surgery year 4 end of posting exam part 1

today is the last day of my fourth year exam.. and i want to share the case that i got..

hope we learn something from this post.

Long case

63 year old Malay male presented with 1 day history of diarrhoea and vomiting.

he is asthmatic since 15 years ago otherwise was previously well.

he had diarrhoea, about 20-25 on that day, watery and yellowish in color, no blood or mucus, associated with abdominal pain.

he had the vomiting after the episodes of diarrhoea, post-meal vomiting with gastric content,no blood about 20 times PTA. he become lethargic and drowsy and was brought by his family member to ED.

associated symptoms, fever,palpitation and SOB on that day, LOA and LOW(3-4kg) for 1 months duration.

there is history of eating outside but no other family member had similar problem.

also had voiding symptoms(LUTS)

otherwise, denied any change in bowel habit, no PR bleed.

no DM/hpt/ptb. he take t.ventolin for the asthma and controlled

had been admitted previously for 6 days in HS after had SOB- treated as asthma and dengue fever.

no allergy

no family hx of malignancy or inflammatory bowel disease.

he was an ex-chronic smoker (42 yrs X 20) stop about 1 year ago.

o/e:

well/not complain in pain/very cooperative

conscious alert to TPP, thin, hydration status good

dry and scally skin over elbow and below, ankle and below, face extended to the neck.

not pale or jaundice

had white patch on the tongue but pt claim it was painless.

no palpable cervical, supraclavicular LNs. no pitting edema.

abdominal examination

the abdomen was not distended and move freely with respiration.

there was a stoma bag at the left iliac fossa with solid stool, no mucus/blood/pus

the was an midline incision measuring 8cm from below extending up to hypochondriac region.

there was also 2 scar at the anterior axillary line, likely to be scar for the drainage of the peritoneum( at the right iliac fossa) and from the chest tube(at the safe area for the chest tube insertion)

the abdomen was soft, non tender, no mass palpable.

no hepatosplenomegaly, the kidney was not ballotable.

posterior abdomen

no abnormality

i'm no able to auscultate as the doctor came earlier, the doctor suppose to come by 9.50 but she was there at at 9.30.

i was not able to do auscultation, do the PR and polish my history as well as  the pe. and the most important,to think about the differential diagnosis, investigation and management that i was suppose to prepare before the examiner come.

so i just blurt out during the exam..

the discussions were:

1. what is your differential diagnosis?

2. how to investigate for your diagnosis?

3. if there is mass at recto-sigmoid junction found during colonoscopy, how you will proceed?

4. what is the type of the benign lesion - polyp - type of polyp?

5. if the lesion is dysplasia, how do you manage the patient?

6. what is the complication of the surgery?

7. how to prevent DVT

8. how do you stage colorectal ca.

if will post the proper answer in the next entry ;) just give yourself a break to think about the question

p/s: this is a very common case we are going to encounter in surgical posting.. goodluck.