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ANATOMY – THORAX AND ABDOMEN

1. Anatomy (Generalised - Trunk)

Identify the external oblique (lower 6 intercostal nerves) – lower 8 ribs
What innervates it?
Innervation of external oblique: Lower 6 intercostal nerves (T6-T12) and subcostal nerves
laterally.
Blood supply of external oblique: Superiorly by lower intercostals arteries, inferior by
branches of deep circumflex iliac artery.
Actions of external oblique: Pull the chest downwards and compresses the abdominal cavity.
Limits flexion and rotation of the vertebral column.

Appendix – What positions can you find it?

1. Retrocolic (60%):
Free in retrocaecal fossa.
May lie between caecum and psoas leading to the psoas stretch sign (pain on passive
extension of the right hip.
May lie under the ueter giving WBC in the urine
2. Pelvic (35%)
Hangs down into pelvic brim.
Easily felt on PR
Internal rotation of hip increases pain (obturator sign)
3. retro-ileal (1%): Poorly localized pain. Hard to diagnose
4. Pre-ileal (1%): Obvious abdominal signs.

Referred pain to T10? Why?

Initially, inflammation of the asppendix causes irritation of the visceral peritonum (layer
around organ) wth afferent fibres to the T10 spinal nerve which also supplies the
periumbilical area
Why later RIF pain?
As the disease progresses, it causes irritation of the parietal peritoneum, which localizes the
pain to the RIF (McBurney’s point)
What forms the anterior muscular component of the deep inguinal ring – internal oblique.
Identify the internal oblique – directions they run in

What branch of the SMA supplies the appendix? Ileocolic branch, giving the appendicular
artery

What supplies the internal oblique/transversus abdominis?

Innervation: lower 6 intercostal nerves + ilioinguinal/iliohypogastric.
Action: Helps diaphragm in exhalation to reduced thoracic cavity volume.
Acts with external oblique from the opposite side to achieve torsional movement of
the trunk.

Mcburney’s incision for appendix: Can damage the iliohypogastric and ilioinguinal nerves,
and the deep circumflex artery.
Lanz incision (lower incision than Mcburney’s, to better cosmesis, hidden by bikini): Higher
risk of denervaiton of iliohhypogastric and ilioinguinal nerves. Leads to denervation of
inguinal canal mechanism (can increase risk of inguinal hernia)
Kocher’s incision: Incision should not be extended too laterally, too many intercostals nerves
may be severed. Beware of superior epigastric vessels.
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1. Scenario: you are the MO assisting in a Whipples procedure

(this is my 1st specialty choice)
Point out the stomach
Name all the parts (cardia, fundus, etc): Cardia, greater curvem lesser curve, fundus, body,
antrum, pylorus.
Name the blood supply and exactly which part of stomach it supplies, and from which branch of
the aorta and celiac trunk
1. Left gastric artery (branch from coeliac plexus) supplies the superior lesser curve.
2. Splenic artery (branch from coeliac plexus) gives the short gastric artery and the left
gastroepiploic which supplies the superior greater curve.
3. Right gastric artery (branch from the hepatic artery supplies the distal lesser curve)
4. Right gastroepiploic from the gastroduodenal from the hepatic artery supplies the distal
greater curve)
What is the space between stomach and pancreas? Lesser Sac
What is the entrance called: Foramen of winslow
Anterior relation: Free border of the lesser omentum (porta traid of hepatic artery (left), common
bile dute (right) and porta vein (behind)
Posterior: IVC
Superior: Caudate lobe of the liver
Inferior: Duodenum (1st part)
Lateral: Splenorenal (lienorenal) ligament and gastrosplenic ligament.

Lesser omentum = hepatogastro and hepatoduodenal ligament.

Point out duodenum, quizzed on its relationship with the peritoneum (which part is retro, which
part in intra-peritoneal)
All the duodenum is retroperitoneal except for the initial portion of the 1 st part of the duodenum
which is intraperitoneal

Posterior relation of the duodenum (aorta and IVC)

1st (Sup) Part

Posteriorly

1. lesser sac

2. gastroduod art

3. common bile duct & portal vein

4. IVC

2nd (Descending) Part

Posteriorly
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1. hilus of R kidney

2. commencement of R ureter

3rd (Horizontal) Part

Posteriorly

1. R ureter

2. R psoas muscle

3. IVC

4. aorta

4th (Ascending) Part

Posteriorly

1. L margin of aorta

2. med border of L psoas muscle

Point out the pancreas

Blood supply of pancreas:
Splenic artery and splenic vein.
Superior pancreaticoduodenal artery (from gastroduodenal from hepatic artery), inferior
pancreaticoduodenal artery (from IMA)

Ductal system of pancreas

Accessory duct of Santorini. From the dorsal bud. Opens slightly above the main duct.
Main duct of wirsung. From the ventral bud which swings over to join the dorsal bud.
Opens into the 2nd part of the duodenum via the ampulla of vatar, guarded by the sphincter of
Oddi.

Development of pancreas: dorsal and ventral buds was all the examiner wanted.
Develops from the large dorsal bud from the duodenum and the smaller ventral bud from the
CBD.
Ventral bud swings round to fuse with the dorsal bud.
The ducts of these 2 buds now communicate. The smaller ventral bud takes over the main
pancreatic flow to form the main duct of wirsung. The original duct of the largery dorsal bud
forms the accessory duct of santorini.

Posterior mediastinum – boundaries

Posterior mediastinum is part of the inferior mediastinum
Anterior: Pericardium.
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Posterior: T1-T12
Superior: Superior mediastinum, becomes the inferior mediastinum from the angle of louis at the level
of T4 (sternal angle)
Inferior: Thoracic outlet.

Take the pointer, and show me the structures of the posterior mediastinum:
azygos vein, sympathetic trunk, thoracic duct, descending aorta, oesophagus, vagus nerve.

Blood supply – arterial/venous/lymphatic supply/drainage of esophagus

Bood Supply
largely by 4 unpaired median branches from aorta
Upper third inf thyroid art
Middle third Esophageal branches
from thoracic aorta
Lower third L gastric art (branch
of celiac plexus)

Venous Drainage
into azygos vein
Upper third brachiocephalic vein
Middle third azygos and
hemiazygous vein
Lower third L gastric vein
(tributary of portal
vein)

Lymphatic Drainage
1. deep cervical (upper part)
2. Superior and posterior mediastinal nodes drains the middle
3. abd nodes (lower part)

Where would the tumour be if it was adenocarcinoma? Lower 1/3

SCC on the other hand arise anywhere, mainly in the middle 1/3

What is the pathophysiology of achalasia?

- Abnormal peristalsis due to absence of the Auerbach's plexus, which are found in the
muscularis propria between the inner circular and outer longitudinal muscles.
- Aetiology unknown, small percentage due to chagas disease. (parasitic disease, american
trypanosomiasi)
 Failure of LES to relax, resulting in dysphagia and regurgitation.
 Barium swallow shows birds beaking
 Gold standard test: Manometric studies looking for hifh pressures at the LES.
 1-10% develop SCC after 15 to 20 years of disease.
 Treatment: Botulinum toxin injection, pneumatic ballon dilatation, Heller
cardiomyotomy.

2. Inguinal canal
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- shown a female specimen

- asked what is this? Inguinal ligament
- what is above this structure? Inguinal canal
 where is superficial and deep ring?

Deep Inguinal Ring  oval opening in transversalis fascia

 2 cm above the mid inguinal point (midway btw ASIS & symp
pubis)

 related lateral to inf epigastric vsls

Supf Inguinal Ring  triangular opening in ext oblique aponeurosis

 immediately above and medial to the pubic tubercle

 what constitutes inguinal canal?


Anterior Wall - formed by external oblique aponeurosis

- reinforced along lat 1/3 by fibres of int oblique

 strongest opposite deep ingunial ring (which

is the weakest part of the posterior wall)

Roof  formed by the arching lowest fibres of internal

oblique & transversus abd muscles

Posterior Wall  formed by fascia transversalis

 reinforced along medial 1/3 by conjoint tendon

(fused insertion of internal oblique and transversus
abdominis)

 strongest part lies opposite deep ing ring

(weakest part of the anterior wall)

Floor  formed by ing lig & lacunar ligament on the medial

end

 what is its content?

Round ligament of uterus
in male? Spermatic cord

Spematic cord:
Coverings Contents

1. ext. spermatic fascia (from 3 arteries:

external oblique
aponeurosis)
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2. cremaster muscle & fascia 1. Artery to vas deferens (from inferior vesicular artery)
(from internal oblique
2. Testicular artery (from aorta)
aponeurosis)

3. int spermatic fascia (from 3. Cremasteric artery (from inferior epigastric)vas

deferens
transversalis fascia)
3 nerves

4. Ilioinguinal nerve (strictly speaking not in the cord)

5. Nerve to cremasteric (genital branch of the

genitofemoral nerve)

6. Autonomic nerves (sympathetic fibres from T10)

3 others:

7. Vas deferens

8. pampiniform plexus of veins

9. lymph vsls (drains testes to the para aortic Lns.)

Covering of testes drains to external iliac nodes.

2. Cadaver with face, neck and thorax. The examiner points to the various anatomy on the cadavar,
then you must label it. Anatomy tested includes,
(a) common carotid,
(b) internal and external carotid,
(c) facial artery,
(d) hypoglossal nerve,
(e) phrenic nerve,
(f) vagus nerve,
(g) thoracic inlet.
(h) some discussion on subclavian steal syndrome, pathophysiology and clinical presentation

1st rib –
- flattened, convex rib
- Has a head, neck and shaft.
- Has articulating head with the T1 and C7 vertebrae, articulating facet with the T1 transverse
process, Has scalenus tubercle which the scalenus anterior inserts into and grooves for
subclavian artery (posterior) and subclavian vein (anterior)
- Phrenic nerve lies anterior on top of scalenus anterior.
- Subclavian vein and phrenic nerve runs infront of scalenus anterior.
- Subclavian artery and brachial plexus runs behind scalenus anterior.
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Thoracic outlet syndrome causes:

Cervical rib
Scalenus muscle enlargement
Scarring post RTA
Repetitive movement (eg violin player)
Roos test:
Shoulder 90 degrees in abduction in external abduction and elbow 90 degrees flexion. Patient asks to
repeatedly open and close fist. Reprodcues symptoms of thoracic outlet syndrome.

Treatment:
Conservative:
Physiotherapy and exercise and stretching
Hot/cold packs
Posture advice
Muscle relaxants
Cortisone injection

Surgical:
Removal of cervical rib
Scalenectomy
Removal of 1st rib.

Pleural domes – sternoclavicular joint draw convex line to peak 2.5cm above the clavicle to junction
of medial and middle 1/3rd

2. Thorax and abdomen (damn tough station) –

(a) Heart (pt out LA, LV, RA, auricle, PV),

(b) Liver lobes by falciform lig, identify quadrate lobe and boundaries, what branch of celiac
supplies both liver n stomach,

Hepatic artery, gives off right gastric artery, gastroduodenal artery and continues on as
hepatic artery proper to split into the right and left hepatic arteries at the hilum of the liver.
Gastroduodenal artery terminates as right gastroepiploic artery and superior
pancreaticoduodenal artery

(c) wat struc might be injured in a stab in epigastrium going upwards,

Liver, stomach, oesophagus, diaphragm, pericardium, heart

(d) liver attachments to diaphragm

falciform ligaments, upper and lower coronary ligaments

(a) what is the costal margin bounded by,

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the costal margin extends from the 7th costal cartilage at the xiphoid to the tip of the 12th rib,
there is a definite step at the 9th costal cartilage

2. whats the border of posterior mediastinum? T1 – T12 vertebrae

3. contents? Oesophagus, descending aorta, vagus nerves, thoracic duct, azygous vein,
sympathetic trunk
4. which level eso enters diaphram? Level of 10 together with anterior and posterior vagus
nerves. what part of diaphgram? In the muscle of the right crus of the diaphragm.
5. where eso begins? Level of cricoids cartilage, C6 level.
6. what LN does esophageus drain to? Upper 1/3: deep cervical nodes. Middle third: anterior
and posterior mediastinal nodes. Lower 1/3: Coeliac nodes.
7. Arterial supply plus drainage?
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Blood Supply
largely by 4 unpaired median branches from aorta

cervical part inf thyroid art

thoracic part Esophageal branches

from thoracic aorta

abdominal part L gastric art (branch of

celiac plexus)

Venous Drainage
into azygos vein

cervical part brachiocephalic vein

thoracic part azygos and

hemiazygous vein

abdominal part L gastric vein (tributary

of portal vein)

8. What is the cells lining the esophagus?

Stratified squamous epithelium.
9. what is barrets esophagus?
Intestinal metaplasia of the oesophageal epithelial lining (stratified squamous epithelium
converted to mucus-secreting columnar epithelium with goblet cells)

10. what risk? Risk of malignant transformation to esophageal cancer.

Risk of development of adenocarcinoma is about 10-15% in 10 years

How to differentiate Rt and Lt lung

o Impressions: Right lung: Azygous vein and SVC impression. Left lung: Arch or aorta and cardiac
impression.
o Relations to heart chambers : Right cardiac impression related to the right auricle and right atrium.
Left cardiac impression related to anterior surface of left ventricle.
o Hilum: In both hilums, the pulmonary veins run inferiorly. In the right hilum, pulmonary artery is
anterior to the right bronchus. In the left hilum, the pulmonary artery is superior to the left bronchus.
o Lobes: Right lung: 3 lobes, upper, middle lower. Oblique (4th intercostal) and horizontal (6th
intercostal) fissure. Shorter heavier wider.
Left lung: 2 lobes. Superior and inferior lobe. Oblique sinus. Presence of cardiac notch and lingula in
medial border.

5. duodenum, micro
spleen, GDA?, heart, papillary muscle, MR
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3.Inguinal ligament, adductor canal, Femoral triangle anatomy

Surgical approach to perforated DU
NCEPOD – National Confidential Enquiry into Patient Outcome and Deaths
Are you aware of any classification?
Elective -
Expedited – do soon within 2-3 weeks e.g. cancer
Urgent – must do within 24hours after resuscitation
Immediate – lifethreatening e.g. massive intracranial bleed)
How would you do the repair? Upper midline laparotomy, primary closure followed by omental patch
repair
How does the NSAID cause gastritis? Affect cyclooxygenases 1 (gastric) and 2 (anti-inflammatory /
analgesia).
How else does NSAID cause gastritis? Direct deleterious effect on the gastric mucosa.
How do proton pump inhibitors work?
Is it just a proton pump? No, it is a H+ exchanger (Yes, one positive ion goes out and one must come
in, right?)

Spleen
Course of splenic artery- what organ does it supply. Supplies the spleen and pancreas. Originates as
one of the branches of the celiac plexus at the level superior to L1. Travels along superior border of
pancreas to enter the hilum of the spleen at the lienorenal ligament.
What organs may be damaged in a splenectomy. Tail of Pancreas, Great curve of stomach, left hepatic
flexure.

Thorax and abdo:

Female anatomy: Identify ovaries, fallopian tube, uterus, pouch of douglas
Abdomen: Appendix, Commen locations of the appendix. Retrocaecal (65%), pelvic (30%), anterior
to ileum (1%) posterior to ileum (1%)
Blood supply Caecum (ileocaecal), ascending (right colic, middle colic) descending colon (left colic),
transverse colon (middle colic).
Explain umbilical pain in appendix: Afferent visceral somatics with efferent to T10 region , therefore
umbilical pain.
Initially in disease, inflamed appendix irritates the visceral peritoneum which sends fibres to the
spinal cord at the level of T10, which is the dermatomal innervations of the umbilical region.
Explain RIF pain localisation: Inflammation of peritoneum cause localisation.
Later as the disease progresses, there is irritation of the parietal peritoneum which localizes the pain to
the RIF region.
What happens when you flex the hip: (extend the hip?)
Psoas sign, irritation of the inflammed peritoneum of a retrocaecal appendix which lies on the psoas
muscle on flexing/extending the hip, therefore causing pain.

9. Anat
Where u insert iv? Median cubital vein.
what structure damage at median cubital vein? Brachial artery.
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what nerve w long saphenous vein? Saphenous nerve, infront of the medial malleolus.
show skeleton: where u insert chest tube/ needle thoracostomy
Needle: Level of 2nd intercostals space, in mid clavicular line.
Chest tube: Level of 4th or 5th intercostals space, just anterior to mid axillary line. (Avoid damaging
the long thoracic nerve) Triangle of safety: lateral border of pec major, anterior border of lat dorsi,
below horizontal line superior to nipple.
Why after insert chest tube get bradycardia? Irritation of vagus nerve??
How u insert Subclavian vein?

Lung anatomy an outline

Orientate the lung (right lung)
What nerve lies in front and what behind – ant: phrenic nerve, post: vagus nerve
Name the fissures: Horizontal fissure (6th costal cartilage), oblique fissure (4th costal cartilage)
How many bronchi pulmonary segments are there? 10 in the right. 3 superior, 2 middle, 5
middle. 8-10 in the left, 4-5 superior, 4-5 inferior
Talk about DVT
What is the best test? PE: CT angiogram and V/Q scan
Talk through the path of a clot starting in the calf – deep veins of the calf -->popilteal vein,
femoral vein, ext iliac, common iliac, ivc, atrium, AV valve, pulmonary valve to the
pulmonary artery
Lower long saphaneous vein anatomy with some lung anatomy surface anatomy- arises from
the dorsal veins of the foot, passes anterior to the med malleolus, rises in the med aspect of
the calf, lies 4 finger breath post to the med condyle of the femur, rises up the med aspect of
the thigh before ending in the SFJ medial to the femoral artery.
What nerve is in close relation to this vein (saphaenous nerve)
X-ray of a pneumothorax
Where would you insert a chest drain; triangle of safety, 5thintercoastal space, bounded
anteriorly by the post border of pectoris major, posteriorly by the mid axillary line
If tension where do you decompress – mid calvicular line, 2ndintercoastal space.

Indications of tension:
Shock, Tachypnea, tachucardia
Deviated mediastinum.
Distended neck veins.

Identify pul vein, mitral valve, papillary muscle., azygo vein and tributaries

Identify duodenum, what artery above it

What enters into minor: Accessory duct of Santorini and major duodenal papilla: Main
pancreatic duct of wirsung.

What structures in danger when doing splenectomy. Greater curve of the stomach,
panceeatic tail, left colic flexure

Identify spleen
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Splenic artery supplies what: Pancreas and spleen.

W'et station
Lung- left or right? Name the fissures. Horizontal fissure for left and right lung. Oblique fissure for
right lung.
Point out the artery, bronchus and vein at hilum
How many brochopulmonary segments in each lung (10 in the right. 3 superior, 2 middle, 5 middle.
8-10 in the left, 4-5 superior, 4-5 inferior)
Why aspiration always middle and lower lobe right lung.
Phrenic runs infront, vagus runs behind
Identify left and right ventricles, atrium
Point out ivc, pulmonary artery
Blood supply of lungs brochial arteries (oxygenated blood) and pulmonary artery (deoxygenated
blood)
If one has dvt, outline course of thrombus before it reaches heart: popilteal vein, femoral
vein, ext iliac, common iliac, ivc, atrium, AV valve, pulmonary valve to the pulmonary artery

What happens to thrombus if patient dont die

ANATOMY – TRUNK & THORAX

Identify the bladder – pathology of the bladder – e.g. types of neoplasia, type of
epithelium
Blood supply of bladder
Muscle of bladder
Nerve supply of bladder
Peritoneal relationship to bladder
Structures behind bladder
What structures are penetrated during an SPC insertion
Symptoms of bladder neoplasia
Causes of haematuria
Risk factors for UTI

Identify azygos vein, name 2 tributaries (intercostal veins, superior lumbar veins), empties into SVC.

Identify sympathetic chain, name 2 structures which sympathetic fibres leave with (spinal nerves,
blood vessels).

Identify pulmonary trunk, ascending aorta, branches (coronary arteries)

Identify papillary muscles, what do they attach to (chordae tendinae), function (prevent eversion of
AV valve)
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Identify spleen, location (behind 9 to 11 ribs), blood supply (splenic artery), course of splenic artery
(she wanted to hear lienorenal ligament in particular), distribution of splenic artery (spleen,
pancreas, stomach)

Identify gallbladder, surface marking (fundus at tip of 9 th costal cartilage) explain shoulder pain in
cholecystitis (diaphragm, phrenic nerve)

Anatomy (Abdomen)

Identify abdominal aorta, level enter abdomen (T12), level of bifurcation (L4), surface marking of the
2 levels.

Branches of abdominal aorta. Tributaries of IVC (remember: only right adrenal/gonadal vein and not
left).

Structures passing in front of aorta (duodenum, pancreas, left renal vein)

See arteriogram: identify branches of aorta supplying GI tract (celiac, SMA, IMA, internal iliac via
inferior rectal)

Look at patho pot of AAA – causes of AAA, complications. Define dissecting aneurysm, complications
if in the arch/ascending aorta (AMI/stroke)

HISTORY TAKING

(a) History taking (Specialty 2 Limbs & Spine) 44 year old man who runs his own gardening
business with back pain x 6 months, pain 7-8/10 wakes him from sleep, same when lying
down and standing up, LUTS with nocturia 2-3x/night and hesitancy.

IBD (3)
Pancreatitis
BPH
Dysphagia
Gallstone disease

Specialty choice 1 (trunk and thorax): Case of IBD

Take history, quizzed on investigations, provisional diagnosis, management

11.
History taking (Specialty 1 Trunk & Thorax): 45 year old woman drinks 25 units/week, smokes 30
years ½ pack a day, acute onset of central epigastric pain radiating to the back progressive worse.
What causes? Acute pancreatitis. Causes of pancreatitis? Ethanol, gallstones, idiopathic, metabolic
causes e.g. hyperlipidemia

(a) Discuss BPH inx

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Classify the patient by the International Prostate Severity Score (IPSS)

U/S: assess residual urine and size of the prostate
Prostate specific antigen if >4ng/ml be wary of Ca prostate
Uroflowmetry – look for peak flow rate and amount of urine passed out

(b) Management

Non-surgical – lifestyle modification, alpha-blockers, 5-alpha-reductase

Surgical – transurethral resection of prostate

(c) Side effects of alpha blockers and 5a-reductase inhibitors

alpha-blockers e.g. alfuzosin:

postural hypotension, fatigue, headache, nausea, impotence
5alpha-reductase e.g. finasteride:
rash, breast tenderness/enlargement, decreased libido, decreased volume of ejaculate,
impotence

hx taking for progressive dysphagia. Cant really remember much. But went all the way to
investigations / management of benign and malignant causes.

Gallstones detected by gp via ultrasound but lif pain and diarrhoea and constipation history
On questioning she will say she is very anxious about having surgery, not being able to afford
being off work due to money.
Always ask is there anything else you want to tell me!
Gallstones do not require management immediately
Asked about provisional and differential diagnoses
Asked about investigations
At the end everything was normal ie she had irritable bowel
Asked about what should be for about the gallstones and the rate of progression to something
more serious

Take a history from lady with ibd, need to exclude colonic carcinoma

HISTORY TAKING & MANAGEMENT

Take history from a young adult who has bloody diarrhoea and abdominal pain for
last 3/12
?IBD
Differentials, investigations and management

History taking

PR bleed 6/12. Change in bowel habits. Suspicious for malignancy. Questions on differentials (IBD,
diverticular disease, angiodysplasia), invx (essentially colonoscopy), staging if tumour found (CT,
endoscopic US, CXR).
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PHYSICAL EXAMINATION

Incisional hernia (3)

Inguinal hernia (3)
Abdo exam: RHC tenderness (2): Gallstone, cholecystitis (management options)
RIF tenderness in female (4)
Pacemaker (many many times): Pre op, intraop and post op management.
Prosthetic heart valve: Pre op intra op post op management
Respiratory exam

3. Examination of the abdomen in a patient with incision hernia, discussion on treatment of incision
hernia, (my 2nd choice specialty)
2. Thorax and abdo: Right indirect inguinal hernia
Young patient in 20s. Examiner was difficult and old school, every candidate was stuck was basic
questions as he refuses to move on. Very unorthodox.
FIndings: Indirect inguinal hernia held reduced at both superficial and deep rings.
Questions:
Differentials. Type of inguinal hernia, how to differentiate them clinically. WHy do you
transilluminate: to exlude hydrocele. What is hydrocoele? Is this likely to be hydroceole. Types of
hydrocoele
As you can see, he kept on asking basic question and was frustrated that i couldnt move unto
investigations and managment. Thankfully i didn't fail this station, i really thought i did, as did most
people.

1. Hernia: Scenario given – you see a patient in the outpatient clinic with a letter from GP for
reducible left inguinal hernia
- what is the common presentation of this patient in the clinic? What would the patient complain of?
- how would you check on examination?
- what are the operative options?
- in what condition will you not operate for this patient?

Specialty choice 1 (trunk and thorax ): RHC tenderness

Standard abdo exam like you do in MBBS. DDx, investigations. Lets say US HBS got dilated
ducts, what will u do next? ERCP vs MRCP, but MRCP not invasive, so do MRCP first to look at
the cause of obstruction first.

PE: CVM; pacemaker, indications, diathermy, warfarin

Male with left sided pacemaker, loud 1st heart sound,

What is VVI? V – Vetricular efferent, V – ventricular afferent, I -
Pre-op assessment – refer to ECG department

Examination (Specialty 1: Trunks) – long midline thoracoabdominal scar

Epigastric incisional hernia 4x4cm, on cough
Guess what the op was for? Esophagus? Nooo… Cardiac operation, possibly for trauma. It’s not for
trauma, but he did have a cardiac operation.
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Treatment?
Depends on him and the condition. If it does not bother him, no difficulty/pain, I would leave it,
optimize conditions, quit smoking, lose weight, treat BPH. If it does bother him, I would offer him
operation.
What operation? Mesh repair, or double-breasting repair. (she seemed satisfied by my somehow
vague answer)
He says he has a paralysed wife at home, he needs to carry her up and down and wants to continue
this immediately after his operation. - I will tell him not to do so, because immediately post-op the
repair site strength is not optimal yet, so he has to refrain for 6 weeks.
What do you think he should do about his wife then? I’m not sure about here, but where I practice we
have respite care. So the wife can be put in a community home for a few weeks and he can fetch her
back home when his wound has recovered. (UK people say arrange with social services for a carer
who can visit twice a day)

Pre-op assessment of respiratory system for patient who is a chronic smoker, discuss pre-op
investigation

abdo exam - RIF tenderness in female, differential diagnosis, inx, what bld test can help dx acute
appendicits (they want ESR/CRP), rem to rule out gynae causes/ectopic pregnancy

CVS exam - pacemaker, CABG, mitral regurg, read ECG, pre op preparation for pt with pacemaker

CVS exam, LBBB pacemaker

Pre op optimization

Abdo-RHQ-actor rebound –
mx- cholecystitis –iv abx emergent or delayed

CPE – Cardiovascular exam.Bioprosthetic aortic valve. Usually there are 2 patients for each stations.
Some of the cases easier to pick up signs some harder. The other patient in this bay had a pacemaker.
Asked about warfarin and how to manage pre op / intra and post op.

Acute cholecystitis.Actor in this station. No signs but actor demonstrated guarding and pain in RHC.
Asked for differentials. Murphy’s positive. Ix and mx u wannado .q straight forward.

2.Abdo exam
Acute cholecystitis: murphy's positive
Ivx, treatment

3. Resp examination
pre op assessment: essentially normal chest
Use spirometry
take BP
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Cardiovascular exam
Mitral regurgitation at pre op assessment
Postpone surgery
ECG, echo

Lady with Acute abdominal pain examination

Go through differential diagnoses

1. CVS exam - pacemaker, CABG, mitral regurg, read ECG, pre op

preparation for pt with pacemake
refer CVM
pacemaker pre op: ask technician to review the pacemaker and set the pacemaker
set to VOO/DOO: no sensing so no pacing inhibition at cautery, tachytherapydeavticated so
no shocks given during cautery
Intraop: use bipolar if possib le, if monopolar then place pad away from defibeg at LL, if
defib needed place pads away from pacemaker

abdo exam - RIF tenderness in female, differential diagnosis, inx,

whatbld test can help dx acute appendicits (they want ESR/CRP), rem
to rule out gynae causes/ectopic pregnancy
DD:
Colon: diverticular disease, Ca, IBD, appendicitis
Ileum: ilelitis,
Ureter: stones,
Bladder: UTI
Gyn: ectopic, ovarian cyust, torsion, PID, endometriosis
blood test: FBC< CRP, ESR, cultures, BhCg
Imaging: u/s, Ct abdomen

CVS exam-pacemaker

b/l subclav scars chest NAD eitherwise

DDX

Pacemaker ecg –identify spikes rhythm

Pacemaker protocol pre peri and postop

Diathermy lap chole concerns

CVS exam pre-op on man with pacemaker and systolic murmur with ECG showing pacemaker spike.
I mentioned indications for pacemaker in surgery and diathermy - don't know if these are standard to
talk about in this station.
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Abdo Exam - terrific actor who managed to reproduce RIF guarding, rebound and rigid as a board
indicating peritonism. includes differential diagnosis of RIF pain expecting structured approach to
explanation.

CVS exam
Mitral valve replacement. Pt wore alert bracelet! Had to undress as was first candidate, then after examination,
look at warfarin book. Was told with a minute to go that I should ask a few questions as well about
anticoagulation.

Incisional hernia. Little on examination technique. Mainly questions on aetiology of incisional hernia and options
of repair.

Generic: Respiratory exam – COPD – questions on lung function, pre-op workup

Trunk & Thorax – Inguinal hernia (recurrent) – questions on management

Cardio examination
Mitral valve replacement. Anti-coag chart book on the bed. When would you bring her in for an elective hernia?
Any other problems? Infective endocarditis prophylaxis

Cvs exam pacemaker and MR

Pre op examination with

Physical examination

Incisional hernia. Already given diagnosis in the stem (GP referred with suspected incisional hernia).
Make a show of palpating the whole abdomen though, including looking for other herniae. I
auscultated the lungs and found bilateral wheeze so said that’s probably the reason. Questions on
risk factors for incisional hernia, management (conservative vs surgical), and some scenario if he has
a disabled wife he has to carry around.

Physical examination

Pre-op CVS assessment. Mechanical heart valve. Examination wise only the loud first heart sound, no
murmurs or pacemaker. Questions on diagnosis, things to do pre-op (refer CVM, 2D echo, ECG, CXR,
titrate warfarin/heparin), what other meds needed (antibiotic prophylaxis for all ops).