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History Taking Station: Dysphagia Station length: 7–9 minutes Task: Take a focused history from a patient presenting with difficulty swallowing. Candidate Instructions You are the surgical trainee in clinic. A patient has been referred with difficulty swallowing (dysphagia). Please take a focused history and summarise your findings to the examiner. Examiner Mark Scheme Total marks: 20 Introduction and Communication (2 marks) Criterion Marks Introduces self and role 1 Confirms patient identity and explains purpose of consultation 1 Presenting Complaint (2 marks) Criterion Marks Clarifies the nature of the swallowing difficulty 1 Establishes duration and onset of symptoms 1 Characterisation of Dysphagia (4 marks) Criterion Marks Differentiates solids vs liquids 2 Establishes progression of symptoms 2 Key diagnostic points expected: Difficulty with solids progressing to liquids Whether symptoms are progressive or intermittent Associated Symptoms (4 marks) Criterion Marks Weight loss 1 Regurgitation of food 1 Pain on swallowing (odynophagia) 1 Persistent vomiting or choking episodes 1 Red Flag Symptoms (3 marks) Criterion Marks Unintentional weight loss 1 Vomiting or haematemesis 1 Progressive worsening dysphagia 1 Gastro-oesophageal Symptoms (2 marks) Criterion Marks Heartburn / reflux symptoms 1 History of long-standing reflux disease 1 Risk Factors (2 marks) Criterion Marks Smoking history 1 Alcohol intake 1 Medical and Drug History (2 marks) Criterion Marks Relevant past medical history 1 Drug history including NSAIDs or medications affecting oesophagus 1 Summary and Clinical Reasoning (3 marks) Criterion Marks Provides structured summary 2 Identifies concerning features suggesting malignancy 1 Example expected summary: "A middle-aged patient with progressive dysphagia to solids associated with weight loss, raising concern for an oesophageal malignancy." Candidates should demonstrate the ability to: Structure a focused surgical history Identify red flag features of upper GI malignancy Differentiate mechanical obstruction vs motility disorder Communicate clearly and summarise effectively Common Candidate Errors Failure to ask about progression of dysphagia- Not asking about weight loss Forgetting smoking and alcohol history Not summarising the case at the end

PRE-OPERATIVE ASSESSMENT BEFORE THR STEM - A 62-year-old man came for his preoperative assessment in Orthopaedic OPD for his scheduled THR in one week, He was diagnosed with OA & months ago, and his operation was cancelled due to his reluctance. Now, his wife has managed him and taken him to Orthopaedic OPD to get a schedule soon as they are going to arrange their daughter's wedding in 2 weeks. Now that you are an orthopaedic SHO, considering this a history-taking station, go through his preoperative assessment to inform your consultant. (This station is deviated largely from the usual history format. Here patient is already diagnosed and has done all the relevant investigations and came to SOPD to get his schedule for THR with his wife who actually convinced him for operation. There's no need to ask about pain, similarly no need ask questions for differentials. This station largely focuses on pre-operative fitness status, co-morbidities, medications, PMH, PSH that are most concerned issues before operation which need to be optimized). Introduce yourself Hello, good morning, I’m Dr. Z, one of your surgical doctors. Confirm patient's ID and verbal consent = Just for documentation purposes, could you please confirm me your name and age please? = Nice to meet you! Good to see you again Mr. X. =I do believe that today you are here to get schedule for your upcoming hip surgery. Before that, I've been told to ask you few questions regarding your health condition and to assess how fit you are for your surgery and anaesthesia so that we can take appropriate measure accordingly. Are you okay with that? Assess respective concern Mr. X, how’re you feeling today? Is your leg hurting much? I'm so sorry to hear that. I understand you are passing through a difficult situation right now. Past medical history & medication history May I know, Mr. X, whether you have been diagnosed with some medical conditions or not? Do you have any chronic illness? (The patient will bring his prescription and drug list & will tell you to check this. Don't take it; instead, assure him you will check his file once your conversation is finished). (Now ask elaborately about those conditions that the patient says one by one) Diabetes How long has it been? Is it under control? Which medication do you take? Dose? How long? Do you have any problems with your feet and hand? Any numbness? Anything wrong with your Vision? Asthma / COPD How long has it been? Is it under control? Which medication do you take? Dose? How long? (ask specially for steroids and inhalers) Cardiac issues, Hypertension How long has it been? Is your HTN under control? Which medication do you take? Dose? How long? Do you have any issues with your heart? Are you attending your cardiology doctor and warfarin clinic regularly? 5. Past surgical history Have you undergone any surgeries before? (H/O CABG 2 years back, pacemaker insertion 4+ years ago, left nephrectomy 7 years ago) Was there any problem with surgeries or anaesthesia? If yes, what was that? Personal history Who do you live with? Do you smoke? If yes, how many cigarettes & how long? Do you take alcohol? If yes, how many units & how long? General fitness & systemic review How far can you walk normally before breathlessness stops you? Is it for pain or are there any other issues? Do you take physiotherapy? Ask for constitutional questions as part of systemic review. Now patient may ask you some questions, for example, “Doctor, when will | be scheduled for my hip surgery? My daughter's wedding is in 2 weeks, Please get me scheduled.as soon as possible”. Your answer would be, “Mr. X. I completely appreciate your concern. Please pardon me, but I can’t tell you my thoughts right now, As you have several medical & surgical conditions and you're on various medications, to ensure a safe surgery and safe anaesthesia for you, we must optimize your health condition and medications first. Considering these, I think you're not fit for this major surgery at this moment. Mr. X, I assure you that I will discuss about your surgery with my consultant as soon as possible, We need to discuss and seek opinions from endocrinologists, pulmonologists, cardiologists, physiotherapists, and urologists (depending on the history) about optimizing your health condition before surgery. Only after the opinion from MDT, we can schedule the date for your hip surgery.” PRESENTATION Mr. X, a 62-year-old man, came to SOPD for the awaiting THR. On preoperative assessment, he is noted to have DM/HTN/COPD/CAD. He has a past surgical history of CAG and pacemaker insertion 2 years back, CABG 4 years back and right nephrectomy 4 years back. In addition, he is commenced on warfarin and oral prednisolone, Considering his past medical and surgical history, he is not fit for surgery this week as he needs an opinion from MDT, and his warfarin and steroid which need to be optimized along with his comorbidities. Is the patient fit for surgery? Why do you think like that? I don’t think Mr. X is fit for surgery and anaesthesia. Because of having Significant cardiac history (CABG, Pacemaker) HTN COPD Diabetes Patient is on warfarin that must be bridged Patient is on steroids which should be optimized to prevent Addisonian crisis What are your differentials for hip pain at this age? I would consider OA RA AVN Paget's disease of bone Neoplasm Septic arthritis How will you optimize his conditions before operation? What are your considerations pre-operatively for this patient? I will discuss with MDT Diabetes control (see OR listing station) HTN control with opinion from cardiologist Pre-op pacemaker setup control (sce OR listing station) Reversal of warfarin (see OR listing station) Asthma’ COPD optimization (see OR listing station) Steroid optimization (see ASSCC steroid station) Optimize pre-op fluid and electrolyte imbalance as he has only one kidney Pre- and post-operatively under supervision of physiotherapist Pre-op thromboembolic prophylaxis (risk factors include orthopaedic operation, patient may have polycythemia due to COPD)

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S — Situation “Hello, it’s David, the SHO on Ward 4G. I’m calling about Mrs Eleanor Thompson, DOB 15/06/1942, who is post-operative day 2 following a right mastectomy with axillary lymph node clearance. She has developed new right axillary swelling, discomfort, and mild shortness of breath, and I’m concerned about a possible early postoperative complication.” B — Background “She has moderate COPD, mild left ventricular failure, and hypertension. Her surgery two days ago was uneventful with 150 mL blood loss, and a drain was inserted. Since yesterday, her temperature has been slowly rising from 36.9 to 37.2 today. Importantly, the drain has had no output today, and the axilla appears swollen and mildly tender. Her daughter is requesting discharge today due to family childcare pressures, but given the clinical changes I feel this is unsafe.” A — Assessment “On examination, she has a swollen right axilla, mild tenderness, and no drain output. Her pain is controlled, and observations are otherwise stable apart from very mild temperature rise. Her bloods today show: WCC 10.2, Hb 11.5, platelets 230. My concern is a postoperative seroma, haematoma, or possibly early infection, or a blocked drain. Given her comorbidities and mild SOB, I also want to rule out cardiopulmonary causes.” R — Recommendation “I’d like you to review her urgently, please. I’d appreciate guidance on whether to: Attempt drainage (needle aspiration) or re-site/flush the drain, Start empirical antibiotics, Arrange ultrasound of the axilla, And confirm whether you agree she should not be discharged today. Could you please come to review her on Ward 4G, or advise on the next immediate steps?”

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@evehiclefan@mathstodon.xyz Contents (NAVEL) Femoral Nerve, Femoral Artery, Femoral Vein, Femoral canal (Empty space), Lymphatics

@florianecaffart @Photosaurus hi hi merci !

Spinal Stenosis Doctor Instruction: Your next patient is a 51-year-old woman called Rebecca, presenting with lower back pain. Please take a history and perform an appropriate examination. Patient History: Rebecca, a 51-year-old female, nurse You have always been having lower back pain for the past few years, but this has been getting gradually worse. The pain is dull and intermittent. Very often, the pain can diffuse and radiate towards the buttocks, back of the thighs, and feet - when this happens, the pain feels like a burning or cramping sensation. It can be associated with weakness in both legs. The symptoms can be triggered or worsened by sitting down, standing straight and walking downhill. It goes away after a few minutes after being at rest. Bending forward improves symptoms. You tried paracetamol, which only helped a little with pain. If you walk for more than 50 yards, you will start noticing numbness and weakness in your legs. No previous injury/trauma. Waterworks normal. The bowels are working normally. No other abnormal sensations or weaknesses. No incontinence. No stiffness. No fever. No weight loss. No night sweats. Ideas, Concerns, Expectations: You think because you often have to bend your back due to work, the pain may be caused by poor posture. You are concerned because it is starting to affect your ability to work in the hospital as a nurse. You would like to see if you can get stronger painkillers and possibly have a scan of your back. Past Medical History: Obesity, hypercholesterolemia, acromegaly, T2DM. No past relevant surgical history. Drug History: Atorvastatin, metformin NKDA. Family History: Father has ankylosing spondylitis. Social History: You work as a senior nurse in a local hospital. You smoke around ten cigarettes daily for over ten years but don't drink alcohol. Live with husband in a semi-detached house. Independent. Examination Findings: Lower spinal tenderness on palpation at L4-5 region. Complete motor and sensory neurological examinations are normal. Features of acromegaly e.g. enlarged hands, feet and facial features. Lower limb vascular examination is normal. No cervical tenderness or restricted movement. Gait normal. No cauda equina syndrome features. Peripheral pulses and ABPI normal. Differentials: Lumbar spinal stenosis - likely to be due to degenerative changes Osteoarthritis of the spine To rule out cauda equina syndrome Ankylosing spondylitis/spondylolisthesis Rule out peripheral arterial diseases Other causes of back pain: spinal tumour, disc herniation, trauma, fracture, and epidural abscess. Investigations: Imaging: XR Lumbar spine (may show degenerative changes/spondylolisthesis) MRI Spine. Alternatively, CT myelography/spine when MRI is not available or unsuitable. Consider ABPI / CT angiogram to exclude peripheral arterial disease where intermittent claudications are present. Special tests: Consider electromyographic (EMG) walking test - increased F latency values in lumbar spinal stenosis Consider electromyographic paraspinal mapping Management: Conservative: Exercise Weight loss if overweight Physiotherapy e.g. exercises that minimally stress the back, such as walking, swimming, or bicycling. Exercise may also strengthen the paraspinal muscles. NSAIDSs e.g. naproxen, celecoxib +/- PPI cover / antacids Paracetamol Medication for neuropathic pain e.g. amitriptyline, gabapentin, pregabalin. Consider oral steroids for acute exacerbation of painful symptoms. Activity modification e.g. limit heavy lifting/prolonged sitting/repetitive bending/twisting of the back. Consider deep heat therapy with massage to relieve spasms associated with back pain Surgical: Consider decompression surgery +/- fusion e.g. laminectomy ( removal of the lamina from affected vertebra) followed by physiotherapy Consider interspinous distraction procedure to reduce backward movement of the spine. Consider epidural injections with local anaesthetic and corticosteroids under specialist guidance for short/long-term pain relief. Viva Questions: Explain the pathophysiology of spinal stenosis. Spinal stenosis is the narrowing of the spinal canal, which holds the spinal cord and nerves. It's often due to age-related disc degeneration, arthritis, and thickened ligaments. This narrowing can compress the spinal cord and nerves, leading to pain, numbness, and weakness. Factors like herniated discs and inflammation worsen the compression. Treatment involves pain management, physical therapy, and sometimes surgery to relieve pressure on the nerves and spinal cord. At what level of the spine does spinal stenosis occur most commonly? Spinal stenosis most commonly occurs in the lumbar (lower back) region of the spine. This is because the lumbar spine bears the most weight and undergoes significant movement, which can contribute to degenerative changes over time. Lumbar spinal stenosis can result in compression of the spinal cord and nerve roots, leading to symptoms such as lower back pain, leg pain, numbness, and weakness. However, spinal stenosis can also occur in the cervical (neck) and thoracic (mid-back) regions of the spine, albeit less frequently. What are the causes of spinal stenosis? Degeneration of spinal structures due to aging. Disc degeneration and herniation. Osteoarthritis and bone spurs. Thickened ligaments. Congenital factors and genetics. Injuries and trauma. Tumors or abnormal growths. These factors narrow the spinal canal, compressing nerves and causing stenosis symptoms. What are the risk factors of spinal stenosis? Age: Risk increases with aging. Genetics: Family history matters. Congenital: Narrow canal from birth. Injuries: Past spine trauma or surgery. Lifestyle: Heavy lifting, certain jobs. Obesity: Excess weight strains spine. Diseases: Arthritis, diabetes, etc. Scoliosis: Abnormal spine curvature. What are the red flag symptoms/signs of back pain? Neurological Issues: Weakness, numbness, or tingling. Bladder/Bowel Problems: Loss of control. Severe Pain: Unbearable or unrelenting. Fever: Along with back pain. Unexplained Weight Loss: Rapid and unintended. Cancer History: Especially if pain is new. Night Pain: Worse at night. Trauma: After injury or accident. Age Over 50: New-onset pain. Steroid Use: Especially long-term.