STATIONS OF OSCE OF SURGERY Dr (1).docx

OSCE STATIONS OF SURGERY

Dr. ABDULHUSSEIN AL-JABERI

[email protected]

History

ABDOMINAL PAIN

Greet the patient by last/first name; introduce self and role; shake hands

Identify and confirm problem list

Negotiate an agenda; establish a plan for the visit

1-Present illness onset and duration2-Location of pain and severity3-Radiation4-Timing related to food5-Aggravating and Relieving factor6-Associated fever and rigors7-Nausea/Vomiting8-Change in bowel motion, blood in the stool9- Weight loss10-Past history of previous episodes11-Past surgical and medical history12-Drugs history13-Jaundice14-Social history, alcohol, smoking

WRITING AN OPERATION NOTE

1-Demographic details (name,age, hospital No.)2-Staff details (you, your assistant, and the anaesthetist)3-Date and location of operation4-Operation title5-Indication6-Incision7-Findings8-Procedure9-Closure10-Post-operative instructions

WEIGHT LOSS




1-Duration2-How many Kgs/week or month was lost3-Loss of appetite ,weakness and easy fatigability4-GI symptoms(dysphagia, vomiting, diarrhea and constipation, change of bowel habits5-Chronic bleeding(hematemesis, malena, hematuria, vaginal bleeding, hemoptysis6-Thyrotoxicosis symptoms(intolerance to hot weather, sweating, tachycardia, palpitation, nervousness)7-Past surgical history (previous surgery, tumour, chemotherapy, radiotherapy)8-Past medical history(DM ,chronic illness)9-Psychological status

VOMITING

1-Greet patient, introduce yourself, establish a plan2-Duration3-Frequency4-Vomitus.(volume, content, character)5-Regurgitation6-Bile stained7-Blood, clots8-Relation to meal9-Abdominal pain (radiation)10-Bowel motion (diarrhea, constipation)11-Jaundice12-Fever,rigor13-Weight loss14-Past history(peptic ulcer, gall stone, endoscopy)15-Drugs history16-Social history(smoking, alcohol)

THYROID SWELLING

1-Greet patient, introduce yourself ,establish a plan2-Location3-Duration4-Change in size5- Pain6-Intllerance to hot Vs cold whether7-Anxiety, sleep disturbances8-Palpitations9-Diarrhea10-Menstrual disturbances11-Miscarriages and infertility12-Fever13-Sweaty palms and skin Vs dry scaly skin14-Change in voice and speech pattern15-Respiratort obstruction16-Drugs,antithyroids17-Irradiation exposure18-Past medical history ,cardiac troubles19-Family history of goiter

THYROID STATUS




1-Age2-Occupation3-Do you prefer cold or warm room4-Gained or lost weight recently: How much and over how long5-Appetite6-Bowel habit7-Changed of mood8-Palpitations or chest pain9-Change in your periods(female)10-Change in your appearance11- Change in your vision12-Have notice alump in your neck ?Does it cause any problems13-Past medical and surgical history14- Any medical conditions15-Operation on thyroid gland or radiotherapy on neck in the past16-Medications and allergies17-Any thyroid drugs18-Pressure symptoms(dysphagia, stridor)SPIKESSettings (s)Privacy: Involve significant others Sit down Look attentive and calm ( ) Listening mode : :: :

Availability Perception (P) ICE : : Invitation (I) : Knowledge (K) : ... ... ... ( )Avoid scientific and technical language : Empathy (E) :1. : 2. : 3. : : Validation Strategy and summary (S) .

S-P-I-K-E-S

S=SETTING*privacy*ask for presence of family members or friends*sit dowenP=PERCEPTION*ask patient what he knows about his conditionI=INVITATION*obtaining overt permission*respect patients right to know or not to knowK=KNOWLEDGE*give your patient a warning that bad news are coming*avoid technical and scientific languageE=EMPATHY*downplay the severity of the situation or give a more hopeful prognosisS=STRATEGY AND SUMMERY*summarize the information in your discussion

PYLORIC STENOSIS




1-When did the vomiting start2-How many episodes per day3-Any relation to feeds4- Character of the vomits and volume5-Number of wet diapers6-Number and character of stool, any blood7-Weight gain in relation to birth weight8-Birth history9-Family history

PEPTIC ULCER / GALL STONE / CHOLECYSTITIS / DU / PANCREATITIS




1-Site,onset ,duration,severity,course2-Quality,quantity3-Aggravating and relieving factor4-Radiation5-Dizziness6-Bleeding P/R, malena, haematemesis7-Bowel movement ,flatus8-Urinary symptoms9-Previous episodes10-Medication-NSAID11-Past medical and surgical history, endoscopy,12-Nausea,vomiting,fever,chills13-Weight loss14-Chest pain, SOB,DOE, cough, IHD15-Social history, smoking, alcohol16-Family history

NIPPLE DISCHARGE




1-Nature of the discharge2-Association with mass3-Unilateral or bilateral4-Single or multiple duct discharge5-The use of contraceptive pills6-Association with pain, tenderness7- Association with fever8-History of trauma9- Family history10- Age of patient

NECK MASS




1-Onset 2-Rate of growth3-Associated pain4- Associated fever, sweating, rigor5-Smoking6-Sun exposure7-Alcohol8-Otalgia9-Hoarsness10-Trismus11-Dysphagia12-Wt loss

JAUNDICE




1-Onset 2-Pain3-Fluctuation4-Progression5-Duration6-Fever and chills7-Loss of appetite8-Loss of weight9-Pruritus10-Change in stool colour11-Change in urin colour12-Past medical history13-Past surgical history14-Drugs and blood transfusion15-Family history16-Alcohol and smoking17-Foreign travelINTESTINAL OBSTRUCTION




1-Pain :character, severity, location, periodicity2-Distention:rapid,sudden,degree3-Bowel habit and flatus4-Wt loss5-Previous obstruction6- Previous abdomen or pelvic operation7- Previous abdominal CA8- Previous intra abdominal inflammation9-Immediat post operative state10-Exposure to radiation11-Past medical history

INFORMED CONSENTS




C= explanation of the condition and natural history and prognosisO= explanation of the therapeutic options, conservative, surgical treatmentN= the name of the procedureS= side effect and complication(anesthetic, infection, bleeding)E= extra procedure(drain, NG tube, Foley catheter stoma information)N= name of the operating person and assistantT= if the procedure under TRIAL the patient must be informedS= second opinion of the other family members may be obtained prior to surgery

INCISIONAL HERNIA / HYPERTENSIVE WRITE MEDICAL CONSULTATION

1-Patients name and Age2-Clear consultation destination3- Greeting the consultant doctor4-Duration of HT5-The drug/drugs used by the patient6-The doses of the drugs used7-Recording the BP8-Any chest pain9-Any kind of dyspnoea10-Clear and direct aims of the consultation11- Greeting the consultant doctor12-Name and position of the consultation writer13-Signature of the consultation writer14-Date of the consultation

HYPOTHYROIDISM




1-How long has she been fatigued2-Has there been a weight gain3-Any swelling in the lower legs4-Notice any change in her hair or skin, any rashes5-Any history of thyroid disease in the family6-Any joint pain or intolerance to cold7-Any excessive intake of water8-Do you suffer from constipation9-Past medical/family history10-Any history of thyroid disease in the family11-Any previous medical conditions12-On you on any other medication

GROIN LUMP




1-Age-occupation2-How long have you noticed the lump?3-Were you doing anything in particular when you first noticed the lump?4-Is it painful?5-Has it increased in size since you first noticed it?6-Does it disappear if you lie down/ can you push it back inside?7-Have you had any previous lump or swellings similar to this?8-Does it discharge?9-Has the lump ever become red, painful or difficult to reduce ? did you have associated episodes of vomiting or your bowel not opening?10-Do you have any urinary symptoms?11-Do you suffer from constipation?12- Do you suffer from cough?13-Does your work/leisure time involve a lot of lifting ?14-Do you ever inject drugs in your groin?15-Have you had any recent night sweats/weight loss?16-Past medical and surgical history17-Have you had any tests to investigate the lump?18- Have you had any treatment for it?GI BLEEDING




1-Duration2-Quantity3-Appearance4-Any clots5-Any abdominal pain6-Bowel symptoms7-Stool8-Any chest pain/Any syncope/Any sweating9-Weight loss10-Past medical history:11-Peptic ulcer12-liver disease13-Any cancer14-Prior bleeding15-Cardiac disease16-Previous surgeries17-Medications/NSAIDS/Aspirin18-Family history19-Social history: smoking, alcoholDYSPHAGIA




1-Hematemesis/malena2-Weight loss3-Difficulty initially with solids and later liquids4-Painful dysphagia or painless5-Diarrhea or Constipation6-Anemia7-Fever,chills,night sweats8-Abdominal pain/mass9-Heart burn10-Nausea/vomiting11-Chest pain12-Medication use13-Cough14-Hoarse voice15-Pneumonia16-Past medical and surgical history17-Family history18-Social history: work, family, smoking, alcohol, eating habits, life styleDVT (POST OPRATIVE LEG PAIN)




1-Onset 2-Trauma3-Fever4-Chest pain5-SOB6-Pregnancy7-Recent immobilization(airplane tripe)8-Occupation9-Past medical and surgical history10-Medications11-Smoking and alcohol12-Drug use13-Family history of blood clots

DIABETIC FOOT




1-Greet patient ,introduce yourself, establish a plan2-Do you have diabetes3-When diabetes diagnosed4-How it had been diagnosed as a diabetes5-What is treatment he/she was on6- What is treatment he/she was on now7-Any incident of hypoglycemia8- Any incident of hyperglycemia9-Is he /she on regular follow up program (diabetic clinic )10-How he/she started the foot problem11-Does he/she feel his/her foot12-What kind of treatment he/she received

CUSHINGS




1-Weight gain2-Truncal obesity3-Muscle weakness4-Depression5-Thin skin6-Bruising7-Hyperglycaemia8-Hypertention9-Headach10-Amenorrhoea11-Impotance(male)12-Pathological Fractures13-Cogestive heart failure

CLAUDICATION/ISCHEMIC LIMBGreet the patient by last/first name; introduce self and role; shake hands



1-Onset2-Duration3-Location4-Radiation5-Alleviating factor6-Provoking factor7-Paresthesias8-Pallor9-Paralysis10-Deformity,swelling,stiffness11-Amputation and ulceration12-Walking distance13-Effects on function14-Reduced range of movement15-Rest pain and night pain16-One or both legs17-Calf, buttock, thigh18-Past medical history(DM,HT,CAD, Dyslipidemia)19-Family history(CAR,HTN,DM,STROKE)20-Social history(smoking, alcohol, diet, activity, cocaine/heroine abuse)CHANGE OF BOWEL HABIT




1-Nature of bowel habit (diarrhea, constipation)2-Duration3-Onset (sudden, gradual)4-Tenessmus5-Mucus6-Wight loss7-Nausea /vomiting8-Blood in the stool(bright red, mixed with stool, dark)9-Past history of previous episodes10-Past surgical history11-Drugs history12-Social history(smoking, alcohol)

BREAST PAIN




1-Relation to M. cycle2-Previous trauma3-Any nipple discharge4-Any abnormality in breast5-Nipple retraction6-Nodularity of breast7-One or both breast8-Any musculoskeletal disorder9-Previous biopsy and result10-Marital status,children,lactating, menarch,1st child11-Family history of CA breast12-History of CA breast

BREAST LUMP




1-Age2-Lump site ,single, multiple3-Lump onset, growth rate, variations with menstrual cycle4-Presence or absence of pain5-Change in breast size or shape6-Skin and nipple changes7-Discharge (serous, serosanguinous, green, bloody, milky)8-Temperature/fever9-Wieght loss10-Bone or abdominal pain11-Arm swelling (lymphoedema)12-Previous radiation or surgery13-Menstrual history(menarche, menopause, contraceptive pill, hormone replacement)14-Obstetric history (breast feeding and complication, parity, previous mammograms, screening)15-Family history(breast, bowel, ovarian carcinoma)16-Symptoms of possible metastatic disease ,other lump (axilla), breathlessness, backache, headache, tiredness, anorexia, weight loss ,jaundice

Assess fitness for surgery patient with GROIN HERNIA




1-Age2-Have you had much trouble with your groin3-Has it ever got stuck out and become painful4-Vomiting , constipation, abdominal pain5-Is it always reducible6-Medical problems7-Heart ,lung trouble8-Shortness of breath and chest pain9-How far can you walk on the flat without stopping10-Can you climb a flight of stairs11-Can you dress yourself without getting SOB/chest pain12-Have you had an anaesthetic before: general, local, regional,13-Do you take any regular medication: warfarin, antiplatelet agent

ANAL PAIN




1-Duration and onset of pain and time2-Associated discharge and color3-Is the pain periodic4-Previous attacks of such pain5-Any associated mass6-Change in bowel habit7-Pain increase by defecation8-Any bleeding on defecation9-Fever,malass,lethargy10- Wt loss11-Constipation

Examination&Management

ABDOMINAL EXAMINATION

1-Greet patient ,introduce yourself, establish a plan2- Expose from nipple to mid-thigh

INSPECTION3-Stand at the foot of patient and observe: ( movement with respiration, symmetry of the abdomen)4- Stand at the right side of the patient and observe : (movement with respiration, contour ,any scar, any dilated veins, umbilicuse inverted* everted or flat, pigmentation, pulsation , cough impulse, any stoma)

PALPATION5-Ask if there is any tenderness point6-Superficial palpation looking for any mass or tenderness (look at the face of the patient)7-Deep palpation:SPLEEN*Right hand on the right iliac fossa of the patient and the left hand placed on the lateral aspect of the costal margin of the patient with compression towards right hand. The patient instructed to take deep breath* Right hand on the left iliac fossa of the patient and the left hand placed on the lateral aspect of the costal margin of the patient with compression towards right hand. The patient instructed to take deep breathLIVER*Hand in the RIF with fingers pointing towards the left axilla*With expiration, slide the hand nearer the right costal margin*The edge of the liver strikes the hand as the patient inspireKIDNEYS*Bimanual8-Cough implse at the hernia orifice

PERCUSSION9-Splenic size10-Liver span: percussion of the right side of the chest ,start at fourth intercostals space to obtain resonant note, then work downwards to determine liver dullness11-Look for the ascites: (shifting dullness, transmitted thrill)

AUSCULTATION12-Bowel sounds13-Renal bruits14-Dont forget (external genitalia, supraclavicular LN, back, PR, hernia orifice)

THYROID EXAMINATION1-Greet patient ,introduce yourself, establish a plan2-Inspection3-Asked patient to swallow4- Asked patient to protrude the tongue5-Observed for restlessness, agitation, sitting unstill6-Observed for lethargy, hypotonia, speech and voice7-Body build and temperature8-Moist palms, skin9-Fine tremor10-PR and BP11-Eye sings:(lid lag, lid retraction, exophthalmos, ophthalmoplagia, chemosis)12-Palpation from the front13- Palpation from the back14-Size15-Shape16-Surface17-Consistency18-Mobility Vs fixity19-Tenderness20-Position of the trachea21-Carotid pulsation22-Examined for possible retrosternal extension 23-Cervical LN including suraclavicular LN24-Auscultate for bruit ,vascular goiter25-Looked for Horners syndromeSUBMANDIBULAR GLAND EXAMINATION

1-Ask patient to suck lemon2-Inspection of the floor of the mouth3-Ask patient to open mouth widely and raise the tip of the tongue towards roof of mouth4- Bimanual palpation of the gland using gloves5-Patients head flexed and inclined to the affected side6-Index fingers inserted in the mouth and fingers of the other hand beneath the jaw7-Examine other side for comparison

SMALL BOWEL OBSTRUCTION MANAGEMENT

1-A-B-C-D-and fluid resuscitation2-History and physical examination3-N.P.O. and N.G.T4-Catheterise5-IV fluid(RL,NS,K)6-Analgesia and antiemetic

RTA MANAGEMENT

1-Introduce yourself ,Greet, Establish a plan2-Ask for C-spine precaution3- Ask for 2 large bore IV line4- Ask for O2,monitors, appropriate fluid boluses5-Check airways ,cyanosis6-Inspect chest7-Palpate chest for subcutaneous emphysema, # ribs8-Auscultate chest for air entry9-Feel for tracheal position10- Vital signs11-Look for external sources of blood loss12-Recognize hemo-pnemothorax13-Check the abdomen for possible abdominal hemorrhage14-Examine pelvis ,long bones, for #

Pyloric Stenosis counseling

Brief overview of the findings

Information of diagnosis

Natural history of condition

Investigation if required

Treatment and prognosis

PREOPERATIVE ASSESSMENT (SURGERY FITNESS)

1-HISTORY :previous surgery / anaesthetic ,ICU admission, exercise tolerance , medication, smoking, respiratory symptoms.2-PHYSICAL EXAMINATION: cardiorespiratory signs (wheeze, cough, dyspnoea, heart murmur, dysrhythmia)3-ECG,CXR4-BLOOD PROFILE: Hb, LFT,RFT,SE, coagulation, blood sugar, ABG, ECHO

PERIPHERAL VASCULAR SYSTEM (ISCHEMIC LIMB) EXAMINATION

1-Introduce yourself ,Greet, Establish a plan 2-GENERAL(look around bed for aids ,oxygen or medication {GTN spray} look at the patient as a whole : well / unwell, pain/ pain-free, SOB, cyanosis ,obesity3-Skin and Nails: colour, ulceration, gangrene, digital amputation/ tissue loss, oedema, hair loss, venous guttering, scar, muscle wasting, 4-Looked for pressure points and between the toes(web spaces)5-Palpation: temperature ,pitting oedema, capillary refill time .PULSES : aortic-femoral-popliteal-DP-PT6-Burger test7- Numbness, paresthesia and absent sensation 8-Auscultation (aortic-renal-iliac-femoral)9-ABPI-CARDIOVASCULAR-NEUROLOGICAL-ABDOMINAL EXAMINATIN

Peptic Ulcer: MANAGEMENT and physical examination and COUNSELING

MANAGEMENT

Level of consciousness

Airways

Breathing

Circulation

Vitals: pulse, BP, Temp, RR

NPO

PHYSICAL EXAMINATION

Wash hands

Solicit consent for examination

Ensure that the patient is properly draped

Relevant general hydration, pulse

Inspection

Auscultation

Percussion

Peritoneal signs

Palpation

Rectal exam (not actually performed but the intention voiced)

Give attention to patients physical comfort

Verbalize the maneuvers on the examination

COUNSELING

Explain seriousness of the condition

Willing to explain the matter to the girlfriend

Explain PEPTIC ULCER and complications

Inform about endoscopy and admission to hospital

Stating H.pylori as a probable cause and cigarette-smoking as an aggravating factor

Counsel on smoking cessation

PANCREATITIS MANAGEMENT

1-A-B-C-D-E- and fluid resuscitation2-History( establish cause: gallstone, alcohol, trauma, steroids, mumps, autoimmunity, hyperlipidaemia, hypercalcaemia , ERCP, drugs, scorpion venom)3-Physical examination4- Arterial blood gases :assess PH,PO25- Blood profile : CBC, LFT, SE, UREA, ALBUMIN,GLUCOSE5-U/S CT scan at 5-7 days

MVA Trauma: EXAMINATION AND MANAGEMENTGreet the patient by last/first name; introduce self and role


Ask for vital signs

Wash hands


Explain about the procedures to be performed

Ask for C-spine precautions

Ask for :

2 large bore IVs

Oxygen

Monitors

Appropriate fluid boluses

Check airways

Recognize cyanosis

Inspect chest

Palpate chest-left subcut emphysema

Auscultate chest-no air entry on the right

Feel for tracheal position-midline

Recognize PTX

Treat correctly PTX

Reassess chest after CT or needle decompression

Reassess the vital signs

Look for external sources of blood loss

Check the abdomen for possible abdominal hemorrhage

Examine pelvis

Examine long bones for fractures

Assess the GCS

Exposed the patient and log roll and DRE

Indicate options to determine intra-abdominal hemorrhage (DPL, FAST, CT)

Asked AMPLE Hx ( at least 3 )

Demonstrate competent approach to the ABCDE primary survey


Give attention to patients comfort and modesty

MANAGEMENT OF GASTROINTESTINAL HAEMORRHAGE

1-Use the ABC approach ,ensure airway, breathing and circulation2-Wide- bore cannulae or central venous catheter3-Rapid infusion of colloid to correct hypotension 4-Estimation of Hb and clotting status and blood for crossmatching5-Monitoring of BP ,PR,UOP/h, and oxygen saturations6- Pass NG Tube7-Commence infusion of PPI or antacids8-Give FFP if PT is abnormal, and give platelets if thrombocytopaenia is present9-Give blood when available if BP is not maintained by clear fluids10-Give unmatced blood O-ve if necessary if the bleeding is massive11-Correct coagulopathies 12-Intervene early in cases with chronic disease or atherosclerosis , as these patients dont tolerate hypotension well13- Endoscopy after patient stabilize

GI Bleeding MANAGEMENT and PHYSICAL EXAMINATION

MANAGEMENT

Safety precautions

Airway management

Breathing- give oxygen

Circulation:

Ask for vital signs

2 large bore IV lines

State to give IV fluids (normal saline/ Ringer lactate)

Draw blood for CBC, lytes, Cr, Ur, PT/PTT, glucose, cross-match 4-6 units

Cardiac monitor/12 lead EKG

Intend to insert Foley catheter to monitor urine output

Stabilize patient

Keep NPO/NG tube

PHYSICAL EXAMINATION

Wash hands


Assess level of consciousness

VS

Examine extremities

Oral exam

Look for signs of chronic liver disease (palmer erythema, clubbing, spider angioma, gynecomastia, jaundice, testicular atrophy, ascitis, hepatosplenomegaly)

Examine abdomen:

inspection

auscultation

palpation (light/deep)

percussion




Intend to perform DRE

Gall Stone. Provide initial management and perform a focused examinationLevel of consciousness

Airways

Breathing

Circulation ( IV line)

Vitals: pulse, BP, Temp, RR

NPO

Wash hands



Relevant general hydration, pulse

Inspection

Auscultation

Percussion

Peritoneal signs

Palpation

Rectal exam (not actually performed but the intention voiced)



Key Points: COUNSELING

Explain seriousness of the condition

Discussed helping with note to be off work

Explain gall bladder stone and complications

Inform about U/S and admission to hospital

Advised may need surgery if the duct or gallbladder is infected

FOOT ULCER EXAMINATION

1-Introduce yourself ,Greet, Establish a plan 2-Inspection/general/gait, shoes, heels 3-Any foot ulcer or deformity4-Inspection/skin/vascular insufficieny-hairlessness ,pallor5-Rubor at pressure points6-Skin breakdown (portal for infection)7-Diabetic dermopathy (brown macules )over shins8-Infection, cellulites( erythema, swelling)9-Gangrene10-Web space, cracked, infected, ulcer, maceration 11-Toe nails, dystrophic, in-grown , paronychia, onychomycosis 12-Palpation pulses: femoral-popliteal PT-DP13-Temp-capillary refill14-Ausculation/bruits, femoral, popliteal

Dysphagia PHYSICAL EXAMINATION

Washing hands

Soliciting consent for examination

Check mouth forloss of enamel

Check throat

Check cervical lymph nodes

ABD: looks for epigastric tenderness/mass, liver

Auscultate chest



Ensure that the patient is draped properly

DVT perform a focused physical examination

Wash hands


Explain the procedures to be performed

Check leg for tenderness and swelling and colour (patients leg will be red and warm to simulate a deep vein thrombosis or cellulitis; if the leg is touched by examinee, the patient will complain of severe pain)

Check the pulse of foot to confirm good arterial circulation

Check for Hoffmans sign (calf pain with dorsiflexion of right foot)

Listen to the lungs in four places



Claudication: physical examination

Wash hands



Ask for blood pressure

Comment on changes in skin color, or temperature

Comment on loss of hair or dystrophic nails

Abdominal aortic area

Bilateral Femoral, popliteal, dorsalis pedis and posterior tibial arteries. To be confident that the pulse you cannot feel is truly absent, you must know the arterial anatomical landmarks. (Posterior tibial at the infero-posterior border of the medial malleolus, dorsalis pedis at the upper third of the dorsal foot just lateral to the extensor halluses longus, popliteal artery in the infero-lateral portion of the popliteal fossa, femoral artery mid-point between the anterior superior iliac spine and the symphysis pubis bone).

Ask for the ankle brachial index (ABI)

Auscultate abdominal aortic and femoral arteries.

Buergers test (blanching of skin of feet noted upon raising legs to 30-45o for 1 min)

Mention DeWeese test (disappearance of previously palpable pulse after walking exrecise)



CERVICAL L.N EXAMINATION

1- Examination of cervical L.N. from behind2- Flexion of the head for exam. of submandibular and supraclavicular L.N.3- Put the hand on the head to adjust the degree of flexion4- Palpate supraclavicular fossa from infront 5- Did he turn the face to one side in examining the jugular L.N.6- Palpate supraclavicular fossa from behind with patient elevating and hunching forward his shoulders7- Palpation of submental L.N. group 8- Palpation of submandibular L.N. group 9- Palpation of jugular L.N. group10- Palpation of supraclavicular L.N. group11- Palpation of posterior triangular L.N. group12- Palpation of postauricular and preauricular L.N. group13- Palpation of suboccipital L.N. group14- Palpation of L.N. group along the posterior border of the sternomastoid muscle15-Make the sternomastoid muscle tense ,turn the head to one side (to determine the relation of L.N. to it)16-Examination of the mouth and looking for any cause of the enlargement of L.N.

BREAST LUMP , NIPPL DISCHARGE INSPECTION

1-Inspection both breasts for size2-Symmetry3-Skin changes4-Congenital anomalies5-Nipple and areola, presence or absence6-Colour, symmetry7-Discharge, nature from which duct8-Retraction, Distraction, Deviation of nipple9-Peu de orange10-Inspection,Breasts11- Inspection axilla and supraclavicular fossa and arms swellings12-Enlargement, Distended veins, Wasted muscles13-Raising arms above head for mass14-Press arms against hips for mass

ABDOMINAL MASS EXAMINATION

1-Introduce yourself to the patient2-Ask for a nurse chaperone3-Obtain consent4-Ensure adequate privacy comfort and exposure5-Ask the patient whether they have any pain6-Wash hand7-INSPECTION-PALPATION- PERCUSSION AND AUSCULTATION-of the abdomen8-MASS:( site, scar, size, shape, surface-regular / irregular, edge, tenderness, temperature, consistency, can you get above / below it ?, pinch skin over it, lift head off the bed (tense the rectus sheath) to determine mobility / fixity of mass, cough impulse, reducibility / compressibility, fluctuance, pulsatility, expansibility, does it move with respiration, can it be balloted, percuss the lump, auscultate over the lump, palpate for regional LN (inguinal and axillary).9-THANK THE PATIENT

OSCE OF ARAB BOARD IN FINAL EXAM. 2009-2010-2011

SLIDS IN ARAB BOARD OSCE

2009 - slides1- History, Mammograph, Ca breast, (finding, prognosis)2- History, CT scan, plan x-ray,(Dx, treatment, prognosis)= chronic calcified pancreatitis3- History, Abd. x-ray, barium, (finding, Dx) = sigmoid valvulus4- History, Cross pathology, operative view (finding, Dx,) = Ca stomach5- History, Isotop scan (describe, Dx, treatment)= GRAVES 6- History, CT scan(describe, Dx,) pancreatic pseudocyst7- History, abd x-ray,(finding, Dx, treatment) = duodenal atresia8- History ,MRCP,ERCP, (describe, Dx) = CBD injury9- History ,Barium swallow (describe, Dx , causes, treatment)= zenker diverticulum10- History, CT scan, (describe , Dx, treatment)= adrenal tumor11- History, CT scan ,angiogram,(describe, Dx, treatment)12- History , lower limb ulcer( describe, causes, treatment)13- History , face tumor(describe, DDx, treatment)=SCC14- History , stoma (describe, Dx, treatment)= parastomal hernia15- History , barium swallow (finding, Dx, treatment ,causes)= achalasia16- History , CXR (describe, treatment, DDx)= plural effusion ? Ca ? fistula ?17- History , CT scan, ERCP( describe ,Dx, treatment)=ca head of pancreas18- History, X-ray, cross pathology, (finding, Dx, treatment)= small bowel obstruction19- History, CT scan, operative,( describe, Dx, treatment)= liver H. cyst20-History,CTscan, operative,(describe, Dx, prognosis, treatment) = Ca gallbladder

2010 - slides

1-Hydrocoele2-CBD injury3-artriovenus fistula 4-Ca breast5-Esophagal atresia6-Megacolon7-Appendicular abscess8- diverticulosis and fistula 9-sigmoid valvulus10-paroted tumor11-splenectomy12-DIC13-Prolaps pills 14-klatskin tumor15-A.P resection16-Gastrostomy feeding tube 17-treachiostomy 18-Necrotizing fasciitis 19-Wound dehisces 20-H.cyst liver and spleen

2011 - slides

1-leomyosarcoma 2-lung abscess 3-forign body4- splenic abscess 5-perforated DU6-sebaceous cyst7-lymphedema 8-Burn9-cleft lip and palate10-BCC11-D.foot12-Ca gallbladder13-fascial wound 14- venous ulcer15-ovarian teratoma 16-dermoid cyst17-adrenal mass 18-melanoma 19-hairy nevus20-poplital artery aneurysm

6 / 2011 (stations)

1- EXAM. THE NECK WHAT YOUR DX AND INVESTIGATION(RETROSTERNAL GOITER)2- JAUNDICE TAKE HISTORY WHAT IS THE Dx (OBST.JAUND. CBD STONE) 3- CUSHING TAKE HISTORY AND WHAT ARE THE INVESTIGATION4- RED COLOR NIPPL DISCHARAGR TAKE HISTORY AND WHAT IS THE INVESTIGATION5- PATIENT WITH CA CAECUM (PHYSICAL EXAM.)6- HEPATOMEGALY ABDOMINAL EXAM.7- RTA GCS 3 HOW TO CONFIM AND LEGALLY TAKE ANY ORGAN AND WHAT ARE CONTRAINDICATION FOR TAKE ANY ORGAN8- PATIENT OPERATED FOR PEPTIC ULCER THEN DEVELOP GASTROCOLIC FISTULA WHAT ARE THE CAUSES AND HOW TO PREPAIR FOR OPERATION9- 70 YEAR OLD PATIENT DM AND HAD 2 VASCULAR STENT AND ILIOFEMORAL DVT DEVELPED ACUT CHOLECYSTITIS WHAT ARE OPTION OF TREATMENT AND PREPERATION10- BOTH LOWER LIMBS PAIN FOR 2MONTHS TAKE HISTORY AND DISCRIB THE X-RAY(ANGIOGRAM)

5 / 2010 (stations)

1- THYROID EXAMINATION2- 2nd POSTOPRATIVE DAY PERFORATED DU MANAGEMENT3- UPPER GI BLEEDING MANAGEMENT4- POSTERIOR NECK MASS HISTORY AND EXAMINATION5- PATIENT ON T.P.N (PHYSICAL EXAM. AND MANAGEMENT)6- LOWER LIMB ISCHEMIA AND ANGIOGRAM HISTORY AND DISCRIB ANGIOGRAM7- CT (PANCREATIC PSEDOCYST) HISTORY AND DX AND CAUSES8- MELANOMA (EXAM THIS PATIENT LEG)9- LOWER GI BLEEDING HISTORY AND INVESTIGATION10- ABDOMINAL EXAMINATION (ASCITES,HEPATOSPLENOMEGALY)

12 / 2009 (stations)

1- THYROID EXAMINATION2- ABDOMINAL EXAMINATION (HEPATOMEGALY)3- CXR HISTORY-TREATMENT (SPONT.PNEMOTHORAX)4- PERFORATED DU (X-RAY) OPERATION AND COMPLICATION5- CT SPLENIC INJURY (COUNSELING)6- DYSHPAGIA HISTORY7- LOWER LIMB VASCULAR EXAMINATION8- JAUNDICE HISTORY9- DDX OF APPENDICITIS IN FEMALE10- BAD NEWS(SPIKES) CA LUNG

12 / 2010 (stations)

1- ABDOMINAL EXAMINATION (ABD.MASS)2- THYROID EXAMINATION INVESTIGATION-AND DX.3- VIDIO BREAST EXAMINATION TWO HPOTO.WHAT IS MISTAKE IN EXAM. DISCRIB THE 2 PHOTO(ON LABTOP)4- DYSPHAGIA HISTORY5- CA COLON RECURRENT OPERATION COPD-SUDDEN CHEST PAIN SOB-(DX AND MANAGEMENT) PUL.EMBOLISM6- CA RECTUM 6cmFROM ANAL VERGE OPTIONS OF TREATMENT ADVANTAGE AND DISADVANTAGE OF EACH7- 140 kg 175cm DM (PREPERATION AND TREATMENT AND WHAT IS BMI)8- AMPULA OF VATER TUMOR OBST. JAUNDICE-DM-WHAT IS THE CURABLE TREATMENT AND PREPERATION9- ABDOMINAL PAIN 2MONTH HISTORY OF CHOLECYSTECTOMY TAKE HISTORY AND WHAT IS THE Dx FROM HISTORY AND INVESTIGATION(DX PANCREATIC PSEDOCYST)10- 2nd DAY POSTOPERATIVE (HYSTERECTOMY)WBC 1600 BP 90/60 PR 105 CXR? (AIR UNDERDIAPHRAGM) DISCRIB CXR , MANAGEMENT, WHAT YOU TALL TO HER AND TO GYNECOLOGEST?

Slides (Yemen exam)

1-DM PT WITH MASS IN TRUNK (MAY BE SOFT TISSUE TUMOUR)2- NEUROFIBROMATOSIS3- DIVERTICULOSIS +COLORECTAL CANCER BARUIM ENEMA 4- TRAUMA TO HAND WITH LOSS OF DISTAL PHALANGES5- BURN -2ND DEGREE6- CLEFT PALATE AND LIP7- RTA WITH LIVER INJURY - CT SCAN8- 2 CASES OF ERCP X-RAY9- PHEOCHROMOCYTOMA -CT SCAN10- AIR UNDER DIAPHRAGM X-RAY

Stations (Yemen exam)

1-ABDOMINAL EXAMINATION (ABOUT 2 CASES ABD MASS & INCISIONAL HERNIA)2- HYDATID CYST LUNG3- CHILD FOR ORCHIPEXY --->TALK TO HIS MOTHER ABOUT OPERATION4- INVESTIGATIONS AND PREPARATION OF PT WITH OBSTRUCTIVE JAUNDICE FOR OPERATION5- COMPLICATION OF ILEOANAL POUCH OPERATION IN PT WITH UC.6- TALK TO FAMILY OF PT WITH EXTENSIVE PANCREATIC TUMOUR7- PT WITH POSTERIOR NECK MASS8- HX OF PT WITH OBSTRUCTIVE JAUNDICE9- HX OF PT WITH NECK MASS

OSCE :

:o Stations . .

: Slides Show .

o 6 10 .o 6/10.o 10 Slides Show 20 .o Slide Show 5 10.o 6/10 Stations Slide Show.o .

References

1- SCHWATRZ2- SHORT PRACTICE3- MRCS PART B OSCEs4- BAILEY AND LOVE OSCE FOR MRCS5- CLINICAL CASES AND OSCEs in surgery6- NORMAN L. BROWSE7- CRACKING THE MRCS VIVA

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STATIONS OF OSCE OF SURGERY Dr (1).docx

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