Tutor name TuBS attendance httpstutorialbookingcom Session overview Common surgical conditions for the OSCE How to present your findings Overview of clinical signssurgical scars Case presentations and viva questions ID: 777500
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Slide1
Surgical abdomen
Preparation for Finals – Case-based LearningTutor name
Slide2TuBS attendance
https://tutorialbooking.com/
Slide3Session overview
Common surgical conditions for the OSCE
How to present your findingsOverview of clinical signs/surgical scarsCase presentations and viva questions
Slide4What is the purpose of an OSCE?
“This station tests a student’s ability to perform an appropriate focussed
physical examination, demonstrating consideration for the patient, and to report back succinctly describing the relevant findings. It also tests a student’s clinical judgement i.e. the ability to decide the differential diagnosis, choose investigations and formulate a management plan.”
Slide5Common surgical conditions in the OSCE
Hernias
StomasSurgical scars
Slide6Presenting your findings
What
were you asked to do?What were your key positive findings?What were the important negative
findings?
What does this
mean
?
How would you
complete your examination
, and what
investigations
would you do?
Slide7Example case presentation
I was asked to examine the abdomen of this ___ year old ___
On examination this patient has a mass in the right groin.It is medial to and above the pubic tubercle, and did not reappear after being reduced when the deep ring was occluded. Bowel sounds were auscultated over the mass.
I therefore think this is a direct inguinal hernia.
My differential would include an indirect inguinal hernia and a femoral hernia.
Slide8Completing your examination
Examine the contralateral groin
Transilluminate the massFull GI examination in particular look for causes of raised intra-abdominal pressure
Slide9Investigations
Bedside
ECGs, urine dip, spirometryBloods and urineBiochemistry, haematology, M,C&SImaging
Plain XR, CT, MRI, US, echo
Other
Biopsy
Slide10Clinical signs
Practise presenting!
Slide11Slide12Slide13Slide14Slide15Slide16Slide17Slide18Abdominal scars
Present what you see, described the scar if you do not know the name
Give a differential diagnosis
Slide19Presentation of a surgical scar
Describe:
this is a xxx incision which is consistent with a previous xxx such as a xxxAge -
old or new?
Healing
- well healed, hypertrophic or keloid?
Complications
- infected or dehisced?
Evidence of incisional hernia?
Slide20Scar 1
Slide21Scar 1
Mercedes-Benz incision
Major upper GI or HPB surgery
E.g.
liver transplant ,
Whipples
procedure
Slide22Scar 2
Slide23Scar 2
Midline laparotomy
Major intra-abdominal surgery
Slide24Scar 3
Slide25Scar 3
Laparoscopy ports
1 port = diagnostic laparoscopy
Slide26Scar 4
Slide27Scar 4
R
utherford-Morrison incisionRenal transplant
Slide28Scar 5
Slide29Scar 5
Loin incision
Renal surgeryE.g. nephrectomy
Slide30Scar 6
Slide31Scar 6
P
fannenstiel incisionOpen gynae surgeryE.g. C-section
Slide32Scar 7
Slide33Scar 7
S
uprainguinal incisionOpen mesh repair of inguinal hernia
Slide34Scar 8
Slide35Scar 8
Lanz
incisionAppendicectomyLanz
now favoured as hidden in skin creases compared to Gridiron which is more oblique
Slide36Scar 9
Slide37Scar 9
Kocher’s incision
Open cholecystectomy
Slide38Scar 10
Slide39Scar 10
Laparoscopy ports
Laparoscopic cholecystectomy
Slide40Case 1
Slide41Please present your findings.
Slide42Case 1 - general
Middle aged man, with walking stickVery slim
No lymphadenopathy
Slide43Case 1 - abdomen
Slide44Case 1 – more
abdoAbdo
soft, non tenderNo palpable massesBowel sounds normalLegs normalPlease present your findings.
Slide45Case 2
Slide46Case 2 - general
45 Year old male
, on examination….Looks well at rest, average BMI.Face – Pale conjunctivae
Legs –
Nil of note
Slide47Case 2 - abdomen
Palpable mass in LIF – 8x6, smoothTender
Bruit present overlying itNo other massesNo other organomegaly, non-palpable bladderBowel sounds present, normal
Slide48Case 3
Slide49Case 2
65 Year old male
, on examination….Looks well at rest, high BMI.
Case 3 - observation
Slide50Case 3 - abdomen
Abdomen softLiver edge palpable 3 cm below costal margin
No spleen/kidneys/bladderBowel sounds presentPlease present your findings.
Slide51What is a hernia?
‘a protrusion of a viscus through a defect of the walls of its containing cavity into an abnormal position’
Slide52Describe the anatomy of the inguinal canal
Deep
ring = midpoint of inguinal ligament (halfway between ASIS and PT)Superficial ring = above PTFemoral
pulse at mid-inguinal point (halfway between ASIS and PS)
Hesselbachs
triangle = inferior epigastric artery, rectus
abdominus
, inguinal ligament
Slide53Anatomy of the inguinal canal
Walls of the inguinal canal
Floor = inguinal ligamentRoof = internal obliqueAnterior = external obliquePosterior = transversalis fascia
Slide54What is your differential diagnosis for a groin lump?
Hernia
– inguinal, femoral, otherVascular: saphena varix, femoral artery aneurysm
Lymph node
Psoas abscess
Undescended testes
Slide55How would you tell a direct from an indirect hernia?
Very inaccurate but liked in exams
Reduce hernia and cover the deep ring with fingers then ask to cough…Hernia controlled = indirect
Not controlled = direct
Slide56What are the complications of a hernia?
Incarceration/irreducibility
ObstructionStrangulation
Slide57Describe the
demography
of hernias
Direct inguinal
Indirect inguinal
Femoral
Men
Above and medial to PT
20% inguinal
Older – weak muscle wall
Superficial ring
Through
Hesselbachs
triangle
Rarely descend into scrotum
Rarely strangulate
Men
Above and medial to PT
80% inguinal
Younger – PPV
Deep ring
Have all 3 layers and descend into scrotum
Women (wider femoral canal)
Below and lateral to PT
Often irreducible
Frequently strangulate
Slide58Richter’s hernia
Rare but dangerous
Part, not all, of bowel wall herniatesTherefore do not obstruct, but can strangulate
Slide59What is a stoma?
‘an artificial union between conduits or between a conduit and the outside’
Greek for ‘mouth’
Slide60What are the different types of stoma?
Content
Site
Surface
Ileostomy
Liquid stool
RIF
Spout
Colostomy
Formed stool
LIF
Flush
Urostomy
Urine
RIF
Flush
Slide61End vs defunctioning stomas
Slide62How can you tell what operation someone with a stoma has had?
Colostomy…
Hartmanns (temporary) or AP resection (permanent)Ask if they still have an anusIleostomy…
Panproctocolectomy (permanent)
Anterior resection (temporary)
Slide63Previous OSCE stations
AAA managed by EVAR
Kidney transplantLiver transplantLaparoscopic port site scarsColostomyIleostomyUrostomy
Hernias
Slide64Summary
Common surgical conditions for the OSCE
How to present your findingsOverview of clinical signs/surgical scarsCase presentations and viva questions
Slide65Please complete
TuBS feedback
Tutor detailsFor more information on Examining for Finals sessions:examiningforfinals@gmail.com
www.sefce.net/pulse
With thanks to previous contributors:
Dr Emma Claire Phillips (FY2)
Dr Kristina Lee (FY2)
Dr
Aman
Shams (GI
SpR
)