SURGERY-

OSCE
STATIONS
Moses Kazevu
 MOSES KAZEVU

TABLE OF CONTENTS
DISCLAIMER .........................................................................................2
OSCE STATION: BASIC SURGICAL EXAMINATIONS ..............3
EXAMINATION OF THE THYROID ............................................................ 3
OSCE STATIONS: SPECIMENS .........................................................6
SPECIMEN 1 (GOITER) ................................................................................. 6
SPECIMEN 2 (INTUSSUSCEPTION) ............................................................ 8
SPECIMEN 3 (CA HEAD OF PANCREAS) ................................................ 10
SPECIMEN 4 (SIGMOID VOLVULUS) ...................................................... 11
SPECIMEN 5 (CA ESOPHAGUS) ................................................................ 13
SPECIMEN 6 (ANAL CA) ............................................................................ 15
SPECIMEN 7 (APPENDICITIS) ................................................................... 16
SPECIMEN 8 (GALL STONES) ................................................................... 19
SPECIMEN 9 (URINARY/BLADDER STONES)........................................ 21
SPECIMEN 10 (MALIGNANT MELANOMA) ........................................... 22
SPECIMEN 11 (CHRONIC OSTEOMYELITIS) ......................................... 23
SPECIMEN 12 (KIDNEY- HYDRONEPHROSIS) ...................................... 24
SPECIMEN 13 (BLADDER CA) ................................................................... 25
SPECIMEN 14 (GANGRENE-AMPUTATION) .......................................... 26
SPECIMEN 15 (BREAST CA) ...................................................................... 27
SPECIMEN 16 (NIPPLES) ............................................................................ 30
SPECIMEN 17 (GASTRIC ULCER) ............................................................. 31
SPECIMEN 18 (CA PROSTATE) ................................................................. 32
SPECIMEN 19 (POLYCYSTIC KIDNEY DISEASE) ................................. 33
SPECIMEN 20 (SQUAMOUS CELL CARCINOMA OF THE PENIS) ...... 34
SPECIMEN 21 (STOMACH CA) .................................................................. 35
OSCE STATIONS: IMAGING ...........................................................36
OSCE STATIONS: EQUIPMENT ....................................................36
BLOOD COLLECTION BOTTLES .............................................................. 36

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DISCLAIMER
Effort has been put in to confirm the accuracy of the information present and to
describe generally accepted practices. However, the author, editors and
publishers are not responsible for errors or omissions or for any consequences
from application of the contents of the publication.

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OSCE STATION: BASIC SURGICAL

EXAMINATIONS
EXAMINATION OF THE THYROID
 Unless stated as a focused thyroid examination examine the patient as a
whole.
 Greet the patient, explain the examination to them and gain consent.
 Position the patient and expose the patient adequately.
GENERAL EXAMINATION
 Comment on the age and gender of the patient:
 Young/ elderly
 Man or Woman
 Comment on the patient’s general appearance:
 Are they sitting still and composed?
 Are they fidgeting about or constantly moving fingers?
 Do they look nervous and agitated or slow ponderous in movement?
 Comment on the nutrition
 Do they look thin or fat?
 Comment on the dressing:
 Are they appropriately dressed, overdressed or underdressed?
HANDS AND ARMS
 Note palms for: Moist, sweat and temperature (hot or cold)
 Check for tremors by placing a paper on the dorsum of the palm with the
arms outstretched and pronated arms.
 Check the Pulse- noting for any Tachycardia or Bradycardia, don’t forget
to comment on the rate, rhythm and character as well as synchronicity.
 Measure the Blood pressure
 Check for lymphadenopathy: Epitrochlear, axillary lymph and other
group of lymph nodes

INSPECTION
 Confirm that the swelling in the neck is in the thyroid gland by watching
to see if it moves when the patient swallows. (the patient may need a sip
of water to help deglutition).
 All thyroid swellings ascend during swallowing.

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 Observe the general contours and surface of the swelling. The skin may
also be puckered and pulled up by swallowing if the patient has a thyroid
carcinoma which has infiltrated into the skin, although this is uncommon.
 Ask the patient to open their mouth and then to put out their tongue.
 If lump moves up as the tongue comes out, it must be attached to the
hyoid bone and is likely to be a thyroglossal cyst.
 Note if there is any neck vein distention (mass obstructing the thoracic
inlet)
 Look at the position of the thyroid cartilage. Is it in the centre of the neck
or deviated to one side?

PALPATION
 This is best done from behind the patient
 Stand behind the patient.
 Place your thumbs on the ligamentum nuchae and tilt the patient’s head
slightly forwards to relax the anterior neck muscles.

PERCUSSION

 Percussion is used to define the lower extent of

a swelling that extends below the suprasternal
notch by percussing along the clavicles and over
the sternum and upper chest wall.
 This can be done when standing in front of or
behind the patient.
 Percussion of the lump in the neck itself is
rarely helpful.

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AUSCULTATION
 Listen over the swelling.
 Thyrotoxic and vascular glands and lumps may have a
systolic bruit.

OTHER SYSTEMS
 Examine the CVS

 Thank the patient and cover them

 Summarize your findings and over some investigations you would love to
carry out:
 Ultrasound of neck
 CT scan
 FNAC
 Serum T3 and T4

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OSCE STATIONS: SPECIMENS

SPECIMEN 1 (GOITER)
QUESTION 1: Identify the specimen
Answer: Encapsulated Mass attached to
a tubular structure (thyroid)
QUESTION 2: What is the pathology?
Answer:
 Diagnosis: Goiter
 Differential: Solitary/ multinodular
goiter, Carcinoma of the thyroid
QUESTION 3: What are the clinical
features of this pathology?
Answer:
 History: Swelling in the neck,
pressure effects (dyspnea, dysphagia and
dysphonia), loss of weight, loss appetite,
heat/cold intolerance
 Examination: tremors, sweaty palms,
eye signs (lid lag, lid retraction,
Exophthalmos), examine swelling
(Described in thyroid examination)

QUESTION 4: What investigations would you undertake?

Answer:
 Imaging:
 Ultrasound of the neck: Cyst or solid?
 Radioiodine (I-123) isotope uptake
 Chest X-ray (AP view): tracheal deviation, Lung mets, retrosternal
shadow
 Cervical X-ray (AP and lateral view): AP- tracheal deviation, Gland
calcification- bleed easily
 Thoracic CT scan: definite anatomy, intrathoracic extension, toxicity
 MRI

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 ECG- arrhythmias and ECHO: especially in the elderly

 Blood: Serum T3, T4 & TSH
 Sampling “biopsy”: FNAC: benign or malignant (cannot specify type)
 Indirect laryngoscopy: litigation (recurrent laryngeal nerve- vocal cords)
QUESTION 5: How would you manage/treat?
Answer:
 Medical:
 Antithyroid drugs e.g. thioamides such as proprylthiouracil,
carbimazole
 Beta blockers (propranolol also blocks peripheral conversion of T4 to
T3 by blocking deiodinase)
 Radioactive ablation: Use of radioactive material (iodine) to destroy
the cell and hence the activity of thyroid is reduced.
 Surgical: Thyroidectomy
 Lobectomy (hemi-thyroidectomy)
 Partial thyroidectomy
 Sub-total thyroidectomy
 Near-total thyroidectomy
 Total thyroidectomy

ADDITIONAL INFORMATION
 Indications for surgery:
 Cosmesis
 Toxicity
 Carcinoma
 Compression on trachea, esophagus and nerves
 Complication
 Bleeding
 Hematoma formation
 Recurrent nerve injury
 Tracheal-malacia
 Thyroid storm/thyroid crisis- atrial fibrillation
 Infections

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SPECIMEN 2 (INTUSSUSCEPTION)

QUESTION 1: Identify the

specimen
Answer: Black tubular
structure, invaginated in
itself (Bowel)
QUESTION 2: What is the
pathology?
Answer:
Diagnosis- Intussusception
Differential:
 Intestinal obstruction
 Sigmoid volvulus
 Paralytic ileus

QUESTION 3: What are the clinical features of this pathology?

Answer:
History
 Abdominal pain
 Distention
 Vomiting
 Constipation
 Dehydration
Examination
 On inspection: Abdominal distention
 On palpation: tenderness, guarding, sausage shaped mass
 On auscultation: ± bowel sounds
 Digital rectal examination: no stool (empty rectum)

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QUESTION 4: What investigations would you undertake?

Answer:
 Plain abdominal X-ray (supine and erect)- erect shows multiple air fluid
levels
 Barium enema- typical claw sign or coiled spring sign (Pincer end)
 Ultrasound shows target sign or pseudokidney sign or bull’s eye sign
which is diagnostic.
 Doppler may show mass with doughnut sign and is useful to check blood
supply of bowel.
 Full blood count
 Urea and electrolytes
QUESTION 5: How would you manage/treat?
Answer:
 Initial management:
 Ryle’s tube aspiration
 IV fluids
 Catheterization
 Antibiotics
 Surgical management- Laparotomy under General anesthesia (Cope’s
method).
 Gentle milking out the intussusception with warm packs. After
reduction, viability of the bowel is checked carefully. If manual
reduction is not possible it is understood that the bowel is likely to be
gangrenous which requires resection and anastomosis.
ADDITIONAL INFORMATION
 COMPLICATIONS
 Intestinal obstruction
 Perforation
 Peritonitis

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SPECIMEN 3 (CA HEAD OF PANCREAS)

QUESTION 1: Identify the specimen
Answer: C-shaped muscular structure
(duodenum with head of pancreas)
QUESTION 2: What is the pathology?
Answer: CA head of pancreas
QUESTION 3: What are the clinical
features of this pathology?
Answer:
 Ascites
 Abdominal pain radiating to the
middle back
 Weight loss
 Loss of appetite, fatigue
 Dark urine, yellow skin and eyes
 New onset diabetes

QUESTION 4: What are the investigations

you undertake?
Answer:
1. CT scan
2. Transcutaneous ultrasound
3. Endoscopic ultrasonogaphy
4. MRI
5. Endoscopic retrograde
cholangiopancreatography
6. Positron emission tomography
7. Baseline labs (FBC, LFTs, U/Es,
Creatinine)

QUESTION 5: How would you manage/treat?

Answer:
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 Surgical: Triple bypass (Gastrojejunostomy, Cystojejunostomy and

jejunojejunostomy)

SPECIMEN 4 (SIGMOID VOLVULUS)

QUESTION 1: Identify the specimen

Answer: Folded tubular structure (Sigmoid
colon)

QUESTION 2: What is the pathology?

Answer: Sigmoid volvulus

QUESTION 3: What are the clinical

features of this pathology?
Answer:

 Acute abdominal pain

 Constipation- early
 Abdominal distension, vomiting and pain (Triad of intestinal obstruction)
 Vomiting- late
 Dehydration
 Tympanic abdomen to percussion
 Fever (infection)
QUESTION 4: What investigations would you undertake?
Answer:
1. Plain X-ray
 Omega sign (omega symbol is seen)
 Supine- gases
 Erect- gas fluid levels
2. Contrast enema

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 Bird-beak sign
3. CT scan: characteristic whirl pattern
4. FBC- HCT and Hb
5. ESR, U/E

QUESTION 5: How would you manage/treat?

Answer:
 Ryle tube aspiration
 IV fluids
 Catheterization
 Antibiotics
 Laparoscopic sigmoid resection and right hemicolectomy after endoscopic
decompression

ADDITIONAL INFORMATION
COMPLICATIONS
1. Strangulation
2. Gangrene
3. Perforation
4. Hemorrhage
5. Dehydration
6. Shock
7. Electrolyte imbalance

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SPECIMEN 5 (CA ESOPHAGUS)

QUESTION 1: Identify the specimen

Answer: Tubular muscular structure with a
lesion on the middle part (middle third)
(esophagus)
QUESTION 2: What is the pathology?
Answer: CA esophagus (most likely squamous
cell carcinoma)
QUESTION 3: What are the clinical features
of this pathology?
Answer:
 Dysphagia
 Odynophagia
 Weight loss
 Loss of appetite
 Hematemesis (rare)
 Cervical lymphadenopathy
QUESTION 4: What investigations would you
undertake?
Answer:
1. Endoscopy and biopsy
2. Barium swallow: rat tail sign

QUESTION 5: How would you manage/treat?

Answer:
Radical Surgical, radiotherapy and palliative care.

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ADDITIONAL INFORMATION
COMPLICATIONS
1. Bleeding
2. Tracheo-esophageal fistula (contrast in bronchial tree on X-ray)
3. Cachexia
4. Malnutrition
5. Shock
TMN STAGING
T-Tumor
Tis- carcinoma in situ
T1- invading lamina propria/submucosa
T2- invading muscular propria/submucosa
T3- invading adventitia
T4- invasion of adjacent structure

N-Nodes
Nx- nodes can’t be assessed
N0- no node spread
N1- regional node mets

M-metastasis
M0- no distant mets
M1- distant mets

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SPECIMEN 6 (ANAL CA)

QUESTION 1: Identify the specimen

Answer: Muscular structure with hairs
at the bottom (rectum extending to
anus)
QUESTION 2: What is the pathology?
Answer: CA rectum
 Differential: Hemorrhoids
QUESTION 3: What are the clinical
features of this pathology?
Answer:
History
 Bleeding per rectum/anum (mimics
hemorrhoids)
 Spurious diarrhea (occurs in the
early morning)
 Tenesmus (painful incomplete defecation with bleeding)
 Bloody sline (mucus with blood in stool)
 Sense of incomplete evacuation, constipation
 Anemia, malnutrition, loss of appetite and weight
 Altered bowel habits.
Examination
 90% of rectal growths can be felt by per-rectal examination

QUESTION 4: What are the investigations you undertake?

Answer:
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 Proctoscopy
 Sigmoidoscopy
 Barium enema
 Colonoscopy: to rule out polyps
 U/S abdomen- looking for mets
 CT scan
 Blood: hematocrit, CEA, blood urea and serum creatinine and electrolytes
QUESTION 5: How would you manage/treat?
Answer:
Surgical: stage dependent
 Laparoscopic APR/AR (Abdominoperineal resection)
Preoperative chemoradiotherapy
Palliative care

SPECIMEN 7 (APPENDICITIS)
QUESTION 1: Identify the specimen
Answer: Muscular tube with a blind end (appendix)
QUESTION 2: What is the pathology?
Answer:
Diagnosis: Appendicitis
Differential:
 Meckel’s diverticulitis
 Ruptured ectopic pregnancy
 Perforated peptic ulcer
 Mittelschmerz (rupture of ovarian follicle during
mid-menstrual period)
 Salpingo-oophritis
 Lobar pneumonia

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QUESTION 3: What are the clinical features of this pathology?

Answer:
History:
Symptoms
 Pain
 Initially around the umbilicus (visceral pain)
 Migrates to right iliac fossa (somatic pain)
 Abdominal pain with coughing
 Nausea and vomiting
 Anorexia
 Constipation/diarrhea (postileal and pelvic appendix)
 Fever (low grade)
 Tachycardia
 Urinary frequency
Examination:
Signs
 Tachycardia
 Tenderness and rebound tenderness in right iliac fossa (Blumberg sign)
 Pointing sign- at Mc Burney’s point
 Rovsing sign- on pressing left iliac fossa, pain occurs in RIF due to shift
of bowel loops which irritate the peritoneum.
 Psoas test- for retrocecal appendix, hyperextension of hip causes pain in
the RIF
 Obturator test- for pelvic appendix, internal rotation of right hip causes
pain in RIF due to irritation of obturator internus muscle.
 Baldwing test- positive in retrocecal appendix- when legs are lifted off
bed with knee extended, the patient compains of pain while pressing on
abdomen (Ribs-ilium)
 Bastede sign

QUESTION 4: What investigations would you undertake?

Answer:
1. Baseline: FBC, LFTs, U&Es
2. Imaging: Abdominal X-ray, Abdominal ultrasound and CT scan

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3. Laparoscopy
QUESTION 5: How would you manage/treat?
Answer:
1. Medical: antibiotics, analgesics, rehydrate (ABCs)
2. Surgery-Appendectomy (Gridiron incision- perpendicular to McBurney’s
point [point between 2/3 from umbilicus and 1/3 anterior superior iliac
spine], 2/3 of incision is below the McBurney’s point)

ADDITIONAL INFORMATION
ANATOMICAL POSITIONS OF APPENDIX
1. Retrocecal (common)
2. Preileal (least common)
3. Postileal
4. Pelvic
5. Subcaecal
6. Paracaecal

DIAGNOSIS
 Based on the Alvarado Score (MANTRELS)
 M- migration to right iliac fossa (pain)-1, A-anorexia-1, N-nausea and
vomiting-1, Tenderness-2, Rebound tenderness-1, Elevated temperature
(Fever>37.3), Lymphocytosis (>10,000), Shift towards neutrophils
(neutrophilia >70%)
 Below 5: not sure
 5-6: Compatible
 6-9: probable
 9-10: Confirmed
COMPLICATIONS
1. Peritonitis
2. Septicemia
3. Appendicular mass
4. Appendicular abscess

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5. Pelvic abscess
6. Gangrene
7. Intestinal obstruction

SPECIMEN 8 (GALL STONES)

QUESTION 1: Identify the

specimen
Answer: Blind ended bag-like
tubular structure filled with round,
opaque, white structures (Gall
bladder)
QUESTION 2: What is the
pathology?
Answer: Cholelithiasis (Gall
stones)
QUESTION 3: What are the clinical
features of this pathology?
Answer:
 Asymptomatic
 Pain in right upper quadrant (may
radiate to tip of scapula)
 Indigestion, nausea, vomiting
 Fever

QUESTION 4: What are the investigations you undertake?

Answer:
1. Imaging
 X-ray (abdomen)
 Abdominal ultrasound
 Abdominal CT scan
2. Blood: FBC, U/Es, LFTs, serum bilirubin, serum albumin
QUESTION 5: How would you manage/treat?
Answer:
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 Medical: oral bile salt therapy (ursodeoxycholic acid), extracorporeal

shockwave lithotripsy (noncalcified gallstones with normal gall
bladder function)
 Surgical: cholecystectomy

ADDITIONAL INFORMATION
 Courvoisier’s law: In a patient with obstructive jaundice, if the
gallbladder is palpable the cause is unlikely to be due to gallstones (but
other causes e.g. tumors- CA head of pancreas, cholangiocarcinoma)
 Types of stones
 Cholesterol gallstones: most common type, appear yellow in colour.
 Pigment gallstones: dark brown or black stones which form when
bile contains too much bilirubin
 Risk factors:
 Forty
 Female- pregnancy, contraceptive
 Fertile
 Fat
 Complications
 Inflammation of the gallbladder
 Blockage of the common bile duct (obstructive jaundice)
 Blockage of the pancreatic duct
 Gallbladder cancer

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SPECIMEN 9 (URINARY/BLADDER STONES)

QUESTION 1: Identify the specimen

Answer: White, solid, opaque,
irregular structures (urinary bladder
stones)
QUESTION 2: What is the pathology?
Answer: Bladder calculi
QUESTION 3: What are the clinical
features of this pathology?
Answer:
 Frequent urination especially
during the night
 Lower abdominal pain
 Pelvic pain
 Burning sensation when urinating
 Dysuria
 Bloody or cloudy urine
 Incontinence

QUESTION 4: What are the investigations you undertake?

Answer:
 Urinalysis
 Kidney, ureter and Bladder (KUB) X-ray, CT scan and Ultrasound
QUESTION 5: How would you manage/treat?
Answer: transurethral cystolitholapaxy (breaking small stones)

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SPECIMEN 10 (MALIGNANT MELANOMA)

QUESTION 1: Identify the specimen

Answer: amputated toe with dark colored, bumpy
lesion (+ excised ulcer)
QUESTION 2: What is the pathology?
Answer: Malignant melanoma
QUESTION 3: What are the clinical features of this
pathology?
Answer:
 Itching
 Bleeding
 Ulceration and pain
 Area of pigmentation

QUESTION 4: What are the investigations you

undertake?
Answer:
1. Excision biopsy (note do not perform incision
biopsy as it can cause early blood spread)
2. FNAC of lymph node
3. U/S of abdomen for secondaries
4. CXR- secondaries
5. Urine for melauria signifies advance disease
6. Sentinel lymph node biopsy

QUESTION 5: How would you manage/treat?

Answer: Wide-local excision, analgesia and antibiotics

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SPECIMEN 11 (CHRONIC OSTEOMYELITIS)

QUESTION 1: Identify the specimen

Answer: Rough, tubular hollow white structure (bone)
QUESTION 2: What is the pathology?
Answer: Chronic osteomyelitis
QUESTION 3: What are the clinical features of this
pathology?
Answer:
 Pain
 Discharging sinus
 Swelling and disuse of the limb
 On examination: reduced range of motion, tenderness,
visible swelling, discharging sinus

QUESTION 4: What are the investigations you

undertake?
Answer:
 X-ray (Sequestrum- dead bone, involucrum-new bone)
 Bone scan (Technetium-99 scan),
 FBC, pus swab for culture and sensitivity

QUESTION 5: How would you manage/treat?

Answer:
 Antibiotic
 Analgesia
 Surgical draining of pus, sequestrectomy

ADDITIONAL INFORMATION

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COMPLICATIONS
1. Pathological fractures
2. Multiple abscess
3. Sepsis
4. Impaired gait

SPECIMEN 12 (KIDNEY- HYDRONEPHROSIS)

QUESTION 1: Identify the
specimen
Answer: Bean shaped structure
with distended renal pelvis
(kidney)
QUESTION 2: What is the
pathology?
Answer: hydronephrosis
QUESTION 3: What are the
clinical features of this pathology?
Answer:
 Dysuria
 Pain on the side, abdomen or
groin
 Insufficient urine production
 Hematuria
 High blood pressure

QUESTION 4: What are the investigations you undertake?

Answer:
 Diagnosis is made medically
 Renal ultrasound and CT
QUESTION 5: How would you manage/treat?
Answer:
 Cause dependent
 Urethral stenting

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 Insertion of a Nephrostomy tube

 Antibiotic

SPECIMEN 13 (BLADDER CA)

QUESTION 1: Identify the specimen

Answer: Muscular pouch (bladder)
QUESTION 2: What is the pathology?
Answer: Bladder CA
QUESTION 3: What are the clinical features of
this pathology?
Answer:
 Urinary frequency
 Dark urine
 Hematuria (most common)
 Dysuria
 Pelvic pain
 Weight loss

QUESTION 4: What are the investigations you undertake?

Answer:
 Urine cytology
 Urine culture to rule out infection
 Urinary tumor markers
 Cystoscopy
 CT and MRI scan
 Baselines (FBC, U/Es, LFTs, Creatinine)
QUESTION 5: How would you manage/treat?
Answer:
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Stage dependent
 Transurethral resection of bladder tumor
 Radical cystectomy

SPECIMEN 14 (GANGRENE-AMPUTATION)

QUESTION 1: Identify the specimen

Answer: amputated foot with an area
of dark colored tissue
QUESTION 2: What is the pathology?
Answer: Dry gangrene
QUESTION 3: What are the clinical
features of this pathology?
Answer:
 Claudication (intermittent leg pain)
 Rest pain
 Shiny, thin pale, cool skin
 Brittle nails
 Poor healing and ulceration
 Area of grey or black necrotic
tissue

QUESTION 4: What are the

investigations you undertake?
Answer:
1. X-ray of body part
2. CT and MRI scan
3. FBC with differential
4. U/Es, creatinine and LFTs
5. Pus swab for culture and sensitivity
QUESTION 5: How would you manage/treat?
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Answer:
 Medical: Antibiotics, wound cleaning and debridement
 Surgical: Amputation

SPECIMEN 15 (BREAST CA)

QUESTION 1: Identify the specimen

Answer: nipple + areola and an ulcer
(breast)
QUESTION 2: What is the
pathology?
Answer: CA breast
QUESTION 3: What are the clinical
features of this pathology?
Answer:
 Painless lump (Sometimes can be painful)
 Bloody discharge
 Skin changes: ulceration, dimpling, skin retraction, peau d’orange

QUESTION 4: What are the investigations you undertake?

Answer:
 Triple assessment
 History and examination
 Radiological scan: Ultrasound (<35 years) and Mammogram (>35
years), X-ray
 Histological assessment: FNAC and Core needle biopsy
QUESTION 5: How would you manage/treat?
Answer:

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 Treatment is stage dependent.

 Primary aim is to remove tumor.
 Medical
 Surgical
 Lumpectomy
 Quadrantectomy
 Semi-mastectomy
 Simple mastectomy +chemotherapy
 Radical mastectomy
 Modified radical mastectomy
 Chemo or radiotherapy

ADDITIONAL INFROMATION
STAGING OF BREAST CANCER
 Based on the TMN staging
 T-tumor size
o T0- no palpable tumor
o Tis- tumor in situ
o T1- tumor 2cm, not fixed/tethering
o T2- tumor, 2-5cm, nipple retraction or tethering
o T3- 5cm (5-10cm) infiltration or ulceration
o T4- any size invading skin or chest wall (10cm), ulceration greater
than the distance of the lump
 M- metastasis
o M0- no distant metastasis
o M1- Metastasis present
 N- metastasis to local lymph nodes
o N0- no palpable axillary lymphadenopathy
o N1- mobile palpable axillary lymphadenopathy
o N2- fixed palpable axillary lymphadenopathy
o N3- palpable supraclavicular lymphadenopathy

NOTTINGHAM PROGNOSTIC INDEX

 This is used to determine prognosis following surgery for breast cancer.
 It is calculated using 3 pathological criteria:
 Size of the lesion (S)
 Number of involved lymph nodes (N)
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o 0 Nodes= 1
o 1-3 Nodes= 2
o >3 Nodes=3
 Grade of the tumor (G)
o Grade 1= 1
o Grade 2= 2
o Grade 3=3
 The index is calculated using this formula:
 NPI= [0.2 x S] + N + G
 Prognosis:
 93% 5-year survival
o >/=2.0 to </=2.4
 85% 5-year survival
o >2.4 to </=3.4
 70% 5-year survival
o >3.4 to </=5.4
 50% 5-year survival
o >5.4

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SPECIMEN 16 (NIPPLES)

QUESTION 1: Identify the

specimen
Answer: nipples
QUESTION 2: What is the
pathology?
Answer: Paget disease of nipples
(ductal carcinoma in-situ)
QUESTION 3: What are the clinical
features of this pathology?
Answer:
 Nipple ulceration
 Itchy red rash on the nipple
that can extend to the areola
 Flaking, crusty or thickened
skin on or around the nipple

QUESTION 4: What are the investigations you undertake?

Answer:
1. Ultrasound
2. Mammogram
3. FNAC
4. X-ray
5. Baseline (FBC, LFTs, U/Es, Creatinine)
QUESTION 5: How would you manage/treat?
Answer:
 Mastectomy with adjunct radiotherapy

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SPECIMEN 17 (GASTRIC ULCER)

QUESTION 1: Identify the

specimen
Answer: muscular structure
with an ulceration (Stomach)
QUESTION 2: What is the
pathology?
Answer: Peptic ulcer
QUESTION 3: What are the
clinical features of this
pathology?
Answer:
 Abdominal pain (epigastric)
that worsens after eating
 Burning sensation
 Heart burn
 Hematemesis
 Melena

QUESTION 4: What are the investigations you undertake?

Answer:
 Gastroscopy with biopsy
 Barium meal
 H. pylori antigen test
 Urease test
 CT scan
QUESTION 5: How would you manage/treat?
Answer:
 Triple therapy:
 Proton pump inhibitor: omeprazole
 Metronidazole

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 Amoxicillin
 Analgesia

 Complication: perforation, peritonitis

SPECIMEN 18 (CA PROSTATE)

QUESTION 1: Identify the specimen

Answer: Bladder and prostate
QUESTION 2: What is the pathology?
Answer: CA prostate
QUESTION 3: What are the clinical
features of this pathology?
Answer:
 Dysuria
 Urinary hesitancy
 Poor urinary stream
 Dribbling of urine
 Excessive urination at night
 Urge to urinate and leaking
 Urinary retention
 Weight loss

QUESTION 4: What are the investigations you undertake?

Answer:
1. Digital rectal exam: nodules felt (usually in the periphery first)
2. PSA (Prostate specific antigen)
3. Transrectal ultrasound
QUESTION 5: How would you manage/treat?
Answer:
 Stage dependent
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 Palliative care
 Medical: radiotherapy
 Surgical: prostatectomy, laparoscopic radical prostatectomy

SPECIMEN 19 (POLYCYSTIC KIDNEY DISEASE)

QUESTION 1: Identify the

specimen
Answer: bean shaped structures
with septate compartments
(Kidney)
QUESTION 2: What is the
pathology?
Answer: Polycystic kidney
disease
QUESTION 3: What are the
clinical features of this
pathology?
Answer:
 Pain
 Hematuria
 Infection
 Hypertension
 Uremia

QUESTION 4: What are the investigations you undertake?

Answer:
1. Ultrasound
2. Intravenous urogram
3. Blood urea and serum creatinine
4. Urinalysis

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QUESTION 5: How would you manage/treat?

Answer:
1. Rovsing operation
2. Ultrasound guided aspiration
3. Laparoscopic aspiration of cyst
4. Nephrectomy and renal transplantation

SPECIMEN 20 (SQUAMOUS CELL CARCINOMA OF

THE PENIS)

QUESTION 1: Identify the specimen

Answer: Penis
QUESTION 2: What is the
pathology?
Answer: Squamous cell carcinoma of
the penis
QUESTION 3: What are the clinical
features of this pathology?
Answer:
 Itching and burning sensation on
urination
 Inguinal lymphadenopathy
QUESTION 4: What are the
investigations you undertake?
Answer:
1. Excision Biopsy
2. Sentinel lymph node biopsy
3. Baseline labs (FBCs, LFTs, U/Es and serum creatinine)
QUESTION 5: How would you manage/treat?
Answer: Wide local excision

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SPECIMEN 21 (STOMACH CA)

QUESTION 1: Identify the specimen

Answer: muscular structure with
mucosal folding (Stomach)
QUESTION 2: What is the pathology?
Answer: Gastric carcinoma
QUESTION 3: What are the clinical
features of this pathology?
Answer:
 Dark stool (melena)
 Indigestion, nausea, vomiting,
hematesis
 Loss of appetite, fatigue, loss of
weight
 Abdominal fullness
 Dysphagia

QUESTION 4: What are the investigations you undertake?

Answer:
1. Esophagogastroduodenoscopy with biopsy
2. Positron emission tomography
3. Chest/abdominal/pelvic CT
4. Endoscopic ultrasound
5. Her2/neu testing
6. Baselines (FBC, LFTs, U/Es, Creatinine)
QUESTION 5: How would you manage/treat?
Answer:
 Stage dependent
 Gastrectomy (partial or total)
 Palliative care

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OSCE STATIONS: IMAGING

OSCE STATIONS: EQUIPMENT

BLOOD COLLECTION BOTTLES

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