Final Surgical Long Case Collection by #classof2016 #pmc
Examiner &
Your Initial Summary & (dx/ddx) History & Examination
Venue (C9/ACC)
kd prof Alif Carr, Mr 59 yo , indian gentleman - Bilateral road maintenance labour for 30 yrs, chronic smoker
Cheong(endocrine) C9 Groin/Inguinal swelling with chronic productive cough, no abdominal pain or
mass, no urinary symptoms, no history of malignancy,
NKMI. Findings: 10 cm hernioplasty scar, right side
direct inguinal hernia, cough impulse superiorlateral
to public tubercle, negative occlusion test. Left:
indirect inguinal with positive occlusion test.
Apa lu mau (gua Mr Cheong, Prof Aliff 56y/o, Chinese gentleman - Dx: Liver History is long and totally not pointing towards any
mau lulus la) Carr (C9) abcess direction but it's okay, keep calm and continue
clerking (because no matter how hard you try to
make sense out of it, that will be the history you
gonna get out of him and the examiners will totally
understand too!). Initially, presented to Adventist
Hospital with 1 week history of general lethargy and
an episode of possible claimed-to-be suprapubic
pain, associated with with 3 days history of urinary
incontinence. (tumpang here. He told me his
incontinence is due to too tired to even walk to toilet,
so he just pee in his pants) Otherwise there were no
other urinary and bowel symptoms. Claimed to be
confused and unaware of what have been done in
Adventist but was then told that they found out that
his blood glucose was in the 30+ range (DKA/HHS
because of undiagnosed DM?). Subsequently,
referred to PGH and was initally warded in Dengue
ward until they found out he has a liver abscess. He
was then warded to C9 and given a course of IV
antibiotics and last CT has shown the abscess has
shrinked in size. P/E: Cachexic, 3 catheters drainage
(2 connected to the RUQ, 1 to the right lung) -
effluent was purulent in one of the 3 bags. Multiple
extensive erythematous scaly patch over the whole of
the back, groin and gluteal region. Respiratory exam:
Dullness on percussion and reduced breath sounds
over the right lower and mid zones.
buzzlightyear of acc both external. one 55 yo india lady with left nipple not much haha (physical examination reveals no
star command - Singh guy and the discharge. no lumps. no tenderness. no significant finding?) aah x ade ape. sorry bruh
to the infitity and other mat salleh. Both skin changes. scheduled for mastec
beyond! ok la later this month
Page 1 of 32
Advices for others, and will they
Question asked by examiner
1)demonstrate examination after presenting findings
(open repair scar, bilateral direct inguinal hernia, one
is recurrent) 2) is it recurrent or incisional?
3)management of the pt, what type of surgery
3)laparoscopic vs open repair? 4)complication of
hernia repair surgery 5) what are risk factors for
hernia development? 6) other management for the
pt?-address his chronic cough
1. Examine the drainage bags and tell me what you
see
2. Diagnosis and why?
3. Liver abscess: organisms and antibiotics (read up
about MELIODOISIS) (they said it is VERY
COMMON, and we should know about it)
4. Describe the skin rash and tell me what do you
think it is
5. Show me how you examine for pleural effusion
6. Risk factors for liver abscess
7. Management of liver abscess
8.Example of the antibiotic you suggested (know at
least 2 examples from the cephalosporine)
9. Can type 2 diabetis patient hasDKA? (rather than
HHS)
10. How does he get pleural effusion from liver
abscess (I said haematogenous but it is wrong) He
said it is 'sympathetic effusion' and was surprised why
I do not hear about it before
1) Show breast examination. whoever yang worry
never do breast exam before, dont worry because i
too never done before but can do well (cewaah) 2)
investigation 3) what can find on u/s: cystic or solid 4)
difference between truecut and nfa. soo nfac xnmpak
extention through the basement membrane. 5)
management: simple mastec and look for symptoms
and signs of mets. 6) Sentinal nodes - korang mesti
tau en. 7) What other department you would like the
patient to refer to before surgery? Psychiatrist Soo all
the best guys!
come on second day?
its a simple direct case, structure answer in
terms of management, surgical
complications, tailored to patient's history-
don't forget to ask whether pt is keen for
surg or not, then what other management if
no surgery(lifestyle modification and truss)
In terms of history, it will drive you nuts and
make you wet your pants like how the
patient had incontinence. Anyways, it is a
long history and i think the patient was not
initially presented with any symptoms or
signs of liver abscess but was then found
out that he had one during his stay in the
hospital. P/E: Make sure you examine his
respiratory, cardio and his dermatological
system other than just abdominal system
as the examiner expected of us.
Presentation: Make sure you spend some
time to organize the awful history even
though it doesnt make sense to you so that
you can present smoothly. Examiners:
Both were super nice and obviously can
tell they are trying real hard to pass me.
Hah!
 Final Surgical Long Case Collection by #classof2016 #pmc

ach acc Prof neil and dr same as buzzlightyear examination same. they asked me to perform full do breast exam. investigation and management r
Krishnan (external) breast exam. i couldnt find any mass. prof neil mainly talk about what is advantage n disavantage of
both are nice solomon also couldnt appreciate mass but the other trucut ( one disadvantage of trucut is it can spread to
fella said he can on bilateral examination. but dont the skin so if want to take biopsy take from area that
worry its too small myb :). i also did knee exam we will excise anyway). mx indication for bcs vs
because pt complain of knee pain. OA. myb no need mastec.
. idk :P
pengsan la gak acc lvl 2, mr neil 46 yo Indian gentleman, part time poliomyelitis @ 2yo, wearing special polio calipers now cannot walk much unless w walking aids and the Honestly i don know much about Polio. I
huhu (doakan la solomons + mr repairmens since 5 years old with walking aids, ADL independent special Polio calipers, however still ADL independent, think the examiners dont know either about
nak lulus) T.T krishnan (examiner since then, hx of hip # d/t MVA back in 2012, socially mmg stable. both surgeons take turns asking Polio. That's Luckily they jump to ask me to
Complicated luar) surgical screws inserted but got a lot of problems so Qs. of course tell me all about polio. intestional do abdomen examination. Try to get your
case 2013 did L THR and now having pain. Apart from obstruction causes back when he was 15yo as marks from there. That's all i can say.
that, multiple surgical scars on the abdomen, 3 compared to now and management, common surgical Good luck people. Hopefully can pass gor.
separate surgeries done since 15yo d/t I/O then sites (how to elicit incisional hernia) and scars God Bless everyone HE IS COMING
multiple complications, stoma bag inserted for a year (possible complications), PE show neurovascular TOMOROW
and then 16yo did reanastomose. PLEASE READ examination- reflex, tone, power etc. not much about
about POLIO k he's coming again tomorrow ddx pun xdan, i totally forgot bout limb length
>!!!!!!! ( discrepancies tho
Important to know some points here: Polio affects
anterior horn cells only therefore there will not be
any sensation loss in this patient (purely motor).
Reflex will be reduced as well as the efferent nerve
cells are affected. (NO Reflex on left ankle or knee) .
Important to know WHO invented POLIO vaccines -
Dr. Jonas Salk ( rmb jonas). In this case patient is
taking Arcoxia ( Etoricoxib ) which works quite well for
him. Important to know the pathways of the COX !!!!!
Why Coxib 2 inhibitor causes less GI side effects ?
Prostaglandin !. I think thats all.

Page 2 of 32
 Final Surgical Long Case Collection by #classof2016 #pmc
cavill acc prof nidhu + mr Mr C 72 yo chinese gentleman. ex ddx recurrent colon cancerHOPI: First p/w bleeding
zulACC - Datuk A- teacher might come again tomorrowwith PR (with stool, bright red, streaked on stool,
Punjabi-Guy and a Mat u/l colorectal cancer, under GH SOPD occasional clots, no tx sought, started in 2014).
Salleh (sorry, exam & onco follow-up 6/12 later, lower abdominal pain (excruciating pain,
stress, i didnt notice Provisional: Metastatic left-sided 9/10, with tenesmus, not relieved by BO, each
their names) :/ colorectal cancer episode lasts 30-45 mins, 4-5 times in total for a
period of 2-3 months).
Also, change in bowel habit (normal habit: 1-2x/day,
formed stool. Changed to become softer, increased
frequency, with mucus, increased amount of blood) --
prompted him to seek medical attn in HLWE.
Colonoscopy & Surgery (Anterior resection -- patient
didnt tell but i thought about it and asked him, and he
confirmed that it was Ant Resection with Ileostomy
=D) in HLWE. HPE showed ca. Referred to GH
SOPD as no oncologist in HLWE. Follow-up, chemo
& RT in PGH.
End 0f 2015, found a ping-pong sized lump under the
skin on the incisional site. In HLWE, lump removed,
found to be ca. Earlier this year, PET scan done,
found multiple mets, third surg in PGH to remove
some remnants.
Currently well.
PMHx, PSHx, DHx: Nil
FHx: Nil
SHx: Ex-teacher in international school. Married with
2 children. Stays in a semi-D. ADL independent.
Smoking Hx (15-30 yo, 10 sticks a day). Social
drinker. Diet hx: high fibre; lots of catering when
working due to busy schedule.
ROS: Nil
She is coming in Prof Kirwan + Imran C9 57yo Chinese lady with mastectomy Mastectomy done on January. Chemo on March.
again tmr scar and ulcer on left dorsum Developed swelling during infusion. Become bullae
and ulcer
Page 3 of 32
basically describe the stoma,what type?
complications? its a
recurrent colon ca so whats your next
management?Was asked to perform abdo PE - esp
liver and spleen and kidney. How would you complete
your examination (hernia orifice and cough impulse at
stoma and his 3 incisional sites)? Didnt proceed on
PE anymore after that as my findings were
unremarkable. HE HAS A STOMA!!! Provisional dx?
How would you investigate him when he first
presented 2 years ago? What surgery did he have?
What kind of stoma is that? Why did he have a
stoma? Do you think the stoma can be reversed?
When can it be reversed? What stage do you think
his colorectal cancer was (considering the fact that
there was mets to the abdominal wall)? At this stage
(ie after op), what advice would you give him (Datuk
was prompting towards stoma care and stoma
reversal)? How would you manage him from here
(follow-up and monitor sxs, ix (what ix? Blood, US
ABDOMEN FOR LIVER METS!!!, CEA!!!!!!))?
No discussion on PE and Ddx.
1) Imran want history of the lump only 2) what is the omg he's coming
cause of ulcer ? 3)Full PE(breast and ulcer) 4)How
do u manage? 5)How long to give tamoxifen for?
6)Mangement of ulcer 7) breast Staging 8) prognosis
of the patient 9) male breast cancer 10) test the
function of the hands- muscles and nerves supplied
The examiners were okayyyy :) Not that
intimidating. The Datuk Mr-Punjabi-Guy
looks very cool :P I thought it was Dato
Manjit at first haha.
The patient was really nice. Ex-teacher in
international school so he spoke perfect
English. He knows his condition well. Eg
he couldnt remember the type of op and
stoma he had off-hand but when i brought
it up, he could recall. Basically, it was kinda
like an one-open-ended-question clerking: I
asked 'Can you tell me more about your
health concern?' and he blah-ed everything
from first presentation all the way to his
next appointment with the oncologist next
month. :P :P
Sorry, i forgot to ask if he's coming again
tomorrow =/
ALL THE BEST, FINE PEOPLE OF
CLASS OF 2016!!!
 Final Surgical Long Case Collection by #classof2016 #pmc

Doraemon prof mane + prof Mr Y/ 19/ Indian male with no MVA 3 years ago, got fracture of wrist, elbow, and refer clumn before. stupid pmc pc, kenot press O and think he's coming again
o'connel? o'reilly? comorbidities, complaint of backward tibia. nothing much n hx but explore more on how the kenot selang. Nail ur knee examination!!!
ACC sagging (straight frward case la) due to PCL affects his functions. Fx- father got scleroderma
MVA (got all CREST), brother just died 2w ago due to
MVA. Sx-he's a flight attendant, has own fam
business (newspaper vendor) Nothing much on hx
actually, I just want to make it a long one. bosan. Do
knee exam in front of them. Show all the sign of PCL
tear (cardboard sign, post sag, medial step off sign,
post drawers). he also got lat collateral tear.
Question: instead f using post sag in summary of ur
hx, use SUBLUXATION instead. Management-
mumbles the conservative (physiotherapy for quad)
and surgery PCL reconstruction (same principles as
ACL). was asked about wound healing (primary?
secondary?) would be better if used skin graft. owh
he also gt mild quad wasting. everything on LEFT
knee.
? ACC mr zul + mr 50 y/o chinese female post left Longitunal neck scar. Clinically euthyroid. Others Throid p/e & ix. Management of papillary ca - preop,
naidhu? hemithyroidectomy. euthyroid normal post op, complications. Mr zul asked only 1-2
questions (when to refer thyroid pts to ortho?)
DD + anak Mr Ronan and another 55yr malay lady, history of trauma 16 history of sports injury, otherwise rule out other knee examination, all the special test INCLUDING Mc Patient is coming again tomorrow, she's
manjaXx external ............... years ago, came in with bilateral knee causes of knee pain in 55 year old, RA, gout, DVT all Murray. what is the pathophysiology underlying been coming for PMC exams for the past 3
Mr Zul and Mr Naidu pain. negative. ask about backpain also negative. Very "locked knees" . what do you see in an ACL and PCL. years. she is a very educated lady and
(ACC)Prof. Aliff and clear history of trauma, able to pinpoint which What are the extraarticular manifestations of RA. how very nice, you can ask her if you have
Mr. Cheong (C9) ligament from her history. *addition* Because of the do your treat ACL? say conservative and sugicl. missed anything or not. she will actually tell
pain, patient was unable to solat, needed to pray When do you do surgery:indication. what type of you how to manage also! :) Mr Zul and Mr
sitting on a chair and could not squat because she surgery do you do. indications for TKR. Naidu were really nice and very
was unable to flex her knees fully. Assess the effects encouraging especially when I answered
of her knee pain on her daily life. she was unable to Mr Zul was delighted to see an Ortho case, so he correctly and they will try to help when I
do sports after the injury and working in the office asked most of the questions* I was asked to do knee couldn't remember the answers. Whatever
requires her to sit for a long time and she needed to examination in front of them too including Mc Murray, case you get, go from basic, thorough
stand and walk about to relieve the pain. her office patient was in pain so be gentle and remember to history and look from all aspects not just
has no lift also, so she needed to take the stairs daily. look at patient's face. she has no other finding except the illness, assess how the illness affect
she has more pain when going down the stairs reduced knee flexion (120 degree? - patient told me the patient's life. Allocate 10-20min to
compared to going up the stairs. she also has "knee- this) bilateral joint line tenderness and crepitus. I was clerk, 10min to examine and 10min to
locking", need to ask her how to release the locking. asked how to manage the patient when she first rearrange your points to make your history
she also has allergy to Voltaren now taking COX-II for came to the hospital, how to investigate - xray (AP, clearer. all the best!patient is super nice
her knee pains, she had arthroscopic debridement in Lateral, skyline view of bilateral knees with the and offered a lot of vital information
2014.she is scheduled for TKR in December 2017. patients standing), MRI. without even needing to ask for.
Goodluck, juniors!
treatment - start conservative (weight loss,
physiotherapy to strengthen the quadriceps muscle,
exercise), pharmacotherapy (analgesia - COX-II, IV
hyaluronic acid (don't say steroid injection, Mr Zul
was surprised when I said steroid injection) and lastly
TKR.All/some of the above and:
- why not bilateral knee replacement surgery (risk
of DVT and bleeding)
- why need to strengthen quadriceps in
physiotherapy (for extension of knee to prevent
fixed flexion deformity)

Page 4 of 32
 Final Surgical Long Case Collection by #classof2016 #pmc

ACC Mr Ronan and another 86 Indian man, calf pain for 2 years. explore more about the pain. rule out neurogenic and perform PAD exam in front of them. 5 features of Patient is a sweetheart, but presenting
indian examiner (both long standing DM, HTN, venous claudication. pulse (rate, rhythm, volume, compare other side, wall complaint was misleading initially,
externals) Hypercholesterolemia. multiple surgery tension). check for carotid stenosis, Afib and motor mentioning his cardiac bypass as the
due to complication of diabetes. never system. they asked about the level of occlusion since reason. Had to screen through symptoms,
smoke, occasional drinker. CABG done. dorsalis pedis, posterior tibial, popliteal are absent but before coming to leg pain as his presenting
Provisional: CLI with intermittent SC: Same case, tumpang :) tq kak AZ! :) femoral pulse is present.Why affected limb looks complaint for this exam ;P
claudication (no signs of critical limb Also, in the physical examination, 1. look for the darker?(poor blood supply) investigation; ABPI(tell
ischemia). Differential(rule out in aetiology of ulcer. them the procedure and value), CT angiograhy (what Doctors are also kind, it is evident that their
history): neurogenicclaudication(Spinal Eg. arterial, neuropathic and venous. do you see). indication for surgery. surgery choice intention is to help us pass, so it is really
stenosis), venous incompetent for neuropathic, do a full neurological examination of acute vs chronic (embolectomy vs bypass). what encouraging to have examiners like that :))
lower limbs.Venous - look for signs of venous structure use as bypass? (LSV. use his right one
hypertension. - Lipodermatosclerosis, edema, ulcers, because tyhe left one already used for CABG) All the best, and God bless! :)
SC: Other differentials of PAD: swelling
Buerger's Disease - young man, Arterial - dry skin, cool temperature, prolonged CRT
extensive smoking history, small on affected side, more hyperpigmented (due to poor SC:Questions for the diagnosis of chronic limb
vessels perfusion of distal tissues), prominent extensor ischemia secondary to atherosclerosis
Raynaud's disease tendons (due to interossei muscle wasting) (peripheral arterial disease)1. Since the patient
As usual, they want you to tell them all the anatomical presented with calf pain, which level would you
landmarks of the pulses. expect the level of occlusion to be? - Femoro-
Popliteal junction
2. Examine his gait - should be normal in a patient 2. How would you confirm this finding? - ABPI
with intermittent claudication with no positive findings 3. How do you measure ABPI? - equipment
on neurological examination. If you are suggesting (sphygmanometer, bedside doppler), formula -
neuropathic ulcer, possibly a high-steppage gait due highest pressure at ankle (dpa vs pta) divided by
to foot drop, but NOT in the case of this patient. highest pressure of brachial artery (right vs left)
4. Patient's ratio is 0.4? What is your
3. Besides peripheral vascular examination, they are interpretation? - Severe PAD
looking for: 5. When would you refer this patient to the
a. CVS examination SOPD? - when the patient has symptoms and signs
b. FULL lower limb neurological examinationc. of critical limb ischemia
Pulses in upper limbs 6. What is critical limb ischemia? - reduced
perfusion to limbs >14 days, WITH rest pain +/-
pr manjit + the UK 70 y/o chinese lady, post op 2 months nothing much just chronic pain needle pricking 1)ask about ddx: forzen shoulder read all 2)how to
guest forgot the name Left TKR. 3-year history of bilateral sensation aggravated by movement and palpation no differentiate from others causes read about cervical
knee joint pain, sharp, 1-2/10 on radiating relieved by resting. not taking any meds to causes eg: cerv spondylosis 3) management:
painscale. Waiting for Right TKR. Came control the pain. no back / neck pain, no numbness investigation: xray for what? for exclude other
in just for our exams on the distal part of UL. no pmx hx pshx. family hx causes, MRI 4)management: conservative.. pain
not relevent. shx housewife currently retired hotel mng, physiotherpy- what do they do in physio? 5)
operator and kindergarten teacher. no what shoulder surgery do u know of? would u do surg
smoking/drinking hx. examination. inspection muscle to this patient? i donno :/ other questions: other place
wasting all deltoid fibres painful arc on L shoulder common for oa-hip,shoulder and fingers(bouchard
start at 90 deg abduction and flexion. limited internal and herberden) other differentials of oa-RA
rotation. palpate tender on ac joint and bicipital Pathophysiology of Swan neck deformity Pathophysio
tendon. sp test: neer sign + , job test +, ext rotation + of bunion-bursities, tight fitting shous and how to
, napoleon belly press test +, speed test +, hawkin manage bunion-bunionectomy
test positive semua pon positive but jobs test less
pain. napoleon most painful. myotome dermatome
normal

Page 5 of 32
 Final Surgical Long Case Collection by #classof2016 #pmc

a external and Irish . Nothing much. Just a scar and some irrelevant signs. 1) OA other than knee? Hip, shoulder, fingers she will come again tomorrow
examiner, ACC 50 years old Chinese lady, post op 6 (heberden and bouchard)
days thyroid cyst (i think) currently no
active complaint.
First noticed lump at left neck. Painless,
soft, not associated with LOA, LOW,
thyotoxicosis sx, obstructive sx, change
in voice
Chronology of the treatment.
After op, no cx.
ML Mr. Lau Ban Eng & Mr Crepitus, tenderness, medial meniscus positive. Ddx, demonstrate knee exam, Ix, How to prepare pre
Uma, C9 op, conservative treatment.
external examiner and ulcer for 5 years venous ulcer, dilated vein perform examination, dx, ddx, causes, investigation,
irish examiner management, complication
Prof Kirwan + Mr. 58 y/o Chinese lady U/L DM on Very vague history. Had to try hard to dig. TKR done 1) Demonstrate knee exam 2) How to prepare patient
Imran C9 medication, history of right Total Knee 5 years ago of which she presented with knee pain pre-op - important pre-op issues pertaining to DM
Replacement and left ankle athrodesis and swelling. The ankle athrodesis done 2 months patients (e.g. replace oral hypoglycemics with insulin,
(didn't know this but Prof gave it away ago. Currently only having pain and swelling of both assess sugar control etc.) 3) How to investigate RA
luckily) presenting with joint pain and hands (swelling more marked at PIP, tenderness (rheumatoid factor, ESR etc.)
swelling of both hands (had to make this over palpation of all joints and reduced ROM.
up cause patient said she just came for However no deformity)
"exam") - Ddx - OA, RA (patient actually
has Rheumatoid Athritis)

Mr. Krishnan + Mr. 62 y.o Chinese lady presented with examination: midline laparotomy scar, kocher incison jaundice(obstructive or not?) i didnt ask about colour
Solomon (ACC) bilateral leg swelling and yellow and stoma bag. hepatomegaly of stool and urine. why got jaundice (lymph node
discoloration of the skin. U/S of the liver obstruct the CBD). what do want to check after
done in LWE and urgent referral to pgh. surgery the complication (discharge, erythema,
investigation done (CT, OGDS and incisional and stoma HERNIA). how to manage the
colonoscopy) confirm to have colon ca. pateint after this? (multidiscplinary team, who
previous presentation early 2014, involved?). demostrate the abdominal exam
change of bowel habit, blackish stool
and mucus. no constipation, no
diarrhea, no tenesmus. also complain of
symptoms of anemia and LOA, LOW.
Dx right sided colon ca mets to the liver

X mr. tan wee jin + mr 70 year old malay gentleman came for ddx : left colon carcinoma with abdomen and stoma 1) indication for stoma REVERSAL. 2) where do u
kevin mossinac exam. currently with a right sided stoma exam. think ca is ? 3)pre op assessment 4)clinical staging
with past history of colon ca. history : for colon ca 4)perform abdo exam and stoma exam 5)
altered bowel habit, per rectal bleed, what would you do next - palpate for
colicky abdo pain for 2 years. did hepatomeg/check lungs/dre/spinal tenderness 6)
surgery and currently waiting for stoma whats liver span 7)perform shifting dullness 8)what
reversal. stoma is it ? 9) other types of stoma
A mr manjit + irish venous ulcer + varicose veins 55 year old chinese gentleman, 10 year non healing 1) differentate 3 types of ulcers 2)arterial exam demo
external examiner ulcer. pmh : gout. pe : short saph vein vv. 3) all anatomical surface markings and pulses 4)what
ix would you do ? 5) indications for vein stripping
6)what surgical options 7) about marjolins ulcer

Page 6 of 32

Both externals 1 irish 1 PVD
indian ACC
AAA Dato Naidu and Dato Clinically Euthyroid MNG. 58 year old
Zul Indian lady. Don't be surprised when
you see her at first because she has
unilateral ptosis and lateral gaze palsy
(Secondary to MVA. phew.). Huge
goitre but no compressive symptoms.
On f/u and meds from endo (she has no
idea, but should be carbamazole). be
sure to take O&G history- hx of 2
miscarriages due to fall (not thyroid
related), Menopause just this year (No
symptoms). Fam hx significant too but
no Ca in family.
Final Surgical Long Case Collection by #classof2016 #pmc
73 yo Chinese female. B/L leg pain relieved by rest,
no rest pain, no swelling, no skin changes noted, no
swelling. Was admitted for investigation, on
discharged was told to avoid prolonged standing,
wear compression stocking and foot lelevation.
Prescribed with Deflon and is well currently. PE:
Only telengiectasia and reticular veins most
prominent on dorsum of the feet. Slight inverted
champagne bottle leg shape but no
lipodermatosclerosis or ulcers. Dry skin and some
excoriation marks.
Page 7 of 32
1. Dx and why. 2. Lower limb vascular examination.
3. What is lipodermatosclerosis and where else you
can get haemosiderin. (Bronze Diabetes) 4.
Pathophysiology of venous ulcer. 5. Explain
Trendelenburg Test and Perthes Test. 6.
Management for PVD and dry skin.
He asked for summary of HOPC: and early
impression. So just chronic, slowly enlarging, painless
lump. no compressive, no constitutional symptoms,
and no symptoms suggestive of Hyper or
hyperthyroid status. so non-toxic MNG. Then asked
to do PE. They want you to INSPECT for
Pamberton's sign before going to palpation. raise
hand and put together, facial flushing and dizziness if
positive. hmm, then the usual, berry's sign, how to
differentiate bet cyst, solid (fluctuance). then IX, U/S
and FNAC. how to differentiate malignant or not.
What to do for surgery? Total thyridectomy only.
Then post op complications. immediate, early and
late: Immediate: bleeding, haematoma causing
dypsnoe and stridor. nerve injury. and hypocalcaemia-
know your chovstek, trosier and perioral numbness.
he wasn't interested in late complications. mr zul
only asked one question. why patient on f/u in endo.
patient have some mild but controlled
hyperthyroidsm. then was asked what are the side
effects of carbimazole. leucocytopaenia. then times
up!
 Final Surgical Long Case Collection by #classof2016 #pmc

ACC Dato Naidu and Dato venous ulcer + varicose veins 55 yo chinese male, pmh gout 10 years, pc 5 years 1) Hx part was short, just discuss on risk factors for sorry, forgot to ask whether he's coming in
Zul (Dato Naidu was non healing ulcer on left leg; PE - ulcer, varicose LSV this patient also summarise 2) no differentials cos tomorrow. but i think for dato naidu, be
the one only one who (didn't do torniquet cos i only see one small varicose, clear cut venous ulcer but he asked why not arterial. practical with your answers (not give the
asked questions but then examiner told me to feel a bit more, lol! - got la and reason out la. 3) was asked to do ulcer textbook ones, he skips all those)
he's really nice) varicose vein at posteromedial thigh) examination only, examine leg a bit and which venous
system was involved (LSV), then explain how to do
torniquet test and perthe's test. 4) mechanism of ulcer
and varicose vein: rmb venous HTN (can go all
around about incompetent veins and stuff but
apparently he wants that specific word) 5) next is how
to manage: again keyword is reducing venous HTN -
so when standing, move ur toes/stand of tip toes,
when sitting, put leg up on chair/stool, when lying
down, lift leg up (all to reduce the HTN), then only
mention those other mx like graded compression
stocking etc. 6) what's the hyperpigmentation in
venous ulcer called and why: guessing you all know :)
7) how to manage ulcer locally: dressing with skin
graft (the new type of dressing, he didn't asked in
detail tho) 8) before sending the patient for surgery,
what would you do & why: doppler u/s check for dvt
bcos dvt will cause ischaemia if proceed to surgery

Page 8 of 32
 Final Surgical Long Case Collection by #classof2016 #pmc
C9 Mr Tan WJ, Prof Kevin choledocholithiasis 55 y.o indian gentlemam, 1 year history of jaundice
starting from lower limbs progressively upwards to
the eye, didn't bother initially until end of May concern
because of progressive worsening jaundice, a/w 1-2
months of epigastric pain, tea colored urine but no
pale stool, LOW 10kg in 1 year, LOA and pruritus. No
fever and had rule out other differentials.H/O bilateral
hernia repair. otherwise no other medical condition.
C9 - very hot, Mr Lim SY (HOD), Mr Colorectal cancer. Ddx: haemorrhoids, 60 y/o chinese man with no known medical illness,
bring tissue.... Abdul Aziz - both quite IBD (they didnt really ask about ddx) presented with 3 months history of PR bleed. During
GOOD LUCK nice, LSY doesnt defeacation, blood on stool, not mixed, no mucus.
GUYS. DONT smile, Abdul Aziz just HOWEVER, no constitutional sx like LOW, LOW,
PANIC asked me one ortho LETHARGY. no change in bowel habit. Just PR
question, which bone bleed. NO ANAEMIC SYMPTOMS, NO METS
will colon ca normally SYMPTOMS. After 3 months to went Chinese
mets to and WHY medicine and got some treatment but still PR bleed
(baston venous so went to LWEH and was told to have cancer. Did
plexus?) what type of resection and had a RIF stoma for about 1 year but
lesion will you see on some complications arose so another operation was
the x ray done and another stoma was done, this time one at
LIF. On examination, some conjunctival pallor,
abdominal examination: keloid scar on RIF and
hypertropic scar midline. Stoma bag filled with faeces
on LIF. PR examination, no anus. (find chaperone)
Stoma, has one spout, <1cm and semi-solid faeces
seen in bag. A bit of incisional hernia seen on the
right keloid scar.
Page 9 of 32
1) The uncle speech is a bit slurred so i couldnt
understand at some point when i need to really clarify
a lot of times( but it's my problem in listening to very
fluent malay LOL. those who are good in malay
shouldnt have any problem). Patient has good
patience and understandable on our tight situation
(he knew i was quite tense up when i couldnt
understand what he said haha). But overall very
typical history of gallstones. P/E very jaundice looking
and slceral icterus ( you wont miss it unless you are
blind!), scratch marks over both arms. palpation i
elicited murphy's sign (which the tone Mr Tan ask me
'so you think that's murphy's sign' actually shake me
off a bit but i still insisted.) There's a left liver lobe
hepatomegaly, which i forgot to measure the span,
they didn't ask me to report my physical findings, just
did the murphy's sign in front of them and that's
because i mentioned it ('since you are so enthusiastic
to show me the murphy's sign, show us'). He asked
me to check for splenomegaly, which i stunted as i
don think there is, so i palpated in front of them and
still convince myself no. He doesn't seem to be
bothered so i guess no splenomegaly. Question wise
is like how you investigate the patient when he first
presented to you. He stopped me when i talk about
U/S abdomen. Then said the findings is dilated biliary
tree but couldnt see stone, how do you proceed? then
i said ERCP, but he doesnt want that, i continue to
say Percutaneous cholangiogram, MRCP, CT scan,
he didnt want those too! and said what's in between
ERCP and MRCP (which until now i also cant find the
answer and he didnt want to tell me either). then ask
Other student 2nd day: just usual
presentation like u always do in the
ward. Present pt history, after that
examiner ask to do full abdomen
examination...the differential and
investigation. Same history..he
started as epigastric pain,then
jaundice ass with pruritus tea color
urine. Otherwise other history not
significant. During pe prof kirwan
did interrupt with question...ask i did
forgot some step..i forgot to check
neck so he ask me to check neck,
so what do u look for in
neck?lymphadenopathy, so
subsequent q what problem in abd
cause lyphadenopathy-- virchow
node for gastric ca, liver,etc. Check
spleen...even though i did check
before but then he want to see
again. Odeme beside leg where
else? Sacral. I did feel but the liver
edge hitting my hand luckily the
liver span is normal. Mr imran ask
ddx:1)choledo 2)hep 3)hemolytic
anemia. Then prof kirwan ask...if
anemia what finding would u find on
 Final Surgical Long Case Collection by #classof2016 #pmc

ACC An irish & singh (both Dx:Frozen shoulder, DDx: OA, rotator 65/chinese lady/single PC left shoulder pain and
very soft spoken and cuffs tear, impingement, septic arthritis limited ROM. Otherwise other history not significant.
patient with me) haha PE: only pain at left shoulder in all directions of
movements. Otherwise no other findings. I perform
full shoulder exam in front of them. They never stop
me until finish. I didn't proceed to special test. They
were quite quiet. (I suspect they not really sure about
shoulder examination). They just ask one question
why i do internal rotation. One of the range of
movement is internal rotation for subscapularis.
Ix: Xray, MRI, what do u on the xray for OA LOSS.
MRI what do u see in. I said soft tissue swelling. I
said wanna look for osteomyelitis as well. Then, they
ask what is that? inflammation of the bone and
muscle. How do u manage? Physiotherapy, hot pad.
How does the hot pad work? I said it help reduce the
pain then they just angguk kepala. Then give nsaids.
They ask any surgery to help? I said i dont know then
ask them is there? They just look at each other and
smile (i suspect they also not sure). They ask me
about septic arthritis how patient may present. Acute
pain with redness and swelling, then they ok.

Acc mr david and Dato Dr chinese, 61 yo, 10 yr hx of right chinese, 61 yo, 10 yr hx of right irreducible inguinal examine hernia only. ix of hernia, pre op
Harjit SIngh irreducible inguinal hernia. hernia. noted swelling after lifting watermelon. has assessment, managment: truss, non pharmaco,
multiple risk factor, chronic cough(though non surgery. type of surgeries, risk factors for hernia,
smoker), bph symotoms, previous chronic difference btw obstructed, strangulated. surgery for
constipation, previous job heavy lifting. also strangulated, how to recognise. how to prepare
has, right knee pain( with lots of chinese herbal patch patient for op of strangulated hernia.
here n there and contact dermatitis due to the patch)
& also bilateral varicose veins, symptoms more on
left with symptoms of stasis dermatitis. also had a
patch of ? fungal infection on left thigh. also previous
mva w ? intracranial bleed, no surgery done. residual
left limbs numbness.

ACC Dato Zul and Dato colorectal carcinoma with bilateral direct 71 year old Chinese gentleman, retired teacher
Naidu inguinal hernia presented with 2 year history of crappy abdominal
pain preceded by episodes of painless bloody stools.
He has been diagnosed with sigmoid ca, and
resection of the sigmoid ca had been done. Be
careful to check for cough impulse in.thr inguinal
region as he has bilateral direct inguinal hernia.
Great examiners,both very nice. Asked to examine
the stoma,palpate for the spleen and general
discussion of what what could be done for the patient.
patient very helpful, English speaking and gave most
of the history without prompting

C9 Mr cheong and mr alif Right sided solitary thyroid swelling (non 58 yr old, right sided thyroid swelling, progressively Uncle speak english and hokkien. Good historian and
toxic mng) enlarging 11 yrs ago. Ix all done, not malignant, dx as cooperate well. Both examiners are nice too. Since its
MNG, no thyroid symptoms, so far no compressive mr cheong, don move the lump with the neck turn.
sx, underlying htn, scheduled for op in june, Read more on post op complication.
previously april but anaes say not cannot because
heart problem but so far no signs of heart failure.
Quite straightforward case. Just clerk how u clerk a
thyroid case, ask abt lump and complication of it. For
PE, do as thyroid exam, thyroid status euthyroid and
no cardioresp signs. Trachea deviated, mistaken the
adam apple as part of thyroid lump so first question
was what is an adams apple (lol). Remember to do
retrosternal percussion and check carotid and lymph
nodes. Question on malignancy fx of ultrasound (dug
my own grave for offering that) , how dx follicular
benign and malignant, post op complication,
complication of recurrent larygneal nerve palsy, which
surgery to do and why and the complications.

Page 10 of 32
 Final Surgical Long Case Collection by #classof2016 #pmc

AAA Prof Kevin & Mr Tan 66 yo Chinese gentleman previously Mr. Tan asked:- Hx: 66 yo Chinese gentleman with
Wee Jin (C9) presented in May with 4 days history of 1. Left side tumour with RIF pain - what underlying BPH, previously presented with
RIF pain. He was surgically treated with phenomenon? Close loop obstruction / intestinal 4 days history of RIF pain, reduced bowel
end colonostomy and was discharged obstruction. habit and passing loose stool with mucus,
home. Currently he is called for exam. 2. Patient unstable so how do you manage him? ABC associated with 4 weeks history of
The patient is not aware of the dx, but including fluid resuscitation. incomplete bowel opening and tenesmus.
he did mention about doing 3. How much and how fast you wanna give the IV No PR bleed, no vomiting, no LOW, no
chemotherapy. So I put my provisional fluid? bone pain, no SOB, no palpitation. He has
dx as Colorectal cancer. 4. Patient hypoK, hypoNa, high urea - so how do you LUTS (medically treated BPH for the past
treat? How much and how fast K wanna give? one year). No other underlying medical
5. Causes of leucocytopenia in this patient (simulated illness and past surgical hx. PE: mid-
scenario) laparotomy wound with sutures and
6. How do you treat the patient since he is unstable functioning left end colonostomy. Mass felt
and having peritonitis? Emergency exploratory at the paraumbilical and suprapubic. No
laparatomy with peritoneal lavage to find out the hepatosplenomegaly. PLEASE CHECK
cause of peritonitis HIS PERINEUM to see whether his anus is
7. What to do pre-op and post-op? still there or not. I was asked by examiners
8. What type of antibiotic to be given to the patient? whether I did DRE or not, but I didnt.
Targeting gram -ve and anaerobes Based on the PE, it can be either
9. Ask for consent from the patient to perform the Hartmann's procedure or
mentioned surgery Abdominoperineal resection, But need to
check perineum to differentiate these two.
Prof Kevin asked:-
10. Another simulation. The patient now post-op Day
1 with stoma. a) Why patient tachycardia? SIRS b)
What do you expect to see in the stoma bag post-op
Day 1? Haemoserous fluid, NOT feces. c) What are
you looking for in the stoma at post-op Day 1? Rule
out bleeding, retracted, ischaemia (dont mention
prolapse as it appears later)
11. Let's say the patient suddenly becomes unstable
with high stoma output until the stoma bag overflows
ana
C9/ ACC on Mr Lim , Mr Aziz 66 y/o Chinese lady with varicose vein Hx: very straight forward , she has family history of varicose vein- know on how to examine, they asked If you come on the second day and the
second day! on the R leg, varicose veins (father and brother). Working as to perform and demonstrate. Distinguish perforator patient to be same patient from previous
(2nd day Prof David helper in canteen for 35 years, long standing. No defect and main valve defect, what's the difference day, just ask them ''what the students
Adams & Dato Dr Harjit (she came again second day, nice pregnancy hx, OCP. Very nice lady, she will guide and how to differentiate. Then, what is Perthe's test. asked you ysterday and how is he/she was
Singh, Consultant fellow!) you through history. Previously got vein stripping on Know anatomy well. asked in front of the examiner?''
General, Hepato- left leg. Never had DVT and no hx of long-haul flight,
Pancreato-Biliary & prolonged immobilisation just when she was admitted Ix: Duplex, u/s of abdomen, CT. That helps alot okay. A big hint on what
Liver Transplant in 2002 form hepatitis d/t autoimmune disease. you suppose to do and where you should
Surgeon of Prince Mx: scelerotheraphy, vein stripping. If deep vein go in the history and examination!
Court Malaysia) U/L Scleroderma, AIHA and under f/up rheumato and system thrombosed, how you wanna proceed. Both
medical for osteoporosis post-steroid tx. examiners are nice. My examiner don't really smile but i dun
give a damn haha
O/E scars mastec on R, (yes she had amstec on R
breast, 1990), abdo null, CVR respi NAD, LL R GSV
varicosity+ SSv varicousity, multiple telangiectasia,
perforator defect, with saphena varix. No ulcers on
right but ulcers left leg d/t burn injury. Scleroderma &
raynauds on hands.

Page 11 of 32

ACC Dato Manjit and 55yo Indian lady with 2 episodes of
external examiner nipple discharge
C9 Mr Lim SY, Mr Aziz 45y/o Indian man, with underlying
Hepatitis C, admitted 4 months ago, p/w
acute onset of severe vomiting with
blood and abdominal pain, subsequently
became drowsy and lost consciousness
on the night of admission. Risk factors
include gastritis, chronic alcoholics,
active smoker, ex-illicit drug user and
tattoo markings.
PDx: Acute pancreatits
DDx: Perforated peptic ulcer disease,
bleeding oesophageal varices
Final Surgical Long Case Collection by #classof2016 #pmc
Straightforward breast cancer history. Nothing to find
on physical examination. Dense breast tissue so it
feels like there is a lump but patient insisted no lump!
I believed her and no arguments from the examiners.
I focused on the initial presentation of the patient 4
months ago (yes, he is a in-patient for 4 months,
probably you guys have talked to him before during
your rotation), and summarised a bit on his
progression since admission. He was initially
admitted to ICU for 40 days, during that time, he was
unconscious and most likely percutaneous drainage
of pancreatic abscess has been done (purely by
guessing). Currently he is able to tolerate orally,
passing urine and bowel motion are both normal and
no fever. However, he complains of right foot drop
and mild pain on both his heels due to pressure sore.
P/E: Tracheostomy scar, generalised muscles
wasting, especially his lower limbs. I personally could
not appreciate any stigmata of chronic liver disease.
Lungs and heart are both normal. Abdomen two
drainage scars on the left lateral side, otherwise no
tenderness and no organomegaly.
Lower limbs examination: Generalised wasting with
right foot drop and pressure ulcers on his bilateral
heels (I got gloves to open the dressing and examine
the ulcer during clerking) and no sacral sores. Tone,
reflexes are all normal. Muscle power are 5/5
bilaterally, except right foot is unable to dorsiflex with
reduced/loss of sensation (pinprick) and
propioception below the ankle.
Page 12 of 32
What kind of abdominal findings will you find?
Hepatomegaly, malignant ascites. Dato Manjit wanted
pelvic mass - Krukenberg tumours via transcoelomic
spread. Discussion on triple assessment, details on
mammogram findings, management of breast cancer.
Mr Lims Question Patient is very nice, English-speaking and
Provisional and differential diagnosis after summary most likely he will be there since he is not
of the case due for discharged anytime soon,
No reporting of physical examination just state examiners are both nice and will guide you
the positive findings (just be prepared for both) along when you are stuck. Thats it. Keep
How would you manage the patient if he presented calm and all the best!
initially at ED? (Ix & Initial Mx based on provisional
dx) serum amylase* (how high is high, is 900
elevated?)
How do you grade the severity of acute
pancreatitis? (List the parameters used in Imrie
score) what investigations would you do?
What do you think happened to the patient when he
collapsed? (Define shock, types of shocks,
differentiate hypovolaemic shock vs septic shock,
pathophysiology of shock in acute pancreatitis)
Complications of acute pancreatitis and
management
Mr Azizs Question
Show me how you examine his lower limb
Cause of his foot drop Im guessing common
peroneal nerve injury causes of this nerve injury
Next Q: why did he has CPN injury correlate
back to the patient (most likely due to prolonged
immobilisation and compression while he was in ICU)
Types of nerve injury (neurapraxia, axonotmesis,
neurometsis) & process of healing from nerve injury
How do you manage his foot drop? Do you think he
can recover? If yes, how long it takes?
 Final Surgical Long Case Collection by #classof2016 #pmc
ACC Mr Manjit, Professor P 68 y/o Chinese man with chronic 30 year h/o varicose veins. 10 year history of ulcer
Horgan venous ulcer (R) over medial gaiter area. Done laser ablation, ligation
and stripping on R leg, also bed rest for 6 months in
PGH for ulcer. Splenectomy due to MVA in 1998.
Gastritis under f/up in PGH. O/E - venous ulcer (all
the typical characteristics) over R medial gaiter area.
Varicose vein left thigh. Midline scar over abdomen
with divarication of the recti (ask him to lift up his
head)
Page 13 of 32
1. How many types of ulcers are there? [3 - arterial, He's coming tomorrow. I went out to ask
venous, neuropathic] for tourniquets and Prof Prem asked me
2. What kind of ulcer is this and why? [Venous, "Why didn't you bring your own?!" I was
describe all the typical characteristics of the venous then given a handful of gloves, but I'd
ulcer] forgotten how to do a multiple tourniquet
3. How do you differentiate it from arterial and test so I just didn't mention it during my
neuropathic ulcers [Describe all the typical presentation and my examiners didn't ask
characteristics of arterial and neuropathic ulcers] me about it either :D The examiners are
4. What is the gaiter area? [I said it's a boot soldiers nice, just keep calm and you'll be fine!
wear, Google says it's a 'garment worn over the
shoes and lower pants leg']
5. Why do venous ulcers happen over the medial
gaiter area? [I said because that's where the course
of the long saphenous vein runs and because there is
venous hypertension there, highest at the bottom of
the leg] Follow up question - So if that is where
venous hypertension is highest, why don't you get
ulcers on the foot where presumably pressure is even
higher? [Uhh, I dunno??]
6. How would you investigate this man? [Gold
standard Duplex ultrasonography, can also do
Doppler ultrasound] Follow up question - Would you
be surprised to find anything underneath the ulcer? [I
had no clue what he was asking. The answer is no, I
wouldn't, there's probably a perforator underneath]
(This is the answer to the earlier question, you get
ulcers over the gaiter area, because there's
perforators there) [I would also like to do an ankle
brachial systolic index to rule out arterial disease
before using compression stockings on him]
7. What ABSI do you expect? [1 or better]
8. What ABSI readings are bad? [<0.9 is mild disease
 Final Surgical Long Case Collection by #classof2016 #pmc

ACC mr manjit + irish 61yo gentleman, irreducible inguinal 10 year history of ingunal hernia, previously reducible ,
external examiner hernia but now no longer reducible. Ask about the site, how
(ACC 2nd floor) he first noticed it, as well as any associated
symptoms eg pain, and ask about progression eg
whether or not the swelling has increased in size or
any new symptoms since he first had it. Risk factors:
he noticed his hernia first when he worked lifting
crates of watermelons. NB do not forget to ask other
risk factors eg urinary symptoms (obstructive
symptoms eg straining, incomplete emptying,
difficulty initiating urination, terminal dribbling,
frequency, nocturia etc), constipation, or chronic
cough. Ask about complications - able to pass
motion? (obstruction) or is it painful with any skin
changes? (strangulation). PMH, family hx, social hx,
drug hx, systems review - he also has varicose veins
for (can't quite remember duration) as well as a
previous accident & head injury 8 years ago a/w left
sided numbness but no weakness.
Not sure if he is coming back tomorrow but
it seems a possibility. Obvious findings +
good historian, though he's only
comfortable with speaking Mandarin and
Hokkien. Also I noticed that you may get
the same patient as someone else, but be
examined by different examiners eg the
guy who wrote entry no 28 in this
spreadsheet saw the same patient but the
examiners were different, so be prepared
for a different set of questions.
Lastly, all the best guys!

Examination: don't forget general inspection first (also

comment on varicosities as well as increased
pigmentation over lower part of left leg), hands, eyes,
mouth, then examine swelling - right scrotum, I did
not notice any scars or skin changes, cough impulse
positive (I think?) - palpate: able to feel both testes
separately, non-tender and no difference in
temperature, not able to get above mass, get patient
to lie down and feel pubic tubercle - above and
medial. unable to reduce hernia. auscultation - bowel
sounds heard (I think?)

Page 14 of 32
 Final Surgical Long Case Collection by #classof2016 #pmc

AYAM, yes, ACC, Mr Krishnan (not 68 y/o chinese gentleman with a 10 Ulcer started very small 10 years ago, throbbing painThey started with simple questions, was his work #pray4c2016
thats my initial PKR, this one is cool) years history of unresolving ulcer on his 3/10 pain scale shooting up to 7/10 when he walks. related to his disease (yes, long standing). They
& Mr Neil Solomon (he R leg, painful and associated with discharges clear sticky fluid that soaks bandage. R didn't ask me to examine his leg again. Though NS
has a tendency to swelling & serrous discharge with a long leg swells up to knee resolves by raising his leg. kept asking if there is still VV on his R leg every 5
mislead you with his standing history of varicose veins. This Ulcer gets progressively worsen as he seeks chinese mins, which I said no (coz really, I dont see any). they
questions, careful with is a clear cut venous ulcer d/t venous medicine but gets better as he follows up in clinic. A
asked whats the cause of his smaller R leg, I said
that trap... sneaky) insufficiency very compliant uncle. Did laser ablation on his R leg.
muscle atrophy, but he wanted me to rephrase, so its
Had a trauma with ICU admission 18 years ago, disuse atrophy. everything seems to be going well so
spleen ruptured, did splenectomy. He has no co- far. doesn't seem like im holding any 'cangkul' atm....
morbidities but his risk factors is working as a fruit
till they ask me to examine the abdomen where I
seller (long-hour standing). He had to stop working mentioned there is no incisional hernia on coughing.
though due to the pain. such pity. *I cant seem to He asked if there's any other method to test incisional
start a new paragraph, so forgive me of my hernia, I ask the patient to flex his neck and theres
newbness* O/E, well healed ulcer on R gaitre
the OBVIOUS incisional hernia staring at you. I gave
area. Typical venous ulcer with sloping edge and a poker face to the examiners, non-chalantly, "sorry,
healthy granulomatous tissue, lipodermatosclerosis. there is an incisional hernia". he asked what
He will point to his laser ablation scars, so take note.
investigation i would like to do, with my mouth faster
very nice gentleman. Continue to examine the than my neurones, I blurted out "FBC!". thats when i
varicose on his L thigh. Trendelenburg test positive knew I'm starting to dig my grave. They had a
(SFJ incompetence), tap test positive. If you confused look, "why would you order FBC?" but it's
measure the circumference of his thighs and calves, too late to back down, and I'm not the type to back
you'll notice that the R side is smaller than L (either
out, so I said to look at the WCC for any raised WCC
disuse atrophy of R or swelling of L). Don't in case the ulcer is infected. NS asked "say its 10k,
forget to examine his abdomen. A midline laparotomy what would you do". I started digging deeper,
scar with incional hernia (though you won't see it if"antibiotics!". They became more surprised, its super
you ask him to cough. so ask him to flex his neck) effective. MrK asked whats the normal range of
WCC. by this time the thought block was so severe,
so I admitted to them, "sorry, but I really can't recall
the normal range right now". So NS asked what if its
16k, and I said its infected (yep, getting deeper now
boy). We discussed and established that WCC is not
helpful. so NS asked the platelets is high, am I
Mr Uma and Mr Lau 66 years old Chinese gentleman physical examination wise: only a midline scar 8 cm What causes palmar erythema? He is coming tomorrow; Only speak
Ban Eng extending to the right hypochondian region measuring normal investigations...justify them all, what to expect
Hokkien and Mandarin. I would
both are very kind and presented with 1 year hx of change in 17 cm, connected to a drainage pot in the reading recommend our non Cina friends to swtich
helpful. Smiled a lot bowel habit patient not only because of language
and gave hints. Very 2 months hx of weight lost He has palmar erythema and loss of axillary hair. How to prepare patient for op barrier, doctors and I agreed that he is a
thankful to have them 2 months hx of a right hypochondria how to prevent DVT; what medications to give bad historian, mainly due to fact that he is
as my examiners mass At last, doctors told me he has hepatocellular in denial, he will tell you he doesnt know
carcinoma after I discussed with them my differential What can a SURGEON do during intra-op to prevent why he was admitted, he is very healthy,
No other complaints diagnosis which is right rided colon ca mets to liver. DVT no medical problem, dont know whats the
surgery is for. Patient doesnt want to
accept that he has malignancy. Took me
they asked me lotsa questions...forgot. lol 10 mins to just really korek korek all the
symptoms from him.

Good luck, guys! All the best!

C9
MAO Dato Manjit and same as buzzlightyear and ach ask ddx for nipple discharge, chemo regime, pts sgt baik, good luck semua, iA
external examiner(Prof hormonal side effect), chemo regime, If patients
Harold) coming with recurrent breast ca, so wht chemo
regime wanna give? and what its side effect? know
as well about paget disease

Page 15 of 32
 Final Surgical Long Case Collection by #classof2016 #pmc

gggajoob Mr. Tan Wee Jin and Two words--Miss Loo Miss Loo (self-explanatory--you should already know 1. Examine the legs, palpate the pulses, how would She will teach you how to examine her
Prof Kevin Moissinac the PMC mascot by now) you test for the patency of the SFJ? varicose veins and also where her hidden
Ward C9 2. What are you worried about regarding chronic scars are from surgery. And remember to
Day 2 ulcers? (malignancy--Marjolin's ulcer) mention that her leg was bitten by a dog.
3. How will you manage this patient now? Also, her occupation is important and she
(Investigations, conservative, medical, surgical) has a strong family history.
4. What do you want to find out about before going
into surgery for this patient? (Rule out DVT). How?
And explain. (Perthes' Test)
5. What do you understand about laser ablation?
6. If a patient with varicose veins comes with a
bleeding ruptured vein, what do you do?
7. What is this leg appearance? (Inverted champagne
bottle). Due to what? (Lipodermatosclerosis)

Ward C9 Day 2 Dr. Cheong and Prof

Aliff
1 Mr. Uma and Mr. Law Venous ulcer, 55yo, Man allergy to aspirin pure clear cut venous ulcer, pe perform, ix, mx,
arterial insuffciency ix mx
Dney Archie Both externals 1 irish 1 30y/o lady, gallstones, with u/l gastritis epigastric pain.2005- gastritis- on histac, diagnosed 1. differentials 2. perform abdominal examination ( tell patient is nice. i asked her if i left out any
indian ACC and PUD with PUD, on pantaprazol for 9M. felt worse now and me the qudrants as u palpating) 3. surface anatomy questions that the previous student asked
U/ done discovered gallstone. of upper border for liver 4. how u palpate for spleen and i asked what did the previous
and kidneys. 5. where are platelets produced, examiners asked to do when examine her
destroyed and what are percusor cells that made and she helped) =) hopefully all went well!
platelets!!! ( mmg tak memorise la kan cell lines tu) 6.
caus eof PUD in this patient. 7. inv and and mx for
her if u first see her. U/S and ERCP are what they
wanna hear. and cholecystectomy ( since pt has no
obstructive sx but still have severe epigastric pain)

X
A

Page 16 of 32
Final Surgical Long Case Collection by #classof2016 #pmc

Page 17 of 32
Final Surgical Long Case Collection by #classof2016 #pmc

Page 18 of 32
Final Surgical Long Case Collection by #classof2016 #pmc

Page 19 of 32
Final Surgical Long Case Collection by #classof2016 #pmc

Page 20 of 32
Final Surgical Long Case Collection by #classof2016 #pmc

Page 21 of 32
Final Surgical Long Case Collection by #classof2016 #pmc

Page 22 of 32
Final Surgical Long Case Collection by #classof2016 #pmc

Page 23 of 32
Final Surgical Long Case Collection by #classof2016 #pmc

Page 24 of 32
Final Surgical Long Case Collection by #classof2016 #pmc

Page 25 of 32
Final Surgical Long Case Collection by #classof2016 #pmc

Page 26 of 32
Final Surgical Long Case Collection by #classof2016 #pmc

Page 27 of 32
Final Surgical Long Case Collection by #classof2016 #pmc

Page 28 of 32
Final Surgical Long Case Collection by #classof2016 #pmc

Page 29 of 32
Final Surgical Long Case Collection by #classof2016 #pmc

Page 30 of 32
Final Surgical Long Case Collection by #classof2016 #pmc

Page 31 of 32
Final Surgical Long Case Collection by #classof2016 #pmc

Page 32 of 32