reddish(Erythema), Painful - Pin prick test is
positive- (severe pain to pin prick) and Heals rapidly by re-epithelialization with no
scars
 (ii) Partial thickness burn-Second Degree

a. Superficial partial thickness:

 Involves epidermis and the papillary dermis, Red, Blistering, moist, Painful, Heal by
epithelialization, complete by 14 days, Minimal or no permanent scars but can
leave discoloration
b. Deep partial thickness:
 Involves epidermis, upper dermis and varying degrees of lower dermis, Pale,
mottled appearance, Fixed staining (no blanching),May be painful or insensate
(depending on depth), Heal by combination of epithelialization and wound
contracture, May take weeks can leave significant scars and contractures over
joints depending on time taken to heal
(iii)Full thickness burns-Third Degree
 Both dermis and epidermis burnt, No blisters, Skin appendages damaged, Look dull
or dark, Pin prink sensation-negative (Insensitive, Eschar to the limb extremities
may be present.

This is a second degree burn.

(d) Management

Initial

 Resuscitation - A, B, C, D, E & fluids

 Catheterize pt.
 Tetanus toxoid 0.5mls IM-single dose
 Wash burnt surface
 Give analgesia

Intermediate [directed to the wound (open or closed method)]

 Daily wound cleaning

 Silver sulphadiazine (flamazine)
 Wet soaks with hypertonic solutions
 Sloughectomy/Escharotomy

Long term

Monitoring

 Fluid replacement
 Urine output (0.5 - 1ml/kg/hr. hence catheterize the pt.)
 Temperature - spikes may indicate infection.
 Heart rate - rapid rate may also indicate infection, or severe dehydration
 Pulse rate
 Mental status
 Edema
Wound healing

 Color
 Pus
 Slough

Nutritional status

 Weight
 Skin fold thickness

(e) Fluid Therapy

 For children, any burn which is 10% (15% Adults) or above is severe and fluid has to be
given IV otherwise give fluids orally in each care.
 There are two regimes of fluid.

(1) Fluid replacement -This is given to replace the loss due to burn. Most of the fluid leave the
circulation and is in the interstitial space.
(2) Maintenance fluid-This is the daily requirement due to insensible losses through sweat, breathe
etc.

(1) Fluid replacements

a) Barclay & Muir formula or Leads formula:

Body wt. x TBSA% = Xmls

2
-1st give 4hrly in 12hrs X (4hr), X (4hr), X (4hr)
-Next- 6hrly in 12hrs X (6hr), X (6hr)
-Then – 12hrly in 24hrs X (12hr), X (12hr)
b) Parkland formula:

Body wt x TBSA% x (2-4mls) = X mls

-1st give half of Xmls in the 1st 8hrs from time of burns event
-2nd give next half of Xmls in the next 16hrs
Important!!! The above two formulae are only applicable up to and including 40% burns. Thus, a
pt. with 54% burns will be considered to have 40% burns, for example. This ensures no fluid
overload.
The fluids used are Crystalloids, N-saline, Ringer’s lactate or Hartmann’s solution

(2) Maintenance fluid in 24 hours.

For a Neonate - 120mls/kg b/wt.
Up to 10kg - 100mls/kg b/wt.
Between 10-20kg - 50mls/kg b/wt.
More than 20kg - 20mls/kg b/wt.
5% dextrose is used for maintenance

(f) Complications
Early
(i) RS
a. Airway obstruction due to inhalation burns(causes pulmonary edema, ARDS, respiratory arrest)
b. Breathing difficulties as a result of respiratory distress due to eschar around the chest
(ii) CVS
a. Edema due to release of inflammatory mediator to produce vasoconstriction and vasodilatation
leading to increased capillary permeability

b. Hypovolaemia due to fluid loss as a result of increased capillary permeability due to SIRS, and
this may lead to renal failure.

c. Hypoxia due to destruction of red blood cells because thermal injury causes coagulative necrosis
to the epidermis and underlying tissue

d. Shock - Due to systemic inflammatory response syndrome (SIRS) or due to an inflammatory

response causing release of inflammatory mediators like cytokines which leads to vasodilatation in
burnt areas

e. Toxic shock can occur if there is 2o bacterial infection causing bacteremia

(iii)MSS
a. Hypothermia as a result of loss of thermoregulatory fxn of the skin due to damage

(iv) GUS
a. Fluid and electrolyte imbalance due to dehydration, hypernatraemia, hypokalaemia and
hypocalcaemia

(v) Metabolic
a. Hyperglycemia due to hypercatabolism and mobilization of glucose as a result of release of stress
hormones


Intermediate
(i) Wound infection due to damage of the protective fxn of the skin
(ii) Septicemia
(iii)Anemia + malnutrition due to haemocoagulation
(iv) Stress ulcers (curling ulcers)
(v) Paralytic ileus due to electrolyte imbalance
(vi) Compartment syndrome due to eschar (slough produced)
(vii) Poor healing, Ankylosing (joint stuffiness)
(viii) Renal failure
(ix) Septic arthritis
(x) Hypoproteinemia
(xi) Ectropion- retraction of eyelid
(xii) Amputation
Late
(i) Contractures
(ii) Hypertrophic scar or keloids
(iii)Marjolins ulcers (malignant)
(iv) Nerve compression
(v) Psychological effects- cosmetic effect

(g) The following is the criteria for admitting patients with burns:
 TBSA >10% - for CHILDREN
 TBSA <5% - in SPECIAL AREAS (Face, Hands, perineum, joint)
 TBSA >20% - for ADULTS
If deep >20% = give blood
20% - 70mls/Kg
Unit 450mls/Kg
For each of burn give 20% of exposed blood volume for 30 min to an hour.
Give blood on 2nd day
(i) In a child with full thickness burns of 10% or more
(ii) Adult with full thickness burns of 20% or more

(h) The following the methods for treating burns:

(1) Open method

Clean & leave open
Topical cream; flamazine cream
(2) Closed method
Clean & dress wound for up to 10 days

(3) Mixed
Clean and apply wet soaks

(4) Other methods

(i) Tangential incision
(ii) Early skin grafting done on 3-4 days of blood transfusion,
(iii) Physiological dressing
- Pig skin
- Amniotic membranes

These respond well to --- healing. In deep burns- wait for 3 days for granulation to form then do skin
graft
(i) The pathophysiology of burns is as follows:
Burns injuries results in both local and systemic response

Local response
The three zones of burns were described by Jackson in 1947
 Zone of coagulation- this occurs at the point of maximum damage. There is irreversible
tissue loss due to coagulation
 Zone of stasis- characterized by decreased tissue perfusion. This is zone is potentially
salvageable. The aim of resuscitation is to increase tissue perfusion here and prevent any
damage becoming irreversible.
 Zone of hyperaemia- in this outermost zone tissue perfusion is increased and the tissue
here will invariably recover unless sepsis or prolonged hypotension

Systemic response
The release of cytokines and other inflammatory mediators at the injury has systemic effect once
burns reaches 30% TBSA
CVS
 capillary permeability is increased leading to loss of intravascular protein and fluids into
interstitial compartment
 Peripheral and splanchnic vasoconstriction occurs. Myocardial contractility is decreased
possibly due to release of TNF
 These changes+ fluid loss from the burn wound results in systemic hypotension and end
organ hypoperfusion
R/S- inflammatory mediators cause bronchoconstriction and severe burns in adult results RDS

METABOLIC- the basal metabolic rate increases up to three times. This plus splanchnic
hypoperfusion, necessitates early and aggressive enteral feeding to decrease catabolism and maintain
gut integrity
IMMUNOLOGICAL CHANGES- nonspecific down regulation of the immune response occurs,
affecting both cell mediated humoral pathways

STATION 3

(a) Look at the abdominal x-ray below and give us you diagnosis?
(b) How does small intestinal obstruction differ from large intestinal obstruction on the plain x ray
(c) Which X-ray is important for evaluation of patient with acute intestinal obstruction?
(d) How many fluid levels in abdomen X-ray may be regarded as normal?
(e) What is intestinal obstruction? And how do you classify it?
(f) What are the mechanical causes and the causes of paralytic?
(g) How are you going to manage this patient?

Answers:
(a) This is likely to be a X-ray of patient with small bowel obstruction because of the multiple
are-fluid levels.
(b) The difference between small and large bowel obstruction is as follows:
Small bowel Large bowel
Central position Peripheral position
Valvulae conniventes( complete rings) Haustrations (incomplete rings)
Many loops Few loops
(c) A supine abdominal film gives better delineation of the gas filled gut loop and an erect film
is not required routinely
(d) In adults three inconstant fluid levels—one at duodenal cap another at terminal ileum may
be regarded as normal. In infants few fluid levels (2–4) in small gut may be regarded as
normal
(e) This is a pathological condition in which the content of the intestines cannot be pushed
download. And it can be classified as follows:
  clinically

 Congenital and acquired

 Onset
- Acute – sudden
- Chronic – insidious
 Site high – small bowel
Low – large bowel
 Aetiology
(a) Intralumen – feacal, gallstonis, etc.
(b) Intramural – congenital atresia tumour.
(c) Extramural – hernia, L/N
(f) The mechanical causes are - Tumours - Intramural - Extra mural, and the causes of
paralytic ileus are - Peritonitis - K⁺ loss - Uremia / Toxins, etc - Anaestesia- Spinal cord
injuries
(g) INVESTIGATION:

1. Plain X – Ray
- Erect- check for the air fluid levels
- Supine- check where the obstruction is. Able to see distended bowel
- Dicubitus- alternative if erect cannot be done
2. U/E
3. Ultrasound
4. CT
5. MRI
So first you have to canulate the patient and start fluids normal saline and also put NGT and
catheterize the patient
TREATMENT
1Gastric solution 2.IV 3. Prophylactic Antibiotic 4. Conservative treatment 5. Surgery

INDICATION:
Dead Bowel:
. Loss of peristalsis, Loss of normal sheen, Colour, Loss of pulsation
 STATION 4.
(a) Exam the abdomine of this patient?
(b) What is a colostomy?
(c) From which part of a colon can you easily make a colostomy and why?
(d) What are the indications of colostomy
(e) What are the complications
(f) What are the different types of colostomy?

ANSWERS:
(a) Examination of a stoma
Expose the pt.
1. Inspection

Seeing a stoma in left iliac fossa

It is not covered by the bag

(i) The mucosal lining looks healthy
(ii) There is a spurt or flush and skin
(iii)It has one opening (end)
(iv) The rest of the abd shows
a. A scar
b. Midline transverse incision

(b) A colostomy is a man-made fistula or an artificial colo-cutaneous fistula on the anterior

abdominal wall for the purpose of discharging faeces and flatus.
 (c) The parts of a colon from which you can make a colostomy are:
According to anatomical location;
 Sigmoid colostomy (sigmoid colon)
 Transverse colostomy (transverse colon)
 Caecostomy (caecum)
This is because these sites are not retroperitoneal unlike the ascending and descending colon
(d) The following are the indications:
Indications
a. Congenital
(i) Imperforate anus (ii) Hirschsprung disease (iii)Anal atresia (iv) Anorectal agenesis (v) Anal
stenosis
b. Acquired
(i) Ischemic bowed disease/ gangrene due to strangulation (ii) Penetrating trauma to the bowel
(iii) Intestinal obstruction e.g. sigmoid volvulus (iv) Retrovaginal fistula prior to repair (v) Tumours
(e)General complications — related to underlying disease:
 Stoma diarrhoea — related to water and electrolyte imbalances, hypokalemia being the
commonest and most important consequences
 Nutritional disorders
 Stones — both gallstones and renal stones increase in frequency following an ileostomy
 Psychosexual — leading to impotence in men/loss of libido
 Residual disease, e.g. Crohn‘s and parastomal fistula
Specific complications:
a. Ischemia gangrene b. Hemorrhage c. Retraction d. Prolapse/intussusception e. Parastomal hernia
f. Stenosis — leads to constipation g. Skin excoriation h. Fistula

(f) Types
Temporary
(i) Loop
(ii) Spectacle
(iii)Double barrel
(iv) Hartmann


Permanent
(i) End colostomy
 STATION 5
(a) What is the name of the set below?
(b) What is the amount of weight needed in relation to body weight
(c) What are the indications?
(d) Give 3 advantages
(e) Give 3 disadvantages
(f) What are the complications?
(g) How the dunlop traction is set up in upper extremity?

ANSWERS:
(a) Skin traction
(b) 1/10th of the body weight
(c) Indications
-Extreme of age
years (longitudinal bone growth may be arrest)
- fragile bones
-Those reacting to pin
-Fixed flexion deformity
-Fractures

-Upper femoral epiphysis separation

-An unstable hip after reduction of a dislocation
(d) Advantages

(e) Disadvantages

(f) Complications
 -Compartment syndrome
 -Skin avulsion
 -Allergic rxn
 -Gangrene or ischemia
 -Joint stiffness
  Hypostatic pneumonia
STATION 6
1. What is name of this set - up and give the specific name of the traction � (1)
2. What is the amount of weight needed in relation to body weight � (2)
3. Give 3 advantages of perkins traction
4. Give 3 disadvantages of perkins traction
5. How is pin tract infection is prevented �
6. How to do insert the pin

ANSWERS
1. Skeletal tractions- perkins tractions
2. 1/7 th
3. Advantages:
a. prevents development of contractures � (3)
b. prevents atrophy of muscles � (3)
c. early healing and mobilization � (3)
4. Disadvantages;
a. injury to the common peroneal nerve � (3)
b. fracture of tibia at the site of insertion of the pin � (3)
c. pin tract infection�(3)
5. daily inspection and cleaning
6. Inserted 2 cm distal 2cm lateral to the tibial tuberosity
STATION 6
(a) What is the function of this tube in this picture?
(b) State 3 indications
(c) State 4 complications/problems associated with the use
(d)State 2 contraindications to use of this tube
(e) What are the types

ANSWERS:
(a) Gastrostomy feeding tube
(b) Oesophageal obstruction, severe malnutrition, major surgeries, severe sepsis, trauma, head
and neck surgeries,. It is done if feeding is required for more than one month.
(c) Leak-gastric fistula, displacement, blockage of tube, tube migration, diarrhea, bloating,
abdominal cramp, wound infection.
(d) Previous gastric surgeries, intestinal obstruction, gastric outlet obstruction
(e) Types of gastrostomy are as follows:
Base on technique;
 Stamm temporary gastrostomy
 Kader-Senn temporary gastrostomy
 Percutaneous endoscopic gastrostomy
 Janeway’s mucus lined permanent gastrostomy
Base on duration;
 Temporal
 Permanent
Base on lining;
 Mucus lined (permanent )
 Serosal lined (temporal)
STATION 7
(a) What can you see in this patient?
(b) What are the indications
(c) What are the different types of amputations do you know?
(d) What are the complications of amputations
(e) How do you rehabilitate the patient?

ANSWERS

(a) Above knee amputation

(b) Indications
 4 Ds
 Indicated when part of the limbs is Dead, Deadly or Dangerous, Dead loss or Damn
nuisance
(i) Dead (Vitality of limb part is destroyed)
 The limb may be dead when arterial occlusion or stenosis causes tissue infarction with
putrefaction of macroscopic portion of tissue (gangrene)
Dry gangrene due to arterial occlusion or stenosis
Arterial occlusion

 Major (large) vessels – atherosclerotic/embolic occlusions

 Small vessel - DM, Buegers disease, Raynaud‘s disease, egotism

(ii) Deadly/ Dangerous (life Saving)
 Limb may be deadly or dangerous

 When wet gangrene occurs with its accompanying putrefaction infection

 ( If infection spreads to surround viable tissue e.g. necrotizing fasciitis
 When cellulitis e.g. severe toxemia overwhelming systemic infection can occur Gas
gangrene due to C. perfringes
 Neoplasm like osteogenic sarcoma, extensive melanoma
 Arteriovenous fistula

 Life of the Pt. is threatened by spread of a local condition

(iii)Dead loss
 Severe laceration, #, partial amputation due to trauma or burns
 Severe contracture or paralysis e.g. poliomyelitis
 Severe rest pain without gangrene in patient with an Ischemia

(iv)Damn nuisance (deformed/ neuropathy)

 Polydactyl
 Severely impaired gait

(c) Types of amputations

 Ray amputation- Amputation of toe with head of metatarsal or metacarpals.
 Transmetatarsal amputation (Gillies’)- Here amputation is done proximal to the
neck of the metatarsals, distal to the base.
 Lisfranc‘s amputation (Tarsometatarsal amputation)- Here tarsometatarsal joint
is disarticulated with a long volar flap
 Chopart‘s amputation (Midtarsal amputation)-Here talonavicular joint and calcaneo
cuboid joints are disarticulated
 Syme’s amputation-It is removal of the foot with calcaneum and cutting of tibia and
fibula just above the ankle joint with retaining heel fl ap (dividing both malleoli).
 Pirogoff‘s amputation-It is like Syme’s amputation except posterior part of the
calcaneum is retained along with heel flap.
 Below-knee amputation
 Above knee amputation
 Transcondylar-Gritti-Stokes amputation with long posterior flap. emur is divided
just above the articular surface and patella is anchored to the divided femur.
 Hip disarticulation
 Hind quarter amputation-Inter innominate abdominal amputation (Sir Gordon
Taylor’s amputation): Removal of one side pelvis with innominate bone, pubis,
muscles and vessels.
 Krukenberg’s amputation
 Interscapulothoracic amputation
  Above elbow
 Below elbow

(d) Complications
Immediate / early
(a) associated with spinal anesthesia
-Hypotension
- Failure to breathe because it can affects phrenic nerve
- Compression of nerve- paralysis
(b) Surgical complications
- Reactionary hemorrhage
- Hematoma
Intermediate
-Wound infection usually associated with hematoma
-Abscess formation
-Wound dehiscence
-Gangrene of the flaps due to ischemia
-Higher amputation leading to Gas gangrene in mid-thigh stump due to fecal contamination
-Deep vein thrombosis (DVT)
-Pulmonary embolism
-Psychological effect – depression
Late
-Pain due to unresolved infection (sinus, osteomyelitis, and sequestrum)
-A bone spur
-A scar adherent to bone
-Amputation neuroma stump
-Phantom limb pain
-Ulceration of the stump due to pressure effects of prosthesis or increased ische

(e) -Exercising proximal stump

 -Molding of stump for prosthesis
-Social and psychological care
STATION 8
(a) Define what you are seeing?
(b) How do you classify it?
(c) What are the causes?
(d) what abnormalities may be associated with it
(e) How is it investigated?
(f) How is it treated?
(g) What are the differential diagnosis
(h) Describe how CSF is formed and flow?
(i) How does OFC changes with age

ANSWERS:
(a) HYDROCEHALUS-Excessive accumulation of cerebrospinal fluid (CSF) in the ventricles
and subarachnoid spaces due to disturbance in its formation, flow or absorption
(b) Classification;
1. Communicating(non-obstructive) or non-communicating(obstructive)
2. Congenital or acquired
3. Hydrocephalus with increased ICP or Normal pressure Hydrocephalus
(c) Causes ;
 Increase CSF production; choroid plexus papilloma and choroid plexus carcinoma
 CSF flow obstruction; aqueductal stenosis, brain lesion and tumour, infections,
intraventricular bleeds, Dandy Walker cyst
 Reduce CSF absorption; obstruction at the arachnoid granulations, otitic hydrocephalus,
sinus thrombosis, arachnoiditis
 Familial causes; Bicker’s Adam syndrome, an X-linked recessive abnormality
(d) Associated abnormalities
 Dandy-Walker syndrome
 Arnold-Chiari malformation
 Spina bifida
  Aqueductal stenosis
(e) Investigations include: The CT scan and/or MRI along with ultrasonography in an infant are
the most important studies to identify the specific cause and severity of hydrocephalus

(d) Treatment;
Medical; pre-operatively is commenced;
 Acetazolamide- a carbonic anhydrase inhibitor
 Furosemide- has synergistic action with acetazolamide
Surgery
Shunting procedure ;
 Ventriculo-peritonel
 Ventriculo-pleural
 Ventriculo-atrial
 Lumboperitoneal
 Torchedsen shunt
(g) Differential diagnosis;
 Hydrocephalus ex-vacuo
 Hydrancephaly
 Familial big head
(h) The following is how CSF is formed and flow: The CSF is formed primarily in the
ventricular system by the choroid plexus, which is situated in the lateral, third, and fourth
ventricles. Normally, CSF flows from the lateral ventricles through the foramina of
Monro into the 3rd ventricle. It then traverses the narrow aqueduct of Sylvius, which is
approximately 3 mm long and 2 mm in diameter in a child, to enter the fourth ventricle.
The CSF exits the fourth ventricle through the paired lateral foramina of Luschka and the
midline foramen of Magendie into the cisterns at the base of the brain.
(i) OFC- occipito-frontal circumference
 At birth average 35cm
 1st year it increase by 12cm to 47cm
 In the 1st 3months, increase by 2cm/month (gain of 6cm)
 In the next 3months increase by 1cm/month (gain of 3cm)
 In the last 6months increase by 0.5cm/month (gain of 3cm
 STATION 9
(a) What can you see?
(b) What are the different types?
(c) What are the indications
(d) What is the absolute contraindication?

ANSWERS:
(a) Suprapubic cystostomy
(b) Open and closed cystostomy
(c) Indications for suprapubic cystostomy
 Retention of urine when transurethral catheterization has failed
 Rupture of the urethra
 Urethral cutaneous fistula
 Per urethral abscess
 Extravasations of urine
 Chronic retention in neurogenic bladder
(d) Bladder ca.
STATION 10
(a) Take hx of this pt
(b) What are the causes of obstructive jaundice?
(c) How do you investigate?
(d) How do you treat?
(e) What is courvoisier’s law?
(f) Is urobilinogen present or absent in urine?
 ANSWERS:
(a) hx taking:
 How did it start, when did start and how has been the progress of jaundice (sudden with
biliary colic or slow and progressive
 Have you had any previous dyspeptic symptoms and relation to fatty food
 Have had any previous similar episode - (recurrent)
 any backache
 any weight loss
 color and consistency of the stool
 color of the urine
 any itching of the skin
(b) the causes are as follows:
Obstructive (surgical )
Extra hepatic and intrahepatic (hepatitis/cirrosis)
i. Gallstones
ii. Sclerosing cholangitis
iii. Carcinoma of Ampulla of Vater
iv. Carcinoma of Pancreas ( head )
v. Carcinoma of bile ducts
vi. Post-traumatic stricture
vii. Metastatic
viiiLymph nodes of porta hepatis
ix Parasitic infestation: as ascaris & fasciola.
(c) I will do some investigations for confirmation of diagnosis.
„ Liver function test
 Serum bilirubin: (a) total, (b) conjugated, (c) unconjugated
 Alkaline phosphatase
 Serum enzymes ALT/AST
 Serum protein:total/albumin/globulin
 Prothrombin time.
„ Ultrasonography of hepatobiliary system.
 Further investigations will be guided by the USG report
(d) Treatment is basically surgical to remove the cause of obstruction. Preoperative
preparations then
- ERCP: Sphincterotomy + dormia basket
- Open: if failed ERCP Cholecystectomy + Choledocholithotomy
(a) courvoiser’s law: If in a jaundice patient, the gallbladder is palpable, then it is not due
to choledocholithiasis as the gallbladder would have been fibrosed by previous
cholecystitis
(b) it is not present
STATION 11
(a) Examine the how ulcer
(b) What is you clinical diagnosis?
(c) How are going to make the confirmatory diagnosis?

ANSWERS:
(a) On inspect
 there is a ulcer on lateral malleolar of the right foot
 it has regular margin
 it has undermined edges
 there is pus on the floor
 the surrounding area looks swollen
On palpation
 regional lymph nodes examination
 sensation examination
 pulses examination
(b) Tuberculous ulcer
(c) Biopsy
STATION 12
a) What are your differential diagnosis
b) What are the various types of malignant melanoma
c) Which has the worst prognosis
d) What are other site lesion could be found
e) What features make a lesion suspicious
f) How is it staged
g) Treatment options
h) Prognosis

ANSWERS:
(a) Differential diagnosis;
 Malignant melanoma, Squamous cell ca, Basal cell ca, Seborrhoeic keratosis,
Cuteneous agiomata, Pyogenic granuloma, Kaposi sarcoma
(b) Types of malignant melanoma
 Superficial spreading (55%)
 Nodular (15-30%)
 Lentigo maligna(10%)
 Acral lentiginous (29-72% in blacks and 2-8% in whites)
(c) The nodular melanoma has the worse prognosis, then the acral lentigenous type. The
lentigo maligna has the best prognosis
(d) Common sites; skin, uveal coat of the eye, GI tract, leptomeninges, perianal skin.
(e) Signs of malignant changes in a benign naevus;
Pain, Itching, Satellitism, >6mm, Deepening of pigmentation, Crust formation,
Inflammatory changes, ulceration, Bleeding, Irregularities of edges, Lymph node
metastesis
(f) Staging
TNM – see text
(g) Treatment;
 Excision
 Excision + elective lymph node dissection (ELND) ELND is recommended
only in patient with palpable or proven lymphadenopathy
  Immunotherapy; cytokine and interferon as adjuvant
 New immune and gene therapies; vaccine and gene therapy
 Melanoma are radio and chemo- resistant
(h) Prognosis
Clinical indicators
 Sex ; better in females
 Age ; better in younger < 60years
 Site; worse in scalp, feet, hands and trunk
 Pre-existing naevus ; better prognosis
 Skin colour ; non- white poorer prognosis
Pathological indicators;
 Tumour thickness (Breslow’s level); < 0.7mm good,>1.5mm
 likelihood to metastesis, >3.5mm greater tendency to met.
 Ulceration; poor prognosis
 Nodular, acral lentigenous and genital; unfavorable prognosis
 Clark’s level (invasion)
 Size of tumour; <2cm without spread good
 Type of melanoma; lentigo maligna good prognosis
STATION 13
(a) What is the name this tool?
(b) What are the indications
(c) What are the complications?

ANSWERS:
(a) Ryles tube (NG)
(b) Indications include:
 Feeding in absence of swallow reflex in unconscious pt.
 Decompression of GIT e.g. paralytic ileus
 Gastric lavage
 Analysis of stomach content
 Physical injury to oral cavity
 Inflammation or ca esophagus
 Premature babies to prevent aspiration
(a) Complications:
Complications
I. Early (during insertion)
(i) Mucosal damage (ii) Laryngo- tracheal obstruction? (iii)Esophageal or gastric perforation (iv)
Bleeding (v) Accidental naso-tracheal intubation (vi) Accidental transbrochial perforation
(vii) Nausea and vomiting
II. Late (during use)
(i) Aspiration pneumonia (ii) Gastro- irritations (iii)Pharyngitis/esophagitis (iv) Vocal cord paralysis
(v) Stenosis or stricture of esophagus (vi) Ca esophagus (vii) Infection (viii) Loss of electrolytes due
to vomiting (ix) Necrosis:- retro- or nasopharyngeal
STATION 14
(a) What is this?
(b) What are the indications?
(c) What are the complications?

ANSWERS:
(a) The first one is A 2-way Foley‘s urinary catheter (1 channel for drainage and the
other for inflating the balloon)
The second one A 3-way Foley‘s urinary catheter (an additional channel for irrigating
the bladder and are used when ongoing hematuria is expected e.g. after transurethral
resection of the prostate (TURP))
(b) Indications
(i) Therapeutic- Urine retention, Urine incontinence
(ii) Diagnostic- Bladder rupture, Renal failure
(iii)Pre- operative -For monitoring urine output before operation
(iv) Unconsciousness
(v) Monitoring purposes - Spinal injury, Urine output, Abdominal pressures
(c) Complications
(i) Early:-Traumatic injury to urethra, Bleeding, By – pass
(ii) Late:-Infections- UTI, Urethral strictures, Incontinence (urine), Paraphimosis, Blockage,
Failure of balloon to deflate, Balloon size – 3-5ml , Excursion of catheter if suprapubic
STATION 15
(a) What is this?
(b) What are the indications?
(c) What are the complications?

ANSWERS:
(a) Endotracheal tube
(b) Indication:
 Facilitate artificial ventilation
 Facilitate surgery around face or neck
 Protect lungs if risk of pulmonary aspiration
 Cardiac arrest
 Serious Head Injury
 Inhalational burn
(c) Complications
Early
(i) Accidental esophageal intubation loss of airway control
(ii) Accidental intubation of main bronchus or RT
(iii)Trauma to larynx, tracheal or teeth
(iv) Aspiration of vomitus during intubation
 (v) Laryngo- tracheal perforation bleeding
Late
(i) Disconnection or blockage of tube
(ii) Infection
(iii)Delayed tracheal stenosis due to prolonged intubation

STATION 16
(a) What are these?
(b) What are the indications
(c) What are the complications

ANSWERS:
(a) Guedel Airway or Oropharyngeal airway
(b) Indication:
(i) Prevent tongue from falling back in unconscious patient
(ii) Endotracheal intubation
(iii)Prevent gastric aspiration
(iv) Administration of drugs- anesthetic, asthma, apneic patients prevent aspiration
 (v) Major operation e.g. cardiac
(c) Complication:
(i) Trauma to mounting pharynx
(i) Blockage of airway
(ii) Get blocked
(iii)Misplacement
(iv) Break teeth
(v) Infection
STATION 17
(a) What is this?
(b) What are the anatomical positions?
(c) What are the types of acute appendicitis
(d) Pt presented with Rt iliac fossa pain. Was taken to theatre were it was removed. How did the
patient present?
(e) What are the complications?
(f) What is the differential?
(g) What are the investigations you are going to do?
(h) How are you going to treat the patient?

ANSWERS:
(a) Blind ended muscular tube: Appendix specimen
(b) Anatomical positions: i. Retrocaecal(common) ii. Preileal(least) iii. Postileal iv. Pelvic
v. Subcaecal vi. Paracaecal
(c) Types
Catarrhal (Non obstructive)
obstructive
(d) Clinical features
Symptoms
  Pain – visceral pain starts around the umbilicus due to distension of appendix, later
after few hours, somatic pain occurs in RIF due to irritation of parietal peritoneum
due to inflamed appendix
 Anorexia- if good appetite not appendicitis
 Malaise, Fever (low grade), Mild diarrhea, Abdomen pain caused by coughing,
Nausea and reflex vomiting
Signs
 Tachycardia
 Abdominal tenderness- maxima at Mac Burney‘s point
 Pointing sign
 Psoas test – for retrocaecal appendix, hyperextension of right
 Obturator test – for pelvic appendix, internal rotation of right hip causes pain in RIF due
to irritation of obturator internus muscle
 Rovsing sign – on pressing left iliac fossa, pain occur in RIF due to shift of bowel loops
which irritate the peritoneum
 Blumberg sign – tenderness and rebound tenderness in right iliac fossa
 Baldwing test - +ve in retrocaecal appendix-when legs are lifted off bed with knee
extended, the pt. complains of pain while pressing on abdomen(Ribs-Ilium)
 Bastede sign
(e) Complications
Perforation (peritonism) – local or generalized peritonitis
RIF appendix Mass, (appendicitis + densely adherent caecum and omentum)
RIF abscess
Pelvic abscess

(f) DDx
 GIT:i. Cholecystitis ii. Ruptured PUD (Peptic Ulcer Disease) iii. Pancreatitis iv.
Intersucception v. Crohn‘s disease vi. Caecal tumors vii. Caecal diverticulitis viii. Meckel‘s
diverticulitis ix. Sigmoid volvulus
 Other abdominal: i. Ovarian cyst/ Torsion of ovarian cyst ii. Ovarian abscess iii. Ectopic
pregnancy iv. Oophoritis v. Salpingitis vi. Renal colic vii. Psoas abscess viii. Rectus sheath
hematoma
 Extra-abdominal: i. Lobar pneumonia ii. Herpes zoster

(g) Investigations
May be normal and are non diagnostic
(i) FBC
(ii) U/S
 (iii)CT
(iv) Laparoscopy
(v) Gravid index in female
(h) Treatment
(i) Resuscitation (ii) Operation – Appendicectomy (iii)Drugs - Benzyl penicillin 2mu 6 hourly iv -
Metronidazole 500mg 8 hourly iv - Gentamycin 80mg 8 hourly iv
All these for five days.

Supportive: Analgesics post operatively

STATION 18
Look at the x-ray below
(a) What is your diagnosis?
(b) What type of x-ray is this?
(c) What are the D/D of a radiopaque shadow in this region?
(d) How will you confirm your diagnosis?
(e) Which type of renal stones are radiopaque?
(f) Which type of renal stones are radiolucent?
(g) Describe how the patient will present?
(h) how will you treat this condition?

(a) This appearance suggests radiopaque gallstones and kidney stone.

(b) KUB X-ray
(c) Ddx are Kidney stone, Gallstones, Pancreatic calculi, Foreign body, Fecolith, Phleboliths,
calcified lymph node, calcified renal tuberculosis, calcified adrenal gland, chip fracture of a
transverse process of vertebra or calcification of costal cartilage.
(d) I will confirm the dx by :
 taking a lateral view;Gall stone lies anterior to the vertebral body and Kidney stone
lies posterior to the vertebral body or overlaps the vertebral body
 confirmation will be by an ultrasonography
(e) The type of renal stones that are radiopaque
 oxalate stones
 Phosphate stones
 cystine stones
 Xanthine stones
(f) Uric acid and urate stones are radiolucent. If these stones are contaminated with calcium salts
they may be radiopaque.
(g) The patient presents as follows:
 Asympomatic stones seen on a routine X-ray or ultra sonography for some other reason.
 Symptomatic:
 Fixed renal pain—dull aching constant pain in the loin or hypochondriac region.
 Renal or ureteric colic—acute, colicky pain starts in the loin and radiates to the groin.
 There may be associated nausea and vomiting and strangury.
 Hematuria—due to irritation by the stone.
 Pyuria—due to associated infection.
 May present with hydronephrosis or pyonephrosis
(h) Treatment:
 Ureteroscopy- This procedure can be used to remove or break up (fragment) stones
located in the lower third of the ureter.
 Lithotripsy- This procedure is effective for stones in the kidney or upper ureter.
 Percutaneous Nephrostolithotomy (PCN)
 Open surgery
STATION 19
(a) What is this?
(b) What are the indications?
(c) What are the advantages and disadvantages?
(d) What are the complications?
(e) What are the most common pathogen associated with the pin site infections?

ANSWERS:
(a) External fixator
(b) Indications
 Fractures associated with severe soft-tissue damage where internal fixation is risky,
or to allow the wound to be left open for inspection, dressing or definitive coverage.
 Severely comminuted and unstable fractures, which can be held out to length while
healing.
 Patients with multiple severe fractures.
 Fractures of the pelvis, which often cannot be controlled quickly by any other
method.
 Fractures associated with major vessel damage.
 Infected fractures, for which internal fixation might not be suitable.
 Ununited fractures which require bone reconstruction
(c) ADVANTAGES
 Less damage to blood supply of the bone
  Minimal interference with soft tissue cover
 Useful for stabilizing open fractures
 Rigidity of fixation adjustable without surgery
 Good options in situation with risk of infections
 Quiet safe to use in cases of bone infections
(d) Complications of external fixation
 Damage to soft-tissue structures by transfixing pins or wires. Nerves or vessels
may be inadvertently injured, or ligaments may be tethered. The surgeon must be
thoroughly familiar with the cross sectional anatomy before operating.
 Over-distraction may prevent contact between the fragments, making union
unlikely.
 Pin-track infection is unlikely with good operative technique; nevertheless,
meticulous pin-site care is essential, and antibiotics should be administered
immediately if infection occurs.
(e) Staphylococci epidermidis and s. aureus
STATION 20
(a) What is this?
(b) How do you classify open fractures?
(c) How do you manage open fractures?
 ANSWERS:
(a) This is an open tibial fracture
(b) Gustillo-anderson classification
(c) Debridement and irrigation, ATT, antibiotics then fracture later

STATION 21
(a) Describe the apparatus?
(b) What are the Indications?
(c) What are the complication?
(d) What care is required?

ANSWERS:
(a) Tracheostomy
(b) Indications include:
1. Upper respiratory tract obstruction ( mechanical obstruction ):
 Laryngeal obstruction: causes of stridor.
 Supralaryngeal obstruction:
 Retropharyngeal abscess.
 Ludwig's angina.
 Tumours of the tongue base.
 Infralaryngeal obstruction:
 Malignant thyroid.
 Cellulitis in the neck.
2. Lower respiratory tract obstruction ( secretory obstruction ):
  Any condition causing abolished or weak cough reflex leads to accumulation of
secretions inside the alveoli. This prevents gas exchange leading to hypoxia and acidosis.
The patient is said to be drowned in his own secretions.

(c) complications
1. Anaesthetic complications:
 Shock from local anaestheisa (idiosyncrasy or overdosage).
2. Haemorrhage:
 Primary hemorrhage: Occurs during operation. Treated by ligation or coagulation.
 Reactionary hemorrhage: Occurs within the first 24 hours due to slipped ligature. Treated
by ligation.
 Secondary hemorrhage: Occurs between the 5th and 10th day due to sepsis. Treated by
antibiotics and ligation.
3. Pulmonary complications:
 Apnea: arrest of respiration due to sudden wash of CO2 after tracheostomy. The
respiratory centre fails because it has been accommodated on a high level of CO2.
Treatment: Close the tube for a while or give a mixture of O2 and CO2 10 %.
 Pulmonary oedema: Intra-alveolar exudation causing noisy respiration, froth and
cyanosis. It occurs due to sudden drop of intra - alveolar pressure after opening the
trachea leading to increased capillary permeability and intra- alveolar exudation.
Treatment:Respiratory and cardiac stimulants and connect the tube to under water seal system
making expiration under pressure.
 Pneumothorax: Due to injury of the pleura leading to entery of the air in the pleural
cavity. The right pleura apex is high, specially in children and females, and may by
injured during operation.
Treatment: Aspiration of the air through an intercostal needle and connected to under water seal.
 Surgical emphysema: -
In the neck: It is air spreading under the skin. It occurs due to leakage of air from around
the tube if it is small in relation to a wide tracheal opening or tight closure of the wound.
Treatment: Remove the sutures of the wound and insert a suitable tracheostomy tube. Very
rarely, multiple skin incision may be needed.
In the mediastinum:
Air extending down to the mediastinum causing cardiac
embarrassment. It occurs due to forgetting to incise the pretracheal
fascia before opening the trachea.
4. Injury of important structures:
• Injury of blood vesseles causes haemorrhage.
• Injury of pleura causes pneumothorax.
• Injury of the cricoid cartilage in high tracheostomy leads to perichondritis
and permanent subglottic stenosis.
• Injury of oesophagus posteriorly by deep incision of trachea or by long
tube causes tracheo-oesophageal fistula.
5. Complications of tracheostomy tube: Fig. (29)
• Small tube leads to surgical emphysema.
• Long tube causes tracheo-oesophageal fistula.
• Obstructed tube by mucous or crustations causes stridor.
• Slipped tube specially in low tracheostomy causes stridor.
• Epithelialization of the site of the tube → tracheocutaneous fistula.
• Failure of decannulation due to laryngeal or tracheal stenosis.

(d) Post operative care:

• Position: semi-sitting to help easy breathing and effective coughing.
• Room atmosphere should be humidified with steam to compensate for the
moisture lost.
• Observation of respiration with the tracheostomy tube by:
Movement of a piece of cotton or condensation of water vapour over
a mirror placed in front of the tube.
The patient can not speak.
• Broad specturm antibiotics.
• Care of the tube:
Repeated suction through the tracheostomy to avoid tube blocking.
Repeated removal of the inner tube to clean it.
• Decannulation: i.e removal of the tube after treatment of the cause.
• The tube is closed with a cork as a test and the patient is observed for 2 days.

(22) STATION ON HEMATURIA

(a) Take a history of haematuria from the examiner
(b) what investigations are you going to do?
(b) What are the possible common differential diagnosis of haematuria
Answers:
(a) 1. ASKS FOR AGE
2. HOW, WHEN, AND PROGRESS OF HAEMATURIA INCLUDING FEVER
3. ASSOCIATION WITH PAIN OR WITHOUT
4. ANY PAST LOIN / REFERRED COLIC PAIN / HYPOGASTRIUM /PERINEUM
/URETHRAL PAIN
5. ANY DYSURIA / PYEURIA
6. FREQUENCY OF URINATION INCLUDING AT NIGHT
7. TYPE OF HAEMATURIA (INITIAL, MIXED, TOTAL)
8. ANY HISTORY OF RECENT TRAUMA
9. ANY HISTORY OF T.B. / BILHARZIASIS IN THE PAST
(b) investigations:
1.Dipsticks pH, glucose, protein, blood, Useful screening test for
bilirubin, ketones, nitrates diabetes, renal and hepatic
disease

2.Microscopy and gram stain RBCs, WBCs, crystals, May indicate infection or
bacteria renal disease

3.Urine culture Number and type of bacteria Diagnosis of UTI

B. Blood analysis Hb, platelets, WBCs May detect

anemia/polycythemia
Urea, creatinine, electrolytes
Raised in patients with renal
Ca++, phosphates, uric acid, failure
albumin
Screening for metabolic
PSA, AFP, HCG disorders in renal calculi
Tumor markers for prostatic
ca and testicular ca
1. Structure KUB Detect bony metastases,
paget’s disease, soft tissue
IVU masses, abnormal
USG calcification

Transrectal USG Delineates entire urinary

tract
CECT
Assessment of renal and
scrotal masses and bladder
emptying
Useful in assessing prostatic
disease
Preoperative staging of renal
carcinoma
2. Function Radioisotope renography Assess function of each
kidney independently
DTPA-99mTc-dimercaptosuccinic acid,
DMSA-diethylenetriamine pentaacetic
acid.

E. Endoscopy Cystoscopy Assessment of urinary tract

for neoplastic or stone
Ureteroscopy disease
Ureterorenoscopy

(c) Differential Diagnosis of red urine:

 Hematuria
 Hemoglobinuria/myoglobinuria
 Anthrocyanin in beets and blackberries
 Chronic lead and mercury poisoning
 Phenolphthalein (in bowel evacuants)
 Phenothiazines (e.g., Compazine)
 Rifampin
(23) identify the following orthopaedic devices and their uses
(a) Plaster shears
 Special shears to cut plaster of Paris casts. Designed to cut
upwards away from the tissues to avoid injury. Called also
plaster scissors, Esmarch plaster shears

(b) Plaster spreader

 A reverse pincer device with flat blades that are fitted down into a cut made in a plaster
cast that is to be removed. Opening the handles forces the plaster apar

(c) Jacobs chuck T-handle: used for remove of a Steinmann pin

(d) Used in the removal of external fixators

(e) Eschmarch tourniquet: for bloodless surgery

(f) Rigid cervical collar: stabilizing the neck in cervical spine injuries(prevents rotations)

(g) K-wire: for fixation of a fracture

 (h) Stock net: used prior to apply POP

(i) pneumatic tourniquet: used in bloodless surgery(controlled pressure)

(j) Thomas splint: to move a pt with fracture from point to another

.
STATION 24
(a) What can you see?
(b) What are the indications?
(c) How do you insert it?
(d) How do you remove it?
(e) What is the physiology behind it?
(f) What is the purpose of underwater seal drainage?
(g) How do you tell when it function?
(h) How do you tell when its active?
(i) How do you transfer the patient?
(j) What are the complications?
Answers:
(a) Underwater seal intercostal drainage: it is a closed chest drainage system used to
allow air and fluid to escape from the plural space with each exhalation and to prevent
their return flow with each inhalation
(b) Indications :
(i) Pleural effusion
 Haemothorax
 Chylothorax
 Malignant/Recurrent pleural effusion
 Empyema thoracis
(ii) Gas in Pleura
 Pneumothorax
 In any hypoventilated patient
 Tension pneumothorax
 Persistent recurrent pneumothorax
(iii)Post operations
 Thoracotomy
 Oesophagectomy
 Cardiac surgery
(iv) Surprise content
 Bowel/Gastric content
 (c) The patient is placed in the lateral position with the unaffected side down, and the head of
the bed is inclined 10—15 degrees. The patient‘s arm on the affected side is extended
forward or above his or her head.
 Triangle of safety – Anterior-lateral border of pectoralis major, posteriorly-mid axillary line
(anterior aspect of lattisimus dorsi), apex-just below the axilla, inferior-just below the nipple.
This is not reliable in female
 With the skin prepared, 1% lidocaine is infiltrated over the 5th or 6th rib in the middle or
anterior axillary line.
 A 2- to 3-cm transverse incision is made through the skin and subcutaneous tissue. A curved
clamp is used to bluntly dissect an oblique tract to the rib.
 With careful spreading, the clamp is advanced over the top of the rib. The parietal pleura is
punctured with the clamp, and an efflux of air or fluid is usually encountered.
 A finger introduced into the tract to ensure passage into the pleural space and to lyse any
adhesions at the point of entry.

 With the clamp as a guide, the chest tube is introduced into the pleural space. It is directed
apically for pneumothorax and basally and posterior for dependent effusions.
 A clamp placed at the free end of the chest tube prevents drainage from the chest until the
tube can be connected to a closed suction or water-seal system.
 The chest tube is advanced until the last hole of the tube is clearly inside the thoracic cavity
 When the tube is positioned properly and functioning adequately it is secured to the skin with
two heavy silk sutures and covered with an occlusive dressing to prevent air leaks. Some
surgeons place a U-stitch around the chest tube to be used as a purse-string suture when the
tube is removed.
 A chest X-ray is obtained after the procedure to assess re-expansion of the lung and the tube

(d) Ask the patient to breath in and on end expiration pull the tube and occlude the insertion
site by tighten the suture
(e) Normally Negative intrapleural pressure keeps the lungs expand
 In expiration it is about -8mmhg and in inspiration it is about -4mmhg
 But this negative intrapleural pressure is disrupted when air, fluid or blood is in
the pleural cavity which leads to lung collapse
(f) Purposes:
 To permit drainage of air and fluid from the pleural cavity
 To establish normal negative pressure in the pleural cavity for lung expansion
 To equalize pressure on both sides of the thoracic cavity
 To provide continuous suction to prevent tension pneumothorax

(g) You tell if it‘s functional by


 Ask patient to cough and check out bubbles in the bottle
(h) You can tell its active by observing the amount of fluids it drainage every day. If the
amount decreases each day for instance the 1st day drainages 200ml, then 2nd day it drains
100ml and 3rd day it drains 50ml. this shows that it is active
(i) You transfer the patient as follows:
 Clump the tube with an artery forceps
 Patient should carry it raised above insertion
 When you reach the place, put it down and unclamp
  The container should always be below the level of the pt. to avoid backflow of
the fluid into the pt. chest
(j) Complications
The majority of complications are due to improper insertion technique and tube placement.
I. Early
(i) Misplacement
Subcutaneous
Intraparenchymal
Dissection of extra-pleural plane due to failure to guide the tube into the pleural space. Diagnosis
can be a difficult but A-P and lateral CXR should reveal a lung that has failed to re-expand and
suggest a chest tube placed outside the thorax. The tube should be removed and placed within the
thoracic cavity to re-expand the lung

(ii) Injury to organs and other structures

Injury to the diaphragm with associated injury to the liver or spleen due to low placement of a
chest tube.
Parenchymal or hilar injuries or cardiac contusions can occur with overzealous advancement of
the tube or dissection of pleural adhesions
Injury to the heart
Phrenic never injury
Neurovascular bundle injury
Esophageal perforation- hemorrhage
II. Intermediate
Contralateral pneumothorax
Subcutaneous emphysema
Re-expansion pulmonary oedema
Tube blockage
Infection along the chest tube
Pain
III. Late
Infection along the chest tube tract
Empyema
Abscess
Fistula formation
STATION 25
(a) Take hx in this pt who has been having difficulty in feeding
(b) What is dysphagia and odynophagia?
(c) What are the predisposing factors?
(d) How do you grade dysphagia?
(e) What investigation are you going to do?
(f) What do you see in a barium swallow in oesophagus ca and achalasia?
(g) What are the usual presentation of patients with carcinoma esophagus?
(h) How will you confirm your diagnosis?
(i) What are the histological types of carcinoma esophagus?
(j) How do you stage carcinoma esophagus depending on the above investigations?
ANSWERS:
(a) Hx taking:
1. Demographic
 Name, age, sex, address, occupation, religion
2. Symptoms
 When did it start?
 Is it new or long standing
 It is rapidly worsening or relatively constant?
 Was there difficult swallowing solids or liquids from the start
 Is it worse on solids from the start
 At which level does food stick?
 Is swallowing painful
 Is dysphasia intermittent or is constant and getting worse
 Can it be relieved by anything e.g. warm drinks
 Is it associated in coughing(fistulae TOF)
 Any changes in body weight (since it is GI problem)
 Does the neck bulge or gurgle on drinking
 Any chest pain? Heart burn?
 Regurgitation or substance cramp
(b) Dysphagia is having difficult when swallowing and odynophagia is having pain when
swallowing
(c) Predisposing factors
 H/o alcohol or smoking
 Diet- H/o hot foods- chili
 Any gastro- esophageal reflux disease Hx
 H/O taking corrosive substance(accidental or intentional suicidal)
 v. H/O surgery(strictures)
 H/O radiotherapy(Ca esophagus)
 Immune suppression
(d) Grading of dysphagia
 GRADE 1 : Complains of dysphagia but still eating normally
 GRADE 2 : Requires liquid with Meals
 GRADE 3 : able to take semisolid ,but unable to take any solids
 GRADE 4 : able to swallow liquids only
  GRADE 5 : unable to swallow liquid, but able to swallow saliva
 GRADE 6 : unable to swallow saliva also

(e) Investigation
(1) General
o FBC
o U/E‘s
o CXR

(2) Specific
- Barium swallow
- Endoscopy
- Biopsy
-Esophageal manometry (if none then Barium swallow)
(f) barium shows;
- Ca esophagus - rat tail sign, Irregular stricture and Shuldered margins
- Achalasia beak sign and Megaesophagus proximal to stricture

(g) The pt with ca presents as follows:

- Dysphagia initially to solids, later on to both solids and liquids
- Regurgitation of food
- Anorexia and weight loss
- cough
- Pain indicates infiltration of tumor to the adjacent tissues
- Hoarseness of voice may indicate recurrent laryngeal nerve palsy
- neck mass due to lymph node metastasis
- Hematemesis and melena.
(h) An upper GI endoscopy and biopsy from the lesion will confirm the diagnosis. If the
diagnosis of carcinoma esophagus is confirmed, what further investigation will you do in
this patient.
(i) Types include;
- Squamous cell carcinoma—common in Asian and African population
- Adenocarcinoma—T0his is common in western countries and the incidence is
increasing and approaches to about 60–70%.
(h) Primary tumor—T
„ T1—Tumor invaded to the lamina propria and submucosa.
„ T2—Tumor invaded to the muscularis propria.
„ T3—Tumor extending to the adventitial coat.
„ T4—Tumor extending to the adjacent structures.
Lymph nodes—n
„ n0—no regional lymph node metastasis.
„ n1—Regional lymph node metastasis present.
Distant metastasis—M
„ M0—no distant metastasis.
„ M1—Distant metastasis present.
STATION 26
(a) Inspect the breasts giving running commentary
(b)Now palpate breast and say what you find?
(c) what is your clinical diagnosis?
(d) what are your differential diagnosis?
(e) state the method of confirmatory?
(f) state the operative management?

ANSWERS:

(a) On inspection:
1. There is Symmetry of the breasts and an obvious mass on the right breast
2. evident Skin changes and skin puckering on the right breast
3. Position and condition of the nipples, areola and no discharge from the nipples
(b) on palpation:
4. Site and size of the lump or lumps

5. Surface and consistency of the lump or lumps

6. Demonstration for fixity to the skin and muscle

7. Axillary and supraclavicular lymph nodes palpation

(c) Breast lump in the right breast

(d) D/D: Carcinoma, Cyst, Fat necrosis, Fibroadenoma, An area of Fibroadenosis, Lipoma of
breast (intra-ductal papilloma),abscess and Phylloides tumor (Brodie tumor)
(e) Triple assessment
a. Clinical – Hx + exam
b. Diagnostic imaging by Mammogram(>35) or U/S <35, bone scan, X-Ray for
metastasis – brain, chest, bones Solid + cysts
c. Histology/Cytology
FNA for cytology
Core needle biopsy for histology
 (f) Treatment of Ca Breast
1˚aim is to remove tumor
Medical
Surgical
Chemo or radiotherapy brachy or tele

Surgical
a. Lumpectomy
b. Quadrantectomy
c. Semi- mastectomy
d. Simple mastectomy + chemotherapy
e. Radical mastectomy
f. Modified radical mastectomy

STATION 27
a. look at the x-ray and say what you can see?
b. What is the likely diagnosis?
c. What are the predisposing factors for development of sigmoid volvulus?
d. what are types of sigmoid volvulus
e. What are the sites where volvulus may occur in the gastrointestinal tract?
f. What are the presentation of a patient with sigmoid volvulus?
g. what are the complications?
h. Apart from plain X-ray of abdomen what other investigations may help in sigmoid volvulus?
i. What is bird’s beak deformity?
j. How will you manage this patient of sigmoid volvulus?
k. What operation will you do?
l. If there is no signs of strangulation, what should be the management strategy?
ANSWERS:
(a) This is a straight X-ray of abdomen along with upper part of the pelvis taken in erect
posture showing a hugely distended large gut loop extending from the pelvis to the
upper abdomen.
(b) This is a typical X-ray appearance of sigmoid volvulus.
(c) The following factors are important for development of volvulus of sigmoid colon:
 Bands
 Long redundant sigmoid colon
 Long pelvic mesocolon
 narrow attachment of pelvic mesocolon
 High residue diet and chronic constipation is also an important factor.
(d) Types:
i. Sub-acute
ii. Acute
iii. Compound
(e) Sites:
 Sigmoid colon
 cecum
 Transverse colon
 Small intestine
 Stomach.
(f) Presentation: „ Abdominal pain „ Distension„ constipation „ There may be similar
history of pain and distension earlier, Vomiting – late, Tympanic, Fever due to abs
infection and Dehydration
(g) Complication
i. Strangulation
ii. Gangrene
iii. Perforation
iv. Hemorrhage
v. Dehydration
vi. Shock
vii. Electrolytes imbalance
(h) If the clinical evaluation of the patient reveals that there are signs of strangulation, no
further imaging investigations are required.
If there are no signs of strangulation and the features are of subacute obstruction the
following investigations may be helpful:
 Contrast enema: A contrast enema using water soluble contrast gastrograffin
may be done.The important findings in contrast enema may be:
• In pseudo-obsruction—the dye flows freely into the cecum.
• In sigmoid volvulus—bird's beak sign.
• In neoplastic obstruction—a shouldered cut off sign.
The contrast media is hyperosmolar and draws fluid into the lumen of the colon,
softening the inspissated fecal matter and allowing it to pass through the obstruction
thereby relieving the obstruction.
  Ultrasonography of abdomen—not very helpful in diagnosis of large bowel
obstruction.USG may provide information if there is a palpable mass in
abdomen, or if there is hepatic metastasis.
 CT scan of abdomen—Very useful in localizing the site of obstruction. The
palpable mass may be delineated well and any invasion of bowel mass to the
surrounding structures may be demonstrated. Lymph nodes and liver
metastasis may be seen well. May also visualize small quantity of free gas in
the peritoneal cavity.
 CT colonography—Provides a three dimensional endoluminal image of the
entire colon and can diagnose any intraluminal lesion better. Any
synchronous tumor may be diagnosed.
 MR colonography—May provide information like cT colonography.
(i) bird’s beak deformity is the column of water soluble or barium contrast stops at the
obstruction and tapers to a point.
(j) If strangulation is suspected and there are signs of peritoneal irritation—reduction
should not be attempted and patient should undergo emergency laparotomy after
resuscitation.
(k) Operation:
 „ Exploratory laparotomy and derotation of the volvulus.
 „ The condition of the gut is assessed—
• If the gut is gangrenous, resection has to be done and if the patient's general
condition is good, a primary anastomosis may be safely done.
 „ If patient's general condition is very poor, other options are:
• Hartmann's procedure—The proximal end after resection is brought out as
colostomy and the distal end of colon is closed, which is reanastomosed at a later
date.
• Proximal loop brought out as colostmy and distal loop brought out as a
mucous fistula
 If the gut is viable a primary resection anastomosis of the sigmoid colon may
be safely done.
(l) non-operative decompression may be tried:
 Pushing a soft rubber catheter beyond the point of volvulus if successful,
decompression may occur.
 Decompression of the volvulus by passing a rigid sigmoidoscope beyond the
point of volvulus.
 Decompression may also be achieved by passing a flexible sigmoidoscope
beyond the point of volvulus.

STATION 28
A 40-year-male patient sustained road traffic accident and brought to ER with suspicion
of head injury.
(a) How will you proceed to manage?
(b) How will you assess level of consciousness in a patient with head injury?
(c) How do you classify head injury?
(d) How does a patient with HI present?
(e) What is cerebral concussion?
(f) What are the features of cerebral contusion?
 (g) What investigations will you suggest in patients with head injury?
(h) What is extradural hematoma?
(i) What are the features of extradural hematoma?
(j) What investigations may help in diagnosis of extradural hematoma (EDH)?
(k) How will you treat EDH?
(l) What are the features of subdural hematoma?
(m)What investigations may help in diagnosis of SDH?
(n) How will you treat acute subdural hematoma?

ANSWERS:
(a) The initial management of patient with head injury will include:
 Primary survey and resuscitation
 Secondary survey.
 Definitive management.
(b) This is done by Glasgow coma scale. This needs to be recorded hourly to monitor any
deterioration during the period of observation. The coma scale involves evaluation of
following:
Eye opening (E):
 Spontaneously – 4.
 To speech – 3.
 To pain – 2.
 Nil – 1.
Motor response (M):
 Obeys commands – 6.
 Localizes pain – 5.
 Withdraws to pain – 4.
 Abnormal flexion – 3.
 Extension to pain – 2.
 No response – 1.

Best verbal response (V):

 Oriented – 5.
 Confused, disoriented – 4.
 Inappropriate words – 3.
 Incomprehensible sounds – 2.
 No response – 1.
There is a total score of 15.
(c) Classification of HI
1. General
- (i) open HI-Pts with bleeding in ear, nose,mouth
(ii) Closed HI- doesn’t have lacerations
2. Mode of injury
- High velocity injury
- Low velocity injury
3. Pathological
 - Primary HI
- Secondary HI
4. Clinically (level of conscience by GCS
-Mild (8 and below)
-Moderate (9 to 12)
-Severe (13 to 15)
(d)The with HI will presents as follows:
-hx of trauma
-headache associated with blurred vision, vomiting, seizures, paralysis and reducing LOS

(e) Cerebral concussion is a condition of temporary dysfunction of brain without any structural
damage following head injury. The manifestations are transient and usually resolves after a
variable period. The manifestations includes:
- Transient loss of consciousness.
- Transient loss of memory.
- Autonomic dysfunction like bradycardia, hypotension and sweating.

(f) Cerebral contusion is a more severe degree of brain injury manifested by areas of
hemorrhage in the brain parenchyma but without any surface laceration. There is
neurological deficit that persist longer than 24 hours. There may be associated cerebral
edema and defects in blood-brain barrier. Contusion may resolve after a variable time
along with associated neurological deficit or the neurological deficit may be persistent.
(g) Investigations:
„„ Baseline investigations.
„„ Special investigations:
• X-ray of skull—AP and lateral view.
• Plain X-ray may show fracture, foreign bodies or air in the cranial cavity.
„„ X-ray of cervical spine—AP and lateral view. May show fracture and dislocation.
„„ CT scan brain. The indications of CT scan in head injury are:
• History of loss of consciousness or patient is unconscious.
• Patient has disturbance of memory.
• Presence of neurological deficit.
• CSF leakage.
• Pupillary asymmetry.
• Penetrating injury.
„„ CT scan may show:
• Skull fracture
• Intracranial hematomas (Intracerebral, subdural or extradural)
• Midline shift
• Cerebral edema
• Cerebral contusion.
Sometimes CT scan immediately after injury may be normal and hematoma develop
hours after the injury. So serial CT scan may be required in patients who are deteriorating
during observation.
(h) Extradural hematoma is collection of blood between the cranial bones and the dura
matter is called extradural hematoma. The extradural hematoma causes increase in
 intracranial pressure, distortion and herniation of brain with compression of brainstem.
The source of bleeding may be:
o Rupture of the middle meningeal artery due to fracture of the temporal
bone.
o Fracture bone edges.
o Tearing of dural venous sinuses.

(i) Patients with extradural hematoma may present in a number of ways:

Classical type:
• Deterioration in level of consciousness with or without lucid interval.
• Pupillary changes.
• Contralateral hemiplegia.
• Lucid interval is absent when patient has associated primary brain injury.
Subacute or chronic type: Slow collection of hematoma.
• Lucid interval is prolonged to days or weeks.
• During this period patient is irritable, confused and has headache.
Hyperacute type:
• Lucid interval is short.
• Patient is extremely restless, talkative, violent but remains conscious.
• Afterwards within an hour or so patient lapses into deep coma and may die rapidly.
(j) Investigations that may help in diagnosis of extradural hematoma (EDH)
„. Plain X-ray of skull: may demonstrate skull fracture.
„. CT scan of brain:
• Appear as a biconvex or planoconvex zone of increased density adjacent to the inner
table of the skull.
• There may be midline shift.
(k) Treatment of EDH
„. If the EDH is localized by CT scan a burr hole is made at the appropriate site.
„. This is done under general anesthesia with endotracheal intubation. In desperate
situation, this can be done under local anesthesia.
„. The burr hole is made at the appropriate site. Once the burr hole is made, the
hematoma bulges out. The burr hole enlarged by either doing a craniectomy or raising a
bone flap with multiple burr hole. The hematoma is evacuated, the source of bleeding is
looked for and the bleeding point controlled with diathermy or suture ligation.
„. The dura is opened only if there is associated underlying subdural hematoma.
„. The dura mater is then hitched up all around the margins of the bony defect with
atraumatic stitches passing through the dura mater and the adjacent pericranium.
„. Bone flap is replaced and the scalp wound is closed.
„. Postoperative care to prevent metabolic, respiratory and infective complications.
(l) The features of subdural hematoma
The diagnosis of subdural hematoma (SDH) is often difficult and needs a high degree of
suspicion for clinical diagnosis.
„. Patient may become unconscious from the time of injury or there may be gradual
deterioration of level of consciousness or rarely there may be a lucid interval.
„. Patient may become increasingly restless.
„. There may be focal or generalized convulsion.
 „. There may be true localizing signs—ipsilateral dilated nonreacting pupil or
contralateral motor weakness.
„. The false localizing signs includes—contralateral pupillary dilatation, ipsilateral motor
weakness due to Kernohan’s notch.
(m) The investigations that may help in diagnosis of SDH
„. Plain X-ray of skull—may show skull fracture.
„. CT scan of brain: Acute SDH appears a hyperdense crescentic shaped lesion that
follows the curvature of the brain.
„. Angiography: Indicated when facility for CT scan is not there. An acute SDH
produces an avascular space between the vascularized brain and the skull.
„. Exploratory burr hole.
(n) Treatment of acute subdural hematoma
„. Initial resuscitation.
„. When the symptoms of acute SDH develops rapidly exploratory burr holes may
be considered immediately without CT scan or angiography.
„. Exploratory burr holes are done at temporal, frontal and parietal regions. Once
dura is opened, fresh blood or blood clot escapes. The burr hole should be extended
by wide craniectomy centered over the hematoma. The underlying contused brain
parenchyma mayneed debridement. Proper hemostasis should be achieved at the
end of operation. Hitch stitches are given between the dura mater and the adjacent
pericranial tissues. Once the clot is evacuated the source of bleeding is sought for
and the bleeding point controlled with diathermy or suture. Bone flap is replaced
and scalp wound closed.
„. If the evolution of symptoms are slower, a CT scan is to be done to localize the
hematoma and the placement of burr hole is planned accordingly.
„. Postoperatively patient is nursed in an intensive therapy unit with the head
slightly elevated.
„. Maintain airway and if necessary mechanical ventillation may be required.
„. Treatment of cerebral edema with mannitol or diuretics.

STATION 29
(a) Look at the picture below and say what it is?
(b) What is the scientific name?
(c) What deformities are there?
(d) How do you diagnose it?
(e) What do you use to score the severity?
(f) How to you treat it?
 ANSWERS:
(a) Club foot
(b) Congenital talipes equino-varus
(c) Club foot is associated with the following deformities:
1. Hind foot
-Equinus (Ankle joint)
-Varus (Subtalar joint)
2. Fore foot
-Adduction (Med tarsal joint)
-Cavus
(d)Diagnosis:
o You can diagnose it in utero by u/s
o Clinically:
-Empty heel
-Equinus
-Posterior crease
-Medial crease/s
-Talus head palpable laterally
-Curve of lateral border
(e) The pirani score is used to measure the severity of club foot.
-each component may score 0, 0.5, 1
Hind foot contracture score
1. posterior crease
2. empty heel
3. rigid equinus
Mid foot contracture score
1. medial crease
2. curvature of lateral border
3. position of head of talus
-
(f) Treatment is:
1. Conservative/non –surgical
- Serial plaster casting from birth called ponsenti method is done
- 1st week cavus is corrected, 2nd week adduction is corrected,
- 3rd, 4th and 5th the varus is corrected
- Then the equinus is corrected via PTAT

2. Surgical intervention
STATION 30. Look at the image below
(a)What type of investigation is this?
(b)What is your diagnosis?
(c) What are the causes?
(d) How is the patient going to present?
(e) How are you going to manage this patient?

ANSWERS:
(a) Retrograde urethrogram
(b) Urethral strictures
(c) Causes: May be congenital or acquired
o Urethral injury, disease, catheterization or surgery that results in
inflammation or scar tissue.
o Urethral infections, such as gonorrhea.
o A tumor in the urethra (rarely)
o A complication of radiation treatment of the pelvis
(d) Presentation:
o Dysuria.
o Hematuria.
o Weak stream.
o Splaying of the urine stream.
o Nocturia.
o Incomplete emptying.
o Pain with bladder distention.
o Urinary tract infection (fever and malaise may be present with a urinary
tract infection.
(e) Treatment :
1. Optical urethrotomy—suitable for short segment urethral stricture.
2. Urethral dilatation
3. Urethroplasty
STATION 31
(a) Take a history of urinary obstruction symptoms from the examiner
(b) What are the possible differential diagnosis
(c) Which investigations may help in diagnosis?
(d) How will you plan definitive treatment?
ANSWERS:
(a) Hx taking:
 ASK FOR AGE
 ANY DYSURIA / SUPRA-PUBIC / PERINEAL / LOIN PAIN
 FREQUENCY OF URINATION INCLUDING AT NIGHT
 STATE OF THE STEAM OF URINE
 EFFECT OF STRAINING ON THE STREAM
 ANY RETENTION OF URINE IN THE PAST
 ANY HESITANCY / URGENCY IN PASSING URINE
 ANY URINARY INCONTINENCE OR POST MICTURATION DRIBBLING
 ANY HAEMATURIA
 ANY LUMP IN HYPOGASTRIUM OR LOIN.
 HISTORY OF TRAUMA OR URETHRAL INSTRUMENTATION.
 HISTORY OF OPERATION OR SPINAL ANESTHESIA.
 DRUG HISTORY: SOME ANTIHYPERTENSIVE DRUGS (GANGLION
BLOCKING DRUGS), ANTICHOLINERGIC DRUGS OR
ANTIDEPRESSANT DRUGS MAY CAUSE RETENTION.
 ANY SYSTEMIC SYMPTOMS DUE TO UNDERLYING MALIGNANT
DISEASE—ANOREXIA, ASTHENIA, WEIGHT LOSS, BONE PAIN.
(b) Possible differential diagnosis:
1. Bladder outlet obstruction due to:
• Benign hyperplasia of prostate.
• Carcinoma of prostate.
• Prostatic abscess or prostatitis.
• Carcinoma of bladder.
• Bladder stone.
• Bladder neck muscular hypertrophy.
• Bladder neck fibrosis.
2. Urethral causes:
• Stricture.
• Calculus.
• Tumors
• Urethritis.
3. Others:
• Rupture urethra following trauma.
• Meatal stenosis.
• Phimosis.
• Fecal impaction.
• Spinal injury.
• Postoperative especially after perianal operation.
• Following spinal anesthesia.
4. Drugs:
 Anticholinergics.
 Antihypertensives.
  Tricyclic antidepressants
(c) The special investigation will be guided by findings of history and physical
examination.
For evaluation of prostatic enlargement:
• Ultrasonography of kidney ureter and bladder region.
• Transrectal ultrasonography.
• Urodynamics study.
• Serum prostate specific antigen.
For evaluation of bladder or urethral lesion:
• Micturating cystourethrography.
• Cystoscopy and urethroscopy
(d) The definitive treatment depends on the cause of retention.
Benign enlargement of prostate: Treatment may be:
• Drug treatment: Two classes of drugs are used for treatment of bladder outlet
obstruction.
−Alpha adrenergic blocking drugs (Finasteride): Inhibits contraction of smooth muscles of prostate.
−5 alpha reductase inhibitor (Terazosin): Inhibits conversion of testosterone to 5 dihydrotestosterone
(5 DHT).
−Tamulosin hydrochloride is also effective in relieving symptoms due to BPH.
Both these drugs improve flow rate and also cause shrinkage of the glands.
Drug of treatment is indicated when:
»» Symptoms are mild.
»» Patient with severe symptoms but surgery cannot be done for medical problems.
»» These drugs are expensive and a significant number of patients require surgical
treatment afterwards.
• Surgical treatment: Transurethral resection of prostate or open prostatectomy.

„„ Carcinoma of prostate:
• Early stage (Tl and T2 tumors): Radical prostatectomy along with pelvic lymph node
dissection.
• Advance disease with urinary retention: Transurethral resection of prostate followed by
hormone therapy.
• Radiotherapy: Radical radiotherapy to prostatic bed and pelvic lymph node is an alternative
option of treatment for localized disease. For disseminated disease radiotherapy has no role.
• Hormone treatment: Androgen ablation is indicated in patients with locally advanced or
metastatic disease.
−− Androgen ablation by drugs:
»» Phosphorylated diethylstilbestrol (Honvan).
»» Progestogens—Depo provera.
»» LHRH agonist (Goserelin)—down regulates pituitary and suppresses LH production,
thereby reducing serum testosterone concentration.
»» Flutamide—blocks the androgen receptor.
»» Cyproterone acetate blocks androgen receptor and also has some progestogenic effect.
»» Androgen ablation by bilateral orchiectomy.

„„ Treatment of urethral stricture:

• Urethral dilatation.
• Optical urethrotomy.
• Open urethroplasty.
„„ Treatment of carcinoma of bladder:
• Noninvasive tumors:
−− Transurethral resection of bladder tumor followed by intravesical chemotherapy or
immunotherapy.
−− Intravesical chemotherapy with either mitomycin C or adriamycin or epirubucin weekly
for 8–10 weeks.
−− Intravesical immunotherapy with BCG is also very effective.
−− Radical cystectomy with diversion of urine is indicated in patients with multiple tumors
and with extensive carcinoma in situ.
• Invasive tumors:
−− Radical radiotherapy.
−− Surgery: Partial cystectomy or radical cystectomy with ileal conduit
−− Adjuvant chemotherapy with methotrexate, vinblastine, adriamycin and cisplatinum.