Monday, January 13, 2014

Surgery Practical Examination

Dear me. Please undo this mistakes. DO NOT REPEAT THEM !


The idiot medic student.

I came to the department of a foreign hospital. I did not study here. Tapi, aku redha dengan apa yang akan terjadi. Sebab ini salah aku sendiri. Aku yang tak kuat untuk hadapi peperiksaan. Hari ni , aku kena hadapai semua yang kat depan mata dengan sendiri. Tak ada siapa yang akan tolong aku. Aku ibarat anak yatim. Tiada tempat nak bergantung. Tiada tempat nak mengadu. 

Malam tu, kepala agak serabut nak study yang mana satu dahulu.

Sepertimana nasihat kat sticker note aku,

" The key to success is not prioritizing your schedule, 
but rather scheduling your priorities"

Well said advice i think.


0700 am : Went to hospital early. 

0800 am: Start taking history of each cases.

1000am : Surgery viva session commenced.

1.30 pm: Lunch break.

200pm : Viva commenced. Ortho viva started.

500pm : Instruments surgery, specimens, X-rays for ortho, simple surgery procedures, 

Long case surgery

35 year old male, Jaya, came with swelling of the right mouth and chin  for the last ____month.
Also c/o wound and halitosis in the mouth.

- concious , cooperative
-well built, moderately nourished
- Pallour -ve, icterus -ve, clubbing -ve, cyanosis -ve, lymphadenopathy +ve, edema -ve.

Mouth and oral cavity examination:

Inspection and palpation:

  • Nose: Normal
  • Maxilla: Normal
  • Mandible (jaw) - Right angle 3 multiple swelling , border diffused in nature, surface irregular,extent 7x5cm extending from right angle of the lip and lateral border of mandible,part of swelling covered by hair, firm on palpation, fixed to the bone, skin over swelling not pinchable.
  • Lip: Normal
  • Oral cavity: 2 ulcer wound present on the right side of buccal mucosa extending to the inferolateral border of the tongue. wound size on buccal mucosa(4x1cm). Wound on tongue (4cmx2.5cm). Both wound no discharge, covered by pus and  slough unhealthy granulation tissue,beaded(?) elevated border(?) , blood tinged discharge, no bleeding on palpation, firm on palpation, involved teeth shaky mobile upon palpation, tenderness mildly present on palpation, 
  • Gingiva: swelling , oedematous, cyanosed, tobacco stained,firm on palpation, 
  • Tongue: An oval wound present over lateral margin of the right side of the tongue, induration present, border elevated, covered with pus and serous discharge.
  • Teeth: Poor dental hygine, carries present, mobile teeth, tobacco stained.
  • Uvula: Normal, no deviation.
  • Lymph node : multiple ipsilateral nodes but all less than 6cm N2B
DDx: Carcinoma of buccal Mucosa (  Viva : Squamous Cell Carcinoma) invading the right jaw and tongue. 

Stage 4: T4,N2B,M1 

Short surgery case

A 40 year old male from kerala presents with swelling behind his back.


  • A diffuse swelling present over the ________(lumbar vertebra/back?)
  • Puncta present over the swelling. 
  • No discharge present.
  • no local rise of temperature.
  • no tenderness.
  • Cystic in nature
  • margin well defined, border not indurated,
  • Skin over swelling; not pinchable
  • Center : indented
  • Mobility: Horizontal+ve, Vertical +ve,
  • Slip sign -ve
  • Fluctuation test +ve
  • Translumination test: -ve

DDx: Sebaceous cyst/ Lipoma/

Rx: Surface excision.(?)

Surgery short case

A 30 year old female with neck swelling c/o hoarseness of voice since 1 month.
C/o pain radiating the shoulder, aggravated on drinking, relieved on medication.
No h/o headache, no h/o deafness.


  • One diffuse swelling, present over the middle of the neck.
  • Size 3cmx5cm, 
  • no redness or discharge.
  • No local rise of temperature
  • No tenderness
  • Mobility: non mobile(fixed?)
 -Papillary thyroid cancer invading recurrent laryngeal nerve.(Under 45 year,female,solitary nodule,deep cx LN involved,fixed LN,) 
-Tuberculous LN
-Secondaries in neck 

Orthopaedics Short Case

A 55 year old female, Mangala from Bankart came with trauma of the right hand two month back.


H/o trauma suddenly and was treated by plaster cast for 25 days. When the trauma has not been cured, she was admitted to FMH for 5 days. Plaster cast was changed for 5 days.After 1 month of care , she was sent for operation when the trauma still not cured. She c/o pain since 2 month back , and not relieved  even after treatment. H/o of decreased movement range.
c/o pain and swelling of the right wrist.

Examination of the hand

  • Irregularity of the lower end of radius ( dinner fork deformity)
  • Th styloid process came to lie at the same level / higher than the ulnar styloid process.
  • Dorsal tilt present.
  • Tenderness present

DDx: Colle's fracture complicated by Sudecks osteodystrophy(pain,swelling,stiffnessof hand after removal of plaster) 

Rx: immobilise, below elbow plaster cast for six weeks

Orthopaedics Short Case

A 65 year old male came with a  left foot drop(?) since 15 years. 


H/o foot drop for 15 years, h/o leprosy  for 45 years , on medication for 5 years,
 Right leg: No sensation from middle calf to ankle, heel normal, 
Left leg: foot drop for 40 years back, decreased sensation,
Both legs have skin desquamation,No pain on both legs.
Able to walk, gait normal, left foot touching the ground.
No h/o physiotheraphy.

Examination of left leg

  • Attitude: Patient sitting on the bed, both knees same level, adducted, heels touching the floor, normal dorsiflexion of the ankle, no shortening, no swelling, skin desquamation present,no tenderness, no local rise of temperature, sensation decreased, wasting of muscles present, 
  • movement active: inability to dorsiflex  left ankle ,  both knee extension and flexion normal,
  • Movement passive: no rigidity/spasticity on both legs. left ankle in plantar flexion upon elevation of left leg above ground.
DDx: Foot drop caused by common peroneal nerve palsy affected by leprosy.

p/s: In ortho no need to write case sheets , but they ask for the paper anyway. So, just write in the paper.

Friday, January 10, 2014


Definition : An opening made in the trachea is called tracheostomy.


  • Emergency: choking, stridor
  • Elective: Coma , tetanus, barbiturate,head injuries, pulmonary insufficiency
  • Anaplastic carcinomathyroid patients presenting with stridor due to infiltration of growth into trachea. 
Anaesthesia: LA

  • Incision: Tranverse curved incision 3-4cm at the level of 2nd tracheal ring. 
  • Dissection: Skin , subcutaneous tissue and deep fascia are incised.Isthmus of thyroid is separated.
  • Procedure: A transversed curved cut is made at the level of 2nd tracheal ring, its edge is held by Allis forceps and a small cuff of cartilage is removed. Cricoid hook can be used to stabilise the trachea (found more usefull in children).
  • A suitable sized tracheostomy is introduced within.
  • The cuff of tracheostomy tube is inflated by using 2-5ml of air and is held in place by passing a tape around the neck.
  • Confirm the tube in the trachea not in the subcutaneous plane.
  • Confirm air entry into both lungs.
Post op Rx
  • Suction of tracheostomy tube
  • Regular dressing
  • Humidification of air
  • Check for air entry
Post op complication
  • wound infection
  • Air leakage
  • Improper air entry
  • cricoid stenosis

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