surgery exam yr 5

Examiner: Mr Ramzi

Wad 7C

For the history, CQ should be in patients own word and use medical terms in HOPI. Eg: patient complained  of blood in the urine for 7 years. HOPI hematuria was associated with severe flank pain. Stenting and ESWL was done 10x and 3 operation was perform however the symptoms did not improved.

For examination, as patient is day 1 post op-PCNL, so patient refused to lie down.

Patient had nephrostomy tube at the back on the left side, 10 cm from the spinous process and 15 cm infrascapular. The NT tube drain 1500ml hematuria and cast seen in the tube. Otherwise, no pus no stone in the urinary bag.

My impression is, patient has left renal stone and was treated with PCNL.

DISCUSSION

Q: why you said it is renal stone not ureteric or bladder stone

A: history of flank pain and hematuria, history of ESWL and had neprostomy tube.

Q: what is the risk factor for renal stone?

A:1) high oxalate diet. Eg:chocolate milk, black tea, soy, yogurt

    2)dehydration

   3) stasis in infection or tumor.

   4)urinary ph: urate and oxalate in acidic urine and struvite and phosphate in alkaline urine.

   5)endocrine abnormality-eg: hyperPTHàhypercalcemia.

   6)metabolite imbalance: hyperuricemia à uric acid stone.

Q: if there is a male presented with flank pain and hematuria, how you will investigate??

A: specific investigation, I would like to perform KUB x-ray which is 90% sensitive for the renal stone

Q: if you cannot see stone on x-ray, what are other modalities:

A: ultrasounds. Ultrasound can pick up uric acid stone and xanthine stone.

    IVU

Q: you had treated this patient with PCNL. What advice you can give to the patient to prevent recurrent.

A: 1) I will investigate if for the uric acid level, PTH and calcium level to exclude endocrine and metabolite problem and treat accordingly if present.

     2)dietary recommendation- I would advice patient to drink adequate water, drink more citrus juice and avoid high oxalate diet, high protein diet and high dose of vit C

Q: what is the complication if you do not remove the stone.

A:The stone can lead to obstruction àinfection. Obstruction also can lead to hydronephrosis and patient later will developed renal failure.

Q: what will happened of this patient develop renal failure (this question is little bit tricky ^_^)

A: as long as the right kidney is normal, patient would not develop any sign or symptoms.

Q: what is the investigation specifically to look for renal damage. Not blood investigation.

A: renal scan. Scincitograpy.

Ok.. lets moved to the short case J

Q: examine the abdomen

A: abdomen is distended at the lower part below the umbilicus……………on deep palpation there is a mass palpable at the pelvic are. The mass irregular surface, hard in consistency and ill-defined margin. No pulse palpable   I cannot go below the mass but can go above it. The mass is fix. On percussion the mass is dull.

Q: how to differentiate between pelvic or abdominal mass?

A: can go above it or below it. As the patient, I cannot go below it, so likely the mass is pelvic origin.

Q: how to percuss pelvic mass

A: from the xiphisternum to the symp pubis.

Q: generally, how the patient look? And what is your diagnosis

A: generally, patient is cachexic and lethargic and the conjunctiva and oral mucosa is pale. I think patient hand pelvic cancer which might be bladder ca, ovarian ca or uterine ca.

SEKIAN.selamat berpuasa and selamat beramal di akhir ramadhan. Semoga bertemu lagi pada ramadhan akan datang and kite semua menjadi insan yang lebih baik and berkhidmat kepada masyarakat. insyaAllah semua orang jadi doctor pada ramadhan akan dtg, last word, kalo ada kekurangan dalam script ni jangan segan2 betulkan atau tambah. Hope all of us will benefit from it.