osces surgical osces

Surgical OSCEs for Medical Students offers readers nearly 70 stations showing how to address surgical problems in a consistent way. Each case provides a structured step-by-step approach: � Differential diagnoses� History� Examination – general and targeted� Investigations required� Diagnosis with pathophysiological explanation� Management

The book offers readers:

� Concise presentation of information to ensure rapid access to important facts

� Stimulating coverage of common surgical topics often encountered in OSCE examinations, such as abdominal distension, dysphagia, muscle weakness and sudden weight loss

� Valuable and trusted input from junior doctors who have successfully passed and supervised OSCEs

9 781911 510376

ISBN 978-1-911-510-37-6

www.scionpublishing.com

FOR MEDICAL STUDENTS

MANDA RAZ AND LIANG LOW

SURGICALOSCES

SURGICAL OSCES FOR MEDICAL STUDENTS

RA

Z & LO

W

SurgicalOSCEsCover_244x172_13.5mm.indd All Pages 30/07/2019 10:58


SURGICALOSCES

SurgicalOSCEsPrelims.indd 1 30/07/2019 10:31SurgicalOSCEs.indb 1 8/2/2019 4:32:34 PM

MANDA RAZ AND LIANG LOW


SURGICALOSCES


© Scion Publishing Ltd, 2019

ISBN 9781911510376

First published 2019

All rights reserved. No part of this book may be reproduced or transmitted, in any form or by any means, without permission.

A CIP catalogue record for this book is available from the British Library.

Scion Publishing Limited

The Old Hayloft, Vantage Business Park, Bloxham Road, Banbury OX16 9UX, UK


Important Note from the Publisher

The information contained within this book was obtained by Scion Publishing Ltd from sources believed by us to be reliable. However, while every effort has been made to ensure its accuracy, no responsibility for loss or injury whatsoever occasioned to any person acting or refraining from action as a result of information contained herein can be accepted by the authors or publishers.

Readers are reminded that medicine is a constantly evolving science and while the authors and publishers have ensured that all dosages, applications and practices are based on current indications, there may be specific practices which differ between communities. You should always follow the guidelines laid down by the manufacturers of specific products and the relevant authorities in the country in which you are practising.

Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be pleased to acknowledge in subsequent reprints or editions any omissions brought to our attention.

Registered names, trademarks, etc. used in this book, even when not marked as such, are not to be considered unprotected by law.

Cover design by Andrew Magee Design Limited

Typeset by Medlar Publishing Solutions Pvt Ltd, IndiaPrinted in the UK

Last digit is the print number: 10 9 8 7 6 5 4 3 2 1


v

Contents

List of contributors vi

Preface vii

Acknowledgements viii

List of abbreviations ix

Station 1 Abdominal distension 1

Station 2 Abdominal mass 7

Station 3 Abdominal pain 12

Station 4 Acute confusion 18

Station 5 Anal pain 24

Station 6 Ankle swelling 28

Station 7 Axillary lump 33

Station 8 Back pain 36

Station 9 Breast lump 40

Station 10 Chest pain 45

Station 11 Clubbing 49

Station 12 Constipation 53

Station 13 Cough 57

Station 14 Cyanosis 60

Station 15 Diarrhoea 64

Station 16 Dizziness 68

Station 17 Dyspepsia 72

Station 18 Dysphagia 75

Station 19 Dyspnoea 79

Station 20 Earache 83

Station 21 Facial ulcer 86

Station 22 Facial weakness 89

Station 23 Fever in a returned traveller 92

Station 24 Finger pain 96

Station 25 Foot pain 100

Station 26 Foot ulcer 104

Station 27 Gait disturbance 108

Station 28 Goitre 112

Station 29 Groin mass 115

Station 30 Gynaecomastia 118

Station 31 Haematemesis 121

Station 32 Haematuria 125

Station 33 Haemoptysis 128

Station 34 Hand pain 133

Station 35 Headache 137

Station 36 Hearing loss 140

Station 37 Hypertension 143

Station 38 Incontinence 146

Station 39 Jaundice 149

Station 40 Joint pain and deformity 152

Station 41 Leg pain 155

Station 42 Leg ulcer 159

Station 43 Limb weakness 163

Station 44 Lymphadenopathy 168

Station 45 Melaena 172

Station 46 Mouth ulcer 176

Station 47 Muscle weakness 181

Station 48 Nail changes 185

Station 49 Neck lump 188

Station 50 Odynophagia 192

Station 51 Oliguria 196

Station 52 Palpitations 200

Station 53 Paraesthesia 204

Station 54 Polyuria 207

Station 55 Pruritus 210

Station 56 Rectal bleeding 213

Station 57 Scrotal mass 217

Station 58 Skin hyperpigmentation 220

Station 59 Steatorrhoea 224

Station 60 Stoma output 227

Station 61 Stridor 231

Station 62 Syncope 234

Station 63 Testicular mass 238

Station 64 Tremor 241

Station 65 Vision changes 244

Station 66 Voice changes 247

Station 67 Vomiting 251

Station 68 Weight loss 254

© Scion Publishing Ltd, 2019

ISBN 9781911510376

First published 2019

All rights reserved. No part of this book may be reproduced or transmitted, in any form or by any means, without permission.

A CIP catalogue record for this book is available from the British Library.

Scion Publishing Limited

The Old Hayloft, Vantage Business Park, Bloxham Road, Banbury OX16 9UX, UK


Important Note from the Publisher

The information contained within this book was obtained by Scion Publishing Ltd from sources believed by us to be reliable. However, while every effort has been made to ensure its accuracy, no responsibility for loss or injury whatsoever occasioned to any person acting or refraining from action as a result of information contained herein can be accepted by the authors or publishers.

Readers are reminded that medicine is a constantly evolving science and while the authors and publishers have ensured that all dosages, applications and practices are based on current indications, there may be specific practices which differ between communities. You should always follow the guidelines laid down by the manufacturers of specific products and the relevant authorities in the country in which you are practising.

Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be pleased to acknowledge in subsequent reprints or editions any omissions brought to our attention.

Registered names, trademarks, etc. used in this book, even when not marked as such, are not to be considered unprotected by law.

Cover design by Andrew Magee Design Limited

Typeset by Medlar Publishing Solutions Pvt Ltd, IndiaPrinted in the UK

Last digit is the print number: 10 9 8 7 6 5 4 3 2 1


v i

List of contributorsThe people named below authored a number of the stations as follows:

V Dr Emma Cole wrote stations 6, 33–35, 42 and 64 V Dr Alice Lee wrote stations 51 to 60 V Dr Peter Lioufas wrote stations 11 to 20 V Dr Kerry Liu wrote stations 31, 32 and 36–40 V Dr Fiona Pavan wrote stations 1–5 and 7–10 V Dr Emma-Leigh Rudduck wrote stations 41 and 43–50 V Dr Darius Tan wrote stations 21 to 30 V Dr Eren Tan wrote stations 61–63 and 65–68

All authors were based at Monash Medical Centre, Clayton, Victoria, Australia, at the time of writing.

SurgicalOSCEs.indb 6 8/2/2019 4:32:34 PM

v i i

The knowledge and skills required to perform well in the surgical Objective Structured Clinical Examination (OSCE) can be learnt through:

V having a clear and solid study guide V following a step-wise approach to addressing surgical problems V practising with colleagues.

Surgical OSCEs for Medical Students offers all the above. The book is a well-prepared written resource, outlined in a convenient structure reflecting the sequential components of patient assessment, and encourages the reader to practise with peers.

Our book presents OSCEs as physical complaints, thus maintaining true fidelity to real clinical experience. For example, patients do not seek surgical care for appendicitis, but for abdominal pain. This method will help students consolidate practical information conducive to better examination performance.

The book is prepared with the busy student in mind. Bullet points replace paragraphs, summaries substitute heavy texts, and tables supplant articles. The content has been carefully selected to achieve a balance between detail and relevancy, therefore ensuring focused and productive study time.

We wish you all the best with your surgical OSCEs.

Manda Raz (MBBS) and Liang Low (MBBS, FRACS)Monash Health, Victoria, Australia

Preface


53

Station 12 ConstipationA 78-year-old man presents to the GP with a 2-week history of worsening constipation, not improving despite the prescription of laxatives.

Tasks1 Take a history2 Perform a targeted examination

3 Describe appropriate investigations4 Formulate a management plan

Differential diagnoses (VIITAMINC)

Vascular

Infective

Inflammatory: V Pseudo-obstruction V Inflammatory bowel disease

Trauma

Autoimmune

Metabolic: V Hypercalcaemia V Hypothyroidism

Iatrogenic: V Medication-induced constipation

Neoplastic: V Bowel cancer

Congenital: V Inguinal / femoral hernia V Coeliac disease

Other: V Large bowel obstruction V Diet

Before starting

Establish rapport: V Introduce yourself V Obtain consent to take a history and examine

the patient V Expose the patient: when physical examination

is required, it will require shirt / vest to be taken off

Confirm patient details: V Name Gordon Crane V Age 78 years V Occupation Retired, previously a

construction worker

History

History of presenting complaint V Onset: over the past 2 weeks

V Pain: no abdominal or rectal pain V Describe the look of your stool: “hardened,

like a brick honestly” V Blood in stool: had an episode last week,

but nothing since V Mucus in stool: no V Change in bowel habit: constipated for past

2 weeks; before this had a few days of diarrhoea V Recent change in diet: no V Nausea / vomiting: no V Early feelings of fullness (satiety): no V Unexplained weight loss: yes, lost about 10kg

over past 3 months V Constitutional symptoms: no fevers /

rigors / chills

Take a focused history V Lethargy: no V Decreased water intake: no V Increased thirst: no


54 | SURG I C AL OSCE S FO R M ED I C AL S T UD EN T S

V Increased frequency of urination: no V Bone pain: no

Past medical history and family history V Nil significant past medical history V Father had a ‘gut cancer’; mother had a lot of

polyps in the rectum that needed surgery

Drug history and allergies V Not on opiates V NKDA

Social history V Smoking history: 30 pack-years V Alcohol and drugs history: non-drinker, nil illicit

drugs

Examination

General inspection (ABCD-V) V Appearance: patient looks comfortable V Body habitus: overweight, BMI 28 V Cognition: patient is conscious and oriented V Devices / Drugs: nil V Vitals: BP 130/70mmHg; HR 70bpm and regular;

afebrile

Abdomen V Inspection: no surgical scars, deformities or

visible pulsations; no spider naevi, no significant bruising noted

V Palpation: soft abdomen in all four quadrants; no tenderness; mass mildly palpable in left lower quadrant, difficult to characterise; no expansile abdominal aorta; no hernias notable while patient standing at femoral / inguinal areas

V Percussion: no shifting dullness; no organomegaly

V Auscultation: normal bowel sounds in all four quadrants; no renal bruits

Digital rectal examination (DRE) V The candidate should obtain EXPLICIT consent

before performing a DRE; if the patient is of the opposite sex, endeavour to have a chaperone at all times; a chaperone should always be offered to the patient prior to the examination

V Inspection: no external anal masses; no anal fissures / tears; no haemorrhoids

V Palpation: no masses noted; no blood on finger – empty rectum; prostate normal calibre and size

Investigations

BBMI-O: Bedside, Bloods, Microbiology, Imaging and Other

Investigation Rationale

Bedside

Bloods

V FBC

V CRP

V U&Es and creatinine

V Tumour markers (CEA / CA19-9)

V Looking for infection and anaemia

V Looking for infection / inflammation

V Looking for electrolyte imbalances and renal injury

V Looking for raised serum levels to suggest the development of colorectal cancer

Microbiology

Imaging

V AXR (PA and lateral views)

V CT abdomen / pelvis

V Looking for evidence of faecal loading, or dilated bowel loops

V Looking for evidence of colonic masses, intra-abdominal collections, metastases, hernias


S TAT I O N 12 | CO NS T IPAT I O N | 55


Other

V Colonoscopy ± biopsies V Looking for areas of thickened bowel wall, inflamed bowel wall; positive biopsies would be indicative of malignancy

Diagnosis

Bowel cancer

A relatively benign abdominal examination with insidious onset of symptoms associated with unintentional weight loss is highly suspicious for malignancy.

The gold standard investigation to confirm bowel cancer is colonoscopy with a positive biopsy.

Management

Treatment for bowel cancer is highly dependent on the stage of the cancer. Cases are usually discussed through a multidisciplinary meeting to determine the correct course of treatment.

Medical V Supportive measures such as analgesia,

laxatives, and anti-emetics should be prescribed to reduce pain and allow the passage of softer stool

V The patient should be referred to a colorectal specialist for further guidance on management

V Chemotherapy / radiotherapy can be considered with appropriately staged colorectal cancer, in both the neoadjuvant and adjuvant setting

Surgical V Surgical management is common for

colorectal cancer and depending on the location of the tumour would normally involve an excision of the tumour, with a wide area of normal bowel taken as well

V This could take the form of a hemicolectomy, (ultra) low anterior resection or total colectomy

Colorectal cancer is a significant diagnosis with a long treatment pathway. The symptoms that may present in early-stage colorectal cancer involve blood in stool, changes in bowel habit

(fluctuating between diarrhoea / constipation) and constitutional symptoms such as unexplained weight loss. Eventually development of colorectal cancer, if left untreated, can result in partial or complete large bowel obstruction. Metastatic disease follows this, leading to seeding within the abdomen and functions of the liver, kidneys and stomach can be affected depending on where the metastatic deposits lie.

StagingStaging of colorectal cancer is dependent on imaging results, and biopsy via colonoscopy.

V Stage 0 (carcinoma in situ) – would usually present as a polyp, hence polypectomy and / or local excision of the tumour can be undertaken; this can be done via colonoscopy

V Stage 1 – bowel resection with primary anastomosis is considered at this stage; chemotherapy / radiotherapy is usually not indicated

V Stages 2 and 3 – usually involves a combination of bowel resection ± the formation of a stoma, alongside adjunct chemotherapy / radiotherapy soon after; if there are clear margins and the cancer is seen to be in remission, then reversal of the formed stoma can be completed months after the initial surgery

V Stage 4 – this stage implies that there are metastatic deposits; surgery, in this case,



is usually of a palliative nature to relieve obstruction or excessive abdominal pain.

Chemotherapy and radiotherapy are commonly first line in these circumstances to help reduce the size of the affecting tumours and to help relieve symptoms. Palliative care management can be considered in late-stage

colorectal cancer where none of the above treatment options would be considered to have considerable benefit.

Other differential diagnoses

V Inguinal / femoral hernia V Large bowel obstruction


57

Station 13 CoughAn 18-year-old woman presents to the ENT clinic with a 3-day history of a cough.

Tasks1 Take a history2 Perform a physical examination



Vascular

Infective: V Tonsillitis V Pharyngitis V Peritonsillar abscess (quinsy) V Epstein–Barr virus (EBV; glandular fever) V Bronchitis V Pneumonia V Pertussis V Bronchiectasis

Inflammatory: V Asthma

V Gastro-oesophageal reflux disease (GORD) V Gastritis

Trauma

Autoimmune

Metabolic

Iatrogenic

Neoplastic

Congenital

Other: V Foreign body

Before starting

Establish rapport: V Introduce yourself V Obtain consent to take a history and examine

the patient V Exposure: when physical examination is

required, it will require top / vest to be taken off

Confirm patient details: V Name Catriona McDowell V Age 18 years V Occupation High school student

History

History of presenting complaint V Onset: worsening over the last 3 days

V Pain: “yes, in the back of my throat; has also been worsening over the past couple of days; dull in character, worse when I cough”

V Radiation: no V Exacerbating / relieving factors: “taking

paracetamol and ibuprofen helps; last time this happened I took antibiotics and things got better”

V Associated symptoms: “feels like there is a lump in the back of my throat“

V Change in taste / hearing: no V Difficulty opening / closing mouth: no V Sputum: no V Blood: no V Rashes: no V Has this ever happened before: “yes, this is the

third time in the past month; I had something like this quite regularly as a kid too”

V Constitutional symptoms: no fevers / weight loss



Past medical history and family history V Nil significant past medical history V Family history: nil

Drug history and allergies V No regular medications; paracetamol and

ibuprofen PRN V NKDA

Social history V Smoking history: non-smoker V Alcohol and drugs history: non-drinker,

nil illicit drugs

Examination

General inspection (ABCD-V) V Appearance: patient looks comfortable V Body habitus: normal, BMI 20 V Cognition: patient is conscious and oriented V Devices / Drugs: nil V Vitals: BP 120/80mmHg, HR 60bpm and regular;

afebrile

ENT examination V Inspection:

ā Ear: no evident masses, no erythema, no discharge

ā Nose: normal inspection, no septal deviation, no discharge from nose

ā Throat: reddened back of throat; small plaque associated with right tonsillar inflammation; no evident abscess formation; gag reflex present

V Palpation: ā Ear: no mastoid tenderness; skin not hot

to touch ā Nose: no evident deformity; no fractures

Chest V Inspection: no surgical scars, deformities or

visible pulsations; apex beat not visualised V Palpation: apex beat not displaced, mid-

clavicular 5th intercostal; no thrills or heaves are felt

V Percussion: no effusions notable; no dullness to percussion at posterior chest

V Auscultation: dual heart sounds with no murmurs; good air entry with symmetrical breath sounds; no added sounds

Investigations



Bedside

Bloods

V FBC

V CRP





Microbiology

V Throat swab for MCS

V Nasopharyngeal aspirate

V Looking for bacterial growth in tonsillar plaque

V To check for viral pathogens


S TAT I O N 13 | COUG h | 59


Imaging

V CT facial sinuses V Looking for opacification of facial sinuses and evidence of inflammation

Other

Surgical V Tonsillectomy can be performed in cases of

recurrent tonsillitis; it is usually performed in the paediatric population to prevent further attacks or the development of a peritonsillar abscess

V Current recommendations suggest tonsillectomy in the event of at least seven episodes within 1 year or at least five episodes per year for 2 years

V The above scenario shows an 18-year-old woman with tonsillitis – this is infrequent but does occur in the general populace; usually, after childhood the size of tonsils regress, and as such tonsillitis becomes less common; at this age surgical management would not be recommended without recurring history of severe tonsillitis


V Peritonsillar abscess (quinsy) V EBV (glandular fever)

Diagnosis

Tonsillitis

An inflamed tonsil with associated white patches in a well-looking patient with a history of similar episodes in the past should raise suspicion for tonsillitis.

Management

Treatment for tonsillitis is rarely surgical; however, recurrent cases or those in the paediatric population can benefit from surgical management. Tonsillitis is more commonly due to a viral pathogen, though can also be due to bacteria. Otherwise, treatment is as described below.

Medical V Supportive measures such as analgesia,

including paracetamol and ibuprofen, can assist in supportive management of tonsillitis

V Antibiotic therapy can be indicated in cases showing high fever, or those not responding to conservative management; the majority of bacterial pathogens causing tonsillitis are due to Streptococcus spp. and as such penicillins, including phenoxymethylpenicillin or amoxicillin, are indicated

Be wary of using amoxicillin, however, as EBV can mimic the above symptoms and a widespread rash can occur if this is treated with amoxicillin.


128

An 85-year-old woman presents to the emergency department as she has been unwell for a few days with a cough, though today she has also noticed some blood.




Vascular: V Pulmonary embolism V Pulmonary arteriovenous malformation V Mitral stenosis V Bronchial telangiectasia V Left ventricular failure

Infective: V Bronchiectasis V Acute / chronic bronchitis V Pneumonia V Fungal infection V Lung abscess V Tuberculosis

Inflammatory

Traumatic

Autoimmune: V Systemic lupus erythematosus V Goodpasture’s syndrome

V Granulomatosis with polyangiitis V Diffuse alveolar haemorrhage

Metabolic

Iatrogenic

Neoplastic: V Primary lung cancer V Lung metastases V Bronchial adenoma

Coagulopathy: V Anticoagulant or antiplatelet use V Platelet dysfunction V Disseminated intravascular coagulation

(DIC) V Thrombocytopenia

Other: V Lung contusion / penetrating injury V Toxic inhalation V Aspiration of foreign body

Before starting

Establish rapport: V Introduce yourself V Consent the patient: “Would you be happy

for me to ask you some questions about why you’re here, and then perform a physical examination after?”

V Expose the patient when physical examination is required – this will require shirt / top to be taken off

Confirm patient details: V Name Shelly Temple V Age 85 years V Occupation Retired, previously

a nurse

History

History of presenting complaint (SOCRATES)

V Site: cough and associated pain across the chest V Onset: over the past 2 days

Station 33 Haemoptysis


S TAT I O N 33 | HAEM O P T ySIS | 129

V Character: sharp pain V Radiation: none V Associated symptoms: haemoptysis, fevers,

rigors and chills since yesterday, confusion (can’t seem to remember the day or time which is not baseline)

V Time: consistent throughout the day V Exacerbating / relieving: pain worse when

breathing in and coughing, nil relieving factors V Severity: limiting day-to-day activities

Take a focused history V Respiratory:

ā Breathing: difficult, hard to take a full breath ā Cough: yes, started 3 days ago, has been

getting worse ā Coughing up phlegm / blood: yes – changed

from baseline amount, initially white but now increased amounts of mucus that is a yellow / green colour; noticed this morning it had blood streaks in it, the amount of blood has been getting worse; approximately 5ml total

ā Wheeze: moderate amount, more than baseline

ā Postnasal drip: no ā Hoarse voice: no

V Cardiovascular: ā Lower limb oedema: no ā Orthopnoea / paroxysmal nocturnal

dyspnoea: no ā Decreased exercise tolerance: yes ā Syncope / light-headedness: no ā Calf pain: no

V Systemic (SWIM): ā Skin: nil easy bruising nor tendency to bleed ā Weight: no recent unexplained loss of weight

or night sweats ā Infective:

T Fevers / sweats / rigors: yes T Sick contacts: yes, husband had similar

symptoms last week, however his symptoms have improved

T Coryzal symptoms or recent viral illness: not prior to symptom onset

T Recent overseas travel: no ā Musculoskeletal:

T Joint pain: no T History of trauma: no

Past medical history and family history V Recurrent chest infections, chronic obstructive

pulmonary disease (COPD), diabetes, hypertension

V Mother had COPD and had a heart attack at age 90 years, father had type 2 diabetes mellitus and hypertension

V Family history of malignancy: no

Drug history and allergies V Salbutamol inhaler PRN, Seretide, metformin,

perindopril V NKDA

Social history V Smoking history: yes, 40 pack-years V Alcohol and drugs history: none V Lives at home with her husband V Requires support from family and once weekly

community help V Requires a 4-wheel frame V Independent with activities of daily living usually,

though currently struggling to keep up

Examination

General inspection (ABCD-V) V Appearance: patient looks uncomfortable and

diaphoretic V Body habitus: normal, BMI 22 V Cognition: patient is conscious and oriented V Devices / Drugs: nil V Vitals: BP 130/70mmHg, HR 70bpm and regular,

RR 22 per minute; oxygen saturation 96% on room air; febrile at 38.8°C

Respiratory V Inspection:

ā Patient looks to be dyspnoeic, though no tripoding / accessory muscle use and diaphoretic

ā Able to speak in short sentences ā Cough present – note the mucus cup next to

the bed with greenish sputum and a tinge of blood through it

ā No presence of cyanosis, scars or chest wall abnormalities

ā No clubbing, peripheral cyanosis or asterixis



V Palpation: ā Trachea: midline, no tug present ā Cervical and supraclavicular lymph nodes:

non-palpable ā Chest expansion: symmetrical; Hoover’s sign

negative ā Chest wall non-tender

V Percussion: ā Resonance in the apices bilaterally ā Dullness to percuss over the left lower zone,

in comparison to right V Auscultation:

ā Coarse crackles in the left lower zone

ā Moderate expiratory wheeze globally ā Vocal resonance: increased in left lower zone

Cardiovascular: V Inspection: no surgical scars, deformities or

visible pulsations; apex beat not visualised V Palpation: apex beat not displaced, mid-

clavicular 5th intercostal; no thrills or heaves are felt

V Percussion: no effusions notable; no dullness to percussion at posterior chest

V Auscultation: dual heart sounds with no murmurs

Investigations



Bedside

Bloods

V FBC

V CRP


V ABG

V Tumour markers (CEA / CA-125)

V Blood cultures

V Pathogen specific antigens: IgM, Legionella urinary antigen assay, pneumococcal urinary antigen assay




V Looking at haemodynamic status in severe haemoptysis

V Looking for raised serum levels to suggest the development of lung cancer

V Looking for pathogen causing sepsis

V Looking for pathogens Mycoplasma pneumoniae, Legionella and Streptococcus pneumoniae

Microbiology

V Sputum MCS

V NAAT (nucleic acid amplification testing) nose / throat swab

V Looking for infective organisms as a cause

V Looking for viral pathogens (i.e. influenza) and some bacterial pathogens (i.e. Chlamydophila pneumoniae)

Imaging

V CXR (PA and lateral views)

V CT chest

V Looking for evidence of consolidation in infection, shadowing of lesions in cancer or abscesses

V Looking for evidence of lung lesions or abscesses


S TAT I O N 33 | HAEM O P T ySIS | 131


V PET scan

V CT angiography

V Utilised in staging of cancer

V Looking to determine the bleeding site

Other

V Bronchoscopy

V ECHO

V Looking for the causative bleeding site and source; therapeutic intervention to stop the bleeding

V Looking at baseline cardiac function if surgery is required and for cardiac causes

Diagnosis

Community-acquired pneumonia

Examination findings of coarse crackles on the left compared with the right, in conjunction with decreased percussion note and increased vocal resonance is suggestive of consolidation in that lung. This, combined with fever and a history of COPD and recurrent chest infections, puts this patient at high risk of pneumonia.

The gold standard investigation to confirm pneumonia is a sputum microscopy, culture and sensitivity (MCS) in conjunction with CXR.

Discussion

Pneumonia is inflammation of the lungs with consolidation or interstitial infiltrates.

Community-acquired pneumonia (CAP): pneumonia that develops from infection outside a hospital or healthcare facility. The most common cause is Streptococcus pneumoniae, with Mycoplasma pneumoniae being a major cause of atypical bacterial pneumonia.

Hospital-acquired pneumonia (HAP): pneumonia arising at least 48 hours after admission to a hospital / health facility, where the disease was not present at the time of admission.

Ventilator-associated pneumonia (VAP) is defined as pneumonia occurring more than 48 hours post endotracheal intubation.

Management

Haemoptysis V Emergency response protocol: DRSABCD

V Maintain patent airway: ā Positioning ā Chin lift / jaw thrust ā Airway adjuncts (i.e. Guedel) ā Endotracheal tube

V Resuscitation: ā Bleeding lung side down; if both sides

bleeding place head down ā Isolate lung (i.e. railroad endotracheal tube

into the non-bleeding lung with endoscope or place double lumen endotracheal tube)

V Fluid resuscitation V Blood product replacement (if severe

haemorrhage or symptomatic) V Treat bleeding source:

ā Correct coagulopathy (if indicated) ā Bronchial artery embolisation ā Bronchoscopic laser photocoagulation ā Iced normal saline lavage (of involved lung

segments) ā Topical adrenaline ā IV vasopressin



ā Surgical resection / occlusion of offending vessel

Pneumonia (CAP) V Lifestyle:

ā Stop smoking / excessive alcohol consumption (aspiration risk)

ā Vaccinations annually (i.e. influenza and pneumococcus)

ā Adequate nutrition V Medical:

ā Analgesia as required ā Oxygen therapy if indicated ā Cough suppressant (i.e. codeine if

uncontrollable coughing) ā Antipyretics (i.e. paracetamol if fever) ā Antibiotics: route, type and duration

dependent on severity of disease (see below)

V Surgical: ā Incision and drainage of abscess (if

indicated)

Antibiotic therapyInpatient:

V Moderate: ā Benzylpenicillin 1.2g IV QDS (until significant

improvement) then change to amoxycillin 1g orally TDS for 7 days total course

T Ceftriaxone or cefotaxime IV then cefuroxime orally if hypersensitive to penicillins

ā PLUS: oral doxycycline 100mg BD, 7 days

V Severe: ā Ceftriaxone 1g IV daily or cefotaxime 1g IV

TDS ā PLUS: azithromycin 500mg IV daily ā Once clinically stable downgrade to oral

therapy as per moderate

CURB 65Scoring system that estimates the severity of pneumonia, assisting in determining if the patient undertakes an inpatient or outpatient treatment pathway:

V Confusion V Urea (>7mmol/L) V Respiratory rate >30 per minute V Blood pressure: systolic <90mmHg or diastolic

<60mmHg V 65: age greater than 65 years

Score Treatment

0–1 Outpatient care

2 Inpatient versus period of observation

3–5 Inpatient admission, with consideration of ICU admission if score 4–5


V Acute / chronic bronchitis V Primary lung cancer


196

A 67-year-old man, day-3 postoperative surgical patient, is reported by nursing staff to have reduced urine output.



Differential diagnoses

Pre-renal causes: V Hypovolaemia:

ā Inadequate fluid intake ā Fluid loss:

T Haemorrhage, via burns, hyperthermia, nephrotic syndrome

T Gastrointestinal fluid loss: vomiting, diarrhoea, nasogastric suctioning

T Fluid loss via kidneys: diuretics, glycosuria

ā Third-spacing of fluid: pancreatitis, bowel obstruction

V Cardiogenic shock causing poor cardiac output:

ā Myocardial infarction ā Congestive cardiac failure

V Vasogenic shock: ā Sepsis ā Anaphylaxis ā Neurogenic shock ā Medications: vasodilation agents,

anaesthetic agents V Obstructive shock:

ā Constructive pericarditis ā Cardiac tamponade ā Pulmonary embolism

V Reduced renal perfusion: ā Renovascular disease, e.g. renal artery

or renal vein occlusion secondary to thrombosis or stenosis

ā Noradrenaline, adrenaline ā Aortic dissection ā Eclampsia (in setting of pregnancy)

Renal causes: V Acute tubular necrosis V Glomerulonephritis V Interstitial nephritis V Rhabdomyolysis

Post-renal causes: V Upper renal tract obstruction V Lower urinary tract obstruction:

ā Prostatic enlargement ā Tumour ā Stones

V Extrinsic compression of renal tract, e.g. intra-abdominal

V Blocked urinary indwelling catheter (IDC), if present

Before starting

Establish rapport: V Introduce yourself V Obtain consent from the patient: “I will be

asking you some questions and then will be

performing a physical examination to find out why you have low urine output. Is this OK with you?”

V Expose the patient: when physical examination is required

Station 51 Oliguria


S tAt i o n 51 | o li gur iA | 197

Confirm patient details: V Name Sean Mcmean V Age 67 years V Occupation School teacher

History

What is the reason for admission? V This patient had an emergency appendicectomy

after presenting with abdominal pain V An IDC was placed pre-operatively

Associated symptoms V Abdominal pain (particularly in the suprapubic

area) especially when trying to pass urine V Dysuria: yes V Fever / chills / rigors: yes, overnight V Sensation of thirst: yes V Shortness of breath, peripheral oedema: no V Paraesthesia / anaesthesia, especially saddle

region: normal

Past medical history and family history V Baseline renal function: estimated glomerular

filtration rate (eGFR) 60 V Type 2 diabetes mellitus, congestive cardiac

failure, hypertension V Known benign prostatic hypertrophy; no history

of prostate cancer / treatment to prostate (such as radiotherapy, surgery)

V No history of renal stones or bladder tumours V Nil family history

Drug history and allergies V Aspirin, furosemide, irbesartan V Recent IV contrast: the patient had a contrast

CT abdomen / pelvis scan performed 1 day prior to the operation

V NKDA

Social history V Smoking history: 20 pack-years V Alcohol and drugs history: non-drinker,

nil illicit drugs V Independent with daily activities; home

with wife

Examination

General inspection (ABCD-V) V Appearance: alert, looks tired V Body habitus: obese, BMI 31 V Cognition: patient is conscious and oriented V Devices / Drugs:

ā The patient is not using supplemental oxygen ā IV fluids are running at a 12-hourly rate ā IDC in situ, small amount of concentrated

urine in the bag; no erythema / irritation at the external urethral meatus

ā Not on dialysis V Vitals: BP 90/60mmHg, HR 110bpm, RR 20 per

minute; oxygen saturation at 95% on room air; febrile 38°C

Fluid review V Check perfusion of peripheries (normal), tissue

turgor (slow) V Check jugular venous pressure (not elevated),

mucous membranes (dry) V Listen to heart and chest (heart sounds dual,

nil added; chest is clear) V No evidence of peripheral and sacral oedema V Review of fluid balance charts (fluid input and

output): negative balance over past day

Abdomen V Inspection:

ā Previous surgical scars or abnormalities: no ā Signs of liver disease, e.g caput medusae,

spider naevi, gynaecomastia: no ā The patient is not overtly distended in the

abdomen V Palpation:

ā The patient is tender to palpation in the suprapubic region

ā Hepatosplenomegaly: no V Percussion:

ā Dullness: no, normal resonant sounds ā Ascites: no

V Auscultation: ā Bowel sounds: normal ā Renal artery bruits: no


198 | Surg i C Al oSCE S Fo r M ED i C Al S t uD En t S

Investigations



Bedside

V Urine dipstick

V Bladder scan

V ECG

V Looking for infection (leukocytes, nitrites for pyelonephritis)

V Assessing if urinary retention is present – bladder volume

V Perform if potassium is elevated above normal, for ECG changes related to hyperkalaemia (K+ >5.5); or if there is reason to suspect a cardiogenic source for low urine output

Bloods

V FBC

V U&Es and creatinine + eGFR

V Venous blood gas

V CRP

V Troponin I

V Looking for infection

V Looking at electrolytes and renal function

V Looking at electrolyte balance

V Can be useful in the setting of infection

V If suspicious of myocardial infarction

Microbiology

V Urine MCS

V Other cultures as appropriate, e.g. blood cultures, sputum MCS

V Looking for infection

Imaging

V CXR

V Renal tract US

V CT urography

V Assess for fluid status, lung field consolidation

V Looking for hydronephrosis and other abnormalities in the renal tract

V Looking for stones in the renal tract; imaging may also visualise inflammatory changes secondary to infection (e.g. pyelonephritis)

Other

Diagnosis

Poor urine output in the setting of urinary tract infection / sepsis

A patient with an IDC pre-op that now presents with fevers, dysuria and clinical dehydration is highly suggestive.


S tAt i o n 51 | o li gur iA | 199

Management

Medical V Review medication chart for nephrotoxins and

rationalise / cease those possible V Supplemental IV fluids may be of benefit in

hypovolaemia, but ensure other causes are ruled out to ensure that the patient is not being overloaded with fluid

V Completing a septic screen and commencing IV antibiotics can be considered in the setting of infection

V Consider flushing or changing an IDC if required (e.g. in the context of a blocked IDC)

Surgical V Not indicated in this case V Applicable in cases of post-renal obstruction

(i.e. stones) causing the oliguria


V Nephrolithiasis V Hypovolaemia


200

A 40-year-old woman presents to the gP complaining of several episodes of palpitations.




Vascular: V Valvular heart disease, prosthetic heart

valves V Cardiac and extracardiac shunts V Arrhythmia V Cardiomyopathy V Atrial myxoma V Anaemia

Infective: V Fever

Inflammatory

Trauma

Autoimmune

Metabolic: V Hypoglycaemia V Hyperthyroidism, thyrotoxicosis

Iatrogenic: V Pacemaker-related tachycardia

V Drug-induced – sympathomimetics, vasodilators, anticholinergics, beta-blocker withdrawal, benzodiazepine withdrawal, caffeine, energy drinks, weight loss medications, nicotine, cannabis, cocaine, amphetamines

Neoplastic: V Phaeochromocytoma

Congenital

Other: V Pregnancy V Postural orthostatic tachycardia syndrome V Stress, exercise V Panic attacks V Generalised anxiety disorder V Somatisation V Depression

Before starting

Establish rapport: V Introduce yourself V Obtain consent from the patient: “I will be

asking you some questions and then will be performing a physical examination to find out why you have palpitations. Is this OK with you?”

V Expose the patient: when physical examination is required

Confirm patient details: V Name Cassandra Clarke V Age 40 years V Occupation Magazine editor

Station 52 Palpitations


S tAt i o n 52 | PAlPi tAt i o nS | 201

History

History regarding palpitations V Site: over the chest V Quality:

ā Regular / irregular: irregular ā Skipping beats / feeling that heartbeat

stops: no ā Sensation of the palpitations: flutter

sensation and sometimes it feels as though heart is racing

V Time course: ā Onset: abrupt, this morning ā Offset: none, as of yet ā Duration: 4 hours ā Frequency: random, a few episodes a year ā Constant or episodic in nature: episodic

V Context: no particular context V Aggravating factors: worsens with excessive

alcohol consumption V Relieving factors: nil specific V Associated symptoms: yes, feels short of breath

and has some chest pain when the episodes occur

Past medical history and family history V Nil significant past medical history V Maternal aunt had thyroid disease with a heart

condition

Drug history and allergies V Nil V NKDA

Social history: V Smoking history: 20 pack-years V Alcohol and drugs history: 2 drinks per day,

binges on weekends, occasional cannabis use

Examination

General inspection (ABCD-V) V Appearance: patient looks comfortable

V Body habitus: normal, BMI 21 V Cognition: conscious and oriented V Devices / Drugs: none V Vitals: BP 110/70mmHg, HR 115bpm, RR 20 per

minute; oxygen saturation at 97% on room air; afebrile

Neck examination V Thyroid examination:

ā Inspection: normal, no goitre ā Palpation: palpable thyroid gland, no goitre

or lumps ā Percussion: no retrosternal dullness ā Auscultation: no thyroid bruit

V Lymphadenopathy: none detected V Trachea: midline

Cardiovascular examination V Hands:

ā Assess hands for evidence of increased sweating, palmar erythema, tremor: none

ā Pulse: radial pulse is strong, though irregularly irregular rhythm and tachycardic; no radial-radial delay

ā BP: no significant postural drop V Chest:

ā Inspection: normal, no surgical scars or abnormalities; no obvious pacemaker visible; no clubbing or stigmata of peripheral endocarditis; jugular venous pressure not elevated (+2cm)

ā Palpation: apex palpable at 5th intercostal space, mid-clavicular line; no palpable heave or thrill

ā Auscultation: T Dual heart sounds, loss of S4; irregularly

irregular contractions T No pleural rub or pericardial rub

ā Assess for pacemaker placement: none

Neurological examination V Inspection: normal V Reflexes, tone, power and sensation: normal


202 | Surg i C Al oSCE S Fo r M ED i C Al S t uD En t S

Investigations



Bedside

V 12-lead ECG V Tachycardia – check if sinus tachycardia; assess for arrhythmia

Bloods

V FBC, TFTs (TSH, T3, T

4)

V Specific thyroid autoimmune blood tests: TSI, TSH receptor Ab, anti-TPO Ab

V U&Es and creatinine, CMP for potassium and magnesium can be useful for patients with AF

V Troponin I (± repeat in 6 hours’ time for trend)

V Limited laboratory testing to rule out anaemia and hyperthyroidism is reasonable, in addition to testing for specific disorders that may be suggested by the history and physical examination

V If suspicious for Graves’ disease

V Aim to optimise K+ >4, Mg2+ >1

V Only for patients who have palpitations and suspected coronary ischaemia

Microbiology

V Appropriate specimens could be sent for analysis if suspecting infection and a potential source (e.g. in a febrile patient)

Imaging

V US

V Nuclear medicine uptake scans, e.g. 99mTc pertechnetate, 123I

V Echocardiography

V To assess size, echotexture and vascularity

V To assess for homogenously increased activity in an enlarged thyroid gland

V To assess for structural heart disease

Other (for other causes of palpitations)

V Ambulatory monitoring (Holter monitor, continuous loop event recorder)

V For definitive diagnosis of palpitations secondary to arrhythmia


S tAt i o n 52 | PAlPi tAt i o nS | 203


V Exercise stress testing

V Interrogation of implanted cardiac devices

V Urine screening when appropriate: metanephrine and electrolyte levels; urine drug screen

V To provoke exercise-induced palpitations

V To see if arrhythmia has been documented on certain devices

Diagnosis

Atrial fibrillation (AF)

A history of fluttering palpitations that worsens with alcohol intake in a patient that examines benignly is suspicious for paroxysmal AF.

Management

Medical V Rate control: beta-blockers (i.e. metoprolol),

calcium channel blockers (CCBs, e.g. diltiazem, verapamil; in patients with heart failure: digoxin, amiodarone)

ā Don’t give beta-blocker and central CCB together – bradycardia risk

V Rhythm control: pharmacological cardioversion: flecainide first choice if no structural disease (IV amiodarone if disease present), sotalol

V Anticoagulation: warfarin, dabigatran, rivaroxaban, apixaban – thromboembolism prevention (4% per year)

V Cardioversion (electrical): ā If symptomatic <24–48h usually cardiovert

without anticoagulation

ā If symptomatic >24–48h anticoagulate for 3 weeks prior and 4 weeks post

ā If patient unstable: cardiovert immediately V Aetiology: treat the underlying cause if

possible V Paroxysmal AF: pill in pocket (sotalol or

flecainide PRN) and anticoagulate

Surgical V MAZE: surgical ablation, use of small incisions,

radiowaves or freezing to create scar tissue which does not conduct electrical activity


V Hypoglycaemia V Amphetamines


osces surgical osces

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