MBBS 2014 - Case Analysis

Format: 1 Case (50min)

- 25min clerking, 10 min summary 15 min discussion
- 3 examiners per student (1 watching clerking + pe, 2 not present during the initial clerking), usually
with additional MO around that comes in with the 2 examiners
- (NUH) In day surgery ward - could take vitals if we want (automated vitals machine) but vitals chart
is actually provided (vitals chart was not provided for me, so had to request that the nurse bring in the
BP machine for me. She (and Dr Chong CS) were nice enough to ask me not to do the vitals myself).

Hello! those who have done the exams: do u mind giving the rest some tips. :):):) would
appreciate it very very very much!
a) How did yall present ur case? did yall do a proper presentation including taking social
history etc .
- i think you can try giving a summary of the salient points in the hx first, like sir i would first
like to give a brief summary of Mr xxx blah blah win liao then going into more detail
regarding the HPC. going into more detail regarding risk factors..
- i had to present the full history and ended off with a summary statement. i guess it varies
from examiner to examiner
- i think it also depends on whether its diagnostic vs mx - mine was a known dx so i
presented h/o PC at diagnosis incl RFs (pt was currently v well) and then went on to other
social blahblah
- I think the opening statement is important. After the opening statement they pretty much
nod/ zone out etc.
- i think even for a post-operative patient, it is very important to clerk the presenting
complaint well to rule out ddx e.g infection/AI/malignancy (achalasia s/p lap Heller
cardiomyotomy)(recurrent pyogenic cholangitis)
b) Is a detailed social history and taking vitals important? do they ask for vitals
- they didnt for me (deb), i asked for vitals and examiner 1 say nvm
- yeah they didnt really ask for the vitals also (me too!) (me 3!)
- social Hx i asked cause it was relevant in mine plus later on the examiners sort of pushed
me for psychosocial Mx (social financial support)
- any relevant social hx will be important
c) how would yall recommend dividing the time? 2 minutes for consolidation prob not enough
right? 12 mins hx, 8 mins PE. 5 mins consolidation? + more qns if necessary ?
- I think case by case? If from the history youre either clueless and not sure whats
happening or if you expect to find a lot on the PE then spend more time on it, otherwise if it
doesnt sound like theres going to be many signs then just allocate more time to history
- i did 15 mins hx, 10 mins PE but had 3-4 mins left over cause my PE only had scars to look
at. examiner 1 told me to just check hernia orifices for abdo so i just did visible cough
impulse and he said good enough
- I hadnt finishe Hx at 15 mins but decided to do the PE first anyway. Quite a simple abdo
PE so once done went on to ask a few more questions as I consolidated everything.
- Hx:15 mins, PE: 5 mins, Consolidation: 5 mins
d) were the examiners nice or mean ? ><
LOL ERM VARIES WIDELY from mouse to crouching tiger hidden dragon
- MOs mostly v nice & try to help ie shake head when youre giving wrong answer lol
- Nice (mostly) sensitivity 97.8%, specificity 99%
e) were the patients well primed like the ones in medicine long case?

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- HELL NO (see mr Chan TK) but i think my experience alr wasnt too bad you can ask like
jia qian the pt told her about some shit for 10 minutes before the examiner prompted him to
talk about his legs
- some patients are also well primed to troll you
- some are perfect historians. for real
- i asked my pt if theres anything hed like to tell me & he said if you ask me, ill tell you~~
(dhilshad is this you? got ~ means its dhilshad)
- unprimed. doesnt even know if she can tell me the diagnosis of achalasia.

DAY 1: NUH
you wait in the advanced surgery centre place. there is free food and drink (apparently got
SIEW MAI!!!) YEAH IT and sandwiches. im not sure how nice the sandwiches were but i ate
the siewmai, if your buffet spread includes siewmai i guess go for that one first cos it looks
the most deliWAS DELICIOUS AND MADE MY DAY. i think there was also gyoza and
random stuff. coffee and tea also. cious of the lot. nice warm food to start the day (just be
prepared for bowel prep before your long case) (HAHA great advice guys XD)(no way, i got
nausea before exams. dont eat too much, later post-prandial and n/v). XD in the morning
when you walk in you will walk past all the examiners eating breakfast and they will say hello
to you and things like dont worry, dont be afraid (ha ha ha). CN Lee is also actually very
short in real life.

Session 1
Summary:
34 year old female with Stage 2 Invasive Ductal Ca diagnosed 5 months ago with significant
RF of OCP use for 16 years, currently on Neoadjuvant Anthracycline/Cyclophosphamide
(AC) regime chemotherapy with plans for wide excision and post-operative radio and
hormonal therapy.
Observer: Nice guy who told me he is blended into the curtains and got me a chair to sit :D
Examiners: Prof. CN Lee (surprisingly super nice) and Dr. Enders Ng (HK guy with high-
level technical questions but nice too)

Learning Points:
1. Get there early/ be on time! I was late and didnt know there was siew mai/ buffet to
eat :( This is actually level up x 100 compared to london chocoroll that we always get fed
2. Know the staging and management options very well for simple conditions like breast and
CRC! Expectations are higher so discussion will likely be more in depth according to
indications for certain therapies based on cancer stage
3. CN Lee is actually very nice. He even saved my ass from the other examiner haha. And
his questions are quite reasonable so dont create a psychological barrier for yourself before
you even start the exam :) ALso during the exam smile beautifully at both your examiners
and dont neglect any one of them!
4. Always classify your answers. It sounds nice and examiners like to see your structure of
thought- they kept nodding away when you first introduce the overall direction of your
answers
5. MOST IMPORTANTLY, it is essential to start presenting with an overal summary of the
patient focusing on the Cs and S - complaints, Cause, Course, Complications, Severity.
Once you give them a broad idea of the patient they will start to switch off

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History
So they lined us up before that and we formed straight lines (like line up in primary school
like that). The helpers handed us clip boards and paper, and my personal usher (according
to the briefing all of us got one) told me my patient is a female and speaks English yes!
So went in, introduced myself and examiner. They were super fast and gan chiong. While
the observing examiner was still getting me a chair they said start start! Then the examiner v
gan chiong also he told me to quickly start while he got the chair.
My patient is thank god- the best historian I ever got in my entire med school. Part of the
reason is that I seldom clerk patients cos history taking is very tiring/ you think you can just
clerk your classmates instead but on retrospect I think constant work is actually better. But
anyway salient parts of the history:

- painless enlarging left breast lump noticed for one month

- no nipple changes/ discharge/ skin changes
- estrogen related RF: Daily OCP usage x 16 yrs with early menarche at 10yo
- non estrogen related RF: nil FH/ personal hx of breast disease
- no constitutional sx/metastatic sx

- MMG and Core Bx performed revealed Stage 2 IDC, ER/PR positive and Her2Neu
negative (shes very well informed about her condition)
- staging CT: no metastatic spread
- treated as Stage 3
- currently on neoadjuvant CT AC regime with Taxol ( I was like wth is AC regime and omg
I forgot what is a Taxol?? then she took out her phone and starting googling for me on the
spot. SO NICE RIGHT.)
- planned for WE with post op RT and HT

- Drinks alcohol regularly for past 1 year

- social financial functional hx unremarkble

Physical exam was straightforward. At first I was doing running commentary for my examiner
but he looked uncomfortable and told me just pretend he wasnt there haha. Even better
save my time. Then I suddenly remembered there was suppsed to be a BP machine
somewhere/ Clinical chart to refer to. I saw the white box beside the bed and wondered if
thats the BP machine? Then thought heck dont waste time taking BP

Spent 12 mins on hx and around 8 mins PE. Had a few mins to consolidate and write out my
presentation. 25 mins bell rang and deng deng deng deng

CN Lee walked in! With a tall co-examiner I didnt recognize.

I was thinking, nooo this cant be happening (b/g info: my CG received a tip that CNL came
back 2 days prior from his Sweden thing to take our exams and I was like freaking out and
my cg mate said to me: dont worry u wont kena one -.-)

Okay so anyway, just put up a professional and sleek show.

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 Mdm __, these are my examiners. Would you mind if I share my findings with them?
Sir, I had the pleasure of speaking with my patient Mdm __.
*Insert summary statement and they listened to the whole history subsequently
CN Lee kept nodding and smiling.

CNL: show me how you do your PE

just demonstrated breast PE with running commentary- 1.5cm irregular lump at
superiolateral quadrant of left breast, non tender, not attached to overlying skin or underlying
muscle
*TIP TO JUNIORs; when assessing for fixation to underlying pectoralis, remember to move it
in 2 directions, one along the direction of the muscle fibres and then perpendicular to this
direction. SGH is quite particular about this
No palpable axillar LN

CNL: what else you like to do to complete your PE? LN, Spine, Respi, Legs
CNL: what stage is it clnically? In view of T1N0, clinically stage 1
CNL: why do you think this is different from the stage patient told you? Could have been
downsized 2/2 neoadjuvant CT

CNL: About the hx, is there anything patient told you about what she had undergone for her
breast?
Me: Neoadjuvant CT?
CNL: No.. other procedures?
Patient: OOPS SORRY I FORGOT TO TELL HER
ME: ???
CNL: she went for a procedure to transfer fat from her abdomen into her breast. How does
this change your ddx?
Me: I would like to consider possible fat necrosis from this procedure
CNL: Ok good. Lets go outside
Patient: so sorry! So sorry!
I was like thanking her profusely for being the best patient ever! And actually I think it was
my fault also cos I asked for previous breast disease, investigations, surgery but not
PROCEDURES in specific. Learning point! J

Questions
-CNL: what Ix would you perform?
-Me: Sir, a complete clinical evaluation has been performed. To complete the triple
assessment, I would like to perform a MMG and obtain histological confirmation of the mass
ideally via core biopsy, in which I would also request for immunohistochemical staining to
ascertain ER/PR/Her2Neu status.
-CNL: Interpret the MMG
- at this point everyone turns and stares at the blank computer screen and the MO who was
hiding behind me all these while and who was supposed to click the computer is now day
dreaming and staring into space. Super awkward. I didnt know what to do so quickly clicked
the mouse to save his embarrassment any longer.
Basically CC view; microcals seen, architectural distortion, no invasion into overlying skin/
nipple destruction.
CNL: pointed at some bubble looking like thingy and asked what is this?
Me: clueless. LN? doesnt look like. CNL hinted about the fat transfer procedure and I was
like oh! Fat necrosis!
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CNL: whats Her2Neu? (epithelial growth factor receptor with tyrosine kinase activity, only
expressed in breast and not found elsewhere in the body, which is a bad prognostic factor
CNL: whats ER/PR? (marker of good prognosis and amenable to hormonal treatment)
EN: What are the surgical principles and number of lymph nodes to remove in SLN Bx?
Me: shot him the puzzled and weird look
EN: Ok maybe this is an unfair question for you. Lets move on
(yay he retracted his own question ha ha)
CNL: survival rate for this patient?
Me: depends on severity of disease and age. In view of her young age and disease stage,
expect 90% in 5 years. (actually was unsure also but I looked him in the eye and smile
confidently then he nodded and move on with life)
EN discussed more about staging and management according to the stage with me
subsequently (so know this in depth)
CNL: principles of breast recon?
Me: implant based vs autologous tissue reconstruction. Autologous can be divided into
pedicled flat (TRAM) vs Free flap. Elaborated more on advantages and disadvantages on
each. He was v nice. Gave you time to elaborate on your answer and kept nodding as you
go along.
CNL: How would you mange lymphedema?
Me: medical vs surgical. Medical: elevate arm, limb compression, exercise, address Cx of
cellulitis. Surgical.. (mind blank) so just smoked something about doing surgery if indicated.
CNL: what kinds of surgery do you know?(half smile)
Me: I have no idea Prof but I would like to look it up the moment I get out of here (haha oops
cant believe I said that)
CNL: chuckled and said nevermind its okay (apparently options include removal of subcut fat
and fibrous tissue with or without creation of dermal flap within the muscle to encourage
superficial to deep lymphatic drainage. Alternatively, one can perform lymphtic microsurgery,
which invoves lymph drainage into venous circulation or lymphatic collectors above area of
lymphatic obstruction)
EN: what is the difference in surgery between lobular Ca and Ductal CA?
Me: lobular Ca arises from the lobules and Ductal Ca arises from the ducts and so lobular
Ca is technically harder to perform
EN: (I do not buy your smokebomb). No its not about the surgical technicalities. Do you
know of another reason?
Me: hmmmmm
EN: okay this is quite an unfair question for you so let me just share with you. Lobular CA
tends to be multicentric hence simple mastec with recon is usually done vs ductal CA in
which WE vs SM can be considered
(YAY he answered his own question)
EN: How would you Mx this patient post-op?
Me: (I thought I already covered everything from earlier questioning including family BRCA
screening to mx of RT to lymphedema Mx and advice on regular Fu, screening and self
breast exam already, so idk what he wanted. Tried to smoke something first.. ) In view of
patients Hep B carrier status, would like to emphasise regular 6/12 FU with AFP and USS
Liver, as well as advise on alcohol cessation. (EN Laughed and said hahaha good good,
comprehensive approach to management and I quickly laughed together with him to stall
time. Then he said, what other specific mx? so does this patient require adjuvant CT?
Me: Adjuvant CT is indicated in stage 3 disease however only indicated in certain high-risk
individuals (eg. deep margins, no. of lymph node) in early breast Ca
EN: so for this patient she was treated as stage 3 initially but now she is clinically stage 1.
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Do we treat her as stage 3 or stage 1?
I was thinking of how to smoke this thing out when.
*DING DING!
YAAYYYYY
But I was still thinking of how to answer the question.
THEN
CNL turned to EN and told him: wah that is quite a hard question to ask and it maybe unfair
for her. Even I dont know the answer! HAHAHAHAHA! Then the 2 examiners started
laughin together. And I actually found it quite funny that CNL saved my ass so I also started
laughing.
The other examiners/ students turned to look at 3 of us lol.
CNL: thank you very much. You may go now.
Me: thank you sir!
BYE AM OUTTA HERE
Thank goodness for super nice patient and examiners!
Going to temple and bathing in the flowers really helps whee
:D

Session 2: Case 2
Case: Functional Dysphagia, progressive 1yr ago sec to Achalasia s/p Lap Heller
cardiomyotomy 6months ago
Observer: Sein Lwin (NUH Neurosurgery) #guardianangel
Examiner: Jimmy So (NUH Upper GI) (Active) #benign, Walter Tan (Raffles Plastic Surgeon)
#giraffe

Things to pray for:

1. Patient factors: English speaking, single pathology, no PMH, female (more aware of their
illness), post-op (can see scars. can ask what surgery was done and work backwards).
2. Examiner factors: My observer was the bomb (sein lwin). He helped me to ask the patient
some aspects of the hx that i missed. asked me to present salient PE to him and added on
relevant negatives (eg cardiomegaly, which can cause extrinsic compression of oeso). Pray
for benign examiners for QnA. When i saw Jim, i knew i will pass. He is also quite cute when
he proptoses and very encouraging (nods) when you are on the right track. Walter was quite
passive...maybe he aint very interested in upper GI stuff.
3. Student factors: STAY CALM, have a clear mind. I had brain freeze when i saw this young
patient tell me dysphagia becoz i was mentally primed for an oesophageal CA (old, male,
obstructive symptoms, cachexia). I was also apprehensive when my helper (we are all
allocated 1 helper each to usher us) told me to follow her to a single bed room at the day
surgery (in my mind, i was thinking whether this means that its a breast case or some other
disease affecting private parts). most students get patients who are in a cubicle so have to
clerk by the bedside.
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Ch/F/39, large body habitus
*brought to the room and told by usher that i can start immediately. no observer doc. heck.
just start. see if can ask for diagnosis before he comes woohoo.
Hi, how are you?
*didnt register her reply coz too nervous*
Whats the main medical problem u have?
- cant swallow, vomit after meals. so bad that i came to the hospital.
*huh. 39yr old, large habitus. cant swallow zzz*
pls tell me more? (open ended qn)
- started 1yr ago. progressive, food stuck retrosternale locale, vomit almost immediately,
NBNB. came to ED 6 months ago
- hungry after vomiting ie no LOA
- no LOW. lost 1-2kg over 6 months
-solids and liquids both cant swallow
*functional oesophageal dysphagia ddx: achalasia, diffuse esophageal spasm*
is it intermittent or constant (ie vomit every meal?)
-every meal. affects my lifestyle a lot
*great. achalasia then. lets see how to confirm the diagnosis. maybe we go for the kill*
Operated? do you know what operation? got cut out any thing? what did the doc say?
- operated in NUH 6 months ago. Heller *woohoo*. just cut the foodpipe.
- doc offered me balloon, heller and some new technique but he said need to wait 3 months
for the new technology to come but i cant take it anymore *shoik. told me the surgical
options. ended up using this in my discussion later on. thanks*
what investigations?
- scope.
- swallow and take my pressure. (hmmm barium swallow or manometry or both?)
*decides to go in for the kill*
so did the doc tell u the diagnosis?
- er yeah he did. er am i supposed to tell you? can tell or not?
* damn tense now. wanna nail it already.
no worries. Is it achalasia?
- yeah yeah. thats it.
*mentally breathed a sigh of relief*
Sein Lwin:do u have any blood in your vomit? any pain?
*thanks. TRO odynophagia or any mallory weiss due to retching. heng. thanks bro.
social hx. fam hx. surg hx. drug hx?
- ..(unremarkable)
any complications after op?
- before op i had a lot of burping. now still have.
*hmm ok.

PE:
*turns to Sein Lwin and says I would examine abdo, neck, cvs, lungs
positive findings: 5 lap scars, well healed
negatives:
A:no abdo masses. no cervical LN. no stigmata of CLD. No cachexia.
H: s1s2, no murmur
L: no creps
Neck and peripheries: no cervical LN. no stig of CLD.
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Sein Lwin-prompted negatives:
H: no cardiomegaly.
L: no ant neck mass. no trachea deviation. no retrosternal dullness
A: no visible peristalsis.

took 5 mins to consolidate. sein lwin told me to calm down and to be steady when i present
#nicedude

Examiners come in. Jimmy so woohoo. walter tan. male MO. i was too nervous consolidating
to intro examiners to patient. haha they friendly. introed themselves without me.

presentation: aim to give a solid opening to have a gd impression

Jim: pls present your hx and exams

I had the pleasure of speaking to Mdm Ng a 39yr old Ch F with no significant PMHx, who
presented 1 year ago with PROGRESSIVE, CONSTANT, FUNCTIONAL DYSPHAGIA with
NO loa, low. diagnosed with achalasia and s/p laparoscopic surgery. currently well
Her dysphagia was presented till the end. my working diagnosis is achalasia. ddx is
other types of functional dysphagia like DES. would like to rule out obstructive dysphagia.
*i presented slowly and loudly, with emphasis on key words. trying to appear confident..
seemed to work
Jim: why oesophageal?
retrosternale locale. able to initiate swallowing
jim: why functional?
both liquid and solid affected
jim: tell me the differentials for functional
rattles
jim: what is one important condition to rule out?
obstructive causes like CA
jim: good. tell me your PE findings
rattles.
*didnt need to demo PE for them.
jim: how would you investigate?
OGD, manometry, barium swallow
jim: ooh ogd. gd. come outside now. lets look at the scan. -thanks patients, sein lwin the
guardian angel observer smiles and leaves-

location: along corridors. OGD is shown on the COW.

jim: tell me what u see.
this is an OGD. however, there are no patient identifiers. i want to verify patients details
with minimum 2 patient identifiers and check the date and time of this investigation to
correlate with clinical hx*#safeHO
jim: er. ok. gd. this is the patients scan. so what do u see?
i am looking for masses and ulcers TRO obstructive causes. ogd appears normal.
jim: ok good. what would you do next for investigation?
manometry, barium swallow
jim: good. -clicks to show next slide. CXR pops up haha. NO manometry and barium swallow
lol. jim turns to MO and says WHERE IS MANOMETRY AND BARIUM? WE SAW HER IN
THE CLINIC! SHE HAD THIS INVESTIGATIONS DONE! mo panicks. comic relief for me. i
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was thinking if i should just say i would do cxr and start to read it. but i didnt.-
jim, turns to me: haiyo, nvm. tell me what you want to look out for in manometry.
1. absent peristalsis
2. increased LES tone
aaaaaand (drag for suspense)
3. absence of relaxation after swallowing.
Jim, jizzed, smiles and nods with approval, climaxed, damn turned on by upper GI: gd gd,
management. how would you manage?
management is classified into medical, endoscopic and surgical (hehe patient told me).
medical: nitrates, CCB
endoscopic: balloon, botox (popped into my mind last min when i was answering)
surgery: heller cardiomyotomy. (i forgot oesophagectomy. i think this only for severe cases)
Jim: so how would you decide on surgical management?
decision is based on severity of patients symptoms...err.. sorry prof, let me classify my
answer. decision is based on patient factors, disease factors and surgeon factors - jim
smiles and nods in approval- patient factors include severity of symptoms, willingness for
surgical, co-morbs of which this patient has none (hehe, was trying to make my answer more
tailored for this patient #gdHO). disease factors include severity and progression of disease
and failure of medical treatment. (at this point, i was starting to panic..what surgeon factors
canthere be. so i decided to smoke. anyway come until management already. should pass. )
surgeon factors include confidence in laparoscopic approach -i looked into jims eyes as i
said it, he smiles #gaymoment- , expertise, infrastructure and availability of surgical
equipment, which may not be available in other hospitals -Jim jizzed a second time.
Jim, still smiling: i have no more qns. (hehe.. managed to satisfy him)
Walter Tan: one last qn, -bell rings!- you mentioned botox. why is that not a good option?
it is not a good option because results are temporary (haha nice plastic surgeon, come and
ask me bout botox)
Walter: do you know how long it lasts? (wa really trying to DA me)
3-6 months, Sir
Walter, smiles, satisfied: good. you may go.

WOOHOO.
#tbiytb

Session 3: Group 3
Case: Gastric Ca
Observer: Caucasian (*cant rmb his name sorry!)
Examiners:Dr Charles Tan, Dr Christine

History
76y Chinese gentleman (Mandaferin speaking)
PMH: HTN, HL, IHD s/p balloon angioplasty
p/w: epigastric discomfort, ?postpriandial? vomiting/regurgitation of partially digested food

(essentially e above 3 lines was all i got from the history. The patient had no idea of his
diagnosis or why he he was here. He could not remember how he presented, nor whether
his vomitus was bloody or bilious. But thankfully i managed to get out the vomiting of partially
digested food. He said it was smts postprandial but more at night ?regurgitation?.
Sometimes forceful sometimes passive pooling of food gahhh.

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5 mins into history i was still clueless..is it oesphageal/stomach/pancreas/liver/gallbladder?
asks him if i can see his abdomen - Rooftop scar, and prior appendicecomy
Decided it could not oesophageal as oesophagectomy needs minimum 2 incisions. And his
presentation sounds more gastric. confirmed with him thrice its gastric problem not liver or
other organs. Ask him if doctor spoke to him about chemo. He said starting tomorrow.

Decided not to stress e poor old man so much. He seemed like he really didnt know why i
was asking him so many questions. Anyway he doesnt know/cant remember his
presentation nor knows the diagnosis either. The observer also said he seems like he
doesnt know much. you should just move on)

Physical examination
- finished in mins. Just abdo exam, and look for mets or lymph nodes. offered PR
- left with 10 whopping minutes to consolidate since i didnt bother to take more history (given
the patient does not know much)

Presentation
(knew i would be all right when CHARLES TAN walked in. Jackpot +++)
Introduced my examiners to patient. Offered to give a summary before detailed history.

Mr Tan is a 76y gentleman with background gastric cancer s/p gastrectomy 2 months ago.
Initially presented with 2 months duration of dyspepsia and symptoms of gastric outlet
obstruction. Currently planned for chemo tomorrow.

Went on to detailed history - *postprandial non bilious projectile vomiting of partially digested
food*, risk factors, complications etc

Both examiners and e observer asked me questions. All pretty standard.

Questions
1) Why do you say is gastric cancer? How do they present
- Gastric ca because of dyspepsia, GOO - postprandial non bilious projectile vomiting of
partially digested food
- presentation can be local, constitional or complications. Local - dypepsia, complications -
UBGIT, symptomatic anemia, gastric inlet/outlet obstruction, perf, transverse colon fistula;
constitional - LOW
2) Differentials? Why this and not that?
- oesophageal ca (given pt also reported regurg however no dysphagia).
- stricture secondary to PUD (given dyspepsia)
3) Would you expect to find lymph nodes in this patient?
- no sir, given the patient has undergone surgery
4) what are these scars?
- port site scars. (took me awhile before i finally said - staging laparoscopy scars; was told by
a tutor we dont do staging laparoscopy in sg. i guess we do after all)
5) what is staging laparoscopy for?
- look for peritoneal mets that can upstage disease
6) what else?
- *honestly didnt know. suggested a few things like extramural extensions, lymph nodes*
eventually just gave up n said dunno, so examiners moved on
7) what will you do if u see peritoneal mets on staging laparoscopy?
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- close up and abort surgical resection
8) are you sure? what if he has marked symptoms of vomiting?
- palliative resection
9) what else?
- palliative bypass
10) what else did u look out for on exam?
- succussion splash. although it was expectedly negative, given he has already undergone
surgery
11) what investigations would you do if he presented to you for the first time?
- bloods vs imaging
- Bloods:
---FBC - anemia, total whites
---UECr - hypoK hypoCl met alkalosis
---LFT - TRO liver pathology
---serum amylase - TRO pancreatitis
--- infective markers/blood c/s - if septic on 1st presentation
- Imaging:
---erect CXR - air under diaphragm in case of perf PUD
---supine AXR - could be small bowel obstruction
- Definitive:
---OGD - gastritis, mass

*Examiner said finally lets go outside. They walked ahead while i stayed back a few seconds
to apologise to the patient for asking him sooo many questions. Honestly felt quite bad for
torturing the old man when he didnt know anything. sigh. Didnt know Charles Tan was
standing behind e curtain eavesdropping and grinning away. lol*

12) *shows me FBC, U/E/Cr, LFT, PT/PTT, CT scan* Interpret.

- Bloods pretty much unremarkable.
- CT scan - honestly didnt know what to say so started smoking This ia an axial cut of Mr
Tans CT abdomen. It is likely at L1 level given i can see the kidneys, spleen, blah blah blah.
Then stones at stomach sigh.
13) Charles tan starts hinting how do patients prepare for CT
- check for renal impairment, asthma, metformin, allergy
14) Charles tan: Yes very good. But they fast too right?
- YES! but i still see food in the patients stomach on CT, indicating of GOO
15) Christine: dont you think the stomach is enlarged?
- YES definitely. (lol)
16) how do gastric cancers usually present here?
- in japan usually early due to screening and hence amenable to endoluminal surgery.
unfortunately in singapore, usualy presents as locally advanced stage
17) Charles tan: how will you manage gastric ca palliatively?
- chemo and symptomatic. in this case if patient has obstruction, then endoscopic dilataion
or surgical resection/bypass. But would like to try non invasive methods first like nasojejunal
tube or open jejunostomy

* we were laughing when i said how i would ideally like to first get consent for
bypass/resection before pts staging laparoscopy for medicolegal reasons. bell rang once 2
examiners and me were giggling away. then they said ok youre done! freeeeedom!*

11
Learning points:
1) If history is not going anywhere, look at the abdomen first. I relied mainly on the rooftop
scar and absence of other scars for my diagnosis, given history was rather ambiguous
2) Dont need to obssess over getting detailed history of presentation if patient does not
know. In the end what matters most is your opening summary. Sound like youre super
confident when giving the summary (although i was praying hard inside it better be a gastric
cancer not partial hepatectomy for HCC given rooftop scar. Heng i guessed right)
3) NEVERTHELESS, ask enough questions to show you TRIED to rule out differentials. I
asked everything about pancreatic/liver/oesophageal/stomach/GB even though i knew the
patient would say dont know till the observer told me to move on. This is just in case you
miss the final diagnosis and your examiner says what else can it be? did you ask for it?
4) NEVER be rude to patient even if he doesnt know anything. Know theyre probably as
stressed out as you also when you ask them so many things and they dont know anything

(All in all, the most difficult part was e 1st 5mins when i realised my poor patient was as
clueless as me. Hope he wasnt too stressed out by e following batches too. He kept asking
me if more ppl were coming to question him. Felt quite bad sigh.
Thank God for everything! BTW, my M3 long case and GS case analysis during M5 GS SIP
were ALL gastric ca with GOO by some coincidence. This MBBS case makes e 3rd gastric
ca lol.
All e best juniors! You will be fine:) Just stay calm and be level headed on that day.
Presence of mind is most important yea?)

Session 3: Group 5
Case: Acute I/O secondary to stoma ?stenosis/adhesion in b/g rectal carcinoma s/p
APR in 1999
Observer: Lincoln Tan
Examiner: Lim Khong Hee (Mount E Upper GIT surgeon), John Tam (NUH CTVS)

Malay lady/54
NKDA, non-smoker, non-drinker, working as secretary

PMH
1) Stage 2 rectal carcinoma s/p APR 1999 (at age 39) by Prof Abu Rauff
- presented with PR bleed (fresh) in 1999
- did scope: found tumour
- did not know level of CEA (she just said it was high)
- initially went for ?LAR/ULAR with temporary ileostomy but found tumour to be invading into
sphincter (did not get this history initially, but saw scar in RIF and then made the link during
history presentation :( )
- re-operated with APR and permanent colostomy
- complicated by parastomal hernia a few years ago, was treated surgically before
2) DM - on diet control
3) ?HTN/HLD (sorry i forgot)

:
Pain at stoma with abdominal distention, vomitx2 non bloody, non bilious, brown in colour,
12
slightly smelly (feculant) and low stoma output (constipation) for 1/7 duration. Acutely
brought into ED, treated with IV hydration and antibiotics. No fever.
Stoma: no change in colour, not dusky, no change in lumen size, no bleed from stoma
output. No prolapse.

Risk factor for Ca:

- diet high in fried food, did not comment on red meat
- FH: auntie had stomach cancer at 40+, no other family members with cancer

F/U:
- knows that she has to measure tumour marker, unsure of last level
- i tried to ask if they did any scopes, she digressed and said ya this time have (o.O?)

Systemic review:
- no symptoms of mets
- no symptoms of local recurrence

Added that she had no financial problems - one stoma bag cost $3 and she uses one per
day - and its not too expensive.

PE: alert comfortable. SCAR ON RIF (WTF???? - questioned patient, she had a temporary
ileostomy before - ?????WTF I ONLY HAVE 8 MINS LEFT - move on with PE first), midline
scar

Colostomy with parastomal hernia. cough impulse +ve. stoma lumen obstructed by faeces.
Otherwise healthy looking, not sprouted, no skin excoriation seen. Abdo exam otherwise
non-remarkable.

Requested for charts - examiner said dont have. :/ no time to take vitals man. Move on

Auscultated and percussed for pleural effusion. negative. spinal tenderness nil.

Look at anus - sealed. (had to ask Lincoln Tan to get gloves for me. zz)

Two examiners step in. Asked for history - which they clued me in into the 2-staged
operation (?LAR/ULAR APR) for this lady - profusely apologised. Asked me how i
approach I/O (said mechanical vs functional, and said in this patient likely stoma stenosis,
adhesion or recurrence of tumour - they seem ok). Moved on to show how to examine the
abdomen.

Thanked my patient profusely and stepped out.

What investigations would you like to do? Split into bloods and imaging. Do FBC, U/E/Cr.
Anymore? LFT for nutritional status. seemed ok with it.
Interpret results? TWC raised with neutrophil predominance. No electrolyte disturbances.
Imaging? Erect CXR. Supine and erect chest AXR
Interpret? fecal impaction seen. air fluid level seen. No rectal gas. seem ok with it
Anymore? Computed tomography of abdomen and pelvis
Interpret? Took a while to see the hernia (said fat stranding at first - proptosed and asked
me to correlate with PE - then i got the hint)
13
Interpret another cut of CT? Air fluid level
Anymore? THIS IS WHERE IT GOES DOWNHILL. Active keep asking, i said i dont know.
How to differentiate between large and small bowel? From history - her history of
feculent vomitus is suggestive of large bowel I/O + parastomal hernia + adhesion. AXR -
vomit large vs small bowel I/O signs.
What other imaging will you do? (i already said i dont know??). No idea sir.
Acute management? Verbal diarrhoea from ABC NBM NGT to ward management, call
doctor if increasing pain, vomitus and distension
What other imaging will help you differentiate small and large bowel I/O? (HELLO I
ALR SAID I DONT KNOWWWWWW) no idea sir.
(Press next image) What is this? Gastrograffin study. I note that the contrast is cut off at
the proximal small bowel.
Are you sure? what are all these (points to enhanced fecal impaction which was not
as enhanced at the stomach and small segment of small bowel)? Sorry sir i would like
to retract my statement. It seems like the contrast flowed down to the large bowel.

BELL RINGS

OMG WHAT JUST HAPPENED?

1) Please learn how to read gastrograffin
2) Learn additional investigations for simple cases
3) Examiners dont prompt as much as in short cases :(

Session 3: Group 6
Dr Cheong Wai Kit and Prof Praba (thank goodness for nice examiners!!)

Last exam for MBBS!! Worried abt bad case, nasty examiners to end it off. My heart sank
when I was told I was gonna clerk patient in mandarin ok Well brain failed me during exam
due to nerves

Case: Acute pancreatitis

Mr Chew 30 yo Chinese man presented with acute episode of epigastric pain. Lasted for 2
hours till reached hospital. Described as colicky pain. Forgot to ask abt progression of pain.
Preceded by 3 episodes of vomiting. Vomitus no food, non-bloody, non-bilious but described
as black colour?!?! No radiation of pain. Forgot to ask abt exacerbating/relieving factors
sigh pain score 10/10. Prior to epigastric pain had 3 episodes of diarrhoea the day before,
described as melenic stools (black, sticky, smelly), no hematochezia. Had such similar
episodes of epigastric pain many years ago but not a/w melenic stools. No sx of anemia
(postural giddiness, palpitations, chest pain, SOB etc). Has occasional episodes of abd
bloatedness, early satiety. No fever/LOA/LOW. No contact hx. Recent travel to Tioman for
scuba diving 3w ago but no consumption of unusual foods/uncooked shellfish.

NKDA. No prev use of NSAIDS, steroids, anticoagulants, anti-platelets. No TCM. No sig past
med hx or past surg hx. No hx of gallstones/jaundice/rash/pruritus. No Fhx of CA/PUD.
Smoker x 15 years, pack per day. Social drinker. Lives with wife and family in 3 room flat,
lift-landing. ADL independent. Noticed he had tattoos so asked him, did them in Singapore.
No prev use of IVDA. Prev CSW contact more than 10 years ago, protected sex.

P/E: Only positive finding was epigastric tenderness, no rebound tenderness, no

14
organomegaly, no conjunctival pallor, no sclera icterus. Offered to do DRE but examiner said
no need. Would like to look at stool color. Just took HR 69 bpm, examiner said no need to do
BP.

At that time, was thinking of PUD cos of epigastric pain and UBGIT. So 25 mins came by
quickly and examiners (Dr Cheong and Prof Praba) came in. Somehow in my nervousness,
forgot to give nice opening statement and went straight into hx findings and pe findings. Felt
like a complete mess. Was caught by Dr Cheong for not asking the pertinent things in
SOCRATES eg. progression, exacerbating/relieving factors which I admitted was my fault.
Asked for my provisional dx. Said was bleeding PUD. Asked for DDx, said everything for
epigastric pain, gastritis, pancreatitis... Because my hx was so bad, Dr Cheong asked me to
quantify why this dx and not that dx. Also was questioned what the black vomitus was. I
really couldnt think at that time. Then he said have u heard of coffee ground vomitus?,
quickly nodded my head. And then was asked to explain what coffee ground vomitus
was?!?! Erm, altered blood in stomach, looking like black dots?? (honestly never seen coffee
ground vomitus ooops) Felt like I really fumbled a lot.

Prof Praba asked so how would like to manage patient if present in ED. So blurt out the
ABC, give fluids, give NBM, inform senior, do I/x eg. CXR for air under diaphragm, FBC,
UECr, LFT, amylase, ECG, cardiac enzymes. Prob praba commented want to do so many
i/x? erm isnt it so? He wanted like 3 top ix to do. Stared into space for a while wondering
which top 3 to do. Seeing that I was stoning, Dr Cheong said why dont u show us how u did
ur pe So proceeded to do PE. Was cut off halfway by Dr Cheong, so what are ur positive
findings? erm just epigastic tenderness, no rebound

Luckily, we decided to move out the COWs to talk abt i/x. First was FBC (leukocytosis,
raised RBC, raised Hb). Was asked why raised Hb (dehydration leading to
haemoconcentration). Moved to next slide. UECr was unremarkable. Saw the ABG result on
the bottom of same page (oops never mention want to do ABG just now). Didnt have time to
properly look at ABG then he flipped to next slide. LFT normal, amylase 1555!!, CRP was
raised I think. So they asked me for dx now, which is acute pancreatitis. Asked me for other
ways to test, said serum lipase. They asked so now you know its acute pancreatitis, what
other test u want to do? Talked abt grading the severity of pancreatitis using Glasgow score
(PANCREAS). Wanted to classify nicely but decided to just quickly say everything out before
time runs out. Dr Cheong made me doubt myself a few times. Are you sure its neutrophil
count? Are you sure its AST not ALT? So AST or ALT? Luckily never fall into his trap. So if
patient is more than 3 is severe want to manage in HD/ICU. Somehow managed to answer
like manage with supportive therapy. I would consider giving IV imipenem You dont give
that to all patients right? Erm yes prof!! Then the last qn was so what ix you want to do in
this young man? At that time was panicking shit what other ix to do?? the bell rang!! Dr
Cheong put his hand on my shoulder come I give u one last chance, what is the one ix u
want to do? erm,erm, ultrasound hepatobiliary system?? At that moment, another doc
stood behind the both of them and nodded his head, so I was soooo relieved. Dr Cheong
heaved a sigh of relief. Then he turned to Prof praba and said must stress him a little bit.
Hopefully that meant I passed it haha. Omg finally over. Yay!!! Good luck to everyone
else. Holiday LOL!!!

Session 3: Group 7
Examiners: Dr Wu Qing hui (uro reg), A/prof ?nararayan gopal (whos he ah i cant find his
name off the net, he was smiley and nice. I think its Dr Gopalakrishnan Iyer from SGH head
15
and neck) this one. He was my tutor last time, MBBS honours
and topped his class in 1998 haha. wah omg yea thats him. shucks does he have v high
expectations then ?? he asked me many questionsssssssssss. I think he is generally quite
nice! YEA he nice and smiley much i kept staring at his braces haha. hes damn nice. i had
no idea he was that smart holy shit (Active), A/Prof Lim thiam chye (passive) + random
female reg following and taking notes the whole time

Case: Choledocholithiasis s/p lap cholecystectomy

So before going in was told that patient was gonna be female and english speaking, then i
was like WAH breast breast???? Then nooooo.

Anw she was a v good historian! Like ramble ++ and sometimes i had to stop her cos no
timeee. So presented with:
1) Epigastric pain x6/12 ago, radiating to the back, increasing in intensity and frequency over
the last few months, a/w abdominal bloatedness, pain not related to position or food intake
2) Tea coloured urine (yea she said i have TEH O urine) and acholic stools, no malena no
change in bowel or urinary habits

No fever/chills/rigors. No LOA but have LOW (3-4kg over the last month) <-sniff i suppose
due to op stress and everything

Pmhx not v illustrious, only has HTN, on anti HTN meds. Prev surgery for appendicectomy,
C-section x 2, total hysterectomy for fibroids.
No extra med intake, no steroids, no TCM (was trying to rule out drug induced cholestasis),
no travel history/risk factors for hep/recent shellfood intake except for sashimi

Fam history non significant, only dad passed away from lung ca at 70
No smoking no drinking no fatty food works as HR lives with family
Initially worked-up at private GP, was told it was gastric and given antacids and analgesia.
pain persisted. Finally went to nuh for further work up due to increasing intensity and
frequency of pain plus presence of tea urine and acholic stools. Did bloods-> LFT raised;
OGD/colono normal; CT AP found stones in GS, US HBS (haha lol she zai know all these
^^). So was scheduled for lap chole 2 weeks ago!

Anw recovering well, no post op fever or wound site pain/ bruising.

Dr Wu rather helpful haha i knew him from electives last time. He prompted me a few times
to ask for stuff i missed out, cos i didnt keep track of time and was anxious to progress to the
PE alr lolol. So anw i did a v cursory abdo exam (didnt even check for ascites), and aft that
he was like ehhh would you like to check for ascites :o and asked for dx and possible invx
16
that i thought she would have undergone , to see if im on the right track

still had about 5 mins to consolidate everything after that

So bell went ring a ding ding, and the profs trooped in. (lol my heart almost stopped cos i
thought lim thiam chye was soo khee chee)-they look alike dont you think. then i saw his
nametag and my heart resumed sinus rhythm.

Did nice nice intro of patient and profs to each other. Then summarised case as such
Mdm xxx, 46/c/lady
Pc: epigastric pain radiating to the back
Likely etiology: Gallstones
Not complicated by cholangitis
Worked up and found to have gallstones, has since underwent a lap chole x2/52 ago.
Post-operatively well, no complications
Then went on to expound on the whole history in full.
Was asked to demo the whole abdo exam to them again so did so. No sclera icterus no
jaundice no organomegaly. only significant findings were that of the gridiron incision for
appendicectomy, lap scars for lap chole and pfannensteil scar, plus mild abdo distension.

Think i kicked myself by saying sth stupid during the PE. said she looked slightly jaundiced
but no sclera icterus
Dr Gopal (G): hmmm so can one have skin yellowing without sclera icterus?
Me: Nooo prof sorry i would like to retract statement, I would expect the mucous membranes
to be affected first
G: okay good, come tell me about your ddx
Me: choledocholithiasis in view of her obstructive jaundice + epigastric pain, however
malignancy such as cholangioca and periampullary tumour will be on my list as well as its
impt to rule out
G: kk come lets go out

was ushered to a cow (moooooo got milk?) what the LOL

G: okay tell me the first blood investigation you were do
Me: to confirm my dx of an obstructive jaundice I would like a Liver panel , followed by a
FBC TRO raised TW for cholangitis
(Interpreted FBC results)
G: why is it impt to look out for Hb?
Me: eh TRO occult bleeding in possible malignancy
G: why must look out for haematocrit
Me: see if px is dehydrated
(Interpreted LFT results)--obstructive jaundice picture
G: okay any radiological invx you will do?
Me : US HBS
(was shown US HBS to interpret)
verbal diarrhoea all the 5 signs that you can see on U/S, then like he kept wanting more and
asking for moremore. i mindblock LOL. so said eh look at the liver. (for any
hypoechoic/hyperechoic lesions to see if theres abscess from ascending infection or occult
malignancy, microcalcifications)--think i was smoking abit here. He wanted me to say dilated
intrahepatic ducts lol sigh totally didnt cross my mind that its in the liver too lol. asked me to
point out where these ducts were. (and lim TC was smiling smiling behind sniff)
17
G: if you are suspecting choledocholithiasis vs malignancy, how will your initial radiological
invx differ?
Me: If malignancy was on the top of my ddx list i would like to do a CT AP instead as it can
aid me in dx as well as in staging (for nodal spread as well as distant mets)
G: what other thing will you do for her?
Me: ERCP as it will be both dx and therapeutic. can delineate the biliary tree for the location,
number and size of stones, can remove as well , like passing a guidewire and using a
dormier basket to remove
G: What are the complications of ercp?
ME: Blah blah can be general or specific. general includes that of sedation risks etc, specific
would include that of bleeding post sphinterotomy, injury to bile ducts potentially leading to
bile peritonitis, pancreatitis , failure of ercp to remove stones
G: any other ways you know of to remove?
Me: can utilize laser lithotripsy, ultrasound or pneumatic drill to fragment the stone
G: okay lets say you tried every possible means , tried till the cows come home and stone
still there how?
Me: Sir I would like to request for help from my learned colleagues for aid in stone removal
(i heard the rest sniggling behind omg)
G: hahah noo you are the learned colleague yourself. what other ways have you seen being
done??
Me: (i secretly dying inside halp halp halp) cannot thinkkk
LIM THIAM CHYE STEPS IN TO SAY: ahem stent?
oh yaaaa omg hahahaha forgot.
LTC: how will a stent help?
Me: helps to keep the duct patent so that stones can come out, and to prevent potential
obstruction of the biliary system
LTC: gave a small grin and said REALLY?
Me: huhh wrong ah (wrong meh??????)

G: any other ways other than ERCP

me: MRCP! but not therapeutic so not my first line
G: yesyes :) tell me one more way! not really done here but overseas
Me: eh OGD ???
cannot think la, apparently he wanted endoscopic ultrasound of the HBS
G: So what can cause air in the walls of the intrahepatic duct?
Me: Cholecystenteric fistula, infection with gas-forming organisms

k fine since someone say story too long i shall be less luosuo :P

so moved on he asked other questions then lim thiam chye asked some then bell ringgggg.
noooo why must ringgg i wanna stand there continue answering questionnnnns.

OKAY THUS CONCLUDES MY MBBS> HAH NO MORE SLOGGING! :D

HAVE FAITH KEEP GOING THE REST OF YOU GUYS ITS GNA BE OVER SO SOON
YOU WONT KNOW WHAT HIT YOU. BAM AND ITS OVER :)
In retrospect I think i was lucky to get a nice classic case and nice examiners who were
smiley abit and who didnt whack too hard :) the best is yet to be! nono auspicium melioris
aevi!

Session 5
18
Case: Gastric ca s/p gastrectomy with no complications, awaiting chemotherapy

Examiner: Prof Walter Tan (active) and Dr Jimmy So

While waiting outside, was told that my patient is Chinese speaking, speaks no English!!
Nearly fainted cos my Chinese CMI. (me too hahaha. Helen chinese damn good she from
China. Agree.Juniors, please note that Helen is very hot)

Timer starts when you reach the bed so quickly introduce yourself to the examiner and just
start clerking

Me: What medical problem are you here for?

Patient: Im here for your exam (HAHA oh no)
Me: Do you have any medical problems?
Patient: No
Me: Why did you see a doctor?
Patient: I didnt
Me: Do you have DM, HTN, HLD?
P: Have HTN and HLD
Me: any other medical problems?
P: No
Me: Did you have a surgery?
P: Yes
Me: Why where and what did they take out?
P: I dont know. I vomited.

Finally clerked the presenting complaint of vomiting non bilious and non bloody. Pt was
clueless about everything did not know about scopes/Ix done/surgery etc. I tot that should
be PUD or gastric ca case but decided on the latter cos PUD shld have hematemesis.

PE: just did a quick abdo exam and looked for cx of gastric ca. Did not bother taking vital
signs or looking at the chart cos din think it was relevant.

Examiners came in at 25 mins mark, introduced my examiner and pt.

WT: Present your history

Me: Summary - Gastric ca s/p gastrectomy with no complications, awaiting chemotherapy
WT: Present full hx
Me: Vomiting 1 week historypresented the whole history. WT clarified somethings like did
pt tell you had some bladder problem and I said he didnt know and WT wanted me to ask
the pt again and pt said he didnt so hopefully he ddint mark me down.
WT: Show me how you do a PE
Me: General status nil cachexia, jaundice, dehydration (moist tongue, CRT >2s, good skin
turgor, no sunken eyes, would like to see urine output for objective measurement). Abd
inspection rooftop scar, nil incisional hernia (asked pt to cough). Did a running
commentary. Looking for epigastric mass, hepatomeg, ascites, cervical LN. Nil hernia. WT
said shld measure liver span even if cant palpate cos liver size might still be large

Questions
- DDx for rooftop scar
19
 Gastrectomy, hepatectomy, whipples op
- Is the scar new or old?
relatively new as there is some erythema. But noted no tenderness, incisional hernia or pus
- DDx for vomiting
Gastric outlet obstruction gastric ca, pancreatic ca, cicatrizing PUD
Gastritis
IO
- Why is this Gastric ca and not PUD
PUD likely presents with hematemesis, previous hx of dyspepsia
gastric ca has GOO, LOWLOA, nil dyspepsia or hematemesis
- Why does gastric ca cause LOW
ca tumour cells have high metabolism
vomiting
LOA cos of gastroparesis
- Pt comes in with vomiting on yr night call, how would you manage
Vital signs
take a hx
keep pt NBM
IV plug take blood for Ix, hydration, replace electrolyte imbalances
NGT and catheter I/O charting
- What electrolyte imbalances
HypoK+, HypoCl, metabolic alkalosis
- Why HypoK+
hypovolemia activate RAAS aldoesterone causes K+ excretion
- How to replace K+
Look at K+ levels
replacement and maintenance (1-2 mmol/kg/day)dont exceed 20mmol/hour
ECG monitoring
- Why need to be cautious with K+?
Cardiac arrhythmias
cardiac arrest (heart stops in diastole)
- What Ix would you like to do
Bloods: FBC, UECr (WT read the results to me and asked me to tell him if its normal)
OGD with biopsy (WT said OGD biopsy showed adenoca at antrum)
- What is significance of biopsy result
Look at Lauren classification pt is elderly male so more likely intestinal type
- Was brought to read the CT scan describe what is shown
Mass lesion at the antrum and extending more proximally. Presence of food debris. Gastric
wall is thickened. Presence of peri-gastric LN.
- How would you manage
definitive gastrectomy which can be subtotal or total
- Pt went for antrectomy, how would you decide his suitability for op
Pt factors comorbids
Pt has HTN and IHD so would like a cardio consult. For HTN check if well controlled, DBP
<110 before op. Look for end organ damage. Do Ix ECG, CXR, BP, UECr
IHD ask pt about current/recent symp of CP, SOB. Do ECG, CXR and stress ECG.
- POD 1, what can go wrong?
Infection, bleeding, atelectasis, IHD since has previous hx
- How to tx atelectasis
assess clinically, see vital signs, chest physio, order incentive spirometry, ask pt to sit out of
20
bed

Lessons:
- Pts may not be primed and may not even know their condition so ask them about their
surgical hx and meds hx early on
- If pt not v primed and youre not v sure about the hx and prob just do a quick PE early on
then go back to hx. Can go back to PE oso cos the 25 mins is really yr OTOT
- Read up on pre-op and post-op care as some surgeons dont ask so much about the op
itself
- Thank your lucky stars for good examiners who ask reasonable questions :)
- Learn to take a history in Chinese!

Good luck everybody!!! :)

Case: Liver abscess secondary to distal CBD stone with ?cholangitis

Observer: Dr Lincoln (the NUH uro guy), not sure who were my examiners (dont recgonise
them which i think it is a good thing (: )

When we were waiting outside the exam venue, waiting for our turn to enter, the admin
people will let you know the basic demographics of your patients. So mine was a chinese
gentlemen who speaks English (: half the battle won!

When i entered, i saw Dr Lincoln as my observer, haha heard that he is nice!

So started clerking my patient, Mr Huang. Omgness he is so nice!!

I asked him whats the main issue he is here for, and he said telling me he has
INTERMITTENT FEVER for 4-5 days and pain over epigastric region and also over RHC
and LHC for 4-5 days that accompanies the fever and he was told that he has a liver
abscess!! woohoo dx in the first 2min!

However I figured that i should make this an approach case instead of guiding the examiner
and the questioning to like the surgical techniques and discussion all about liver abcess >.<
So i did a very detailed and thorough hx regarding the ddx of epigastric pain, the cause of
his liver abscess and also complications of the disease and procedures he went for.

In summary:
59 yo chinese gentlemen who was admitted for an acute onset of intermittent fever and
severe epigastric pain for 4-5 days. My differentials are etc etc (listed 20 ddx for epigastric
pain and explained my hx accordingly)
Investigations done in the hospital and his issues are
1) liver abscess s/p percutaneous drainage (D? abx via PICC line)
2) distal CBD stone cx ?cholangitis s/p ERCP
3) asymptomatic AAA

Demonstrated PE, presented as running commentary and showed them the expansile
motion of the AAA.

So basically i timed myself properly at 10,10,5 with the last 5 min to consolidate and
reorganise my ddx and pre-empted the questions they will ask.
21
Questions:
1) Can you tell me more about your ddx? (yes! i prepared this in the 5min so i went on and
on, both examiners were nodding non stop(: )
2) anything else? i was like eh? i listed 20 ddx you know, still got anything else? So i got
probed and probed and guess what? i missed out PUD omgness i cant believe I made such
a mistake in mbbs to exlude PUD as a ddx for epigastric pain. (I guess exam really stresses
you out) But i was allowed to redeem myself and started volunteering what i know about
PUD and what i would like to ask in the hx)
3) Okay good, how to investigate? FBC (got cut off)
4) Come, lets go outside!
Patient: good luck girl! you did well (: yay nice patient impt ++
-given FBC to interpret-
me: this patient has marked leukocytosis with neutophilia and reactive thrombocytosis. So i
am worried about sepsis in this patient. i would like to do.. (got cut off)
-showed me LFT and CRP to interpret-
me: the conjugated bil is high with elevated liver enzymes. This shows a mxed picture,
predominantly cholestatic, hence i would to do US HBS.
- pulls out US HBS-
me: i see a loculated mass in the liver with ?dilated ducts (i am not good at US pls) i would to
see the gallbladder and other bile ducts? haha starting to throw smoke bomb
- pulls out another view-
me: erm. there is pericholecystic fluid, with dilated bile ducts and probably a distal CBD
stone because it is not v well seen, could be blocked by the duodenum. I would like to a CT
scan of abdo pelvis.
(at this point, the MO was nodding like mad)
examiner (finally spoken!): good!
- pulls out CT scan-
me: (omgness i dont know how to read, just saw some masses in the liver but doesnt look
like the usual liver abscess i have seen so decided to throw smoke bomb) i see two masses
in the liver, loculated, ?double walled ?fluid collection. (i dont even ustd myself at this point
of time)
examiner: okay sure. what else you would like to do?
me: amylase, hepatitis marker..
examiner: how would like to manage this patient?
me: I am worried about cholangitis *vomits mgmt for cholangitis* say wanna do ERCP
-pulls out endoscopic pictures-
me: (omgness!) erm this is the papilla, it is cut! oh yes this is spincterotomy with stone
removal!
examiner: okay good, now one problem is resolved. what else would you do for this patient?
me: treat the liver abscess!
examiner: oh wait, there is another slide. here!
- shows me the AAA on the CT scan-
me: oh. i note a mass in the midline structure which is likely the aorta, this is likely the AAA
which measures 80mm. (haha i didnt know how to describe further)
examiner: so is this big or small?
me: big!
examiner: why? whats the normal?
* brain block*
me: sorry sir i cant rmb what is the normal but i assume this is big because i know that one
of the criteria to operate is more than 5.5cm so 8cm is big. (normal is about 2-3cm)
22
examiner: okay sure *smiles and laughs to himself* okay what else would you do for this
patient?
me: treat the liver abscess! which can be divided into percutaneous drainage and open
drainage! this patient can offer percutaenous.
examiner: *nods. you know the complications?
me: yes! *vomits
examiner: okay nothing much to ask you already. hmm okay what are the complications of
ERCP?
me: *vomits
examiners + MO; thank you, go enjoy yourself!
MO: *pats my back. you did well! dont worry (:

thats all! good luck to those who are taking your long case in the next few days! (:

Session 6: Group 2

Case: CRC s/p APR Cx by POD 8 anastamotic leak (currently POD 11)

Observer: Dr Lwin. Examiners: Prof Jimmy So (Active) and Prof Walter Tan (Dont know if
they are profs but they are both profs in my heart cos they are so nice)

Clerked in chinese

Mr Wang 68yo/C/Male

presented with 6 month history of change in bowel frequency, consistency, tenesmus,

mucoid stools with blood streaks and LOW. strong family history of colorectal CA (Both elder
sisters died of colorectal CA in their 50s)

Referred to NUH by polyclinic. Underwent OGD and colonoscopy. Found two polyps (one in
colon and one in anal canal. yes. he could tell me it was in the anal canal. ) Staging
investigations were negative. Went for APR (could tell me he had no more anus) and had
permanent stoma now.

POD 8 started to have a fever associated with LOA. was told he had to have NGT inserted,
kept NBM and needed antibiotics for some infection inside the abdomen.

PE

cachetic. surgical scars noted.

Stoma noted on left side of abdomen. draining greenish liquid. stoma opening was stained
with the greenish liquid that I couldnt really see the spout.

Did not need to do PR but just observed that he had his anus sealed.

Was still on urinary cath as well as surgical drains still in situ.

Examiners came in when they felt like coming in. shook their hands and introduced examiner
23
to patients and vice versa.

Presented the story.

Was told to show him how I did the abdominal examination

Questions:
1) What stoma is this?

2) How do you tell a colostomy from ileostomy?

3) How do they decide where to site a stoma?

4) What are your differentials for his initial presentation?

5) What are the causes of POD8 fever?

6) If you are the HO, and you are called to see this patient with a fever, what would you do?

7) How would you investigate this patient?

mentioned colonoscope so we went out to see pictures! :)

8) What do you see on this colonoscope?

9) How else would you investigate?

(mentioned CT AP and was shown it)

10) What are you looking out on the CT?

11) How would you investigate this patient pre-operatively starting from history all the way to
examination?

12) What is the management for this patient?

13) How would you decide which operation would be suitable for him?

14) How would you counsel him?

15) So the nurse called you on POD 8 about this patient cos he has some fever and abdo
distention, what would you do?
ABC, call senior, try to localise source of infection. Worried about anastamotic leak of
intraabdominal collection/abscess do CT AP. they agreed.

16)you mentioned that he went for FOBT before. What is FOBT?

17) What are the principles of a screening test?

18) What other modalities of screening are there for colorectal CA?

(Prof Jimmy decided to let prof Walter talk)

24
19) So what are the principles of bowel prep before op?
low residue diet, PEG, antibiotics

Bell rang and they released me.

END OF MBBS!!!! :) :) :)

Session 6: Group
Case: Chronic arterial and venous insufficiency with ?arm problem b/g IHD s/p CABG
aka approach to f**king up your history and PE pretty bad

Examiners:

Dr Lim Khong Hee from Mt E and Dr John Tam from NUH CTVS - both of whom were
extremely tolerant and patient, cant remember who watched me take history but he was
nice enough to prompt me to examine, help me with moving the patient around. nice MO too

Mr Chan TK 71 yo Chinese gentleman was very pleasant and tried very hard but either very
poorly primed (ask the earlier sessions who got him) or very well primed to NOT reveal what
he had. i spent 10 minutes chasing his leg problem and vein problem and he would
regularly tell me my brain is not working these few days if i tried to ask him more about why
he was here. he would then apologise to me for wasting my time. sigh.

The patient was in NUH scrubs, lying in bed with both arms wrapped up in bandages.
greeted and asked him about his arms and he said they were ?painful?cold!?!and that youd
better ask me about my legs instead. he subsequently spent the entire clerking time waving
his arms around and said they were more comfortable that way.

so i asked him what leg problem he had and he responded with (the first of many episodes
of) golden, sacred silence (henceforth referred to as GSS (<- GSS also stands for goh shao sheng,
handsome VJ swimming captain). and finally said sth vague about leg pain in his right calf/thigh 3
years ago. any pain mr chan? no pain. any ulcer before mr chan? what is an ulcer. (sigh ok
buang alr) so after a few fruitless minutes digging along these lines i decided to ask him
about past medical history, and expose his legs.

he had bilateral stasis eczema, one random patch of varicosities over the GSV on the
R, ?healed ulcer over the R medial malleolus, some pitting oedema. no other visible
deformities or DM dermopathy or other ulcers

25
has DM, apparently well controlled
had previous heart problem for which he underwent CABG (so i assumed it was IHD, on
hindsight coldnt really find a saphenous graft scar on his legs maybe it was IMA)
attempted to do a systemic review. no signs of infection or LOW/LOA. no prev trauma. asked
if any prev abdominal problems. more silence and then a no. no previous cancer (yes i got
desperate enough to ask that). what meds are you taking? meds for my heart. i used to take
warfarin.

Mr chan do you have any problems passing urine/passing motion? what is motion. my god.
(LOL) any bleeding anywhere any black stools? yes a bit black (ARGH). actually not really.

decided to attempt to examine him, with the examiners helpful prompting. was told not to
remove pants/stand him up but Mr Chan really deserves an A for effort cos he did both of the
above. varicosities. tap test positive. no saphenovarix. actually really gabra-ed this and
totally ignored the left leg. decided to hell with the tourniquet test cos no time alr will offer
later. examined abdomen and found hepatomegaly and more distended veins. mr chan do
you have any liver problem anot? yes i have but the doctor say its not very serious. at this
point i felt, okay. fail lor. offered PR examiner said dont need. chest midline sternotomy scar
H S1S2 ?murmur L ?creps but nvm im not going to present anw IGNORE

so uncle you have a vein problem? more GSS. yes yes i have a vein problem! is it because
the veins cannot work or cos got a clot inside? GSS and more waving of arms. so which
doctor are you seeing? is it a vein doctor? (GSS) yes its a dr. lim. so uncle is your arm
problem related? GSS. mr chan waves his arms around some more. have you had a scan
before? yes. have you had any operation before where they take out the vein? errrrr no.

didnt ask social history/family history. balls lah

examiners came in and i presented CVI with varicose veins, currently on follow up and invx
with scan but not treated with surgery. b/g IHD s/p CABG and DM. then presented my HPC
proper which was so short and poorly taken it was basically a summary. presented PE
findings but said i didnt have time to do the tourniquet test.

asked to demonstrate PE. described all the venous things i could see. described tourniquet
and perthes tests verbally and told no need to do. asked to show pulses so vomited out the
landmarks and said couldnt feel anything. mr Chan fell asleep while i was presenting.

made the mistake of committing to NO concomitant art insufficiency despite being not be
able to feel pulses (i assumed it was the oedema and my paucity of skill). asked how to invx
and offered duplex U/S and angiography (forgot simple invx). was brought out and shown an
FBC which had NCNC anaemia no raised TW. UECr had raised Cr and U. Ignored the
eGFR of 30 and was prompted to say this was renal failure.

shown ABPI and TBI. ABPI was like 2.sth bilaterally and TBI was 0.35 so said sorry i retract
my statement there is art insufficiency. got quizzed on the false elevation of ABI due to his
diabetes. shown duplex report which is basically drawings of legs and veins and very helpful
written descriptions of which vessels are incompetent (he had alot lah). at some point i said
sir i think in view of his prev healed ulcer this is class 5 venous insufficiency but i want to
confirm this on hx

26
tell me about critical limb ischaemia. decrease to limb perfusion potential threat to limb
viability blah blah rest pain tissue loss gangrene ulcers he had none.
how to treat critical limb ischaemia? reperfusion plus minus surgery, treat risk factors
(aspirin lah statin lah shit never take smoking hx advise him on smoking cessation lah
exercise to stimulate collateral formation lah)
what options are there? angioplasty, bypass, i also mentioned subintimal angioplasty
how to decide which one to do? sir it depends on the type of lesion i understand angio is
more for focal stenotic lesions, bypass also needs good distal landing site, pt must be able to
tolerate surgery
how to treat chronic venous insufficiency? brain farted. said rule out arterial, 4 layer
compression stockings, daflon, surgery - high tie at SFJ with stripping (after ruling out DVT)
and stab avulsions
lim khong hee hands the mic over to john tam.
how would you treat cellulitis? iv abx and monitor? some more. uh can consider surgical
debridement (he seemed ok with this but i think he was looking for ABCs whoooops) and if i
suspect nec fasc then aggressive surgical debridement would be necessary

around then they asked for how much time left about 2 minutes. since we were all taking a
leaf out of Mr Chans book and indulging in our own GSS i decided to try and salvage my
shipwreck of a long case by volunteering what i knew about DM foot since mr Chan had DM
and i had mugged it for ortho even tho they were already writing my marks down sigh. then
got asked
what clues would tell you its a neuropathic ulcer? location, pain, punched out
appearance, DM dermopathy
any deformity of the foot yes sir charcots joints

then the GSS became overwhelming and they decided to put me and themselves out of our
collective misery. the MO was very nice tho every time i looked in his direction he would nod
in encouragement and also acknowledged it was a difficult case.

1) dont rely on asking who they follow up with unless you know every damn doctor in the
hospital and their subspecs
2) approach to poor historian is very impt: if the pt is being blur/not forthcoming, offer to
examine first. if still CMI then you can try asking for prev op/planned ops. on hindsight i
would have tried to be more complete in the rest of my hx instead of pegging away at the
presenting complaint and at least remembered to take smoking and social hx.
3) dont ask the examiner if you pass, ask the MO! theyd prolly be more likely to tell you
4) remember to practice clerking in chinese and also get your layman explanations of shit
like angiography/scan/ulcer down pat. what is an ulcer?

GOOD LUCK PPL. THE END IS NIGH FREEDOM AWAITS

Okay Ill just add on to Debs account since its the same patient. Dont worry Deb you
actually got waaaaay further than I did
Was the first to clerk the patient I think and he was really VERY unprimed :(

Examiners: Prof Praba, Dr Cheong Wai Kit and kind doctor (EXTREMELY THANKFUL
cause I think I would have failed it otherwie if they werent all so nice)

71yo/chinese/male - very nice but very very poor historian

27
ADL independent, community ambulant
NKDA

Patient lying in bed, covered completely with a blanket.

Started out by asking Mr Chan why is he here today. He says I had a fall then the
ambulance sent me to the hospital (???) okayyy... so took brief history about the fall.. which
took quite some time because he had to pause quite a bit to remember details.basically
was out with relatives for breakfast, walking back felt legs tired, told relatives to go on first
then fell while walking, had some leg weakness (???) and was sent to hospital. Waved both
his arms around a bit to show his bandages. Sigh. Asked if he had any other problems?
Mentioned heart problem, many years ago, taking wafarin (???) Didnt know what heart
problem he had, said he did not have a heart attack, no irregular heart beat.. (Was anxiously
glancing at my watch cause all this was taking too much time. On hindsight may should have
asked him what problem is he here to talk about today?!) Asked him okay other than this
anything else??? (It was already nearing 10 mins and I was NOWHERE T.T) Kind doctor
watching my sorry state stopped Mr Chan, Uncle, just tell her about your legs.. Oh both
my legs got swelling. Okayyy (but I guess this should have clued me in to CVI since it
was a surg case but my brain went into med mode -.-) Only swelling in the legs, started 2
years ago, I saw a doctor then thats why I am at this hospital lor. Didnt know what was the
problem with his legs, no pain, doctors did nt give him any medication (time was ticking
awayyyyy). Kind doctor again interrupted this time flipping open his blanket revealing 2 black
legs, looked at me and said okay now you know what history to take right???
(OMGGGGGG should have just looked at his legs from the start when he said it history
doesnt always have to come before PE esp if youre going nowhere!!!)

Sped through CVI history. No symptoms other than itchiness, swelling and occasional pain.
No predisposing factors, claimed never had DVT (no blood clot in leg, no swelling of one leg,
redness, pain, warmth), doctors checked his stomach no mass. No complications of ulcers
(any large wound in the leg cannot heal must see doctor), had previous admissions for leg
problem does not know what and why (vaguely sounded like cellulitis as he said ya some
pain some redness and he think he was given antibiotics when I asked specifically). Forgot
to ask about BPH, chronic cough but offered later. Treated with advice for leg elevation,
graduated compression stockings but non-compliant as they were too uncomfortable. No
surgeries performed to the legs. Not bothered by the leg problem too much except for the
occasional swelling.

PMHx + PSxHx of (what I presumed was) IHD (no never had surgery before except my heart
- didnt know what surgery until I specifically asked if it was a bypass - oh yes yes bypass)
on heart medicine. Compliant to medication. Type II DM previously on OHGA converted to
insulin x 1-2 years due to poor control. Not sure about HbA1c. Not compliant to diet, doctor
tell him control not so good. (Didnt have time to screen DM Cx!!!) Nth else.

Stopped his wafarin already didnt have time to ask when or why.

Ex-smoker. Stopped 10 years ago after bypass. Non-alcoholic. Married, stays with wife and
has 3 children. Was a mechanic then policeman currently retired. Job did not involve
prolonged hours of standing.

Rushed to do PE (Likka less than 10 mins how to do everything?!). Kind doctor requested for
28
Mr Chan to shift upwards slightly so his legs could straighten (he was a pretty tall old man).
His hand started cramping after he pulled himself upward with my assistance. Tian, damn
bad but I got no time so told him to Sorry Mr Chan you stretch your hand yourself okay??? I
check your legs okay???) Forgot to stand him up initially cause I was soooo flustered but
kind doctor said its okay no need. Described bilateral hyperpigmentation,
lipodermatosclerosis, excoriations over both LL, stasis eczema with dry and scaly skin, no
scars, no ulcers, obvious varicositis along distribution of GSV on the right thigh, dressing
over the right shin slightly above gaitre area (I scratch until bleed they put bandage for me),
mild pitting edema bilaterally (but his skin was really tough). Palpated for warmth (did not
really feel but kind doctor stealthy pointed to an area partially hidden by his bandage) slightly
red and warm, mentioned possibly cellulitis (nod). No time to do other venous nonsense,
offered pulse. Couldnt feel DP, PT, popliteal, bilateral femorals well felt. (Feeling pulses
spends so much time :OOOOhis skin so thick!!! (yeah i got totally foxed by this sigh))
Offered to do hand-held doppler to check for DT, PT, popliteal.

THEN EXAMINERS CAME IN T.T Kind doctor said okay quickly consolidate. SIMI never
do abdo, respir, cardio and offer DRE T_________________T offered all these later during
presentation.

Introduced examiners and patient. Presented some shitty history due to consolidation of all
of 1 min, Patient with CVI x 2-3 years, on conservative treatment however non-compliant, no
surgical treatment offered, likely complicated by recurrant cellulitis, no ulcers. While
presenting history vaguely saw Prof Cheong giving kind doctor a what kind of lousy history
is this look and kind doctor inclining his head slightly at Mr Chan and giving it a slight shake
(LOL).

Got asked to describe the legs again,

If his varicosities are GSV in thigh where do you think the insufficiency is: Possibly
SFJ sir.
Possibly or definitely?: Definitely SFJ sir!
Landmark the SFJ: 2.5cm below and lateral to the public tubercle
Where is the pubic tubercle: down from the umbilicus to the pubic symphysis, first bony
prominence (then I agar 2.5x2.5 and said SFJ is around here)
Where?: Here sir.
Where?: re-landmarked. Still not satisfied so I whipped out my ruler and actually measured
2.5 x 2.5 :/
Why are his lower limbs hyperpigmented:Due to hemosiderosis sir
Where is the most common site of incompetency: perforators
Show me where: 5, 10 and 15cm above the medial malleolus. Again had to whip out ruler
and measure 5, 10 and 15 cm (was lol-ing away in my own head cause I felt so ridiculous
doing it and Prof Cheong was laughing at me the entire time)
Patient said no history of DVT how do you ask: blood clot in leg, leg swelling, redness,
pain
Why do you think he was on wafarin: possibly AF due to IHD/prev AMI or previous DVT
requiring anticoagulation (never found out why he was on wafarin probably really had DVT
since Prof asked ._.)
Did you find any AF: Sorry sir, idnt manage to. Ideally like to feel for irregularly irregular
pulse.
With his IHD and DM what other problem is he at risk of: PVD sir, on examination
pulses were not well felt except for femorals. This can be partially affected by thickened skin,
29
would like to ask patient for history of claudication, ask about reproducable pain on exertion
relieved with rest, rest pain better with dependency, any ulcers or gangrene though patient
mentiond no ulcers and on examination his toes are not discoloured and are all intact.
Did you notice anything on his abdomen: (sigh). Sir, I was only able to complete
examination of the LL however I would also have liked to examine the abdomen, respi
system, cvs and DRE.

Flipped open shirt and there were several spots of pigmentation and dilated abdominal veins
(T_T GGXX). Felt and hyperpigmentation were nodular and hard Likely lipohypertrophy
from patients insulin injections sir, would like to ask if the patient rotates inj site regularly.
Prof Cheong looked perplexed because he only wanted me to mention the abdominal veins I
think. (oh so thats what they were sigh)

What can the abdominal veins be due to: portal hypertension or IVC obstruction.
Differentiate by looking for retrograde or antereograde flow after emptying the veins. On
restrospect should also have offered to check for hepatomegaly, signs of CLD. Sigh brain
really only works on retrospec. (Sian cause he really had liver according to Deb. PE fail.)
(nvm jiaqian your CVI hx was much more than mine lol i actually totally dieded. i didnt
present the liver or anything besides he has varicose veins basically)

Moved on to Ix. Prof Cheong damn nice helped me to cover up the patient told me to quickly
follow Prof Praba out.

What investigations for him: FBC for leukocytosis ?cellulitis, RP for renal impairment
since DM, LFT for liver problems since possible portal hypertension. (got interrupted here to
read bloods didnt get to offer other things.)
Interpret bloods: NCNC anaemia, no leukocytosis (Prof was scrolling down damn fast I had
to speed read), Na borderline low, urea and Cr elevated, urea more than Cr likely some
element of pre-renal impairment, eGFR low renal impairment likely DM nephropathy
What is this scan: ABI, TBI. Verbal diarrhea all the SBPI, TPI figures. Element of ischemia
likely to have vascular claudication. However not yet critical ischemia as TPI >0.3. ABI was
acutally 2.35 damn high should have mentioned likely calcified vessels due to DM.
What is this scan: venous duplex ultrasound. Used to detect level of insufficiency and any
underlying DVT. Labelled quite nicely but I no see any perforator insufficiency??? Prof says
have but didnt point out where.
How would you treat his CVI: Patient education. Patient non-compliant however. But is not
bothered by any symptoms, cosmesis can consider further conservative. Prof says unlikely
to be compliant. So I would like to offer the patient surgery which includes vomit out all 3.
Which is most suitable for this patient: endovascular laser therapy as less pain and may
not have to stay in hospital for long hence patient more likely to agree (but Prof says actually
all day surgery so no admission required)
How would you treat venous ulcer, what are the principles: If chronic unhealing ulcer,
ask history + Ix TRO SCC. Treat the CVI (elevate etc etc), 4 layer compression bandage,
must check for adequacy of peripheral circulation before administering.
How would you treat his cellulitis: ABC if unstable, septic. Abx target skin commensals
mainly stap/strep - augmentin, cefazolin

THEN THE BELL RANG.

Like that lor. Sigh.

30
QUITE GOOD WHAT your CVI hx was much more complete than mine chill la. on another
note, do we know/will we ever find out why his arms were wrapped up like that -deb. no we
wont. ever.

Session 6:
Case: Colorectal cancer (till now, I have no idea if his was left or right, upstairs or
downstairs, infront or behind)
Examiners: Dr Cheong Wai Kit (NUH head of colorectal), Prof Prabha (NUH Head of Paeds
Surg)

Walked into the clerking area (essentially a 6-bed ward cubicle), immediately ushered into a
curtain-drawn cubicle with patient at bedside and examiner 1 at the foot of the bed. Again I
forgot to start my stopwatch cos it happened all too suddenly. Asked examiner 1 if I could sit
on the bed and take history and he said go ahead.

Mr J, 59yo/Indian/Male
Came in for follow-up and now awaiting 2nd round of chemo on 31st March.
Patient was very well primed, just verbal diarrhea-ed everything out, saying in March 2013
he presented with abdominal pain and visited the GP who referred him to hospital. Found
out to have diabetes in the wards and subsequently started on Metformin. Nothing found at
that point yet.

Next few months began to have PR bleed coating stools, alternating bowel habits (diarrhea
4-5x/day interspersed with periods of constipation), some LOW unquantifiable, LOA,
lethargy. No symptoms of anemia, bone pain, jaundice, headache, air/faeces in urine,
sudden abdominal pain requiring hospitalisation. Elder brother also had colorectal CA, done
similar op 5 years ago. Mr J is single, lives alone, non-smoker non-drinker.

He then had a colonoscope done end of last year, which he revealed to be a RIGHT sided
colon mass, then proceeded to remove about 15cm of colon (he showed me how long, he
could not tell me if its hemi, partial or whole). CT scan then showed to be Stage 3 colorectal
CA. Op was done in Jan 2014. No stomas created so at this point I was assuming primary
anastomosis. Completed 1 cycle of chemotherapy - no SE e.g. loss of hair, fever, vomiting.
Awaiting 2nd cycle on 31st March, a total of 8 cycles to be completed. He is on follow-up
with Dr Cheong. At this point I confirmed with him again if it was RIGHT side he said yes.

Proceed with PE, did a full abdominal examination. (offered examiner 1 for vitals and DRE
he said no need). Nothing significant, just some conjunctival pallor, multiple laparoscopic
scars and one transverse incision at LIF, no midline laparotomy scars. At this point I was
growing a little suspicious of his diagnosis, so asked him for the third time, UNCLE IS IT
RIGHT OR LEFT? He said RIGHT, so I gave it to him.

All this finished in just over 20mins, I had 5mins to consolidate which went by freakishly fast.
Looked at examiner 1 for any clues, nothing.

In steps Dr Cheong Wai Kit (active) and Prof Prabha (passive, from NUH Paeds Surg, what
is he doing here). Heaved a sigh of relief as we all knew we had a 1 in 7 chance of re-
celebrating Chinese New Year. Introduced both examiners to Mr J, and Mr J to the 2
examiners. Obviously the patient was Dr Cheongs patient so no need for formalities there.

31
Summary statement: Mr J is a 59yo Indian male with a background history of RIGHT
colorectal CA s/p possible RIGHT hemicolectomy and adjuvant chemotherapy with no pre-
or post-op complications, currently well and awaiting his 2nd round of chemotherapy.
*pauses for any response* (I then went on to present the rest of the above cos both
examiners stayed silent. All this while, CWK was frowning furiously, so I knew saying the
RIGHT side was a wrong thing.)

Questions
CWK: You said RIGHT CA, what did the patient present with?
Me: Alternating bowel habits, PR bleed coating stools, LOA LOW. At this point Im thinking
this is more suggestive of a left sided lesion but patient reports to me as right.
CWK: What is the most common site of CRC?
Me: Sigmoid.
CWK: And rectum right? Okay and why you say hemi?
Me: Sorry I am unsure if this is a hemi but patient reports as about 15cm of the colon was
removed, this could be a segmental colectomy with primary anastomosis as no stoma was
created.
CWK: Okay tell me about his PR bleed.
Me: (shit forgot to ask, cos I thought this was management case so took his initial
presenting complaint very briefly) I would ideally like to take a more detailed history about his
PR bleed but from what I know, he has PR bleed coating stools, not mixed, moderate
amounts. I would like to rule out any malena of UBGIT. (cannot smoke cos examiner 1 is
there)
CWK: Show me your examination.
Me: (proceeds to do a running commentary of abdo exam)
CWK: Patient comes in with PR bleed and abdominal pain, how would you manage him in
the wards?
Me: Resus ABC, take bloods e.g. FBC UECr then arrange colonoscopy
CWK: What will you do before colonoscopy and after bloods? (this went on for 1-2 mins, with
me repeating my above answer and he repeating his question)
Me: er keep him comfortable?
CWK: What OTHER bloods will you do?
Me: PT/PTT for coagulopathy and GXM if he needs tranfusion
CWK: Patient Hb is 10, would you transfuse?
Me: For a healthy young male, 10 is below normal, I would consider transfusion.
CWK: What if hes well, asymptomatic?
Me: Hmmm I will monitor and still consider later?
CWK: Prabha any questions?
Prabha (opens his mouth for the first time, but still the same expression): You said he has an
elder brother with CRC. What will you be worried about?
Me: It is a risk factor for developing CRC. I will also be worried about familial genetic
conditions like HNPCC and FAP (fumbles with the full names). However I do not think he fits
into the Amsterdam criteria (fails the bait) and colonoscopy does not reveal any FAP.
CWK: Which one is more common? I know both are rare.
Me: HNPCC is more common.
CWK: What else will you screen for?
Me: If this is a female patient I will screen for endometrial, breast and ovarian CA. (then got
stuck here)
CWK: What else?
Me: erm. thyroid? but that is more for FAP?
32
CWK: Okay not thyroid. never mind. Lets say you do colonoscopy for him, you cannot pass
the scope around the tumour. What would you do?
Me: I would stop the procedure, offer an alternative diagnostic modality such as CT
colonoscopy and if not fully obstructed, I can offer repeat colonoscopy. (CWK corrects me by
saying CT colonoscopy also cannot do when fully obstructed)
Prabha: You said Stage 3 CA. Tell me what is involved?
Me: At this stage, the tumour would have been quite invasive and also having nodal
involvement. However no distant organ metastasis at this point.
Prabha: What lymph nodes are involved?
Me: Paracolic LNs prof.
Prabha: If I say para-aortic LNs are involved, what stage would it be?
Me: I would say Stage 3b sir (not too sure, please check! they nodded so I think correct?)
Prabha: So in this case, open vs laparoscopic approach, whats the difference?
Me: Lap has been shown to have shorter hospital stay, better cosmesis outcome, less pain
Prabha: How about long term survival of the patient?
Me: *stunned* hmmm prof I would think there is no difference as it depends more on the
excision margins, nodal clearance *looks at CWK for nods/shaking head*
Prabha: Wai Kit, got any difference not? (haha i think prof prabha also not sure, paeds
surgeon ma. CWK nods his head. ohwells)
CWK: So this patient has undergone laparoscopic approach, what complications would you
look out for on follow-up?
Me: Recurrence of tumour on PE, any wound infection/incisional hernias, general well being
*bell ringssssssssssssss*
CWK: Okay other than incisional hernias, what specifically would you look out at the port
sites? Specifically for laparoscopy?
Me: *face blank*
CWK: Port-site recurrence (WTF IS THAT?) http://www.ncbi.nlm.nih.gov/pubmed/9845574

Observing MO pats me on my back on the way out and said well done. Hopefully thats a
reflection and not a consolation!

Take home points

1) Patients can either be trolling you or totally oblivious to their actual condition. Not blaming
them, but as some tutors mention, take their words with a pinch of salt. This patient probably
had left sided CA according to his symptoms and CWKs constant frowning at my
presentation
2) Know your CRCs well, and their acute Mx and f/u. I felt a bit hesitant in my answering of
his questions. But CWK is known to ask funny questions la haha
3) Know a bit about surgical approaches. Not always asked but I was.
4) The whole exam and Q&A was done at bedside. My mind was half-exploding mentally
pleading them to take me to the COW so at least I know I passed. Anyway, dont fret if they
dont cos sometimes its their style. Checked with other circuits and confirmed CWK and
Prabha dont use the COW for discussion lol.
5) Specialists can still take their own subspecs. I bet CWK had a lot of fun tekaning me -.-

Hey did u look if patient got totally implantable intravenous access for chemotherapy? I
didnt. He pointed to the vein site but i didnt feel lol. wasnt asked anyway.

Session 4: Examiners Prof TC Lim (nuh plastics) and an indian prof who is in the
33
picture shown above.
Case: Colorectal Cancer

Observer for hx taking: Dr Wu Qing Hui (super super super nice)

Typing this here as I got the same patient as the above.

59yo/Indian/M

Super nice guy, was smiling at me when i entered. Introed myself.

Patient was a very nice guy, genuinely trying to help, but extremely long winded and speaks
very slowly. He also spoke out of point several times which made me damn kanchiong as
time was running out. Only managed to get pertinent history from him, didnt even have time
to explore social hx. but thankfully the examiners didnt ask.

Presented the case as : 59yo/Indian/Male with significant family hx of colorectal cancer, was
diagnosed with colon cancer few months ago s/p anterior resection with primary
anastamosis and is currently undergoing adjuvant chemotherapy.

It took me almost 5 min before i got any history relating to the CRC from the pt. Initally asked
why is he here today? Pt started going on (while speaking extremely slowly) about how it all
started when he was diagnosed with DM few months back. Made me think..new onset
DM..cld it be pancreatic??

Long story about how he went to see GP for DM, given metformin etc etc. Until he finally
said he had abdo pain. Abdo pain was also in an odd location, affecting the entire
suprapubic region. Pain progressively worsening over 3 months and he thought the
metformin was the cause of the pain so he went back to the GP blah blah.(really wasted
alot of time cos i didnt want to cut him off too abruptly) Then he said he had diarrhea and
LOA and again i was still puzzled with the diagnosis. Until he finally said, the GP sent him to
the colorectal clinic to do a colonoscope (FINALLY).

Asked patient if they found anything on the scope, he said yes thats why must do op (okay
heng, colorectal ca) went for CT AP also, CT clear. now doing chemo.then started
elaborating more about the entire colorectal ca hx. SOCRATES the suprapubic pain, asked
about diarrhea and all the bowel symptoms. Pt had change in bowel habits, alternating
diarrhea and constipation, pencil thin stools and per rectal bleed. dark red, coating stools,
small amounts. Asked pt if they told him the mass was in large intestine or rectum, he said
large intestine.

Thoughout the entire time while patient was going off about irrelevant hx, Dr Wu was being
extremely nice and kept telling me to calm down and that he is here to help me. He told me
this at least 4 times. Pt was also abit too well primed as everything you asked him, he wld
say yes. when asked if he had constant urge to defecate but cannot do so he said yes.
confused me abit why suddenly got tenesmus but i decided to ignore it in the hx since this
wasnt a rectal ca. He then started telling me long story abt how he didnt know he lost weight,
but yet he did. asked how much, he didnt know. how he know he lost weight? he also didnt
know.. sigh.

significant family hx of colorectal ca in brother. he told me his brother had tumour in the
34
small bowel and started pointing to his epigastric region. was super stunned. Lucky Dr Wu
stepped in and said he means transverse colon. Otherwise no significant familial GI stuff or
IBD.

PE was super rushed also as i only had 5 min left and i hvnt consolidated my presentation
yet. pe was unremarkable except for a scar at LIF. kept asking him if he had a bag put in
after the surg, he kept telling me yes and there was urine inside -.- until again, Dr stepped in
to prompt me to realise there was never a stoma put in for the pt and primary anastamosis
was done.

Did PR on the patient as well, was hoping he wld reject but he said okay. nth much on PR as
well.

25mins, examiners stepped in. FIRST thing was to look and omg it wasnt prof cn lee and my
heart jumped for joy.

presented my hx as above. examiners listened without cutting me off. was asked what were
my differentials. gave differentials as for LBGIT. seemed satisfied, moved on.

Did PE in front of examiners, made extra show of asking pt to cough to show no incisional
hernia and pulled pants down damn low to show no inguinal hernia also. Pt had some weird
muscle spasms from cold and when i palpated his abdo, he JUMPED and made examiners
proptose as it appeared like i was causing him pain. luckily he clarified. was asked to
measure liver...whats normal liver span and if i expect it to find hepatomegaly. show to
examine for splenomegaly also. Prof Lim kept asking me if i expect to find dullness now, said
no cos no splenomegaly. then he kept asking until i just gave him a ??? look then move on.
demonstrated shifting dullness also.

After few more qns (cant rmb alr) then went outside to look at scans..
What Ix you wna do? said to confirm my dx i wna do colonoscope to biopsy etc. but cos the
first slide prepared was the FBC result and not scope, prof kept prompting till i said bloods
first only said fbc and it was flashed to me, didnt even get to mention other bloods.

FBC showed microcytic anemia. prof asked why..said Fe def anemia secondary to bleed.
didnt even see the tiny CEA result at the bottom till they pointed it out. it was normal. said
even if normal doesnt rule out CRC. Prof asked how many percent of CRC pts have positive
CEA? said i dont know..

Then next investigation to read was colonoscope. showed a lesion with areas of bleeding,
not completely obstructing lumen. Asked examiners which part of the colonoscope this is,
they just hmm.not sure. i was like lol okay. but subsequently the indian prof said what do
u think, left or right. said left in view of pts symptoms and surgery done. he agreed and said
prob sigmoid. asked what else to do..i said must bowel prep before scope. asked when do u
not bowel prep..said perforation and IO.

was asked to read CT. asked what cut. coronal cut. prof pointed to liver and asked me
whats this lol.

just briefly mentioned no lung mets no liver mets. was asked what else can see in liver but
liver looked completely normal so i didnt know. was asked to point tumour out. pointed to a
35
random mass around the area, both profs were like are you sure? and then they realized it
was the wrong cut shown. lol. so they scrolled down and tumour was pretty obvious. asked
what else to see on ct scan? lymph nodes. where do u find the LN? i said they follow the
blood supply of the colon, so IMA. then they ask me to point where IMA is i didnt know.
then they prompted asking me how contrast flows in CT scan etc and then i pointed to this
bright vessel which was correct. and said no obvious masses around it that looks like LN.
also no local invasion of the tumour.

Was asked how to stage CRC, said TNM and Duke but elaborated on TNM. gave a brief
elaboration and prof just nodded...lol i think he cant rmb the details himself.

asked abt management of this patients CRC, whats the significance of staging the cancer.
mentioned it affects curative vs palliative management.

Last qns : do u think CEA will be useful for this patient? i said may not be as original levels
were normal so may not rise even with recurrence.

and thats it!! ended my long case more than 5 min early and stood there chitchatting with the
random MOs standing around.
thankful that both examiners were pretty chill and nice.

Session 6: Group 4:Colorectal cancer (sigmoid tumour) s/p resection.

Examiner 1: Mr Chong Choon Seng (NUH, colorectal)
Examiner 2&3: Mr Peter Robless (active), Mr Iyer Shridar (passive)

Was told by the DO lady who escorted me to the patient that he was a Mandarin speaker but
then i would get a translator to help with history. Was slightly nervous at the thought.

Went in, saw Mr Chong and breathed a sigh of relief. Then saw that there was only one chair
at side of bed and requested one for the nurse. I sat on the chair, nurse brought in one for
herself and Mr Chong sat at the foot of the bed. (Might have gotten a bit of a brownie point
for asking for that chair haha, if not very weird for me to sit there and talk to patient with the
nurse standing behind my back.)

Tip for those who will need a translator: sit and face the patient and direct your questions to
the patient as much as possible, this builds rapport with the patient (this patient actually
knew enough english to give me most of the history). Have the translator sit behind you or
on the opposite side of the bed so that you can turn to them and ask for help if necessary.

History: Mr Lim, 55/Chinese/Male, NKDA

PMH: HTN on amlodipine 5mg OM, Gout on diet control
Prev surgeries: about 15 years ago for piles
Prev hospitalisations: 10 years ago for cholecystitis, no op done then

Presenting complaint:
Cancer of the colon, operation done in Feb 2013
First symptoms were 15 months ago: had lower abdominal pain and bloating with a lot of
wind and constipation. Went to GP (family doctor) who gave him charcoal and a sweet
liquid to help with the constipation. The GPs medications helped the symptoms for awhile
but they came back and he went back to the GP again. This time GP decided to take a blood
36
test and a stool sample. Stool sample came back as positive for blood. Blood test had a
number that was in the hundreds when it was supposed to be very low (hypothesized that
this was a tumour marker).

Then referred through polyclinic to NUH, where they did a scan and a scope.
During the scope, they said they couldnt get past the tumour.
So a CT scan was done, was told that he had a left sided tumour, which was about 2.5 or
3cm.

Had a single episode of hematochezia about 2 weeks prior to onset of abdo pain, which he
didnt think was significant because of his previous history of piles. Blood was coating the
stools.

Did see a reduction in stool calibre

Had no alternating constipation and diarrhea.
Had episodes of tenesmus during the abdominal pain as well (times when he had a painful
urge to pass motion but nothing came out when he went to the toilet).

Social History:
Non smoker, non drinker
Works as a taxi driver, stays at home with wife and 4 unmarried adult sons, aged 32, 28, 24,
22. The youngest has Downs syndrome.
Disease did not affect ability to work, able to go to work after surgery.
Finances were not stretched thanks to the CPF and Medishield (he thanks the PAP for this
haha).

Family Hx:
No family history of colon cancer
Only first degree relative to have cancer is youngest son who had leukemia at age of 1.

Post surgery:
No immediate complications, uneventful hospital stay of about 5 days, able to eat and drink
afterwards. No stoma was created.
Was told that his cancer was stage 3 because out of the 11 lymph nodes taken out, 4 had
cancer.

Questions i should have asked but didnt:

- any symptomatic anaemia prior to op
- any loss of weight or appetitie prior to op
- any chemo done before or afte the op
- any diarrhea after the op and how significant it was

Physical exam:
Unremarkable peripheries,
Midline laparotmy scar, no incisional hernia, no inguinal hernia,
No palpable masses, no ascites
Bowel sounds normal, no bruits

PR exam offered and told not necessary by Mr Chong CS

Vitals requested and done by nurse, unremarkable.
37
Questions asked:
Did you ask about symptomatic anaemia?
- didnt ask.
Did you ask about loss of weight or appetite prior to op?
- didnt ask
How did you check for hernias?
- stood at foot of bed and asked patient to cough and looked for any masses that came up
- also exposed inguinal region and asked patient to cough.
(Dr Chong chimes in here with a smile and says Yes, he really did!)
Did you check for lymph nodes
- No, I did not.
Which lymph nodes would you have checked?
- Left supraclavicular as well as inguinal
(Examiner 1 is present when you are asked these questions, so dont lie, if you didnt ask or
didnt do just be honest.)
Okay lets move out to take a look at some tests
*Examiners 2 and 3 move out with me to a computer, computer has slide show with name of
patient*
How would you investigate this patient if you saw him when he was referred from the GP?
- FBC: looking for anaemia
- LFT: for any derangement, likely to be none
- PT/PTT because he is going for op
Do you expect it to be deranged?
- No, just to be sure
- Renal panel as well
Anything else?
- If he was going to go for op in the next 48 hours, a GXM. (Im not sure if it should be 48 or
72 hrs but i just said 48 and they didnt bother to correct me)
- And a tumour marker, CEA to monitor response to treatment.

What is the role of tumour marker in this patient?

- I have been taught that tumour markers should not be used for diganosis or screening and
are mainly useful for follow-up to detect recurrence. This is because they tend to be sensitive
but not specific enough for diagnosis.

What is sensitivity and specificity?

- a sensitive test would be positive in the presence of the disease but can be subject to
confounders. A specific test on the other hand would only be positive in the presence of the
disease.
(examiners kinda frowned at this point)
- a sensitive test helps to rule out a disease if its negative while a specific test, if its positive
enables you to rule in a disease.
(didnt seem fully satisfied but moved on)

What is the difference between screening and diagnosis?

- screening is for the asymptomatic patient, where the aim is to find the disease before it
causes symptoms. Diagnosis is for the symptomatic patient.

Anything else you would want to do in the clinic?

38
- DRE, proctoscopy

What would you be looking for in the DRE:

- tumour, whether it is hard, whether there is contact bleeding. In terms of distance from the
anal verge, would want to know whether it is more than 7cm, because the sphincter complex
is at 5cm from the anal verge and the distal margin for a well defined rectal tumour is 2cm so
if it is more than 7cm from the anal verge then sphincter-sparing surgery can be considered.

How can you be sure that this patient is not in acute I/O?
- he was still passing stools and flatus
- did not complain of vomiting and progressive abdominal distension

This patient presented with symptoms suggestive of subacute I/O, would you do a
colonoscopy?
- A full bowel prep necessary for colonoscopy would not be suitable if this patient is in
subacute I/O, so probably do a fleet enema and a flexible sigmoidoscopy.

Describe sigmoidoscopy pictures:

- Fungating lesion, areas of hemorrhage and necrosis, dont see a way through the lesion
Are you sure, what about his picture? *points to a picture which shows normal mucosa*
- Ah, okay, so maybe not completely obstructed.

Would you do a biopsy for this patient?

- initially said yes because i want histological confirmation.
Do you really need histo confirmation in a patient like this who has such a classic history and
gross appearance?
- ideally i would still want histology
Would this lesion bleed if you took a biopsy?
- Yes, probably, so i would like to retract the statement please.

Describe CT scan (saggital section)

- tumour in sigmoid
- no lesions seen in this section of the liver and lungs
- no LNs seen on this cut
Any features of acute obstruction?
- said no because there was fecal matter visible in the rectum.
Describe CT Scan (coronal section)
- cant see any LNs or tumour. nothing in the lungs or liver again.

What investigation would you want to do to definitively exclude mets?

- ideally a PET-CT, not sure of the specific tracer
Was told that ideal would be FDG-PET.

What are some of the long term complications of surgery?

- possibility of anastomotic breakdown
He has a shortened gut right...?
- Ah yes so he would probably have some diarrhea after the surgery
Did you ask him?

39
- not specifically, but he said he was satisfied with his bowel habits after the surgery and he
was able to eat and drink normally as well as able to go back to driving his taxi so I dont
think any diarrhea was significant enough to impair his function.

Its 11pm on day 2 after surgery and youre on call. This patient has some fever and
breathlessness. what would you do?
- First I would go and see the patient
Haha, thats a good start! What would you do when you see the patient?
- I would want a set of vitals. My main concern would be to rule out a pulmonary embolism. I
would examine him for any features suggestive of DVT such as lower limb edema, and
reduction in SpO2 requiring increasing amounts of oxygen.
His SpO2 is about 93% on room air, would you be concerned?
- yes I would be concerned, would want to give him some oxygen first, put him on a Hudson
mask with 5L of oxygen then asses the response. I would put him on hourly vitals monitoring
for now.
So would you want to do a CTPA in the middle of the night?
- First I would do a risk assessment with the Wells score..
Okay, but what is a more common cause of breathlessness and fever post op?
- Atelectasis
*bell rings*
Yes, so you should examine his breath sounds and do a CXR first.
- Okay, thank you.

Thanks for adding! Congrats on finishing!!

(Session 8: Group 5: patient told me it was right sided colorectal cancer too. turned out be a
left sigmoid cancer -.- I was taken by Dr Lim Khong Hee from Mt E and Dr John Tam from
NUH CTVS. examiner 1 listening to my history taking and observing my PE was dr lincoln
tan from urology NUH)

History is similar to the the one presented above. no symptoms of anemia. offered to do PR
and vitals but dr lincoln tan tell me it is okay no need. then two examiners came in leaving
me barely with time to consolidate my thoughts
Questions asked:
LHK: What in your history doesnt tally?
ME: errrr.
LHK: Okay how does right colon cancer usually present?
ME: symptomatic anemia
LHK: Does it usually cause bleeding?
ME: No sir.(I spent quite a while thinking before I said) it could be left sided cancer or rectal
cancer sir
LHK looked at me with a disapproving look. I bet he thinks I am cui already. Too those
reading, this is not the way you would want to start the exam.
LHK: Please perform the PE in front of us.
(ME went on reluctantly to do PE even though there was nothing except lap scars and more
scars)
LHK: do you start with abdomen first?
Me: no sir i look at peripheries first
LHK: what else would u look for?
Me: (stoned for a while before I said) just now I palpated for cervical lymph nodes (in front of
40
Mr lincoln tan) but didnt feel any
LHK: but you never told us
ME: sorry sir
LHK: what else
ME: I would look for peritoneal metastases, listen to lungs
LHK: what else
ME: I would look for ascites
LHK: demonstrate shifting dullness and fluid thrill
ME: (went on to perform shifting dullness and fluid thrill though there was nothing)
LHK: how does colorectal cancer spread?
ME: lymph nodes and through peritoneal cavity
LHK: what else?
ME: (thought for a long time) skin?
LHK: (chuckles)
ME: sorry sir I am not very sure how else (in retrospect he could be referring to falciform
ligament)
JT: so why do you think it is right sided?
ME: patient told me
JT looked at patient and thought for a while and then goes and write something down
LHK: How to differentiate between left sided and right sided colorectal cancer?
ME: left sided blood coat stools, right sided blood mixed with stool
What are your differentials for this patient?
ME: colorectal cancer, hemorrhoids, (the last two I just crapped one) diverticular bleed,
upper GI bleed
Anyway during the process I even volunteered hepatomegaly though afterwards I retracted
it. I swear I felt a phantom liver at the start. exam really does crazy things to your
propioception. Anyway all the while I was looking at my watch praying that I can go out
before the 40 min mark.
At the 40 min mark, LHK: so do you think it is right or left sided cancer?
ME: left sided sir
LHK: okay lets go out
ME: ( thanked the patient before scurrying out like a squirrel)

LHK: What are your investigations?

ME: FBC, UECR, for complications, colonoscopy and biopsy for diagnosis and CT abdomen
pelvis for staging
LHK: What else?
ME: ..
LHK: What investigation would you look at when patient comes back for follow up?
ME: CEA sir
LHK: what do you see on the CT scan?
ME: air fluid levels in the ascending colon
LHK: u sure?
ME: sorry just air in the colon
LHK: what else
ME: there is a tumour at the top left hand corner
LHK: u sure?
ME: no sir actually it is a tumour at the sigmoid colon.
LHK: How would you treat the patient?
ME: anterior resection for sigmoid cancer with ligation at the root of the inferior mesenteric
41
artery and adjuvant chemotherapy as this was stage III sigmoid CA
LHK: How would you counsel patient for operation?
ME: risk of operation: bleeding infection, anesthetic risk: AMI and stroke, anastomotic leak
and recurrence
LHK: What would you do in event of an anastomotic leak?
ME: call my reg, may have to bring patient into OT
LHK:You would bring patient into OT for suspected anastomotic leak?
ME: no sir, i would do a CT scan first
LHK: How else would u look for anastomotic leak?
ME: fever, tachycardia, tachypnoea, rebound tenderness, guarding and look at the drain
contents
Ice cream bell ringggggggggggggggggggggggggg

Take home points

1) really have to double check triple check patients history whether makes sense.
2) luck really matters for MBBS. you are really as good as your patient allows you to be. pls
be a good person and accumulate good karma. dont scold vulgarities, help old lady cross
the bridge, etc

Session 6: Group 3
Case: Chronic venous ulcer over dorsum of left foot complicated by recurrent
infections
- Examiners: Dr Charles Tan, and a nice lady examiner
- Observer: Dr Ridzuan Farouk (he wasnt your normal observer and was quite active during
the 10 minutes and also during your pe as well which is quite good actually! damm lucky)

42/M/female
No PMHx
Complaint of left dorsum foot ulcer
- Asked about ulcer...then got her to remove the blanket immediately to look at the ulcer in
like 1 min into hx
- ruled out all causes of ulcers: arterial (no RF, no claudication, no rest pain etc.),
neuropathic (no rf for neuropathy etcetc no dm alcohol famhx lead chemo/cancer not
vegetarian), malignant (no famhx of skin cancers, no low/loa, no contact bleeding, no
inguinal lumps, no tcm/tmm), pyoderma gangrenosum (no ibd symptoms, no autoimmune
symptoms)
- Venous hx (prolonged standing in job, otherwise no significant risk factors/ pu/bo normal)
- asked for management so far:
- tx with 4 layer compression bandage, 1 episode of complete ulcer healing, subsequently
recurred, repeated infections before (2X) treated with hospitalisation and antibiotics, in view
of recurrence and non-healing, asked if they did any biopsy, pt said yes and said found
nothing,
asked if they ever told her about any skin graft procedure, she said told not an option doctors
said ulcer infected, and dorsum blood supply not good or smth, was told by nuh surgeons
after this ulcer healed, might be suitable for vein surgery
- invx so far - ultrasound scan of leg
- ruled out secondary causes of varicosities: no prev dvt/pe, no fam hx dvt/pe, no chronic
cough etc, no increase abdo girth, no fam hx of colorectal/ ovarian cancer, no change in
bowel habits pr bleed mucus etc, pre-menopausal, no heaviness in pelvis, no significant rf
for ovarian cancer (all the menarche stuff quickly), no imb/pcb, no hx of birth marks/ dilated
42
veins elsewhere
pmhx: nothing significant
social: only occupation prolonged standing, otherwise nothing much

physical examination:
- so summarised for pt and told ill proceed to examine, dr farouk was like okay tell me what
youll want to do along the way
- so okay examined the ulcer, checked monofilament, checked arterial pulse, crt
- said ill like to check the groin to look for inguinal ln, concomittant hernia coz raised
intraabdo pressure, saphena varix, palpate femoral pulse, den this is when dr farouk became
super duper helpful
- he said in view of pts modesty and convenience, its okay dun need to remove her pants ill
tell you what she has. so no varix, no cough impulse, fem pulse 2+, no hernia,
- said wanted to do tourniquet test to look for level of incompetence (they had like 3 foley
catheter on table) - dr ridzuan just said...dun need :)
- decided to abuse my newfound power by saying: do digital rectal exmaination to check for
rectal masses, blummer shelf (negative); do a bimanual palptation for any ovarian or uterine
masses (negative)
- went on to examine abdomen for any dilated abdo veins, abdo masses (negative)
- said wanted to examine rest of body for varicosities and telangiectasias (dr farouk said
once again okay negative)
- so ended with like 2 minutes den dr farouk said anything else you want to do? so requested
vitals etc (all normal), den decided to start summarising my hx

at exactly 25 min dr charles tan and nice lady examiner came in

- presented hx, den when i said so now ill like to go on to present pe, dr farouk started telling
them...so this student requested to do quite alot of things but in view of pts modesty and
convenience i just told him findings XD (so nice rite)
questions:
1. Why do you say its a venous ulcer?
2. What about the location that makes it atypical?
3. What are the types of ulcers you know?
4. How do you distinguish them?
5. What are some features of an arterial or neuropathic ulcer? In this patient, what is
particularly worrying/ why did they do biopsy? Dr. Farouk who was observer then started
asking what nerves are you testing for the monofilament testing. so sural saphenous tibial
deep peroneal, and what root? l4l5s1
6. What are the factors that can contribute to poor wound healing? Pathophysiology of
venous ulceration?
7. If this patient has diabetes, something about mechanism for poor wound healing (the aziz
triad - neuropathy, immunopathy, vasculopathy)
8. How will you work up this patient in the clinic? abpi duplex blood tests etc.
9. What do you expect to see on a venous duplex?
10. What is a normal arterial duplex? How many different flow patterns do you know? What
do they mean?
11. What other investigative procedures can be considered besides the duplex to look for
arterial disease? ct angio/ digital subtraction angio
12. How do you do ct angio? how do you do dsa? complications of procedure?
13. Any other modality you know for venous system? mr veno, conventional venogram
*okay lets go out*
43
*showed a series of investigations most essentially normal one* (just said essentially normal/
normal but this test is impt to do this/ check renal function may need contrast/ may need
invasive procedure check ptptt/platelet, check for infection etc...but all normal blood tests -,-
)
14. Was shown arterial duplex, describe. normal abpi, tpi, arterial duplex did not show any
significant stenotic lesions, triphasic waveform
15. Was shown venous duplex, describe. ssv no incompetence, lsv tributaries showing
incompetence below level of knee
16. Manage pt? Pt ceap 6 active ulcer, manage conserv, adjunct medical can be considered
like dalfon, surgery if healed to prevent recurrence since superficial dx only, can consider
skin grafting if prolonged non-healing, otherwise compression bandage leg elevation
decrease standing etcetcetc
17. What types of skin grafts do you know? ssg vs full thickness skin graft and mentioned
differences, sites to graft, layers removed, usual indications
18. What is important for a skin graft to take at the recipient site? blood supply underlying
must be good
19. So what types of venous surgeries will you do after the ulcer healed?
high tie ligation sfj strip lsv to knee stab avulsion v.s. evlt
20. What are the differences between the 2 and differences in outcomes?
mentioned same rate of recurrence and outcome, by evlt less length of stay, less pain cause
stab avulsions painful), smaller scar, faster healing (but i think the lady examiner said pain is
similar for both but yes the others okay, and rates of recurrence similar)
21. Okay, so any other treatment you can think of or essentially youll just wait it out for the
patient with compression bandages at this stage? (not sure what examiner wanted so i just
said...ya wait it out...den they both laughed, then they checked with MO den MO said around
<1 min left. so okay you can go)

It really really helps when you have a nice patient and good examiner! Good luck guys!

Session 7: Group

Case:
Hepatic Abscess secondary to Cholecystitis with an incidental Abdominal Aortic
Aneurysm
Nil PMHx (woohoo)

Examiners:
Mr Wu (examiner 1): he was supposed to keep quiet and all, but he was too excited lol.
asked me what the PTC was to check if I got it right, asked me what my differentials were,
advised me to have a list of differentials. made me worried man, thought he was preparing
me for the fires of hell.
Mr Gopal (active) I dont know what his full name is, he told me to call him Mr Gopal, I
glanced at his name and there was a Kri-somethingsomethingsomething (Walao Aly dont
racist leh), Prof Lim Thiam Chye (passive)

P/C: severe intermittent right hypochondrium pain associated with high (Tmax 38.7) spiking
fevers, chills and rigors of 2/52 duration not responding to oral antibiotics. Admitted,
underwent PTC drainage and IV Abx, currently 2/52 into treatment

Approach: TRO cholecystitis, ascending cholangitis, acute pancreatitis, acute hepatitis and
44
acute PUD.

O/E: PTC with stoma bag over, draining hemoserous fluid. PICC on right forearm. Visible
pulsation in left para umbilical region. Nil tenderness, organomegaly, murphys sign -ve. Nil
ascites. expansile mass 5cm in diameter that does not extend upward beyond 5
fingerbreaths below the xiphi sternum ~ transpyloric plane. therefore infrarenal. Nil murmurs
suggestive of valvular lesion, nil stigmata of IE (hematogenous spread) or CLD.

took Hx for 15 min to screen for the D/dx, then did abdominal exam, then CVS and respi
screen. No need to take vitals because they provided a chart (how awesome is that?). No
need to DRE because they told us not to DRE unless we suspect an abnormal DRE
(HURRAH)

Presented uninterruptedly, a whole bunch of negatives frankly. Was asked to demonstrate

abdominal examination, so I did. Demonstrated the expansile mass:
Qns:
1) If you notice a pulsatile mass in the abdomen what must you do?
- Proceed with caution and palpate gently (they nodded their heads with great approval LOL)
- Palpate peripheral pulses (somehow this didnt matter so much)
2) How do you define a AAA - demonstrate expansile mass, then demonstrate tracing AAA
up till it is no longer palpable

Ushered out to discuss case:

1) What are your differentials
- I said hepatic abscess, then they said: really? thats your first thought?
Then I offered:
cholecystitis, ascending cholangitis, acute pancreatitis, acute hepatitis.
Prof Lim: Anything else more common?
Me: Lower lobe pneumonia?
Mr G: good thought
Prof Lim: nothing else more common? *incredulous look*
Me: recurrent pyogenic chola Im not sure sir
Prof Lim: Acute PUD? (whooops! but HIGH SPIKING FEVERS LEH)

2) How would you investigate

Me: Imaging: erect AXR, ultrasound HBS, CTAP
Bloods: FBC, LFT, CRP, Blood C/s
Shown ppt of FBC, described, shown LFT showing obstructive picture, raised CRP
Shown u/s HBS: describe: hypoechoic lesion in the liver with heterogenous echoes, no
posterior acoustic shadow, well demarcated, likely to be abscess. shown another u/s image
of gallbladder with sludge, thickened walls, pericholecystic fluid.
shown CTAP: liver with abscess in it, describe hypodense lesion with well-defined margins, i
couldnt see any rim-enhancement and neither could the examiner yay. GB enlarged with fat
stranding, thickened walls. No stone seen. requested for another cut to examine for CBD,
pancreas. No other cut. Requested to see cut with AAA. Cut with AAA shown. 8cm! Said:
Sir, this CTAP shows a large AAA of 8cm in diameter, minimal thrombus formation, no
visible dissection. I would like to counsel the patient on the need for surgical management!
Examiner: okay (end of AAA story wow)

3) How would you manage?

45
resuscitate, IV abx, monitor vitals, input output
drainage procedure, culture and gram stain fluid before starting ABx.
- Mr G: what abx?
- ceftriaxone and metronidazole, my best friends
- Mr G: okay why?
- gram negative cover and anaerobe cover, and shootmyselfinthefoot to cover for amoebic
abscess
- Mr G: oh? which one covers for amoebic?
- me: metronidazole sir
- Prof Lim: IS THAT WHAT THEY USE TO TX? me: yes?? MO, Mr G, looks doubtfully at
each other. (yes youre right!)
4) okay so what considerations must you take before draining
- check PT/PTT/INR, contrast allergy, renal fxn, asthma, metformin (okay okay go on?)
- um. Do it under radiological guidance? to prevent damage to surrounding structures?
- Mr G.: okay so how will you do it under radiological guidance
- . . Using the seldinger technique?
- Mr G: yeah, okay, so what is the seldinger technique?
- (damn, smoke fail), um, I use an introducer, to introduce the tube? mumble something
about a needle, trochar, *foam foam foam*
- Mr G: what else? you use a guide wire right? *face palm* yessir
5) okay so after drainage the patient doesnt respond what would you do
- take another culture. re-scan the patient to look for loculation, reposition the PTC?
-Examiner: okay, go look at the scan again
-me: OH, sorry sir, the GB is likely the source of the infection and thus I would like to perform
a cholecystectomy to remove the gall bladder and also evacuate the abscess
- examiner: you mean open drainage of the abscess me: uh, yes sir, open drainage
#sonotasurgeon
6) How would this help?
- remove the source of infection? IV abx unlikely to penetrate the abscess

learning points: when they ask you to demonstrate, can do a running commentary. saves
them from asking you what youre doing HAH. Save some time for consolidation, it really
helps! say the general things first, ALWAYS. even if the dx is pretty certain. For scans, just
describe as much as possible. okay I was really blessed with a fantastic patient who spoke
good english, and wonderful examiners. Hope you all will get the same too!

Session 7
Case: Choledocholithiasis
Patient is the best historian Ive ever encountered in my 3 years of clinicals. Seriously. BEST
HISTORIAN.

Observer: Dr Lincoln Tan (NUH Uro)

Presents with 6 months of upper abdominal pain associated with bloatedness

sharp stabbing pain, 10/10
radiates to back/scapula
no baseline pain, usually the pain-free intervals are really pain-free
not associated with fevers, did not notice jaundice. No previous admissions required for this
similar complaint
46
unrelated to food intake, not relieved or exacerbated by any positions
consulted GP twice and treated for gastric, no improvement
episodes started increasing in frequency
nil relief with panadol
arranged for appt with NUH, consulted private physician before that to do some
investigations
diagnosed with gallstones
also noted to have some loss of weight but not sure of the time period
admitted following NUH appt, and 3 days before that had obstructive jaundice (she could
even tell me she had teh-o dark urine and pale stool), and was told by the NUH physician
that she had jaundice
more investigations done, negative hepatitis serology
confirmed presence of gallstones, ?ERCP done
arranged for surgical consult
lap chole scheduleded
nil complications, recovered well, obstructive jaundice symptoms relieved, now just slightly
yellow urine but no longer having acholic stools
nil wound tenderness etc

PMHx
appendisectomy 20+ years ago
2x caesarian section
hysterectomy for fibroids 2 years ago
hypertension on amlodipine

Drug history
amlodipine
not on TCM
allergic to ampicillin

Family history
Father had lung cancer. otherwise no significant family history

Social history
married with children, no financial issues
no recent travel

PE:
unremarkable actually. just a few scars for the proceures mentioned above
nil abdominal tenderness, no palpable masses
just some slight scleral icterus
did a quick listen to the heart and lungs, clear
offered PR, examiner said no need

DINGDINGDING

In steps Dr Lim KH (active) and Dr John Tam (passive). Proceed to introduce them to my
patient

47
LKH: can present your history
(history presented)
LKH: Ok, show me how you examine. can do a running commentary
So anyway i gabra-ed a bit, essentially presented the scars and the slight scleral icterus. To
be honest i cant really remember this part very clearly, i must have been in spinal mode
LKH: what are your differentials
Me: choledocholithiasis (since she had obstructive jaundice), cholecystitis, lower down on
the list would be things like cholangitis, would be worried of possible pancreatitis but also
less likely. for obstructive jaundice would also worry about HOP tumour as she also has
LOW but also less likely because that would be painless progressive jaundice
LKH: ok lets discuss
so we walk over to the COW
LKH: what investigations would you like to do
Me: FBC looking for raised TW, LFT looking for transaminitis, hyperbilirubinemia, UECr to
assess renal function etcetc
LKH: any other blood investigations you can do?
Me: (thinking for very long)..... not very sure. hepatitis serology (she was negative). OH OH if
worried about pancreatitis, would do the investigations relevant such as calcium.
LKH: Anything else? How do you diagnose pancreatitis
Me: Sir, pancreatitis is usually diagnosed based on clinical+biochemical. OH SO I WOULD
DO AMYLASE TOO SIR
LKH: what else
Me: OH OH OH I WOULD ALSO DO SERUM LIPASE URINARY DIEASTASE
LKH: ok. what imaging
Me: U/S HBS, ERCP, MRCP. ERCP if suspect stone in CBD like for this patient. got
advantage of both diagnostic and therapeutic etcetcetcetc
LKH: ok. what do you see on this U/S
Me: gallbladder with gallstones, posterior acoustic shadowing, GB may look slightly
edematous, not sure but dont think the wall is thickened. dont really see fat stranding.
LKH: anything else you would look out for?
Me: (i cant really remember what else i said. spinal mode engaged)
LKH: any other investigations you would do?
Me: other than ERCP, MRCP. can consider doing a PTC for imaging of biliary system.
LKH: anything else?
Me: (thinking for very
long.) sir im not very
sure
LKH: you mentioned it just now.
Me: (after thinking for very long again) sir I would like to do a CT
Shown a CT scan, interpreted it. gallstones in GB, GB enlarged. otherwise unremarkable. oh
possibly some renal cyst.
Discussed some points on management (ABCs, stabilise, definitive management,
complications of lap chole). DONE

Learning points
1) study your simple stuff like cholecystitis. bread and butter case you see in the wards
everyday. dont neglect it. no point knowing bismuth classification for cholangiocarcinoma
and then stunned when you get acute appendicitis or cholecystitis
2) time management is very important. time will pass by faster than you notice. before
clerking, quickly scribble important things you dont want to miss out (drug allergies, all the
48
domains of history etc)
3) dont panic. i was kinda nervous and jumpy which clouded my thinking a bit. calm down
and speak slowly and if you need to, take a deep breath before speaking.

ALL THE BEST GUYS

Session 7: Case 3
Case: Achalasia s/p laparoscopic Heller cardiomyotomy
Observer:
Examiner: Charles Tan, Kristen Teoh

We were given the clipboard from the very start so we could scribble stuff on them.
The helpers were so nice, they told us our patients gender and if they were English
or Chinese-speaking.

I was very tired from all the waiting. Session 7 aint no joke. No ones in the mood for
studying after awhile. Our exams were held at Day Surgery at Kent Ridge Wing, and
we had a false alarm before the actual exam started.

I was pretty blessed with an awesome patient. After I entered, I saw my observer
(some angmoh surg dude that I can barely remember his name), and my patient, a
young lady. So I was like YES! NO CANCER! (at least I sincerely hoped so)

I had to like awkwardly stride over the chair so that I could get to my patient. I hope
they dont do stupid things like this anymore. I could have zao-genged seriously.

So it began!

Me: Hello, (introduce myself), I will be asking you some questions, but before
everything can I ask you for your name?
Patient: My name is ________, (proceeded to spell it out), and was quite concerned
when I mispronounced it.

I was like omg, I DONT CARE WHAT YOUR NAME IS, but I smiled sweetly and
clarified before I continued. Perhaps it is important to her that I got her name right.

Then I asked for age, occupation and drug allergy. With these out of the way, I
asked, So, what condition are you come in for?

The next 6 minutes was the best 6 minutes of history taking I ever had.

She told me she had difficulty swallowing, started in Aug last year, solid as bad as
liquid. Initially thought it was nothing, but it worsened and it even caused her to
aspirate at night. She had to sleep almost sleeping upright. This disease had
affected her sleep badly. She went to see a doctor, and they did a scope and the
scope is normal, so they did this test where they attached this tube to a pressure
thing, and hers was very high, so they asked her if she wanted a balloon op, or a
49
Heller

I was thanking God every moment as she spewed out her entire history..

Hmm.. thanks for telling me this, do you happen to have this condition called
Achalasia?

Ah yes! I do have that problem!

So did you ever do a test called a barium swallow, where its like an Xray, but they
make you drink something before that.

Nope!

Okay, so which op did you go for?

They also asked if I wanted this new technology, but I cannot wait anymore, so I
had my Heller surgery during December

Ohh.. did you have like reflux or heartburn after your op?

No, everything is back to normal. I feel very good now

Hmm, before this, did you ever travelled to any rural country? and fell sick?
(attempting to rule out Chagas)

No, I did not travel anywhere

Thank you so much, you did very well to tell me your condition, maybe I can just ask
some questions to rule out cancer.

Hence, I asked for low of weight and appetite, risk factors, family history how the
disease has affected her life and her family how she is feeling now after her op All
the social history, drug history, past medical history, past surgical history

Nothing.

I looked at my watch and I pretty much had 15mins left before the examiners will
come in to discuss.

Hey, if you dont mind, I will just write on my paper for a moment consolidated my
stuff, was able to write out word for word.

Then did a full abdo exam, ausculated the lungs and heart, took her vitals. Looked at
her neck, no scars no swelling.

Unremarkable.
50
I had 10mins left. I was really bored, so I started chitchatting with my patient and
doctor.

Then, the bell went off and my examiners came in.

Presented a summary statement.

My patient is ____/_____/_____, presented with progressive dysphagia associated

with difficultly in swallowing of solids and liquids equally. Diagnosed as Achalasia in
Aug last year, s/p lap Heller, no complications of GERD, currently well as before.
She had a OGD done, normal findings, and a manometry where they noted that her
pressure was high. She has no complications post-op.

Charles Tan and Kristen Teoh were angels!!!

They basically asked me what was already done for the patient., and if I were
worried about cancer, and how cancer would present differently.

It was a very straightforward case. I forgot to asked for ingestion of caustic

substances, but the history did not hint at it. So they let me off as well..

Other than that we were pretty much done by 10mins, and we still had another
15mins.

Then we went out to look at all the investigations that my patient has already told
me, I have already presented, the examiners have already discussed and asked to
interpret them. They were all normal.

I got stuck when shown a Erect Chest Xray that was normal too. Apparently Charles
Tan wanted me to say that if the esophagus was dilated, I would see lucency and
maybe a widened mediastinum. (which in my jitterness I said mediastinal mass)

Also the patient has scoliosis. So Kristen Teoh asked me what is this?
a curved spine.
do you know the term for it?
scoliosis..
yeah but its not orthopedics today
oh, so yeah scoliosis and do you want me to measure the cobbs angle?
nah thats fine
Then there were no manometry, so yeah. Didnt have to interpret that.
Was asked what I would find. Fumbled abit and said, raised pressure in the
esophagus. Yeahhh hahahaha.

Then there was a lateral c-spine x-ray

This looks normal

51
Kristen
why do you think they did this?
maybe looking for some foreign body? I dont know I dont know why they did this
really
so you mean you wont do it?
yeah, probably not.
I wont either
MO tried explaining why its done, but we all agreed it was not necessary.

Hmm maybe I will ask you a question ahhh.. but it might not be fair for a final year
student

Ohh.. then please dont ask it >.< I just wanna pass

Then we stood in silence for 2mins.

Bell rang!!! WHEEEEEE! Its over. And I am very happy!!!!!

Thank God for lovely examiners and an awesome patient!!!!

Session 7:
Case: Esophageal CA
Observer: Dr Rajesh Babu
Examiners: Prof Prabha + Dr Cheung Wai Kit (v v thankful they were really nice! :))

(Clerked in Mandarin...but dont know how Dr Rajesh will mark my v poor mandarin Hx)
Mr Chia/61/Chinese/Male
NKDA
ADLi, CA
Occupation: Boat driver (uhm at least i think thats what he said)

H/oPC
P/w painless dysphagia in 2010 x3/52 > tried TCM, didnt work > went to polyclinic,
referred to NUH, had OGD done, showed tumour at 26cm from incisor > started on
RT/CT (idk exactly if he was saying either or both in mandarin...) 1x/week for 8
weeks > esophagectomy Aug 10. Had problems with solids and some food, was
not intermittent. throat tightening, not so much of food stuck in throat.
Esophageal - difficulty initiating. pointed to chest.
Mechanical - problem with solids
Also h/o CVA - numbness, weakness (wah eh how you get the no sign)(on
macs its option + o) cool beans :D
nausea but vomiting. regurgitation.
? LOW (did not keep track of weight, but was ~54kg at > 60kg after trying to put
on weight for preop, also stopped smoking and drinking for a while). Good appetite
Also pins & needles (insisted that it wasnt pain but ants crawling sensation) at
epigastrium & RHC (?!) - constant, radiation, relieving factors etc
RFs: Smoking, drinking. Diet: eats hot foods, quite unhealthy diet. h/o GERD,

52
 prev instrumentation.
Cx: SOB, chest pain etc. bone pain. headache. yellowing of skin

Systemic: BU/PO normal. fever, joint pain, rash.

PMH: Nil DM, HTN as far as he knows. PSH: Had neoadjuvant RT before Ivor-Lewis
esophagectomy in 2010 (he told me they joined in the chest)
Drug: NKDA. Nil meds. Nil TCM.
FHx: nil.
Social: Smoker of 30 pack years (stopped for a while, resumed but has now cut down).
Drinker (1 beer/day x many years, has since stopped). Lives with wife & children in 3 room
HDB flat with lift landing. financial issues now.

O/E: Thin, but not quite cachexic (he says hes always been thin). R lateral thoractomy scar
+ upper midline abdo scar. Also 2 scars on R for prev pleural effusion drainage (according to
pt).
Offered to complete with the usual, including respi. Examiner 1 said just check hernia
orifices so I just checked for visible cough impulse - none.

(Finished PE quite fast - examiner 1 said take the remaining 3-4 mins to consolidate, think of
and invx and mx)

Questions
x for dysphagia
What causes strictures?
Prof: What other things in your Hx did you miss out that is important?
Me: Err other risk factors
Prof: So why didnt you tell us about them?
Me: Sorry prof, my mandarin isnt good and I didnt know how to say preserved foods,
radiation etc in mandarin, but id like to look it up and ask him
Prof & CWK: er okay.
Cx?
The usual incl invasion to surrounding structures etc, but they wanted to
discuss:
Tracheo-esophageal fistula > How would he present? > coughing out food,
possibly bleed
Aspiration pneumonia > where in the lung would you look for it? > R
bronchus > which lobe?
Recurrent laryngeal nerve > hoarseness
Pleural effusion, Pyema
How would you give him nutrition?
Oral route preferred. Can try NGT if scope can go around, KIV PEG.
TPN if completely obstructed
Where can it spread to? How would they present?
Tracheo-esophageal nodes > etc
Invx (done at presentation in 2010): then stage then Cx, preop
OGD: does lesion look benign or malignant? Why?
Where to do bx from? Edges
EUS only if scope can pass through > what are you looking for?
Bronchoscopy: What is this investigation? Why would you do it? What are you
looking for in it?
53
 FBC: NCNC anemia, thrombocytosis, low RBCs
Causes of anemia?
UECr: Cr 52, albumin low
Why is Cr low? > Low muscle bulk at
LFT: albumin low
PT/PTT: aPTT high
CXR: COPD (smoker), nodes. aspiration pneumonia. pleural effusion
CT thorax, AP > what can you see on CT? where is the esophagus? where
is the trachea? is there invasion?
Mx
Cx of esophagectomy
Early: anas leak of greatest concern
Late: Stricture. Regurg.
How to maintain GI continuity? Stomach.

Examiners were very nice! MO was v helpful too - trying to tell me when I gave wrong
answers!

Session 8
Examiners: Profs CN Lee, Enders Ng
case: Pt w Renal stones/ureteric colic

History-taking/PE/presentation was all over the place >.<

Patient spoke in Mandarin:

64/Chinese/Male
NKDA
Premorbidly independent, community ambulant
Occupation: Cook

Initial presentation:
First episode of sudden severe loin pain which ?became generalised, constant, cramping in
nature, pain score of 10/10, no exacerbating/relieving factors
went to ED (forgot to ask after how long he had the pain)
Found out he had haematuria only when asked for urine sample at the ED
X-ray was done and showed left kidney stone
was not admitted and only observed and given analgesia

Had another similar episode few months later, also similar presentation and also
conservative management at the ED and discharged.

Both times
no fever/chills/rigours
no LOA/LOW/backpain
no other LUTS
No chest pain/SOB/palpitations/postural giddiness

Currently asymptomatic for 3-4 years and on follow-up at NUH yearly

Each time blood test done, urine test done normal
54
IVU done before also showed stone
Conservative treatment - no removal of stones

Past medical history:

HTN, DM, HCL followed-up at GP claims well-controlled
Chronic tophaceous gout

Medications:
Metformin, glipizide, antihypertensive, and med for cholesterol, aspirin
Stopped allopurinol on his own (didn't manage to ask why)

Family history: Dad had HCC, Mum and Brother had IHD

Social history: non-smoker/non-drinker, no $ issues, does not feel affected by his condition

PE: quite unremarkable, except for gouty tophi at elbows

Examiners came in:

Presented real haphazardly >.< didn't even managed to present physical exam

CNL: so did the pain radiate anywhere?

Me: Erh no, there was no loin to groin pain but patient mentioned that the pain was so
severe he felt it was generalised
CNL: so how long did the pain last? seconds, hours?
Me: Ooops sorry should have asked
CNL: the haematuria was it terminal, dribbling, throughout?
Me (tried to ask just now but Mandarin too terrible, gave up): sorry i didn't managed to.
CNL: why don't you ask him now?
Me: ok... (so managed to find out it was throughout, i think CNL looked amused as i
struggled in Mandarin)
EN: If patient known to have kidney stone, now presents again with haematuria, what would
u look for in exam?
Me; vitals, check postural bp (EN: u think they will have postural bp drop??? Me: erh ok less
likely), renal punch, palpable bladder, DRE for prostate etc

CNL: what investigations would you do?

Me: verbal diarrhoea..blood test, urine test, imaging

shown blood tests/UFEME which was quite unremarkable...urine RBC was only, quite
unusual which CNL agreed
shown a KUB
CNL: what's the diff between KUB and AXR
me: KUB from T12 to pubic symphysis to view entire urinary tract.
CNL: what else??
Me: errrr....
in the end, found out that cause retroperitoneal structures, so more radiation for KUB.
Asked to interpret the KUB, IVU (explained the phase and what to look out for in each
phase)..nth much except for a small stone lodged in one of the renal calyx
CNL: if u can't see the stone on the film, why?
55
me: radiolucent stones! (quickly mentioned uric acid and cystine stones)
CNL: second cause?
me: errr not sensitive enough? stone too small?
CNL (laughs): ok fine third cause?....stares at my blank face...because the stone may have
been passed right?
me: oh yes. that too prof.
had more questions regarding what investigations u would do let's say u did urine cytology
and it came back positive for malignant cells....cystoscopy, CT urogram, and
ureterorenoscopy if CT urogram inconclusive (was prompted for this)
EN: let's say pt passed out stone that caused his symptoms alr and u still see the left kidney
stone what would u do?
me: leave it, cause it is not causing any trouble to patient
EN: so how would u manage pt?
me: lose weight, avoid fizzy drinks.....and EN said to avoid tea also, cause it is high in
oxalate
CNL: if big stone is causing problems?
me: ESWL or PCNL

bell rings!
me looking at CNL: err..was it ok?
CNL: yup it was.
YAYY byebye

tips:
speak slowly, don't stumble over your words like i did, looking like an idiot.
practise practise practise.
CNL was actually ok surprisingly.

Okay same case as above but different examiners! Dunno who they are and was honestly
too flustered to check their name tags -.- Some angmoh guy and indian dude both damn
nice+++

I was in the first session so damn kanchiong. Rushed in and saw this super nice examiner
smiling at me. Felt slightly better. Until I asked patient what he came in for and he said MY
KIDNEY IS WEAK in mandarin T.T My mandarin sucks so apologised beforehand and
said ill try my best pls be patient if i dont understand.Super nice examiner assures me that
he will help me translate. OH THANK YOU :)- he ended up translating more than 50% of my
history LOL

So anw eventually patient said he had stones in the kidney.

P/C:
1. Generalised abdo pain
-presented 5 years ago
-Cramping, no radiation, severe (10/10), no relieving factors, ?worse on movement
-Lasted a few hours and stopped after being given analgesia at the ED
-Associated with flank pain, dull in nature, severity 6/10
-Associated with painful urge to urinate but inability to produce much urine, have to strain
(Sigh i later said the word STRANGURY)

2. Gross haematuria 5 years ago

56
-Present throughout stream of urine
-No obstructive/ irritative LUTS
-No fever/chills/rigors
-No LOW/LOA/bone pain

Was diagnosed to have left kidney stones. Subsequently had another episode of ureteric
colic 3 years ago. Offered surgery but declined as mostly asymptomatic.

PMH:
-HTN, HLD, DM, Chronic tophaceous gout, BPH (had to dig this out of him)
-Follow up at GP. All well controlled but GP said ???KIDNEY WEAK. He wasnt able to
elaborate further so i decided to ignore that.
-Was on terazosin for BPH but stopped cuz had insomnia.
-On aspirin
-No previous gastritis/PUD/scopes done
-No risk factors for RCC/prostate cancer/bladder cancer (took damn long cuz examiner had
to translate all the industrial dyes etc for me. Mandarin super fail -.-)

The rest more or less the same as above. The kind examiner kept rushing me to do P/E so i
quickly examined abdomen. No masses, bladder not palpable. No conjunctival pallor. Renal
punch negative, not vertebral tenderness. As i was percussing the spine and asking for pain,
the patient said in Mandarin, No pain at all. Very comfortable like a MASSAGE I burst out
laughing and so did the examiner LOL.
No time for DRE. I looked at my watch and omg 1 MIN. WTS. Promptly forgot to offer DRE
and scrambled to consolidate everything. Came up with a super haphazard opening
statement just as examiners walked in. Kind examiner saw me freaking out and said dont
worry la RELAX. Easy for you to say la haha.
Presented as 64 year old chinese gentleman, non smoker/non drinker, b/g history of
DM/HTN/HLD, gout and BPH, diagnosed 5 years ago to have kidney stones for which he
presented with diffuse abdominal and flank pain and gross heamaturia. Now admitted for
regular surveillance X ray/IVU and currently asymptomatic.
Actually was more messy than that but strangely, examiners didnt seem to notice LOL. So
quickly presented P/E findings.
Ang moh examiner was the active one.
Examiner: Did you do a DRE?
Me: (Shit) No sir I ran out of time, but I would have liked to especially given the fact he has
BPH.
Examiner: How are his comorbids?
Me: Well-controlled sir. Occasional joint pains from gout but on follow up no evidence of
nephropathy from DM or gout.
Examiner: What about the BPH?
Me: Was on meds but stopped due to side effects. Last follow up no abnormalities detected
or increase in prostate size.
Examiner: U mentioned strangury. What is that?
Me: (Crapped out some crude definition and ended by saying it was sth like tenemus but in
urinary context. OMG kill me now)
Examiner (looking confused) Never heard of it.
Me (Relieved +++): Yes sir, I probably wouldnt use that term sorry. Since its quite obsolete.
LOL
Examiner: What are your differentials?
57
Me: Ruled out all the causes of generalised abdo pain including non-renal causes like
gastritis etc. Said I wanted to rule out ARU too (examiner was pleased)
Examiner: Okay. Causes for urolithiasis?
Me: Hypercalcemia, dehydration and in this patient, probably his gout and BPH.
Went out to discuss investigations and management and smoked through the interpretation
of uroflow haha.
Other questions:
-What investigations? (I stupidly forgot to mention urinalysis SIGH. Examiner was like, would
a urinalysis be helpful perhaps? Hahah. Quickly hid my oh-shit face and looked innocent and
was like, oh i didnt mention that? YES IT WOULD DEFINITELY BE HELPFUL!!)
-Phases of an IVU
-Acute management of this patient
-Treatment options for his stones (Conservative I said manage his gout, encourage
hydration, avoid foods high in oxalate, treat any UTI, monitor regularly with imaging. If large
stones can do ESWL, PCNL)
-If he came in with UTI and dilated system how would you manage? PCN, IV antibiotics
-Common organism causing UTI
-Antibiotic of choice
At this point there was like 3 mins left and they ran out of questions. Stared at each other for
awhile.
Examiner: Tell me about BPH
Me: (That is like THE MOST non specific question ever!) Er its a benign enlargement of
the prostate affecting elderly males.
MO at the back snickering.
Examiner (decides to randomly switch topic): How would you prepare patient for PCN
Me: Pt/PTT, platelets to rule out coagulopathy, informed consent
Examiner: Good. Anything else? What must you ensure before you do it? (silence) On X
ray?
Me: Oh, a dilated system?

Bell rings!!
Examiners: Good u may go! Well done. (Really??? YAYYYY)

Day 2: TTSH
TTSH GOT CHICKEN WINGS, BEE HOON, KUEH, COFFEE, ICE MILO :D so glad there
is NO LONDON CHOCOROLL

First account for TTSH! #ahbunehneh

Peripheral Vascular Disease complicated by Traumatic Wound & Osteomyelitis

Examiners: Prof Harvinder Raj ; Alexandra Hospital. Passive Unknown

Patient:
Mdm Violet, 66.y.o Chinese Lady
58
B/G: Poorly controlled DM, HTN, HLD, Non-Smoker

Presenting Complaint
1. Traumatic Mechanical Fall, Sustained large wound over Right Ankle

This was an atypical Vascular case for the following reasons:

i) No Intermittent Claudication
ii) No Rest Pain
iii) No Ulcers/Gangrene
iv) No Peripheral Neuropathy

Basically shes a very well Diabetic who has no complications of neuropathy, nephropathy,
IHD, Stroke etc. Only had laser photocoagulation for her retinopathy.

History was very smooth, presented completely without any interruptions. Dr Raj then
decided to scrutinize my physical examination. Spent alot of time here, as he wanted me to
describe and landmark everything. All done without any hitches. Then began the quizzing :

Q: What else you wanna examine for in the leg?

A: Charcots Joint
Q: What is Charcots Joint?
A: Deforming Arthropathy secondary to loss of proprioceptive & nociceptive receptors
leading to a loss of the protective mechanisms that modulate the joint.
Q: Describe what you will see
A: Er...Loss of contours of the normal joint?
Q: Some more?
A: Rocker-bottom feet & Neuropathic Ulcers
Q: What is rockerbottom feet?
A: Equinovarus of the foot & pes planus
Q: What is this thing here? *Points to this funny gauze thingy on the wound*
A: Er...gauze?
Q: You sure? Look at it, its staring at you.
A: Looks everywhere...OMG VAC Dressing! (The ones Ive seen are usually black spongey
material. This one looked white and funny so took me a couple of seconds for the lightbulb to
appear)
Q: Okay, lets go out. What investigations will you order?
A: Ill start with some hematological investigations. FBC, U/E/Cr, HBA1C, Lipids
Q: *Interrupt* What else? Any markers you want to order?
A: CRP, ESR, Ill also like to schedule patient for a Doppler Ultrasound - *Cut off*
Q: Not so fast! Before that?
A: Wound swab, Blood Cultures
Q: Yes! Need to culture the wound right? What else you wanna do for the patient?
A: Id like to order an X-Ray of the foot looking for changes of OM *Bait*
Q: What are the changes of OM? *Bait success!*
A: Swelling, Bone Destruction, Peri-osteal Elevation, but these changes only occur later at 1-
2 weeks *Bait*
Q: Then like that how?
A: Ill order an MRI of the foot *Bait success x2!*
Q: Okay, CT or MRI Better?
59
A: Er...MRI to visualise soft tissues
Q: Okay, then what you wanna do for the patients wound?
A: Drain the wound
Q: Good! Drain where?
A: Er...Drain externally la, then where else?
Q: No no, I mean drain where, in the ward or OT?
A: .*duh* In the OT sir
Q: What will you do in the OT?
A: Start IV Antibiotics, Take Photo, Debride Wound, Irrigate with Saline, Document
Neurovascular status before & after
Q: Anything else?
A: Hmm*Thinks for 5 seconds*...Tetanus toxoid and Immunoglobulin!
Q: YES!!! *Booms* Tetanus very important for diabetics
A: Yes sir!
Q: Okay then after that what you gonna do?
A: Send wound samples and pus samples off for culture
Q: Some more?
A: *Scraping the barrel here* Decided to be wise and admit that I wasnt sure instead of
guessing.
Q: Bone culture right!
A: Sigh. Yes sir. Bone culture.
Q: Okay look at her investigations now. What do you see?
A: She is anemic, which may exacerbate her peripheral vascular disease. She also has an
unacceptably high HBA1C, as well as leukocytosis suggesting bacterial infection.
Q: Why is she anemic?
A: She may be anemic due to chronic blood loss or dietary factors. I would like to assess her
iron panel, as well as the morphology of her anemia to direct my investigations. The patient
has never done FOBT or colonoscopes before, and she is in the appropriate age group for
screening.
Q: Okay, what investigation you wanna do for her now?
A: DSA
Q: Before that?
A: ABPI and TP which I already mentioned earlier
Q: Why TP?
A: Falsely elevated ABPI in diabetics due to stiff & calcified arteries. I expect her TP to be
<50mmHg, and <30mmHg if critical
Q: So what ischemia is this?
A: Chronic Limb Ischemia compounded by Traumatic Wound
Q: So what is that?
A: Critical Limb Ischemia
Q: Okay NOW what investigation do you want to do?
A: DSA
Q: Interpret this DSA
A: Occlusion of Post. Tibial, Common Peroneal, and 70% Stenosis of Superficial Femoral on
the Right
Q: How to manage?
A: Endoluminal Techniques such as - *Cut off* (Damn! Wanted to show off knowledge here
but no time)
Q: Okay say Endoluminal failed cos lesion too long. How?
A: Surgical Bypass. However this patient is a poor candidate for surgery, and we need to
60
meticulously control her risk factors *Cut off* *RIIIIIIIIIIIIIING*
Q: How will you bypass?
A: Given that the occlusion is very distal..Popliteal-Tibial Bypass with saphenous vein
graft/Dacron/Teflon?
Q: Haha...this one too high-level, its okay. Well done.

MO : Well done man

Tips:

A) I was the last to leave the room, so I think we overshot by 45 seconds or so. Spent too
much time in the room doing the whole PE and discussing signs that werent even present
such as Charcots Joint. So do your PE faster, I spent alot of time landmarking pulses etc. to
show the examiners that I knew my PE.

B) Dont be thrown off by atypical vasculopaths. Not every patient listed will have classic
PVD symptoms. This patient was totally asymptomatic until her fall last week.

C) Despite the stereotype that surgeons want you to say Definitive Investigations (E.g DSA,
CT, Colono) first, I think its actually safer to start from the bottom up with Hematological
Investigations first. Could have avoided silly prompts like Wound Swab etc.

D) Smile at your examiners, and give both of them an equal share of your attention. I always
presented to both active & passive, and was met by alot of nods from the passive which was
rather encouraging

All the best juniors!

Case: Diabetic foot complication s/p right big toe ray amputation (inpatient),
surrounding area necrotic, erythematous, swollen (still infected)
Examiners:
Observer: Dr Glenn Tan, TTSH vascular (very nice and helpful)
Dr Enders (?external, Hong Kong accent) and an Indian doctor

Chinese, 64yo, Mandarin speaking

Straightforward history, noticed blistering and swelling over right big toe, followed by
progressive pain. No history of vascular claudication/rest pain. Has diabetes and
hypertension. Non-smoker, non-drinker.

PE: Examined as for PVD. Both DP and PT absent on right foot, Weak DP, absent PT on left
foot. Popliteal and femoral well felt bilaterally. Screen abdomen for AAA and renal artery
bruit, both negative. Screen carotid for bruit. Screen heart, S1S2. Noted the still infected
area over the amputation site, necrotic, blister, pus collection, swelling, erythema.

Dr Glenn Tan was very nice, told me not to worry. Could present the PE findings to him
which he helped confirm by nodding.

Examiners came in, presented history uninterrupted.

Q&A
E: Demonstrate how do you palpate the popliteal artery
61
A: Flex knee
E: Why do you have to flex the knee?
A: Relax soft tissue??
E: What structure are you relaxing?
A: [Not very sure, popliteal fascia maybe? Please go check]
E: Characteristic findings in a diabetic foot; Pathology of arterial disease
A: Described the neuropathic changes; Micro and macrovascular changes in the arteries -
describe narrowing and stuff, also possible neuropathic change leading to vasodilation of
arteries (pathogenesis of Charcot joint)
E: Why do you say diabetic foot complication over peripheral vascular disease?
A: Lacks the characteristic symptoms of peripheral vascular disease such as claudication
and rest pain, although often there is overlap of these two conditions
E: What do you notice about the patients foot?
A: Described the necrotic changes, swelling, erythema; likely still infected, requires further
wound debridement, work up of status of vessels..

Okay lets go out

E: Investigations you would like to do (Bloods and imaging) Read this FBC and UECr
A: Raised TW, anaemia Hb 10.4, UECr normal
E: What could be a possible cause of anaemia? (No MCV provided)
A: Could be nutritional? B12 deficiency?... But also could be iron deficiency anaemia, would
like to do scopes to detect any occult source of GI bleed.
E: Yes, very good, also must look out for other possible problems right? Okay you wanted
ABPI right? Read it.
A: Right foot raised ABPI at 1.27, TBPI 0.37. Left foot ABPI 0.7, TBPI, 0.4. However, the
values could be falsely raised because of calcification especially in diabetic patients
E: Yes, so not very good right. Read X-ray (essentially normal).
A: No osteomyelitis, no foreign body, no gas seen
E: What organism causes gas?
A: Clostridium
E: Read arterial duplex scan (pan arterial disease, many stenotic areas) What can you do for
her?
A: Suggested angioplasty, but noted may fail due to multiple areas, although only needed to
open one of the arteries. (He asked which one I would want to open and why) ATA cos it
supplies dorsalis pedis and big toe. (Why only need to open one?) Got collateral circulation
joining at the plantar arteries. (Which comes from which?) Posterior tibial artery to lateral
plantar artery which joins the deep plantar branch of dorsalis pedis
E: What else can you do if cannot angioplasty?
A: Bypass grafting, but need to look for good landing site, which is absent (How else can you
look??) Hmm, CT angiogram?
E: So whats the next step in treatment for this patient?
A: Wound debridement, IV antibiotics, possibly requires more proximal amputation if
circulation cannot be re-established. (What are the types of amputation?) Mentioned
transmetatarsal, Lisfranc, Syme, BKA.. Likely she would need a BKA.
E: So what are the principles of amputation?
A: [Felt like I was repeating myself again, not exactly sure what he was driving at] Need to
re-establish circulation if possible, then clear the infection, and evaluation of her pre-morbid
function and current status
Then the bell rings about then Thanked the examiners and walked off to freedom. Oh, the
MO just kept nodding throughout, but didnt really notice him.
62
Day 2 (TTSH) Session 1

Case: Middle-aged male. Rectal CA (stage III) s/p APR

Observer: Dr. Dokeu Basheer Ahmed Aneez Ahmed (TTSH CTVS)

Examiners (equally active): Dr Chong Yew Lam (TTSH Uro), Dr Ng Kheng Hong (Private
Colorectal)

They actually provided buffet breakfast! A lot of food but maybe cos I was first session, quite
nervous and didnt have appetite to eat. The food actually looked not bad, should have tried
some.. Got a mountain of ondeh ondeh covered with shaved coconut, so colourful! Ive
always wondered if different coloured ondeh ondeh tasted different, or is it just food
colouring with no taste? Haha missed my chance to find out.

Random fact if you thought the names of the rooms at annex 1 are funny, those in annex 2
are better! They have names like good outcome etc. Hopefully all of us have good outcome
for surg long case! (hehe wx some of us actually studied there to collect some good outcome
luck) (Dr Yong, so did it work? Haha maybe next time annex 3 the rooms called "discharge
early" and "no complaint letter")

So we were ushered to this ward in CDC2 where we practiced OSCE during our TTSH SIP
postings, and waited in one corner. Then suddenly the examiners all streamed past us into
the ward area and it feels like we are the paparazzi and they are superstars walking down
the red carpet. Everyone cheered when we saw prof Low Cheng Hock walk in! I wonder if
CN Lee thought we were cheering for him instead heh.

The helpers lined us up and told us your patient is a Chinese speaking male etc etc.., and
we were allowed to write on our paper already. The helpers were all female and during that 3
mins they already couldnt resist flirting with Haresh who was the most handsome among us
(and among the general population as well)

Anyway TTSH only provides MANUAL BP set, so those kiasu can bring your own automatic
BP machines.

Went into my room and the uncle sitting in bed, still eating breakfast and using the chair to
put his plate of food. Chinese speaking guy, only knows little bit of English. Ask me to wait a
while, let him eat. So just introduce myself and small talk. Got a screen with another patient
on the other side, went over to peep and say hi also. Went to get another chair for myself to
sit, then bell rang and Dr Dokeu walked in, shook my hand, intro and sat on the chair that I
took. Ok the chair the uncle used is full of bee hoon sian spent 1 min wiping away
before sitting down.

(Whole history was in Chinese. Wonder if Dr Dokeu could understand anything at all
Lucky didnt need his help to defend my history)

Patient not primed at all, but very friendly, very willing to help. Said he has cancer, has a
bag, now cant work because when he lifts heavy things there will be bleeding and slight
pain. I only asked 1 open question (what medical conditions do you have) and thereafter all
closed questioning. Must really dig out from, but cant blame them, theyre not primed.
63
 Rectal CA s/p APR October 2012 with end colostomy
Intermittent constipation with spurious diarrhoea
Symptomatic anaemia
Coronary angiogram ?normal
Platelets low, dunno reason. No bleeding symptoms
No chemo before or after op
Adjuvant EBRT
Lives alone, divorced, not working
Not sexually active anymore, no ED
Stoma care quite ok
Didnt ask family history of cancer

My time management wasnt very good, spent too much time on his angina and low platelets
and figuring out why no chemo

Running out of time alr quickly do PE, request to take BP then nurse came in with manual
BP set.
Dr Dokeu: heh heh manual BP set eh!
Me: Yes sir, I know how to take
On hindsight I shouldnt have wasted another precious 2 minutes taking the BP which I
never reported and the examiners never asked. Sigh
Feel feel abdo, check stoma up down left right (functioning very well), no anaemia. Turned
him around to check anus. Parted his butt cheeks and probing here and there then realised
SHIT IM NOT WEARING GLOVES! Quickly went to wash hands (waste 1 more min) before
going back to auscultate heart and lungs. On hindsight his anus probably quite clean cos he
doesnt shit from there anymore

At 24 mins, the patient said actually I have my discharge summary and my list of
medications, you want to see? wah siao. Immediately I proptosed and said in a slightly loud
voice huh you got bring ah? Yes please! uncle starts fumbling around his barang.

Anyway I wasted a lot of time here and there, then I FORGOT TO ASK FAMILY HISTORY
FOR COLON CANCER! GGXX bell ring examiners come in alr

But when I saw Dr Chong Yew Lam I was super happy!

Shake hands, short intro, then I put down clipboard, look examiners in the eye and
presented
Sir, I had the pleasure of talking to Mr ___, a very jovial (age) Chinese gentleman
He has rectal cancer, status: post-APR in October 2012 with a well-functioning end-
colostomy which he has no problems taking care of.
Let me tell you how he presented 3 years ago. He had symptoms of a rectal mass causing
obstruction and bleeding, and I say this because he had blood-coated stools and episodes
of constipation with spurious diarrhoea. These symptoms had an insidious onset.
Due to his blood loss, he also had symptomatic anaemia which presented as angina on
exertion and decreased effort tolerance
Due to time constraints, I didnt manage to take a family history of cancers, but I would have
liked to ask about colorectal or other HNPCC cancers, number of relatives, what age they
had it, what degree of relationship they are (they accepted this smoke bomb and just asked
me a bit more Q&A later, heng ah!)
64
Time for Q&A

Chong: What are you looking out for in family history

Me: HNPCC and FAP
Chong: What are the HNPCC cancers?
Me: Colorectal, endometrial, gastric, etc etc
Chong: What type of urological cancers does HNPCC have? (then he and Ng looked at each
other with evil smile)
Me: er bladder?
Ng: Correct. What type?
Me: erm.. TCC?
Ng: Yes! (wah close shave)
Chong: Share with me your physical examination findings
Me: share share..
Chong: show me how you examine
Me: show. Mainly just described stoma
Chong: what type of stoma is this?
Me: end-colostomy. Because (standard answer)
Chong: ok lets go out to look at investigations

Then at this moment the uncle finally found his discharge summary and asked me if I still
want it. He looked a bit sorry that he didnt give to me earlier but I told him its ok, give to the
next student! Haha thanks uncle, so nice!

Chong: lets say you saw him at first presentation. What investigations you wanna do?
Me: (vomit out a pre-memorised script) My diagnostic investigation of choice is a
colonoscopy with biopsy and histology, but before that I would do other simple investigations
such as FBC to look for U/E/Cr to look for
Ng: (cut in) what electrolyte abnormalities you expect for this guy?
Me: hypokalemia (Ng smiled and nodded)
Chong: (shows me a blood result with normal FBC except platelets 157, normal coagulation
and normal electrolytes. CEA 1) what do you make of this?
Me: mostly normal, platelets mildly decreased
Ng: is this level of thrombocytopaenia significant?
Me: no sir, he is not symptomatic because no petechiae, nosebleeds, gum bleeds, although I
might worry that this is a differential for his GI bleed
Ng: good, what level is significant?
Me: 50 (I anyhow guessed, but seems like he accepted it)

Suddenly Dr Dokeu Basheer Ahmed Aneez Ahmed interrupted, shook my hand and said
hell make a move first. Then I realised that a bell was ringing in the background

Ng: what do you make of his CEA level

Me: it is normal
Ng: does this change your diagnosis?
Me: no sir, 30% of colorectal cancers do not produce CEA
Chong: read this colonoscopy
Me: (this was before I know Ng was a colorectal surgeon) sir, I believe this is the level of the
rectum because I can see Houstons valves. (like tempting him to ask me about anatomy
65
haha!) There is an exophytic lesion spanning about half the circumference of the lumen, not
completely obstructing. No ulceration or bleeding, but one small black spot over here (point
with pen) which may correspond to a previous bleeding point that gave rise to his symptoms
of BGIT. The other mucosa in this still image appears normal with no polyps and mucosal
irregularities.
Chong: lets say you are the Emed MO, he comes in breathless and angina. How would you
manage?
Me: (standard ABCs answer, but forgot to say oxygen)
Chong: anything else?
Me: GXM, prepare to administer packed cells if needed
Chong: hmm what else?
Me: call my senior for help?
Chong: no no what can YOU do? Something that you can ask the nurse to do.
Me: serial ECG
Chong: ok what else?
Me: (a bit exasperated alr) monitor vitals? SpO2? Pain score?
Chong: saturation?
Me: SUPPLEMENTARY OXYGEN SIR!
Chong: good
Ng: What type of fluids is best for resuscitation in colorectal cancer patients? (sorry cant rmb
the exact question)
Me: I was taught to use normal saline, but I have heard that Hartmanns solution may be
more physiological, especially if they are losing potassium
Ng: ok apart from crystalloids?
Me: colloids?
Ng: anything else?
Me: maybe packed cells? But I will call for help first
Ng: yes packed cells. What blood group you wanna give?
Me: I will match with GXM
Ng: what if emergency and he really needs it right now?
Me: O. minus?
Ng: you sure? (look at Chong and they exchange evil smile)
Me: I will call my senior to clarify
Ng: then your senior ask you to give. So?
Me: ok let me think
Ng: if you watch enough medical dramas on TV, you will see them ask for (he went on a
while but I a bit switched off trying to figure out the answer)
Me: sorry sir, I cant figure out, I will stick to crystalloids and monitor him closely and ask my
seniors one by one quickly till I get an answer
Ng: O positive!
Me: ok thank you sir! (Im a bit suspicious of this answer though)
Chong: ok imagine I am the patient, just reviewed this results. Counsel me for further
management
Me: sir, you need surgery because. Sphincter involved so need to take out. Stoma..
chemo..
Chong: ok so biopsy results comes back as adenocarcinoma. What investigations next?
Me: staging investigations such as rectal MRI, EUS, CTAP, CXR
Chong: he goes for APR and patho comes back as pT2, 2 mesorectal LN positive etc what
do you think?
Me: sir this is stage III, and I would offer adjuvant chemo
66
Chong: but he didnt have chemo
Me: yes this puzzles me. He had EBRT instead
Ng: what is EBRT for?
Me: it is to kill off microscopic foci of cancer left behind etc
Ng: then chemo?
Me: to kill of micrometastases in the whole body
Ng: yes more or less you are right. (he launched into 3 minute lecture on chemo and
radio)
Chong: apart from surgery, are there any other ways to treat his cancer?
Me: (thinking this is trick question) I believe surgical resection with clear margins etc. is the
best curative treatment. Otherwise, I would be considering palliative treatment instead
Chong: other methods?
Me: chemotherapy? Radiotherapy?
Ng: (launches into 5 minute lecture on pelvic exenteration, mortality of these kind of surgery,
etc etc. chemo can reduce the tumour to T1)
Me: (sudden brain wave) MUSOCSAL RESECTION FOR T1 CANCERS!
Ng: yes!
Chong: (to MO) how much more time?
MO: 3 mins
Chong look at Ng and me, Ng look at Chong and me, I dunno where to look
Chong: (with evil smile) what if histology came back with squamous cells?
Me: anal carcinoma
Chong: tell me about anal carcinoma
Me: SCC, usually below dentate line, different lymphatics and arterial supply, drains to
superficial inguinal LN
Chong: what are the risk factors
Me: (about to say smoking, spirits, spices, sex) er trauma, anal warts from HPV infection
Chong: trauma?
Me: yes trauma, anal warts, infection
Chong: trauma 1 time get anal carcinoma?
Me: repeated trauma, sir
Ng: what common perianal condition predisposes?
Me: haemorrhoids?
Ng: fistula-in-ano
Me: yes, sir, there is chronic inflammation

BELL RINGS! Shake hands, thank examiners, Ng pats me on my back

Went to ask the MO if I passed, he smoked some ambiguous reply like you should be ok
etc I think this year the MOs become quite useless alr. All the way just stand there no
expression, no hints, no nothing

Neverthelss, thank God all went well! sleep early the night before, be calm (easier said than
done), be polite to patient all the way, stand up straight and look into examiners eyes when
presenting and answering questions.

Learning points:
- Dr Chong Yew Lam and Dr Ng Kheng Hong are super nice! They didnt seem to have
killed me for not asking family history in colorectal CA, which I think is a grave sin. Or
maybe they smile smile and fail my history taking component?
67
 - Maybe Dr Dokeu Basheer Ahmed Aneez Ahmed understands Chinese?
- Good examiners make a difference
- Some guy in my circuit got a breast case with Prof Low CH. So good!
- Manage time properly. Dont bother too much with the non-surgical things like chest
pain or thrombocytopaenias that are not really related to main problem
- Everytime before Dr Chong and Dr Ng ask a difficult question, they will glance at
each other with an evil smile
- Study your basic emergency and ward management steps

Liver Abscess cx by lung abscess/empyema

77 yo/Chi/Male (Chinese speaking)
Retired, pre-morbidly ADL-I, Comm ambulant
PMHx: DM on OHGA, HL
NKDA

presenting complaint:
1) Fever x2/7, a/w chills and rigors
- was on a cruise trip to vietnam and hong kong. didn't eat any raw seafood.
- a/w nausea & vomiting. vomited undigested food, NBNB
- no diarrhoea
- abdominal pain, worse over RHC ("lung area" according to him")
- no pain on PU
- got non-productive cough, a/w difficulty breathing

2) RHC pain x2/7 (didn't ask much, got whacked by examiners)

3) ? obstructive jaundice
- patient did not notice yellowing of sclera/skin, but people around him said he was
- tea coloured urine
- yellow light coloured stools

I asked him what was done for him in Vietnam, he said nothing much.
Then observer dr (some consultant) asks me, "he had some procedure done in Hong Kong,
ask him what it was". (haha thanks!) so, patient went to a hospital in hong kong. did blood
tests which showed problems in lung, liver, kidney and GIT. had a drainage procedure for a
collection (he was not sure where) measuring 6.5cm in diameter. but was not drained
properly, so had to go back to TTSH yesterday to do another drainage procedure. currently
feels well, no fever.
(on hindsight, should have asked for more risk factors for hepatitis)

observer examiner prompts me again: what are the SURGICAL causes for liver abscess?
(didn't really understand his question.) answered: hematogenous spread, ascending
infection from CBD, direct inoculation... then he said "Gallstones is a risk factor right?" Yes
sir, so I asked the uncle for some biliary dyspepsia, which he said he had... but no U/s or
scans done or known gallstone disease. (subsequently was also asked what ENDOSCOPIC
procedure would you do for this patient? think they wanted ERCP to look for stones.)

PMHx: DM, HL. no surgical hx

took vaccinations before travelling for pneumococcal and influenza, but didn't have hepatitis
68
vaccine.
contact hx: sister in law who travelled with him, also sick and hospitalized (not sure if that
was a positive contact hx)

social hx:
ex-smoker stopped for 20 years
ex-drinker, now stopped
lives with his son, has 5 children, no financial problems.

O/e:
2 drains, green opaque colour (radiologically inserted drains - one connected to a chest tube
underwater seal, one connected to a radivac drain. both draining hemopurulent fluid.
underwater seal not oscillating not bubbling, but not clamped also (don't know why)
IV meropenem at the bedside
felt some mass in the RHC, but when measuring it, it was 12cm in the mid clavicular line
abdominal examination otherwise unremarkable
(I forgot to, but please ask for vitals, I/O charts and request for PR exam)

had 1-2 mins to consolidate. then 2 examiners walked in, with 1 MO. one chinese middle
age (Dr Lee? active), one young indian Dr with specs (passive). (sorry can't remember the
names!!)
Chinese examiner: present your findings (they let me present the whole history without
interrupting)
- what are your differentials for him?
said liver abscess, pyelonephritis (cos I thought fever chills and rigors ma)...
- would you like to start again? what did this patient present with?
sir, this patient presented with fever chills and rigors, a/w RHC pain and jaundice..... I would
like to rule out a surgical emergency such as acute cholangitis!
- yes.... what are your other ddx?
acute cholecystitis, choledocholithiasis, acute right sided diverticulitis (on hindsight should
have included acute hepatitis and pancreatitis), and liver abscess.
- ok, show us how you examine the abdomen of this patient
so had to go through the whole abdo exam AGAIN doing running commentary starting from
the peripheries. asked to show how to feel for splenomeg + how to percuss over traube
space , how to detect ascites, where to auscultate for bowel sounds and renal bruit.....
- went to the drains, show us which drain is which
- what is the chest tube drain device called?
(after much prompting) UNDERWATER SEAL sir
- why do you need an underwater seal?
(I didn't know. anyway, it's to prevent the air from going back into the patient)
- how do you know that the underwater seal is working?
it should be bubbling and oscillating (but it wasn't ><)
- how do you make it bubble and oscillate?
ask the patient to take 2 deep breaths? (but it still didn't bubble and oscillate! AHHH)
- what would happen if the seal is disconnected from the patient?
erm, patient would get an open pneumothorax? (not sure if this is correct, but I saw the MO
nodding from the corner of my eye)
ok, then went out to interpret results
1) FBC: low Hb, high TW, high Plt (normal ranges were given)
- is this expected in this patient?
69
I forgot that there can be reactive thrombocytosis :/
asked for causes of low HB - bleeding (no bleeding), production problem
2) LFT: low albumin (22), normal bil (18), AST 50+, ALT normal, ALP and GGT raised
- interpret? obstructive picture as ALP and GGT are raised
- is this expected in this patient? yes as the liver abscess can compress on the bil ducts
3) CXR: with right pleural effusion up to mid thorax and blunting of costophrenic angle on the
left side. said there was some meniscus sign, suggestive of pleural effusion.
- so what do you expect to find on physical examination? decrease breath sounds, a/w
decrease vocal resonance and dullness to percussion on the right side.
4) CT scan (one cut)
- tell me what are these structures: aorta, esophagus (which i didn't know), portal vein,
hepatic artery, outline the liver margins, and point out the abscess
- how would you manage this condition?
management of liver abscess: 1) IV antibiotics, cover for gram negative gut organisms, such
as ceftriaxone and metronidazole, 2) drainage procedures for large abscess - radiological or
open surgery.
- bell rings - thank you

learning points:
1) learn how to read CT scans!
2) know your drains - how they work, how to describe, how to manage
3) know your examination technique well, how to look for specific signs and interpretation of
signs (I was asked where to ausculate for bowel sounds, renal bruit. where to percuss for
traube space, how to do shifting dullness and explain, where is the best place to look for
jaundice....)

Acute cholecystitis s/p lap cholecystectomy

Examiners: Prof Dean Koh (active), Dr Dale Loh

i thk ive got bad karma, supposed to get CVI case (peeked at the ulcer before pt went into
toilet, prepared template nicely, my partner also nicely told me what else to look out for
during PE, was damn happy and confident) but pt was stuck in toilet and then came a
reserved pt WHY WHY WHY WHYYYYYYYYYYYYYYYYYYYYYYYYY

31 yo Fillipino lady
Past hx of GERD, PUD, appendicitis s/p appendicectomy, C-sec

Presents with epigastric pain radiating to right hypochondriac region, intermittent pain with
background of constant pain X1 week duration, worsened with food (was damn sad it has no
relation to fatty food), not relieved by antacids or painkillers. current episode of pain different
in terms of severity and nature from her previous GERD and PUD episodes

Rest of history clerking was approach to epig/RHC pain, quite standard. jsut that it was quite
confusing, cos got to exclude all the risk factors for PUD, GERD and gallstone disease

PE: dunno what to examine lol. feel here feel there, only saw lap scars, a lower midline scar
for her C-sec and appendicectomy scar at mcburneys point

Questions
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During hx presentation, interrupted by ProfDK HUH? CAFFEINE IS RISK FACTOR FOR
GERD?! weakly said yes, it lowers LES tone, and he was not convinced, but dr loh was nice
enough to save me by saying yes it does

interrupted quite a few more times during hx presentatiion HUH? cholesterol is a risk factor
for gallstones?! how r gallstones formed WTH why u keep interrupting my hx presentation -
.- then weakly said yes, it oversaturates the bile acid blah blah smoke smoke smoke, he
wasnt convinced sigh

then moved on to pe. started quizzing me bt all the scars she had. why her c-sec scar not
pfnnastiel? I DUNNO, never ask. whats an appendicectomy scar called? i also dunno, SIGH
WHY WHY WHY

ok lets move out. YES, half battle won

what ix would u do:
- standard bloods blah blah, imaging
- intepret LFT: had mixed picture, bil wasnt raised though
- intepret CTAP: lady had obvious cholecystitis..named all the signs.. plus dilated common
bile duct (note this pls), no obbious stones seen in GB or ducts
- intepret another cut of CTAP: this cut had gallstones in the GB, and dilated CBD again
- so what will u do for this pt nw?
- ABC blah blah, IV abx, pain mg, arrange cholecstectomy and bile duct exploration
- and thats when everything bad started .
HUH, BUT NO STONES? U DO WHAT EXPLORATION?
- HOW DO U KNOW PT HAS GOT STONEs?
- er i would like to do an ERCP, cos its therap and diag (I NOTED PT GOT DILATED CBD
WHAT!!!and the LFT ALSO SUGGESTIVE OF AN OBSTRUCTION!!!!)
HUH BUT U SAW NO STONES JUST NOW RIGHT? what will u do now
- im was damn lost then, like didnt catch where he was going, so said can do EUS too if not
too convinced bt stones then he proptosed sorta, eyes grew bigger lol
- if u were the pt, what will u do??? what do u want to do?
hmm, u can do MRCP too, i would prefer that, cos non invasive
- YES!! (wth wth wth -.-, ive never in my life seen an MRCP done before, i really tot EUS
was damn good for the ambiguous cases, my dad had gallstones dz too, no stones found,
and they did EUS FOR HIM!!(@&*@(@*)@)
- and to my utmost horror, he flased an MRCP on the screen WHAT WHY WHY WHY is it so
horrible. READ THIS
- er...this is the bile duct..i m not able to comment on size, really ive never seen an mrcp
before, i really dunno
what do u see?
er...i dont see any filling defect, got a bit of rat tailing towards end, bt i suppose thats
normal i almost pee-ed in my pants
YES OKAY, WHAT DO U WANT TO DO NOW
er so pt has no stones, bt got dilated ducts, i wanna do CTAP to see any masses comp on
CBD
WHAT? i SHOWED U CTAP JUST NW WHAT!
oops , sorry sorry, errrrrr.
er (then it all clicked suddently). OKAY PROF PT DOES NOT HAVE ANY STONES, NO
InDIC FOR BILE DUCT EXPLORATION, i would just wanna do cholecystectomy
71
 YES!!!! WHY U COMPLICATE THINGS!
and i was damn relieved but cursing swearing &^@&@*((_ in my brain, cos BILE DUCTS
WERE DILATED WTH WTH WTH i still thk im right leh, they were the ones that complicated
things, why show me a slice with dilated ducts WHY WHY WHY :(
and that was how a simple case became a complex case sigh sigh :(
then they let me off early, thinking im a retard
i was so stubborn i kinda asked prof dk at the end er prof, i wanna ask a question. i tot EUS
is gd enough for small stones, sludge etc.. and he was like no, MRCP is good enough.. ok
lor, if the patient is loaded :((

conclusioon: i thk i was digging my grave, so pls try not to do, especially for very clear cut
easy case. if ur really confused where the tutors are leading u too, try to paraphrase, get the
examiners to get ur train of thought then slowly work from there, u guys can do it! i was so
terrified at the end, and made sure i paraphrased whatever he was asking, and he was like
talking to a retard, bt who cares, so long as u get the correct answers

Obstructive Jaundice secondary to Gallstone disease s/p ERCP + stenting

Examiners: Prof Low Cheng Hock + Another nice clinical Prof
While waiting outside for our turn, we saw our dear friendly Prof Low going to the toilet.
Everybody prayed hard to get him. I guess I prayed the hardest.

For juniors reading these accounts early, please practise taking history in Mandarin. Even
though my Mandarin was not bad, it definitely took longer than I would have wanted as
compared to English. The timing definitely screwed me up.

Biodata: Mdm ____, 57 year old chinese lady. Retired factory worker, currently housewife
looking after her husband who had bilateral leg amputation, with 1 child. NKDA

CC: Jaundice x 2/52

First presentation
Noticed to be an acute episode.
a/w tea-coloured urine, pale stools, steatorrhea, pruritis
No alcohol intake, no TCM, no history of CLD
Was hospitalised when presented with the Jaundice and had scan which puts my whole
body through (assumed to be CTAP). Then had a tube down my mouth plus put a stent
and take out stone (if it is not ERCP with stenting, I dont know how to pass this then)

Also noticed to have abdominal distension but did not have LOW, early satiety, N/V, GERD
symptoms

Etiology:
No hep B/C serology done, but was not told to have them
No travel history, ingestion of seafood, family history of any problem
No fever/malaise/LOW/LOA
No pain/no progression of jaundice
No bone pain, dyspnea

Cx:
No fever, chills, rigors

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Systemic review: Unremarkable

PMHx:
DM, HTN, HLD x 10+ years on medications. (Insulin injection was given too) Wasted too
much time here asking for the control.

FHx
Unremarkable

Social Hx
Non-smoker
MSW for financial assistance
HDB 3 room flat
By the time I finished asking hx, 15 minutes had passed. The oh-shit drive kicks in and
quickly moved to PE

P/E:
No time to take vitals. Dont think it is very important in my case too. But more importantly,
no time.

H S1S1, L Clear,
Scleral icterus with pruritic scratch marks
No stigmata of CLD
Also noticed to have diverticula of recti -> Auscultated and BS +
Pedal edema present

Asked my Hx examiner whether DRE was required.

Her:For completeness sake, you can do it. My god! I only asked, but I dont really want to
do it! Wasted time waiting for gloves and KY jelly. Brown stained with no melena. Anal
sphincter intact. No other masses felt.

And then bell rang without me having time to consolidate! This left me flabbergasted. Then lo
and behold, Prof Low and another nice examiner came in. Okay, since no time to
consolidate, Ill just read everything as written on my piece of paper without synthesis. Prof,
being his usual self, stood really close to me and looked at my face intently while listening
closely to my presentation (as above) without disruption. He was the active examiner for the
10 mins of Hx and PE presentation.
Q: So based on your hx, what do you is the main thing you are worried about? (painless
progressive jaundice, so HOP cancer, periampullary ca)
Q: what else? (Forgotten about mets) What are the other common cancers? (erm
Duodenal?) Is it common? (Prof, I dont think it is common. I think we should consider gastric
and colorectal ca). Okay. -> Think my brains were fried. Mets didnt come naturally then.
Q: Other differentials? (Hepatitis, cholecystitis, pancreatitis..) Likely? (No, because no
pain)
Q: Show me PE. (As above)
Q: Baited him on stigmata of chronic liver disease and he took it! (Verbal diarrhea: just take
note that female does not have gynecomastia and testicular atrophy)
Q: Show me the mass in the abdomen. (Diverticula of recti) Is it a mass? (no, and BS +)
Q: The abdomen is distended. Is there fluid? (No prof. Shifting dullness negative) Show me
how you elicit shifting dullness. So how much do you think will be present before shifting
73
dullness positive? (Erm.. Im not sure prof) Nvm. (Checked Talley: around 2 litres)
Q: What else at the neck? (Virchows node) Did you check? DID YOU CHECK?? (Erm, sorry
Prof. Ideally I would have, but due to time constraint.) Do you think it is impt since you are
suspecting GI malignancy? (Yes prof. Absolutely. [if only DRE was not done])
Q: Tell me DRE results. Show me pedal edema. What are the causes? (unilateral vs
bilateral. So this patient has bilateral, need to entertain CCF, nephrotic syndrome/RF, liver
cirrhosis, protein-losing enteropathy.) Do you think it is consistent with this patient? (erm)
RIIIINNNNGGGSSSS.
Then MO came in to say times up. Should go for Inx and Mx now. Prof still smiling and
trying very hard to decide whether to wait for my answer or to go out. The other prof decided
we have wasted enough time and out we go.
Q: So, with your history, how are you going to investigate? (Prof, as presented in my hx, the
patient had undergone..) No no no. What will YOU do? I dont care what others have
done. (Erm Okay, so I would like to confirm my hx and pe with investigations doing bloods
and imaging) Okay. What bloods? (FBC and renal panel)
Showed FBC & renal panel
Q: Tell me. (Prof, the patient is slightly anemic, leucocytosis, hyponatremia, and [sorry forgot
what else was there]) Okay. What other blood tests? (Liver function test, renal function test,
PT/PTT)
Showed LFT and INR
Q: Tell me. (Prof, bilirubin high suggesting hyperbilirubinemia. AST and ALT high, but GGT
and ALP higher, so suggesting biliary tree) cholestatic picture right? (Yes, Prof!) (Albumin
is low too)
Q: Causes? (Synthetic function of liver impaired) Okay. Probably. What else? (Erm.
Malnourished?) Yes! As you have elicited in your hx right? She felt distended after each
meal right? (Yes prof) [Probably this was what prof low was trying to drive at too, therefore
with her presentation of pedal edema]
(Prof, the INR shows. Sorry prof, I am not too sure of the range)
Q: Hahaha. Yes. Since you brought it out, I want to ask you about the range too. What do
you think? What does INR stands for? (Brain fried already: Erm. International. ratio? Oh.
International normalised ratio.) Okay. So what to what? (Erm. patients PT to normal PT?) To
a control PT result right? So? (Oh.. Prof, normally, it should be 1) Yes! Hahaha.
Prof, dont mind, please go on quickly. Time is running out!
Q: Okay. What imaging. (CTAP)
Showed axial cut first then coronal cut.
Q:*Pointing to axial cut. So, what is this? (liver) These? (aorta and IVC) and the thing that
lies above the vessels? (pancreas)
Q: So, this pancreas has a very shiny object in the middle. What do you think it is? (Stone in
the pancreas.. Likely calcium since it shines so freaking brightly)
Q:*Pointing to coronal cut. Tell me what is this. (Big gallbladder with stones). *Next cut. This,
which corresponds to your axial cut? (Erm? stone in the pancreas?) Is it in the pancreas?
(Oh sorry prof, it is actually in the CBD) Now, there are stones in the gallbladder as well as in
the CBD. The CBD stone is very very large. [at this part, Im not too sure what he is asking.
Dont know whether is causes of gallstones or other places where gallstones can be formed.]
Where are some other places for gallstones to be formed? (Anyhow answered. Erm. Prof,
not too sure. Maybe in the intrahepatic duct?) *frowned a bit, but moved on. [On hindsight,
maybe they are asking for chronic hemolysis (black pigment stones) or infection with
bacterial degradation of biliary lipids (Brown stones = RPC)
Q: Okay what is your next management? *he actually accidentally pressed the next slide
showing ERCP. (Prof, I would like to do an ERCP for him)
74
Q: This is the picture. What would you do? (Biliary decompression, so probably put a stent
first) Okay. Would you remove the stone first? (No prof. Because the stone is really really
really big, so decompress first) Okay, good, then? (Then, prof, I would have the patient
return a couple of weeks later to remove the stone by dissolving it.) *the patient actually told
me they will use something to dissolve the stone and take out. So I just regurg out. Dont
know whether correct or not
Q: Now, after taking the stone. What would you recommend the patient to do?
(Cholecystectomy) And? RRRRIIIIIIIINNNNNNNNNNNNGGGGGZZZZZZZ And?? So many
stones(Erm CBD Exploration?) Okay good. You can go.

THANK YOU PROFS!!!! THANK YOU !!!!

Conclusion:
1) Pray really hard for good examiners.
2) Read senior accounts early.
3) And really, just look at the big picture. Its all about breadth.
4) Remember to clerk in Mandarin. Dont be like me, without time to properly synthesis.
Luckily kind of straightforward.
All the best!

Gastrica s/p gastrectomy

Examiners: Cheong Yew Lam and nice private colorectal surgeon Dr Ng (?) both very nice
and chill :)

i was told my patient only spoke malay and i would have a translator. thought to myself that it
cant be that bad, i mean after all most would understand some english. but i was wrong. my
observer was a nice indian surgeon, i think hes from ttsh thoracic, and told me to relax and
take it easy.

my patient was a 50+ yo Malay gentleman, lying in bed, wasnt very active, recently post op
and still NBM so not very well. he didnt understand english, but thank goodness i had a
really nice nurse who was helping me throughout! :)

hpc:
he opened by saying that he had low blood. acute onset of vertiginous (? shouldnt be, but he
said that the room was spinning) giddiness for 1/7,posturally related, associated with
generalised weakness. went to see polyclinic was referred to TTSH the next day. no other
symptoms of anaemia such as CP, SOB, palpitations, or decreased ET. had some
diaphoresis. admitted to ttsh, was given 3 pints of blood (or was it 2nd admission). noted
malena on day 2 but did not tell the drs cause he didnt want them to do more ix. discharged
without scopes cause he refused. r/o hematemesis, coffee ground vomitus, coagulopathy,
stroke, ear symptoms, liver probs etc.

3 days later same symptoms returned and he went to ttsh ed. was admitted and this time
scopes were done. OGD found a tumor in his stomach. he underwent a total gastrectomy
last week, told there was no spread, and heard something about needing adjuvant chemo
next.

so, by the time i got to this, i was a little flustered cause quite a bit of time was lost in
between translation. hell speak quite a bit, but i would have no idea what he said so that
75
took quite a bit of time. but thankful i knew he had gastric ca, so i clarified his vomiting
(which sounded like GOO cause NBNB partially digested, an hour after eating), probed hard
for early satiety (yay he had!) and LOW, LOA. glad that he had no PMHx, no prev surg, no
family history etc. ran through the mets symptoms (lumps, jaundice, bone pain, forgot
headache) and risk factors (smoker 150 pack years, drinks 3-4 cans of beer for past 40
years, and eats preserved foods). forgot to ask about financial, how it affects his work (he
works with horses!) who he stays with etc even though i wrote it all down, but thank
goodness they didnt ask.

o/e:
requested for vitals and the examiner said provided (ie dont need to take), offered DRE.

cachexic. nil jaundice or conjunctiva pallor. had a drain in his right flank draining
haemoserious fluid 350ml and 4 bandages on his abdomen. no hernia, asked him to cough.
poor guy and tender wounds. otherwise SNT, no hepatomegaly, no ascites. no cervical LN,
no boney tenderness. Air entry decreased on left LL and pitting edema around his right
ankle. i forgot bowel sounds!

i didnt realise the bell had rung and was wondering why there were drs standing outside my
door. then they entered. say chong yew lam and i was like YAY nice examiner! dr chong
immediately went up to the patient to introduce himself and thank him.

Q&A:
this is ___56yo malay gentleman, nil PMH and drug allergy, recently diagnosed with gastric
ca s/p gastrectomy awaiting adjuvent chemo. presented in feb 2014 with giddiness and
weakness suggestive of symptomatic anemia a/w early satiety, malena, LOW and LOA. etc.
they listened to my entire history. pe i just described and drain and bandage.
Q:why unilateral LL edema?
A: hypoalbunemia?
Q: but shouldnt that be bilateral? what would you be worried about?
A: DVT.
Q: what are the signs of DVT?
A: painful swollen calf etc.
Q: why decreased breath sounds? atelectasis
lets go out! that happened very early.
Q: where is the drain located?
A: in the abdominal cavity?? i have no idea
Q: what can it drain?
A: haemoserous fluid, bilious, prurulent, chylous? completely smoking.
Q: if you were seeing him for the first time, how would you approach?
A: take history (done), do PE looking for signs of anemia (BP, HR, collapsing pulse, flow
murmus, conjuctiva pallor, pale palmar creases), do DRE. then moved on to investigations.
do FBC first cause hes anaemic.
*FBC and RP-->Hb low at 5, alb low at 32*
Q do you think it is an acute or chronic bleed? (chronic cause his body seemed to have
compensated)
Q: what sort of anemia to expect (NCNC), why MCV normal (cause hes alcoholic as well)
what are the components of Fe study (they wanted to hear B12 and folate)
Q: what other ix to do?
A: shot myself my saying LFT, managed to salvage by saying coagulopathy secondary to
76
alcoholic cirrhosis. PT/PTT, GXM. CXR (proptosed and i retracted), ECG, then OGD
*showed an OGD with a huge polypoidal mass. then dr cheong said this was beyond my
level so dont need to decribe! showed a CT. dr Ng automatically pointed out the stomach for
me!*
Q: what else are you looking out for ? (liver, peritoneal mets, ascites)
Q: how to break the bad news to the pt? OSCE again!
Onto Dr Ng
Q: he has no distant spread, no LN, how would you manage? (andre tan broad principles)
Q: what are the ways of re-establishing gastric continuity (bilroth 1 and 2, roux on y) what is
bilroth 1? i have no idea? sorry. whats the diff between bilroth 2 and roux on y? prevent
reflux. how? i wanted to draw but he said dont need. im bad at surgery so i was like in
layman terms: connect stomach to jejunum but i dont think his surgical mind absorbed that
and he proceeded to (happily) explain it to me.
Q: how would you remove LN? i have no idea so he proceeded to explain to me
Q: what is chemo? stunned for a moment, then said neoadjuvant and adjuvant, can use 5-
FU. learnt that even if you shrink the tumor the margins still remain the same!
Q: what are you looking out as a HO if the pt returns post op?
A: cx of GA and surg. check drains and dressing (they looked happy with that), DVT, lungs,
Q: what about day 5-7?
A: more infx, DVT, anastomotic leaks
Q: what are the late cx of gastrectomy (Fe, B12 deficiency, recurrence, early satiety, early
and late dumping syndrome, LOW) mechanism of Fe (acid needed to convert it to ferrous)
and B12 deficiency (no intrinsic factor cause loss of parietal cells)
Q: what are the risk factors for stomach cancer (andre tan)

Conclusion:
- The focus seems on functioning as a HO and seeing the pt for the first time rather than
surgical things
- get the big picture early, dont have to find out the exact timeline or details, you may not
have time and theyre not too interested. cover broad (rmb to ask for risk factors, cx and
metastasis)

SO THANKFUL FOR KIND EXAMINERS (AND TRANSLATOR) who asked basic qns. sorry
patient for being rushed with you!

Acute on Chronic Critical Limb Ischemia

Chong Yew Lam , Ng Keng Hong (Gleneagles Colorectal)
66/Malay/Lady
Allergic to Penicillin, Ampicillin (rashes, itch and SOB)

History
6 weeks of bilateral calf pain, right worse than left.
Worse on exertion, better with rest (standing still is sufficient)
Progressively getting worse, now have rest pain that wakes her up from sleep
Right leg feels cold
No back pain / shooting pain down the legs

Admitted to TTSH from the GP 3 weeks ago after the ulcer became infected
Treated with IV antibiotics, scans were done and told there was a blockage
Angioplasty was done for the right leg (No post op complications, leg felt warm and better)
77
Given aspirin after discharge-- checked for complications of aspirin use (no melena, gastritis)

Past medical history

- Diabetes mellitus for 10 years, now on insulin 18U and metformin. Unsure of HbA1c. No
stroke/ AMI/ retinopathy/ nephropathy. Some numbness of the feet
- Hypertension on medications
- Gastric problem (didnt dwell on this)
- Previous LSCS

Social
No smoking / alcohol
No special diet: claims that she cuts down on sugar and fats
Exercise: does not do exercise
ADL independent, community ambulant, no need for walking aid

Went on to do PE at 13 minutes:
Full vascular examination (did arterial: skin changes noted, buergers angle <30 on Left
side), used orange stick for peripheral neuropathy, monofilament test (first time doing this in
my life), stood her up and made her walk
Examined abdomen for AAA , asked her to cough because of the LSCS scar
CVS examination: No carotid bruit, pulse regular, no murmurs

Questions:
- Summarize your case
- Please show me vascular examination of the lower legs (redid everything again and
mentioned findings, please comment where you are looking for the pulses as you examine)

Went outside:
- Ok, if the patient came in with an infected DM foot ulcer how to investigate?
Bedside: hypocount
Bloods: FBC , RP, septic work up, if patient very sick do ABG
Imaging: X ray of the foot
- (Showed x ray, please comment): this is a AP/Lateral X ray of the patients foot. I do not
see any deformities, no fractures, no changes of osteomyelitis such as moth eaten
appearance, no septic arthritis as theres no juxtaarticular osteopenia, no subcutaneous gas
- so what other investigations? ABPI (explained what it was, asked if its systolic / diastolic:
systolic)
- Showed the results of ABPI (pre and post angioplasty): basically <0.9 limb ischemia, <0.5
critical limb ischemia. For toe brachial index its -0.2 off the ABPI.
- What next? Arterial duplex! (showed a scan with total occlusion of the superficial femoral
artery and the anterior tibial artery with atherosclerosis throughout the vessels)
- If theres complete occlusion, how come the leg hasnt dropped off? Considering that the
patient has a background history of peripheral vascular disease, collaterals have formed
thus allowing flow to the distal vessels
- What next? angiogram. please counsel me as if Im her son why she needs to go for
scan
- Indications of the angiogram: we want to do something about the leg to revascularize. after
checking that her kidney function is ok for contrast, she will be put under conscious sedation
and a needle will be put in through her groin area into the leg vessels, a balloon will be put in
78
if necessary.
- Risks: 1) of the sedation: low BP (dont worry we will monitor), 2) of the procedure itself
(bleeding, worsening due to embolism, pseudoaneurysm).
- What if it becomes worse? (I had a brain fart and said then sorry sir we may have to
amputate the leg O.O) Retracted the statement and said bypass
- What kind of bypass in this patient then? (shows scan again) Femoral popliteal bypass
with anterior tibial artery angioplasty
- How to manage other than surgery? lifestyle modifications (diet, exercise), control co
morbidities (DM check HbA1c), vaccinations cos she has co morbidities (yearly influenza,
pneumococcus), make sure that she has a good GP to follow up

RINGGGGG :)
I was just squealing with joy, no seriously, I couldnt contain it and just kept saying mbbs is
over, mbbs is over shook all of my examiners hands including the really awesome MO who
squirted the alcohol rub for me and reminded me to calm down :) walked out and thanked
the Lord

Learning points:
- Always ask about contrast allergy / kidney problems or if the patient is on metformin if shes
going for a scan. this patient had rashes post angioplasty, but she claims that its from the
antibiotics
- If started on anti platelets, ask about any problems: gastric pain, melena
- Speak slowly and confidently like you know your stuff, categorize your answers : bedside
test, bloods (always say what youre looking out for), imaging
- If youre doing your exam at TTSH TBCU, please draw the curtains, I didnt know that there
were curtains in those isolation rooms, felt really bad after I exposed her :(

Breast Cancer

Examiners: Active: Dr Harvinder Raj (vascular surgeon from AH/NUH). Passive unknown
The Student helper told me 5 minutes before I went in that mine was a Chinese-speaking
female. Tried my best not to freak out because my Chinese really sucks. But it when okay,
really. I actually asked my consultant how to translate nipple discharge somewhere during
my history. He was very nice about it, laughed and just helped me ask the patient.

History
69 year old Chinese female, who first felt a left breast lump in January this year. Symptom-
free, no pain, no itch, no nipple discharge, no skin changes.
Saw a doctor, who also felt axillary lymph nodes. Mammogram and ultrasound were
suspicious and she underwent core biopsy, results pending.

Went through all the risk factors, she didnt breastfeed her kid because of G6PD. Otherwise,
she had her kid at 27 (before 30), menarche and menopause ages were normal, no
OCP/HRT, no chest radiation, no personal or family history of breast or related cancers.

No constitutional symptoms, no evidence of mets (bony tenderness, change in bowel habits,

headaches, cp/sob/hemoptysis, etc)

PMHx: DM, HTN, HLD all well-controlled. Prev cholecystectomy in 2008 for gallstones, no
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anesthestic complications at that time. Quite fit for a 69yo, probably fit for op again this time.

Had a lot of time, so I took a detailed social history, along with patients ideas, concerns and
expectations. Mainly worried about cancer.

Physical Examination

Did a full breast exam, 2x2cm breast lump in left upper outer quadrant. Hard, mobile, not
attached to skin or chest wall.
medial axillary lymph node, no supraclavicular/cervical lymph nodes

Examined (percuss+auscultate) posterior lungs, no masses, no pleural effusion.

No spinal tenderness
Didnt have time for abdo exam, so I requested for it to check for hepatomegaly. Plus DRE
for PR bleed.

They didnt have much to ask about my PE. Had to demonstrate for them a few steps. The
patients breast had a bruise, so I commented on that and said probably because she just
had a core biopsy a few days ago and Mr Raj looked quite pleased.

Discussed differentials, most likely cancer, given that its hard and has axillary LN.

Taken out of the room for further discussion

Q: How do you want to investigate?

A: Triple assessment! (He smiles). I have completed clinical assessment, and thus I would
like imaging and histology. U/S and mammogram for imaging, core biopsy for histology
Q: Why not FNA?
A: Cos I want histology. FNA will only give me cytology
Q: Why do you need histology?
A: Architectural distortion, carcinoma vs CIS
Q: What else can core biopsy give you that FNA cant?
A: Uh
Q: Like what tests can you do with core biopsy?
A: OH! ER PR receptor! and cerb-2!
Q: Yes yes. Okay now, for imaging.

I had to read the ultrasound and mammogram, exactly the patients ones. Please learn how
to read, both location of mass as well as describing and naming the positive/negative
characteristics suggestive of carcinoma

Discussed staging and management. Pretty standard, wide excision vs simple mastectomy.
Reasons for and against each. Although the tumour is small, and I thought both can, Mr Raj
felt that the patients small breasts precluded wide excision. Agreed with him because its
wise to just agree with whatever your examiners think.
Talked about RT, chemo, hormonal therapy

Finished Management discussion with time to spare. Mr Raj asked me what I would do if the
axillary LN biopsy comes back negative.
A: Sentinel lymph node biopsy.
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Described sentinel lymph node procedure

He nodded then got a very evil look on his face, like he wanted to ask me something weird.
opened his mouth and then the bell rang. He laughed and said saved by the bell

Since he didnt say killed by the bell, I really hope I passed!

Session 2, Station 4 Recurrent pyogenic cholangitis

Examiners: Low Cheng Hock (passive) and ?Kenneth Mak (active)
Observing examiner: Some young pretty dr probably a reg or young con(Just stood there
quietly and at one point started unzipping my exam kit which I placed on the table and
started looking through my exam barang?!?!?! piangz cute ah, so bored then help me clerk)
51/Malay/Female
Allergies: Paracetamol and unknown painkiller med (think its NSAIDS)
English speaking whooohooo (her english wasnt v good and she spoke slowly but still
waayyyy better than clerking in chinese)
(Before the exam I was praying really hard for 1. English speaking patient and 2. no HPB
cuz I studied everything else really thoroughly except hpb :( but you know God more than
answered my prayers with LOW CHENG HOCK!!! Everyone in my circuit was praying for
him but I guess I was the chosen one hoho) (and damn sian, every room has two patients
and they alternate between the two patients, apparently the other pt in the room was a
breast case, I WAS THIS CLOSE)
Summary: Presented 2 days ago with 2/7 of fever with chills and rigors(38-39 degrees, not
swinging) , intermittent severe RHC pain, jaundice and tea coloured urine, no pale stools a/w
vomiting(nbnb, white in colour small amounts)
Negatives:
Pancreatitis: No radiation of pain to the back, pain not better on leaning forward
AMI: No cardiovascular risk factors, no radiation anywhere la
I/O: No change in bowel habits, no constipation or diarrhea, no abdo distention
HepA/B: No h/o hepatitis, mother did not have, no IVDA, blood donations or transfusions or
tattoos
Funky infection??: no travel or significant contact history
Autoimmune: No rashes, no joint pain, no inflammatory bowel disease
Malignancy/mets : No LOA/LOW, bone pain, headache no SOB, lumps on neck, masses in
abdomen
Systemic review: no malena no LUTS blahblahblah..

PMHx: TWO CHOLECYSTECTOMIES 1998 and 2004 ?! (she said she removed gallbladder
twice wth, asked to see her scar and saw a mercedes benz scar errrrrrrr. Aiya never study
hpb properly, dunno what, heck first)
Recurrent admissions for stone problem. (Sounded like recurrent admissions for cholangitis,
she couldnt tell me how often she came in for this problem, just said alot of times la )
Occupation, fam hx, social nothing much. Has financial problems on MSW assistance.

Spent the next few mins making sure I didnt miss anything due to horror stories of students
clerking the wrong problem . So I just pointed to every single body part head to toe and said
sure got no more problem ah? here got problem? here got? here got? (Observing examiner
was choking back her laughter at this point)

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Started examining after the 16 min mark on my stopwatch. Did an abdo exam. Looking back
I was really sloppy, didnt even check for inguinal hernia or cervical lymphadenopathy or
parotids. win. Nothing in her abdomen anyway not even tenderness. Just a mercedes benz
scar. No stigmata of chronic liver disease. When I was done, the MO came in to say theres 5
min left.
Spent 5 mins consolidating, looking at the observing examiner hoping for some clues. But
she just stoned back at me HEH. (Heard stories of observing examiners who helped
students by asking them to present a summary to make sure they were on the right track.
Mine never *pout*) - hahaha why you so cute

All the while at the back of my mind I was stupidly wondering how she got two
cholecystectomies and what the mercedes benz scar was for. Somewhere deep down in my
mind, I knew the answer but was too brain blocked for it to surface and it required some, no
alot of prodding from the examiners for it to surface.

After 5 mins, examiners started to come in. Kenneth Mak came in first and in my head I was
like die la die la my hpb so cui. Then from behind him emerged.LOW CHENG HOCK.
When I saw him, I just STUNNED there for 3 seconds staring at him before I quickly
regained my composure and introduced them to my patient. argh then realised I forgot my
pts name because of my shock at seeing prof Low, (I was reciting her name in my head
before they came in) exams do strange things to your brain.

Summary: 51 yo Malay Lady s/p cholecystectomy with recurrent episodes of cholangitis

currently presenting with yet another episode of cholangitis. LOL
Then presented my history. Observing examiner started beaming really brightly and nodding
her head as I presented (was pleasantly surprised cuz she was so stone face just now zzz)

Q&A
Q :Can you show us the scar you described in her abdomen?
Q: So what operations are done for this scar?
(ok I cant rmb what I said I was just really anyhow whacking but i didnt hit the op she went
for)
Q: Can you demonstrate to us how you examined her liver?
Q: So whats the liver span? 8-10cm in mid clavicular line
Is it normal? yes
Q; Can you demonstrate to us how you felt for the spleen? Is it enlarged? (no)
Q: So what do you think it is? (RPC)
Q: So what operation do you think she went for? BRAIN BLOCK. dunno la walao
Q:So what are your differentials in this case?
(said as per my history above and gave reasons) and then stupidly said I/O when I ran out of
ideas cuz they looked like they wanted more cuz their head just keep nodding. *PROPTOSE
ALL AROUND* SORRY I RETRACT SIR IT IS VERY UNLIKELY GIVEN HER HISTORY.
Prof Low quickly forgives me *bless his soul*
Ok lets go out to the computer.
Ok there was such a huge audience around the computer because the observing examiner
decided to hang around. In addition to the assigned MO to this case, my MOs from SIP days
saw their SIP having exam and thought it would be really fun to watch. (they must have been
thinking OUR SIP SO CUI SO EMBARRASSING)
Q: So how would you like to start investigating?
A: FBC,LFT, serum amylase
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Q: ok we show you the biochemical results first, please intepret
A: So raised bilirubin, raised liver enzymes, GGT and ALP esp, leukocytosis, amylase
normal
Q: So whats the normal for bilirubin
A: (ok crap i always look at reference ranges, never memorized in my life. I just know its
high) er, not as high as this. (and then it went on for each and every single component in the
panel, and I just kept going it looks elevated sir, Im not sure of the exact values)
boohooohooooo
Q: What other investigations?
A: ERCP (dont have ercp) ok MRCP then. (before that?) what? er ok CTAP
*flashes the ctap* and made me point and name every single organ. Damn fail called the
spleen the stomach, pancreas, kidney before saying spleen. (exam nerves la I swear Im
normally not so stupid)
Q: Ok whats wrong in this cut
A: Dilated intrahepatic ducts
Q: Whats the black thing in the duct?
A: bile? bile pigment? stone!
Q: nooooo, whats this? What else is black in the CT, points to bowel.
A : huh...OHH AIRRRRRR, aerobilia (sorry really not radiologically or surgery inclined)
Q: What are the causes?
A: Gas forming organisms, instrumentation..
Q: LIKE? (kenneth mak getting v excited)
A: ERCP?
Q: noooo, she didnt get ERCP right?
A: Her cholecystectomy!!!
Q: So many years ago why would it still have air?! What operation would cause it to still have
air? (kenneth mak trying to hint desperately to my bimbotic brain T.T)
A: OH OH OH I KNOW. ITS A HEPATI-CO-JUJENOS-STO-MYY.
Kenneth mak: YES!! *looks v pleased with HIMSELF* for managing to strangle the name of
the operation out of me.
Q: Ok now read the MRCP
A: Points to the right hepatic duct and called it the duodenum
Kenneth mak no thats not the duodenum, the liver is around here *points*
A: oh sorry sir thats the right hepatic duct. It appears to be grossly dilated due to an
obstruction
Q: Ok point to me wheres the obstruction
*points*
Q: ok good what do you think it is?
A: A stricture
Q: ok yup. Then whats this black thing here? (pts to a black spot above the obstruction) You
mentioned it just now
A: AIR
Q: *bang head* No the other one
A: Oh stone (hehe really cui, dont dare look at my MOS so malu)
Q: So what are the principles of management?
A: (I dunno ok, please go read up) I said: ABC, NBM, IV antibiotics and KIV biliary
decompression with a PTC
Q: SO what antibiotics?
A: Broad spectrum IV antibiotics for anaerobic and gram negative cover so metronidazole
and ceftriazone
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Ok prof low do you have any questions?
Prof Low takes over
Q: If you were the houseman in the ward how would you prepare the patient for the
operation she went for?
A: NBM, IV drip, NG tube for gastric decompression, strict I/O monitoring, insert IDC, take
preop investigations like FBC, GXM, PT/PTT, RP,LFT, ECG AND CXR IN VIEW OF HER
AGE
Q: why do you want to do RP?
A: Look for any dehydration or electrolyte abnormalities so that I can correct it. and in case
the surgeons want to do intraop cholangiogram? (anyhow whack, dunno if correct)
Q: ok.. why do you want to do ECG,CXR
A: Actually she does not have any cardiovascular risk factors but in view of her age
Q: ok can, Just now you mentioned some antibiotics, you are missing one.
A: (lol I knew I was missing something but really didnt know la. ) er.
Prof Low : Okay nvm, I think can already. Anything else you want to ask her?
Prof Mak: nope
MO: still got time
Prof Mak: Nvm, go out and rest.

Conclusion:
1. I am a HPB foamer but a very blessed one
2. Mugged damn hard for everything else and was hoping to get a standard cancer case or
arterial case lol. Whatever got low cheng hock pass alr yyay.
3. Foamers can still pass mbbs (MO who peeped at my marks told me I did well yeah right,
but probably meant I passed yippeeee)

Session 5 (TTSH)
Left distal CRC s/p APR with end colostomy s/p 30 cycles of radiotherapy
Examiners: Prof CN Lee (NUH), Prof Vijayan (TTSH)

I wanted to cry when the student helper told me that my patient speaks only chinese.
sighhhh. i guess it was good that i tried practising all my chinese terms while waiting for my
turn.

anyway, Prof CN Lee was really really nice to me. i dont know why but i thank my lucky
stars. he even hinted to me when i was lost for words twice and offered to carry my neurokit
and my box of gloves and KY jelly. hahahaha.

57/chinese/gentleman
Allergic to antibiotic (?type), has anaphylatic reaction
Odd job labourer, single
Chronic smoker 48 pack years, ex alcoholic
History of CRC s/p APR with end colostomy s/p 30 cycles of radiotherapy
Presenting Complaint
1. PR bleed in 2011(? duration)
- minimal amount, noticed upon wiping buttocks
- a/w alternating constipation and diarrhea, change in stool calibre
- no pain, tenesmus or straining, no mucus
- no fever, URTI, UTI symptoms, no fecaluria
- LOW/LOA of 5kg over 4 months
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 - did not seek medical treatment
- OGD and colonoscope + biopsy done after admission to TTSH (our friend had no idea
what these were and i had to explain to him how a camera is inserted into his mouth and his
butt)
- CT scan done (? results) (again he had no idea what scans were done until i asked him if
he went into a mini tunnel that makes a lot of noise)
- was told that he had CRC, underwent op in 2012
halfway through our friends handphone rang and he started chit chatting with his friend?!?!?!
i wanted to die, uncleeeeee im trying very hard to describe everything to you in chinese and
take a history from you please dont kill me like this please please please!!!
2. Chest pain
- central, not crushing in nature
- described as discomfort
- no shortness of breath, giddiness, palpitations, diaphoresis, no decrease in effort tolerance
- fatigue
- decided to seek treatment at polyclinic and was referred to TTSH
- had some tests done (? tests)
- told doctors of PR bleed and investigated as above
No family history of cancers or polyposis syndromes
No complications of stoma except bleeding initially when he lifted heavy stuff (now only does
odd jobs that do not require heavy lifting)
No complications from radiotherapy
Functionally not impaired, no sexual problems
Currently on folic acid, B12, omeprazole (he brought all his meds, and started asking me
what they were for) sorry, uncle if i had more time and if this wasnt the scariest exam in my
life, i would patiently explain them to you.

PE
Well nourished and not pale or jaundiced
A: midline laprotomy scar (i did not notice this because it was so well healed, sigh my
downfall), end colostomy in left iliac fossa (omg i confused my left and right when i saw my
examiners because i was so damn scared), stoma functioning well, can see faeces passing
through
DRE: observed healed scar

didnt have time to consolidate, but my angmoh examiner was so nice, she threw away the
gloves for me and packed my stuff for me while i try to think of my summary <3

doors open and *deng deng deng profs walked in and prof lee announced cheerfully hi im
prof lee and this is prof vidjaya, what is your name and matric number, practising 2 patient
identifier on me my heart totally quaked in fear, sighhhh karma. anyway, introduced my
patient and examiners, then presented as: Mr XX is a 57yo/chinese/gentleman who has a
known history of CRC s/p APR with end colostomy. He has undergone 30 cycles of
radiotherapy and is otherwise well. He first presented with (as above)

prof lee stopped me in between my history while i was trying to present family history
CN lee: what in your history helps you differentiate right and left tumour
Me: change in stool calibre, colour of blood etc
CN lee: so based on the colour of the blood, how would you differentiate high from low
tumours
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Me: low - bright red
CN lee: how do you know this is not haemorrhoids
Me: no pain
CN lee: what are the risk factors that you know for CRC
Me: vomit andre tan
CN lee: what cancers will you ask for in HNPCC
Me: gastric, breast, ovarian, colon, uro
CN lee: present your physical findings
Me: as above except i didnt say scar and got hammered (HOW CAN HE HAVE STOMA
AND NO SCARS?!)
Vidjaya: lets look at the abdomen
angmoh reg pointed the scar to me and said i think you missed it cos it was covered by the
stoma AND its well healed SIGH!!!! WHY?! please dont fail me
Vidjaya: so is there a scar or not?
Me: yes im so sorry
Vidjaya: describe what you see
Me: midline laprotomy scar with scar in LIF (drain) and stoma in RIF
Vidjaya: which is your left and which is your right?
Me: (shit) omg sorry!! (demonstrated left and right to him)
Vidjaya: *looks satisfied, so what complications of the scar are you worried about
Me: bleeding, wound infection, dehisence, hernia
Vidjaya: how do you check for hernia? show me
Me: *demonstrate
Vidjaya: what is a parastomal hernia
Me: er, the loop of bowel protrudes out into the stoma bag?
Vidjaya: how do you differentiate the types of stoma?
Me: standard stuff
Vidjaya: how do you know that the stoma is functioning well?
Me: can see it draining faeces actively, pink, not dusky, not tender or erythematous
Vidjaya: what are the complications of a stoma
Me: vomit
Vidjaya: how to check if you suspect that the stoma is stenosed?
Me: digital examination
CN lee: what do you call the scar in the anus?
Me: er anal scar?
CN lee: okay, think about the region and its name, what do you think the scar is called?
(WAH HE ACTUALLY HINTED TO ME HERE - i must be really bad thats why he saw the
need to save me =()
Me; perineal scar!
CN lee: *nods approvingly and SMILED, why does the patient need an APR?
Me: low tumour, cannot preserve anal sphincter complex
CN lee: how low is low?
Me: less than 7cm from anal verge
CN lee: does this mean that 6cm from anal verge cannot preserve?
Me: ermmm i think so
CN lee: what are the margins for resection
Me: 5cm proximally, 2cm distally
CN lee: so where does the anal verge begin?
Me: errrr, anus? im not too sure prof, sorry
we all went out to look at scans, my patient asked me why you so scared? and then i told
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him uncle i having the scariest exam in my life and i so happened to have the most dreaded
examiners too. he looked so apologetic i felt so bad so i told him not to worry and wished
him best of health, thanked him and ran out of the room while vidjaya held the door open for
me (thanked him profusely). went to the central counter where the cow and scans were
trying to balance all my stuff in my hands then CN lee offered to help me carry them. OMG
almost died from shock and quickly dumped them onto the table beside me and thanked him
for offering.
CN lee: so how do you wanna investigate him?
Me: i would like to confirm the diagnosis first by doing a colonoscopy with biopsy and some
blood investigations like... got cut off
CN lee: this is his blood results, interprete them for me
Me: slightly low platelets, everything else normal
Vidjaya: so his haemoglobin level is normal, why do you say he has symptompatic anemia?
Me: sorry. (on hindsight, i should have said actually because hes a smoker his
haemoglobin should be higher than normal, his was 14 so it could have been low for him)
CN lee: so what do you think caused his chest pain?
Me: perhaps an underlying ischemic heart disease
Vidjaya: describe the colonoscope pictures to me
Me: lesions occupying the top right and left quadrants, occluding the lumen by about 50%
Vidjaya: with these pictures, what other complications do you anticipate in this patient?
Me: i would be worried about intestinal obstruction
Vidjaya: do you think he would have an obstruction?
Me: erm, partial obstruction likely if tumour continues to grow since he has 50% occlusion
plus he already has alternating constipation and diarrhea
CN lee: where will you take the biopsy, centre or edge, why?
Me: edge to avoid sampling error from obtaining necrotic tissues
CN lee: his CEA is 1, what do you make of it and how will you explain it to the patient?
Me: it is inconclusive cos it can be falsely elevated in other conditions. it is also not used as
a diagnostic marker and should be correlated with other investigations such as colonoscope
and biopsy
CN lee: *nods approvingly, so how accurate is a resting ECG in detecting IHD, ill give you 3
choices 90%, 50% 10%
Me: errrr
Vidjaya: its a simple question just pick one!
Me: (omg), 10% prof
CN lee: good! so what other investigations will you do for this patient?
Me: stage the disease with CT scan and endoscopic ultrasound
CN lee: tell me what you are looking out for in the CT scan?
Me: invasion into surrounding structures, distant mets
CN lee: what staging classification do you know of?
Me: Dukes staging - explain
CN lee: if tumour spread to prostate, what stage? to sacrum what stage? to lymph nodes
what stage?
Me: (i got damn confused here)
CN lee: how will you bowel prep the patient for op?
Me: PEG for 1 day then fast from midnight onwards
CN lee: what is PEG?
Me: polyethyleneglycol?
Vidjaya: how does it work?
Me: causes diarrhea by osmosis?
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CN lee: what is the evidence for bowel prep?
Me: improve wound healing and decrease infection
CN lee: what else? (hinted to me again) you take the bowel and cut then you do something
to it right?
Me: yes prof it also helps to reduce risk of anastomotic leak
CN lee: what will you look out for as a HO when patient finishes op?
Me: vitals, active bleeds, pain, signs of anastomotic leak
CN lee: if patient has leak what do you do?
Me: ABC, confirm with clinical signs, call senior, start IV antibiotics
CN lee: if you were the surgeon what will you do?
Me: generous peritoneal washout, repair leak, continue antibiotics
CN lee: what else will you do to the leak? how do you repair it?
Me: WHAT?!?!?! sorry prof i have no idea, perhaps pull out a defunctioning stoma
CN lee: where do you site the stoma?
Me: proximal to the anastomsis
CN lee: is the defunctioning stoma double lumen?
Me: yes (i think its not so please check)
CN lee: what will you do if stoma is stenosed
Me: ABC, inform senior, drip and suck, assess for peritonitis or perf etc
Bell rang, and we were still Q&Aing, my MO was nasty ++ told me to get out while CN lee
was still questioning me.
Learning points
1) CN lee can actually be really really nice
2) Vidjaya is fierce because he used to be an army doctor, or so i heard, and apprently hes
nice (he was very intimidating though)
3) just go back to basics and just admit it if youre not sure, the surgeons will move on or
guide you along
ALL THE BEST!

Session 3 Station 1 Complex Thyroid Cyst

Examiner: Prof Anders Ng (EE), Dr. Koura (TTSH Upper GIT) + Dr. Glenn Tan (TTSH Vasc)
History:
56 year old female who presented to the clinic with a neck lump 2 years ago. Asked the
patient to swallow, and the lump moved. So went down the thyroid path.
Asymptomatic, but her sister noticed it and advised her to see the doctor
No mass symptoms. Clinically euthyroid.
No previous cancers in the head and neck or abdomen (to exclude LN)
No associated autoimmune disorders vitiligo, pern anemia, type1 diabetes
No family history of cancers
Doctor did FNAC for her, and swelling subsided. But came back again months later. As the
report came back as benign, kept of follow up subsequently on yearly basis
PE
Left anterior neck mass
Moves with swallowing, not with protrusion of tongue
Able to feel lower border, no associated cervical LNs. No tracheal deviation.
Questions:
1. What specific family history would you have asked? MEN2
2. What would suggest hashimotos? Preceding URTI, assoc autoimmune disorders, initially
hyperthyroid then hypo. Still not convinced, so dont know.
3. What investigation would you order? TFT, Ultrasound
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4. Describe ultrasound? Cystic hypoechoeic lesion, well circumscribed but had a smaller
solid looking cyst within in.
5. Is this benign or malignant? Looks benign Prof. Are you sure? Okay, I guess we have to
investigate and poke the solid lump too.
6. If result comes back as follicular? Proceed with Hemi. If patient also has few small lumps
on the other side that cannot be characterized what surgery would you recommend? Not
sure about this but I said I will discuss the pros and cons of total and hemi with the patient.
7. What are the risks of total thyroidectomy? Early Late stuff. What nerves are injured?
8. If the patient has tingling sensation of the fingers, and goes into tetany, whats your
management? Call senior, measure serum calcium, administer calcium.
9. How will you administer calcium? Calcium gluconate, dilute, slow infusion, with ECG
monitoring

Session 8 (TTSH): Mirrizi Syndrome S/P ERCP + Stent

Examiners: Prof CN Lee (NUH), Prof Vijayan (TTSH)

Same case as someone already wrote above. Examiners were a killer combo but in
retrospect it wasnt as bad as it looks. Basically an approach to obstructive jaundice with lots
of questions.

History
2/52 progressive painless obstructive jaundice without fever
slight dyspepsia with food 2/52
no LOW/LOA
no past hx of stones
No bleeding, only pruritus

Initially I thought was CA but patient said underwent CTAP and confirmed no cancer so I
was like okay.. CBD stone with no cholangitis? What kind of case is this. Rest of history
unremarkable. No pre-hepatic / hepatic cause for jaundice.

PE
Essentially normal except for marked jaundice
No liver, no spleen, no liver stigmata
In retrospect, should have looked hard for a palpable gallbladder

Questions
Both Profs took turn to ask questions but CN Lee asked more. I will just list all the questions
and my answer (pls double check from internet or sth)

Is this jaundice yellow or lime-green? (limegreen - biliverdin)

Why splenomegaly important in this case? (portal hypertension, chronic hemolytic anemia)
Why will get pruritus? (bile salt accumulate in skin)
Pruritus is short or long term complication? (?long)
What is Charchot triad? (RHC pain, fever, jaundice)
What is choledocholithiasis? (Stone in the CBD)
So hepatic duct stone can still be called choledocholithiasis? (-.- no? apparently vijayan says
yes)
What is medical term for gallstone in gallbladder? (cholecystolithiasis)
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Would you expect gallbladder to be palpable in this patient? (no, stones will not have
palpable gallbladder)
Why? (courvesier law)
How come in that law, gallbladder is not palpable? (cos its contracted due to chronic
inflammation)
Moved out of the room to look at investigations, altogether was shown FBC, LFT, CTAP and
ERCP
Why is bilirubin raised in jaundice? (decreased enterohepatic circulation due to obstruction
thus accumulation in blood)
Conjugated or unconjugated? (conjugated)
What levels must AST/ALT rise to such as its considered significant. (?3-5X)
What levels must amylase rise to such that its significant? (3X or >1000)
Where is AST/ALT found? (hepatocytes, marker of liver damage)
Where is GGT/ALP found? (bile duct epithelium)
Will urobilinogen be raised? (yes) - should be no if obstructive jaundice?
Will stercobilinogen be raised? (no, decreased)
What is INR? (prothrombin time)
What is INR marker of? (liver synthetic function)
What clotting factors are produced by liver? (2,7,9,10)
Since INR raised, if I want to op, what are you going to do? (Vit K, or FFP)
How to give Vit K? (oral, ?IM)
Why does Vit K work? (reverses Vit K deficiency due to malabsorption)
Why does FFP work? (replenishes all clotting factors)
Benefits of US HBS vs CTAP for stone? (standard)
Benefits of ERCP vs MRCP? (therapeutic)
Moved on to scan
Describe the scan? (stones in gallbadder near the cystic duct)
Whats that area called? (Hartmann pouch)
Diagnosis? (mirrizzi)
Moved on to ERCP
Describe the ERCP. (filling defect at the hepatic duct with dilated hepatic duct)
Why not CBD? What is the CBD? (CBD is after cystic duct join common hepatic duct)
Definitive treatment? (ERCP, cholecystectomy)
When to do the treatment - immediate or interval for her? (interval)
What immediate post op complications you expect for her? (bleeding, infection, poor wound
healing)
Any more? (.....)
What about urine output? (....might be low Prof)
Why? (....)
How to link liver with kidneys? (Hepatorenal syndrome -.-)
What is hepatorenal syndrome? (seriously, refer to medical notes)
DING DING
PHEW SURVIVED IT!!
Learning points: if simple case of stone with no complications, think of the rare stuff like
mirrizi or double impaction. cases are never so simple. if faced with fierce examiners, just be
calm and slowly answer. no need to rush and appear even more unconfident. please learn
how to say simple scans and different body parts in Chinese cos my patient can only speak
chinese. luckily the first examiner sitting in was an angmoh so i dunno if she could
understand the history lol. PR is plus minus depending on the case and my patient was
already PRed by someone before me so I told her in chinese (no need PR not compulsory,
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just tell the examiner later if he asks) and i think the angmoh examiner didnt understand
haha so no need to PR her again. anyway good luck to everyone reading this!

SIMPLE THYROID GOITRE (easy)

Examiners: Chia Sing Joo (TTSH Uro) , unknown #2, Indian doc with thick bushy
moustache

HOPC:
56 yo Chi Female
NKDA

1. neck mass x2 years

unilateral, diffuse, non-nodular
no increase in size
no skin changes (bleeding/ulceration)
no pain
Thyroid status: euthyroid
Complications: no compressive symptoms, no cosmesis issue
Etiology: no radiation exposure, no hx of AI disorders, no PHx of thyroid disorders, no
FHx/PHx of MEN2/FAP
Treatment so far: f/u at TTSH thyroid clinic, FNAC showed benign, U/S showed benign, no
TFT done, not on any medication
Family hx: mom had same problem, but mass shrunk after a while

O/E:
Inspection: unilateral L sided diffuse neck swelling, no scars or skin changes, moves on
swallowing but not tongue protrusion
Peripheries: no signs of thyrotoxicosis, reflexes and proximal power normal
Eyes: no signs of thyroid eye disease
Neck: non-tender, not warm, non pulsatile mass on left. diffuse, 4x2cm. soft, not fixed to
overlying skin or muscle, mobile. does not extend across midline.
Complications: no retrosternal extension, no pembertons
Others: no pretibial myxedema
Summary: unilateral diffuse L sided diffuse neck swelling, benign features, not complicated
by compressive symptoms or thyroid eye disease, currently euthyroid

Questions:
1. What other risk factors to ask for in history?
MEN2 (hypertension etc), FAP (LGITB etc)
1. Why do you think her mom's thyroid shrunk in size? What pathology do you need to
exclude?
Hashimoto's thyroiditis
1. Show me how you do a thyroid exam. How do you do Pembertons? What signs to
elicit for hypothyroidism? What are the thyroid eye disease signs? What is chemosis?
What is active thyroid eye disease? Where does the thyroid gland usually extend to?
What is the first lymph node it spreads to? What are the levels of lymph nodes? What
is the anatomy of the RLN and ELN?
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 2. What investigations? Read this ultrasound and comment - point out all the structures
on this ultrasound. Where is the trachea, oesophagus, blood vessels. Intepret this
thyroid function test
3. How would you manage this patient? If she is bothered by it and wants to cut, what
surgery would you do? How would you council the patient on complications? How to
avoid the RLN during surgery?

Tips:
1. You are given 25 minutes: make sure you take 10 min for hx, 10 min for PE and 5
min to consolidate. For easy cases like thyroid - I took 7 min for hx, 5 min for PE and
10 min to consolidate, 3 min to flirt with patient and observing examiner
2. TTSH has sucky food. I expected them to cater Fat cow's foie gras and wagyu
donburi but they were stingy. If you are the last batch taking the exam (i.e. report at
7.30 and exam is at 1) please bring plenty of food. Preferably some red bull to get
you pumped up before exam
3. If you go into the exam worrying that you may get CN Lee or Wong HK, you have lost
the battle already. Its all in the mind
4. Aim to take a brilliant history and make the examiners jizz with your presentation.
Emphasize the key words during presentation for that extra jizz effect. The
presentation is the most important part of the exam, so use the consolidation time
wisely.
5. Learn how to stall time by saying motherhood statements.
6. TTSH has nurses to help you take BP and Temp. Nurses to help you chaperone and
draw curtains also.
7. Thyroid case
1. Learn your anatomy well - course of RLN
2. Know the definitions of the signs of thyroid eye disease
3. History don't forget to ask MEN2 and FAP
4. Don't neglect hypothyroidism in history and PE
5. Learn how to read thyroid ultrasound and point out structures
8. Be nice to the patient. If she is attracted to you, she may tell you what you missed out
in history, whether your examiners are nice. She will even automatically drink water
without you instructed her to do so.
#tbiytb

same case as above (gave my differential as dominant nodule of MNG, solitary thyroid
nodule, TRO thyroid CA-although no features/risk factors)
additional hx-brother had some cancer, pt dunno what kind. no other RF like previous
radiation/iodine deficienc/MEN/FAP. on the history also remember to quicky screen through
other causes of neck mass eg lymph node-ask travel history,URTI, TB symptoms. forgot to
ask dysphagia, hoarseness in the history-nice examiner1 prompted.
o/e-felt the mass more solitary nodule rather than diffuse. mostly over the left lower pole.
mostly benign features, no other lumps felt no cervical lymphadenopathy, euthyroid, no
complications/compressive symtoms/retrosternal ext.
no time to consolidate history and physical cause examiner number 1 dont understand
chinese then must keep translating for her what i asking/examining -.-
dean koh and dale loh came in very kindly gave me 1 min to consolidate. presented history,
asked to perform physical. they propotsed when i said lump was mobile...dunno why?
presented findings and gave summary.

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questions:
1. what ix=US, TFT, FNAC
2. read TFT-normal
3. read ultrasound-showed a whole picture of a simple cystic lesion with a well defined area
of hyperechoic lesion within the cyst
4. what is that lesion? apprently blood clot, smoked some shit here.
5. are you worried about this-yes
6. read further FNAC results to me-many other cysts elsewhere
7. diagnosis?- MNG with prominent nodule, currently euthryoid, no complications
8. management-back and forth discussion here for quite long, i said counsel patient on most
likely benign, ask to watch for features of malignant change, come back asap, offer surgery
(hemi) for compressive, cosmesis, cancer, failure of medical therapy. answer they wanted
was to schedule a follow up outpt to monitor.
9. other random questions-complications of thyroid surgery (vomit) indications for surgery.

Session1 (TTSH): Breast Ca

Examiners: Dr Dean Koh (active), Dr Dale Loh (passive) both suuper nicee
Historytaking Examiner: Dr Chong (TTSH Uro)

pre-amble
i was told my patient is an english speaking Chi lady, i was so thankful was thinking
maybe breast??
Intro-ed self and smiled to the heavens when pt told me she has a lump in her right breast
she was a super gd historian

Hx
Y/55yr/Chilady
Nil DA/PMHX/SURGhx
Single, unmarried, lives with brothers family
Admin executive

Right breast lump x1 yr

-self noticed
-progressively gorwing larger
-assoc with bloody discharge FROM skin of lump, nil nipple discharge
-noted skin changes
-nil pain
-nil other lumps noted (axilla, contralat breast)

Risk factors: nil children, nil breastfeeding, famhx of ca (mom had gullet cancer)
otherwise nil smoking/alcohol/HRT/radiation/prev breast disease or cancer/famhx of breast
ca

nil s/s of anaemia

nil LOW/LOA
Nil fever, chills, rigors
nil SOB, bone pain, jaundice, early morning headache

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Social Hx: nil financial issues, coping alright so far

Workup so far:
-referred from polyclinic to TTSH
-done MMG, biopsy, awaiting results of biopsy, CT Scan of body + bone scan (all normal so
far)

PE
well nourished Chi lady
4x4cm hard lump posterior to nipple-areolar complex of right breast, non mobile, irregular
edges, non-tender
nipple retraction noted
bruising over skin of right breast, over biopsy site
nil axilla lumps

1x1cm lump in l breast, soft, mobile, regular edges, nontender

nil cervical LN, nil pallor, Lungs clear, nil hepatomegaly, nil bony spine tenderness

left with 5-7 min for consolidation, thought of presentation and prepared self for next 25min

**examiners come in, super happy to see dr dale loh!!**

Q: Pls present this pts history

A: Mdm Yap is a pleasant 55 yr old lady with RF of blah blah presents with R breast lump for
1 yr. This is progressively growing larger in size and associated with bloody discharge from
lump and skin changes. Nil constitutional s/s, nil mets s/s.
currently workup is as follows: got stopped here and asked to proceed to PE

Lots of time was spent scrutinizing breast PE, exactly where to palpate for axillary LN and
cervical LN as well (rmb to stand behind pt to palpate cervical LN, i forgot to and got
reminded by dean koh), and asked to present all findings. also rmb to cover other breast with
clothes when you are examining one, examiners appreciate you caring for pts modesty.
also offered to examine lung, abdo, bony spine. then thanked pt and brought out to interpret
invx

dr dale loh reminded me as i was going out, you rmbed to wash hands right!! i was like
yessss

all qns asked by dean koh, hes quite particular with the way you package your answer so be
as accurate as possible.

Q: whats your dgx?

A: likely breast ca, ddx include benign breast lump like fibroadenoma etc.
Q: ok how likely is this to be benign?
A: errr not very likely since nipple involved plus progression, so i would like to only offer
breast ca
Dean Koh: Ok good.
Q: how will you invx?
A: triple assessment, mmg + biopsy + stain for ER/PR/her 2 status
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Q: interpret mmg
A: this is a mlo or cc view (i dunno hahah) of right breast, but he let me go at that haha
spiculated mass with microcals (they gave me their pen to actually point, just pointed at
some specks) and architectural distortion
Q: say staging scans show no mets, ER/PR/Her2 neu all negative, how will you manage?
A: (this is the part where my england got in the way lol) i said i would like to manage the pt
surgically or non-surgically. then dean kohs eyes lit up and asked me alot of qns on what is
1st line mgt of non-surgical mgt etc etc. i tried to say chemotherapy for downstaging etc and
adjuvant but he didnt accept, i had to retract my statement and say i would like to FIRST
manage this pt with SURGERY. then we moved on lol
Q: what surgery and why?
A: simple mastectomy vs WEAC, pros and cons
Q: will you do a sentinel lymph node biopsy?
A: yes i will, and if postiive, then will clear axillary LN/ dean koh also wanted me to say SLNB
is now a STANDARD OF CARE.
Q: what other therapies available?
A: nonsurgical things: CT, RT, Drugs-hormonal/targeted
Q: risks of surgery?
A: faster breeze through general surgical risks, then surgery specific risks: seroma,
lymphedema, damage to long thoracic and thoracodorsal nerves
Q: how will you f/u pt?
A: 2-3mthly with PE, yearly MMG etc etc (this part i was whacking haha)
Q: ok tell me more about chemotherapy for breast ca
A: ??? err for neoadjuvant, adjuvant purposes. neoadjuvant to downstage disease, adjuvant
to eliminate any small ca areas.. 6 weeks post wide exicison dunno what else to say
liaooo.. i was like i dunno alr

bell rings and they pat me on back and say thank you. I thank them and run off to embrace
freedommmmm!

Day 3: KTPH

Session 1

Acute pancreatitis

examiners: two distinguished indian profs, didnt catch their names

56/Ch/M
NKDA
PMHx: HTN on losartan, no surgeries

2 episodes LHC pain

First, 2 years ago, admitted for IV drip, scans, d/c with ?meds, unsure of dx, was d/c from f/u
Last admitted to TTSH in Feb, for abdo pain
S/ LHC
O/ gradual
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 C/ unclear
R/ nil to back
A/w LOA, subjective LOW noticed by family, pants not looser, no weighing
T/ one month
E/ by fatty foods, fried food, not worse with non-fatty meals, not better on leaning forward
S/ 8
(was admitted, for blood test, scan, IV drip, d/c on PPI omepraezole and told to avoid fatty
food)
(seemed honestly blur about dx, no OGD/colonoscope done)
Nil vomiting, diarrhea, constipation (BO 1/day)
Has no sx to suggest CRC (but dunno caliber, color, blood), ? tenesmus but likely red
herring
Systemic r/v: normal (no SoB, cough, fever; no chest pain, palpitations)

Social: retired, stays with wife only, 4 daughters married. Smoker 46PY, drinker avg 2
units/day (beer) recently quit {denies Hx of liver problem}
Fam Hx: no Hx of gastric Ca

o/e
no anemia, no sclera icterus, well hydrated
B/L parotidomegaly (alcohol)
+/- CLD signs (no armpit hair, some ?spidernaevi/telengactasia on upper chest)

Abdo distended
But no organomegaly
No shifting dullness
No inguino-scrotal masses
Examiner prompted to get patient to raise head, saw divarication of recti

DDx: PUD, biliary colic, pancreatitis, other HPB causes, extra-abdominal (LL pneumonia,
AMI) {insert justification for and against each ddx}
Show me your abdominal examination
If patient had ascites, differentials would now be (didnt answer this)
Biliary colic?? Yes: worse with fatty food, No: location is very wrong
Pancreatitis possibly secondary to alcohol
Ix: bloods FBC (TW ?infection), serum amylase looking for pancreatitis (714)
o 714 is not high enough to diagnose pancreatitis
o Do a serum lipase (441) sorry I do not know the reference range for lipase
o Do urine diastase (was not actually done)
o when can you have sub-1000 amylase in pancreatitis?
Chronic
Late presentation >3days of acute pancreatitis
Bloods- renal panel, other electrolytes (its clear that its pancreatitis now) for Ransons
scoring
The components of the Ransons scoring are?
Other scoring systems include modified Glasgow scoring, and Balthazar index for severity
on CT but this is not so relevant in the acute presentation
Ix: imaging CTAP any simpler one first?; CXR looking for air under diaphragm; AXR

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 o Signs of pancreatitis on AXR
Acute: sentinel loop sign, colon cut off sign, possibly can spot GB radio-
opaque stones
Chronic: pancreatic calcifications
o CTAP: 3 coronal cuts
Identify the structures: liver, spleen, stomach, pancreas, aorta
no gall stones seen only three cuts can you really comment? no
gallstones seen in these 3 cuts okay
Pancreas was edematous, with areas of hypodensity signifiying poor
uptake, can kinda see pancreatic ducts, not dilated. Have fat
stranding. No calcifications.
is this acute or chronic pancreatitis?
Acute: edema, fat stranding, fluid, necrosis
Chronic: atrophic, calcifications, possible duct dilation if
blocked, ?pseudocysts
Hence this is acute pancreatitis
Outline your management if you saw this man in EMD, assuming diagnosis of acute
pancreatitis
o ABC
o Circ: get BP, HR, set 2 large bore IV cannulas, start IV hydration
o Take bloods to do Ransons scoring
o Give analgesia How? IV morphine What dose? I will check
o Inform senior
o Consider disposition why? go where?
o Am I to understand that you will wait for your Ransons score and keep
patient in EMD until the results are out? (dodged the question somehow)
o Check for SIRS, treat with aggressive fluid resuscitation
o Check for electrolyte abnormalities
o Look for and treat underlying etiology
Common causes of pancreatitis: alcohol and gallstones; also hypercalcemia etc etc//(got
cut off)
So if patient was sent to GW, what are your orders to the nurse? What vitals to check?
o BP, HR, SpO2
o how to measure SpO2? by pulse oximetry
o ok, if he has SpO2 92%, how?
Check if patient got nail polish, any peripheral vasoconstriction, if none,
give O2 via intranasal cannulae
have you seen it being given/really?
I will recheck in 5min and change to venturi/NRM if still low
Then examine respi system, do CXR
what will you suspect if SpO2 stays low even with your NRM?
ARDS, maybe pulm emb

Thoughts: diagnosis wasnt clear from history, and PE wasnt helpful, but they guided
towards pancreatitis. Its fine as long as one of your ddx is the diagnosis.
-----------------------------------------------------------FIN--------------------------------------------------------
Session 1:
? HCC

97
Dont know who the examiners were
Led to the clinic stood outside the room, introduced myself to observer and patient. Sat in
clinic room my resident physician told me to not start first. this was followed by a good 7
minutes of golden sacred silence (GSS). Got news that Uro will be a huge component when i
heard my patient was elderly chinese male, i wrote down all the uro stuff on my clip board.
Patient started talking to observer about his op during the GSS and they mentioned Cheah
Yee Lee did the op for him. i died (somehow i thought she was upper GI) so i wrote down all
the gastric and oesophagus stuff. After a good 7 minutes of GSS i decided it was too much i
opened the door and say E1 and E2

E: HUH? youre done?

Me: Er. i havent started
E: HUH WHAT?! start now.
Me: okay owell.

Me: uncle so what op did you have (observer was indian and uncle only speaks chinese ^^)
E: cut my liver.
Me: zzzzzzzz so its HPB. wasted my GSS

63/ch/male

epigastric discomfort x 8 months ago

no pain
no obstructive symptoms: pale stools tea coloured urine
no risk factors of cirrhosis: alcohol etc etc etc
no constitutional symptoms
no association with meals (pancreatic, biliary colic/ acute chole)
no fever chills rigors (cholangitis)
no constituitional symptoms (LOW LOA)
no symptoms of decompensated liver disease
no symptoms of metastasis

since then did u/s, CT dont know whats the diagnosis dont know the stage
went for liver resection (cut off of liver)

after that no symptoms of recurrence

been well since.

non smoker non drinker

family coping well and supportive
no vaccinations done

PMHX: Htn, HLD, DM

PSHX: ?ureteric/renal stones in 1990s with an inguinal incision. (troll..)

physical examination wise only has a RHC scar, inguinal scar and a drain scar (i initially
missed it but the observer came to ask me what i thought that thing was. i said laproscopic?
he was like no. drain scar. NICE :D)

this was the exciting part i was giving a running commentary while doing examination and i
98
didnt know my observer went out and in came E2, E3. FML. i finished my examination and
turned to them

Me: i would like to complete...wait you look a little different.. (HAHAH this is such a deb
moment)
E2, E3: yep we are your examiners.
Me: *wtf. *i thought observer was supposed to be inside to clarify my history and PE.
E2, E3: oh no he went for break. nevermind. present your history

YES I DIDNT HAVE TIME TO CONSOLIDATE

Me: sir i will give you the full details of the history then i will attempt to come up with a
summary if i manage to synthesize it at the end
E2, E3: what are your differentials?
Me (gave all the differentials for RHC pain but they only wanted 3 main ones, they also
wanted cholangioCA on top of hepatic adenoma, HCC and mets)
E2, E3: what are the common sites of primary giving mets?
Me: GIT, Lung, Breast in women. cholangio took a while to come out
E: assuming he presented with RHC pain what would you want to do?
M: FBC showed everything so didnt have to recite

bloods were essentially normal: asked on why no conjugated picture and why no raised liver
enzymes, AFP were not raised here so abit troll. (did a mental calculation of the Child Pugh
preemptive)
Me: u/s HBS, CT triphasic
The CT looks damn strange looks like an loculated abscess kinda thing freaking weird. never
seen before. not typical of HCC
what else: do MRI/ biopsy

E: what are the management options

Me (got a bit too excited) curative / palliative (verbal diarrhoea): asked on indications of
sorafenib (must biopsy before starting), UCSF criteria of transplant, asked on factors
affecting resectability
-Patient factor: talked about how to optimize patient if DM change to insulin, call anesthetist
do 2Decho, ECG, asked about Effort tolerance)
-liver factor (portal htn, child pugh, indocyanin green)
-tumour factor: site (left sided, or at the portahepatis)
E: so assuming im the patients son counsel me on hepatectomy
asked on complications of surgery i was smoking alot but managed to get most of it
1. draw out the scar show the patient, educate on indications and alternatives
2. General risk: GA risk so can get AMI stroke, hypotension, post op N/V
3. risk of procedure itself:
- Resect alot of liver, potential liver and renal failure
- Cut common bile duct: bilious peritonitis, intraabdominal abcess might need open/ VIR
drainage
- Bleed: Type II AMI, Shock and can die
Risk of mortality from hepatectomy 2-5%
4. what to expect post op.
5. informed consent.

99
DONE.
lessons: dont count on your MO to help you, hes a troll told me not to start and i had 7
minutes less than everyone.

Hi i got the same case. I died too. Got Tay Kok Yang and Enders Ng. Sounds like i got it
much worse than you. Pathophysiology of palmar erythema anyone? Pathophysiology of
Gynaecomastia? Didnt get to your last 20 lines at all.

Session 1: CRC

Examiners: dont know their names. one from upper GI, the other from Uro. cant find their
photos in NUH though (heard their from there)

55/Chinese - quite dubious though, i thought he was malay at some point in the history
taking/gentleman

: stage II CRC s/p resection 1/12 ago

diagnosis given out to me on a platter. told him that we should go back to the beginning.

p/w:
1) change of bowel habits x6/12
- once in 3-4 days to once a day
- stools looser
- no mucous
a/w
2) bloody stools
- fresh red
- at the end of defaecation
- not coating stools, or mixed in them
- malaena previously -> black stools and wife complained that stools stink when she was in
the bedroom

No pencil thin stools. Tenesmus? (should ask for this, but i forgot)
No LoW/LoA.
- I made sure by checking if he still fit into his clothes
- gained weight even 1kg over the last month
No symptomatic anaemia.
No obstructive symptoms.
No faecaluria/pneumaturia.
No extra-colonic manifestations.

No painful defaecation/previous piles

Should ask for polyps detected on previous colonoscopy but couldnt cos he only heard of
colonoscopy at diagnosis

PMHx:

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1) HTN
- on enalapril, hydrochlorothiazide (he had a whole plastic bag of meds)
- on f/u 6/12ly
- said pressure was good

2) Hyperlipidaemia
- on simvastatin
- said last reading was good

3) previous surgery for ?umbilical hernia

- he kept telling me that there was piles at his umbilicus
(the last i checked, piles only occured at the anus)
- anyway i just bought it, thinking to examine it later

No other hospital stays, surgeries.

4) his current CRC

- presented to the polyclinic for PR bleed x 5/12
- referred to KTPH and subsequently underwent a colonoscopy
- polyp found, stage II, unable to specify the histology
- underwent a resection but unable to specify the location
- no adjuvant CT done
- now on f/u with KTPH 1/12

Drug Hx:

NKDA
Packet of medicines given to me
Social Hx:

Smoker 1 year x pack per month

Social drinker
Red meat lover (i found out that this is NOT a risk factor for colon cancer. the examiners
asked me to find a paper to prove it after the examination, albeit in a joking manner)
Ate vegetables after married wife
Stays with wife and two children
In HDB 4 room flat with lift-landing
Job as a administrative personnel

FHx:

Mother - HTN, DM
Father - Stroke
None with CRC

o/e:

Midline abdominal scar, well healed

Scar at left rectus below umbilicus for drain
No other findings, at umbilicus or otherwise.
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Did the entire examination.
On hindsight, should have asked for the vitals in the beginning.

Told the examiner I wanted to do a PR.

Asked me what I was looking out for.
MASSES. Blood/malaenic stools. Prostate size, surface, nodules. Said anal tone also, but
dont think he was really looking out for that.

Ask for proctoscope if you think its piles!

The examiners later impressed this point upon me, but they didnt harp on it.
Managed to sit down, organise my thoughts. Had plenty of time.

-bell rings-
examiners stride in

E: present your patient

M: my patient is a 55 year old gentleman who presented with PR bleed..
E: physical findings?
M: midline laparotomy scar with.. Ill do a PR
E: what are you looking out for?
M: masses, malaenic stools, prostate
E: summarize your patient
M: 55 year old gentleman with stage II CRC s/p resection, not on adjuvant CT. Has a well
healed laparotomy scar, no PR findings. my issues are
1) CRC s/p resection, not on CT
2) hes a current smoker
3) social issues (said he presented after 6/12 of PR bleed because he was concerned about
employment.

M: lets take a sit. what investigations would you like to do?

E: split into diagnostic and those looking out for complications. diagnostic is colonoscopy..
M: woah hang on, lets do something simpler
E: the investigations Ill do are divided into bloods, imaging and special tests
(just follow the flow of the

-pulls out blood results on the computer at this point-

E: please interpret the results

M: shows anaemia, thrombocytopaenia, tw normal. LFT normal. RP hypokalaemia but the K
was 3.5. CEA was in the thousands. (interpreted all these)
E: other investigations youll do?
M: erm..
E: what are your differentials?
M: CRC, haemorrhoids, angiodysplasia, diverticulitis
E: and so..
M: colonoscopy!!
E: interpret?

-whisks out colonoscopy pictures of a fungating polypoid mass, ulcerated, bleeding-

(said all that)
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E: what else? (kindly)
M: CT looking for complications

-CT scanned brought up. one cut only. obstructed sigmoid near the pubic symphysis-
Described this.

E: what sign is this called? like the one on barium enema..

M: apple core lesion sir
E: okay other investigations?
M: erm..about:blank
E: he smokes right? and you want to do surgery?
M: CXR, ECG (thinks - he smokes only so little leh)
E: whats the management for CRC?
M: broken down into medical and surgical..
E: stage II you sure medical?
M: oops sorry sir, i mean surgical
E: okay
M: -verbal diarrhoea-
E: what else would you like to do?
M: -addresses his other issues-
E: you can go

Ended early!
Remember, in a CRC case, DO A PR!!
Some examiners dont subscribe to the diagnostic/complications split for investigations, just
go with the flow. you always have the bloods/imaging/special tests to fall back on.
All the best!!

Session 2, Station 3: Approach to Massive UBGIT

60/Ch/male. Very helpful patient but I didnt always get his hint!
Drinks 9 bottles of beer/d x 16 years which I later established to be alcohol dependence via
CAGE questionnaire
Nil sig PMHx

Presented with 2 episodes of massive haematemesis (8 cups) over 3 days, on a background

of small volume (wisps) haematemsis for 6 months. Was drinking alcohol before the
haematemsis. The doctors told him haematemesis was due to the alcohol!
No symptomatic anaemia
No SOB, abdominal/chest pain, no abdominal distension, other bleeding manifestations,
jaundice
No LOW/LOA/NS, F/C/R
Sys r/v normal

Never done any OGDs, liver tests before

On admission, claims only OGD done, no treatment given, only IV meds. Started on
diazepam, thiamine, omeprazole and potassium.
No blood transfusion needed

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Other RFs/ fHx all normal.

O/E: No signs of CLD, Abdomen normal, no pallor, vitals stable.

Examiner 1 interrupted me 5 minutes into my history taking to tell me to move on to PE

because there are only 10 minutes left but after my PE I still took the rest of my history and
had time to summarise back to the patient. Derailed me a little, but told me to present what I
had to him and asked me for Dx. I said varices. He said Ok, but the haematemesis was
preceded by.? And I said Mallory Weiss Tear (which turned out to be the Dx, never
knew it could present with such large volumes of haematemesis).

Questions from E2, E3 (both nice TTSH people):

- Dx and DDx
- Issues: MW tear, Alcohol Dependence
- Show me how you feel for a spleen
- Ix: FBC, U/E/Cr, LFT, PT/PTT/GXM, OGD, ECG, CE, CXR
- Showed me blood results, Hb 11.7, Hct 33, U/E/Cr NAD, LFT GGT 700 AST 100 Alb N Bil
N, ABG: HAGMA.
- Why is there HAGMA? Do you expect HAGMA?
No, I expect alkalosis. But maybe we need to ask him where hes getting his alcohol from?
They laughed and said very good thought. anything else? and they were looking for DKA
(glucose was only 7 though), but on hindsight, probably more of alcoholic ketoacidosis.
- CXR: Where was this CXR taken?
I said at the A&E. They asked why. I said poorly inspired, many lines, etc but they were
looking for There are the words Supine and Portable at the top right hand corner of the film
which I said as a desparate measure. They said good and moved on.
- OGD: Showed clots with slight stricturing. No varices/ ESRH
Why is there stricturing? Alcohol GERD
- You are the HO. How would you manage him on the day after admission?
Just looked at drugs prescribed and said I would prescribe them. Refer for alcohol cessation.
- What resources are available for alcohol cessations? Alcoholics Anonymous.

Now it gets hypothetical.

Lets say his bleeding was due to varices.
At this point I kept saying ok new variceal bleed must rule out HCC and they seem pleased
- How would you treat definitively.
Went all the way up the treatment ladder from OGD haemostasis, SB tube, TIPSS to
transection of oesophagus
- How do you do a TIPSS? Cx of TIPSS? Decompensates hepatic encephalopathy.
- What are the stigmata of CLD? Just said some very very quickly
- How does somatostatin and beta blocker work in variceal bleeding?

Let me off 5 minutes early. Yay Im free!

Points:
1) I was in a slight dilemma whether to tell the examiner he mis-timed when he told me to
move on to PE. I decided not to, because (a) I realised he was probably trying to help me ,
(b) arguing would probably waste more time and theres always more time for hx later.
The fact that he interrupted my hx already disrupted my train of thought so I had a lot of time
for Hx after the PE.
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2) Think broadly. I guess it always pays to think beyond the obvious. I was gunning for
varices and about to take a perfect CLD history (which would have been inappropriate) when
my first examiner was kind enough to guide me back to the right Dx.
3) Take CAGE questionnaire. Dont assume that GS means just focus on the surgical part. I
did my Hx template for this and now I realise my social history part was underdeveloped, just
thought that finances/ depression/ how this has affected your life kind of questions would
come out, but fortunately realised the importance of the underlying issue. The surgeons also
focused on this point, saying that it was good i picked up dependence, or else it will just
recur.
4) In KTPH everything happens in the clinic room. When they flash the blood results you
have very little time to think. It helped that there were up and down arrows (cause its the
Singhealth system) which I just used to quickly describe what was going on and I think it was
good enough for them.
5) Dont forget interpretation of electrolytes/ ABGs, as they can sometimes come out like in
such. I do think they were rather amused when I mentioned possible alcohol (methanol etc)
contamination because it seems like they didnt think about it.
6) Treatment of everything = Multidisciplinary Approach.
7) Ive always found it useful to summarise the hx back to the patient, because firstly you get
a chance to practise your presentation and secondly its the time for you to sneakily clarify
things that you forgot to ask/ didnt realise were important at the time you asked them
without sounding too disorganised.
8) Its good to have the first examiner in the room. 1 additional layer of protection to prevent
you from bombing your long case. (And hes only worth 1 point anyway, if you fail his point
but get the hint its likely you get the other 4 points).

Session 2, Station 5

Mr Huang, 64 year old Chinese Gentleman

NKDA
Hx of HTN and hyperlipidaemia

Hx taken in Mandarin
Presented acutely 2 months ago with symptoms suggestive of I/O (constipation, distension,
pain, vomitting)
No suggestion of complications of IO (e.g. aspiration, perf, shock)
Has hx of abdominal pain (points at umbilicus) 5-6 years recurrently, colicky in nature,
resolves on its own, no radiation, exacarbating or relieving factors. Pain tolerable, different
from the pain above. Tries to vomit as he feels it relieves the pain. No blood in vomit, not
greenish, mainly undigested food. Vomit not projectile

Otherwise nil LOA, LOW of 3kg when he had the IO

Note: For anyone who is using this case as practice for history taking, can distract your
friend by saying the pain (of IO) started when he went to Cameroon highlands, how he
thought it might be due to infection. This is fairly important as you never know what you
might get in exams la. In the end I also counselled him over his HTN meds as he was
thinking about stopping-->bet that earned me no extra marks lol

So at this point if you are thinking GOO I guess we are both on the wrong track cos he then
told me they inserted a NG and set a drip, and the scan they did showed a mass at the left
105
colon, possibly malignancy. Luckily now also took like 5 mins so quickly went on to ask
colorectal things:

Pencil thin stools, Alternating diarrhoea with constipation

Nil bleed/malaena, tenesmus
Nil symptoms of anaemia
Nil faecauria, pneumaturia
Nil bone pain, SOB, jaundice

Underwent an op to take out the colon, was told it was benign, had a stoma formed (on p/e
looks like a end colostomy), had a stoma bag with well formed stools inside. Also had this
midline lap scar that was erythematous, pus-sy, which was covered by a wound dressing I
requested to my observer to take it out, which he agreed)

Asked also for complications post op (4 days in ICU-->had low blood sugar, no idea what
happened, was intubated, then spent 7 days in gen ward, not aware of any problems)
Asked for stoma cx, again said no issues, asked for pain, fever, diarrhoea etc. Stoma not
meant to be permanent

PmHx:
On atenolol and simvstatin, both of which were on the bedside table.
NKDA, not on any other meds, no other chronic diseases

Fhx/ShX:
No hx of CA in family, doesnt drink/smoke, stopped working as a chef assistant due to
stoma, boss told him to take it easy and come back when hes better.

So I did my p/e, summarised to the pt (gd strategy, as you can conveniently ask qns you
miss initially without sounding forgetful) P/e unremarkable la, signs as mentioned above, no
hernia of any kind.

So i was consolidating, then bell rang and (my mind suddenly just flashed to this WWE
superstar Kurt Angles theme song-->he is some olympic champ) and in came Prof Abdul
Rauff (R) with Mr Anton Cheng (C)from KTPH. I did the usual introducing of patient and so
prof Abdul started the qning:

R: So, present your pt

M: Prof, this is Mr Huang, a 64 year old Chinese gentleman with a history of hypertension
and hyperlipidaemia p/w signs and symptoms suggestive of IO 2 months ago. This was--
R: IO! What are the symptoms of IO
M: Regurg
R: Constipation! Did you ask about flatus?
M: Oops, sorry prof, i should have asked
R: What if he cannot pass?
M: Obstipation prof
R: Good! What do you think is the likely cause of his IO
M: Most worried abt Left sided colonic CA prof
R: But pt told you his disease was benign? what other ddx would yu consider
M:(Mind blank) sigmoid volvulus prof?
R: Possible, anything else?
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M: Hernias, adhesions, adenoma
R: How does adenoma cause ob? What is in history that is against this?
M: Long time of symptoms, tried to smoke some mass lesion thing
R: It is due to intussuception (tried to suck up by showing a grateful face for the fountain of
wisdom-->trust me everything counts for mbbs)
C: What do you know about diverticular disease
M: Goes into a rant on diverticular disease then realises the hint. So prof this could be
chronic diverticulitis
R: Good good, shows supine AXR
M: Prof this is both small and large bowel, large as haustrations, small as plicae circularis
Both: Frowns and ask whats that (realised the older gen prob more used to valvulae
conniventes lol)
M: Explained, said will do a a erect film as well to look for FA and air fluid levels
R: Shows a CT coronal view
M: Prof I see a mass lesion at sigmoid colon, loops distended blahblah
R: Whats this? Points at this radio-opaque thing at the top of the CT
M: Mind blankssaw the MO (who happens to be really pretty, or maybe its because she
was like an angel helping a distressed soul) mouthing NG
M: Prof this is an NG tube
R: Excellent! (Looks at C and ask him what he wants to ask)
C: Proceeds to grill on significance of rectal air, closed loop obstruction, standard stuff.
Strangest qn was whether I expect colon to be constricted or dilated in divert. Smked first by
talking about pathophysio of divert (increased intraluminal pressure) before realising it was
constricted due to compensatory hypertrophy of muscles. (I now you are prbably thinking
strictures or distension from IO, but they told me to ignore those and focus pure divert)
Both: Excellent!
C: Asks about post op care, noted wound infection etc.
C: What procedure is this? Hartmanns (prof rauff even went Ha. LOL)
C: Would you want to replace the colon continuity
M: Yes
C: what do you have to do then? As pre op?
M: Scope both places, thrugh stoma as well as trhough anus
C: what is the risk for this pt, give me a percentage?
M: Low.. (both proptose) Sorry sir I retract my statement, it is high, probably around 10-30%
of cx, althogh I am not sure
C: Actually its more than that

Bell rings!

Both: Well done, good job, leaves.

M: Thank you profs! Thank my pt, wanted to thank MO but left.

Learning pts: Mandarin is very important la given our population. Its ok if you are not chinese
as you can get a translator, but for those chinese guys who cannot speak chinese er
practice la. Not your fault that you werent brought up on chinese, but then MBBS is not fair
and so is life.

And juniors please dont be afraid to activate Sorry sir, I retract my statement. I freaking
retracted my retraction for med shorts and they were still fine so abuse this power (most
useful when your examiners faces are expressive and you will do fine la)
107
KTPH Session 3
Examiners: Dr Tan Kok Yang + External examiner
Case: LeRiche syndrome, presented with acute-on-chronic limb ischemia s/p multiple
angioplasties

56/Indian/male
PMHx: HTN, HLP, IHD

1. Bilateral leg claudication, right > left, x 5 years

- Currently followed up in KTPH, looking for further treatment options
- First presented to SGH in 2013 with severe pain - much worse than anything I
experienced for the past 4 years, 4 hours duration
- Associated with coldness, leg turned blue, no pallor/paraesthesia/paralysis
- Did angioplasties (multiple) + 2 coronary angioplasties on the same day of admission
- Currently complains of pain in thigh, calf and foot upon walking distance of 50m, no buttock
claudication
- Erectile dysfunction x 1 year (need to ask specifically - do you have any problems with
your sexual function? or patient would not have said this)
- Differentiate from neurogenic claudication - no back pain, relieved by standing still, worse
on walking uphill, has to sleep with foot dependent at night
- Claudication is lifestyle limiting - patient works as a security officer, has not been able to
catch robbers because of leg pain

2. Night pain x 4 years

- Worsened by lifting leg up, relieved with movement and dependency
- Does not require use of opioid analgesia
- Resolved after angioplasties done last year

No rest pain
No signs of tissue loss - ulcers/gangrene

3. Vasculopath history
- IHD (surmised from his coronary angioplasties)
- HTN
- Smoker x 80-90 pack years
No DM, HLP, previous CVA, doesnt complain of angina

Drug history: Aspirin, plavix, anti-hypertensives

Social history: Affecting his job + his wife says his leg is ugly

On examination:
- BP 163/97
- Signs of trophic changes - dry scaly skin, fissuring in between toes, trophic nail changes,
no loss of hair
- Warm bilaterally
- DP and PT absent bilaterally, popliteal absent (but admitted to examiners that Im unable to
palpate the popliteal pulse even in normal patients)
- Femoral pulses 1+
108
- No AAA, no carotid bruits, brachial/radial normal
- Buergers positive bilaterally, angle around 50deg
- Heart S1S2

Summary:
Mr X is a 56 year old Indian gentleman with a significant vasculopath history of IHD, HTN
and smoker of 80-90 pack years, who has chronic limb ischemia of 5 years duration.
He first presented with acute-on-chronic limb ischemia 1 year ago and is currently status
post multiple angioplasties.
His current main complaint is that of lifestyle limiting vascular claudication.
I suspect that he has LeRiche syndrome as he complains of thigh claudication, erectile
dysfunction of 1 years duration and has weak femoral pulses on examination.

Questions:
1. Explain why this is vascular claudication and not neurogenic claudication
2. What is LeRiche syndrome, where is the level of occlusion (aortoiliac)
3. What are the details in the history that pointed you to the fact that he presented with acute
limb ischemia last year?
- Severe acute onset pain associated with coldness of limb and blue discolouration
4. What do you think is the etiology of his acute limb ischemia?
- 2 main causes are thrombotic and embolic
- Likelier to be thrombotic in patients case as he had chronic limb ischemia for many years
prior to that, had time for collaterals to form which would explain lack of pallor + blue
discolouration
- Less likely, but could possibly be embolic in view of his IHD history - AMI would result in
regional wall motion abnormalities and hypocontractility of the heart, causing formation of
intra-cardiac thrombi
5. Questions on examination - how do you tell where is the ASIS? (first bony prominence
encountered upon running hand along the iliac crest)
6. What investigations will you do for this patient
7. Explain ABPI. Why would there be false elevation of the ABPI - why does TBI not cause
this? (TBI is measured via plethysmography, not doppler + cuff)
8. How will you advise on management?
- Control underlying vasculopath risk factors - quit smoking, BP, IHD
- Claudication is lifestyle limiting - will advise for therapeutic management with angioplasty or
bypass
- In view of previous multiple angioplasties and history that indicates multiple stenoses,
would advise bypass surgery - do angiogram to look for good landing site of bypass graft

Learning points:
1. KTPH only offers manual BP set (has been the case for both 2013 and 2014) - good to
bring your own automatic BP set, esp in setting of PVD where BP is actually very important
2. PVD exam takes at least 10 mins because of need to feel for all the pulses etc - good to
split History 12, PE 10, consolidate 3. Timing yourself is super important!! Learnt my lesson
after med long and ortho long.

KTPH Session 3
Prof Julian Wong and Prof Heng Chin Tiong (both nice)
Case: Vascular (arterial)

109
Walked into the room and saw this indian man lying on the couch. next to him was his
automated wheelchair. the ang moh examiner in the room asked me to start. i look around
frantically, got no chair to sit down and his automated wheelchair blocking me. i guess due to
my flustered appearance they finally get the idea that this arrangement isnt gonna work.
they proceed to spend the next 1 min moving his wheelchair away. not such a great start.

ok. lets start proper. clerked this guy, he is an inpatient. came 2 weeks ago for pain in his
left thigh, underwent surgery. there is a vac dressing still on. his legs look typically vascular-
like. trophic changes etc. his right foot was wrapped in sterile dressing, he told me charcots
foot. good historian. said fever and lump on his left thigh, underwent surgery. i had a quick
look at the wound and decided this was likely an abscess. spoke further and he also insisted
he had rest pain in his left thigh, alleviated by putting in dependent position, but nowhere
else in his LL. thought this was strange. was this really rest pain i.e. critical limb ischaemia??
otherwise no other signs of gangrene or ulcer.

Anyway besides that he is a vasculopath, had all the complications of DM. insisted no other
surgery (i was wondering why his right foot wrapped up). so after he denied having any other
surgery other than this recent one, i proceded to examine. His R foot had a previous ray
amputation HAHA. but i dont blame him la he was trying his best. Typical vascular exam.
Rushed through the physical examination because time flies while youre in there.

bell rings. examiners walk in

present a summary and then present the whole story

Presented as possible critical limb ischaemia cx infection secondary to DM and CVS risk
factors

HCT: did you do a full neuro exam?

Me: sorry, no time, just did it in cursory fashion
HCT: can you do one now?
proceeded to spend the next 5 min using the monofilament to show his sensation was lost.
The skin over the R dorsum (where the charcots joint was - he said sensation intact)
HCT: so how come you say he has charcots joint when his sensation over there is intact?
Me: (agreed) yeah i dont know oops

JW starts on the ppt

JW: can you interpret the results
Me: FBC shows markedly elevated TW, ESR and CRP high, CR high (he has ESRD on
haemodialysis)
JW: why the sodium low?
Me: uhhhh. sorry dont know.
JW: SIADH in sepsis. (really??? haha). what is the Hb we aim for renal patients?
Me: His current Hb is 9.1. That is generally low because we usually aim for 10-12g/L.
JW: how to read this arterial duplex
Me: (i have never read an arterial duplex before gg). I stare at it for 5 seconds and just as I
start to open my mouth he brings me through and gives me a tutorial. wow. damn lucky. i
just agree and say yes prof, i agree.
JW: so you think his disease is mild moderate or severe?
Me: um. Moderate? (when you dont know the answer its best to choose middle ground)
JW looks satisfied
110
JW shows me AP/Lateral X ray of patients left leg (tibia and fibula)
JW: any sign of infection?
Me: No? no gas gangrene, no osteomyelitis (come on his abscess was in his left thigh)
JW: Good. tell me about this foot x ray of his right foot
Me: the subtarsal joints all destroyed. charcots joint?
JW: what is the pathophysiology of charcots joint
Me: I blurt out something along the lines of sensory and proprioception loss due to DM
JW gives me tutorial on how because he has neuropathy, the intrinsic muscles of the foot
atrophy and hence cannot hold up the arch anymore.
Me: I agree. thanks prof.
(turns out his joint destruction is likely due to chronic osteomyelitis. dont ask me why)

The last few questions were about his AVF and how to manage his PVD. just regurg
everything in andre tan.

bell rings. YAY!!

Lessons:
1. time flies. clerk fast
2. nice examiners are great.
3. for our exams there is one examiner listening to us clerk so dont try to make things up. if
dont know or didnt ask, just say so.
4. if there is one condition you need to know super well for mbbs (and real life), please study
diabetes. came out for med mcq, med meq, my long case for med, PVD for surg shorts and
now long.
ALL THE BEST!

KTPH Session 3
Large bowel Intestinal Obstruction
Observer: Dr Sim HL
Examiners: Prof KK Madhavan, This other dude

82/Ch/Male, mandarin speaking, but really good historian (:

Presented 2 years ago with:

-Obstipation x 5/7 (normal BO once a day)
-Generalised abdo distension
-No nausea/vomitng
-No abdo pain
-No fever
-No stool changes previously- no change in frequency, no diarrhoea, no blood, no mucous,
no tenesmus
-No LOA/LOW
-No anemia symptoms
-No hx of chronic constipation, diverticular disease, hernia, volvulus, surgery or scopes

-Patient said the doctors did a scan for him, and told him that his obstruction was due to
Ya gu tou (Duck bone) Clarified like 4-5 times with him, because my chinese is quite cui,
maybe yagutou is actually some colloquial term for volvulus or something Duck bone?
111
you mean the bone of the duck? Duck bone Really duck bone? Yes, yes, really duck
bone! Ok ok!

-Underwent surgery to resect colon, and colostomy was made

Then presented one month ago with:

1/7 x bleeding from stoma - dark red blood with black stools - about cup
-A/w giddiness, no other symptoms of anemia
-No previous hx of epigastric pain
-No previous episodes of hematemsis
-No hx of PUD
-No early satiety, no LOA/LOW
-No CLD hx, no jaundice
-No bleeding elsewhere
-Scope was done - no ulcer found
-Likely to be due to aspirin as patient was on the medication back then, but has since been
stopped
-Transfused 3 pints, bleeding resolved spontaneously
-Other than the bleeding, no other complications from stoma
-Offered option of reversing stoma but did not want to as he did not want to go for another
operation

PMHx - HTN, HLD, DM - on medications, good control

No family history of malignancy, colonic disease

Non smoker, occasional ethanol intake

Lives with wife, able to care for himself, changes his own stoma bag
Only concern now is that changing the bag is very troublesome
No financial difficulties

O/E
Well, no pallor, well hydrated
Midline laparatomy scar
Stoma sited at LIF, feculant material, looks like a loop colostomy (examiner later asked why i
never stick my finger inside to see if its loop or not ><)
No erthyema or tenderness around scars or stoma
No hernia - incisional or inguinal
L clear, no cervical LN

Had 2 min to consolidate, examiners then walk in

Presented hx, talked about issues-

1. How would you differentiate large bowel and small bowel on hx? (progression of
symptoms - obstipation vs vomiting) Tell me all your differentials for large bowel IO.
2. How would you differentiate between UBGIT and LBGIT? Tell me all your differentials for
LBGIT and UBGIT. If a patient presents this way (fresh blood seen) and its a UBGIT, how
would you expect his condition to be? (Probably unstable, hypotensive since there is so
much blood loss)
3. How would you manage this patient for his IO as the HO?
112
4. What are the principles behind large bowel IO surgery? 1. Decompress the bowel 2.
Identify and resect obstruction 3. Establish gut continuity - primary anastomosis or staged
procedure (LOLLLL said all of these points in a long and windy way, examiner was so nice
he basically summarised my points as I said them)
5. What do you think was done for him? Left colectomy with loop colostomy formation
6. Why would you do a colostomy instead of primary anastomosis? Peritonitis, poor wound
healing, patient unstable
7. What invx do you want to do for someone with IO?
8. What will you see on CXR? looking for free air
9. What will you see on AXR? dilated bowel loops, haustrations since this is large bowel,
also more located in the peripheries
10. What is one thing you want to look for in AXR that will make you worried? Closed loop
obstruction - very dilated caecum
11. Complications of stoma?
12. Is it common for patients to come with bleeding from stoma a year after it has been
created? What are some possible causes? (No, it is not common. Could be due to bleeding
diathesis, or drugs like aspirin such as in this patient)
-Cant remember what else was asked, but the questions were quite standard! THANK
GOODNESS. Haha when the bell rang I was just like Er.. is it over already? And the
examiners were like, ya I think so. Really?? Its over?? Ok ok thank you profs byebye!!

KTPH Session 3
Hx + PE examiner: still dunno who the guy was
Active: Prof Abu Rauff (The Legend)
Passive: Prof Anton Cheng (KTPH)
Case: Head of pancreas CA

Okay so finally after reading all those seniors accounts its my turn to pen my own. Pretty
standard case of head of pancreas CA presenting with obstructive jaundice.

55/Ch/Male, fully Mandarin speaking, but still good and cooperative historian.

HOPC
- Progressive yellowing of skin and sclera x 2 weeks
- a/w pale stools, tea-coloured urine
- no pruritus
- Bloatedness and flatulence x 1-2 days
- on further questioning noted stool changes suggestive of steatorrhoea: oily and extremely
foul-smelling
- No metastatic symptoms: chest pain, SOB, bone pains, weakness or numbness
- Unquantified LOW without LOA

Subsequent treatment
- Saw GP, done blood tests, noted a marker is high (most likely did an LFT and found bil
high)
- Presented to KTPH, admitted for workup: blood tests, scan and scope
- Confirmed malignancy affecting pancreas , bile duct , and liver (at this point
patient wasnt really sure of the technicalities)
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- Was told Stage II
- Undergone resection (Whipples procedure), no post-op complications (screened briefly
about requiring second op, bleeding, infection)
- Chemotherapy at NCC, no evident complications
- Follow up at KTPH so far revealed no recurrence
- Weight has been stable since op

Comorbids
- None

Risk factors
- Smoker of 30 pack years
- No family history of GIT malignancy, but mother died of leukemia at age 53
- No DM
- No previous HPB investigations, therefore premalignant conditions unknown

Social
- Stays with wife and children
- Financially stable
- Works as a furniture maker

PE
- Not anemic, cachectic, jaundiced, peripheral exam unremarkable
- Midline laparotomy scar with some laparoscopic scars around (weird, maybe a lap-assisted
Whipple? Clarified that those scars were from the one and only op he ever had)
- No incisional hernia
- Otherwise no findings

25 min mark, Abu Rauff and Anton Cheng walked in. The session didnt really go like how I
imagined it to be...

Rauff: Okay, so tell me based on history anything to point to the diagnosis.

Me: This patient is Mr. ****, a 55 year old chinese man
Rauff: No youve done that. Now tell me the diagnosis.
Me: Sir Ive managed to narrow it down to a lesion in the bile duct or
Rauff: He had with obstructive jaundice, right? (uh thats not a diagnosis what more like a
syndrome)
Me: Yes, he presented with painless, progressive jaundice associated with pale stools and
tea coloured urine
Rauff: How do you know its progressive?
Me: Uh, as opposed to sudden? Well he did mention that it was picked up by his family and
friends
Rauff: So it was observed by his family members! What else?
And so the next 5 mins were about the basic symptomology, like suspect cancer you ask for
what? LOW! Why is stool pale? Why tea coloured urine? What jaundice doesnt give tea
coloured urine? (Hemolysis. Cos unconjugated bilirubin is not soluble in water. Heh but
technically urine will be smoky due to hemoglobinuria but doh surgeons just wanna hear the
keywords and move on. So dont even need to act smart and mention smoky urine.) What
physical findings? Palpable gallbaldder. When can you have obstructive jaundice but no
palpable gallbladder? When obstruction is above the cystic duct. Basic science and
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symptomology. DO NOT FUMBLE HERE. If not, down and down you go along the
long, narrow, and tortuous path into surgery long case hell.

So at this point the examiners are like okay this guy is decent we cant crack him down with
the basics. So then I went straight to investigations! No need to present whole history like I
detailed above, and no need to present current physical exam findings. This is what I meant
by the session didnt go as intended.

Ix: Just list off the investigations + what you looking out for and he tells you everything is
normal, except the LFT and scan of course. FBC, UECr, PT/PTT, LFT, Amylase, CA19-9.
U/S HBS, CT scan, CXR for staging.

Proceeded to read the CT scan. Asked to identify the structures: pancreas, aorta,
gallbladder, CBD, etc.

Rauff: What artery are we interested in evaluating a pancreas CA?

Me: brain failure. For some reason looking at the scan I saw a nice splenic artery so I said
splenic artery. Wrong. Gastroduodenal artery? Wrong.
Rauff: SMA. Because encasement will preclude a curative resection, right?
Me: Oh yes prof I knew that! -smile smile smile- accually iz dunno
Rauff: So, what is the operation for him?
Me: Whipples
Rauff: Do you know who is Whipple? Thats right you dont. Give me the anatomic name
Me: Pancreaticoduodenectomy
Rauff: Tell me the anastomoses gastrojejunostomy, pancreaticojejunostomy,
hepatojejunostomy
Rauff: What to tell your patient after the diagnosis? Lets say staged, no nodes, 3cm tumour,
resectable.
Me: Explain dx, explain procedure, complications. Elaborated a bit more about each.
- Bell rings -

Advice

1. Like treating any autoimmune condition, you need to hit hard and hit early to induce
remission. This means knowing all your history and PE basics well, know how to explain
every single symptom or sign and its pathophysiology. Once youve induced the remission
you can even skip some stuff; they just assume you got it. Although this isnt really a
shortcut, because to be that good you have to be that good.
2. Think like a surgeon. Every surgeon is looking for very specific answers in their
questioning. Clarify the question if you need to. Dont waffle about too much and smoke
something. You either know or you dunno.
3. If youre on the long and painful road to hell, the only way to salvage it is to beg the
examiner to dig you out. Honestly at that point very little on your own part can save you. But
since youre reading this account it means youre doing some advance prep. Therefore, go
read Talley OConnors and Norman Browse in detail. These books explain the basic stuff in
the most fantastic manner.
4. Andre Tan, Washingtons manual, UpToDate, whatever tutorials will supplement you with
the discussion pointers. The struggle is getting there. Good luck!

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KTPH Session 4
57 y/o/Malay/M
HCC s/p resection

Observer: Dr Roy (neurosurgery KTPH)

Examiners: Dr Tan Tzu-Jen, Dr Cheong Wai Kit. Both v patient and nice

presenting complaint: RHC pain (acute, non-radiating, progressively worsening. not a/w
abdo distension, jaundice, fever, n/v, symptoms of obstructive jaundice, constitutional
symptoms). Subsequently diagnosed with liver mass, resected.
Been well since, no other issues socially
PMHx: HTN, hyperlipidemia, gout, prev CABG
examination: lexus scar, everything else normal

Discussion:
Started with approach to RHC pain.
-Differentials (State all possible and qualify which is more likely)

demonstrate examination
In a patient with a previous malignancy and resection what are you looking out for on
abdominal exam

-How would you investigate and manage a patient who initially presented with RHC pain
FBC, U/E/Cr, LFT + albumin, Hepatitis serology, AFP, serum amylase, serial cardiac
enzymes
ECG
U/S HBS followed by either CT AP or Triphasic CT based on results of U/S HBS

showed investigations
US Liver - nodule, multiloculated, margins seen, slightly irregular
MRI (i dno why MRI was done instead of CT but they seemed to agree when I suggested CT
initially) - large mass in the right lobe of liver

- Differentials for liver nodule

- What investigation would you do to differentiate
- Based on MRI what would be your most likely diagnosis
- How would you prepare a patient for liver resection surgery
- Oncologic principles of management of HCC

Tips: If examiners are nice and try to guide you, let them.

Session 5

GIST in my pants -> need translator too -..-

Prof Julian Wong & Prof Heng Chin Tiong
75/Male/Chinese
NKDA
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PMHX: Hyperlipidemia, Bradycardia s/p pacemaker

Presented with syncope into the ED with massive melena

Took hx as per upper git bleed
Had melena previously for about x2-3 months
Not getting worse, black stools, not green
No bleed elsewhere, no easy bruisibility
No other symptoms of anemia
Nil haematemesis, loa, low, early satiety, n/v,
Nil pr bleed, tenesmus, diarrhea, constipation
Nil cld symptoms eg itch, swelling, easy bleeding
Nil bone pain, headache, sob, jaundice, urinary symptoms
Nil family history of cancers
Had 3-4 years of epigastric pain with dyspepsia
Seen by gp and given omeprazole
Nil scopes done prior to that
Nil alcohol, stopped smoking x30 years already
Scope was done after patient resuscitated
Hb was low
OGD & colonoscope done
OGD showed bleeding ulcer with some?polyp in stomach
Lives with wife, financially well

Examined the patient

Nothing found. Nil masses, scars. Nil LN. No CLD symptoms. No pallor.
BP machine failed so had to get a new one. Fail max. Offerred to do PR but no need.
Took BP using another machine and examiner came in.

Heaved a sigh of relief when i saw Prof Julian & Prof Heng( NICE PEOPLE)
Presented the case as UBGIT with presenting with dizzyness and syncope. Presented the
rest of history & summarize at the end. Presented clinical findings

Examiner: So what is your differentials for this patient?

Me: PUD, gastritis, gastric CA, AVM, variceal bleed etc etc
Examiner: So how you differentiate gastric ulcer vs duodenal ulcer?
Me: worse after food for gastric and better after food for duodenal but not every accurate
Examiner: what types of gastric Ca do you know of?
Me: adenoCA(intestinal vs diffuse), GIST, MALT, rhadomyosarcoma?
Examiner: So how would you tx this patient in ED?
Me: ABC resus, fluids, blood, iv ppi, call senior, do emergency ogd to stop bleed
Examiner: Interpret the blood results(showed me blood results)
Me: Hb of 8, no mchc, no infection etc etc etc, no platelet or pt/ptt dysfunction
Examiner: ogd was done. interpret the ogd
Me: ulcer seen at antrum with adherent clot, no active bleeding, well defined edges. seems
to be a mass that does not involve the mucosa as mucosa appears to be smooth
Examiner: what type of tumour cause this appearance?
Me: GIST
Examiner: so what will you do?
Me: biopsy the lesion, stage the lesion using eus, ct abdo pelvis, chestxray etc etc
Examiner: *shows CT* interpret it for me. tell me all about the different structures seen(LOL)
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Me: liver normal, kidney normal, gut normal, pancreas normal, aorta normal, ivc normal. a
mass in the stomach seen at the antrum. well defined hyperechoic mass with central
hypodensity likel central necrosis?
Examiner: how would you treat this patient?
Me: Not metastatic dx, treat with curative intent. For GIST tumour, can treat medically with
gleevac(tyrosine kinase inhibitor) and tx surgically if medical tx fail and tumour >2cm.
Examiner: what type of surgery is done?
Me: partial gastrectomy as distal stomach affected with LN clearance and reanastomosis
with roux-en-y or billrothII
Examiner: okay were done. BYE
(done with 7 mins to spare. wtf right?)

Totally didnt expect GIST to come out. but oh well. nice examiners will guide you along so
no worries la. And try not to calm yourself down when presenting, and try to have some time
to consolidate everything

KTPH Session 5
Critical limb ischemia secondary to peripheral vascular disease due to DM and
chronic smoking

Examiner: Mr Cheong Wai Kit (NUH colorectal), Mr Tan Tzu Jen (KTPH)
Observer: Mr Roy Koh Kok Miang
56 yo, Indian Male, NKDA, ADL independent
IMH resident
PMHx:
1. DM x 1-2yrs on oral hypoglycemics (claims compliant) cx by DM retinopathy (not on follow
up with opthalmologist. No laser photocoagulation performed before). No other
micro/macrovas Cx
2. Schiz on some unknown meds
No past Sx Hx. :)))

c/o:
Symptoms of critical limb ischemia:
1. Left toe pain x 1-2mths
- rest pain
- Better on a dependent position, worse on elevation of the leg
- Not alleviated by analgesia

2. Ulcer on plantar surface of the 1st web space x 1-2mths

- No inciting event (eg trauma)
- a/w swelling, pain, redness, bleeding and purulent discharge
- No systemic symptoms eg fever

No gangrene
a/w:
1. Vascular claudication x 2-3mths with claudication distance of 4-5 steps
- constant claudication distance
- Crampy pain at the left calf provoked on walking 4-5steps
- Got to rest for 2-3mins before continuing

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- No back pain/ radicular symptoms
- No buttock pain/ thigh pain
- No systemic symptoms (eg fever, LOA, LOW)
- Not worse when patient is walking down stairs

Cause (other than PMHx of DM):

- No hx of trauma/ heart problems/ murmurs
- No hx of aneurysms

Progress:
- seeked treatment at KTPH, underwent a failed angioplasty as unable to pass a guidewire
through
- Advised to go for bypass. Still considering.

FHx:
- Mother and sister has DM.
- Brother has leukemia, mother has brain cancer

Drug Hx:
- Not on aspirin/ warfarin/ statins

Social Hx:
- Smoker: 80 pack yrs
- Alc: 6-7cans for 14yrs
- works as a cook in IMH.
- Notable social concern: unaware of importance of good footwear (advise patient on that) +
poor social support when he comes out of IMH

PE (focusing on arterial + DM macro and microvas Cx)

- 1x2cm ischemic ulcer on plantar surface of 1st web space
- Purulent and sloughy base with discharge
- Sloping edges (examiners didnt say anything. Qualify by saying that I note that its
atypical of
ischemic ulcer)
- Not deep. Unable to see the underlying muscle/ bone

Presence of trophic nail changes with hyperkeratosis

No atrophic skin changes on bilateral LL (no loss of hair)
No pallor/ DM dermopathy/ ulcers on gaiter region
No other ulcers/ gangrene
No deformities

Capillary refill time prolonged >2s on both legs (but L>R)

L DP and R DP - absent
L PT (absent), R PT (1+)
L popliteal (1+), R popliteal (2+)
L and R femoral 2+

Initially requested for everything - Buergers, ABPI, CVS exam, carotid bruit, femoral and
popliteal bruit + assessment of macro and micro vas cx of DM (includ: VA, urine dipstick,
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peripheral neuropathy exam, palpation of foot for OM and septic arthritis (Prof Aziz
immunopathy.., pronator drift)

Observer nodded his head. Then check watch 20mins, still got some time, so heck la,
decided to go ahead and do the rest of the arterial exam + CVS exam ( focusing on pulse,
murmurs, carotid bruit) lol..

What the observer did:

1. Instructed me to clerk as though he was not there
2. Double checked all the physical findings himself to make sure its all correct. Initially I
said no difference in temperature on both lower limbs and he was like "HARH ARE YOU
SURE?" proptose +++. Then he really went to feel, slide up and down before saying 'ok
lah, can can carry on'. So juniors, stand firm on your findings and act yi ge confident. :)
3. Present to him summary statement (So quite nice la, helping me to prep for the big
shots)

Questions:
1. Present your history [They allowed me to present without interrupted. v nice of them :)]
- Tips: Please make sure you present the truth. Dunno say dunno and dont fabricate.
Coz my examiner actually clarified with the patient on the spot (as patient is in the room
during presentation) on the presenting c/o and vascular claudication. But good for me, coz
waste time. Just want the bell to ring man..
2. Show me your arterial examination. Mr Cheong scrutinise like siao, capillary refill he also
looking over my shoulder like a hawk
- Demonstrate the PT, DP, popliteal pulse, femoral pulse
- Point to me the exact location of the pulse (ie, for PT: he wants me to draw an
imaginary line on the patient from the medial malleolus and calcaneum, divide into 3 parts,
1/3 distance from medial malleolus)
- Point to me location of medial malleolus (WHUT?), ASIS and symphysis pubis
3. Tell me how would you do an ABPI?
4. What does the different values of ABPI mean? What if >1.0? (If 0.9-1.25, can be
considered as normal)
5. What is the natural progression of PVD?
- Will get worse. But collaterals can form to supply the distal limb so rate of
deterioration can be attentuated
6. How would you like to further investigate patient?
- Bloods for baseline, arterial doppler ultrasound for loss of triphasic waves and
arteriography of bilateral LL
- Image X ray of left foot: OM changes (haiz didnt ask me more about it)/ fractures/
s/c gas
7. How would you like to mx this patient?
- Conservative, pharm and surgical (bypass) {vomit Andre Tan}
8. How would you like to prep patient for procedure/ op?
- Hx: hx of allergies to contrast/ anaesthesia/ asthma/ kidney problem
- PFO: Baseline FBC, Renal panel to look at Cr for possible nephropathy, GXM,
coagulation profile, ECG, CXR, ?lung function test due to long smoking hx, possible cardio
and anaesthetist review

Brought me to the com to read ppt slides of scans

9. Read the bloods (HAGMA. Lactic acidosis) -> Requested to do ABG to look for any
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metabolic acidosis and adequacy of compensation (both didnt say anything)
10. Read Xray of left foot (no om changes, quite normal)
11. Read angiogram of the thigh and lower limb (PLEASE LEARN HOW TO READ AN
ANGIOGRAM)
- Occlusion of the lower third of the popliteal artery with formation of collaterals
- Poor flow of contrast into the arteries of the distal limb (namely the anterior tibia and
peroneal vessels). Unable to see any flow into the posterior tibia arteries
- Since patient presents with critical limb ischemia with poor flow, require urgent
balloon angioplasty +/- stenting

Mr Cheong: ok can. -10s of silence to wait for him to continue questioning. silence v
unnerving-
12. As a HO, how would you manage this patient holistically
[smoking time..]
- Patient education on foot care, ulcer care, wear covered shoes to prevent injury, referral to
podiatrist, especially impt to this patient since he has poor insight
- Control risk factors: stop smoking (v impt! earned a "good" from Mr Tan), control DM,
improve compliance to medications, regular eye screening, urine dipstick, foot screen for
peripheral neuropathy.
- Prevent complications of pvd: eg acute limb ischemia (educate patient on 6'Ps" so that he
can come to seek treatment early
- Pharm: as above (Mr Cheong was like "okok can no need to elaborate" in his usual stone
demeanour)

13. You mentioned bypass graft, what are the principles of surgery?
- Indications of bypass graft: unable to pass a guidewire through, a long stenotic portion,
must have good landing site on both ends
- Can choose either synthetic (PTFE)/ non synthetic graft material (*purposely baited them.
praying that they ask the subsequent similar questions that CN Lee asked for my friend.
Thankfully they did :D*)

14. Mr Tan interjected: So which do you think is better, synthetic or non synthetic?
- Non synthetic (less risk of thrombosis) [thanks Joanne!!]

15. Mr Tan: so how to manage patient after op?

- vitals, bleeding, symptoms and signs of cpt syndrome, wound site infection
- start patient on aspirin immediately [thanks Joanne again!!] as thrombosis would start
immediately
- check nv status of peripheries frequently

16. Mr Tan: So do you think that the long term prognosis of a bypass graft is good?
- Not really as DM and smoking can still affect the graft. But better than angioplasty.

*BELL RINGGGGGSSSSSSSS*

Reflections:
1. Please read your friends' (same batch) accts/ discuss the questions that your friend got.
Might save you on your big day
2. Quite thankful to get a straightforward case. But juniors, if a case is so straightforward,
cannot afford to miss out stuff.
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3. Read your Andre Tan and please please please read BROWSE! Mug all the proper
definition, surface markings and impt differential diagnosis (kope from the blue boxes).
4. For presentations, aim to write out a GOOD one-line summary in the 2mins as a bare
minimum. Surgeons confirm switch off after that.
5. When performing the physical examination during the first 25mins, DO A RUNNING
COMMENTARY so that the observer can give you marks and help you if you go offtrack.
- Rmb: losing 1 AP is better than losing 4.
6. ALWAYS keep calm and speak loudly. Act yi ge confident. :))

ALL THE BEST GUYS!

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Day 4: CGH

CGH Session 1 - Newly diagnosed Crohns complicated by enterocutaneous

fistula
So here comes my epic end to mbbs. Sigh. Hope the examiners will be nice in their marking.
For those reading this, haiya, I seriously do not think you will get Crohns for Surg long case.
I mean, common things come out commonly right? But of course I was obviously wrong. So
if you happen to have the same luck as me, here goes the case

57yo Chi gentleman

(I dunno who my examiners are. sorry. they werent exactly the nicest. but they werent too
cruel either, thank God for that)

Patient starting telling me his story. Seemed very excited to tell me everything. Started with
telling me he presented with severe crampy abdominal pain 5 years ago. Pain was so
intense it wakes him up from sleep. Generalized pain, but more in the central part. Did not
resolve with pain killers. Went to SGH. SGH did everything, scopes, scans..OGD and
Colonoscopy. Told me They said I have an ulcer in the intestine, but they took biopsy and
they said it was okay, not cancer. So anyway, SGH told him he had irritable bowel
syndrome.

Patient now presents 1 year ago @ Cgh (Feb 2013) with a large mass on his right lower
back. *Patients points to me this big scar at his back, looks like there was a healed open
wound*.
Patient said he had this mass, that was very painful. (I dunno why my mind started thinking
abt an enterocutaneous fistula causing abscess). So i quickly screened for IO symptoms
symptoms also (TRO other complications of diverticulosis). Patient had constipation for the
past 5 years (but he said he has gotten used to it), and abdomen feels like got a lot of gas
(just take it as abdo distension), abdo crampy pain but no vomiting.
Other things in the history:
- the tender mass, no discharge, no overlying skin changes
- no fever/chills/rigors
- has LOW/LOA
- no melena/PR bleed
- urine pattern normal
- no history of cancers, no other risk factors for cancer
- except that he smokes >20pack years

So anyway, the story goes that when he present with this mass in Cgh (Feb 2013), they
worked him up and told him he had Crohns!!!! (when he told me this, i thought..oh great) *I
clarified with him, wah uncle so in that 5 years, when u saw Sgh, they didnt tell u you had
crohns?* And he said no. So anyway went to cgh in Feb 2013, where they made an incision
to drain the abscess (??). Then he said they left the wound open, no stitches. In Sep 2013,
he came to the hospital because he said the wound site kept on draining feces material. So
he said the doctors put stoma bag for him, but did not do any surgery. Doctors just gave him
Infliximab and told him his body cells are attacking each other. Was for conservative
management at that point of time. Then patient came to Cgh again in Feb 2014 for a
resection of the diseased bowel. Showed me the laparoscopic scars.
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By now I was super flustered already. This guy had such a complex history. and his timeline
was all over the place, I had to keep clarifying the timeline with him. And no time already,
need to quickly screen for extraintestinal manifestations of Crohns. He has oral ulcers, but
no eye/skin/joint/perianal signs.

Then quickly do a screen of his past med hx/drug history (cldnt tell me the meds)/family
history/social hx. Basically not significant so I wont type it in.

P/E: No significant findings. Just need to look for all the scars. Patient had a central
longitudinal scar above the umbilicus and 3 lap scars. He told me all from the same surgery.
Then his scar on the right lower back from where the mass used to be. (Dont forget to ask
the patient to cough for any incisional hernias! of which he didnt have)

25 mins up. Examiners came in. Introduced to patient yada yada..

(I was very nervous cos didnt really know what was going on. Decided to go with my gut
feeling to just say enterocutaneous fistula and if they proptose, then quickly think of
something else)
So.. Sir this is my patient, Mr XXX. He has a background history of Crohns disease
diagnosed one year ago, now presenting with complications of what I think is an
enterocutaneous fistula and possible intestinal obstruction. More about his history Sir

Profs didnt wince so I was thinking..okay phew. Then just present the presenting complaint
and complications he had as per above.

He asked me to do abdo P/E for him and present. nothing much. dont forget to mention no
extra-intestinal manifestations of crohns.

Question time. Wah this one can die already.

E: So what are your differentials?

Me: Sir, my first differential will be that of enterocutaneous fistula as a complication of
Crohns. Others cld be a diverticular disease with cx of abscess/enterocutaneous fistula. I
will want to also rule out colorectal CA.
E: Okay..what else..esp in this region where we live in?
Me: (i dunno..but just guess) Hmm maybe it could also be colorectal TB? (he seemed to
accept that ans)
E: Okay so what investigations wld u do?
Me: If I suspect an enterocutaneous fistula/abscess, then I would want to do a CT scan.
E: (shows me the CT scan) okay now u can scroll up or down and tell me what you see
Me: (wah die already. How to find a freaking fistula. so i scrolled up and down like crazy and
pointed to a super vague area. haha)
E: Why dont u point to us with a pen?
Me: (shit. smoking failed) I think i pointed to a wrong area. So he tried to direct me to the
correct area, then i just tried to follow his lead. Basically, it was super hard to find k. Esp if
you havent seen one before like me. He tried showing me some super small gas bubbles in
the abdominal muscle. Sigh. HOW I KNOW!!
E: What will you ask the patient (in history taking) if you think its an enterocutaneous fistula?
Me: Any discharge, feculent material, bilous fluid..?
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E: What else?
Me: (i dunno man) Uhm, if infected then there may be pus? also look for any bleeding?
E: Okay.. what else?
Me: (wah got summore ah. Just surrender lah) Sorry Im not sure prof
E: What else is there in the bowel other than what u said?
M: Basically the examiners were trying to say that patients may also tell u that gas passes
out of the fistula. (err okay. learning new things everyday)
E: (epic qn) So what are your principles of management for a fistula?
M: (omg seriously. I dont know. Tried to force my brain to think of broad principles) Sir,
firstly, if there is an infection, I would like to treat the infection with Abx. (he seemed pleased
with that). And maybe we can offer a fistulectomy?
E: Wah so fast jump to surgery ah? What else in between, before surgery? After you give
Abx?
M: (After much prompting from the examiners..the ans they were looking for) If there is high
output from the fistula, need to replace fluids and electrolytes accordingly.

Okay that was the essence of my case. I am too traumatized to rmb anything else. Lol
All the best everyone!
Tips: When u feel stuck, just smoke ur way through with broad principles. Then see if the
examiner guides you. That was what I tried to do ah. Hopefully itll be okay.

CGH Session 1 UBGIT Bleeding peptic ulcer (eventual diagnosis gastric CA)
Examiners:
Observed History: Mr. James Ngu
Active Examiner: Prof. Tan Su Ming
Passive Examiner: dunno cant remember

45/Chi/M/ ENGLISH SPEAKING YES

I was in an extremely good mood today dunno why. Had a bit of fun going through the process
of this exam, even though my history taking was a bit fail ^_^ Anyway this guy came in with
fainting spells, haemetemesis and malena x2 episodes, both episodes similar, first and second
episode separated by 4 months without symptoms in between. Decided to seek medical attention
after second episode.

Asked typical questions for vomiting and shitting. This guy no other symptoms, fainting spells
probably from anaemia. Was trying to think of what risk factors and complications to ask for, but even
though I was really calm, sometimes brain just fails I guess.

Eventually managed to squeeze out that he has some burning sensation around the solar plexus
and sometimes epigastric discomfort, attributed it to his job and irregular meals. So some gastritis /
GERD symptoms over the past year before presentation. No NSAID / steroid / TCM use. Systemic
review nothing, no chest pain diaphoresis sob. All else normal also. No other PMHx.

FHx: Father died of HCC. No financial / social issues.

What did they do for you on admission?

Cannot really remember cos I was very drowsy.
But he eventually said that they did a scope, found an ulcer. Also did CT scan which found another
ulcer. Huh ulcer do CT scan for what zzz. In retrospect this was probably the staging CT scan. I think
the patient wasnt aware of the diagnosis >_> dunno. Forgot to ask whether got blood transfusion.
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Doctor said he had a heart attack during the admission also, but he cannot remember anything, really
too drowsy.

Smoker 10 pack years. Alcohol also forget to ask hahahahaha. Really brain fail.

Physical exam also nothing much, just conjuctival pallor ++

And then they walked in. Yay Tan Su Ming! And another guy I didnt recognise. The quizzing
actually felt like presenting to her at M&M all over again :) She kept smirking at my answers
like she usually does, and I think I was smiling like an idiot trying to suppress my laughter
LOL.

Presentation: 45/Ch/M, premorbidly ADL independent, smoker 10 packyears, no other significant

PMHx, presenting with 2 episodes of upper gastrointestinal tract bleeding, likely secondary to a
bleeding peptic ulcer. *Presented the rest of the history in detail, they didnt interrupt at all, even social
hx.*

Prof: Differentials?
Me: Bleeding peptic ulcer, gastritis, gastric CA, bleeding varices, Dieulafoy lesion. Gastric CA not
likely because no constitutional symptoms + looks well nourished, but would still like to exclude. No
stigmata of chronic liver disease also, and variceal bleed is unlikely.
Prof: What is malena?
Me: (lolwut. Why ask this kind of thing one) blablabla
Prof proceeded to poke my history a bit also. Why never ask this why never ask that blabla.
James Ngu: how about you present your physical findings first.
Prof: Yes, show us how you performed your examination.
*do abdo with running commentary. They stopped me here and there to skip steps and ask basic
questions. Think they just making sure you know how to examine abdo. Offer DRE also, and what you
expect to find*
10 mins bell, James leaves.

From here on, the discussion was mainly about the differentials, they nitpicked a little as to why I
thought its a peptic ulcer (umm cos the patient said so? LOL. Actually didnt have symptoms such as
pain in relation to food etc, so probably would have been hard to say @ presentation.)

Prof: Ok nevermind. Lets say he first presented to you with this history, and is hypotensive. How to
manage?
Me: Immediate goal is to stabilise the patient so he can undergo an OGD. Blablabla about ABC. Was
also asked about how much blood you would order, how to give fluid supplementation while waiting
for blood. Also some specifics like how long does it take for 1 pack of blood to be administered etc.
Somehow said somatostatin cos brain switched to varices mode dunno why. Earned proptosis and
retracted as appropriate.
Prof: Patients BP still dropping even with your IV fluids.
Me: Ongoing severe bleed? Need OGD like right now? No wait but need to stabilise before OGD
right? *fumble fumble ++* but then all they wanted me to say was I WILL CALL A SENIOR. Juniors
pls just say this early haha.

Went out to corridor COWs. Which was noisy like marketplace cos all the students answering at the
same time in the narrow day surg corridor.

Showed blood invx, FBC normal UECr got elevated Ur and Cr. Asked really basic stuff. Describe
OGD gastric cardia photo of the ulcer. Histo poorly diff. adenoCA!!! Now what would you do. Talked
a little bit about staging CT. How to prepare for OP? blablabla.
THEN THE BELL RANG I was like noooo havent reach the operative management is that bad? Haha
126
whatever.

Think everyone also stun a while staring at our respective examiners. 25 minutes got so short meh?
Then we slowly regained consciousness and left yay.

Overall a rather uneventful exam; hope thats a good thing. All the best to everyone :)
END

Session 1
HNPCC
A/Prof Adrian Koh (CGH) and Dr Goh Yaw Chong (SGH) both nice +++

Shall cut my history short.

60 year old lady with family history of colorectal cancer++++ (4 direct family members,
earliest at 40yo). Only started screening in 2008 despite strong family history. First malignant
growth detected on screening in 2011. Asymptomatic then. Resected, hospital stay
complicated by wound dehisence. Had adjuvant chemo. Second malignant growth one year
later, resected again. Uneventful recovery. Currently well.

No other HNPCC associated cancers. No other risk factors for colon Ca.

Sequence of events:
1) Presented history. Conveniently forgot to bring out my trump card and missed mentioning
that it's likely HNPCC. But anw, doctors didnt question my history phew.
2) Asked to demonstrate abdo PE. (stood at foot of bed, inspected, asked pt to cough to look
for incisional hernia. My lousy non-surgeon eyes couldnt see any, so reported as such)
3) Dr Koh proceeds to patient's tummy and touches it and asks patient to cough. "Are you
sure there is no incisional hernia?" (you say until like that, of course there is lah wah lao.
wayang and did what he did, then retracted my prev statement of not having an incisional
hernia zzz)
3) Dr Koh interrupted my abdo exam when i was gg to move to peripheries. "You missed out
something ". I was stunned for a while, tried to figure out what I missed, but couldnt. "You
mentioned you would like to cover the patient for modesty sake", "ahhh yes, sir i would like
to examine the external genitalia". Wah lao, i usually offer at the end of my peripheral
examination mah.
4) How would you handle this patient if she came to your clinic? Just rattled off all the
investigations, but then patient was asymptomatic, so also nothing much to check. "Is there
anything else you want to do?" Couldnt think of any so admited defeat. "What about
FOBT?" , "Ahh yes sir, that too" , "Do you think FOBT will be useful for this patient?" " Yes
sir" (if not u ask me do it for what). "Actually it's not useful because you will still scope the
patient anyway because of her risk factors" wah sian, kena troll, first tell me to do then now
say not useful. "anything else?" , CEA sir for surveillance.
5) Management questions (stage, take consent, assess fitness and optimize for op,
principles of surgery blah blah)
6) "Even though she had a resection in 2011, the cancer still recurred, will you now do a
total colectomy to prevent another new tumor ? No idea what the answer was, so throw
smoke bomb. Said must weigh risks and benefits. If cut everything, she will laosai everyday
cox no more large bowel to absorb water. If dont cut everything, risk of metachronous tumor.
They seemed to accept this smoke bomb.
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7) Moved outside. And suddenly i find myself having my final surg mbbs in front of an
audience of 8 nurses who appeared out of nowhere to join in the fun. "Now that she had her
resection, is she cured? " At this moment, it dawned on me that I didnt mention my suspicion
of HNPCC while presenting history. So, tried to save myself. Said no, she is still at risk of
other associated cancers of HNPCC such as xxxxxx, I suspect HNPCC as she fulfils the
Amsterdam criteria (bait)
8) Bait taken. "Tell me about how she satisfies the Amsterdam criteria" Yay.
9) "Ok, let's talk about her incisional hernia. How will u manage it? ". Said usually managed
conservatively, unless symptomatic or complications occur. They didnt seem too satisfied.
So added on, however this incisional hernia quite small, so higher chance of strangulation
due to tight space, so may offer surgery. They seemed more satisfied with that answer.
10) Why do you think she developed this incisional hernia? Was all prepared to regurg all
the pre-op, op and post-op factors but they cut me off. Asked specifically what happened for
this patient. Took me awhile after some prompting before realising it's because she had
wound dehisence post surgery.
11) "When will you start scoping her nephews and nieces?" 10 years before the earliest
case, so 30 years old sir. (correct ans is 20-25 zzzz, but they also nv correct me so hopefully
they dont know also)
12) Anything else can be done? Genetic testing
13) Showed scope picture with obstructing tumor. "The scope can't pass through, how?" Sir,
i would like to consider other imaging such as CT colono or contrast studies
14) What contrast studies? Barium sir. What kind of barium study? Barium meal sir, with lots
of barium? Any other way, requiring less barium? Yes sir, the other way, from the backside.
Barium enema
15) Your reg wants to scope again tmr, how? Bowel prep lor.
RINGGGGGG byeeeeeeee

CGH Session 4
Tends to have the reputation of very standard cases
Tips: start with PMH / PSH. Always ask them to show you scars 1st. gives u a good
idea with what you are dealing with or what you dont have to .

A bit about CGH:

You will be doing your long case in the day surgery ward.
You will be separated only by curtains.
Outside - they will give you your patient with name and race and language spoke.
You can start writing your differentials and approaches and questions. you have like 10
mins.

Liver abscess
Dr Benita Tan (SGH breast) nice
Dr Ng something something nice
Observor some private (nice)
Nice female MO who was smiling and nodding throughout.

I had an excellent historian which told me everything including the investigations and
management that he was undergoing. Praise the lord.

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46/M/Eurasian PMH of gastritis uninvestigated presenting with high spiking Fever and
jaundice investigated and s/p percutaneous drainage current on oral 6/52 augmentin for
further investigation colonoscopy in 1 weeks time.

Fever started 16/2

T max 38-39
Spiking fever
Saw GP 3 times.
No better with antibiotics
No alleviating factors
3 time GP noticed jaundice

Jaundice
1st onset
no dark coloured urine
pale stools
pruritus
not complicated by steatorrhea
not complicated by bleeding diasthesis.

Abdominal distention start with fever

RHC and LHC
Not ppt with fatty meals
Not worst with sitting or lying
Unremitting discomfort not progressive

Cx
SOB start 1 year ago exertional in nature.
With worsen SOB since 5 days ago on the right currently seeing CGH PT.

Systemic r/v
No dysuria
Change in bowel habits
Neurological weakness.

Admitted on 24/2
CT scan revealed mass in liver
Underwent perc drainage on 25/2
d/c POD8
after ophthalmology review

currently on 6 weeks augmentin with TCU for colonoscopy.

SH
Smoking 31 pack years
Social drinker
Financially stable

FH
Father history of likely bladder cancer
129
CH/TH
Nil
Although brother had similar episode after trip to Tanzania.

IVDA
Nope

Sexual history
Nil promiscuous sexual history (it is really weird saying this quite loudly when there are 6
patients all around)

Vaccination
Uptodate completed hep b since army. Unsure of his current hep b status

PE
needle/scar right hypochondrium - still red.

hepatomegaly 16cm
firm
non nodular
tender on palpation
moves with resp and dull to percussion

no a/w with portal hypertension no ascites and splenomeg

no signs of CLD no palmar erythema, gynaecomastia, spider navei
no dupuytren suggestive of alcoholism

well nourish no cachexia no leukonychia or pedal edema

no signs of pallor
well hydrated oral mucosa is moist.
no scleral icterus.

Lungs are clear bilat. No dullness to percussion and no adventitious breath sounds.

ok show us how you do an abdominal examination?

Put the bed down (note that you go to the foot of the bed to turn the handle and put the bed
down)
Felt for liver percuss loudly to show it is dull. Measure.
Felt for spleen
Etc
Auscultated and check for hernia

why did you aus. the abdomen

to listen for bowel sounds and to listen for bruit over the mass.

Thanked the patient for the 4th time.

so what are your differentials?

1st liver abscess (spiking fever)
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 2nd rule out cancers HOP and cholangio
really
no sir it is unlikely as he has no LOW but I would like to consider medical causes such as
3rd Acute hepatitis flare.
anything else
4th surgical emergencies (forgot -_-) cholangitis too!
what are the other differentials? Name at least 2 more?
Cholecystitis .
Pancreatitis

Oh if you ignore the jaundice?

Oh pyelonephritis
Gsd
Peptic ulcer disease

So how would you investigate this patient the first time you see her in the emergency
(THANK YOU MONICA FOR GS CALL. The one case I followed from ED to wards to Mx
was a lady with liver abscess likely 2 infective endocarditis)

1. ABC
a. Explained. Why it is necessary.
2. Loa, nausea worried about hydration. Start IV fluids (nodds)
3. In addition, would like to take blood cultures first before starting the patient on antibiotics.
(nodds)
4. what antibiotics ceftriazone and metronidazole for anaerobic and gram ve

to confirm diagnose I would like to do ultrasound hepatobiliary system look for stones in the
CBD and liver for a cyst / abscess
6. is there anything you want to do before the ultrasound
7. yes! I would like to do blood investigations most importantly LFT looking for obstructive
jaundice. (nodds)
8. FBC look for raised TW. As well as the plt level. If it is below 50 (patient may not be able
to go for perc drainage or will require platelet cover) (nodds)
9. U/E/Cr any electrolyes that require correction as the patient has LOA
10. PT/PTT/INR and albumin for the synthetic function of the liver and to see if she has any
coagulopathy which may be a contraindication for intervention.
11. Hepatitis B and hepatitis C serology

*ring
ok time to go out

thanked the patient for the 5th time.

Interpret the results

Alb 25 slightly low possible poor nutrition due to LOA.

Total bil 120
Direct bil 45 obstructive jaundice
ALT 65
AST 59
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(both mildly high)
ALP 201
(markedly higher than ALT,AST)

I would also look at the GGT to confirm an obstruction

GGT?,
yes I would expect it to be raised as well

other things
Amylase N
CRP raised
ESR raised

What will you do next?

Ensure that the patient is stable before considering CT scan.
Inform my senior first as well. Smile.
Before I order any further test.
But I would potentially order CT abdomen
Noticed that this patient has no PMH of asthma and not diabetic to suggest possible
metformin use. Once I look at renal panel to confirm he does not have renal impairment, it
would be safe to perform the scan with contrast.

Do you have to do a CT scan?

No. if you see stones with fever and jaundice it is sufficient to warrant an ERCP. stones
where? (MO was helping me tell con that I was referring to common bile duct
Common bile duct (nodd)
Or if you see there is an abscess then you can drain without need for CT scan.

How if the abscess is 6cm?

Unlikely to resolve with just IV abx. (Benita tan goes hmmmm)
Will recommend for surgery open or percutaneous
As the patient is symptomatic.

CT scan read this

first want to confirm that this is of mr _______ (they actually nodded)
describe a mass in the liver variegated, heterogenous, not well circumscribed.
no other mass
hepatomeg
smooth non cirrhotic
no ascites seen
what do you want to measure the diameter the size yes mdm.
what else do you want to measure?
housnfield units to determine if it is cystic or solid. As it is around the same hounsfield units
as blood (30) likely to be cystic.
K good. So if it is solid?
want to rule out malignancies, most commonly want to rule out metastasis from the GIT
other wise you would consider HCC
so can this be a tumour
yes . As it is variegated in appearance although I would like to confirm by doing a triphasic
ct scan looking for enhancement on arterial phase and rapid washout in venous phase with
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 capsular enhacement and variegated appearance. (smiles and nodds)

so what else do you look out for for this patient?

1. look for origins/source of spread
2. most commonly in our population would be klebsiella and ecoli
3. as no th / ch unlikely to be tropical infections amoebiasis (although brother had similar
history of amoebiasis)
4. for klebsiella refer ophthal worried about kleb endophthalmitis
5. for staph aureus - examine CVS for infective endocarditis if clinically indicated do 2d
echo (nodds)
6. worried about meliodosis look for abscess elsewhere in the body do PR for prostatic
abscess important as meliodosis is a MOH notifiable disease and need to adjust IV abx tx
to ceftazidine (MO smiles) (nodds) i guess surgeons do not know about meliodosis.

ok so where else do you want to look?

Colonoscopy for diverticular disease, diverticulitis with diverticular abscess
ok . Fair enough
what else is more common?
GSD
yes any other reason why they are doing a colonoscopy?
previous appendicitis with phlegmon? inflammatory bowel disease .. gastroenteritis
colitis .
sorry I do not know other reasons
oh its ok

how would you manage this patient?

Medical and surgical management
Explained medical long time IV abx.
Adjust IV antibiotics according to sensitivity.
Surgical
Open or perc drainage
Depending on the location and number
This patient single and superficial can do perc drainage. (Benita was like hmmm I guess).
Perc drainage call interventional radiologist.

What are the advantages of each method?

Perc draing - usual. Decrease hospital time. Faster wound healing. No risk for GA. Only
slight sedation. But may be inadequate drainage and need to stay in hospital for drainage.

So how do you know that drainage was adequate?

Several ways
1. clinical most important. Fever subsidizing. Hepatomegagly improving. Discomfort
improving. Taking well orally
2. radiological assessment
3. forgot to mention bloods - inflammatory markers CRP etc.

*ring.

MO who I knew when she was still in medical school did thumbs up and patted my back. off
to grad trip with peace of mind.
133
Juniors I learnt a lot from senior accounts and I hope you will remember to write yours too.
Regardless of how busy you are after your mbbs exam is over.

CGH session 2: varicose veins!!!

examiner 1 dr gan ?? from nuh, at first was silent but really nice during PE, told me no
need to take vitals, reminded me to feel ALL pulses and not just dp pt
examiners 2 and 3 mr chan weng hong (active - sgh upper gi), mr edmund chong
(passive - nuh uro), both super nice and kind of funny hahahaha
nice lady MO who kept nodding and smiling at me (i hope you become an epic
colorectal surgeon :) )
ok before i begin i just want to say that it would be really great to have a stopwatch or digital
watch for proper timing, and plan your time really well and allow yourself ample time to
consolidate because honestly you most likely wont know who your examiner is and its
always better to have a good solid summary. i tried to do 10 10 5 but since i was using an
analog watch it kind of screwed up there, so nervous i forgot to keep track

also thank you friends who came down to school to encourage us poor day 4/5 people, love
you all

it was an epic morning because when all the examiners filed pass we saw prof i mean mr
kow and all the super nice examiners and we were all cheering!!!!!

also i heard changi has epic vascular and uro so i went to mug those but as you will see
later i mugged the wrong vascular topic because i got a patient with VARICOSE VEINS D:

hx from mdm T, 67 yo chinese lady, speaks mandarin ONLY

opened by greeting her, asking what med probs she had, she said NONE, but leg pain. GG.
so i asked her to show me her leg and say where the pain was, and she said, calves, and
yay jackpot i thought PVD (cgh vascular land what)!!! but then i saw VARICOSE VEINS
and i was like oh dear me. thought i escaped it when i didnt get any vascular stuff for
shorts
and yes she had evlt stab avulsion done 3y ago for R leg, no cx no symptoms :)

so bilateral leg pain x 5-6y. however, now only L leg pain as R leg was cured 3y ago (see
above)
worse at end of day
happens 2-3x a week, getting worse
relieved by TED stockings/ elevation at night (no cx of TED stockings such as numbness,
pain, gangrene)
a/w numbness at night
a/w varicose veins x 5-6 year also
also pruritus
no swelling

DDx i wanted to rule out were

pvd mainly (as it also affects mx)
LL infection/ cellulitis
trauma
forgot to ask about other ddx such as neurogenic claudication, orthopaedic causes, but i
134
guess it wasnt so important as the symptoms were not suggestive of claudication anyway

wrt Cx of venous disease

no bleeding, thrombosis, infx, no fever
no ulcers

wrt aetiology and RFs

no fam hx or personal hx of dvt/ coagulopathies (should also rule out other rfs also lar but
they didnt care haha)
no abdo/ pelvic masses pt felt (pt actually went for colono, pap smear and mammogram on
her own and told me it was better to go screen than to wait for something to happen so
cute)
no loa low
family hx + for varicose veins (sister working as nurse, has varicose veins also, but also cos
she needs to stand a lot)
no pmhx, so no stroke/ immobility, patient very mobile (as you will see from social hx later)
a bit hard to ask for AVM lol

systemic review uneremarkable

Pmhx wrt her varicose veins prob

R leg affected her so she went for ?evlt and stab avulsion (hx a bit iffy here cos she
mentioned that the veins were in the lower leg and you dont do evlt for lower leg right???
btu she said something about laser plus stab avulsion, im not too sure!)
after surg she was told to walk, not work for 1mo and wear stockings 6mo for which she was
really compliant with
however after that, stockings v uncomfy so ditched them, only wearing them when she feels
the pain coming on
no other side effects such as dvt, numbness
has FF, she say may want to do sth about it but no pain so maybe not
asked if she wanted to use stockings for other leg, she say trouble some and painful, so
made mental note about indications for operation in this case
according to pt, on follow up here at cgh, venous duplex done recently no dvt, planning for
similar surgery soon (cant rmb when)

fam hx unremarkable otherwise

no fam hx cancer also

Social hx
works as hospital attendant for 30 years and loves her job
stands 8hours a day
doesnt want to quit
stays with husband and has 2 children
no financial problems
asked her who takes care of her
she said I TAKE CARE OF MYSELF!!! cute lol
no smoking/drinking

examination
checked for conjunctival pallor
135
pelvic/abdo masses
examined her venous system (spider veins, varicose veins in distribution of short saph vein,
NO gsv varicosities, this affected both legs. NIL other signs of cvi)
crt normal, temp normal, ankle ROM normal
checked all pulses
wanted to try doing trendelenburg/tourniquet LOLOL but the observer said dont need, later
will do

tried to summarise a bit here but was so flustered and felt kind of screwed because i have
NEVER done a real varicose vein exam

at this point Mr chan and Mr chong walked in and asked me to present

mr chan was super nice but he said eh varicose veins management very easy, lets focus
more on pe!!!
died here. LOL
mr chong was silent but was SOOO nice and kept nodding so i kept looking at him for
reassurance

presentation
my patient mdm T is a 67 yo lady, no significant pmhx except that of bilateral calf pain and
bilateral varicose veins x 5-6y, for which she underwent evlt and stab avulsion of the R leg
with resolution of sx for the R leg. currently she complains of increasing L calf pain. she is on
follow up with cgh vascular and has been worked up and is planned for a similar surgery
(insert date here)

presented as above, they allowed me to ramble++ the entire hx, cutting me off at points to
ask why you ask her if she was screened for cancer and why you ask for family hx of
coagulopathies said proximal venous obstruction can cause dvt, and fam hx of
hypercoag states can predispose to dvt (THANK YOU prof sgtan for your epic 8 weeks of
vascular tutorials from sgh when i was in m3, which i will remember foreveerrrrr)

made note about her risk factors of varicose veins, how i tried to rule out 2 pathologies in hx
and exam, and also NO other complications from varicose veins noted except pruritus.
emphasised about her previous management which was successful in controlling her calf
pain but not preventing recurrence of varicose veins, and how conservative treatment has
been attempted and wsa not really successful (patient found it hard to adhere to use of
compression stockings) and how she will not want to change her occupation

epic exam part

mr chan happy, said ok now let us examine her varicose veins and i whipped out my
HERNIA TOWEL CLIPS!!!!!!
showed how i examined for pelvic masses
offered PV PR
Mr chan said ok u must also mention you want to look for PERINEAL masses
OK!!!!

running commentary was done

Mr chan wanted all the cutaneous manifestations of cvi
ramble ++

136
Demonstrated tap test
OK NOW SHOW ME YOUR TOURNIQUET TEST *bright smile from Mr chan*

So the thing here was that there was NO great saph varicosities so i offered to tie it at the
saph pop junction, so he was quite ok, even help me hold pts leg and said i help you hold,
you buy coffee for me later ok. Stood pt up, refilled above tourniquet, did not refill below so
said saph-pop incompetence. released and didnt see increased filling also. he commented
this is a bit unusual and unlike your normal varicose vein exam cos usually have gsv

Asked to describe perthes test and what it tests for (incompetent perforators, deep venous
obstruction)
Asked again for cx of varicose veins that i asked for (pruritus, thrombophlebitis, BLEEDING,
ulceration, thrombosis, cosmesis) (i forgot to say bleeding earlier and that was the cx he
wanted to hear)

others
Then left the cube to go to the cows :)
Qns were as follows.
Mr chan did the grilling

What invx?
venous duplex, abpi, kiv mri/ ct ap
They just opened the whole file on the cow and obviously didnt give a hoot about whether i
stated anything else like bloods

What is venous duplex? what do you want to look for?

dual modality, u/s with doppler flow
assess DVT, perforators, distribution of varicosities
check for reflux by putting probe at both ends

OK read this venous duplex. Ok lar not fair to ask you, but can try right?
(at this point in time the MO was like.. ehh good job lar, show her the R leg instead of the L
leg scan?)
smoked something then gave up. they didnt care haha

What are varicose veins?

ABNORMALLY DILATED, TORTUOUS veins

What are the indication for op?

stated cx as above

Yes but what is the most common indication?

Cosmesis? (yes apparently!!!)

What do you want to specialise in?

Proptose ++

Mr chan and Mr chong look at each other and LAUGHED. then he said ok imagine you are
a physician what will you do if the varicose veins pop
Pressure to stop bleeding, refer to vascular
137
How do you mx varicose veins?
andre tan mx

What op can you do for her?

EVLT above knee, stab avulsion below

Benefits of EVLT?
(cant rmb what my ans was here)

Whats not so good about EVLT?

said potential dmg to surrounding structures from heat
he wanted to hear cost

Anything else you know of?

Foam sclerotherapy???

I am very old school what do I like to do?

HIGH TIE SIR

Where else do you find varicose veins? (pop quiz deng deng deng)
Varicocoele (MR CHONG V HAPPY HAHA he said now im impressed)

Im an upper GI surgeon, where do I find them

Esophageal/ gastric varices

*Points to MO* she wants to do colo, so where will she see them
I said haemorrhoids but not sure if he wanted rectal varices (from portal htn)

They let me off 5min earlier!! Btw i also asked Mr Chong if varicocoeles were a/w varicose
veins and he was like .. WHY ARE YOU ASKING THIS LOL and its cos we previously saw
this guy in the wards with bilat varicocoele and were wondering if need to examine for
varicose veins so NOPE theyre not related! (just in case)
thank God really for really nice examiners, the sweetest patient ever who was so
encouraging when i was really a bunch of nerves.
all the best for tomorrow guys

Stage II Breast Cancer(T2 N0 M0)

Examiners: A/Prof Tan Su Ming and Prof Enders Ng

History
45/Indian/Female
Said she was diagnosed with breast cancer.
Presented 3 weeks ago for a right breast lump she noticed while showering. Had not noticed
it before. This was associated with pain over the lump which developed 2-3 days after she
noticed the lump. There was no erythema, nipple discharge or skin changes. There was no
loss of weight or loss of appetite. However she compained of pain over her right arm,
starting around the same time as the pain from the breast lump started, no neck pain
associated with this, pain does not wake her up at night. She takes voltaren and it helps the
pain.
138
Upon noticing lump, the following day she went to the polyclinic and the made a referral to
CGH within the next week. She then underwent an ultrasound and mammogram, where she
was told the lesion was suspicious. Following that, had a core biopsy done where she was
told she had breast cancer. She already had a bone scan and CT scan last week, there were
no metastases found. Today she was going for a simple mastectomy with no breast
reconstruction as she did not want the breast to be reconstructed. She was not sure about
the stage of her cancer, when asked about lymph node spread she was also not too sure
about this. But said she was going for what sounded like a sentinel lymph node biopsy. She
was not told that she had to go for radiotherapy or chemotherapy yet following the surgery,
her doctors said they will inform again after the operation.

Risk factors included; One child but only when she was 32, did not breastfeed her child.
(Menarche was at 13, not menopausal yet, took hormones but sounded like progesterone to
control her irregular periods, but on and off for 3 month periods as it did not so well. No
personal history of breast cancer, family history none except for her cousin, no history or
ionizing radiation or alcohol ingestion. Non-smoker)

Past Medical History

Sarcoidosis: diagnosed 11 years ago when there was a lump on her sclera, since then it was
removed and she has no other issues with regards to the sarcoidosis. On yearly follow- up
with SGH where she has a CXR every year, they have all been normal so far
GERD: On lifestyle modification, no medications taken.

Social History
Stays with husband and daughter. Feels quite depressed, just wants the cancer out of her,
but other than that she has a very supportive family. Financially, has sought MSWs help and
has seen them once, is just waiting for what they can do for her.

Systemic review otherwise unremarkable. Family History was asked along the way as
above.

Physical Examination
Alert and Comfortable at rest. No cachexia.
On inspection of the breast there was no dimpling, discolourations and no obvious masses
or skin changes.
Left Breast was normal, generally felt as though there was fibrocystic change. No enlarged
lymph nodes in the left axilla. Right Breast also background of fibrocystic change, but there
was a hard irregular mass about 4x5cm in the upper outer quadrant, quite hard to define in
terms of margins. Painful when pressed down to test for mobility. However, it was not
attached to the underlying muscle or overlying skin. No enlarged lymph nodes in the right
axilla.
No enlarged lymph nodes in the cervical or supraclacivular lymph nodes
No spinal tenderness on percussion
Lungs were clear with vesicular breath sounds with no indication of pleural effusion
Had no time to test for hepatomegaly.(Decided I should take time to consolidate my thoughts
first)

Examiners came in: Presented a brief summary 45/Indian Lady with a past medical history
of sarcoidosis on follow up with SGH annually, with newly diagnosed breast cancer, awaiting
139
simple mastectomy and what sounds like sentinel lymph node biopsy today Went on to
describe the chronology of events, but they wanted more about the lump so pushed me in
that direction.

Was asked to demonstrate breast and axillary examination. Then asked about my physical
findings.(as above)

Questions asked:
If she presented to you in the clinic with a lump, assuming you have taken the history
and done the examination, what would you do next? Complete the triple assessment- 1)
Imaging 2) Histology. For imaging I would do both a mammogram and an ultrasound scan
given that she has a lump so as to better delineate the lump and features. Histology core
biopsy.
Why would you do both a mammogram and ultrasound? Repeated what I mentioned
above. Mentioned how ultrasound you can look out for suspicious features, determine the
size, and can more easily see the axilla. Mammogram generally you can get an idea of the
other breast and is useful for comparison
What features are you looking for in a mammogram? Asymmetry, spiculated mass,
microcalcifications especially if pleomorphic, scattered or linear, changes in the other
structures(nipple, lymph nodes)
What does pleomorphic mean? Said that they look different from one another in terms of
shape and size.
I was then shown the mammogram and describe: there was a very small hypodense
lesion which was irregular with scattered microcalcifications in the breast tissue surrounding
the lump. Was asked whether this density in front of the lump was a calcification, I replied no
as it was to localize where the lump was palpated prior to the mammogram. Other breast
was normal. (there were not ultrasound images only the report so was not asked to read
this)
Assuming histology now shows she has invasive ductal carcinoma what is next? Next
step is staging, I would do a CT TAP and bone scan to look for metastases in the body and
in the bone respectively.
Was asked about TNM staging for breast cancer and asked what T staging she is based
on my clinical examination. I said T2 and regurgitated TNM staging. Prof Tan said my
staging was wrong which was the one from andre tan, and what everyone remembers so I
am not sure if she wanted pathological staging. But i said i was sure it was the staging for
breast.
So she is going for a simple mastectomy, do you know any other surgeries? For
curative intent one would also consider wide excision but there are certain indications.
Adequate tumor to breast ratio, no multicentric disease, no contraindications to radiotherapy
So you said she was going for sentinel lymph node biopsy what is that? Explained that
can either use the blue dye or Tc99. (I actually said methylene blue but the examiner asked
me are you sure they use that in this centre? I said not sure but methylene blue can be used
so maybe he wanted isosulphan blue as this is commoner? because he said something but
his accent was very hard to understand) Then the node picked up is sent for frozen section
and if positive proceed to axillary clearance
What do you mean by axillary clearance? I believe the lymph nodes in the axilla are all
cleared? (Are you sure?) No I am not sure I will go back and check. I think he wanted level 1
and 2(but didnt know this at the time), level 3 nodes are not commonly cleared.
So lets so you have to take concest for axillary clearance, what are the complications
of axillary clearance the patient might have? General and specific. General like with any
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operation, bleeding and infection. Specificl such as lymphedema where by the arm will be
enlarged, have to tell the patient to elevate the arm and can send for physiotherapy but
nothing else can be done. Nerve injury such as intercostobrachial nerve injury which can
cause paraesthesia or anaesthesia in the medial part of the arm and injury to long thoracic
nerve which can cause winging of the scapula.
Lets say this patient now comes post-simple mastectomy and you are told to review
her. What would you do? ABCs, check vitals. Ask her how is she feeling. If she is in pain
can give her analgesia. Does she feel nauseous. Would expect her to be a bit drowsy.
Check drains if any
How many drains would you expect? Up to 2 generally but can be more or less
depending on what happens intra-operatively
So lets say you see 500mls in the drain when you review her what would you do?
(sorry not sure of the normal amount) so I said ABCs, vitals, call senior and ask as I am not
so sure what is normal post- op day 1. (Seniors not around, manage yourself). So I went
back againto ABCs, vitals, check the wound site and the drains.
Now 300mls in the next 2 hours so how? I said Now I am very worried ABCs, call a
senior and..
THE BELL RANG(: I was saved, not sure what she wanted. I think because it was a breast
case Prof Tan Su Ming was quite fierce but anyway, its over and for breast they love to ask
about surgery specific things so that is really important. All the best for yours.

CGH Session 4 Group 1

Examiners: (cant remember who was observing me but quite nice) Prof Tan Su Ming (CGH
Madam), Prof Enders Ng (external examiner)
Patient: Mr Neo, 63yo Chinese gentleman, speaks Mandarin only

Patient was sleeping very comfortably when I went to the bedside. Bell rang. I stared
helplessly at the patient but greeted my observing examiner. Luckily kind nurse came and
gently whacked pts legs, Uncle, wake up, your student come already! Okay lets go.

History
Pt was supposed to undergo pre-op counselling yesterday, but got rescheduled to today
because of MBBS exams. Asked him what op he was going for dont know. So asked
what problem he had they found something here *points at RHC* but he had no idea
what it was. Is it a tumour? dont know. Okay nvm. Do you have previous medical or
surgical hx? no, I seldom see doctor Okay sure. Decided to just clerk presenting
complaint la. So what did you first see the doctor for? friends and relatives noticed that I
was turning yellow. My skin and my eyes. But I didnt notice it myself. Bingo. Finally were
getting somewhere. Okay rest of hx summarized as follows:

63yo Chinese gentleman, jaundice x 3/12 first noticed during CNY when he was at his
relatives place. At that time they commented that he was more yellow than usual but no one
told him about it (only talked amongst themselves). He only realized something was up
maybe 1/12 ago. Actually he also said that the jaundice was getting better and that he is
less yellow now and Im like damn it there goes the perfect picture of painless progressive
jaundice. Also a/w tea-coloured urine x 1/52, said initially thought to be related to
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dehydration as he works under the sun at construction sites, so drank ++ water to see if
urine would become more dilute but it remained dark. (initially said urine was more
yellow/darker yellow compared to normal, had to probe a bit before he agreed that it was
tea-coloured). Asked about acholic stools, even pointed to the clay-coloured walls in CGH
day surg. Pt insisted his stools were light yellow in colour, but they have always been like
that and there was no recent change in stool colour or bowel habits. Mentioned that he had
one episode of ? black stools but I decided to dismiss that unless probed. No pruritus, no
nausea/vomiting/diarrhoea/steatorrhoea. No fever/chills/rigors/abdo pain.

Constitutional symptoms LOW (subjective) and LOA. Some early satiety/abdo bloatedness
but couldnt really quantify. Also felt more lethargic than usual (had to probe a bit for this,
kept saying his body just felt uncomfortable) and was feeling more unwell. Otherwise
systemic review was unremarkable.

Risk factors: Smoking x 40 pack years. Social drinker. Previous CSW contact when much
younger but not anymore. No other risk factors for hepatitis (no Hep B/C hx, no IVDA or
transfusions). No recent travel or contact hx.

PMHx: ? gastric surgery 30yrs ago (said stomach got a hole then asked if it was PUD or
cancer, said dont know, asked if it was subtotal gastrectomy vs omental patch repair
also dont know), hyperlipidaemia not on meds, no other hx and no hx of haemolytic
anaemia (so not pre-hepatic jaundice)

Drug hx: Occasional TCM for flu/cough/acute ailments (possible ddx for hepatic jaundice,
Prof Enders says any dose of TCM, even just once-off, is a risk factor for hepatocellular
damage. Yes Prof). No long-term meds. NKDA.

Social: $$ problems, but otherwise okay. Stays with wife and daughter. Functionally ADL
and IADL-independent. Works as supervisor at construction site and driver.

Family hx: Does not know if there is family hx of cancer. Younger sister passed away due to
stroke. 2 other family members also recently demised but pt unsure of cause.

Physical examination
Well, not cachetic. Midline laparotomy scar, no incisional hernia. Palpable gallbladder 4cm
from R costal margin (globular mass that moves inferiorly on inspiration, unable to get above
it, non-tender, dull to percussion, clearly distinct from the rest of the liver parenchyma), mild
hepatomegaly 1cm below R costal margin. Scleral icterus.

No stigmata of chronic liver disease. Rest of P/E unremarkable. Offered DRE to look for
acholic stools but observing examiner said no need. Didnt give me the findings though :(

Towards the end I think pt finally realized that I was here for an exam, so he was quite
apologetic that he didnt know anything and wasnt of much help to me (I asked him if he
knew which organ the mass/lump/tumour was arising problem. It was like a guessing game, I
would name the organ -in Mandarin!- and he would say dont know. At that point I was like
okay nvm this is purely diagnostic la). Then he reached over to his bedside cabinet and took
out his appointment card and some envelope, and asked if I wanted to see it and that
maybe it can help me. I decided to play it safe and asked the observing examiner if I could
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take a look. He pondered for a while then said better not, no need so I said its okay,
uncle, thank you very much for offering though and decided okay it is just me and my brain
now.

Examiners Prof Tan and Prof Enders enter.

Introduced pt to examiners. Started presenting my hx but after my first line Prof Enders said
that it was too noisy (cos there were other students presenting in the same cubicle) and so
we moved to the corridor outside where the COWs were. It was dead silent outside except
for me talking. Nervous +++ especially because I think both pt and I had no idea what was
going on, hurhur. Presented my hx as per approach to jaundice and was only interrupted
when I got to the social hx part.

Differentials? Malignancy (Ca head of pancreas, periampullary tumour, cholangioCa),

benign causes such as Mirizzi syndrome, choledocholithiasis, hepatitis -got cut off-
What is the typical patient profile for gallstones? Fat, female, forty, flatulent okay sorry
Prof, then in this case unlikely to be gallstones. Although I thought about it because pt said
that his jaundice was getting better.
You mentioned pt has significant hx of a previous gastric surgery. How is that
relevant in this case? I couldnt think of anything then but on hindsight, maybe he wanted
me to say that the gastric perforation might be secondary to gastric Ca and then now there is
porta hepatis mets causing jaundice (although his gastric op was >30yrs ago...oh well).
What were your positive abdominal findings? Painless palpable gallbladder, which in the
context of this pt is highly suggestive of Ca head of pancreas, as in Courvoisiers law (bait!)
What are the caveats to Courvoisiers law? Mirizzi syndrome, double duct pathology
(stone in CBD and cystic duct), recurrent pyogenic cholangitis
Lets go examine the pt. Show me how you check for incisional hernias. Ask pt to lift
head and cough, then also checked for palpable cough impulse and it was negative.
Demonstrated the palpable gallbladder.
How do you differentiate gallbladder from other structures in the area? Firstly, unable
to get above the mass and it is non-ballotable, dull to percussion -> so not kidney. Globular
mass that moves inferiorly with respiration, does not extend along the subcostal margin like
a normal liver edge would -> so more like gallbladder compared to liver.
What else? ...sorry didnt know anymore.
How do you classify jaundice? Pre-hepatic, hepatic, post-hepatic.
You mentioned mainly post-hepatic causes of jaundice. How did you rule out pre-
hepatic and hepatic? No hx of haemolytic anaemia, no hx of hepatitis (although noted that
he has previous CSW contact), no recent travel hx, no symptoms suggestive of infective
causes e.g. fever/chills/rigors, no cardiac problem so not cardiac cirrhosis, no infiltrative
conditions such as amyloidosis/sarcoidosis
Yes, but what about his medicines? You said he occasionally takes TCM right? Sorry
Prof, so yes Im aware that hepatotoxic drugs can cause acute liver failure and jaundice,
however I note that pt only occasionally takes TCM and not on a regular basis.
One dose of TCM can be enough to wipe out your liver. Sorry, yes Prof.
If you were the HO in the ward, how would you manage this pts jaundice? Stabilize
ABC, get vitals(cut off)
What constitutes your vitals? BP, HR, SpO2, RR, (almost forgot) temp. -At this point I
realized the hint-
So what other differentials would you consider for the jaundice? Sorry Prof, so yes I
would like to rule out cholangitis especially if the pt is febrile and has RHC pain (Charcots
triad), but I note that it is negative in this case. Also need to exclude cholecystitis,
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pancreatitis, perforated PUD (? previous perforated PUD 30yrs ago) if pt presents with acute
abdominal pain.
-finally, I think Prof Tan was appeased that I finally said cholangitis. If not I think she would
have killed me there and not let me leave the bedside. Oh also, I think she would fail me on
the spot if I had read whatever was inside the pts envelope. Luckily I asked the observing
examiner first-

Went back to the COWs in the corridor.

What investigations do you want to do? FBC, U/E/Cr, LFT, amylase if suspect
pancreatitis(cut off)
Shows me investigations one by one. FBC normal, U/E/Cr normal. LFT: conjugated
hyperbilirubinaemia with raised liver enzymes (ALP >> AST, ALT).
What LFT picture is this? Obstructive jaundice
Then the aPTT slightly prolonged, hepatitis serology -ve.
What other Ix? U/S HBS.
Dont have, we are very high tech here. Okay CTAP.
Shows CTAP. Distended gallbladder (was asked to point out), and mass at head of
pancreas. -next CTAP cut- double duct sign with dilated CBD and pancreatic duct, again
noted distended gallbladder and mass at head of pancreas. This confirms my dx of Ca head
of pancreas.
What do you want to do now? Obtain histology via ERCP.
Shows ERCP. Dilated CBD cos the diameter is bigger than that of the scope.
How big is the scope diameter? 1cm
Actually, its more than 1cm, but yes the CBD is dilated because its diameter is bigger
than that of the scope. Yes Prof. (in my head I was thinking I thought Dr. Alfred Kow said
that the ERCP scope is 1cm in diameter?? Okay nvm yes Prof, whatever you say Prof!)
So you didnt manage to get a biopsy from ERCP because you couldnt pass through
the ampulla of Vater. So how? Need to relieve obstruction. Can try sphincterotomy(cut
off)
How much of the sphincter do you think you can resect with ERCP? Sorry Prof, unlikely
to be enough to relieve the CBD obstruction. Maybe can try percutaneous drainage via PTC
tube or T-tube?
Yes, yes. That is possible. But what else? -thought for a while- Something you can do
during your ERCP. Oh yes sorry Prof, can also try biliary stenting.
Shows next image - ERCP with biliary stent in-situ.
You still dont have histology. So how? Actually, the hx and CTAP images are already
suggestive of Ca head of pancreas. But can also do tumour markers e.g. CA 19-9. If raised
and combined with the above findings, definitely diagnostic. But dont need positive CA 19-9
to rule in Ca head of pancreas in this pt.
Okay lets say its confirmed Ca head of pancreas. How? Do Ix to stage(cut off)
You already have CTAP! Sorry Prof. But would like to do CT thorax or at least CXR to rule
out lung mets.
Okayyy no lung mets. Then in this case, with pts good premorbid function, aim for curative
resection via Whipples procedure.
Describe Whipples. Removal of the head of pancreas (with the tumour), duodenum,
proximal jejunum, distal stomach and surrounding LNs. Re-establish bowel integrity via 3
anastomoses: gastrojejunostomy, pancreaticojejunostomy, hepaticojejunostomy.
How would you prep the pt pre-op? Check for coagulopathy, do pre-op bloods including
FBC, U/E/Cr, PT/PTT and GXM. Optimize nutrition(cut off)
Why is nutrition important? Important for post-op wound healing and also to prevent
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anastomotic leak.
How would you counsel the pt about the op? Possible Cx include anaesthetic risks and
procedure-specific Cx - which include bleeding, injury to surrounding structures, infection,
anastomotic leak, early satiety, bile reflux, post-op incisional hernia
*Bell rings.* Okay times up. You may go.

Learning points:
- Do NOT ever be exasperated or rude towards your pt. This poor gentleman was pulled out
of nowhere from his outpatient f/u yesterday and thrown into our exams today, probably
because he has one of the nicest gallbladders I have ever palpated. I was the first student to
clerk him and he really didnt know what was happening to him. Even though I couldnt get
much from him, I was nice to him and apologized profusely if I asked too many questions or
probed after he said he was unsure. Pts are always trying to help us, its just sometimes they
really dont know what they have or why theyre here for our exams.
- Try not to be nervous, even though I brain-blocked many times. Go back to basics (like
approach to jaundice) and just take it from there. Long case examiners dont give specific
hints or prompts so you may have to pull yourself out of your own grave.
- Just show that you are a safe HO. Any HPB presentation pls just have stuff like cholangitis
and pancreatitis at the back of your head. Even if the hx is super unsuggestive (like no abdo
pain, no fever, FBC completely normal), Prof Tan wanted me to say these two ddx before
she allowed me to leave the bedside to discuss Ix and Mx. Good luck juniors! :)

CGH Session 5 Group 1

Observer: Dr James Ngu (CGH Consultant)

Examiners:

Prof Tan Su Ming (THE CGH Madam), (Queen of CGH GS Dept)

Prof Enders Ng (external from HK)(I will just smile and add random qns)

Patient: Mr X (de-identified cos I revealed too much social hx here), 46yo Malay gentleman,
speaks English (whew)

Okay, so heres my story. I really really really wanted an English patient badly (due to my
terrible Ortho Long Case experience where an Ortho Doc told me to speak Chinese to my
patient, FYI, I dont speak Mandarin). But for some reason I forgot to wish hard enough to not
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get my GS CEX Examiner (Prof Tan Su Ming) for my GS Long Case. And for my SIP
Assessor (Dr James Ngu) from GS Posting to not be an examiner too. AND, vascular is my
worst topic (for some reason that only my clerking friends can understand). So yes, I
probably must have done something very very very wrong to get this combination.

So, before you start, they give you the clipboard with paper and you are given some time to
wait (so start scribbling) and then you are given Gender and Language of Pt.

When I walked in, I saw James Ngu. (my SIP Assessor who expects a lot a lot from me, and
was my residency referee >.< before I pulled out from Residency. Pressure max max.).

TIME STARTS NOW

Hx-Taking:

46 year old Malay man (large habitus on eyeballing, HUMONGOUS varicosities out of
Charles Tans OSSE book, some hyperpigmentation over bilateral legs, dressing on right
foot.)

I went Oh Fuck. VEINS.

Presenting Complaint
1. Bleeding 6 months ago from his right foot
a. No ulcers, gangrenes
b. No leg pain (asked for both rest and claudications)
c. No bleeding diasthesis (asked specifically for hematuria, BGIT)
d. No previous trauma
e. Was walking around and it SUDDENLY bled. Did not hit anything.
f. No numbness or lack of feeling over lower limbs.
g. No fever

2. Noticed Varicosities for a few years

a. Considered it NORMAL
b. Did NOT notice skin changes in LL (like really?)
c. No increased swelling (pitting edema)
d. No itching (for stasis eczema)

Risk Factors
-No Chronic Cough, Constipation, Urinary Symptoms (Increased Abdo Pressure)
-Not noticed Abdominal Distension/Masses (Increased Abdo Pressure)
-No recent LOW/LOA (Possible Cancer)
-Works as a Security Guard. Walks around a lot.
-BMI 40 (I asked him for his height and weight and whipped out my calculator to calculate)
-No recent travel history or plane rides or prolonged immobility (DVT)
-No Family History of Varicosities

Other Med Hx
1. Stroke (actually sounded like TIA)
a. 2 years ago
b. Was blanking out but had no weakness
c. Did not fall
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 d. Stayed in hospital for a few days
e. No residual symptoms
2. DM, HTN, HLP
a. Found out to have DM, HTN, HLP during admission 2 years ago
b. Given Meds for a few weeks but did not take anymore (possibly aspirin as
well)
c. Defaulted follow up COMPLETELY
d. Thus, no follow up for possible DM cx (DRP, DFS, Urine Dipstick)
e. Tried to symptom screen for MI (asking for any CP, Breathlessness), PVD (as
above), Neuropathy (as above), Nephropathy (asking for frothy urine),
Retinopathy (asking for visual problems)
f. Does not know HbA1c level (asked if it was done 6 months ago when he had
the bleeding leg) or Lipids level
g. Does not measure BP

Fam Hx of DM HTN HLP in late mother who died due to ?DM, he wasnt exactly sure what.
No Fam Hx of CA.

Social Hx for this guy was super extensive. (so heres a gist of it)
1. Smoking: 47 pack years (it was very complicated cos he said 35 sticks then cut down
to 15 sticks 2 years ago, so i did some weird calculations on my paper for this)
2. Alcohol: being Malay myself, I had to be sensitive and say I have to ask this to all my
patients, do you happen to drink Alcohol? No.
3. Financial Difficulties: Yes, MSW just came in to reply his need for Support.
4. Job: Security Officer, hasnt been working for 3 weeks as it has been affecting him.
5. Marriage: Wife in Indonesia, 2 Children in Singapore (1 studying, 1 working) ALL not
in contact with him :( currently staying with adopted sister and her family :( didnt
wanna ask anymore lest I start crying

(So generally I have this habit of RUSH clerking the presenting history as deemed fit and
then discuss what invx and mx plans have been done for patient after that)

Invx and Mx at presentation 6 months ago

1. Asked about Ultrasound he said YES. Asked if any other scans/X Rays done, he said
no, only ultrasound.
2. They controlled bleeding and discharged him at AnE :S didnt give him any meds
both for leg and DM/Htn, didnt give him any follow up
3. Did not have any other admissions/appointments since (in retrospect maybe he just
defaulted entirely)
4. I actually did not ask why he came to hospital this time around (in fear he says For
your exam.)
5. No plans for surgeries have been made for him actually.
6. In Retrospect should have asked him if he had plans to lose weight (though risking
possibility of offending patient)

I took all of 10 mins for history since there were a lot of negatives so I just went on to do my
Venous exam. I have to admit: I have done venous exam a total of 0 times in my life (juniors
please practise this on your friends until damn smooth)

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I dont wanna describe my whole examination lest I bore you so Im just gonna point out
certain things:

1. DECIDE to stand the patient first. You need the varicosities to fill properly to fully
inspect them. I initially just inspected the feet and legs since patient was already on
the bed, but then I felt dumb cos the varicosities had to be examined while patient
was standing.
2. If you dont feel like doing a running commentary, DONT. James Ngu was nice
enough to leave me alone throughout the whole time without asking me to do a
commentary, so, thanks James. Especially in this dire situation.
3. I forgot to do a tap test while the patient was still standing, so UGH, after I did the
tourniquet test (lying down, milking his leg after LIFTING the leg over my shoulder)
(SO HEAVY), when I eventually released the tourniquet when patient was standing
up, I quickly made a show of doing tap though the order of PE steps was obviously
wrong.
4. REQUEST for whatever you want to do. James was really nice so he will answer you
quickly as follows:
a. Shall I expose the dressing: YES PLEASE EXPOSE
b. Ideally I would like to examine the other limb: SURE, NO NEED
c. Ideally I would like to examine the arterial system: SURE, NO NEED
d. Ideally I would like to examine abdomen, respi and do DRE: SURE, NO
NEED
e. I would also take the vitals: OK STABLE
f. This way, you really save a lot of time cos then you (a) dont waste time doing
unnecessary things (b) dont second guess what they want/dont need you to
do.
5. Anyway just wanted to tell you all the ulcer under the dressing was over the dorsum
on the lateral side PUNCHED OUT, no sloping edges and no granulation tissue, non
tender as well. So I think was probably Arterial Ulcer. (Maybe Mixed Arterial/Venous)

Other things
-No cough impulse over SFJ although LSV all the way dilated bilaterally, and SSV also.
-Cannot really find saphena varix (it was incredibly hard to find this patients pubic tubercle)
(no kidding)
-Arterial Ulcer as described above
-Healed scars suggesting possible previous venous ulcers

All these within 18 minutes or so. So I had 7 mins to consolidate, recategorise my hx (as
above) and come out with a powder-ful opening statement. (very important for GS)

Mdm Tan Su Ming and the HK Dr walked in. James very nicely introduced everyone to
everyone else.

Me: So I have spoken to Mr X, who is a 46 year old Malay gentleman with a significant
medical history of stroke and 2 year history of DM, HTN and HLP NOT on any long term
medications presented 6 months ago for bleeding over the right foot associated with
varicosities of many years duration. And then presented everything as organised above.

History History History History History History

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Thus my Provisional Diagnosis is that of Chronic Venous Insufficiency namely that of
Varicose Veins that has led to torrential bleeding 6 months ago. Ideally, I would also like to
rule out any possible peripheral arterial disease in view of significant risk factors for this
patient.

(Contd)IMPORTANT: After assessing the history leading to the presentation 6 months ago,
I enquired him regarding the invx and mx plans that were done at that admission. Shall I
continue to present regarding this?
Yes please go on.
(For Juniors: I think generally for the purpose of exam, please present it this way and
dont mix all the diagnostic invx and mx that were done for patients with the
symptomology and the main crux of history because some examiners want it to be a
diagnostic case, so they get irritated when you actually say Oh OGD shows Gastric
CA. because they may not want you to just get invx diagnosis. Suggest presenting,
and if they said okay, then go on, its probably a management case then.)

I have also already conducted a Physical Examination and would like to present my findings.

THEY DIDNT ASK/QNS ME ABOUT MY HISTORY WOOHOO.

GRILLING TIME (I WAS TALKING LIKE A SPEEDBOAT)

James: Okay, show them how you did your PE and explain your significant physical
findings. (this took me a very long time)
(UGH I had to do the whole thing again including heavy lifting his legs but this time they were
enquiring every single thing I did including where the landmarks for SFJ is, how I do the tap
test (and how to interpret it) and how I do the tourniquet test) Again I said that I have already
requested the other examinations (refer above) Requested Perthes this time and was asked
to describe and what it was for (rementioned that I already screened for possible DVT by
asking for pain, edema, prolonged mobility and travel hx) Talked a bit about perforators
since varicosities filled on standing without release of tourniquet and got quizzed a bit about
perforator levels (Yay HDB 5 10 15)

Tan Su Ming: Tell me about the ulcer that you see. It is located over the dorsum of the
right foot between the 4th and 5th toe in this patient. It appears punched out, non-sloping
edges and no granulation tissue is seen. I suspect this is an arterial ulcer based on the
location and morphology despite the obvious background features of Chronic Venous
Insufficiency on this leg.

Tan Su Ming: You said you wanted to do arterial exam. How and why? because this
patient has multiple CVS risk factors resulting in a previous stroke and also the likelihood of
the ulcer being arterial in origin, I want to exclude arterial insufficiency. Thus I would look for
signs of Ischemia such as (your Ps) and check CRT <2s and pulses (mentioned all 4 LL
pulses), completing with Buergers Test.

Enders: How will you manage this patient when he presents 6 months ago. I would like
to ensure that patient is stable from his vitals and well as he is bleeding profusely.
Enders: Yes, he is sitting down on a chair and he is talking to you.
Okay, after which I would attend to his bleeding right foot by firstly cleaning the area and
then applying direct pressure.
Enders: But what if continually bleed.
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I would have done primary blood investigations to look out for any underlying
thrombocytopenia and coagulation profile for any coagulopathy. And I would like to inform
my senior about this current admission.
Enders: But you are the only doctor! The results will only come back in half an hour!
How? You have many other patients. The bleeding stops when you apply pressure but
comes back when you let go. You cant just hold on to it right.
Erm, I would like to apply MANY layers of bandage and tape it down? (I was really confused
what this HK doctor wanted from me)
Enders: I told you that he is sitting down. Do you want him to change his position?
(Errr duh in AnE of course he will be lying down.) YES SIR (SMILES). I would definitely have
brought him to a bed and elevated his legs. (I actually said torniquet then I self-proptosed
and actually said out loud, oh no no that will make it worse. Hahaha I think they were
amused by my self-reflection)
Enders: Yes, thats right. (lol)

Tan Su Ming: Investigations?

Bloods and Imaging. FBC looking for Anemia as he is bleeding and for thrombocytopenia
that may worsen bleeding. PT/PTT for Coagulopathy that may worsen bleeding also. UECr
due to uncontrolled multiple RFs. HbA1c and KIV Fasting Lipids. U/S Venous Doppler
(described a bit about the WHOOSH and the double WHOOSH, and where I would have
placed it) and U/S DVT to exclude a DVT.
Tan Su Ming: Okay lets go outside. (YES! profusely thanked patient and apologised
for making him move around so much)

(COW shows FBC, RP, PT/PTT and CXR initially) I just stared at the results, it looked fairly
normal for me but the PT and PTT had no ref range so I was like hmmm, I cant really
remember whats abnormal, but I wouldnt be expecting it to be high. I was obviously damn
tired. I was trying to interpret but nothing came out of my mouth, esp when I saw the CXR
which I didnt understand why it was ordered, then the MO just scrolled down. (so I guess it
was normal?)

ULTRASOUND DUPLEX. It is possibly the messiest piece of investigation I have ever seen.
Basically its this paper with a terrible drawing of legs and the vein systems inside and there
were multiple weird numbers accorded to different veins (and I saw something like patent but

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at the same time reflux) what the shit is this? The whole thing was handwritten (by a doc) so
it was super messy and ugly (some may say artistic). Do I look like Sherlock or something?
Anyways I just traced all the way and it said some fluffy thing like Reflux at where the SFJ
was located so I just presented it as such. But they apparently jizzed in their pants and
asked me about MX.

Standard answer:
-Conservative: Elevate leg, Lifestyle Modifications, Weight Loss (exercise, diet plans),
POSSIBLE graduated compression stockings after excluding DVT and arterial insufficiency.
Daflon. ( <- HK Dr never heard of this, so scared he would ask me MOA, but according to
my classmate, its a venotonic, which makes sense as it works in Hemorrhoids too)
-Surgical: High tie with stripping, stab avulsion, endovascular laser therapy and foam
sclerotherapy.

Then I think Tan Su Ming was bored with veins (you should see her during Vascular Grand
Rounds), so she asked me how I prepare patient for op (take consent, tell him risks, and
alternatives as mentioned above) and then optimise risk factors such as DM, Htn, HLP
(lucky she didnt ask me the details haha, I may have said refer Endocrine :P). Then
stunned... so I said NBM before op. (smiles widely trying to hide my insecurities) She also
asked me if I would want to do bilateral high-tie with stripping. I said no, but I smoked
my reasons by saying prolonged hospital stay due to poor recovery etc

UTD only says: General principles We prefer to perform surgical vein removal on one leg at a
time because bilateral surgery is often not well tolerated. No reasoning. Go find yourself if interested.

She seemed half (maybe a quarter) satisfied by my answers and was obviously still very
bored with the topic and asked me what I would look for in patient post-op (I said vitals,
check wound sites if infected, check Op notes. I have never seen a post op patient with
venous surgery before. Or even any Patient with venous sx. Or for that matter, I have never
seen management for a venous disease ever before, even in clinic. So what I just said was
just a list of fundamental nothingness. Learn to smoke very well yet not obviously.)

What if patient becomes hypotensive post-op? (okay at this juncture Im gonna tell you
guys if you ever get Madam she is somehow gonna ask you about hypotension when she
gets REALLY bored of the topic (which is often since she specialised in Breast and almost
nothing else), she asks EVERYONE this qns and she asked me this qns during CEX also.
She seems to have an algorithm to Hypotension which is elusive as every answer I give her
everytime is wrong. Just agree with her)
I would like to check Op notes if there was any blood loss or structures such as the femoral
artery damaged (interrupted) You expect a lot of blood loss here meh? RINGG No
Madam probably not (OKAYLA, NVM. Finish already.) :D

Lessons
1. Practise with friends for long cases! It can actually be more fun than just plain
mugging as well as enriching. I get too bored studying off books and notes all the
time. PRACTISE PRESENTING. You may not be very smart but acquire the finesse.
2. Practise all your GS short cases. Even though your short case is over, it can come
out again. I so did not expect veins for long case but I guess it does come out.
3. Learn how to summarise and present your history as if youre selling a case. Anyone
of you under the tutelage of some of the Docs (who give multiple tutorials) will be
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 very lucky to have this privilege of being taught different CLASSIC statements for
different disease presentations. Or you can just form your own lah, not very hard.
4. Learn to bait your examiner. Remember, your examiners may be specialised. My
examiners were Breast and Upper GI doctors respectively, who dont do Vascular
like since their Reg days or sth. So when you say I would also like to exclude DVT in
my PE. The next qns they will ask you in excitement is :Oh what test is that called?
tadah, perthes :) same goes for invx and mx (in a different case) I would like to do
an OGD to find the lesion which I suspect is a Peptic Ulcer and further characterise
to grade it? Oh so how do you do that? TADAH you can either Rockalls score or
Forest Classification depending on whether you wanna take abt px or Rebleeding
la. :) Likewise, learn to bait your examiners AWAY from what you dont know. For
example, when she asked me about bilateral surgery, I just suggested to discuss
other things like expanding on PFO (which was her prev qns)
5. Be respectful to patients and seniors. This sounds really whiny, but it really reflects a
lot on your personal character and it shows during your exams/OSCEs. A Kow
actually said some people failed certain stations in short cases as they came off as
disrespectful. Practise courtesy while you are in the wards with everyone. It pays.
6. Read seniors accounts. And as said in an account above, PAY IT FORWARD. Just
as you are reading this, remember to write your OWN accounts for your juniors as it
serves well for future generations. Write it immediately after your exams so your
accounts are as real as it gets!

NOW TIME FOR ME TO ENJOY GRAD TRIP WOOHOO!

CGH Session 6
Esophageal CA with AAA (b/g stage 3 colon Ca resected 7 years ago)

Observing Examiner: ??? (maybe Dr Tang Tjun Yip??)

Examiner: Dr Chan Weng Hoong (SGH)- super encouraging and nice! Cant remember the
2nd one sorry, looks like quite a young con though (maybe ?? Dr Sng Kevin Kaity )

The nice ushers will tell u the demographics of ur patient + bed number, and heres time to
write down your template while waiting outside the room, so pls have a nice template! And
can scribble down important things that you scare u will miss out (like CHECK HERNIA!
POSTURAL BP! Big big at a small corner)

Oh yes, and bring a stopwatch if you think that you cannot keep time properly cos it really
helps in time management! Try to allocate 10 for hx and 10 for PE then 5 mins for whatever
else you need to do, even if you really cannot finish hx at 10th min, go for PE cos it might
help you to point to certain pathology, and can go back to history after that
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My circuit all had chinese speaking patients except for one haha
AND DUN BELIEVE WHEN THEY SAY AAA CANNOT COME OUT (scare the medical
students press press press until rupture >< just remember to be super duper ultra gentle)

Mr Shen/86/chinese/male/ CHINESE speaking haha

He was sleeping when I reached, so paiseh, had to wake him up
And because CGH surg long cases are in day surg with 6 beds in one cubicle, one can
totally hear the voices from the other cubicle while clerking haha (sir I would like to inform my
senior and resus . ) *block out block out*! Lol

After taking basic biodata, asked for symptom of presenting complain: oh I vomit after I eat
(okay, post prandial vomiting GOO?!) and I got this chest tightness since 6/12 (ok) got go
hospital check but they say no prob (?!)
After much clarification, dig out that its regurgitation and not vomiting (okay but to be fair, to
a layman regurg and vomiting is the same so PLS CLARIFY PROPERLY! Can practice this
in ur history taking. Sure kena ask to differentiate one haha) and it got worst in the past 2/12.
Eat porridge vomit (ok he meant regurg) porridge, eat milo also regurg milo
Dig out dysphagia + significant LOW of 11k over 6 months
No early satiety (so thinking more of eso CA)
Then asked for complications he had symptomatic anaemia with dizziness + some
palpitations (I FORGOT ASPIRATION PNEUMONIA OOPS), hoarseness of voice (think the
examiners were quite happy this was picked up), etc
Constitutional symptoms
Metastastic symptoms
Risk factors (remember all ur RF for the various CAs and classify to non-modifiable and
modifiable)
PMHx HL and HTN controlled on meds, NKDA, and then he dropped a bomb when I asked
previous surgery OH COLON CA taken out 7 years ago (?!?) doctor told him stage 3..
didnt know if I was supposed to focus on that, hurriedly clerk a any bowel +bladder
symptoms history (and he told him he thinks his stools a bit hard recently.. decided to ignore
first) and then he dropped second bomb oh my stomach got this pulsating mass they say
very big, can explode (ok right so u also have a AAA)
Social history smoker 35 pack years, used to drink alcohol but stopped completely 7 years
ago. Asked specifically if got any liver probs he said no have. Retired used to be a teacher.

Decided to move on to PE since I know theres a AAA to examine (and my stopwatch said
12th min ><)
Asked for vitals yay dont need
Asked for all the usuals lie patient flat (the examiner super nice, help me to wheel the bed
flat!), exposure (ideally I would like to . remember to say these! Little things count!)
Started from peripherals (slight temporal wasting, with palmar erythema) didnt do running
commentary cos examiner didnt seem keen, wah the AAA is like freaking 10cm, located at
the left of umbilicus, a bit the scary ah. The nice examiner also go and touch touch feel feel
the AAA.HAHA. And he said no need feel for spleen. Too dangerous to press too hard YES I
AGREE. Oh and I happen to have those long cotton buds in my neuro kit which can show
the transmitted vs expansile AAA quite nicely so would be good if u prepare some in ur
neuro kit!

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I was looking for the scar from the colon CA (cannot see anything) the nice examiner said
maybe it was laparoscopic but then patient pointed to this VERY WELL HEALED white line
at the LIF haha wow.
Coughed for hernia, finish up abdo and request the rest
Nice examiner saved my life again by asking me for my diagnosis (eso CA??) and telling me
that the colon CA is unrelated to this episode so I can heck it (phew) so since I have more
time and I know the diagnosis, go ask more about the presenting complain! (angel from
heaven..)

2 nice examiners entered at 25th min HELLO

86/chinese/male with pmhx of HL and HTN controlled on medications and stage 3 colon CA
resected 7 years ago, currently presenting with 6/12 hx of progressive dysphagia a/w
regurgitation +LOW
Presented hx but got interrupted a few times for questions
- Why do you say its regurgitation and not vomiting (regurg is effortless return of food
from stomach to mouth usually occurs mins after a meal, the food undigested and
recognizable, vomiting is forceful sometimes projectile and occurs hours after a meal and
food is partially digested or biious - pradip surg approaches notes are really good pls go and
read!)
- Why is it not GOO? (GOO usually vomiting)
- Tell me the other causes of dysphasia (divide into oropharyngeal and esophageal, and
then functional and mechanical bah blah blah. He was trying to dig out causes of strictures...
previous instrumentation? Ehh GERD? Then he hinted last time ppl use this method to die
and I dunno why I had a eureka moment and said OH ingestion of caustic agents (which I
forgot to ask in history oops)
- Why is it not achalasia? erm patient is very old already right! Less likely (oh okay
yes sir)
- Why do you say his dysphagia is progressive (ehh initially was solids, and now liquids
and it is causing a functional impact on his life? Maybe they just want to hear symptoms
worsen cos tumour got bigger?)
- Apparently I said b/g of STOMACH CA in my earlier opening statement (O.o and all 3
examiners said they heard stomach CA omg brain mouth dissociation but the nice examiner
justified that I wanted to say colon) so Dr Chan WH wanted to ask me if previous stomach
CA resected and now presented with dysphagia what will u think of? But due to the fact that
its a colon CA, he let me off haha (I was thinking whether can be like recurrence + spread,
but a smarter answer (from another batchmate) could be gastrectomy with bilroth 2
predispose to refux then increase risk of gastric CA so if reflux higher then risk of eso CA
also? No idea haha

Show us how u perform PE (nice examiner took handrub for me and help me squeeze!)
some points:
- When looking for jaundice must ask patient to look to the side or look down so can see
better
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- Say liver flap (not asterixis haha okay yes sir)
- Know ur CLD stigmata signs
- Demonstrate AAA examination with the expansile pulsation and measure (why u want
to know the size? Sir because if its bigger than 5.5cm it needs surgical intervention)
- Know how to describe any lump! I thought I covered all the description he wanted, but I
forgot to say I can get above the mass (means infrarenal) and he also wanted to know if can
get below, cos can be dilated at the common iliac bifurcation and apparently can see like 2
lumps in a Y shape hmmm (yes sir, yes sir 3 bags full, all of us become bah bah black sheep
during the exam)
- Differentials for the lump (retroperitoneal mass like kidney? But that would mean a
transmitted pulsation right? Yes sir yes sir. Colon mass can? Also possible, yes sir)
- What else to examine in AAA (CVS, ascultate for other bruits, check for trash feet)
- I showed them the super well healed scar and they say WAH SO NICE, next time dun
need laparoscopic surgery liao LOL

Okay summarize and follow them out

Asked for inx bloods, imaging, special tests. Bloods: FBC, FT, U/E/Cr
Why u think patient got anaemia? Ehh could be complication from Eso CA, dietary
factors, ,
U think AAA can contribute? Ehhh can compress on the kidneys (?!?) or the renal
arteries? But u said its infrarenal right? Oh sorry sir, I would like to retract my statement
But its still possible! Although not very common, can have renal artery stenosis
right? *looks enlightened* oh of course, yes sir
Interpret the OGD ulcerating mass with irregular margins and some bleeding, partial
obstruction
What to do now? Want to do biopsy (the result showed SCC) stage the cancer using EUS
to look at depth. U think can pass through? Erm sir, no complete obstruction so perhaps
its possible No lah I think cannot pass through.. oh okay yes sir
So cannot pass through what else? CT TAP okay interpret
Okay I stupidly thought that dilated circle with air fluid level was the stomach (?!) but hello its
an eso CA case, of course its the esophagus! Luckily saved myself in time. Another cut
showed the tumour itself and Dr Chan HK pointed out to me that the mass is actually
invading into the trachea (not very fair so he pointed out to me instead LOL)
So one of the complication is TEF, how u think patient will present? Coughing when
eating
How to check for fistula (mind block) erm barium? Gastrogriffin? Hint : Starts with a B.
Bronchoscopy!
So how you want to counsel patient on management? Ehh was there any lymph nodes
sir? Or metastasis on the scan (cos I obviously didnt see properly heh) no distal mets
(so I was thinking no mets can try to cut?) I would offer the patient curative surgery
patient is 86 and got AAA somemore, u sure u want to cut? U know esophagectomy
how high risk?! Omg sorry sir I would like to retract my statement, offer patient palliative
options like stenting for the obstruction..

RINGGGGGGGGGGG
Okay one last question u say got hoarseness right, so what is involved? RLN. Yes
so involve RLN cannot cut right? (haha ONE LAST TIME) oh right, yes sir, thank you very
much, see you bye bye

YAYYY okay so sorry for the naggy entry with bits of tips here and there, jiayou guys!! Hi
155
jobi :P

CGH session 2

Prof Adrian Koh and Dr Goh Yau Chong both nice

Observer : not sure
Same case as above

Was told outside that my patient was male and spoke mandarin. Had time to scribble some
rough template outside. Was then ushered to the patient. Greeted the observer

And then spoke in mandarin to the Uncle,(and the nightmare began!).

Uncle, wo shi di wu nian de yi xue sheng, zhen yang cheng hu ni ah (meaning how may i
address you), for which the patient took like 15 seconds and said, wo bu zhi dao >.< i
freaked out. die la, confirm poor historian ++. a nice MO then popped her head into the room
to tell me his name was Mr S. zzzzz (so wasted a good load of time)

eh, somehow the patient was very very unprepped at the start. went one whole round before
he finally got to the presenting complaint.initially said he had chest pain(remembered
thinking, am i really in a surgical long case >.<)

so yeah, managed to finally elicit his symptoms of dysphagia a/w LOW/LOA with
regurgitation of food that was progressive from solids to liquids. the rest same as above.
besides that i asked the patient as the start if he was admitted, was told he was
admittedsince the 21st, and has undergone chemotherapy sessions at SGH, but was unable
to quantify. patient somehow did not know if hisbiospy results was benign or malignant for
some strange reason, but i presented it as such later on(was thinking might be quite bad to
say it in front of the patient if he did not know his diagnosis)

oh yeah, cos patient wasnt very prepped, the nice observer told me to move on to this other
comorbids which was a wise move

basically
1) HTN
2) HCL
3) COLORECTAL CA s/p resection and subsequent chemotherapy with no stoma (i asked)
4) AAA??? no op yet
5) BPH

was also thrown the bomb of the AAA around the last few minutes. sigh.SO my patient went,
i have this thing in my stomach that jumps around??what a description :/suspected AAAso
went to ask him if he knew his vessel in his abdomen was dilated, for which his reply was I
DONT KNOW :/ zzzz. subsequently told me the diagnosis of AAA in MANDARIN(Which i did
not understand) :/ so yeah made an effort to figure it out during the physical examination
later

SO on physical examination, BEWARE OF HIDDEN SCARS, asked my patient where the

scar was cos couldnt be seen, then patient pointed to LIF, where there was a super well
healed scar, no incisional hernia (please check, very IMPT)

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Requested for vitals, for which the nice observer told me to assume it was normal.

So at 25 minutes, in comes the 2 examiners.i asked for 2 minutes to wrap up, they said it
was eating into my question and answer time, so i just presented,albeit a bit hapharzardly

Sirs, I had the pleasure of clerking my patient Mr Sim, for which I will be giving you a
summary of his presenting complaint and then elaborating on his other medical problems.

My patient is Mr Sim, an 86 year old chinese gentleman blablabla so presented a

summary.
Important points:
1) remember key words: painless progressive OESOPHAGEAL dysphagia, for cancer
2) remember to present aetiologies you ruled out: so i presented as wrt to the other possible
etiologies for his presenting complaint: he has no previous stroke, no background of
previous dysphagia/when young suggesting a congenital cause, no tremors suggestive of
PD, no joint pain/rash suggesting AI/scleroderma
3) remember to include complications of the condition: any haemoptysis, any coughing
suggesting aspiration pneumonia, hoarseness,
4) include investigations and management in hospital: especially important as this patient
subsequently went for chemotherapy BUT STRANGELY NO RADIOTHERAPY, and is
CURRENTLY ADMITTED (not sure the reason why still admitted though hmm), ask about
ABx use as might have aspiration pneumonia. forgot to ask about NG insertion.

Was then told to examine the patient. Stood at the foot of the bed for inspection, then did the
peripheries. they werent very interested and told me to go straight to the abdomen.
mentioned the significant findings of a scar over the LIF with NO INCISIONAL HERNIA
(demonstrated no positive cough impulse), for which the examiners had a MUCH CLOSER
LOOK, cos the scar was super well healed. :P was also asked to examine the AAA as i
mentioned the pulsatile mass in the abdomen. only had to estimate size, they din want the
ruler LOL. so yeah used 2 fingers, then they also felt it themselves. LOL. about 7-8 cm
(somehow my 2 fingers din manage to show the expansile pulsatile thingy :/ but they did not
question my examination, so should be fine) then they ignored the rest of the examination. :/

Questions: (VERY WEIRD QUESTIONS, not like the basic ones)

1) Goh: Do you know if his colorectal cancer has been cured?
Sir, based on history, patient mentioned that he initially presented with change in bowel
habits, subsequently underwent partial colectomy with no stoma, and also had adjuvant
chemotherapy, and hence i would say he is adequately treated? (He nodded)
Now, we left the cubicle, and walking past the other cubicles
2) Goh: Since patient was unsure of the biopsy results, what do you think is the diagnosis?
Since patient presented with painless progressive esophageal dysphagia, most likely cancer.
(they did not ask me about differentials at all, think maybe cos i presented in history above?).
then i added, might be squamous, cos he has risk factors of smoking.
3) Goh: Now im impressed you said risk factors of smoking for squamous. They then pulled
up a scope of the tumour (DID NOT NEED TO INTERPRET haha). Then he asked me this
damn weird high level question. So if i tell you this is not primary esophageal, what are you
thinking about?
I said, err secondaries, and he went, other than that? then i got confused, wah, if not
primary, not secondary, got tertiary one meh? :P but yeah mentioned strictures and webs.
still not what he wanted :/ then he said if not intramural, intraluminal, then ? so i said
157
extramural (but wah, how can extramural get a similar picture on scope as an esophageal
cancer right?) so yeah, he kept emphasizing in a smoker. the answer is LUNG CANCER
INVADING INTO ESOPHAGUS (wah lau, cheem :/. din get it)
4) They pulled up a CT scan. Goh: tell me where is esophagus.
Pointed to it, and told them there were air fluid levels, suggestive of obstruction. They were
quite happy. Koh proceeded to scroll down the scan, then they came to this point with a
homogenous hyperdense structure within what appeared to be the tumor itself.
5) What is that? (weird questions seee.)
Err.. foreign body? They were pleased, they said yeah can be tablet or sth, cos patient got
severe dysphagia
6) Koh: so if patient presents with cough what are you worried about/what are the possible
causes (cant rem who asked this actually)
Aspiration pneumonia, concomittant oropharyngeal dysphagia, then err paused, they
showed me the CT scan which reached the L and R bronchus (which i accidentally
mentioned was the arch of aorta, and then immediately corrected myself), for which i then
said, oh possible TEF or BEF, for which i would like to do a bronchoscopy for the patient.
(they were very pleased, and asked the MO if they had a bronchoscopy results for me to
interpret, for which there was none haha)
7) Koh: How would you like to manage this patient?
Oh sir, this would depend on patient factors, disease factors and surgical factors. could tell
they were very happy i did not give some definitive treatment.
8) Koh: What are the patient factors?
Oh, his comorbids - HTN, HCL, colorectal cancer. AND??? on physical examination?
OHHH.. his AAA
9) Koh: Would you be worried? He pulled up the CT scan and measured the diameter to be
7+ cm.
Yes sir, as it is >5.5 cm and risk of rupture 10% in 1 year.
10) Good, ok so which surgery would you do first? the AAA or the esophageal?
(WHATTTT???, how would i know)
Sir i dont think i am qualified to determine this, but for the AAA i am worried about the risk of
rupture, and for esophagus, i am worried about patients nutrition, for which he went you are
concerned about both? then i just agreed haah
11) Got asked by Goh about nutrition, how you would assess and what you would do. said
stent at first which should nto hav ebeen e first answer but quickly corrected myself to say
NG/NJ, for assess, just clinical and lab results
12) How do you know when you can insert NG?
I said, oh scope can pass through, so i paused, then told them i was notsure, thinking i
was going down the wrong track, for which Koh asnwered, so yah la, can pass through
means can ma :P (zzzz, should not have doubted)
13) So since you mentioned about stents? tell me more?
Ok sir, stents usually for palliative care, based on what i know about stents, but not sure if it
applied to esophageal, there are both BMS and coated stents (drug eluting slipped my
mind). for which the subsequent treatment post stenting differs.
14) Oh forgot to add this question. They asked what other therapies, besides chemo?
Told them radio, and they asked why. Said err because its more receptive, SCC that is, and
haha, they corrected my term usage, and said sensitive you mean :/ haha

At this juncture, Goh has nth more to say, and looked at Koh, they kept looking at each
other, and had like no more questions? Awkwardly glances between the 2 profs. LOL, finally
Koh smiled and said, you may go now.
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So yay finally done, left about 3-5 minutes early.

CGH Session 6 Group 2

Case : Chronic limb ischemia s/p right leg artery stenting

Examiners
Observer: Dr Tang Tjun Yip?
2 Examiners : Dr Bernita Tan (Active) , Dr Ng TC (very passive)

Patient : Mr M/ 67YO/ Malay Male/ NKDA (A very nice english speaking patient)

Introduced myself to patient and Observer doctor. Examiner told me to start and keep watch
of time.

History
- Calf claudication
o Started last Jan 2013, gradual onset
o Left leg then right
o Worsened to involve upper thigh
o Walking distance 2 busstops, stops to relieve pain
o Elicit vascular claudication symptoms TRO Le riche syndrome (buttock
claudication, impotence)
o S/B polyclinic, tried painkillers but not relieved
o Referred for appt to vascular clinic but waiting time too long and didnt go for appt
since pain transiently stopped for a few weeks
o Restarted again in Oct 2013. Became worse again.
o S/b Vascular clinicscans done showed both leg arteries blocked.
o Decision made to stent right leg first
o Awaiting next op
o Nil varicose veins, ulcers on feet
- Otherwise systemic review unremarkable except for some lower back pain
- PMHx : IHD s/p triple bypass in 2006, HTN, HLD(claims good control to all), previous
slipped disc many years ago managed conservatively, nil DM
- Drug Hx: On many medicines including aspirin
- Family Hx : DM (mother), HTN/IHD (Father)
- Social: Ex-heavy smoker of 60 pack years stopped 20 years ago, no alcohol, retired
(previously runs own restaurant)

Physical exam
- Performed an arterial examination
- HR, BP stable
- Chest - midline sternotomy scar + venous graft scar on left LL
- Peripheries hairless skin, nil pigmentation/pallor, slightly cooler, cap refill <2s, felt for
pulses (absent DP, PT on leftor so I think), femoral pulses palpable
- Upper limb pulses good, carotid pulse good, no abdominal aortic aneurysm
- Performed a buergers test, negative.
- Auscultated heart nil murmurs

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I noted the time I started clerking so finished all by 23 mins. Had 2 mins to sort of try
consolidate before the 2 other examiners came in.
RINGGGGGGGGGGG

ALL MY EXAMINERS STONE FACE. I couldnt even figure who was active. Luckily had a
nice MO who smiled at me once in a while. Kept me sane. :/ So just picked myself up and
introduced my examiners to patient.

Soon I realized Dr Bernita was the active.

B : So present ur case

Me: My patient Mr M is a 67YO Malay gentleman with past medical hx of IHD s/p triple
bypass in 2006, HTN and HLD. He presented last year with s/s suggestive of chronic limb
ischemia s/p a stent put in for his right leg. I shall now elaborate more on the presenting
complaintblah blah.presented everything(Hx and PE) without stopping. Still stone face.
Some raised eyebrows. Haiz.

Observer: Are u sure about ur pulses? Could u show us again how you would palpate for the
pulses?

Me : (DIE) So sir this is how I would palpate. Stood at foot of bed and verbalized my
landmarks while trying to feel. DIE. I COULDNT FEEL IT NOW. Waited for ard 10s, he
asked me to move on for other pulses. Also couldnt feel PT, DIE!!!!! Already losing my hope.

Dr B: So u mentioned that u performed Buergers test. Could u tell us how you would do it
and how u interpret?

Me: (Ok this one shld be finerelax) Mam, I would raise the leg as the patient lies flat and
look at the sole of the foot looking for any pallor. And I would measure the angle at which it
turns pale.

Dr B: So is that how u perform it? Are u sure its not two legs at the same time?

ME: Sorry mam, I was taught to do it one leg at a time. :/

She had a slight smiledunno wat that meant

Other qns:
1) What are ur other differentials from the presenting complaint? And how would you
differentiate that from the history? (Basically talked about how I would try TRO neurogenic
claudication)
2) Are there any more tests you would like to do? ABPI, TPI

Moved out to interpret duplex study (my heart racing already)

Qns
1) Please interpret this study. What is it? Obvious arterial duplex Doppler study showing
left leg arteriesatherosclerotic changes, complete occlusion at bifurcation of PT and
peroneal arteries. >50% stenosis at superficial femoral artery.
2) Why do you say this is chronic limb ischemia?
3) If you see this patient in the clinic, what would you do?
4) What are the conservative management options for this patient? Analgesia. She only
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started smiling after mentioning claudication exercise rehab
5) So do you know how it works?

Was left out 5 mins before end. URGH.

I didnt care..I AM DONE!!!

Learning points
1) Standard cases come out most of the time. So pls know all the common CAs.
2) Study tip - Read Andre tan :)
3) Keep calm and pass mbbs - really just stay calm at all times.
4) If you arent sure of your physical findings, btr to say so than make it up :/

CGH session 6 No. 7

Prof Adrian Koh (CGH Head and neck) and Dr Goh Yau Chong (SGH upper GI) both nice
but naughty+++
Observer: Dr Tiong Ho Yee NUH Uro transplant surgeon. Obstructive Jaundice- HOP
cancer. 65 year old Chinese Male Chinese speaking

Hello Uncle !
Ok set HPB obstructive jaundice. So Patient basically presented 1 month ago with tea
coloured urine, no pale stools, slight pruritus and generalized jaundice in his eyes and body
as described by his friends. Also complained of mild dyspepsia. Thank God for a Classical
textbook case.
So need to rule out causes of obs jaundice Stones, Bile Duct Malignancy, Mets from
Colon/Stomach. Rule out Hepatic causes of jaundice i.e. ask risk factors (Sexual History etc)
but I realized the surgeons are not v interested in this but it is nevertheless impt. Briefly
ask about prehepatic. Asked about change in bowel habit and he said black stools I was a
bit skeptical but just noted it down as malaena.
Ok asked patient to lift up his shirt and noticed a midline abdominal scar patient said he
had previous perf PUD. Examined the patient checked for incisional hernias , LN . Anw
guys I forgot to time myself so halfway I asked the observer whats the time now and he said
I dno: / So next time must rmb! Patient was a smoker 50 pack years.

Prof Koh and Dr Goh walked in. Ok present your history

So patient w a PMH of perf PUD presents with painless progressive obstructive jaundice ,
constitutional symptoms of LOA and LOW, and malaena.
Top differentials : 1) HOP CA, Cholangio Ca, Periampullary Tumour ( likely cuz malaena +
obs jaundice sloughing off of tumour can cause malaena )
2) Gastric CA mets to Liver since w malaena and previous PUD (I will live to regret this :D)
3) Choledocholithiasis but mentioned this is pretty unlikely.

Q: Why do you say he has malaena?

A: Black stools
Q: Is that enough?
A: Oh no sir, the stools are sticky, foul smelling and black, and I would like to dip it in water
to watch it dissolve completely.
Q: yucks. But ok thats right. So why do u think its a gastric CA mets to porta hepatis
causing jaundice?
161
A: ok sir so he has previous PUD which predisposes him to gastric Ca (I see 3 examiners
smirking at each other at this point), presents w Malaena (Upper GI Bleed) and dyspepsia,
LOA, LOW and jaundice so this actually ties everything up.
Ok basically in Andre Tan it states theres a <1% chance of PUD becoming gastric Ca. its
more of the H pylori/chronic atrophic gastritis that causes gastric CA and not PUD I think.
Goh Yaw Chong who is an upper GI surgeon was waiting to devour me when I said this and
I had to pacify him later :D I rmb him mentioning this to us during our GS tutorial in SGH but I
clearly forgot.
Performed PE for the examiners so jaundice, midline scar and cachexia. Examiners didnt
agree w the jaundice part. Said done ERCP and not really yellow now (probably stented)
Q: Ok lets go out!
HAHA goh yaw chong first to question me again: So why do you say he is likely to have
gastric cancer again? Ok this time I dint fall for it. I said LOA LOW and a bit of dyspepsia.
Even though he has peptic ulcer, this is NOT a risk factor for gastric cancer. He LOLed and
gave me a nice little wink. Yes absolutely.
Q. Ok so what Ix you wanna do for patient
A. FBC, LFT (which showed obstructive picture), Albumin low. Do CT scan
Q. Lets look at the CT. So what do you see? (So basically the GB and the CBD were
enlarged. Pancreatic duct enlargement was Plus minus. But I just gambled and said double
duct sign, didnt think they would misinterpret me .
Q: So where are the double ducts? Ur referring to This (GB), and This (CBD) right?
A: OH NONO sir. Im referring to the CBD which is obviously enlarged and the pancreatic
duct which seems to be equivocally enlarged.
Q: Ah thats better. Sorry for maligning you. :D ( wasted 1 min naming all the parts of the CT
scan as a result to prove my innocence)
Q: So why do you think this is not stone disease? Based on CT scan
A: Ok Sir so I say this because of Courvosiers law
Q: Whats Courvosiers law :D
A: Painless jaundice is unlikely due to stones in the presence of a palpable and enlarged
GB.
Q: Ok is that it? Whats the 2nd part. Why is that so?
A: Ok sir so in chronic choledocholithiasis the GB is chronically inflamed and will be
shrunken
Q: nodded head.
Q: This is the ERCP what do you see?
A: named the 5 characteristics of abnormal intraop chlangiogram . Learn to read a
cholangiogram.
Q: which gastric cancers cause obstructive jaundice?
A: Distal antrum and pyloric cancers which are in close proximity to CBD.
Q: When will u decide to do ERCP for a patient? All jaundiced patients?
A: No Sir, when patient is itching v badly and having climbing LFTs or coagulopathy?
Q: one more indication? Pretty impt. Fever?
A: Oh yes sir. Cholangitis is an absolute indication.
Q: What are the complications if you dont do ERCP, besides worsening liver function etc
A: ??? Bleeding? Vit K deficiency so need to replace Vit K?
Q: Ok its poor wound healing too, esp for post op patients.
Q: So how will you manage this patient?
A: Assess suitability for surgery by staging the patient. Whipples procedure if it hasnt
invaded into SMA and no distant mets. A Whipples op iis a procedure which is a
pancreaticuduodenectomy with 4 anastamoses ( JJ, GJ, PJ and HJ)
162
Q. Good. Palliative options?
A: Ok so once again relief of the obstruction if there is cholangitis etc by inserting a stent, or
periodic ptc drainage.
Q: More aggressive op? ( pointed 3 fingers at me)
A: Triple bypass sir, which is almost similar to a Whipples except with 1 less anastomosis
(pancreaticoduodenal)
Q: You may go!

Study the new andre tan well and you guys will be fine! Thank God through all blessings
flow. I got Asthma, OA and Obs jaundice really full house of basic ++ cases. J

Day 5: SGH
For the guys who got SGH, there was a rumour that there would be many Head and Neck
cases, tongue cancer and epic weird cases like plummer vinson and nutcracker esophagus,
penile SCC so we all freaked out . IDK if anyone actually got a oral cancer or tongue cancer.
but APKD came out. so if posted to SGH do read up on APKD too.
Well if u are posted to SGH chances are youll be on the last day and will have alot of time to
mug for the long case. We had 6 full days to study for it which is actually a blessing. so dont
be too upset abt ending on the last day ok. rest and relax and go play for the 1st 2 days and
start studying for the last 4 days before the exam. Ull start feeling emotional when u see
friends who have ended their long case and posting photos on FB. Just tell yourself that
youre lucky and had the opportunity to have an earlier break than all the others and play for
two days right after GS short case and so dont emo ! Just study hard after the break cox u
nvr know what cases youll get in SGH. Working hard for 4 days and doing well for the long
case is better than doing badly cox u didnt study hard enough and fretting for the next 1-2
months about whether uve passed the case.
Whats impt is to know your basic anatomy, lymph node drainage, diff between hind gut and
mid gut etc and approaches to symptoms well. Practise clerking in chinese too. For my
circuit, 70 % of us got a chinese speaking patient. the google translate app is damn
useful ><
When students fail an exam, its because they didnt know basic stuff and not because they
didnt know the surgical approaches for an achalasia or esophagus cancer case. For simple
cases like breast and CRC, know how to stage and manage accordingly.
Also, GS long case at SGH isnt really as scary as it sounds. Theres someone to vouch for
your history, Drs are there to guide u along to the diagnosis. In SGH,we all did our long case
on a saturday in the clinics which is a really conducive environment as compared to the
wards. SGH examiners maybe really big shot guys but they are generally nice and benign
ppl. :):) Their expectations can be really high though? So, its generally easy to pass but not
that easy to score very well in SGH in my opinion
ALL THE BEST SGH LONG CASE PEEPS

163
SGH Session 1 Group 1: Esophageal cancer
Observer: (sorry I cannot remember his name)
Examiners: Prof Wong Wai Keong, Prof Enders Ng (Hong Kong Prof)

Summary: 57 year old chinese gentleman with esophageal cancer with nodal metastases,
currently status post 4 cycles of neoadjuvant chemotherapy, awaiting esophagectomy

History:
First presented 8 months ago with a 1-2 month history of progressive painless dysphagia,
occurs after swallowing, has globus sensation, associated with immediate regurgutation of
undigested food. No bilious or bloody vomiting. Dysphagia is notably worse for solids than
liquids, got progressively worse. No associated odynophagia, chest pain, abdominal pain,
heartburn, water brash or acid brash symptoms. Bowel and urinary habits unchanged, no
melena or per rectal bleeding noted. Systemically noted loss of weight of 8kg over 10
months, no loss of appetite, fever or night sweats. No shortness of breath, bone pain or
abdominal distension noted. Symptoms suggestive of anemia such as easy fatiguability and
decreased effort tolerance noted.

Risk factors for esophageal cancer: 40 pack year smoking history, 40 year of alcohol history
averaging 1-2 bottles of beer a day. Otherwise no betel nut chewing, habit of drinking hot
soups quickly, previous caustic ingestion, GERD symptoms, palmoplantar hyperkeratosis or
family history of any cancers noted.

Socially, married with 2 young boys still schooling, lives in lift-landing 2-room HDB flat, ADL
independent and community ambulant. Used to work odd-jobs but unemployed since
diagnosis and treatment. Financial concerns present, known to MSW and already receiving
aid.

Initially presented to the polyclinic, referred to SGH surgery where they did a scope for him
and found a esophageal tumour. Subsequent scans revealed tracheoesophageal
lymphadenopathy and a right infraclavicular lymph node. Given chemotherapy, and
reassessed for response. Repeat scans noted an interval decrease in lymph node size.
Currently awaiting further reassessment, keeping in view esophagectomy later down the
road.

Physical Examination:
Cachexia ++ (wasting of temporalis muscles and guttering of fingers), no pallor, no jaundice
Abdominal examination revealed palpable liver 3cm below right subcostal margin, but liver
span was 13cm (so I said I think the liver is ptosed, maybe due to underlying undiagnosed
COPD given his significant smoking history); otherwise no splenomegaly, ballotable kidneys
or any ascites present
No pitting pedal edema, no cervical lymphadenopathy
Was going to perform DRE when bell rang and the profs came in zzzzzzzz

Grilling:
Prof Wong gave me a minute to consolidate what I wanted to present cause I had not
prepared at all. Presented the full history as above, got cut off when I started on the social
history.
164
WWK: what are your differentials?
Me: esophageal CA, gastric cardia CA, achalasia
WWK: so why you say esophageal CA most likely? because patient told you so?
Me: no prof, i say it because he has painless progressive dysphagia, solids worse than
liquids (hence more likely mechanical than functional obstruction), has significant weight loss
constitutionally, and has significant smoking and drinking history as risk factors
WWK: so you said his liver is palpable, show me how you examine
Me: *prays damn hard I didnt imagine a liver*, repalpated and percussed to show him
dullness in the right subcostal margin
WWK: so how you know that is a liver?
Me: located in right hypochondrial region, dull to percussion, descends with respiration,
unable to get over it
WWK: so how you know it is not liver mets?
Me: it was smooth, regular edge, soft to firm in consistency
WWK: show me how you felt for his lymph nodes?
Me: support one mandible, feel the other one starting from the submental group, then
submandibular, then anterior cervical chain, then supraclavicular in the posterior triangle;
then repeat for the other side
WWK: supraclavicular lymph nodes are in the posterior triangle???
Me: ummm yes prof, at the base of the posterior triangle
WWK: what are the boundaries of the posterior triangle?
Me: anteriorly bounded by the posterior border of the SCM, posteriorly by the anterior border
of the trapezius, inferiorly by the clavicle
WWK: so you are sure the supraclavicular nodes are in the posterior triangle?
Me: *stares at patients neck again, stones* umm yes prof
WWK: so if you saw him when he first presented how you want to investigate?
Me: screening bloods, FBC for anemia, RP since he poor intake, LFT for albumin and any
possible derangements though I know it is not sensitive for mets, coagulation panel and
GXM if he is bleeding at presentation. otherwise I will do an upper GI endoscopy
WWK: *pulls up 4 scope photos on the com* so tell me what you see
Me: this is an OGD done on [date] for my patient; this are likely views of the esophagus as I
do not note any gastric rugae; I see undigested food in the esophageal lumen, as well as an
irregular bleeding mass here *points to picture* which is narrowing the esophageal lumen
WWK: so what on the scope would you be interested in?
Me: the distance from the upper incisors, take tissue biopsy for histological confirmation and
see if scope can pass through to look for synchronous tumours
WWK: ok histo comes back as squamous cell carcinoma, then what?
Me: now that SCC of the esophagus is diagnosed, I would like to stage the patient with a CT
thorax abdo pelvis, looking out for the local T stage, regional nodes, lung and liver mets
WWK: *pulls up CT TAP* there you go, tell me what you see?
Me: *scroll scroll scroll* umm I note that in this level of the esophagus there is an increased
mural thickness with resultant narrowing of the esophageal lumen
WWK: scroll up slowly, yup more, more...ah there, what do you see
Me: oh sorry prof, THIS is the thickened segment of the esophagus with narrowed lumen
hahahahaha
WWK: what is that structure anterior to this segment of the esophagus?
Me: its the carina, bifurcation of the trachea
WWK: so say if this scan also shows a right clavicular node that is enlarged, how?
Me: assess for fitness for op (lung function test especially), then treat with neoadjuvant
chemoRT then curative op
165
WWK: so how do you know this node is involved?
Me: i can do a FNAC for it, radio-guided since it is clinically not palpable
WWK: ok, Prof Ng any questions?
Enders: so other than FNAC, any other way to know the node is involved?
Me: I can do a PET scan to see if it lights up
Enders: so tell me about how PET works
Me: positron emission tomography, works by injecting a radioactively-labelled fluoride-
attached glucose, tumour cells are hypermetabolic, hence would demonstrate increased
uptake of the radioactive glucose tracer
Enders: other than glucose do you know anything else that can be used for PET?
Me: Ive no idea prof
Enders: okay, so if this guy comes in to your ED after starting chemotherapy, vomiting
blood, how?
Me: stabilize, ABCs, consider elective intubation
Enders: good, why airway important?
Me: vomiting blood, has pre-existing dysphagia, high aspiration risk which would portend a
poor outcome if it happens
Enders: okay, then what else?
Me: do bloods, fluid resuscitate, arrange urgent OGD to treat
Enders: so what do you think is the likely cause in him?
Me: likely bleeding from the esophageal cancer, but if he has torrential hematemesis its
unusual in cancer alone, so I need to exclude an aortoesophageal fistula
Enders: okay, so he is undergoing chemo now, any issues you wanna consider for him in
general?
Me: ummm *vague much prof* i think he is cachectic so I want to optimize pre-op nutrition
with help of a dietician and monitor for chemo-related side effects like alopecia, nausea,
bone marrow suppression
Enders: so if dietician say he not tolerating food well, keeps vomiting, how?
Me: can still be enteral, via feeding NGT or NJT; can consider parenteral if he still cannot
tolerate
Enders: so say so stenotic cannot pass a tube down anymore, how?
Me: can parenteral then
Enders: other than that?
Me: can do an open feeding gastrostomy or jejunostomy
Enders: do you know how an open gastrostomy is done? how many types are there?
Me: no prof Im sorry Ive never watched an open gastrostomy op before
Enders: okay can Im done
WWK: okay last question, if patient comes in with acute episode of throwing up and violent
retching and coughing after eating, what are your thoughts?
*bell ringsssssss*
Me: I will be worried about a tracheoesophageal fistula prof

FINISHHHHHHHHHH MBBS IS OVAAAAAAAA. GOOD LUCK JUNIORS!!!

SGH Session 1 Group 1: Ruptured renal cyst s/p Right nephrectomy on b/g of CRF 2/2
SLE
Observer: Dr Wong Jen San (SGH HPB)
Examiners: A/Prof Yong Wei Sean (SGH surg onco), A/Prof Charles Tsang (prev NUH
colo, now pte)

166
Summary: 41 y/o Chinese lady with history of SLE nephritis progressing to chronic renal
failure currently on hemodialysis, presented with acute R flank pain and sudden ARU 3
months ago, s/p R nephrectomy

HISTORY
(Patient (Chinese speaking) mentioned she had kidney inflammation with bleeding into the
abdomen from the beginning, heard that and was confused +++)
Presenting complaint:
1. Acute R flank pain - sudden onset 1 day after dialysis, severe 9/10, unable to
characterise, no radiation, no alleviating factors, exacerbated by lying down, wasnt sure of
duration of pain, no previous similar episodes of pain.

2. Sudden inability to pass urine - had urge but was unable to PU. A/w flank pain. Was
eventually able to PU in the ED and did not require catheter. Noted gross hematuria
throughout stream, no clots, no dysuria

No symptoms of anemia
No fever
No preceding URTI/signs of infection
No LOA/LOW
No change in bowel habits/constipation prior to this episode
No urinary symptoms prior to onset of flank pain

Past medical/surgical history:

1. Laparoscopic R nephrectomy
- Done beginning of March
- No cx so far except for mild tenderness over op site

2. Chronic renal failure

- HD 2,4,6 via left B-C AVF
- No issues with compliance to f/up, dialysis or salt and fluid restriction
- Cx by anemia managed with fe supplements
- Cx by renal osteodystrophy managed with Ca supplements

3. SLE
- Diagnosed 20+ years ago
- Currently ?well controlled on Prednisolone 5mg/day
- Compliant to medications and f/up
- Noted doctors wanted to increase her medications recently but she refused?
- Couldnt really tell me if there were other complications besides the lupus nephritis, only
that there was one previous flare? (didnt have time to go into detail)
- No symptoms of active SLE currently

4. HTN
5. HLD
- All on f/up, compliant
6. Prev ?angina ?AMI
- Said sth about an episode of chest pain and was told her heart was blocked but later on
after investigation found to be normal o.o

167
No previous hx of renal stones/ureteric colic
No previous hx of upper or lower UTI
No personal hx of other A/I conditions

Drug Hx:
- Allergic to contrast and some antibiotic
- Prednisolone 5mg/day
- Antihypertensives (couldnt rmb what)
- Lipid lowering agents (couldnt rmb what either)

Family Hx:
- No family hx of other A/I conditions
- No family hx of renal diseases

Social Hx:
- Non-smoker, doesnt drink
- Works as kitchen helper
- Lives with sister, functionally independent
- Coping financially, doesnt require MSW help

(Wasnt quite sure what to ask for history so just jumped around abit and made sure to do a
systemic review for p/c even though it sounded like quite a uro case. still felt like i missed out
quite abit though:/ When I moved on to examine the patient Dr Wong walked over to the
table to peer at my clipboard haha)

PHYSICAL EXAMINATION
Vitals: BP 145/87, HR 67
General inspection: Sallow++, alopecia++, thin
Peripheries:
- UL: pulse regular, nail bed pallor, no scratch marks, no clubbing, no joint deformities, no
uremic flap, old AVF on R arm no longer in use (can take BP), current left B-C AVF with
evidence of recent needling, bruit and thrill present.
- LL: Hyperpigmentation & dry skin ++ over bilateral shins, no LL edema
- Face: subconjunctival pallor, no oral ulcers
- Neck: Single R cervical LN just below angle of the jaw, ~3cm, soft mobile non-tender
smooth surface with regular edges, no overlying skin changes (Asked a little more about the
lump at this point: pt said lump has been present for a few years, not progressing in size, not
painful, dr told her to surgically remove it but she refused, not sure why its enlarged or if its
even a LN)
Abdomen:
- Laparoscopic scars over R flank with one larger scar (presumably where they removed the
kidney)
- Some diffuse macular (1-2mm) hyperpigmentation over her skin, looked like freckles so
didnt think much of it:/
- Abdomen not distended
- Couldnt really palpate deeply/ballot because she was tender ++ but no obvious
organomegaly
- No shifting dullness
- No renal @ bruit
Quick CVS: just auscultated the heart (normal,S1 S2) and checked JVP (not elevated)
168
PRESENTATION (Didnt have time to consolidate)
Presented as above
Got interrupted by Dr Wong while I was presenting my PE findings What else did you notice
on the abdomen?
Me There was some macular hyperpigmentation
Dr Wong *proceeds to pull down the neckline of the back part of patients top to show
examiners* (this was when i noticed it was over basically her entire skin) so what do you call
this?
Me Uhh.. hyperpigmentation? (No idea!)
Dr Wong yes.. so what drink does it look like?
Me *stunned*
Dr Wong what colour is it?
Me Brown? Tea? Coffee?
Dr Wong Coffee.. black coffee?
Me OH CAFE AU LAIT (Honestly did not look like cafe au lait to me but I guess I havent
really seen enough of those :/)

Continued presenting until i got to the part about cervical LAD. At this point CT interrupted
me
3cm? But thats quite big *gestured with his finger*
Me Yes prof, it is 3 cm
CT *proceeds to feel it himself and nodded

Finished presenting, WJS leaves.

YWS So say this patient presents to you in the ED with acute R flank pain, what goes
through your mind?
Me: So I would think of a possible pyelonephritis..
CT But usually for an inflammatory condition like that what else would they present with
besides pain?
Me Fever
CT Did she have fever?
Me No, but considering that she is immunocompromised (chronic dz +LT steroids), she
might not have been able to mount a normal response
YWS Okay fair enough. So what are your other differentials?
Me - went down uro: pyelonephritis, ureteric colic, RCC, perinephric abscess; GI: divert,
maybe appendicitis but less likely, HPB: should rule out hepatitis/cholecystitis as well
YWS So what would you do for this patient, what investigations?
Me Ensure vitals stable, basic blood stuff (FBC UECR LFT)+ what i was looking out for,
ESR/CRP, cardiac enzymes, ECG, imaging: CXR looking for air under diaphragm for
possible perf
YWS Is it likely that this is a perforated viscus?
Me um.. considering the sudden onset and the fact that she sounded quite peritonitic with
severe pain, no alleviating factors, worse with movement, I would like to rule it out
YWS Okay fair enough
Me So I would also like to do a Xray KUB looking out for stones, renal U/S looking for
stones, gross pathologies blah blah, also a CT KUB without contrast if patient is stable
YWS Why would you do a CT without contrast in this patent?
Me CT KUBs are usually done without contrast
YWS really?
169
Me erm.. I think they do at least one without contrast and maybe another one with contrast
for comparison, but in this case she also has a contrast allergy
YWS any other reason?
Me She has renal impairment?
YWS Is she on dialysis?
Me yes she is. (not sure what the other reason he was looking for was either:/ )

MO had investigations ready on the comp

YWS You asked for some investigations, can you interpret them?
Me Borderline low Hb,
CT Would you expect anemia in this patient?
Me yes, she has documented anemia as a result of CRF and is currently on Fe
supplements
CT okay
Me (continuing) TW not raised, amylase and lipase slightly elevated (200+) but unlikely to
be pancreatitis as it is usually in the 1000s
YWS yes fair enough
Me Cr was elevated ++ at 411, expected in this case but I would like to compare with her
baseline creatinine levels
YWS okay, what about the CT?

At this point, still wasnt sure what patient had until I scrolled through CT and noted multiple
cysts in BOTH kidneys but only R kidney enlarged, L quite small (thought OH NO dont tell
me she has concurrent ADPKD + SLE??? why got cysts?)
CT So based on your differentials what would you be looking out for?
Me Looking out for any signs of inflammation such as fat stranding, any stones which may
not have been seen earlier, any evidence of neoplastic disease. I also noticed multiple cysts
in both kidneys and the right kidney is much bigger than the left
CT okay why do you think there are cysts?
Me Could be acquired cysts due to long term dialysis.. could also be due to ADPKD???
CT unlikely right, if not both kidneys will be enlarged, so what could have caused her R
kidney to be larger than the left?
Me Thought he was going down the causes of unilateral enlarged kidney so mentioned a few
CT Taking into account her presentation?
Me Cyst rupture with hemorrhage into the renal parenchyma!
CT Yes. so why do you think they removed the R kidney
Me Could be because residual renal function is already bad, if done in the emergent setting
could be because they cant stop the bleeding
CT Any other reason? is she on dialysis?
Me Yes.. (Not sure where this is going)
YWS Any problems with coagulation?
Me Yes! They usually flush the ACV with heparin to present it from being thrombosed, so
she is at increased risk of uncontrolled bleeding
CT yes, so how would you measure renal function in this patient?
Me A MAG-3 renogram
CT anything else?
Me er.. DMSA scan? But I think thats more for renal scarring
CT Heard of DTPA?
Me Sorry prof, not really..
170
CT okay nevermind, any other reasons? what happens if you leave a collection of blood
there?
Me secondary infection, could rupture ??
CT okay so blood is very nutritious to microorganisms right? so what will happen if it
becomes infected
Me It will result in an abscess

Think they kinda ran out of questions at this point so CT asked you mentioned something
about divert just now, what would you look out for, do you know the radiological criteria for
divert blah blah

BELL RINGS THE END!!

weird case but so thankful for nice examiners:) Q and A was very directed!

session 1: group 5- Breast cancer

observer: Dr Chew Min Hoe (helpful and very charming)- YES he is:) ><
examiners: Prof Pierce Chow (slightly more active), Dr Ng? (sorry not too sure)
nice examiners

Summary: 63 yo Chinese lady with Breast Ca first dianosed in 2004 s/p WEAC, presented
Jan this year with local recurrence, s/p simple masectomy.

PC:
Breast lump on the right first detected in 2004 by BSE
saw a doctor in 1 day, did not notice whether growing or not
no skin changes, no discharge, no chest pain
no symp of mets: bone pain, jaundice, cough/sob
no LOW/LOA

After WEAC developed lymphoedema, no cellulitis, wearing ?stocking

went for adjuvant radiotherapy , compliant

Jan 2014 found ?recurrence on mammogram
Also went for ultrasound to confirm (pt only told me this after the exam)
completely asymptomatic then (same as 2004), no lumps felt as well
went for simple masectomy

RF:
nulliparous (not married)
otherwise no early menarche, late menopause
no OCP/HRT use
no family Hx of any cancers (including BRCA stuff like prostate, GI, ovary)

Other PMHx:
CVRF ++, heart no good (on warfarin)
osteoporosis (hmm retrospectively could it be secondary to adjuvant lanastrazole inhibitor?)

Drug: (usual) Drug allergy to ?gout medicine (Shit I said NKDA during presentation! Ahhh)
But Chew Min Hoe also din say anyth leh
171
Social: not married, retired, occupation ??executive , non smoker/non drinker

o/e:
(WOAH), not easy, considering the last time i did a full breast exam was quite long ago.

General: rather large body habitus, not cachectic. Vitals (no one cared)

Peripheries: no conjunctival pallor, scleral icterus. Neck got sth lumpy there (not sure
whether its lymph nodes but doenst really tie in so decided to dismiss it ><)

Breast: Big transverse scar across right breast. With wound dehisence (wah piang) palpate
gently, not tender, no discharge. The wound doesnt look too good imo (surgery done 2-3
weeks ago) but patient says everything okay. Maybe cuz she couldnt really see the wound
dehisence.

Otherwise, no abnormality (I think). No masses, no lymph nodes (except for the weird neck
lump) and no bony tenderness, lungs clear.

Ok so this clerking was pretty straightforward and I finished at 18 minutes by now Chew Min
Hoe was already playing with his phone + looking for a hospital gown for the patient cuz
kinda lay chay for her to keep taking her shirt off, rather distracting. So I had a whopping 7
minutes to consolidate, though I admit I was a bit distracted and also worried about missing
anything major.

I was quite concerned about the breast exam because there was this lump of fat underneath
her right armpit next to the transverse scar. It really looks quite weird but after a while I
convinced myself that its nothing, n didnt get questioned about it later on anw

Then Examiners 2 and 3 came in. Appeared nice, shook my hand, I said Morning Prof! and
Morning.. Dr... (examiner 3 is not a Prof ma) So they let me present.. uninterrupted. Only
point of interruption was when I said no early menarche and late menopause
- Q: what is early menarche/late menopause?
- A: early menarche <12, late menopause >55 (I think)

Presented PE findings half way and mentioned wound dehisence so they asked me to show
them. So demonstrated specific steps of PE again
- me: told them about the lumpy thingy in the neck , not sure if its LN
- Q: you are supposed to tell me if its a LN.
- me: (start to describe a bit)
- Q: ok why doont you demonstrate how you examine LN?
- me: (moved the patient from couch to a chair and stood behind her.
- Q: which LN are you concerned of in Breast Ca?
- me: supraclavicular
- Q: does she have?
- me: no

(at this point examiner 1 excused himself)

172
Ok anyway thats all for history and PE, moved on to Ix and Mx (rather messy questioning
IMO, pt was sitting in the clinic room throughout.
Q: describe mammogram
A: Ideally 2 pt identifiers bla bla.. This is craniocaudal view
Q: Are you sure? What are other views you know of?
A: MLO, magnified view
Q: (?trying to be nice or tricky?) what other views could this be?
A: (damn scared now, I mean, is identifying wrong view on mammogram a fail criteria??
really damn scared. But I cant bring myself to say that it is anything else, and the freaking
scan says RCC. Seriously!! ) (okay later mo told me it is really the RCC view. OKAY HENG)
Q: where is the tumour?
A: (tmd, memorised all the suspicious features from andre tan, but when presented with a
REAL mammogram I actually cant find the tumour. Pointed at a total of 3 different places,
but in the end doctor also din tell me where the tumour actually is. Maybe they themselves
dunno?)
(Pt later revealed to me that mammogram was non conclusive and she went for ultrasound
before op.)-.-
Q: what do you think this guidewire thing is for (seen on mammogram)
A: guessed that it is for locating tumour after neoadjuvant therapy.
Q: okay, what else could it be for?
A: (really dont know, feeling desparate, said something about SLN biopsy and they had
some fleeting proptosis and I quickly retracted the statement)

Q: interprete lab tests

A: FBC, Uecr bla bla provided, basically all normal, dunno put there for what. But I
commented INR was 0.98, I expect 2-3 since shes on warfarin
Q: so why do you think it is 0.98?
A: may be subtherapeutic , or maybe they withhold warfarin for the op. (I think they
accepted)
Q: what adjuvant therapy did she receive in 2004?
A: RT and chemotherapy
Q: what will be your choice of chemo?
A: anthracyclines or taxanes? (they raise eyebrow~~) (quoted from Andre Tan Ma)
Q: So, in her, is it anthracyclines OR taxanes?
A: (What?) .not sure
Q: What adjuvant therapy will you give her now
A: Said hormonal may be suitable such as SERM since she is post menopausal
Q: but she is post menopausal, do you think it is suitable ? (?!?!
A: Also need to consider the ER/PR/Her2 status when selecting adjuvant bla bla (ok think
they accepted)
Q: how would you monitor her post op
A: 3 monthly 2 years, 6 monthly 3 years, yearly 5 years, follow up with tumour markers ,
cant do mammogram cuz no more breast liao
Q: is there any role of mammogram in her?
A: oops yes sir, mammogram her contralateral breast.
Q: what tumour markers are relevant?
A: Ca 153, Ca 2729 (more specific than 153)
Q: how is it done (??)
A: It is a blood test that is done in the outpatient setting?? (What are you asking Sir?)
173
Examiners frown a bit. I dont know what they want.
Q: Okay I dont know what else to ask you (lol) Asks other examiner for questions, he
shook his head.
Q: what advice will you give her post op?
A: Take care of wound, be compliant with followup, continue to do BSE for the contralateral
breast
Q: ok good (asks MO how do we know if time is up, MO says 2 minutes left)
ok la can byebye!

(Okay actually examiners are very nice and it is a straightforward breast case with local
recurrence so Im generally pretty happy. But some of the questions they ask really a bit
tough for my tofu brain. Missed out some other qns in between thats about all I can recall.
Good luck everyone!

Thanked the patient profusely and wished her Really glad its over!

174
SGH Session 1 Group 6
Ruptured HCC s/p Right Hepatectomy
Examiner 1 (Observer): Dr. Sulaiman (CGH)
Examiners 2 & 3: Dr. Dean Koh (Colorectal, ex-NUH) (Active) & Dr. PC Cheow (HPB,
SGH) (Passive)

History:

Presenting Complaint:
RUQ Abdominal Pain
56-year-old Chinese Male, presented with sudden onset right upper quadrant abdominal
pain on 3/3/14. Pain was severe (8/10), constant, and exacerbated by movement, with
radiation to the back. Associated with nausea, giddiness & pallor. Went to A&E, received 3
blood transfusions, and underwent CT-AP which showed a 7cm seed (HCC) in the liver
that had burst. Subsequently underwent Catheter Angioembolization on the same night and
was admitted. Staging investigations found no metastases (patient was unsure of other
investigations results such as AFP), and patient underwent a Right Hepatectomy (removed
50% of the liver) and Cholecystectomy on 11/3/14. Post-operatively, he had no
complications, except some mild jaundice, which improved without intervention, and he was
discharged well on 26/3/14 (and subsequently came for MBBS 3 days later).

Risk factors:
Chronic HBV carrier diagnosed in his 30s, but never had treatment or any follow-up. Father
was also a chronic HBV carrier and had HCC.
Drank alcohol and smoked for 10 years, but not heavily. Had a few beers twice a week, and
smoked 1 pack a day, but stopped both completely since he was 28-years-old.
No fatty liver disease, obesity, family history of liver disease
Not a known cirrhotic

Systemic review:
No constitutional symptoms, no LOW/LOA prior to onset of abdominal pain
No metastatic symptoms, no bone pain, fractures, or SOB
Has some back pain for the past 4-5 years but appears mechanical in nature, with no night
or rest pain
No change in bowel or urinary habits, no previous colonoscopy or OGD, but had an FOBT
during admission that was negative
No chest pain

PMHx:
HTN, was on meds for 2 years, but they were stopped on admission
Chronic HBV, not on antivirals until they were started during the recent admission
Gastritis 30 years ago, for which he takes PPIs
No DM, HLD, IHD, CVA, PVD
No previous surgeries besides the hepatectomy

Drug Hx:
Only takes PPIs and now anti-virals
No other long-term meds
NKDA
175
FMHx:
Father - chronic HBV carrier and HCC
Mother - ?dilated cardiomyopathy

Social & Functional Hx:

Stopped smoking and drinking since 28 years of age
Lives with wife and 2 children
No major financial problems, but due to see MSW soon
ADL independent, community ambulant
Occupation involves manual labour

Physical Examination
BP 135/66
Alert, comfortable
No conjunctival pallor
Mild scleral icterus
No stigmata of CLD, no signs of hepatic decompensation
Mild pitting LL edema
Large 2-part scar on the abdomen, with an upper midline component over the epigastrium,
and a second diagonal component towards the right flank (Im assuming this is a normal
hepatectomy scar)
No palpable masses, splenomegaly or ascites
Liver not palpable below costal margin, liver span 6cm on percussion (but Im not sure about
this, the examiners seemed to disagree with me, and I honestly dont know what to expect
after the patient has had a right hepatectomy)

Examiners 2 & 3 come in, I present the case

S: Besides family history of HBV/HCV, what other risk factors for HBV/HCV would you have
asked in the history?
Me: History of previous blood transfusions, IVDA, needle-sharing, needle-stick injuries,
tattoos especially from foreign countries, high risk sexual activity
Examiner 1 leaves
DK: Can you show me how you examined for liver span and hepatomegaly again?
We go back to the patient and I demonstrate, and he subsequently also tries to feel
DK: If you were in the A&E, how would you manage this patient if he came in acutely?
Me: ABC, consider intubation if GCS<8, supplemental oxygen, 2 large-bore IV cannulae and
run IV N/S 500mL fast over 20 minutes, urinary catheter to monitor urine output, take bloods:
FBC, GXM 4 units PCT + FFP + Plt, LFT, U/E/Cr, call GS Reg
Asked to interpret FBC, shows Hb 10
DK: Given this blood result, would you have opted to transfuse this patient?
Me: Considering that the Hb is not that low, I would opt to observe the patient first, but I
would still GXM and keep the bloods on standby (in retrospect this was really stupid, I should
have just said transfuse because he was symptomatic, but somehow this didnt occur to me
in the moment)
DK and CPC give weird looks but move on
DK: Interpret the rest of the blood results
U/E/Cr is normal, LFT shows Bil 120, ALT/AST 100, ALP 500, Alb 31
I interpret but I somehow forget to mention that the Bil is raised, and they question me on it
(always remember to say these things, even if it seems really obvious)
176
DK: What other investigations would you do for this patient?
Me: Triphasic CT-AP
Asked to interpret Triphasic CT scan, shows a heterogenous nodule in segment 4B
(just lateral to the gall bladder), which shows arterial enhancement, mosaic
appearance and washout in PV phase, no background of liver cirrhosis, no other
nodules, some fluid surrounding the liver
I mention the mosaic appearance on the non-contrast phase, because the nodule
appears heterogenous, but Im corrected by CPC who says you can only say that on
the arterial phase (oops), and then I say that there is no background of cirrhosis
CPC: What do you see on the CT scan if there is cirrhosis?
Me: Umm.. regenerative nodules, macronodular cirrhosis, architectural distortion, and (after
much prompting) a small shrunken liver with irregular edges
DK: What do you think is the fluid surrounding the liver?
Me: Probably blood
CPC: How would you tell on the CT scan if this is blood?
Me: Go back to the arterial phase and look for contrast extravasation and blush (which were
not there)
CPC: Any other way?
Me: I can get the Hounsfield units
CPC: So what are the Hounsfield units for blood?
Me: Sorry Sir I dont know
CPC: What about water?
Me: I think its 0?
CPC laughs (dont know why, I just googled and its really 0) and moves on
DK: Okay so once this patient has been successfully treated with angio, how will you
manage him?
Me: I will proceed to stage the disease by looking at the CT-AP for LNs and mets, and will
also do a CT-Thorax to look for lung mets. A bone scan is probably not indicated in this
patient as I do not suspect bone metastases.
DK: Okay, but what would you do before staging?
Me: Oops, I would look to confirm my diagnosis by checking the AFP
AFP 250
Me: Sir, this AFP is elevated, but it does not meet the WHO criteria of >400. However,
seeing as this patient has characteristic CT-AP findings, as well as an established risk factor
(chronic HBV), the diagnosis of HCC can still be made by the WHO criteria (2 out of 3),
without the need for a biopsy
DK: So how would you treat this patient?
Me: If there is no extra-hepatic disease and the aim of treatment is curative, then he should
go for a liver resection
DK: What would you resect?
Me: Seeing as the lesion is in segment 4B, I think the patient needs to have a major
resection of the right lobe of the liver?
DK: So a right hepatectomy?
Me: Yes?
DK: Okay, what else would you remove? Look at the CT scan again?
I stare at it for a while, trying to figure out if any major bile ducts are involved, until DK
points at the gallbladder
Me: Oh yes I would also like to remove the gallbladder - ie. a cholecystectomy
DK: So how do you know if this cancer is resectable?
Me: Absence of extra-hepatic disease, general fitness for surgery, and adequate remnant
177
liver function, which can be assessed in various ways, most commonly by the Childs score.
If he is Childs A, he can go for a major resection, if he is Childs C, he should not go for
surgery
DK: What is the Childs score for this patient?
Me: (After scribbling on a piece of paper) 8, therefore he is Childs B. Some good Childs Bs
can go for resection, some poor Childs Bs cannot. Therefore we need to use other
modalities to assess remnant liver function, such as the ICG retention test - if 15 minutes
after giving ICG, the concentration is <15% of what it was, then this patient has enough
remnant liver function to go for resection. Other ways include CT volumetric assessment, or
using the presence of portal hypertension and its complications as surrogate markers of liver
function.
CPC: So what if this patients Childs score was C, and he couldnt go for resection?
Me: Then the option would be liver transplant, and this patient would need to be assessed
for suitability by either the Milan criteria or UCSF criteria.
CPC: So can this patient have a transplant?
Me: No, his nodule is 7cm, and the upper limit of the UCSF criteria is 6.5cm
CPC: So if this patients disease was not resectable and he is not eligible for transplant, how
would you treat him?
Me: There is the option of systemic therapy such as sorafenib
CPC: Anything else?
Me: Palliative treatment of HCC can be divided into various modalities, such as local ablative
therapy like RFA (I get cut off)
CPC: What about in this patient?
Me: Locoregional therapy like TACE or SIRT with Y-90
CPC: You mentioned RFA. Can this patient have RFA?
Me: No, the upper limit of effectiveness for most local ablative therapies including RFA is
generally about 3cm. Some of the newer probes can go up to 5cm, but this patients nodule
is too large.
Bell rings!

Tips:
Remember to stay calm and mention even what seems really obvious on the investigations,
like the raised Bil on the LFT, because thats what they want to hear
Try and practice reading CT scans for GS, especially for HPB, because usually thats where
quite a bit of the discussion seems to be spent

Good luck!

178
Session 1 grp 7
Approach to Malena, PUD
Sorry didnt recognize my examiners and kinda forgot their names
But they were nice people

58 yo Ch lady, works at National eye centre, admin stuff, handles call complains. ADL
independent, NKDA

Past med hx
1. Hep B
dxed 27 yrs ago on pregnancy screen
Since then on f/u with 6/12ly US screen, no AFP done
Claims no Cx so far

Current complaint:
3 episodes of malena since last wed
Acute onset, no previous episodes before
No associated hematemesis, coffee-ground vomitus
No hematochezia
No associated abdominal pain

Negatives in hx:
- No hx of recent violent vomiting
- No dysphagia
- No hx of PUD, no scopes done previously; No significant risk factors such as NSAIDS,
steroids, alcohol, smoking. Some stress at work, skip lunch meals
- No hx of post-prandial vomiting, no hx of dyspepsia, reflux
- No jaunidce, abdominal distension, encephalopathy (sleep wake cycle reversal)

Cx:
- No symptomatic anemia

Ix done:
- Referred by polyclinic to A&E, OGD done this tue showing ulcer at possibly
gastroesophageal jn (pt not sure whether stomach or esophagus)

Tx:
- Unsure if any tx done during scope
- Biopsy obtained awaiting results
- Discharged well, uncomplicated recovery
- Discharged with antibiotics (said 2 kinds, unsure of what ABx are) and Fe supplement

Systemic r/v:
- No fever, chills, rigors
- No constitutional symptoms
- No evidence of metastasis

Past surgical hx: LSCS

179
Drug hx: nil
Family hx:
- Denies any family hx of gastric, CRC Ca
- Denies any family hx of gastric ulcers

Social hx
- Occupation
- Married, stays with husband and 2 children
- No financial concerns of note

PE:
- Mistook lower midline laparotomy scar for pfannestiel incision
- No obvious hernia
- Examination normal, no stigmata of CLD (forgot to present initially, later prompted to do so
and list stigmata of CLD)
- No conjunctival pallor

Presented hx and PE as above to examiners

They allowed me to present uninterrupted with summary

Qns:
1. What is malena
2. Do you think this is acute or chronic bleed
3. Dy/dx, RF
4. How to check for anemia
5. What do you think is pts Hb
6. Examiner who was watching me do HX and PE asked some qn:
- Why never ask for LOW ( I though I asked under constitutional symptoms but maybe not
just admit I never ask and moved on)
- Stigmata of CLD, faulted me for not exposing pt adequately while examining for spider
naevi (attempted to look actually doing my PE pulling clothes down but nevertheless
admitted mistake and moved on)
- How to percuss for liver dullness had to percuss from breast fold, pt wearing bra so didnt
do properly during initial PE
7. What initial Ix like to do for pt
8. Interpret OGD
9. Initial mgmt. of pt in ward before OGD
10. Mgmt of recurrent ulcer and bleeds
- offered dy/dx of malignancy, esophageal varices
- Didnt want that, told that it was benign talked a bit abt surgical mgmt. then got
interrupted cos he wants mgmt. of duodenal ulcer which is more common
- Started talking rubbish.. said whipples ON NO! retracted statement. Thought long and hard
talked about mgmt. of pt with PPIs (examiner started nodding head), vagotomy (asked for
Cx of truncal vagatomy which I do not noe, what surgery it is commonly done tgt with which I
also dont noe)
- Admitted I dont noe, they say alright not expecting me to be surgeon also
11. Why this presentation unlikely variceal bleed
- Tried to smoke my way with on regular f/u, no Cx she claims, asked for but did not elicit
any Cx of CLD, jaundice, abdo distension, encephalopathy (sleep wake cycle reversal)
- Not satisfied, wanted me to explain common presentation of variceal bleed, gabraeed say
180
no coffee grd vomitus, cos blood irritative, vomit out immediately. Were not impressed.
Examiner disappointed that i did not know about pathogenesis of variceal bleed and
explained that it was becos of venous bleed, volume high, intact Lower esophageal
sphincter, so blood just comes pouring out.

Looked at each other, flipped marking sheet few times, say ok no more qn released early!

Thanked patient for her time. Shook her hand.

SGH SESSION 4
Gastric outlet obstruction and obstructive jaundice secondary to metastasis to lymph
nodes
basically it was an approach to GOO-ish vomiting and obstructive jaundice

59 YO chinese
Smoker 20 pack years
Non alcohol drinker

PMH
gall stones s/p op in july 2013
found a black mass intraop, did biopsy, found to be malignant
uncle said gall bladder not removed ( i asked many times and he said no , they nvr remove
gall bladder - OK><)
No hepatitis, DM, HTN, HCL
Dr didnt mention if mets to any other organs

PC
vomitting x 2/52 - non bilious, non bloody, undigested feed, occasional coffee ground
vomitus, projectile vomitting, 1-2 hrs after each meal
NBO x 2/52, occasional flatus, when admitted and given milk via NGT/ NJT started to have
blackish, smelly, brownish stools? no steatorrhoea
RIF pain, constant, nil radiation to the back or elsewhere x 2/52
jaundice - 6/7 progressively worsening
teh o like urine
pruritus for months
no fever chills or rigour
LOW 13 kg past few months
LOA
systemic review- SOB on flat ground, no chest pain, no bone pain, no LL weakness

no other Risk factors for hepatitis

Not much RF for GB cancer or cholangiocancer
No recent travel history
no FMH of cancer

PE: cachetic, jaundice, sclera icterus

bruising on arms
on NJT
181
mass in RIF felt ( hard, globular)
liver 2 cm fm costal margin
nil other organomegaly
Heart and lungs clear
no shifting dullness
nil pedal edema

Had very little time to consolidate :( cox so many things to ask in history sigh

examiners walked in
Presented - case of GOO and obstructive jaundice, due to mets? recurrence of tumour?
PE: bluh bluh bluh mass in RIF likely gall badder cox of location and tubular structure?

so qn went on to where exactly is the lesion - erm gastric outet

why got obstructive jaundice - compression on CBD
where is bile formed - liver
where does it flow to fm gall bladder - duodenum
via - ampulla of vater
which is at - D2 of duodenum sir
OMG anatomy ! >< foam
more anatomy qns
how does GB cancer spread - via hematogenous route and lymphatics, via bile ducts????
differentials for his symptoms: HOP, periampullary - duodenum, ampulla of vater, CBD?,
mets to port hepatis lymph node
Dr shanker : no just tell me which is MOST likely in this patient - tie in PE etc
me: gall bladder? can feel a GB mass
Dr shanker: he had his GB removed alr.
Me: oh! but he told me it wasnt removed >< ( PLS JUST LET ME READ THE CT TO KNOW
WHERE EXACTLY IS THE PROBLEM! ISNT THAT WHAT THEY DO HUH)
silence .
Oh then maybe metastasis to Lymph nodes sir, porta hepatis LN? ( shouldnt have
mentioned porta hepatis cox he proptosed.. arghhhhh)
Dr Shanker: OK Lymph nodes
PHEW
( so maybe what i felt at RIF was a mega huge Lymph node? since the gall bladder was alr
removed. what a weird case just let me read the CT! )
how will you manage in the emergency setting - ABC , NGT to decompress, arrange for op -
got cut off as i was still rambling away :( i havent even said call my senior yet ><)
Why circulation is impt - worry abt GOO causing dehydration
What electrolytes deranged? hypok hypo cl metabolic alkalosis
What are u most worried abt fm dehydration - end organ damage - AKI, arrythmia fm K
drangement
What ix to do? AXR, LFT - wanna see cholestatic picture etc, renal panel ( got cut off again
sigh ), CT
went onto read AXR - NGT, no gastric bubble seen
asked abt what to expect in GOO - maybe enlarged gastric bubble?
Dr Shanker: Ok dont think theres a need for u to read CT...
Tell me about cancer staging - TNM
What Ix to do for cancer staging - CTAP ( got cut off )
182
why do CT - erm delineate the lesion , find out exactly where it is, determine how much
lumen is obstructed- impt for management, see if we can still insert in a NGT, NJT etc, look
out for mets to liver?
Dr Shanker: ok quickly tell me about management in general - palliative vs curative, for this
patient likely palliative
BELL RANG..OMG!
what stage do you think he is at- stage 4? because of metastasis?
How to manage him : palliative. symptom relieve. analgesia. nutrition - NGT NJT vs
gastrostomy. (Dr nods in approval)
Go feel the tube and tell me if it is NGT - erm, feels hard, not like usually ryles tube
Dr shanker: its a silicon tube. this guy had NJT insertion
What a scary case- hope i passed man

Tip 1: learn your chinese well! practise clerking in chinese cox most of the guys in my circuit
got a chinese speaking patient
Tip 2: clerk quickly! THERE IS NO TIME TO BE THINKING OF HOW TO TRANSLATE ONE
WORD TO ANOTHER WHEN U GET AN EPIC CASE LIKE THAT
Tip 3: know your approaches and anatomy very well
no point knowing about bismuth classification and not knowing abt simple anatomy , Dr
shanker wasnt even interested in hearing me rattle off bismuth
Tip 4: stay calm - i was totally not calm cox of the complexity of the case.
Tip 5: know how to manage emergencies
Tip 6: offer to take vitals and DRE. usually wont need to do
Tip 7: dont count on your MOs. Unlike those at NUH,my MO at SGH was useless. saw her
for like 5 minutes and the only thing she did was to click on the AXR for me.
Tip 8: think of many differentials.
Tip 9: learn how to read simple AXR too . honestly im better reading CT scans than and AXR
( only know how to read AXR for I/O but for GOO, i was a bit stunned, said there was NGT in
stomach and paucity of air in small and large bowels. should have mentioned about the
gastric bubble - large in GOO vs absence after NGT inserted for decompression)

GOOD LUCK
SGH GS LONG CASE ISNT AS SCARY AS IT USED TO BE:) theres someone to vouch for
your history etc so no need to worry too much about poor historians
BUT still pray for good historians and good examiners.

SGH SESSION 6:
Achalasia s/p Hellers myotomy and fundoplication 2 yrs ago
Observer: Mr Chew Min-Hoe, Active examiner: Mr Pierce Chow, Passive examiner: Mg Ng
Tze Kiat

50yo Chinese gentleman [history in Chinese]

183
Chief complaint:
Dysphagia x30yr
- First started having difficulty with swallowing solids at 18, less difficulty with fluid
- No nasal regurgitation or coughing
- Persistent not intermittent symptoms
- Food stuck in retrosternale location [asked patient to point]
- Consulted a doctor at 28 years old and was told needed surgery but was not keen
- Symptoms progressed and developed regurgitation at 48
- Food contents recognisable, shortly after eating
- Had intermittent episodes of fever, no cough, never diagnosed with pneumonia
- Admitted to SGH and underwent OGD, manometry
- Offered balloon dilatation, and Hellers myotomy w fundoplication [pt was trying to describe
procedure]
- Patient opted for Hellers myomotomy
- No regurgitation symptoms post-op, regained 10kg

No previous caustic ingestion, no RT, long term medications such as aspirin [pill esophagitis]
No LOA, no FHx of Ca, no symptoms of anaemia but ex-smoker 40 pack years

O/E:
Good nutrition, hydration
Several laparoscopic port scars over abdomen, no incisional hernias
No leukonychia, koilonychia
When asked to demonstrate PE, after I said no leukonychia to suggest
hypoalbuminaemia, no leukonychia to suggest severe iron deficiency anaemia, when
examining his peripheries, examiner moved on to investigations.
I mentioned this because ddx is Plummer-Vinson which is a/w IDA

No cervical lymphadenopathy, abdominal masses or conjunctival pallor

Discussion:
Q: What are your differentials if he presents with a long standing history of dysphagia:
A: Achalasia, stricture, cancer

Q: What is achalasia:
A: Primary disorder of esophageal hypomotility characterised by impaired LES relaxation
and impaired peristalsis

Q: Where in the esophagus:

A: Distal

Q: What investigations would you do?

A: OGD tro pseudoachalasia, looking for lesion at gastro-esophageal junction. I would also
look for presence of residual food.
[no images available]

Q: If OGD normal?
A: Manometry, to look for characteristic findings of elevated resting LES tone, impaired
relaxation
[no images available - flips through report]
184
Q: Results were equivocal, what would you do?
A: Barium swallow - [images available so asked to look at images on screen]

Q: What do you see?

A: This is a barium swallow done for my patient Mr Yup in 2012. I see a tortuous
oesophagus - here there is a short segment in the mid-oesophagus that appears narrow -

Q: Can that be peristalsis?

A: Yes sir, as evidenced by the following image where the diameter of the lumen appears
normal
Further, I note presence of bird beak narrowing here

Q: How would you treat him?

A: Sir, management can be divided into conservative or surgical management -

Q: Are you going to let the patient choose?

A: I would discuss with the patient the various options.

Q: Ok, what surgical procedure would you offer him?

A: Hellers myotomy with an anti-reflux procedure such as a fundoplication

Q: What is that?
A: The muscle at LES is divided. However, although the LES is a functional not an
anatomical sphincter, the pt will have regurgitation post-op hence the fundus is wrapped
around the esophagus to prevent that.

Q: What is the pathophysiology?

A: Degeneration of myenteric plexus

Q: What other condition has a similar pathophysiology?

A: Hirschsprung disease

Q: Is achalasia a genetic condition?

A: Not to my knowledge sir
Google search reveals that there is a condition known as Triple A syndrome: achalasia,
Addisons disease, alacrima

Q: What would you monitor him for?

A: I would monitor for complications of regurgitation which he presently does not have
Secondly, he is at increased risk of developing oesophageal cancer of the SCC type

Q: How would you monitor him

A: Clinically, anorexia, LOW
PE: cervical lymphadenopathy -

Q: - Thats a late symptom right?

A: Yes sir, investigations-wise, I would do an OGD

Q: How frequently?
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A: Sir I am not certain of the exact surveillance intervals -

Q: But you would monitor right?

A: Yes sir, I would monitor the patient.

Turns to passive examiner for further questions.

Passive examiner was ok with it so session concluded before bell.

Quick summary of approach to dysphagia:

1. Oropharygeal
quickly exclude by asking for nasal regurgitation, coughing
possible aetiologies: Parkinson, Myasthenia
2. Oesophageal [patient can indicate level where feels stuck]
Mechanical
Intrinsic
Cancer
Stricture: secondary to caustic injury, RT, pill esophagitis
Webs: e.g Plummer Vinson
Extrinsic: goitre, LN, enlarged left atrium of aorta
Motility disorder
Hypermotility: diffuse esophageal spasm, hypertensive LES
Hypomotility: achalasia, scleroderma

SGH Session 2
Approach to Painless Obstructive Jaundice ?Cholangiocarcinoma
Before we started Long Case, the GS Reg came by to tell us all that it would be cases that
we would normally see in the ward. After all that crap about SGH listing weird H&N cancers
186
and the infamous penile SCC, I think so far everyone I know did okay, or at least those in my
circuit. Anyway, we were told that the Examiners were all big shots but mostly benign.

Before you begin short case, they will tell you gender and english/mandarin speaking. Mine
was a Mandarin speaking 67 year old female. Immediately wanted to die, because my
Mandarin CMI (ACS boy here) but it actually went okay.

Observer: Mr Sulaiman (CGH GS) - Took me for short case as well, he was like we meet
again when I walked into the room
Examiners: Mr PC Chow (Mr Pringles) and Prof Dean Koh - Surprisingly both were pretty
placid, didnt ask too many tough questions, although every answer is always followed up
with what else what else? I dont know whether its because my answer is not
comprehensive or they are just trying to push you.

67/C/Female
Housewife
DA to Abx - gets Rash
Previously well

Presents with 2/52 history of Dark Urine

First episode started 2 weeks ago
Saw GP, treated as per UTI
Completed 5/7 course, not improved
Went back to GP, was told by Doctor to be yellow
Got a referral to SGH and has undergone scans/investigations
Was told that there was an obstruction in the bile duct, not sure if there is CA, not confirmed
yet
Underwent a CT/MRI and mouth scope ?ERCP
Not associated with any urinary symptoms
Not associated with any cholestatic sx, pale stools
Not associated with any pain
Other than that PU/BO normal
No fever/infective symptoms
No constitutional symptoms, no LOW/LOA

PMHx
32 years ago had a US HBS and found stones, managed conservatively then, no surgery
done
6 years ago had endometrial CA, s/p Laparoscopic Hysterectomy
No Chronic Diseases, No HTN/DM/Hyperlipidemia
Gastric problems on ?PPI, she was not sure this part
No other medication use
No TCM

Fam Hx
Mother has lung CA

Social Hx
Non-smoker, non drinker
Lives with husband and son
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Says has some financial concerns because depends on the diagnosis
Scared if it is cancer

Currently is awaiting what appears to be a cholecystectomy on Monday

o/e
Alert, comfortable
Very jaundiced - scleral icterus +++, truncal jaundice
Previous lap scars from hysterectomy
H S1S2
L Clear
A SNT, was looking out for a palpable gallbladder but didnt find one
No stigmata of chronic liver disease
PR: empty rectum, no acholic stools

The whole time, Dr Sulaiman just kept quiet, and looked very blur, because he doesnt
understand Chinese. They tried to get an MO to sit in, but she just left halfway through hx
taking. While I was examining, Dr Sulaiman was staring at my clerking sheet, I guess to see
what I had clerked.

Note to Juniors: No need to do running commentary, I think SGH told the observer not to ask
for it, because Dr Sulaiman asked me to pretend like he was not there when I offered
running commentary. Also never stopped me when I offered PR, told me to just do what I
need to do.

Patient was super nice, at first she seemed very annoyed, but warmed up towards the end.
On a completely random note, the patient asked me whether I was from China (This has
happened many times over the past 3 years of clinicals, because my accent is
undecipherable, or rather my chinese is CMI). Then when I insisted I was Singaporean
Chinese, and that I only speak that way because I was AC boy #tbiytb and only spoke
English at home. Then she started telling me about her son who is also an AC boy, and how
come he never became a doctor. RANDOM MOMENT. Then during my consolidation time,
she spent the whole time asking me about my life, almost like reverse history, what my
religion is? what I want to do? dont worry you will pass?
Another awesome thing she did, was during the discussion part, I think she thought I looked
very flustered, so she actually cut off Dean Koh and told him that If I said anything wrong,
that its her fault because she might not have explained it properly because of language
difficulties. The examiners looked super amused at that point.
She gave me her phone number at the end, and told me to give her a call when I pass. I
really hope you turn out not to have cholangioCA in the end man, she was so nice.

Anyway, after 25 minutes, Dean Koh and PC Chow walks in. Introduces patient and
examiners to each other in fractured Chinese. Internally wanted to die because I heard
horror stories about these 2 people.
Presented history as per painless obstructive jaundice, and as per hx above. Cut me off at
the social hx and asked what are the risk factors for CholangioCA. (PSC, RPC, Previous RT,
Previous Gallstones, Previous Instrumentation)
What other things do you want to ask in history, I had to offer a lot of other things, but I never
really seemed to get what they wanted?
Asked to demonstrate PE
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How to demonstrate scleral icterus?
How to palpate for palpable gallbladder?
Why are you looking for a palpable gallbladder? They proptose a bit when I said I was
looking for palpable gallbladder, I said if there is distal obstruction then it would cause it.
They didnt look very convinced. They said can there be a CholangioCA with no palpable
gallbladder, I fumble fumble fumble until finally spat out if it is above the cystic duct.
What else do you want to examine for? Im not sure this one, I said Heart and Lungs, they
accepted and moved on
What are causes of obstruction, I said can be stones, carcinoma, strictures? They ask for
more, I dont know about this one
What are causes of jaundice, I started talking about pre-hepatic, hepatic, post-hepatic, then
they said they only wanted post hepatic causes.
What are you ddx in this situation? I said CholangioCA, HOP CA, Stones. I stupidly said
Stones first differential until I retracted when they pointed out no biliary colic pain.

Invx: Blood, Imaging, Others

I started with FBC, then in the background the MO pulled up this powerpoint with like ALL
THE BLOODS on it. So I literally just walked to the computer and asked for everything on
the screen. FBC, UECr, LFT, Cancer markers.
Interpret the results. FBC/UECr Normal
LFT mixed picture, not really obstructive or hepatic
CEA not raised, Ca19-9 raised
What would you like to do since mixed picture?
Prompted until I said Hepatitis markers
What imaging? US HBS, CTAP, Offered MRCP since patient said she underwent one.

They pulled up CTAP (Triphasic) and MRCP, asked me to interpret. I only could point out the
structures (pancreas, liver, gallbladder) but I could not find the mass. I only could see dilated
intrahepatic ducts and distended gallbladder. Dean Koh spent like 10 minutes trying to get
me to see the mass. He pointed out this heterogenous mass thing, I really dont know what I
was looking at. At this point, bell rings, they continue questioning.

How would you like manage? Stage the tumor, and decide whether palliative or curative. I
would like to do a CXR blah blah (cut off by PC Chow), if no mets then how to op. I said can
do whipple. What if palliative? said can do stenting of the obstruction, what else what else,
err can do chemoRT, maybe palliative whipple? (I think its bypass op) Okay you can go.

MBBS IS OVER, ELATED +++ Hopefully I wont have to reread these accounts in 6/12

Note to Juniors: Learn how to read CTAP and MRCP since based on these accounts
everyone seems to want you to interpret scans.

Batch 6
=============Same case as above, 68 year old Chinese lady with painless jaundice, b/g
hx of endometrial CA six years ago and asymptomatic gallstones==============

Examiners - Prof KK Madhevan, Prof Tang CL

Passive - Dr Alvin Eng

History with this patient was abit messy initially because I thought it was a simple gallstone
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jaundice. But after talking about her current admission and investigations done in SGH, she
said there was a small nodule, ?malignancy. So had to change gear and think about
cholangioCA.

Questioning -
KK - Did you determine if this jaundice was progressive? ( Oops no, cos this patient
complained of dark urine x1 week, didnt notice her own icteric sclera.) you must ask
whether the urine became progressively darker, or whether there were intervals when it
became normal
KK - Based on your history, what are your differentials ( Choledocholithiasis and TRO
malignancy like pancreatic CA or cholangioCA)
KK - What in your history suggests malignancy? (nothing really much, just that it was
painless, and that the CT showed it, but I guess without the CT, i wouldnt have really
suspected it)
KK - Present your PE findings. Show me how you see if theres fluid in the abdomen
KK - Now, what are your differentials (Choledocholiathsis, malignancies less likely cos
gallbladder is not palpable)
KK - Why do you say gallstones when you cannot palpate the gallbladder (chronic
inflammation, scarring)
KK - Can there be a malignancy on top of gallstones? (yes, most definitely)
TangCL - Ok so now what tests do you wanna do? (confirm the jaundice first, exclude
cholangitis, so ALP, GGT, ALT, AST, direct & indirect bil, FBC)
TangCL - Interpret the results (T.bil 100 so jaundice, ALP GGT elevated, so cholestatic
picture, ALT AST in the 600s, but cholestatic jaundice can cause transamnitis in this range,
so nothing surprising. Tests consistent with obstructive jaundice, CA 19-9 like under a 100,
not very specific at this level as CA19-9 can be elevated in cholestasis)
TangCL - Ok what other tests ( Determine etiology - U/S HBS first)
KK - What can the U/S HBS tell you (presence of gallstones in the gallbladder, CBD
dilatation. Since I am suspecting choledocholiathsis initially, U/S HBS is the better choice
over CT for gallstones) Is the U/S HBS good for CBD stones (Not sure???) Well, if it shows
you that the intrahepatic ducts are dilated, the distal ducts are collapsed, what does that tell
you (obstruction likely in CBD)
TangCL - Ok so what else do you wanna do to exclude malignancy (CT scan)
pulls up CT scan, arterial phase, asked to identify right portal vein, gallbladder, intrahepatic
ducts. Was asked if they were dilated, and to my untrained eye, I said Im not sure. But they
guided abit and then said yes, they are. Was asked to identify the mass, which was a
heterogenous mass in the hilum. I said since Im suspecting cholangioCA, then I would like
to look at the PV and delayed phase for progressive enhancement through the PV and
delayed phase.
TangCL - So what else do you want to do (Get a better look at the biliary system, so ERCP)
KK - Why do you want ERCP (cos can be therapeutic and diagnostic) Do you need to
decompress the biliary system in this patient (well not really cos the patient is not
cholangitic) Do you need to get a histological diagnosis before sending this patient to your
colleague who can do the surgery (I dont know lol, but it would be good to know??) well its
not important to get a histological diagnosis before referring this patient to a surgeon. Why
not do MRCP? (discussed MRCP vs ERCP) What are the complications of ERCP? What
other modality you can do if you are suspecting CBD stone? (endoscopic ultrasound)
TangCL- given this patients history and the scans, what else are you worried about
(secondary mets to the porta hepatis, could be her endometrial CA, or another primary)
so what do you wanna do? (look at the CT for any other masses, do a colonoscope for
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colorectal CA)
bell rings, its over!

Lessons - 1) be careful of red herrings. poor patient had klatskin and a big gallstone.
2) the examiners arent really listening to you present. for eg, when presenting my PE, i said
liver span 9cm. then like 2 minutes later, TangCL asks did you measure liver span?
3) Dont ignore your less common conditions! Klatskin tumor is like barely a page on Andre
Tan, but must at least be aware of these things esp cos they are quite important differentials
in your approach to common conditions. But the examiners are fair cos they did not touch on
management of this condition, but rather, management and investigation of jaundice.

Batch 7 session 3

Examiners - Prof KK Madhevan, Prof Tang CL

Observer - Dr Alvin Eng (pokerface)

80/chi/male/retired

Summary:
presented with progressive obstructive jaundice a/w LOW on B/G of lung CA and ?chronic
smoking . S/p failed ERCP stenting. Had PTC done to decompress biliary obstruction and
scheduled for op next week

1 min gone waiting for patient to come back from toilet break (-.-)

old uncle speaks mandarin and hokkien only and took a further 30s to ask for his name. he
said his name was Mr DI? LI? TEE? he even tried to spell out for me but i decided to just call
him Mr DI and move on from there.

uncle said his YI ZHANG (pancreas) spoil and i was thinking to myself bingo HOP! uncle
was really nice and cute but a really poor historian objectively. he likes to go into his own
stories and theories about why he has this or that symptom etc. had to try my very best to
move him on w/o sounding rude. long story short, he went to china x 4/12 ago for 1/52 and
family realised he was turning yellow. had pruritus, tea urine and pale stools. LOW x 8kg in
3/12. no steatorrhea, abdo pain, fever, anemia, Hep B/C, recent raw seafood. no symps of
mets. syst review unremarkable. decided not to ask about sexual contact, IVDA cos i was
scared uncle will give me a lecture on drug abuse/ sex education. i asked uncle if he had
pancreatic CA but he just said spoil lor.

with the hx he went to poly and subsequently TTSH. worked up with CT scan. ?ERCP for
stenting but failed. had a ?PTC done. transferred to SGH for op next week due to personal
preference.

pmhx: HTN/ HLD x unknown no of years (had to tell me how he thought his HTN and HLD
was cured after 10 years on med and perhaps he didnt have them in the first place)

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pshx: Hip op ?THR? x 5 years ago. lung surgery x 1 year ago? basically they did a CXR
when he went for ?THR and they found a small nodule. nothing was done. 1 year ago he fell
and had rib #?? had lung op to fix ribs and remove the nodule at the same time. (long story
+++) denies any personal hx of CA. sounds freaking weird but decided to move on cos im alr
at the 15min mark wtf.

drug: NKDA, on some weird TCM (-.-) and ?HTN ?HLD med

fyhx: no CA

travel: china x 4/12 ago for 1/52

social: smoking x ? pack years. uncle said he smoked 3 to 4 sticks per day for ?? uncle:
hmmm hmmm hmm hmm wah i smoked for damn long ago (tries damn hard to recall for
long long exactly x 100) this was really going nowhere so i asked to examine him and screw
the rest of social hx.

O/E:
alert and well
cachexia
closed PTC at LUQ with dressing
no organomegaly. liver span 8cm
no ascites
no stigmata of CLD
no cervical LNs

no inguinal hernia
offered DRE to examiner 1. examiner 1 said just do what you need
2 mins remaining
serious dilemma btw doing it vs checking for mets vs consolidating hx (totally forgot to check
the ?lung surgery he had)
decided that ill do it since i offered it and its an abdo exam
DRE: soft brown stools. no melena. no masses. no BPH

introduced examiners to patient and gave a brief summary before going into details.
presented everything but they grilled me on the ?lung surgery part. in the end, i agreed that
the surgery is most likely for a NSCLC and not for #ribs.

KK: so did you do a respi exam?

me: ran out of time sir

KK: why dont you show us how you do one. i want a FULL respi exam
so basically thoracotomy scar on the right followed by a oblique scar beneath it. did chest
expansion, trachea deviation, auscultation, vocal resonance on the front. offered to check
peripheries.

KK: is that how you do a proper respi exam? do you want to examine the back?
so went back to do the same on the back. was thinking wtf this is final MBBS and im here
doing a full respi exam for my surg long

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KK: so present your phy findings
me: mentioned scars, decreased chest exp on the right. percussion resonant bilaterally. BS
heard well bilaterally but slightly reduced on the right lower zone

KK: present a summary of the hx again

me: old uncle with ?HOP on B/G of prev ?lung CA s/p lobectomy presents with painless
progressive obstructive jaundice x 4/12 with sig LOW. s/p failed ERCP and now on PTC.
planned for op next week

KK: what ix you want

me: ill start with supportive ix like FBC, renal panel

KK: any scans

me: CT abdo

KK: read the scan

me: sir im looking for double duct sign but i can only see the dilated pancreatic duct but
cannot find the CBD

KK: okay. what are the black holes in the liver?

me: hmm most likely intra hepatic bile ducts? (in retrospect most likely due to ERCP
aerobilia)

KK: okay. what are the bright dots in the liver

me: those are contrasts so hmmm hepatic arteries (arterial phase here as aorta is super
bright)

KK: what other scans you want

me: i want to stage the dz so CT.T.A.P

KK: why you want CT pelvis ?

me: hmmm maybe dont need

KK: so you want anot?

me: okay i want it so i can stage the dz properly to check for mets

KK: any other ix?

me: EUS with biopsy to dx as well

KK: do we have any EUS images? (MO: nope..) okay lets say it comes back as
adenocarcinoma. how you manage
me: most likely a pancreatic CA. so mgmt depends on patient fitness and stage of Dz. if
early stage can go for curative whipples operation.

KK: so you think the tube is a PTC? why?

me: patient said it was draining greenish stuff. calibre is quite small too

KK: if patient does not have PTC and is going for op, do you still want to decompress?
me: yes would do it

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KK: so if pt going for op tmr but biliary syst not decompressed yet what would you do and
what would you be worried about?
(Jaundice+surgery = prone to renal failure, sepsis, issues with coagulopathy)
me: i would take consent and do pre op bloods such as FBC, renal panel, GXM and PT/PTT.
in view of pt age and co morbids, would do a CXR and ECG dingdingdingdingding

KK: okay you may leave

thanked the examiners and Mr DI. even though he was a poor historian, he was super cute
and i know he was trying his best to help me as well.

(worried about cholangitis? not too sure but anw not enough time to answer)

AND ITS FINALLY OVER!

okay juniors, just pray you get a good historian who speaks english. if your pt happens to be
80YO, then be prepared to clerk like a tornado
#offeredDREandhadtodoit
#doubleglove
#kyjelly

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