Table of Contents
- How to answer definitions ?
- How to answer causes and etiologies ?
- How to answer the clinical features of the given disease conditions ?
- How to answer the investigations for given disease conditions ?
- How to answer treatment for a give disease conditions ?
- How to answer the asked procedures ?
- How to answer the complications of a procedure or surgery ?
How to answer definitions ?
Definitions are often asked in the exams – both in theory exams and viva-voce. As the content is vast, mugging them up is not a good idea. If you have a good understanding over the topic, you can write down a good definition by including following things wherever possible:
- Basic pathophysiology or process: Nature of infection, Premalignant condition, Benign/malignant neoplasm, Localized collection, etc.
- Involved structures: Layers of skin, Structures invaded by malignancy, etc.
- Peculiar identifying feature: certain size, duration, etc.
- Can include: Diagnostic clinical feature(s), Indication, The difference from a common differential diagnosis
Delayed Primary Closure (DPC): Surgical closure of a wound (1) 3-5 days after the thorough cleansing or debridement of the wound bed (3) when there is contamination or high risk of contamination (4).
Aneurysm: Pathological, localized, permanent dilation of an artery (1) to >1.5 times (3) the original diameter involving all 3 layers (2 and 4 – mentions the involved layers and also differentiates from pseudoaneurysm which doesn’t involve all the 3 layers of arterial wall) of its parent wall.
Locally Advanced Breast Carcinoma (LABC): Malignant neoplasm of the breast (1) that has not spread to distant sites i.e. Mo (3) but may be one of the following (2):
- Primary tumor >5 cm (T3)
- Chest wall and/or skin involvement including inflammatory carcinoma (T4)
- Ipsilateral fixed axillary lymph nodes and/or internal mammary nodes or infraclavicular or supraclavicular nodes (N2 or N3)
How to answer causes and etiologies ?
List down the causes in a systematic manner after classifying them. The general rules for doing them are –
a. Causes involving conditions in a hollow viscus:
- In the lumen: usually stones, foreign body or worms
- In the wall: usually inflammatory or neoplastic conditions and strictures
- Outside the wall: usually enlargement of adjacent structures, lymph nodes or abnormal protrusions
- Non-mechanical: usually neuromuscular and metabolic causes
Causes of dysphagia:
- In the lumen: Foreign body (dentures, coin)
- In the wall:
- Inflammation: Infectious esophagitis, tuberculosis
- Neoplasm: Carcinoma esophagus
- Inflammatory or post-irradiation strictures
- Outside the wall: Aortic aneurysm, retropharyngeal abscess, thyroid enlargement, cardiomegaly, mediastinal nodes
- Non-mechanical: Myasthenia gravis, Polymyositis, Achalasia, Scleroderma, Cranial nerve IX and/or X lesions
Causes of intestinal obstruction:
- In the lumen: gallstones, impacted feces, meconium, worms, foreign body
- In the wall: Inflammatory or malignant strictures, Diverticulitis
- Outside the wall: Adhesions and bands, cancers, hernia, volvulus
- Paralytic ileus: postoperative abdominal surgery, mesenteric ischemia, hypokalemia, hypothyroidism, etc.
b. For answering all other etiologies:
Use a surgical seive and remember them using a mnemonic like “MEDIC HAT PIN”
Causes of splenomegaly –
- Idiopathic: Idiopathic thrombocytopenic purpura
- Vascular: portal vein obstruction, Budd-Chiari syndrome, haemoglobinopathies (Sickle-cell disease, thalassemia)
- Infective: AIDS, mononucleosis, septicaemia, tuberculosis, brucellosis, malaria, infective endocarditis
- Traumatic: haematoma, rupture
- Autoimmune: rheumatoid arthritis, SLE
- Metabolic: Gaucher’s disease, mucopolysaccharidoses, amyloidosis, Tangier disease
- Inflammatory: sarcoidosis
- Neoplastic: CML, metastases, myeloproliferative disorders
Note: Always highlight the commonest and more common causes when using these systems for answering.
How to answer the clinical features of the given disease conditions ?
Classify into symptoms (subjective complaints and remember to elaborate using a mnemonic – SOCRATES; elaborate the main complaint and keep others as associated features) and signs (objective findings) expected in the disease condition; Use eponymous signs and elaborate in one line whenever possible –
In Acute Appendicitis –
- Site of pain: Right iliac fossa
- Onset of pain: Acute over 24-48 hours
- Character of pain: Initially dull visceral pain, later becoming sharp and localized due to parietal peritoneum involvement
- Radiation or migration: Migrating to RIF from umbilicus
- Associated symptoms: Anorexia, Nausea/vomiting, Fever, etc. (Murphy’s triad – pain, vomiting and fever)
- Timing: No association
- Exacerbating and relieving factor: As in all cases of peritonism – increased by movement and coughing and relieved partially by rest
- Pointing sign, Blumberg’s sign, Obturator sign, Psoas sign, Rovsig’s sign, Sherren’s triangle hyperesthesia, Rectal wall tenderness on PR, etc.
How to answer the investigations for given disease conditions ?
Always mention the expected findings of the tests and answer in the following order –
- Investigations to prove diagnosis
- Investigations to rule out differential diagnoses
- Routine investigations, pre-operative investigations and Investigations to rule out or identify complications
- Investigations for monitoring the disease
In Acute Pancreatitis –
1. Investigations to prove diagnosis:
- Serum amylase and lipase: Increased by atleast 3 times
- Abdominal USG: Can detect gallstone, biliary obstruction and pseudocyst formation
- CECT abdomen: Confirms the diagnosis and aids in providing prognosis to the disease
- Plain AXR: Sentinel loop sign, Colon cut-off sign, Renal halo sign, Pancreatic calcifications
- LFT: can suggest if the cause is gallstone or alcohol
2. Investigations to rule out differential diagnosis:
- ECG: To rule out MI
- Plain abdominal X-ray erect and supine: To rule out perforation
- Stool for occult blood: To rule out mesenteric ischemia
- USG abdomen: To rule out cholecystitis
3. Routine, Pre-op investigations and Investigations to identify complications:
- CBC and HCt: resembling SIRS or septic shock
- RFT: to rule out renal failure due to hypovolemia
- RBS: Hyperglycemia
- Serum albumin: Decreased
- Serum calcium: Decreased
- ABG: Metabolic acidosis
- Plain Chest X-ray: Pleural effusion, ARDS
- Pre-op investigations: Serology, Blood grouping and cross-matching
4. Investigations for monitoring disease progression: CBC and HCt, ABG, Serum calcium, RFT, etc.
How to answer treatment for a give disease conditions ?
Whenever possible, follow the following order –
- Firstly: Stabilization of vitals (Go with ABC approach as in BLS) and emergency management
- Secondly: Conservative management (if possible)
- Thirdly: Medical and Surgical management
For treatment of nephrolithiasis –
Firstly: Manage acute pain, UTI and deranged renal function if present
- Analgesics: NSAIDs (1st choice), Opioids (2nd choice)
- Anti-emetics: If vomiting
- Alpha-blockers: reduces recurrent colic
- IV hydration
- Antibiotics for UTI
- Percutaneous nephrostomy for decompression may be required
Secondly: Conservative management if possible
- Adequate water intake (atleast 2 litres per day)
- Urine alkalizer +/- allopurinol for suspected urate stones
- Periodic evaluation
Thirdly: Medical or Surgical management with indications
Replicate contents from textbooks into concise flowcharts whenever possible.
This has 2 advantages:
- Saves time
- Easy to the examiner’s eyes.
How to answer the asked procedures ?
Be concise and answer in following order – Indications, Requirements, Description of procedre site, Procedure (Position, Anesthesia, Incision, Dissection, Performing targeted procedure, Closure), Confirm correct placement and if the intervention is functional and Complications
Explaining Chest tube insertion –
- Traumatic hemothorax
- Traumatic pneumothorax
- Drainage of empyema
- Following thoracotomy
- Requirements: Sialistic chest tube drain, Underwater seal drainage bag, Inj. 1% lignocaine, Straight and curved clamp, Suture and dressing set
- Working site: Safety triangle – bounded by anterior border of latissimus dorsi, posterior border of pectoralis major, superior border of 5th rib
- Anesthesia: Backrest lifted to 45 degrees
- Anesthesia: LA 1% inj. lignocaine (skin to parietal pleura)
- Incision: Over safety triangle
- Dissection: Intercostal muscles separated using curved clamp, Blunt dissection with finger down upto pleura
- Chest tube inserted towards apex for pneumothorax and towards base for effusion
- Chest tube clamped and closed end cut-off to connect to a water seal draiange bag (2-3 cm inside water)
- Drain fixed – stictch in a circular fashion
- Sterile dressing pad applied
- Correct placement: Chest X-ray
- Functional: Tidalling, Bubbles in the underwater seal drain (pneumothorax)
- Intercostal neurovascular injury
- Lung and mediastinal injury
How to answer the complications of a procedure or surgery ?
Classify and present as following:
- Surgery-related: Anatomical injury (Vessels and Organs)
- Anesthesia related
- Immediate (<24 hrs):
- Local: Reactionary hemorrhage
- General: Asphyxia (Airway obstruction with tongue fall or aspiration of vomitus)
- Early (upto 3 weeks):
- Paralytic ileus (abdominal surgeries)
- Infection (wound, peritonitis, pelvic, subphrenic)
- Secondary hemorrhage
- Dehiscence (wound, anastomosis)
- Obstruction (fibrinous adhesions)
- Pulmonary: Collapse, Bronchopneumonia, Emboli
- Urinary: Retention, ATN
- Late (>3 weeks):
- Obstruction (fibrous adhesions)
- Incisional hernia
- Persistent wound sinus
- Recurrence of original lesion
- Scar probles (hypertrophic scars, keloid)
- General: After extensive resections or gastrectomy
- Vitamin deficiency
- Steatorrhea and/or diarrhea
- Dumping syndrome
After thyroidectomy –
- Surgery related:
- Vascular injury: Primary hemorrhage from superior or inferior thyroid artery, thyroid ima. artery, carotid artery, jugular vein
- Nerve injury: External laryngeal nerve
- Solid organ injury: Injury to parathyroid gland, apex of lung
- Hollow viscus injury: Trachea, esophagus, larynx
- Anesthesia related
- Local: Reactionary hemorrhage, Asphyxia due to hematoma, Hoarseness due to recurrent laryngeal nerve injury
- General: Asphyxia, Thyrotoxic crisis
- Local: Wound infection, Laryngeal edema
- General: Chest infection
- Local: Scar, Stitch granuloma
- General: Thyroid and parathyroid insufficiency