SHORTCASE : STOMA EXAMINATION

THIS IS MOCK SHORTCASE ONLINE.
please try to answer orally in front of your screen. timing yourself.
when you are done, look for the suggested answer below.

Inspect the patient's abdomen.
Do running commentary.

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fever, chills, rigors

DEFINITION FEVER
elevation of body temperature that exceeds the normal daily variation and occurs in conjunction with an increase in the hypothalamic set point—for example, from 37C to 39C (shift of the set point from “normothermic” to febrile levels)

CHILLS
a sensation of coldness

RIGORS
exaggerated shivering

how all of these related?
fever comes with abnormally high body temperature, but why the patient can has chills and rigors (or shivering)?

read more below

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vital signs

heart rate
respiratory rate
blood pressure
temperature
pain score

i'm not very sure whether pain score is still the vital sign, but in 2008, KKM add in the 5th vital sign which is PAIN SCORE.

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MOCK OSCE SURGERY - Informed Consent For Colonoscopy

|||suggested steps for informed consent for colonoscopy|||

ONE
Introduce; build rapport; greet

TWO
Explain what the patient have; possible diagnosis, based on the trigger given

THREE
Explain what is colonoscopy

FOUR
Indication for colonoscopy
PR Bleed
unexplained alter bowel habit
family history of cancer
IBD

FIVE
Procedure of colonoscopy
Bowel prep (explain how to bowel prep)
Register on the date
change cloth
Enema
LA / GA bring partner to ensure safety after the procedure because patient may still be in sedative state
Position left lateral
Insert per rectal
Insert air may cause abdominal discomfort, flatulence
Insert camera
Biopsy may be taken depending on findings

SIX
Possible findings during colonoscopy
bleeding
mass
ulcer
inflammation

SEVEN
Complication of colonoscopy
Bleeding
Perforation
Pain

EIGHT
Benefit
Diagnostic
Therapeutic

NINE
Let patient ask


TEN
If patient refuse, give alternative (patient has right to refuse; DONT FORCE)
alternative --> barium enema

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MOCK OSCE SURGERY - X-Ray

Describe the salient features. (5 marks)
Increased radiolucency right hemithorax
Trachea shifted to the left
Loss of vascular markings
Mediastinal shift
Collapsed right lung

What is the diagnosis. (3 marks)
Right Tension Pneumothorax

What is the immediate treatment? (2marks)
Needle thoracocentesis at right 2nd ICS midclavicular line

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MOCK OSCE SURGERY - Male Catheter Bladder

MOCK OSCE SURGERY

Demonstrate the method of male catheter bladder


SUGGESTION ANSWER

Introduce and greet

Explain to patient and obtain consent

Ensure privacy

ASEPTIC TECHNIQUE!

Prepare equipments

Wash hand and wear sterile glove.

Clean and drape

Squirt local anaesthetic gel into urethra

Hold penis upward position

Insert catheter gently

Check the drainage of urine; press bladder if no urine drained

Inflate balloon with amount of water (not normal saline!!! why not normal saline?) as stated on the catheter

Pull back catheter until resistance encountered

Connect catheter to urine bag

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MOCK OSCE SURGERY - Peripheral Venous Cannula

EXAMPLE OSCE SURGERY

A 68 years old female is admitted to the ward.
Clinically she is dehydrated and requires intravenous hydration.
You are the house officer in charge.
Please demonstrate the insertion of peripheral venous cannula.

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SUGGESTION ANSWER

Introduce and greet
Explain to patient and obtain oral consent
Select appropriate site (where?)
Apply tourniquet
Clean with alcohol swab
Venepuncture made comfirmed by ‘flashback’
Advanced the cannula 2-3 mm into vein
Sheath advance into vein and needle withdrawn
Tourniquet released
Cannula secured with adhesive tape
Flush with saline prior to use to ensure cannula is in-situ

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Vermicular Appendix

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Source : Bailey and Love, Surgery

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Sepsis & SIRS

Infection:  Inoculation of pathogen into normally sterile tissue

Systemic inflammatory response is triggered by ischaemc, inflammation, trauma, infection to protect the host from the damaging effect of insult. However, the response can be overexaggerated when the damage and insult is too great.

Systemic inflammatory response syndrome (SIRS) criteria---> 2 or more of the following:

• Temp: <36 or >38
• HR: > 90 bpm
• RR: > 20/ min
• WCC: >12 X 10^9/L or <4X10^9/L
• MAP: <65 mmHg (Systolic BP < 90 mmHg/ Diastolic BP < 60mmHg)

Sepsis: SIRS with the presence of infection (documented).

Severe sepsis : SIRS with organ dysfunction (SOFA criteria)

Septic shock : Sepsis-induced hypotension despite fluid resuscitation

Sepsis Organ Failure Assessment (SOFA) criteria

Goal in treating sepsis :

1. MAP > 65 mmHg (To maintain BP > 90/60 mmHg)

2. ScvO2 > 70%

3. CVP: 8-12mmHg

4. Urine output > 0.5ml/kg/h

Recap MAP calculation:

MAP : (systolic - diastolic)1/3 + diastolic

A114954

Edited by: Wong Yee Ming

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Ascitic fluid analysis and its differential

~emmzesyra~

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Cerebellum: Knowing their functions then knowing their dysfunctions

Functions of cerebellum

3 parts:

1) vestibulocerebellum

-maintain balance

-controls eye movement

2) spinocerebellum

- enhance muscle tone

-coordinate skilled voluntary movement

3) cerebrocerebellum

-plan and initiate voluntary activity

-provide input cortical motor area

Cerebellar dysfunction

· Ataxia (unsteady widebased, limp on side of lesion, cannot walk in straight line)

· Scanning speech (dysarthria- cannot coordinate skilled voluntary movement)

· Dysmetria/ past pointing (unable to plan and initiate voluntary activity. Usually had problem to past his/her finger initially but still can reach at the end of process)

· Intentional tremor

· Unable to stop movement promptly- rebound phenomenon

· Dysdiadochokinesia

· Ipsilateral hypotonia

· Cerebellar nystagmus

· Pendular jerk

· Romberg’s test usually negative, positive when lesion at dorsal column tract

Function of basal nuclei:

5 components:

1. Caudate nuclei

2. Putamen

3. Globus pallidus

4. Subthalamic nucleus

5. Substantia nigra

Roles:

1. Inhibit muscle tone throughout body

2. Select and maintain purposeful motor activity

3. Suppress useless/unwanted pattern of movement

4. Coordinate slow, sustained movement

Dysfunction causes:

1. Hyperkinesia

· Chorea- rapid involuntary movement

· Athetosis- continous slow writhing movement(dance-like)

· Ballism/hemiballism- involuntary movement that are flailing, intense, violent

2. Hypokinesia

· Akinesia - difficult initiate movement

- Reduce spontaneous movement

· Bradykinesia - slowness of movement

Disease due to basal ganglia dysfunction:

1. Huntington’s disease

· Hyperkinetic due to loss of GABAergic pathway

· Autosomal dominat (chr 4)

· Early: jerk trajectory of hand when reaching to touch spot

· Later: hyperkinetic choreiform

· Slurred speech

· Progressive dementia

· Death 10-25 years after onset

2. Parkinson disease

· Both hyperkinetic (rigidity and tremor) and hypokinetic (akinesia and bradykinesia)

· Sporadic idiopathic/ familial

· Loss of dopaminergic neuron and dopamine receptors in basal ganglia

source: lecture note second year by Prof Ruszymah

*alert: this info can be ask during short or long cases (in case dpt parkinson and cerebellar disorder)

~emmzesyra~

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