Long case surgery Farah Hanani 1.lecturers : prof khoo, prof adeeba, external examiner 2. specialty : surgery 3.

brief history : 65/chinese/gentlemen presented with right HPC pain+early satiety+bloating+consitutional symptoms. problems started last year, only went to UMMC after his friends advice him. chronic smoker, likes to skip lunch due to satiety. k/c/o of DM with retinopathy, hypertension, hypercholesterolaemia. went to UMMC early this year. OGDS, CT scan and blood investigations were done. CT scan shows lung and liver mets. 4. PE finding : normal except he looks cachexic and pallor. he told that his doctor said he has palpable left supraclvicular nodes. but i double check, no lymph node. little bit of hernia~aishhh 5. diagnosis : stage 4 stomach ca with lung and liver involvment 6. questions - symptoms of anaemia - physiology of lymphatic drainage - demonstrate abdominal PE and why you do so - differential diagnosis - interpret CT scan - other investigation - how to manage palliative....~good luck guys about a week ago Report

Kin Wong Chan Prof KL Goh Prof Azad Prof Azmi Speciality: Surgery C/O: Recurrent Epigastric Pain x 1 year Brief Hx: 43 y/o Malay Lady, well till 1 year ago develop epigastric pain, sharp, gradual onset over few hours, tolerable pain, assoc w eating, relieved by bending forward & radiate to the back. Frequency of the acute pain is about twice a month until 3 months ago when the pain starts to

become more frequent and she had it almost daily now. Most of the time the pain will resolve spontaneously our a few hours. However there's 2 episodes where she experienced a severe pain with score of 10/10 3 months ago and 3 weeks ago. During these severe episodes, she had jaundice, fever, chills, rigors which was preceeded by the pain. She came to UMMC for both the episodes and pain resolved after some treatment antibiotics, painkiller & fluids. The jaundice was also resolved with treatment. She was told to have a liver condition 3 months ago & after radiological ix she was told of some pancreatic condition which she was unsure of. diagnosis: gallstone pancreatitis questions: PE: abdo examination, signs that i would look for(pt was completely normal with no signs at the moment) room: ask about differentials & why (coz didnt mention the wanted dx stated above although mentioned common bile duct stone w reflux pancreatitis) Ix: fbc, lft, serum amylase, US & reasons why give blood ix results of one of the acute attacks and asked to interpret (Bilirubin, ALP, GGT, amylase high) mx: what to be done if pt acutely admitted with the above ix results (resus,med, ercp) others: why pt w stones hv intermittent pain ask why bilirubin can b high but no conjunctival jaundice what does tea-coloured urine imply discussing over the final diagnosis out of my differentials about a week ago Report

Roszita Bt Mokhtar 1.examiners:prof philip poi(geriatric),prof dhamendra(neurosurg),Dr cheah(external-paed) 2.speciality:surgery 3.c/o: 65y/o/C/M -per rectal bleeding-2 weeks.DM + HTN for 4 years on meds 4. Brief history. Previously well,1st episode,hx of passing out fresh blood associated with mucus and loose stool.no abdominal pain or swelling, no symptoms of infection,no loa low.ex-smoker stopped 10 years back.previously smoke 40 sticks/day for 25 years.occ drinker, fx of esophageal carcinoma.

5.PE midline scar,stoma on left iliac fossa,chemo port insertion scar, incisional hernia over the distal part of the scar. 6. Diagnosis colorectal carcinoma 7.Question asked by lecturer 1.what do u mean by tenesmus? 2.how u diff melena and fresh blood?why they are diff? 3.is the patient depress? 4.pe:ilicit hernia,do hernia examination, 5. ix: what is diff between barium enema and colonoscopy? 6.mx:follow up patient what do u want to look for?-NUTRITION! Gud luck guys:) about a week ago Report

Esther Lee 1. lecturers who took u: prof BK lim(O+G), prof wan arrifin(paeds), dr KL ng (surgery-not dr michael) 2. specialty: surgery 3. chief complaint: nil 4. brief history: 82/I/gentleman hx of BPH post op June 2010. prior to that, in 2009 one episode of AUR a/w abdo distension, fever one day.no urinary sympt prior, no other GI symp (pain, tenesmus, bloody diarrhoea). presented to A+E, catherized got haematuria, Xray KUB done, no stones.family was called middle of night that pt needed emergency op.found got perforated colon and colostomy was done. 5. PE finding distended abdo,laparotomy scar, left sided colostomy 6. diagnosis:??? discussion was lead to diverticular ds with lotsa hinting 7. questions asked by lecturer (so interested with AUR ended with colostomy, BPH ignored) Do u think that AUR and perforated colon related? wat can cause perforated colon? why do u think it is a colostomy?

complication of diverticular ds wat investigation u wanna do wat do u expect to find in barium enema BK lim was so nice today! hinted so much... hope i din irritate KL Ng by sudden aphasia at the end T.T huhu

Iu Kwang Kwok My case: Gallbladder Carcinoma , p/m/Hx asthma and hypetension Examiner: Prof Subramaniam (External), Prof Pan (External), Prof CT Tan HOPI: Diagnosed gallbladder ca 7 month ago, presented with obstructed jaudice. 3 days post chemo Presented with Fever assoc with cough and sore throat. Examiner: Prof Subramaniam (External), Prof Pan (External), Prof CT Tan Question: Why do you said this is obstructed jaundice? What is the causes? Can u tell me what is the pathophysiology of him getting pale stool Why he get multiple episode of fever Tell me About hepatitis other than hepatitis B What u will do for this patient for his jaundice problem and the management What will you manage if he come to A n E with the similar complaint and what is ur management (mainly management about neutropenic sepsis) All the best...............

Ho Kean Teng Same case with kwang kwok(neutropenic sepsis with underlying gall bladder CA) add on=what do you wanna do if you accidental found few stone in the gall bladder and the pt is asymptomatic. mirizzi syndrome. why puritus in obstructive jaundice?bile acid accumulation what cancer cause obstructive jaundice? what medical condition and drugs cause obstructive jaundice? how is the jaundice in pancreatic CA?progressive

why periampullary CA will cause intermittent jaundice?

Hwang Ing Siong MBBS(Malaya) 06/11 Final Exam Data Store Hwang Ing Siong 1. lecturers who took u external caucasian (sur), chan lee lee (paed), nik sharina? (pcm) 2. specialty Surgery 3. chief complaint gradual abdominal distention 1 month 4. brief history 53/c/gentleman,underlying colon ca (caecal), c/o 1 month gradual abdominal distention, 2 weeks lower abdominal pain, vomiting 2 days prior to admission. pshx:acute appendicectomy find out to be malignant tumour. Thus, a midline open laparotomy done. 12 cycle chemo. 2nd CT scan revealed stage 4. 5. PE finding anaemia, scars, peritoneal drainage, ascites. 6. diagnosis IO secondary to colon ca 7. questions asked by lecturer - PE: show incisional hernia. do abdominal examination. - in the room: investigations, what iv fluids chosen, electrolytes imbalance of vomiting. show abdomen CT->small bowel obstruction and ascites, ix of acute IO, ix of ascites about a week ago Report

DumDum Lay Teng

1. prof yip, prof eugene n ??? 2. surgical 3. per rectal bleeding 4. 73 year old indian lady, c/o per rectal bleeding associated wif mild abdominal pain and loss of weight. history of hypertension past surgical hx: ectopic preg, cholecystectomy and TOP due to German measle 5. colon carcinoma 6.post op laparotomy scar, kocher scar 7. if colon ca: which site n y? investigation: what u expect to see from colonoscopy other easy ix to diagnose carcinoma how long is d sigmoidoscopy can reach risk of synchronous interpret chest X-ray y u wan to do CTscan if CTscan not good enough, wat u wan to do staging of carcinoma management of each staging tis pt need chemotherapy? if not operable on laparotomy, wat u wan to do? post op complication if post op patient complain of vomting, wat u suspect? wat other sign n symptom u wan to look in post op wat cx of ectopic pregnancy

Devanraj Selvam 1. Lecturers who took me. Prof Rokiah Ismail (*she was really nice today!), Prof Chin KF, Prof Thong 2. Specialty Surgery + Medicine 3. Chief complaint Elective admission for parathyroidectomy (Tertiary HyperPTH). Known case of CKD for 7 years. Secondary Hypertension (diagnosed at 21 years old) 4. Brief history

36 year old Chinese lady, single, with no family history, congenital problem, or any underlying cause. *I said possibly undetected scarred kidney due to recurrent UTI during childhood. (*Prof Thong said okay) 5. PE finding Post-surgical scar. Oedema causing RLN palsy-hoarseness of voice (*was asked why, what other post-op complications). BP high. Otherwise okay. *I was asked about pallor and leuconychia (*exact location) and the AVF(*why bruit/thrills-talk about different callibre of vessels, turbulent flow). Talk about scar, jaundice, anaemia, describe the mass at the neck. BMI, nutrition, 6. Diagnosis Tertiary HyperPTH due to a long standing CKD with a background history of secondary Hypertension. 7. Questions asked by lecturer Surgical question: If I am performing a parathyroid surgery, how do I do a simple test to differentiate the gland from a fat lump? Remember OT has water. I was like fill the water in a beaker and place the removed specimen. Suppose if it floats, it is fat lump. Why? Because of its density. Phew, Form 4 Physics saved me. Then the anatomy, size of gland. Hypocalcaemia. What clinical test. Chvostek and Trosseau. How do you do it? I could answer until show me how the hand would finally lie with Trosseau. I did like a claw hand because I thought it was carpo-pedal spasm. They were smiling and Prof Rokiah asked whether am I sure. I sheepishly smiled and said no. Apparently it is like http://www.kuwait-md.org/?q=node%2F923 . Haih. Very brief management of the CKD. Prognosis, how would you counsel the patient. I can't remember much la, they did ask few questions here and there. But I was glad when it finished. My final question was how a patient with CKD would get shortness of breath. I told the anaemia in CKD pathophysiology. I got the same patient with Sahrul (*Tambah la apa-apa if I left out). Apparently they rotate 2 students per patient. Good luck guys!

Benjamin Lim

Prof Sanjiv Mahadeva ( he was runnign da show, asking most of da questions....and dun expect him to hint u, he will never) Prof Cheah Fook Joe from UKM.....keep tambahing question to Prof Sanjiv Prof Razif....silent mine is same as anis.....malapetaka i think.....1st,i started out late, cause they cannot find da patient, 2nd, when i was doing halfway, anis came in with his lecturers for PE, another 10 minutes, total about 20-minutes....and i was given extra 10 minutes ( eveyrone given extra 10 minutes), so 50 minutes to clerk and PE for all da problem below, i was like, i am fking dead !neway, summary of da probem No CC, purely for examination purposes, TCA 24 April for ESWL f/u 25 years PTA: Right inguinal hernia repair with vasectomy 12 years PTA: DM, HTN 10 yr PTA: KUB calculi, surgery done to remove in pelviureteric junctiion, transfused blood once,r euccerence twice, with ESWL 10 yrs PTA: bilateral cataract surgery 10 yeras : dun ask me why, ev erything oso 10 yeasrs....PID, under ortho red team f/u, cured by physiotherapy 7 yeras PTA; Ix for Hyper Ca: Parathyroidectomy done 6 months PTA: LUTS, Uro f/u, under some medication, which i dunt know PE: peripheral neuropathy : glove stocking, and also L5 dermatome interestingly... and INTERESTINGLY!!!!! got bilateral pedal edema up to knee....i was like wtf....no bibasal crepitations i was stuck in Hx, and PE quite long, no reach Ix not Mgmt...... i thought i presented quite well m Hx ( despite being interrupted), can answer some of their question, but some i cant answer, but stuck a bit in PE, haih.....anyway.....hope i can pass and pray dat they can understand my case is a dam complicated with multiple prob case and pass me.....reli need lotsa lucks here....

Jareth Chong Chan Teng 1. lecturers who took u -Prof.Azad,Prof CT Lim and Dr Sofia

2. specialty -Surgery 3. chief complaint -67 y/o Chinese gentleman who work as a lorry driver -electively admitted for surgery tomorrow -history started from May 2010..presented with lower urinary tract obstructive symptom like frequency, incomplete bladder emptying, intermittency, terminal dribbling and poor urinary stream. No symptom of incontinence, nocturia or straining. One day later, presented with gross haematuria for one episode during the morning urination. No pain, dysuria, fever. Went to private clinic and referred to UMMC. Investigation was done show high PSA,CT scan and MRI and diagnosed. Start with medication which only take at night. Regular follow up at UMMC with PSA monitoring and it is fluctuating around 12 to 19 mg/dL. Currently do not have obstructive symptom except poor urinary stream. Past medical history of bronchial asthma--well controlled Questions asked by lecturer -history:1.why u specially stress he is a lorry driver?cos they may be have multiple sexual partner and he will prone to STD and get urethral stricture 2.U mean he is sexually active?(forgot to ask)..why is it important in this case? cos treatment will cause sexual dysfunction..psychosocial impact. -PE:Negative finding..ask to show what i have examine.. then i show no evidence of jaundice, anemia, hepatomegaly,spine tenderness(why?spinal metastases),inguinal lymph node -Ix u want to do?....i forgot to order UFEME..then prof prompt lo like ask how to investigate haematuria?i answer ultrasound and cystoscope...then he give me the answer UFEME. interpret UFEME and what information u can get from it and rule out other cause of haematuria. -PSA 9+ mg/dL?wat do u think?u want to do free or total PSA?which one? -how to do a transrectal ultrasound and biopsy?have u see one?wat is the complication? (bleeding, introduce infection) -how would u manage this patient..let say is early stage?i answer surgery like turp but actually prof want radical turp. -hormonal therapy..complication of orchidectomy?haha..osteoporosis -any role of chemotherapy?hormonal therapy better than chemotherapy -if patient come to clinic..how u monitor?history and pe to look for relapse and monitor PSA

-wat is the prognosis..let say in early stage?good.

JiEa AmIr 1. lecturers who took u~ prof azad,prof ct lim,prof sofia 2. specialty~surgery 3. chief complaint~painless hematuria 4. brief history~68y/o chinese gentleman presented 6 month ago with painless haematuria for 1 day. Assoc with LUTS and lethargy. No LOA n LOW. Non smoking. 5. PE finding~not much for abdmen n other system..PR~irregular prostate,cannot feel median sulcus,firm 6. diagnosis~ Prostate cancer~early stage,not mets yet 7. questions asked by lecturer ~diff diagnosis ~inv~ LFT, RP for wat? normal value psa? they gv me d value n ask whether high or not, TRUS n biopsy,wat complication can we get? n all about imaging inV.dUN 4get bone scan. Then, bed site~ wat u want to look?? demonstrate hw to check for bladder for urinary retention..wat u xpect if there is mets to lung? n finding for PR..luckily,i did d PR..=) wat do u think about this patient body build? Then, went to d room again.... ~ wat mx dat u want to do? How to take consent? wat complication from d surgery? wat other mx if pt refuse surgery?~hormonal therapy n radiotherapy ~wat risk factor for prostate ca for dis patient? wat diet can cause prostate ca? milk n fat..haha..prof azad tell me... ~ then prof ct lim ask pathophysiology haematuria...errkkk..then,kring!!!!!!! save by d bell~~heee

Er Lz lecturers: prof zuraida(psy), gurdeep singh, and one mat salleh (dunno from where) Specialties: surgery chief complaint: acute abdominal distension with epigastric pain a/w unable to pass urine and constipation X 1/7 brief history: (patient is not very educated, could not tell the diagnosis, could not name the doctor who asked him to come for exam). his chief complaint was almost 2 months ago. at that time he was admitted to sri kota hospital in klang and then only referred here. i totally hv no idea what's wrong with this pt until i saw his ultrasound report from sri kota hospital saying that he has necrotizing pancreatitis. the abd distension was acute, n epigastric pain was at that night itself. the previous night he consume alcohol as usual. PMH: hyperuricemia and hypercholesterolemia not on treatment chronic smoker and alcoholics for more than 20 years, unemployed. * beware: his complaint of unable to pass urine has nothing to do with his current complaint. it was there for long time, n he has symptoms suggestive of BPH. PE: tatoo at suprapubic area. 2 drainage tubes with bags at left hypochondrium and left loin draining some green brownish fluid. a mass 10 X10cm found at the left hypochondrium region, non-tender, smooth. per rectal - enlarged prostate with smooth surface. diagnosis: pancreatic pseudocyst secondary to acute pancreatitis. questions: -differential diagnoses for all his symptoms -causes for pancreatitis (memorize the GET SMASHED in Oxford handbook) -causes for a mass at left hypochondrium region -what is the fluid in the drainage bag -investigations to be done -interpret CT scan (the computer was opened with the patient's CT scan. i was asked to show him the normal structure first) -what would u see on the CT of someone with chronic pancreatitis -how to manage in the acute setting -what analgesic to give -what is the function of pancreas (exocrine and endocrine) what complications would they get in chronic pancreatitis -what is insulinoma and glucagonoma and what would they present with?

the bell rang.

Wen Mangteen ecturers who took u ( Prof Ong, Prof.Zuraini, UK external examiner) 2. specialty ( surgery) 3. chief complaint-65 year old, chinese geltleman. painless gross hematuria 4. brief history presented 8 years ago with painless gross hematuria, serial ix show bladder CA, neoadjuvant radiotherapy, surgery, adjuvant chemotherapy........ well until 1 yr later, recurrence. 5 yrs later hv ?pelvic abscess, I+D done then experience intermittent right hip pain...... admitted this time bcz gross hematuria, painless.

5. PE finding -pale, nt cachexic, on CBD, left nephrostomy tube... hematuria. abdomen, midline laparaotmy scar, laparoscopic scar, right iliac fossa scar( for I+D), no hernia. no abdomen findings..... 6. diagnosis- recurrence bladder carcinoma 7. questions asked by lecturer 1) what is the differential dx? recurrence, trauma, stone, UTI, prostate CA, BPH......... 2) what is the IX? 3) lets say is unilateral hypronephrosis, where will be the level of obstruction? 4) contrast or non-contrast CT? 5) show me the antegrade pyelogram and ask wat is this. wat u see, why? 6) wat will you do if u see a growth in bladder during cystoscopy? 7) wat will you do to make pt feel better? i think is all i can remember...... good luck last Tuesday Report

Rosdi Pon Please present your long case following this format. 1. lecturers who took u Prof thambi, prof philip phoi, prof nik sherina 2. specialty surgery 3. chief complaint currently no active complaint 4. brief history 62 y/o chinese gentleman, with history of colorectal carcinoma diagnosed on 2006. first p/w bloatedness and fresh pr bleed. non smoker occasional drinker no fhx of crc 5. PE finding a lot of scar. got i chemopot. midline scar appendicectomy scar, scar from previous stoma, scar from previous hernia examination 6. diagnosis colorectal carcinoma (sigmoid ca) 7. questions asked by lecturer how to check for ascites? staging for crc? where commonly metastases? how? screening for other family members? follow up what to look for? metachronous tumour, is it common? last Tuesday Report

Cheng Joo Qing 1 prof raman(paeds surgery), prof khoo( PCM), prof mary ann(external) 2 surgery 3 left facial swelling 4 left facial swelling, increasing in size, multiple negative biopseis..CT abdomen, found renal mass,

for nephrectomy 2morow 5 left facial swelling,10X8cm, nonmobile, smooth surface, firm..no LN, no other positive findings 6 RCC wit mandible mets?( examiner lead me to dis dx, at first i said LN, pf raman asked: do u think LN will be so large???) 7 where does RCC mets chemotherapy for RCC, trial in UMMC-i dunno tx for this pt-radical nephrec, chemo for lung mets, radiotherapy for bone mets tumor marker for RCC-i dunno, pf raman ask do u think troponin will be high, i said yes interpret CT scan frm prof mary: prognosis for dis patient frm prof khoo:wat did hospice do

Zahratulhuda Khairulezuan 1. lecturers: Prof Nur Aishah, Prof Chan Lee Lee, Dr. Ho (all the profs and dr are nice =)) 2. speciality: surgery 3. c/o: per rectal bleeding for 1 day 1 year ago 4. HPC: 62 years old indian gentleman. started to have constipation for 1 week. then passed out pencil shaped stool. then did not have bowel opening for 2 days. the subsequent day he had per rectal bleeding. 4 drops of dark red blood. no mucus and no clots. assoc with abdominal discomfort, tenesmus. no LOA, no LOW, no abd pain. he was diagnosed with colorectal Ca after colonoscopy. defunctioning colostomy was done. MRI was also done to stage the dss. it has metastasize to the lung but no lung symptoms. neoaduvant therapy was done to shruken the tumor. he underwent radio, chemo xeloda (chemo pill). then after 5 months abdomino perineal resection was done. he end up with permanent end colostomy. no chemo or radio done after surgery. 2 months after that came back for discharge at anus (anus dah stitch coz APR kan). drain was inserted then OK. family history of colorectal ca. he also had mild depression 5. O/E: No signs at periphery. on abdominal inspection there was midline scar from laparotomy. a transverse scar at right upper quadrant from previous defunctioning colostomy. there was stoma bag at the lower left quadrant. describe the stoma la (there was solid faeces inside so

of course colon la). also had incisional hernia at the transverse scar. 6. dx: colorectal carcinoma mets to lungs (duke D) 7. discussion was mostly about colorectal carcinoma and incisional hernia kt patient on bedside la. -show the incisional hernia (suruh patient cough la) -what's important (determine hernia strangulated or not) -how to determine that (they ask to find the neck of the hernia). so ask patient to tense the abdominal muscle by flexing the neck. then ask patient to cough. then rasa the neck. if small neck most likely to strangulate and need to arrange for surgery. tp patient ni wide neck. so no urgent surgery needed. then showed them the anus and say it was healing well since there is healthy granulation tissue and no discharge. then dlm bilik: -on f/up in clinic what u want to do. find symptoms and signs of recurrent colon ca, complications of surgery. then do CEA to monitor for recurrence. -can patient have normal CEA although have colon ca? ans: can. therefore CEA is not use for diagnosis. it is use to monitor progression and recurrence. -on f/up i will look for depression also -then CLL asked, how you manage the depression i said if severe refer psychiatrist (then diorg laugh la). they asked me to manage. then i said since he has mild depression and he is embarassed to go out, he is wearing cloths kan so org x nampak the stoma bag. then to manage the smell, asked him to clean the stoma bag before going out anywhere. -then tanya staging (duke D coz dh mets to lung) -then prof asked MRI was done in this patient, is it usual? i said no. usually CT thorax, abdomen, pelvis. -so why MRI was done? i ans: MRI is good for soft tissue. it was probably to assess local invasion for eg. to the bladder (they agreed) -what other way to assess local invasion: transrectal ultrasound -how does it help the surgeon: assess depth of invasion and local invasion (i'm not sure this one) -do you think he has familial syndrome that predisposed him for the colorectal ca ans: no coz he got the ca at old age and so did his sister. usually in familial syndrome the age of getting colon ca is younger. -what familial syndrome can predispose to colorectal ca (yg ni ans wrongly...huhu) polyposis synd (FAP and Peutz Jeghers) HNPCC (Lynch syndrome)

good luck!~ =)

Deeyana Mohd Hud Please present your long case following this format. 1. lecturers who took u External examiner ( Caucasian), I forgot the name~main examiner external examiner, Prof Nortina (neurology) observer 2. specialty Surgery 3. chief complaint 61 year old, malay, single came in with right iliac fossa pain. 4. brief history 8 months ago, she presented with right iliac fossa pain for 1 day, the pain was severe, acute, and colicky. No change in bowel habit and urination. No nausea, vomiting and fever. She experienced loss of appetite and loss of weight 10 kg for the past 6 months. She underwent surgery as she suspected to have acute appendicits and was found out to be perforated right colon cancer ( ascending colon?). She then had Ct scan and PET scan done, and was told the cancer has spread to the liver. She underwent chemo and radiotherapy. A few months ago. she started to experience bilateral lower limb weakness, unable to walk and need to use the wheelchair. No bowel or urinary incontinence. Later, 20 days ago, she experienced with one day history of central abdominal pain, with severe vomiting, passing very hard stool for 1 week. Since that, she was on total parenteral nutrition in the ward. She has family history of colorectal cancer, where her elder sister was diagnosed to have colon cancer at the age of 66 years old. She is single, live alone in 1st floor flat house with no lift. She was able to take care od herself, but sometime she required help from other family members. 5. PE finding cachexic looking with TPN. positive finding was hepatomegaly 8 cm below the right costal margin...i forgot to look for incisional hernia~ 6. diagnosis Examiner didnt ask~Colon cancer mets to liver and (spine?) 7. questions asked by lecturer

what the usual presentation of acute appendicitis? pls describe about colicky pain? what type of operation she had?why? right hemicolectomy~ show me on this pic ( he drew the colon) until which part the colon was resected. why patient wears diapers? where the TPN was administered? how u want to manage this patient? he showed me the CT scan- show me the normal finding plus there was multiple liver mets. if there is only single lobe affected what u want to do? the staging of colon cancer- i told Duke's criteria...A, B,C, and D. he said Dukes until C only as it based on histopathalogy, so cant comment on dukes D which is distant mets. can patient allow to go home: he said no. tell me about the prognosis of this patient. if she and her sister had colon cancer at 40 years old, what do u think?- HNPCC, FAP, etc. what the risk factor of colon CA-my answer including ulcerative collitis. when do u think people with UC will have colon ca?- the answer is 20-25 years. what the screening programme available in msia-breast and cervical cancer. any screening programme for colon Ca in msia? what tool we can use for screening purpose: i answered colonoscopy ( no idea actually),but he told me flexible sigmoidoscopy. how can u decrease the prevelance of colon ca in the public? there were a few question i couldn't remember. I have been asked all the way by the Caucasian external examiner~~he seem to hear about figure and percentage~ the last question was what the psychosocial support in this patient...huhu .he asked me to leave b4 the bell rang..good or bad sign? for the rest of u....gud luck!! last Tuesday Report

Aiwoon Goh i get breast lump. 64 year old chinese women. with post thyriodectomy due to goiter, post nephrectomy due to rcc. pe- exam the breast. full set. after that look for sign of metastase, liver, cns,bone pain, pleural effusion,consolidation. and thyroid eye examination. how will u investigate this patient, triple assessment. intepret mammogram. malignancy change-microcalcification. management-if it is

malignant, mascetomy. TNM staging. if femur pain, wat u suspect? how u investigate, plan x-ray, bone scan

Shafiq Papik 1. lecturers who took u: Dr yeaw* an external surgeon, the main examiner, Prof Cheah *external paeds and Prof Philip Poi 2. specialty: Surgery 3. chief complaint: 49 y/o lady presented with painless lump on the right breast for 4 months. 4. brief history: post menopausal for 5 years. no other medical illness. lump noted in november. one painless lump, hard in consistency, no discharge, no skin changes, no other lumps noted. the only main breadwinner in the family. the only risk factor, age and oral contraceptive pill, depot progestogen. Past surgical hx; bilateral tubal ligation. 5. PE finding: painless lump noted on the upper quadrant. at midline with dilated vein. skin dimpling noted. lump is not attached to skin or muscles. mobile, hard in consistency, edge is well defined, size 2 x 3 cm. no lymphadenopathy. 6. diagnosis: breast Ca 7. questions asked by lecturer: differentials; throw out everything including benign breast disease, fat necrosis, duct ectasia. If see this first in the clinic, what would you do? take a proper history. do the triple assessment. explain about triple assessment. indications of choosing core biopsy than fine needle aspiration cytology. staging of the disease ( TNM staging). indications of mammogram and ultrasound. explain the mammogram ( no clacification noted on the right upper quadrant of the breast). then how would u treat this patient. ( I screwed the qestion alot!). surgery; lumpectomy, mastectomy, and breast conservative surgery. indications. (yet I quote too many from Burkitt which happen the external surgeon did not read it -_________- )..chemotherapy. Tamoxifen the estrogen receptor blocker pun ditanya. then how to screen women nowadays if I were happen to be the deputy DG one day. I answered breast lump? NO. Family history? NO!!!! ring ring. I begged him to answer the question; mammogram for certain age. (please read this in the newspaper today)... Short cases pulak :D

Yip Hing Wa Main Examiners: External (russia), plus Prof CT Lim and Prof Azmi (both of them silent only) Specialty: Surgery C/O: 63 year old Chinese man intermittent painless per rectal bleeding HOPI: Dec 2010, 1st episode of per rectal bleed stained on toilet paper, otherwise no abd pain, tenesmus, fever or altered bowel habit. Stool stained with stale blood and mucus with more loose consistency. No anemic, constitutional, metastatic symptoms at all. No risk factor other than ex smoker for 30 pack-year. Stop 8 years ago (forget to ask why). Went to private clinic, DRE notice some mass, arranged for colonoscopy 2 weeks later. Colonoscopy showed rectal mass and sigmoid polyps. Biopsy done rectal polyps and benign sigmoid tumour. Refer to UMMC for management. Just had surgery done 3 weeks ago and plan for chemo in April. PMH: generalized psoriasis for 20 years, first presented with skin lesion in left forearm and spread diffusely. Biopsy confirmed psoriasis on treatment (medication alternate day I think is MTX) now got left knee pain (I ignore it). No DM, HPT, IHD, Asthma (thank god) No PSH other than colonic surgery. Allergy to sambal (swt=.=) No family history, social half than examiner ask stop d. Question: Differential diagnosis (colorectal ca, diverticular dz, angiodysplasia, polyps, IBD) What is character of stool repeat and he ask difference with malena.. Then difference of bleeding in colorectal ca with diverticular dz (dunno goreng different site different color. He said ok nevermind.) What is angiodysplasia? Then go to patient. Show abdomen examination multiple scars, 4 laparascopic scars with 1 transverse LIF scar, tenderness and mass like thing at scar site. I said got mass. He ask do u want to consider is induration as a result of surgery? YES YES YES!! Showed how to palpate for liver. Why important to know liver size? Back to room and disaster started: Investigation: - FBC, LFT, CEA, CT TAP Why CEA? Function? Why CT TAP? I said staging. What do u mean and please elaborate. (as opposed by Prof A must precise =.=) Showed CT scan and point me the abnormalities. (no one rescue me. Luckily tembak correct) Where the tumour will spread to? (not iliac, not inguinal and not left supraclavicular, he wants spread radially to mesentery) What operation the patient has. (anterior resection) Tell me about ant resection. How many types. (tembak high and low. he said 3 types) How long is the rectum? (tembak 10cm. ans: 15cm :( What is the difference between each anterior resection. ( I said sphincter involvement. Ans: that is APR. Nvm) Do you heard mesorectal excision? (yaya coz the tumour will 1st spread to there and blah)

 Why patient had so many laparascopic scar? For operation lo. Whats the difference between laparatomy and laparoscopy? Which 1 cheaper? I said laparascopy cheaper coz less hospital stay then answer the other way although stay longer coz expertise needed. =.= Patient what stage? I said stage 3. Tell me staging. I said TNM and Dukes. He ask about dukes. Apparently rectal ca only up to Dukes C. wrong again. Then prognosis each stage. I said stage I 80%, II 60-70% and III 20%. He said III less than 5%. Swt =.= What complications from the surgery? I said all. the end he prompted me to say anastomosis leakage. How u prevent DVT? I said early mobilization and anticoagulant (forgot TED stockings.) what is the dose for DVT? (depends which type of heparin. Examiners: so?? bell rang!! i tembak 1mg/kg at the end he wants low dose only) Good luck everyone in sho

Teh Cheah Hooi Prof Apri(main examiner)l, Prof David Choon, Prof Hussein Specialty: Surgery History: Right painless breast lump for the past one year. Increased in size with some skin changes~~ bla bla bla! all the lump history as we clerk as usual. Nothing else significant. no constitutional symptoms, no signs and symptoms suggestive metastsis. No risk factors. Went to seek traditional medication. Prof david choon asked: do u know what the traditional medicine she took? he means for Malay 6traditional medicine? i'm not sure?! then brought by the son to UMMC here for further management. Patient was not sure who's the Dr in-charge, what investigation she had undergone?? She just said she was admitted to there and was given IV drip?? WHAT?? Is it Neo-adj chemo? But I forgot to ask if the any hair loss after this drip? Not sure with this since patient was not sure. She kept denying she had undergone any procedure even though she had 2 scars on both breasts. Then i jz carried on with the rest of the history. Other than that, jz hypertension for the past one year, good controlled with no complication! P/E: as usual all the lump examination. Otherwise not much significant except for the traced

proteinuria. Prof didnt ask me to present P/E also, straight away go there and did short case. Breast lump examination! Elicit the signs if there are metastasis, lung for pleural eff, bone pain(path frac). Jaundice, brain.. As we walked along to see patient, what diff u want to consider if she is a young patient-2 5 year old?! I forgot others d?! Questions: Diagnosis based on the history and P/E Why u said breast cancer?! Analyse the history and give the supportive points. What investigation u want to do if the patient initially present to the clinic. The triple test. What is triple test? Whats diff btw FNAC and tru-cut biopsy. Which one better and what's the complications. Mammogram is better, why? Whats the common place the tumour metastasis? if the tumour mets to other place, what u expect to find in the history and P/E. if mets to bone which blood iX u want to do, ALP level! Other than that, what imaging u wants to do? Staging of the patient. T3N0M0. What surgery is preferred? Wide local excision? Mastectomy? Radiotheraphy, chemotherapy? Elaborate all the management. Do u read the journal?(asked by Prof david choon)? Erm.. hehe.. no la.. jz update from the internet lo. How u want to treat this if the patient refuse to go for surgery,chemo, radio? How how how? I said keep on following up the patient and tell her to go for surgery since its still a preferred management. But, if the patient still refused?! RING then Prof April said, do u know Estrogen receptor!? Oh ya, I said tamoxifen and aromatase inhibitor, bla bla bla.. Some of the Qs could not remember d, this is what I could get. Good luck everyone =)

Siti Khalimah 1. lecturers who took u : DR KL NG(leading) PROF ADEEBA(a bit of interruption) & DR NG(observer, consoling) 2. specialty : Surgery 3. chief complaint : Breast lump x3/52 4. brief history : 65 Malay housewife,menopause, known of DM, HPT, hyperlipid. Present with painless, immobile breast lump not changing in size since discovery.No nipple/skin changes. No discharge. Had mild prickling pain of the breast, fever (--> lead to discussion on breast abscess) LOA, no LOW. Risk factor: OCP 2years, female, elderly. No fhx of cancer. 5. PE finding : Symmetry breasts, breast non tender, no nipple retraction/discharge, no peau

d'orange,no tethering, bruised overlying lump and site of FNAC. Lump --> superior medial quadrant of left breast, hard, not fix to deep muscle, fix to skin, painless, smooth surface, regular margin, size 5x5cm. 6. diagnosis : Breast cancer, breast abscess (?fever?pain) 7. questions asked by lecturer differential diagnosis investigations (triple assessment) other investigations? what to do if FNAC result return as ductal ca?--> inform patient (breaking bad news) do CT scan for staging, surgery on Thursday Report

Leong Yan Ning 1. Prof Ong Teng Aik (Surgery), Prof Ida (Medicine), Prof Poh (External, not sure which specialty) 2.Surgery -Breast 3. 64/C/ lady, c/o: left breast lump x 1 yr (electively admitted for surgery 2moro) 4. HOPI: progressively enlarge over 1 yr, hard, painless, no discharge & skin changes, no LOW/LOA, no family hx of breast or ovarian ca, no previous breast lump PMH: THyroidectomy 20 yrs ago (i thk is MNG tat cause SOB & hyperthyroidism), Right renal cell carcinoma 5 yrs ago with radical nephrectomy, HPT, Hyperlipidemia, Hyperuricemia. 5. Breast: A lump in left upper outer quadrant, oval shaped, 5x6cm, hard, mobile, no skin changes or axillary lymph nodes involvement. No signs of mets. Abd: a well healed right subcostal scar measured 22cm Neck: a tyroidectomy scar, no lump felt. 6. Left breast carcinoma Diff dx: fibroadenosis, fibroadenoma (usually not at dis age), lipoma... 7. Mainly asked by Prof Ong :) Provisional & differential dx Perform breast exam on pt n present findings Name the right nephrectomy scar ( subcostal or Kocher scar aft he leads me, haha), what type of

appraoch did d surgeon use in dis nephrectomy (Prf Ong gav me 2 choices: retroperitoneal or transperitoneal? transperitoneal appraoch since d scar is subcostal:>) What eye signs in hyperthyroidism pt n perform on pt (exophthalmos, lid retraction, lid lag, extraocular muscle weakness (diplopia in H pattern), another medical term of extraocular muscle weakness (Prof Ida dun wan opthalmoplegia) What you wana do aft P/E? (triple assessment: mammography & biopsy) Interprete mammogram of dis pt (CC & MLO view) What do u thk? (an opacity wif irregular margin, no microcalcification, no retracted nipple, no lymph node in an old age lady --> Breast carcinoma) Which stage is dis pt in nw ?(T3N0Mx) What u wana do next? (Biopsy- FNAC) What do u expect 2 c? (high NC ratio, mitotic changes, check for estrogen or progesterone receptor on cell) How would u prepare dis pt if u r a HO in ward? ( FBC for Hb level, cross match, LFT for preparation of chemo, RP (Dt previous right nephrectomy 2 look for renal impairment), ECG ( dt HPT, risk of MI), CXR ( baseline for anest, mets 2 lung n ribcage) External den ask: what alse u wana 2 do pertaining 2 d mets in dis case? is CXR sensitive? ( I said i would like 2 do CT thorax as well, since it picks up smaller lung lesion n mets) Den he asked hw sensitive it is? Do u noe hw small d lesion can a CT picks up? (I said i m not sure. I remb in radiological class was ard 0.5-1cm, but u all nid 2 double check) Which place breast ca tends 2 spread as well? (I said bone esp thoracic spine n ribcage) he den asked which site else? (I answered long boe n pelvis as well, i forgot what was his response) What test u would like 2 do 2 look for mets in dis case? (Bone scan--look for high absorption area) How would u manage her aft confirming it is breast ca? ( mastectomy dt large size lump although pt's size is C cup--can't do breast conservation surgery in lump >3cm, >4cm in large breast) Would u like 2 do axillary LN clearance as well? ( Do sentinel node biopsy, if d 1st node tat receives lymphatic drainage frm breast is infiltrated, do axillary LN clearance straightaway) What r d complications of axillary LN clearance? (lymphadema n cutaneous nerve injurynumbness) How would u decide d level of axillary LN clearance? base on which muscle? (Pect. minor, level 1: lateral 2 pect minor, level 2: beneath pect. minor, level 3: medial 2 pect. minor) Does d prognosis in dis pt good? Hw would u predict it? (I said overall quite good, Prognostic factors in breast ca: axillary LN involvement, lump size, age (yonger age more aggresive), ER, PR & HER2 positive (better response 2 tx)) Bell rang & times up!!

Nur Nadiatul Asyikin

1.Lecturers who took u: Prof Yip (surgery main), prof siti zawiyah ( OnG) , Prof Chan (external,same with azwa n Ngam)

2. Specialty-Surgery 3. chief complaint & 4. brief history : 52 yo malay gentlemen , a chronic alcoholic drinker, currently has no active compliant, one week back, he has hx of fever for 2 days associated with epigastric pain for 6 hour b4 admission. epigastric pain, no radiation, no relieving Assoc w pain ( mild only) + chills but no rigors ,sob, tea colour urine, x realise jaundice, no pale stool 2 years back- hx of gallstone , ERCP done-stenting risk for hepatitis/liver disease-chronic alcoholic

5. PE finding: On examination: forget to calculate BMI!!..at first thought he had ascites but its actually his fat. (aiyoo~ ZZZzz) the only positive sign is palmar erythema. No positive Murphy sign.. (prof yip reconfirm back with him bcoz, previously he said theres pain.. but this time he denies n all the profs laugh)

6. Diagnosis- Ascending cholangitis (AC)secondary to gallstone 7. questions asked by lecturer 1)Dx 2)what are the stigmata of chronic liver disease ( at bed site) 3) what can u see from inspectionnothing except his obese 4)why do u say AC- charcoat triad 5) what is the other classification of AC Raynaud pentad (hypotension + alter mental status) 6) what MX at emergency- Resus, (prof say ok not much to resus.. then? ) Ultrasound, interprate U/S, this is us of mr amirudin,taken on...written there CBD dilated.no presence of stone How do you know its dilated?--> the measurement is 1.63mm (written there with * on top), So whats the normal CBD? 0.5mm 7) now , what else u like to do? Blood ix,so inteprate n summarize the finding, increase wbc n bilirubin n liver enzyme n blood glucose How many percentage of increase conjugated bilirubin does it considered as significant.. 75% Why does liver enzyme derrange? Bcause AC , what liver enzyme indicate obstruction? GGT n ALP. How do you know liver enzyme deranggement is due to AC not liver disease ..albumin normal,coagulation normal. Blood glucose high. So? Patient need to be screen for DM.. what to do.. i answer OGTT but actually they want me to answer fasting blood glucose 8)patient had stent, why do you think he had AC? Stent dislodge (ptn told me) , stricture, block from residual stone...then cannot think anymore..prof answer impaction due to slough/mucus

plug 9) why patient can have infection in choledocholithiasis, im thinking of complex mechanism but prof only want me to answer ascending bacterial infection .. 10) what common organism, dunno why i answer s.aureus (with confidence but of coz salah), then i answer anerobes, E.coli and klebsiella ( gut organism), so antibiotic? Metronidazole and cephalosporin 11) what else do you like to do in this patient, i answer ERCP ( now prof siti says, patient had ERCP done already.. what else..)owh, colecycstectomy... prof yip want me to answer cholecycstectomy n exploration of the bile duct to prevent recurrent.. 12)other mx? Follow up n give antibiotic (if havent completed ) P/s:Hope we all pass..Did mess up here n there. Lecturer will help ya.. Good Luck juniors~ Same case with cindy.. that all that i remember~ if theres anything else just add ok.. ^_^ on Friday Report