CHAPTER 1

Mention common diagnoses first in differential.

Surgical sieves

1) THE ANATOMICAL SIEVE

 Congenital
 Acquired – TIN (trauma, inflam, neoplast) CAN (circul, autoimm, nutriti) MED (metab, endo, drugs)
DIP (degen, iatro, psychosom) = ‘tin can med dip’

e.g. CAUSES OF BOWEL OBSTRUCTION

 Can occur in different anatomical regions (stomach, small bowel, large bowel)
 The bowel is a hollow tube that can become blocked at 3 sites:
o Extramural – adhesions, strangulated hernia, volvulus, extrinsic compression
o Intramural – tumours, infarction, strictures, inflammation (crohn’s)
o Luminal – impacted faces, foeign body, large polyps
o (muscle, bone, joints, nerves)

2) GENERAL AND SPECIFIC

e.g. POSTOPERATIVE COMPLICATIONS
 Generalized (apply to any op) – risks of anaesthesia
 Specific (to that particular op) – e.g. recurrent laryngeal nerve damage in thyroidectomy
 Then split them into: immediate, early or late.
 Model answer on complications of thyroidectomy: “Any operation has both general and specific
complications and each can be divided into immediate, early and late. The specific complications of
thyroidectomy are…”

e.g. CAUSES OF HAEMATURIA

 Generalized – e.g. bleeding disorders, use of anticoagulants.
 Specific, relating to any of the anatomical structures in the region –
o Kidney – stones, trauma, carcinoma
o Ureter – tumours, stones, infection
o Bladder – infection, tumour, stones
o Prostate – benign hypertrophy, tumour, infection
o Urethra – stone, infection, trauma
 (consider if not true haematuria: beetroot ingestion, rifampicin, bleeding from vagina/anus)

3) TISSUE TYPES
e.g. CAUSES OF A LUMP IN THE GROIN
 A lump in the groin can arise from any of the tissue types in this region:
o Skin – sebaceous cyst
o Adipose tissue – lipoma
o Connective tissue – fribroma
o Lymphatics – enlarged LN
o Blood vessels – saphena varix, femoral artery aneurysm,
o Inguinal canal – inguinal hernia, hydrocoele of the cord
o Femoral canal – femoral hernia
o Testes – undescended testes

Investigations

1) SIMPLE URINE & FAECAL TESTS – urine dipstix, microscopy & culture, pregnancy tests, faecal occult
blood
2) HAEMATOLOGICAL TESTS – ROUTINE e.g. full blood count, or SPECIAL e.g. tumour markers

3) RADIOLOGICAL TESTS – CXR, US, CT

4) SPECIAL INVESTIGATIONS – e.g. gastroscopy, V/Q scans

Justifying/Reasons for the choice of investigation:

 To determine baseline of patients being admitted to hospital (esp elderly)
 FBC to check for anemia in young females
 U&Es in patients on diuretics

Management

e.g. DISCUSS THE MANAGEMENT OF BPH (include all steps that deal with that clinical problem)
 History
 Examination
 Investigations
 Formation of a diagnosis
 Treatment

e.g. HOW WOULD YOU MANAGE A CASE OF ACUTE CHOLECYSTITIS (imagine you are the Dr in A&E)
 Give Px adequate analgesia
 Arrange admission to a surgical bed
 Put up a drip
 Keep nil by mouth
 Then… liver function tests or US scan etc. (as these are not available immediately)
 Consider what you would actually do in that situation and the steps of management that occur
early on as the Px is being admitted (thereby demonstrating practical awareness of being a junior
Dr):
- What observations would you ask the nurses to take?
- When would you review that patient?
- Would you inform someone more senior? IMPORTANT POINT!
- Would you put in a urinary catheter?
 Consider ‘POSSET’ if appropriate:
- Physio
- Occupational therapy
- Specialists (e.g. stoma care, breast care, speech therapists)
- Social workers
- Education – explain when the stitches will come out; what you can and cannot do (such as
when you can drive, have sex).
- Terminal care – means involving the Macmillan nurses; arranging the syringe pump to deliver
analgesia; speaking to the GP.

Treatment

e.g. DISCUSS THE TREATMENT OF BPH (nb. this is more focused than ‘management’)
 Treatment can be conservative, medical or surgical. For example in this case:
 Conservative – Usually means ruling out cancer.
o PSA <4 and a normal examination
o Allows Dr to reassure the Px
o And adopt a policy of watchful waiting until symptoms get worse.
 Medical – Drugs such as a1-adrenoceptor blockers or 5a-reductase inhibitors
 Surgical – e.g. trans-urethral resection of the prostate (TURP)
 (If appropriate, define BPH & say 1-2 sentences on the condition and its investigation too)

Pathological sieve

 Definition
 Aetiology (incidence, age, sex, geography)/ Risk factors
 Histology (macro and micro)
 Clinical features (signs and symptoms)
 Diagnosis and differential
 Clinical staging (if appropriate)
  Investigations/Treatment/Management
 Complications
 Prognosis

History of a lump

There are 5 important questions, regardless of site:

1) When and how did you first notice the lump? – incidentally/pointed out by partner

2) How has the lump changed since you first noticed it? – got bigger/smaller/stayed same size/come &
gone; changed its appearance/consistency; does it get bigger during a period?

3) What symptoms does it cause you? – is it painful? Nipple discharge (breast lump). Affected voice,
breathing or eating (neck lump); Symptoms of hypo/hyperthyroidism (thyroid lump).

4) Have you got any more/have you had this before? – are they the same? What happened to it the last
time? What did the Dr say it was? Does it come periodically, with every menstrual cycle?

5) What do you think this is? – to become aware of Px’s anxieties, such as cancer, and reassure the Px
when appropriate (eg. if young Px and painful lump)

History of pain

1) site – where is the pain? (also consider referred pain at the shoulder from diaphragmatic irritation)

2) character/severity/radiation – what is the nature of the pain? What does it feel like? Constant/comes
and goes in a regular pattern? Severity on scale of 1-to-10 being worst pain ever?

3) onset/duration/progression/frequency/timing– how did the pain start? Sudden or gradual? Has the
pain got better or worse since it started? what has happened to it since?

4) alleviating/exacerbating – what relieves and what exacerbates the pain? Does the pain make you want
to writhe about (usu when have colicky pain, e.g. biliary colic) or lie very still (usu when peritoneal
inflammation as movement makes pain worse, e.g. if cholecystitis)?

5) associated symptoms – are there any associated symptoms? E.g. nausea, vomiting, signs of sympathetic
stimulation (in cardiac pain). Anorexia, weight loss, change in the bowel habit, rectal bleeding (in bowel
cancer).

6) ever before? – Have you ever had this before? Does this feel the same as the last episode (e.g. repeated
episodes of acute pancreatitis in an alcoholic; or angina sufferer?

7) ideas – What do you think it is?

8) PMH/

Answering viva questions

- Apply your answer directly to the question – i.e. take a specific approach, rather than a generic one.
- E.g. HOW WOULD YOU MANAGE SOMEONE WITH A BREAST LUMP?
o In my history I would… find out about the history of the lump and ask in particular for risk
factors for breast cancer or for factors suggestive of benign breast disease.
o On examination I would inspect the breasts, followed by palpation, examining the normal
side first.
o My investigations would then be tailored to my findings from the history and
examination, but should involve an imaging technique plus or minus a fine needle
aspiration.
o The patient would then require counselling about the disease, and
 o Treatment could be divided into medical and surgical (which can be subdivided into
curative and palliative)

--
Other possible questions to cover:
- What would you say to the patient when consenting him for this operation?
- Tell me about postoperative complications
- What are the causes of haematuria?
- How would you investigate such a patient?
- What are the risk factors for breast cancer