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Surgical abdomen. Preparation for Finals – Case-based Learning Tutor name. TuBS attendance. https://tutorialbooking.com/. Session overview. Common surgical conditions for the OSCE How to present your findings Overview of clinical signs/surgical scars Case presentations and viva questions.
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Surgical abdomen Preparation for Finals – Case-based Learning Tutor name
TuBS attendance • https://tutorialbooking.com/
Session overview • Common surgical conditions for the OSCE • How to present your findings • Overview of clinical signs/surgical scars • Case presentations and viva questions
What 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.”
Common surgical conditions in the OSCE • Hernias • Stomas • Surgical scars
Presenting 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?
Example 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.
Completing your examination • Examine the contralateral groin • Transilluminate the mass • Full GI examination in particular look for causes of raised intra-abdominal pressure
Investigations Bedside ECGs, urine dip, spirometry Bloods and urine Biochemistry, haematology, M,C&S Imaging Plain XR, CT, MRI, US, echo Other Biopsy
Clinical signs Practise presenting!
Abdominal scars • Present what you see, described the scar if you do not know the name • Give a differential diagnosis
Presentation of a surgical scar • Describe: this is a xxx incision which is consistent with a previous xxx such as a xxx • Age - old or new? • Healing - well healed, hypertrophic or keloid? • Complications - infected or dehisced? Evidence of incisional hernia?
Scar 1 • Mercedes-Benz incision • Major upper GI or HPB surgery • E.g. liver transplant , Whipples procedure
Scar 2 • Midline laparotomy • Major intra-abdominal surgery
Scar 3 • Laparoscopy ports • 1 port = diagnostic laparoscopy
Scar 4 • Rutherford-Morrison incision • Renal transplant
Scar 5 • Loin incision • Renal surgery • E.g. nephrectomy
Scar 6 • Pfannenstiel incision • Open gynae surgery • E.g. C-section
Scar 7 • Suprainguinal incision • Open mesh repair of inguinal hernia
Scar 8 • Lanz incision • Appendicectomy • Lanz now favoured as hidden in skin creases compared to Gridiron which is more oblique
Scar 9 • Kocher’s incision • Open cholecystectomy
Scar 10 • Laparoscopy ports • Laparoscopic cholecystectomy
Case 1 - general • Middle aged man, with walking stick • Very slim • No lymphadenopathy
Case 1 – more abdo • Abdo soft, non tender • No palpable masses • Bowel sounds normal • Legs normal Please present your findings.
Case 2 - general 45 Year old male, on examination…. Looks well at rest, average BMI. Face – Pale conjunctivae Legs – Nil of note
Case 2 - abdomen • Palpable mass in LIF – 8x6, smooth • Tender • Bruit present overlying it • No other masses • No other organomegaly, non-palpable bladder • Bowel sounds present, normal
Case 2 Case 3 - observation 65 Year old male, on examination…. Looks well at rest, high BMI.
Case 3 - abdomen • Abdomen soft • Liver edge palpable 3 cm below costal margin • No spleen/kidneys/bladder • Bowel sounds present Please present your findings.