CLINICAL PRESENTATION – SOME IMPORTANT POINTS TO REMEMBER

Attire, appearance & equipment

Communicative skills and clear expression
Follow strict protocol, unless you are exempted
Imagine a real situation of similar patient in the ward/ER/OR

History in chronological sequence

Draw a clear line between past & present history, where you draw is your choice
Relevant positive & negative history
Differential diagnoses to be mentally worked out to elicit complete history
History of present illness in 3 (imaginary) parts
Elaborate the chief complaint
Elaborate any other symptoms patient may have, not mentioned under chief complaint
History related to general health; appetite, weight, fever, cough, bowels, micturition etc
Treatment history and result
Reduction of size with GP’s treatment doesn’t exclude Ca or Koch’s disease
Eg : Lymphoma may regress with steroids
Tuberculous lesion may regress with general antibiotics, such as kanamycin, ofloxacin, moxifloxacin
Pay attention to co-morbidities; eg : IHD, DM, HTN, hypothyroid, bronchial asthma, epilepsy

Physical examination : Eliciting physical findings and their interpretation are vital
To be examined in supine & erect positions : breast mass, varicose veins, groin hernia, undescended testis, varicocele, lymph
varix, communicating hydrocele, engorged veins of abdominal wall, Malagaigne bulges, mobile kidney etc
Common mistakes :
Anatomic plane (malignancies and inflammatory conditions may involve several planes)
Abdominal areas occupied by the mass
Abdominal mass visible but not palpable – distended hollow viscus
Lumbar lordosis
Fecal mass
Ballotability (the mass has be smaller than the AP diameter of the abdomen, difficult to elicit)
Gravid uterus, distended urinary bladder
 Fixity (to bone ?)
Lobular, granular, nodular or bosselated
Nodular : Most probably lymph nodes. Exceptions : liver, thyroid
Systemic examination (relevant systems first)
Peripheral pulses
PV / PR / Pupils / Fundus examination
It is important that your history & physical findings should lead to your provisional diagnosis

Investigations : Simple, inexpensive, noninvasive first

Think of shortest route to clinch the diagnosis
Eg : In a palpable breast mass, needle biopsy is more clinching than a mammogram
Have primary objective in mind, while choosing the investigations
E.g : In thyroid disease – primary concern may be either Ca or toxicity
Staging investigations should be done in all cases after confirming malignancy
Tumor markers, where relevant, should be mentioned (for diagnosis, surveillance or screening)
Bacteriological studies for infections – Gram stain, culture, fungal studies
Even in emergencies, some essential investigations have to be done
Eg : Perforated duodenal ulcer, strangulated hernia, acute appendicitis etc
Evaluation of nutritional status, fluid, electrolyte, acid-base balance and their correction

Diagnosis : Split it into definite and indefinite components

E.g : chronic cervical lymphadenitis (definite) & tuberculous (indefinite)
Sometimes go by statistical data, if there is no other clue
E.g : Adenoma in a solitary nodular goiter
MFH or fibrosarcoma in a soft tissue sarcoma
Never say there is no differential diagnosis
Common conditions are always common
Rare conditions may be mentioned for completion or in unusual situations
Remember : If you make a rare diagnosis, you may be rarely correct
If any single finding is materially altering the course of events, it should be proved beyond doubt
E.g : opposite axillary node or a liver nodule detected in USG in stage I or II breast Ca
As far as possible, try to fit all the findings into one disease.
Don’t overlook incidental diseases; eg : lipoma, sebaceous cyst, thyroid nodule, phimosis, hydrocele
Remember limitations of every investigation :
FNAC, prefer core needle biopsy if the lesion is >2.5cm
Negative needle biopsy may be due to sampling error (false negative)
Role of sentinel node biopsy & its technique

Treatment
If there is medical treatment, describe it first
Spell out the indications for surgery & if this patient has the indication
Then talk about the operation and anesthesia
Preoperative correction of nutrition, anemia, fluids, acod-base, electrolytes, DM, azotemia, thyrotoxicosis
No treatment for Ca without tissue diagnosis
No mutilative or radical procedure without tissue diagnosis
No mutilative or radical (risky) procedure for palliation
In thyroid Ca, histology is crucial
Histology also decides which modality of tmt to be preferred
Remember TNMG staging
In malignancy : Aim must be clear - cure (reasonable) or palliation
Palliation : spell out what symptom you aim to palliate and then mention the procedure
No undue morbidity or mortality is acceptable during palliation
Surgery for solitary secondary (in liver, lung, bone etc) : 4 criteria to be fulfilled
No other metastases, primary has to be potentially curable, well differentiated tumor and should be able to resect without
undue morbidity/mortality
No therapeutic embolization to reduce vascularity of malignancy, if surgery is not contemplated, since it makes other
modalities of treatment ineffective
Minimally invasive or endoscopic procedures to be mentioned where applicable
If two procedures have to be done to a patient at one sitting, cleaner of the two should be done first
Eg : hernia & hydrocele, GJ & appendectomy, oophorectomy & mastectomy etc

Discussion
Have some working classification in listing out conditions
 E.g : Causes of secondary hydrocele, recurrence of hernia, lymphedema of limb or generalized lymphadenopathy,
complications of surgery
Features of a condition to be described in an order : symptoms, physical findings (signs) and lab data
Admit if there are any features against your diagnosis – explain why you overruled them
Areas where TB & Ca can coexist : lung, lymph nodes & cecum
3 filters, where secondaries are far more common than primary cancers
Lung, liver and lymph nodes
Complications of proposed surgery, their prevention and treatment

Be prepared for a discussion of subjects related to the main disease

E.g : Testicular tumors in hydrocele or undescended testis
Strangulation or prostatic disease in a hernia
Perforation or hemorrhage in peptic ulcer
Ostomy care in Ca colon, rectum or ulcerative colitis
Complications of thyroid, parotid, gastric surgery or lymph node dissection
Exophthalmos in Graves’ disease
Thyroglossal disease or lingual thyroid in a goiter
Edema of arm in Ca breast
DVT prophylaxis or pulmonary embolism in high risk cases
Nutrition in malignancies or debilitating illness
Minimally invasive approach and staplers, where applicable
Types of meshes used in hernioplasty or vascular grafts

Further therapy for malignancies

Don’t stop with surgery for cancers
Chemotherapy, radiotherapy, hormone therapy, immunotherapy etc (neoadjuvant or adjuvant)
Concept of Targeted therapy
Know the common cytotoxic agents, their indications and side effects
Complications of radiotherapy and newer techniques of RT
Eg : Radionecrosis of bone – reason for dental extraction before giving RT to Ca tongue ot cheek
Radiation to sensitive neighboring normal organs – lung during pectoral RT or liver, kidneys, bledder, rectum during abdominal
RT
Post-therapy surveillance – clinical, imaging, tumor markers etc
General information

Definitions (it is said that if you know the correct definition, you know half the subject)
Normal laboratory values of common investigations
Surface anatomy, including origin, insertion and action of superficial muscles
Applied anatomy, embryology, physiology, pathology, pharmacology, anesthesia, genetics, statistics
Even in areas falling into the territory of superspecialities, such as Ortho, Neuro, Uro, Vascular, Thoracic, Onco, Gyn etc. know
some general principles
Cases of acute illness, trauma or burns may not be kept in the examinations, but be prepared for discussion about them
Common antibiotics, including anti-Koch’s drugs in use, their indications and side effects

Ultimately one should remember that the primary aim of any examination is to evaluate the knowledge of the candidate.
Whether the patient has a particular disease or not, is only secondary, at that point of time.
Be honest, gracefully admit your mistake or oversight, when pointed out
Respond to a remark made in lighter vain, with a smile, to show that you understood it
Never try to evade a question or outsmart the examiner (remember all examiners were once students)

Compiled by Prof C M K Reddy DSc FRCS (Glas) FRCS (Ire)

General & Vascular Surgeon
Halsted Surgical Clinic, Apollo & Lifeline Hospitals
C H E N N A I – 600 010
98843 13344 & [email protected]

DEFINITIONS IN SURGERY

1. ABSCESS : Localised collection of pus in a pathological space (ref : Empyema)

2. AGENESIS : Failure of development of an organ or structure (ref : Atresia)
3. ANEURYSM : Abnormal dilatation of a blood vessel
 FALSE : not containing all its layers
TRUE : containing all its layers
4. APOPTOSIS : Physiological process of death of abnormal cell, which is eliminated (ref : Necrosis)
5. APUD : Amine precursor uptake & decarboxylation
6. ATRESIA : Failure to canalize, of a normal opening or canal (ref : Agenesis)
7. AUTOIMMUNITY : A state when the body treats its own tissue as foreign and reacts
8. AZOTEMIA : Subclinical renal failure, with only biochemical abnormality (ref : Uremia)
9. BACTEREMIA : Circulation of bacteria in blood without producing disease (ref : Infection, Septicemia,
Toxemia & Pyemia)
10. BURN : Injury by dry heat (thermal, electrical or chemical) (ref : Scald)
11. CARBUNCLE : Infective gangrene of skin & subcutaneous tissue, usually caused by Staph. aureus
10. CELLULITIS 10 12. CELLULITIS : Spreading inflammation of tissue planes (ref : Erysipelas)
13. CENTRAL VENOUS PRESSURE (CVP) : Pressure of central venous pool, in continuity with right atrium (without valves interposed)
14. COMPRESSIBILITY : When the contents of a swelling can be reduced partially or totally and it fills back immediately on releasing the
pressure
15. COUGH IMPULSE : Expansile impulse seen or felt over a swelling while the patient coughs, cries or strains
16. CYANOSIS : Bluish discoloration of skin or mucous membrane, due to the presence of more than 5gm% of reduced hemoglobin in
blood
17. DERMOID : Cyst formed due to entrapped ectoderm
18. DIARRHEA : Passing frequent loose stools (ref : Dysentery)
19. DISTAL RUN-OFF : Arteriographic visualisation of the main vessel distal to occlusion
20. DIVERTICULUM : Abnormal projection for a hollow viscus
FALSE : not containing all its layers
TRUE : containing all its layers
21. DYSENTERY : Diarrhea with mucus &/or blood (ref : Diarrhea)
22. DYSPHAGIA : Difficulty in deglutition (ref : Odynophagia)
23. EMBOLISM : Detached substance carried in blood stream & lodges in an artery (ref : Thrombosis)
24. EMPYEMA : Collection of pus in a physiological space (ref : Abscess)
25. ENDARTERITIS : Inflammatory obliteration of terminal blood vessels
26. ENDOTOXIN : Toxin liberated by dead bacteria (ref : Exotoxin)
27. EPULIS : Swelling arising from the gum
28. ERYSIPELAS : Spreading cuticular lymphangitis (ref : Cellulitis)
29. EXOTOXIN : Toxin liberated by living bacteria (ref : Endotoxin)
30. FISTULA : An abnormal track between two hollow viscera or one to exterior lined by epithelium or granulation tissue (internal or external
respectively) (ref : Sinus)
31. FURUNCLE (BOIL) : Infective gangrene of a hair follicle or sebaceous gland usually caused by Staphylococcus aureus (ref : Carbuncle)
32. GANGLION : Mucoid degeneration of a joint capsule or tendon sheath
33. GANGRENE : Macroscopic death of tissue with superadded putrefaction (ref : Ulcer, only epitheliem involved)
34. GOITER : Enlargement of thyroid gland
35. GRANULOMA : Mass formed in a chronic inflammatory disease
36. HAMARTOMA : Tumor-like formation, by tissue indigenous to the site, due to developmental aberration
(ref : Teratoma)
37. HEMATEMESIS : Vomiting frank blood (ref : Melenemesis)
38. HEMATOCHEZIA : Passing frank blood per rectum (ref : Melena)
39. HERNIA : Abnormal protrusion of a viscus through a normal or abnormal opening, lined by a sac
(ref : Prolapse)
40. HYPERPLASIA : Enlargement of an organ or part, due to increase in number of constituent cells
(ref : Hypertrophy)
41. HYPERTROPHY : Enlargement of an organ or part, due to increase in size of its constituent cells
(ref : Hyperplasia)

42. INFARCTION : Death of tissue due to cessation of blood supply

43. INFECTION : Invasion by microbes causing disease (ref : Bacteremia, Septicemia, Superinfection)
44. INFLAMMATION : Reaction of living tissue to sublethal irritant
CHRONIC INFLMN : where inflammatory & reparative processes co-exist side by side
45. INTUSSUSCEPTION : Telescoping of a bowel into its distal segment
46. ISCHEMIA : Impaired perfusion of blood to an organ or an area
47. JAUNDICE : Yellowish discoloration of skin & mucous membrane, due to excessive circulating bile pigments
48. KELOID : Mass formed due to fibrous tissue hypertrophy, extending beyond the original scar
49. LASER : Light amplification by stimulated emission of radiation
50. LUDWIG’S ANGINA : Florid cellulitis of submandibular spaces
51. MELENA : Passing black tarry stools due to the presence of altered blood (ref : Hematochezia)
52. MELENEMESIS : Vomiting altered (coffee-ground) blood (ref : Hematemesis)
53. MUSCLE GUARD : Protective increased muscle tone of anterior abdominal wall, due to underlying acute inflammation
(peritonitis). It is voluntary (ref : Rigidity)
54. NECROSIS : Death of a cell, tissue or an organ, caused by degradative enzymatic action (ref : Apoptosis)
55. ODYNOPHAGIA : Painful deglutition (ref : Dysphagia)
56. PERFUSION : Injection of an agent into an artery of a part and recovering from its vein
57. PERIODICITY : Pain-free remissions ranging from weeks to months, with or without treatment
58. POLYP : Overgrowth from an epithelial surface
PEDUNCULATED : when the base is narrower than its head
SESSILE : when the base is broader than its head
 59. PROLAPSE : Abnormal protrusion of a viscus through a normal or abnormal opening, not lined by a sac (hence the viscus is visible) (ref :
Hernia)
60. PYEMIA : Circulation of infective emboli of clumps of bacteria, vegetations & clots in blood stream
(ref : Bacteremia, Infection, Septicemia)
61. REBOUND TENDERNESS : Tenderness felt when the palpating hand is suddenly withdrawn over the anterior abdominal wall (in
peritonitis)
62. RIGIDITY (ABD) : Involuntary spasm of abdominal muscles, indicating underlying peritonitis (ref : Muscle guard)
63. SCALD : Injury by moist heat (ref : Burn)
64. SEPTICEMIA : Circulation of bacteria in blood, producing disease (ref : Bacteremia, Pyemia)
65. SEQUESTRUM : Dead bone seen in chronic osteomyelitis
66. SHOCK : State of generalised decreased tissue perfusion, over a protracted period of time
67. SINUS : Abnormal blind track from the exterior, lined by epithelium or granulation tissue (ref : Fistula)
68. STENOSIS : Constriction or narrowing of a short segment of a canal or orifice (ref : Stricture)
69. STRANGURY : Painful, frequent, ineffectual attempts of micturition (ref : Tennismus)
70. STRICTURE : Constriction or narrowing of some length of a hollow viscus (ref : Stenosis)
71. SUPERINFECTION : Disease caused by ‘otherwise harmless’ organisms due to suppression of pathogens by antibiotics (ref : Infection)
72. SYMBIOSIS : Living together of two dissimilar organisms, beneficial to both
73. TENNISMUS: Painful, frequent, ineffectual attempts of defecation (ref : Strangury)
74. TERATOMA : Tumour-like formation with more than one germinal layer, by tissue not indigenous to site, due to developmental
aberration (ref : Hamartoma)
75. THROMBOSIS : Intravascular coagulation of blood (ref : Embolism)
76. TORSION : Twisting of a solid organ on its pedicle (ref : Volvulus)
77. TRANSFUSION : Administration of blood or its components
78. ULCER : Breach in continuity of skin or epithelium due to molecular death of tissue (full thickness)
EROSION : Loss of partial thickness of epithelium (ref : Gangrene, where deeper tissues are involved)
TROPHIC ULCER : Ulcer due to sensory deficit or arterial insufficiency
79. UREMIA : Clinical syndrome of renal failure (ref : Azotemia)
80. VOLVULUS : Twisting of a hollow viscus in the axis of its mesentery (ref : Torsion)
81. WHITLOW : Suppurative infection of fingers &/or hand.
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Compiled by Dr (Mrs) R S Sudhalakshmi, SMC (USA), from the teachings of
Prof C M K Reddy DSc(Hon) FRCS(Glas) FRCS FRSH(Eng) FICS FICA(USA) FVSI