Surgical Short Case Scripts Last updated 23/4/14 Nigel Fong The surgical short case benefits from a running commentary. The purpose of the commentary is twofold first to explain to the examiner what you are going to do, and second to identify any signs and interpret what they mean. Doing a slick running commentary requires multitasking. It is hence useful to have thought through the thought algorithm, and how you could present a case. This document suggests sample running commentaries for common surgical short cases (except lumps and bumps). Be warned not to regurgitate the script when it is inappropriate e.g. the sign is clearly not there do not fit your patient into a template when it is not so! Groin hernias 1. Is there a hernia? 2. Is it an inguinal or femoral hernia? 3. Is inguinal, it a direct or indirect hernia? 4. Are there any complications? 5. Why is this patient getting hernias? Patient is an elderly Chinese gentleman, alert and comfortable at rest. I will like to inspect the patient standing up. INGUINAL LUMP: On inspection, there is a 3cm x 3cm right groin swelling. This is well circumscribed, with no overlying skin changes, and no surgical scars. There is a cough impulse. INGUINOSCROTAL LUMP: On inspection, there is an inguinoscrotal swelling with a cough impulse. There are no overlying skin changes and no surgical scars. I am now palpating for the anterior superior iliac spine by tracing the iliac crest for its anterior and medial- most point. I am now palpating for the pubic tubercle, by first palpating the pubic symphysis and going laterally. The inguinal ligament runs between these two points. The hernia lies superior to the inguinal ligament, therefore it is an inguinal hernia. INGUINAL LUMP: On palpation, the lump is soft, non- tender, nonpulsatile, nonfluctuant, with an expansile cough impulse. The testes is normally located in the scrotum INGUINOSCROTAL LUMP: On palpation, the swelling is soft nontender with an expansile cough impulse. I cannot get above the swelling. The testes are separately palpable in the scrotum. 1
I will now request the patient to reduce his hernia. It is reducible/irreducable. I will now attempt to distinguish between a direct and indirect hernia by occluding the deep inguinal ring which is located 2cm superior to the midpoint of the inguinal ligament, and asking the patient to stand up and cough DIRECT: Occluding the deep ring does not control the hernia. It is a direct inguinal hernia. INDIRECT: Occluding the deep ring controls the hernia. It is an indirect hernia. I will also like to perform Per- rectal exam for benign prostatic hyperplasia causing straining and increased intraabdominal pressure Respiratory exam for causes of chronic cough Abdominal exam for masses or causes of increased intraabdominal pressure All of which predispose to hernia and should be optimally treated before hernia repair is carried out. Neck lump thyroid 1. Confirm that the neck lump is a thyroid 2. Assess the thyroid lump and local effects 3. Assess thyroid function 4. Assess for metastases The patient is a middle- aged Chinese lady, alert and comfortable at rest. On inspection, there is a visible anterior left neck lump. The lump moves superiorly with swallowing, but not with tongue protrusion. I will now palpate from behind. I am able to palpate a single 3cm by 3cm lump in the anterior triangle of the left neck. This lump is firm, non- tender, with regular well- defined edges, and is mobile. I am able to feel its lower border. I do not note any enlarged cervical lymph nodes I do not note tracheal deviation. On percussion, I do not note any retrosternal extension On ascultation, There is no thyroid bruit. I also note that the patient s voice does not sound hoarse. 2
I will now assess for thyroid status. I do not note any lid lag suggesting hyperthyroidism, or exopthalmos, lid retraction, and opthalmoplegia suggesting Graves eye disease. I do not note any tremor of the upper limbs There is no thyroid acropachy The palms are not sweaty The pulse is regularly regular and the patient is not tachycardic There is no pretibial myxedema. I will like to complete my examination by Ascultating for any lung nodule Examining the abdomen for hepatomegaly Percussing the spine for bony tenderness Breast lump 1. Identify the lumps in the breast ± axilla 2. Determine if more likely CA or more likely benign 3. Look for mets The patient is a middle- aged Chinese lady, alert and comfortable at rest. I will like to expose her from waist up. I will like to inspect the breasts. Mdm, can you please rest your hands behind your head? Can you please now press down on your hips? I do not note any Visible lumps, asymmetry Scars, skin changes Nipple discharge or any sign of Paget s disease I will now palpate the breast. Mdm, can you please rest your hands behind your head? LIKELY FIBROADENOMA In the right breast, I note a 2cm x 2cm lump in the 2 o clock position, 2cm from the axilla. There is also a 1cm x 1 cm lump in the 11 o clock position, 1cm from the axilla The lump is firm, non- tender, with well- defined edges. It is mobile and does not appear fixed to underlying structures. Mdm, can you now press down on your hip? The lump is not fixed to the pectoralis muscle. LIKELY CA: In the right breast, I note a 2cm x 2cm lump in the 2 o clock position, 2cm from the axilla. The lump is hard, non- tender. It is nodular with poorly- defined edges. It is non- mobile, appearing fixed to deep structures. Mdm, can you now press down on your hip? The lump is fixed to the pectoralis muscle. I will now palpate the axillary lymph nodes. Mdm, can you please rest your hand on my hand? I do not note any axillary lymph nodes. 3
Mdm, are you able to express any nipple discharge? I will now palpate for cervical lymph nodes. I do not note any cervical lymph nodes. I will like to complete my examination by Examining the chest for any metastases Palpating for hepatomegaly Tapping the spine for bony tenderness. Arterial exam of legs 1. Describe features and complications: skin changes, ulcer, gangrene 2. Estimate perfusion and arterial flow in the limb 3. Demonstrate insufficiency: Buerger s test. 4. Examine for any other arterial pathology especially in the abdomen. The patient is an elderly Indian gentleman, alert and comfortable at rest. I will like to expose the patient from the inguinal ligament down. I will now inspect the legs, including between the toes and behind the heel. I note Previous amputation of the right fourth toe. A small patch of dry gangrene on the right second toe, with no sign of infection or autoamputation A 2cm x 2cm ulcer on the medial border of the right foot. This ulcer has a dry and pale base, punched out well- circumscribed edges, shallow depth, and no discharge. The right foot appears pale, shiny, with loss of hair. I will now palpate the legs. The right foot is much colder than the left. Capillary refill time is 3 seconds in the left limb, and 4 seconds on the right. The ulcer is painful. I will like to palpate the limb pulses I am now palpating the femoral pulse, located at the midinguinal point, which is the midpoint of the line joining the pubic symphysis to the anterior superior iliac spine. The femoral pulse is well- felt bilaterally I am now palpating the popliteal pulse, which is located deep in the popliteal fossa. I am not able to palpate this pulse, however it may not be palpable even in healthy individuals I am now palpating the posterior tibial pulse, located one third way down a line joining the medial malleolus to the heel. This is not palpable on the right, and very weak on the left I am now palpating the dorsalis pedis pulse, located one third the way down a line joining the midpoint of the two malleoli to the first webspace. This is impalpable bilaterally.; I will like to ascultate for femoral artery bruit suggesting any aneurysms. 4
I will like to demonstrate Buerger s test first by elevating the leg slowly to determine the angle at which the leg turns pale, indicating that arterial pressure is insufficient to overcome gravity. Buerger s angle is 45 degrees in the right leg, but the left leg does not turn pale even at 90 degrees. I will now hang both legs down. There is dependant rubor in the right leg. I will now examine the abdomen and Palpate for any expansile pulsatile mass which is an aortic aneurysm Ascultate for renal bruits I will also like to Perform a full cardiovascular examination Palpate all remaining pulses including carotid, radial, brachial bilaterally and feel for radial- radial, radio- femoral delay. Ascultate for carotid bruit Check blood pressure in bilateral upper limbs Use the doppler probe to check for pulses and perform ankle brachial pressure index Varicose Veins 1. Describe the features and complications: ulcers, edema, varicose veins 2. Demonstrate varicose vein incompetence 3. Identify the site of incompetence 4. Assess for deep venous competence The patient is a middle aged Chinese lady, alert and comfortable at rest. I will like to expose the patient from the waist down. I will now inspect from front, side, and back. On inspection, there are Bilateral varicosities over the long saphenous vein distribution. There is also venous ulceration over the gaiter region. On the left, it is 4cm x 3cm, and on the right it is 5cm x 2cm. The ulcers have pink granulating bases, regular sloping edges, and do not have active discharge. In the surrounding skin, there are signs of venous insufficiency such as lipodermatosclerosis, hyperpigmentation, and venous eczema. I will now go on to palpate the legs. On palpation, I note pitting edema up to the mid shin bilaterally. The ulcers are non- tender. There is no evidence of thrombosis in the varicosities. I will now perform the tap test. The tap impulse is transmitted distal to proximal indicating vein patency, and proximal to distal indicating incompetence. I will now palpate for saphena varix 2.5cm inferior and 2.5cm lateral to the pubic tubercle. There is no saphena varix. I will now attempt to elicit a cough impulse at the saphenofemoral junction. There is a positive cough impulse indicating saphenofemoral junction incompetence. 5
I will now do the tourniquet test by applying two tourniquets at the sapheno- femoral junction and sapheno- popliteal junction just above the knee, elevating the leg and milking the veins to collapse them. I will now ask the patient to stand. There is rapid refill of the varicosities indicating incompetence of medial calf perforators. I cannot make any conclusion on SFJ and SPJ competence. There is no rapid refill of the varicosities indicating medial calf perforator competence. I will now release the tourniquet at the saphenopopliteal junction o There is rapid refill of the varicosities indicating saphenopoliteal junction incompetence. I cannot make any conclusion about SFJ competence o There is no rapid refill indicating saphenopoliteal junction competence I will now release the tourniquet at the saphenofemoral junction. There is rapid refill indicating that the SFJ is the only site of incompetence. I will now do the Perthes test by applying the tourniquet below the knee and asking the patient to repeatedly tiptoe up and down, looking out for worsening of the varicosities or pain which indicate incompetent or obstructed deep venous system. I will now ascultate over the veins for any bruits indicating arteriovenous fistula. I will like to complete my examination by Performing an arterial system examination of the lower limb Examining the abdomen for causes of raised intraabdominal pressure such as masses, enlarged deep inguinal nodes, examining the external genitalia, and performing digital rectal exam for enlarged prostate causing straining; all of which can predispose to varicose veins Doppler ultrasound of the veins. (put probe proximal, squeeze distal: hear forward and then retrograde flow) Parotid Exam 1. Describe and identify the lump 2. Look for features of cancer The patient is a middle aged gentleman, alert and comfortable at rest. On inspection, I note a lump behind the angle of the right mandible, lifting the earlobe. This is a parotid. The lump is 3cm x 3cm, and appears to have well- defined edges. There are no scars or overlying skin changes. I will now palpate the lump. On palpation, the lump is firm non- tender with well- defined edges; it is immobile over underlying structures but the skin is mobile over it. I will now look inside the mouth for the parotid papilla, which is unremarkable with no stone felt. The tonsillar arch appears normal with no medial deviation of the lateral wall. I will bimanually palpate the lump and palpate for the stensen s duct. The lump is bimanually palpable while the stensen s duct is unremarkable. 6
I will now examine all branches of the facial nerve. Temporal branch raise eyebrows Zygomatic branch close eyes Buccal branch smile Mandibular branch say E or puff out cheeks I will now palpate for cervical lymph nodes, which are unremarkable. 7