Mastery in General Surgery Short Cases

The following sections are included:

• Dedication
• Foreword by Kenneth Mak
• Foreword by Abu Rauff
• Preface
• Acknowledgements
• About the Authors
• Contents

The inguinal hernia examination is commonly encountered in the surgical exam. How smooth the station goes is directly related to the amount of practice the examinee has done. It is critical that no pain is caused during the hernia examination, or the pain of the patient would soon manifest as the tears of the examinee.

The incisional hernia is commonly encountered in the short case examination and its complexity varies hugely. Pain is commonly encountered when attempting to reduce the hernia to feel for the fascia defect and should be carefully avoided. When discussing the causes of an incisional hernia, one must cautiously tread between blaming the patient (medical causes) and the surgeon (technical factors). A few examinees have confidently declared that the primary reason for the incisional hernia was a technical issue with closure only to find out that the examiner was the primary surgeon of the patient.

The examination and management of the umbilical hernia resemble that of the incisional hernia. Be careful not to miss a scar around the hernia as that may alter your diagnosis. Any etiology that precipitated the hernia should be observed and mentioned. Finally, the management should be tailored to patient’s co-morbidities — a laparoscopic repair may not be the best option in an umbilical hernia in the end-stage chronic obstructive pulmonary disease patient.

The examination of the stoma is a common topic, of which the most tested would be the colonic or small bowel opening to the anterior abdominal wall. The range of questions expected would vary from the type of stoma the patient has, to the management of stoma complications or even to reconstruct the type of surgery the patient underwent. The candidate must display familiarity with the stoma (ileostomy vs colostomy should be a spot diagnosis) and be sensitive to the patient in any event of stoma complications.

The approach to the neck in the surgical short case can be tricky. It is important to understand there are more things to examine in the neck than just the thyroid. Many a lymph node, thyroglossal cyst and even branchial cyst have been wrongly mislabeled a thyroid nodule. Often, the presence of used cups by the patient’s bedside hints toward the diagnosis of a thyroid mass. Prior to examining patients, it is important to first practice on your fellow colleague. Honest criticism should be welcomed as we often underestimate how uncomfortable the examination is especially when digging deep in the neck for an obscure nodule. The examination steps mentioned below contain important and salient positive and negative findings to guide the examinee past what is otherwise one of the easier surgical short cases to negotiate.

The venous system examination typically centers on the lower limbs of the patient. It is a station dreaded by the examinee as it appears that he would have to be well versed with the (seemingly) endless number of obscure clinical examination techniques (e.g. Perthes, Trendelenburg) to appease the examiner. This chapter hopes to demonstrate a thorough yet simple-to-understand process to perform the venous system examination.

The examination of the arterial system requires a systematic approach. The patient, often uncomfortable and in pain, would have a disease that is variable in location and severity. A detailed clinical history of the patient may not be made available to the examinee during the short case examination, thus removing one vital component in diagnosing peripheral arterial disease (PAD). Conscientiousness and attention to detail would be required to differentiate arterial, venous and peripheral neuropathic disease.

Diabetes is on the rise in Singapore with one in nine Singaporeans being affected. Despite the extensive media coverage on the consequence of this disease, one in three diabetics still have poor glycemic control. The war on diabetes was launched in Singapore in 2016 and the fight has been ongoing since. It is important as a doctor to be well versed in such a prevalent disease, especially its complications — in this case, the diabetic foot. This chapter serves as a summary on the clinical examination and management of the diabetic foot ulcer.

While the approach to a patient with jaundice is typically divided into evaluating the pre-hepatic, hepatocellular and post-hepatic cause, most surgical patients tend to center around the post-hepatic cause for jaundice. In the exam, a safe routine would be to examine closely for stigmata of chronic liver disease suggestive of cirrhosis (and possible hepatocellular carcinoma). If this is not present the candidate should be alert to the possibility of malignancy (abdominal, liver masses) before settling on benign diseases (gallstones).

The pathology of each salivary gland presents differently and has a unique physical examination. A smooth examination is essential to help soothe the patient as an anxious patient would make examination of the intra-oral cavity including bimanual palpation of the glands challenging.

The wide diversity of pathologies that may arise from the head and neck may frighten the inexperienced examinee. In our book, we divide the head and neck section into thyroid, salivary glands and other head and neck lumps for easier understanding of the subject. For either of the scenarios, one must understand that the approach to the patient does not change. In this chapter, we hope to give a broad approach to the patient such that the examinee will be able to achieve a reasonable diagnosis.

The breast examination remains an important part of the repertoire of a doctor. Common complains such as breast pain, nipple discharge, breast lumps and skin changes mandate a clinical breast examination. When done well and in detail, one can gain critical information that can be used to help guide investigation and management. It is important to be familiar with the steps so as not to make the examination awkward for yourself or the patient. After gaining verbal consent, and a chaperone if necessary, one can then follow the steps below to achieve a good clinical examination.

Skin lesions and lumps are the bread and butter of the surgical OSCEs. It is common to find patients with skin lumps and it is important that the examinee be well acquainted with them as this knowledge would be critical in future surgical practice. While this chapter describes benign pathologies, it is important to rule out malignancy in all cases. This chapter describes the basic approach to skin lumps and lists a few examples of common benign lesions.

While not as common as benign skin lumps and lesions, it is important to recognize malignant skin lesions. Early tumors may appear small and harmless. However, missed malignancies result in late diagnosis with the unfortunate problem of metastases and ultimately poor outcomes. This chapter covers the approach to skin cancers and the broad principles of managing them.

Over the years in our interactions with students, we see the hesitancy and uncertainty when examining a patient and encountering an abdominal mass. Approach the mass first! Spending time on the mass early helps you plan your thoughts and differentials. This chapter can be viewed as a broad approach on what to do when findings a mass on examination and how to make a best educated diagnosis on what the mass is.

With recent emphasis on laparoscopic approach for many abdominal surgeries, the number of patients with classical abdominal laparotomy scars will dwindle. Nonetheless, abdominal scars remain an important part of the surgical examination as they reflect the ability of the examinee to piece the patient’s past surgeries into his current diagnosis. Surgeons are direct and straight to the point, a characteristic that is also reflected in the surgical approach — the incision would lie close to the site of organ resection. This chapter summarizes the approach to abdominal scars.

The approach to the surgical drains can be challenging to the surgical novice. While the type of drain placed into the thorax and abdomen varies slightly between practices, we present a logical approach to the patient when a drain is visualized as well as examples of common drains used in various scenarios.

The approach to the scrotal examination is similar to the approach of the hernia examination. When asked to examine the patient’s scrotum, the examinee must decide rapidly if the issue with the patient is testicular or hernia in nature. Sometimes, paying attention to the examiner’s question is critical. We believe that the approach in the inguinal hernia chapter is safe and should be followed primarily. This chapter should be utilised if the mass is clearly arising from the scrotum without any inguinal swelling and the suspicion of inguinal hernia is low.

The following section is included:

• Index