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Cytology looks at cells, and is done via FNA Histology looks at the tissue, and is done via core needle biopsy
Awake Intub : can topicalize pt. and place awake. Difficult mask b/c of beard, large/small mandible, redundant tissue/big tongue Blind : distal aperture of LMA sits directly over the laryngeal inlet can pass an uncut, lubricated 6mm cuffed ETT through the mask rotate tube 90 ’ to left (CCW) during passage to bring bevel anterior to pass through aperture bars one study showed 72% success in avg 13 sec. and additional 12% after re-adjust. Later study by same author -->90% success w/ blind can also used a soft ETT changer (gum-rubber bougee) Failed : per Dr. Brain, LMA may be easier to insert when larynx is anterior (when tracheal intubation is most difficult) try before crich. low risk/benefit ratio per Benumof. full-stomach pt controversial cricoid pressure may make placement more difficult FOB: 5.0mm FOB will fit through #4 can be used as above in awake placement, or asleep. FOB can be used and then ETT passed over OR wire can be passed through suction port and used as a guidewire Unskilled : 2 studies: personnel w/ no previous experience using the LMA were successful in 90+% of cases NOT USEFUL IF PT HAS LIMITED MOUTH OPENING
OSCERevision ClassDr. Syed Asad AliFCPSDEPT:OF SURGERY
Q#1.What does OSCE stands for?• A)Objective Structured Clinical Examination• B)Over Stimulation and Crying Event• C)Opportunity for Showing your Competenceand Excellence• D)All• E)None
What is OSCE?The candidates rotate through a series ofstations at which they are asked to carry out avarious task(usually clinical)
OSCE includes several "stations"examinees are expected to performspecificclinical tasks within a specified timeperiod .students rotate through a series ofstations (as few as 2 or as many as 20).
Osce Stations• 1.INTERACTIVE• 2.STATIC• 3. INTERSTATION or TAG STATION
1.Monitored station, where An EXAMINERscores the students performance,Encounters:patient history,performing a physical examinationdiagnostic procedure,teaching/counseling/advising a patient.A standardized checklist is used for markingof each station.INTERACTIVE STATIONS)
here the student answersquestions about the encounterWhat is your differentialdiagnosis?What investigations will youorder?What treatment will you advise?2. Interstation or tag station
a student is asked to answerquestions, about 1.Instruments2.interpret findings such aslab reportsx-rays,3.Clinical photographs(spotdiagnosis)4.Clinical Scenarios3.STATIC STATIONSare not observed
Osce StationsNO:16•1.INTERACTIVE -4.(1-INTERSTATION or TAG)•2.STATIC-12
HISTORY TAKING STATIONS• 1.Abdominal PAIN/MASS• -EPIGASTRIC• -HYPOCHONDRIAC REGION• -PERI-UMBILICAL /R I FOSSA•
HISTORY TAKING STATIONS• 2.DYSPHAGIA• 3.PAIN in the LOIN/FLANK• 4.HEMATURIA• 5.PAINFUL DEFECATION• 6.BLEEDING P/R• 7.HEMETEMESIS/MAELENA• 8.INGUINO-SCROTAL SWELLING• 9.BREAST LUMP• 10.GOITRE• 11.JAUNDICE(Surgical)
Station ProfileA) Instruction to students: .Mr.Mohammed is a 22-year-old, presentedwith sudden pain in periumblical regionassociated with nausea,vomiting and pyrexiafor the last one day.
Station Profile (cont)A) Instruction to students:(cont)• You have 4 minutes to assess this patient,by taking the proper and relevant history• An observer, using a checklist, will assessyour performance while you interact withthe patient• No questions will be asked by the examiner
Checklist• Student greeted the patient• Introduced her/himself• Asked the patient’s name• Site of pain/• Onset• Duration of pain• Nature of pain
ChecklistRadiation/ReferralAggravating/Alleviating factorsAssociated featuresChange in appetiteFever –typeBowel functions
INTERACTIVE-2(Tag Station)Here the student answers questionsabout the encounter on Interactive-1.1.What is your differential diagnosis?2.What investigations will you order?3.What treatment will you advise?
CLINICAL EXAMINATION• 1.Exam of a SWELLING• 2.Exam of ABDOMEN• 3.Exam of THYROID• 4.Exam of PAROTID• 5.Exam of an ULCER• 6.Exam of a BREAST LUMP• 7.Exam of VARICOSE VEINS• 8.Exam of INGUINAL HERNIA• 9.Exam of SCROTUM
Station ProfileA) Instruction to students: .Mr.Mohammed is a 22-year-old, presentedwith this Lump(Swelling) inNECK,BACK,SCALP,FACE etc
Station Profile (cont)A) Instruction to students:(cont)• You have 4 minutes to examine thispatient,• An observer, using a checklist, will assessyour performance while you examine thepatient
A FEW QUESTIONS• What are your findings• What is your dignosis?• D/D• Investigation• Treatment
BREAST EXAMINATION• Introduction and Consent• Inspection– With the patient sitting– With the patient leaning forward– Arms above head– Push hands into hips
BREAST EXAMINATION• Palpation– Start with the normal breast– Arm behind head– All 4 quadrants– Axillary tail• Examine lymph nodes– Axillary– Cervical
A few questions...• What is meant by triple assessment?– Clinical examination– Imaging – mammography and ultrasound– Cytology• What is the difference between cytology andhistology?• What are the risk factors for breast cancer?What is MRM? What are the risk factors forbreast cancer?
LOOK at this picture and answer thefollowing question:• 1.what is your diagnosis?• 2.justify• 3.what is the underlying pathology?• 4.Name 2or 3 investigations• 4.list 3 complications.• 5.mention treatment options.
Ostomy•Show a normal stoma Not painfulAlways red and moistRose Red Bud
Stomas Continued• Complications– Early• Haemorrhage• Stoma Ischaemia• High Output• Obstruction (adhesions)• Stoma retraction– Delayed• Dermatitis,• Stoma Prolapsed• Parastomal hernia• Fistulae• ObstructionTypes of stoma– Temporary– Permanent– End– loop– Counselling– How to manage stomas– Stoma site avoided:• Bony areas, umbilicus,scars, waistline skin fold &creases
Look at this operative photographLook at this operative photograph-1- Dist = 1.30cm-2- Dist = 0.91cmLook at this operative photograph
QUESTIONS• Identify this organ• What is your diagnosis• List 3-4 clinical features• What complications occur if treatment isdelayed
Ranula9• Is a term used formucoceles that occurin the floor of themouth.• The name is derivedform the word rana,because the swellingmay resemble thetranslucent underbellyof the frog.
LOOK at this picture and answer thefollowing question:• 1.what is your diagnosis• 2.what is the underlying pathology?• 3.list 3 complications.• 4.mention treatment options.
Table 1 Classification of patients with renal cell carcinoma according to tumorthrombus levelKarnes RJ and Blute ML (2008) Surgery Insight: management of renal cell carcinoma with associated inferior vena cavathrombusNat Clin Pract Urol doi:10.1038/ncpuro1122
QUESTIONS• 1.What is this lesion.• 2.Name the commonest causes of thislesion in lower leg.• 3.What are the different parts of thislesion?• 4.How will you treat this lesion?
CASE 1.A 28-year-old man presents to the emergencydepartment complaining of anal and lower-back painfor the previous 36 h..The pain is progressively getting worse and he isuncomfortable to walk or sit down.ExaminationInspection of the anus reveals a 3cm 3 cm swelling atthe anal margin. The swelling is warm, exquisitelytender
Questions• What is the diagnosis?• What are the aetiological factorsassociated with this condition?• How are these lesions anatomicallyclassified?• What treatment is required
AETIOLOGY.in 90% of cases the abscesscommences as an infection of ananal gland.
classification of the perianalabscess:• Perianal• Ischiorectal• High intersphincteric• Submucous• Pelvirectal.
Treatment1. Incision and drainage may be done under localanesthesia. packing to keep skin edges open.2. Antibiotics .
Case Scenario I• 32 years old male, complaining of painlessbleeding per rectum and a palpable lumpwhile abluting. Pt sometimes has mucusdischarge and pruritis.
Scenario I• What is your provisional Diagnosis?• What are the investigations you need andwhy?• Mention 4 complication in such pt?
CASE SCENARIOA 60 years old man, presented to thesurgical OPD, complaining of left sidedloin pain, associated with occasionalhematuria.on examination his left kidney is palpableand U/S shows is mass in the upper poleleft kidney,
Q.#.1.What is your differential diagnosis?Q.#.2.What investigation is now required?Q.#.3.Name often relevant investigations forplanning management.Q.#.4.Mention treatment options.Questions:Keys:
50 years male with mass epigastrium movingwith respiration, associated with vomiting, wtloss for two months .O/E : Left supraclavicular node palpableA Ba-meal –Ray is ordered which is shownbelowCASE
QuestionsQ.#.2.What is your likely diagnosis?Q.#.3.Which investigations is needed to cofirmdiagnosis?Q.#.4.Q#5.Name any 3investigationto stage the disease.List treatment optionsQ#1. Mention the finding on X-ray
ANSWERSQ.#.2. Cancer of StomachQ.#.3. Endoscopy/ BiopsyQ.#.4Q#5.1.CT SCAN 2.EUS 3.PET SCAN 4.StaggingLaparoscopy1.Surgery-Gastrectomy(subtotal/total)Palliative gastrojejunostomyLymphadenectomy.2.Radiotherapy3.aAdjuvant ChemotherapyQ#1. Apple core appearance-body of stomach
SCENARIOA 62 year-old woman with chief complainof neck mass.Physical exam reveals a thyroid nodule,2*2*2 cm.Clinically she is Euthyroid.
Questions:Q.#.1. What is your diagnosis.Q.#.2. Name any 3 causes of this lesion.Q.#.3.Q#4.Mention any 3 signs which suggest malignancy.List any 3 investigation which will help indiagnosis of this lesion.Keys:
Keys:Q.#.1. Solitary Thyroid noduleQ.#.2. 1.Thyroid cyst2.Thyroid Adenoma3.Thyroid cancerQ.#.3. 1,Firm to hard nodule2,Fixed nodule3.Rapid increase in size4. local invasion-Vocal cord paralysis-Dysphagia5.Cervica Lymphadenopathy1.T3,TSH 2. Thyroid scan3. FNA4. Thyroid uptake of I-1315. Ultrasound
X-RAY Small Bowel Obstructionis suggested by a“ladder” pattern, whenobstruction occurs, bothfluid and gas collect inthe intestine. They produce acharacteristic patterncalled air-fluid levels.The air rises above thefluid and there is a flatsurface at the air-fluidinterface.
SBO Vs LBOLarge bowel Small bowelPeripherally placed dilatedbowelCentrally placed loops dilatedbowelHaustra (do not cross wholediameter of colon; no morethan 1/3 of the way across)Valvulae conniventes extendacross whole bowel lumenFew loops Many loops
Gastric cancer– No ability todistinguishbetweenmalignant andbenign ulcers.
HEPATICFLEXURESPLENICFLEXURETRANSVERSE COLONCECUMASCENDINGCOLONDESENDINGCOLONTERMINAL ILEUMNORMALCOLONNormal air contrastbarium enema showsfilling of colon with airand barium retrogradeto the cecum with refluxinto the terminal illeum
The standard questions tobe asked:•What is this instrument?•Name the parts.•What are its uses?•What complications canarise
Ryle`stube:•For gastricaspiration.•Afterlaparotomy• Intestinalobstruction• AfteranastomosisCatheterDistal (inner) endProximal (outer) end
1. What is the use of this? For nasogastric feeding. To aspiration gastric secretions or contents beforeemergency surgeries & in bowel obstruction. Gastric empty because emergency surgery( Roadtraffic accident2. What are it`s different parts?
1. What is the use of this object? Drainage of urine from bladder. Fluid management of patient. Measure urine output.2. What is the use of 2 channels? 1,Passage of distil water through x & inflate theballoon located at the end of the tube in order tokeep the catheter inside the bladder. So we call it“self retaining catheter.”2. For drainage of urine
Used for irrigation of the bladder byusing normal saline after surgery Also used as gastrostomy tube
3. What are the indications? Gastrostomy Pt, loss of Autonomic NS functions, incardiac failure.4. Disadvantages: - Connect the external and internal environment.Therefore infection can be spread to exterior to interior.
What are the uses of this tube? To maintain Pt. air way in injured or unconscious Pts. To ventilate unconscious Pts. To give anesthetic drugs.e.g.:-halothane To ventilate pts. In intra oral surgeries. To prevention by use of cuff. What is the use of “a”? Inflation of “a” with air helps to keep the tube inposition & prevent aspiration. How does this tube an adult differ from that of ayoung child? In children’s endotracheal tube is a 3.5 mm area whichis radio opaque that help to detect the position of thetube in x-rays.
What are the uses of it? To depress the tongue preventing thetongue falls back To maintain a pts airway To keep air way pt until recoveringfrom anesthesia
1. What are the indications? Acute airway obstruction.e.g.:-forging body. To ventilate Pts following surgeries including oral cavity. To protect the lower airwaye.g.:-aspiration of saliva in unconscious Pts. For Pt requiring artificial respiration – respiratoryinsufficiency. Who has dead space depression
2. What are the advantages? Anatomical dead space is reduced. Work of breathing is reduced. Alveolar ventilation is increases. Level of sedation needed for Pts comfort, isreduced. No damage to the vocal cords
3. What are the disadvantages? Loss of heat & moisture exchange performed in upperairway. Desiccation of tracheal epithelium. Loss of ciliated cells & metaplasia. Over production of mucous
4. How do you manage tracheostomy postoperatively? Suction. Humidification. Change of the inner tube & remove mucousplugging. Physiotherapy.