1. Objective structured clinical examination (OSCE)
Presented by
Dr.MOHAMMED MAREE
Surgical Department
Al-Makassed Hospital

2. Urine exit to urine bag here Inflate the balloon here
Foley's catheter
Balloon

4. Types and sizes of catheters
Diameters: 6fr, 8fr 10fr, 12fr, 14fr, 16fr, 18fr, 20fr, 22fr, 24fr, 26fr, 28fr
The higher the number the larger the diameter of the catheter.
1Fr. = 0.33mm (i.e. a 24fr. catheter is 8mm in diameter)

5. Types: Straight-single use catheters
Have a single lumen with a small 1¼ cm opening.
2-way Foley catheters (retention catheters)
Have an inflatable balloon that encircles the tip

6. Curved or Coude
Catheters have a rounded curved tip (elbowed) used in older male patients with enlarged prostates which partially obstruct the urethra.

7. 3-way Foley catheter
Have 3 lumens that encircle the body of the catheter.
One lumen drains the urine through the catheter into a collection bag.
The second lumen is used to inflate and deflate the balloon.
The third lumen may be used to instill medications into the bladder or provide a route for continuous bladder irrigation.

8. Urinary Catheter Indications:
1-Urinary retention.
2- Monitoring Urine Output.
3-Urine Incontinence.
instill medications into the bladder or
Continuous bladder irrigation.
Contra-indications:
1- Suspected Urethral Injury.
2- Pelvic Fracture.

9. T-Tube

10. T-Tubes Indications: Are those of exploration of the common bile duct:
Stones in the CBD
Dilated CBD on US.
History of jaundice.
History of pancreatitis or cholangitis.
Small gallbladder stones, with large cystic duct.

11. Nasogastric tube

13. NGT Tube Indications:
Decompress the stomach to prevent acute gastric dilatation.
Decompress the stomach, as a preparation for DPL.
Vomiting from intestinal obstruction or pyloric stenosis.
Enteric Feeding.
Prevention of GOR.
Protection of surgical anasmatosis in the esophagus
Pre-operative preparation.

21. Sengsatken-blakmore Tube

23. Pericardiocentesis Indications:
Cardiac Tamponade
Penetrating chest trauma.
Pericardial effusion.
Complications:
Laceration of coronary artery or vein.
Cardiac arrhythmia.
Puncture aorta, vena cava or esophagus.
Pericarditis.

24. Under-water seal

25. Chest Tube Indications:
Penumothorax
Hemothorax.
Pneumohemothorax.
Surgical emphysema.
Large pleural effusion.
Empyema.
Post-operative in thoracic surgery.

26. Removal: When it stops draining.
Complications:
Infection.
Injury to intercostals artires and veins.
Mediastinal or subcutaneous emphysema.
Local cellulites
Local hematoma.
Removal: When it stops draining.

27. ERCP

35. Peripheral Vascular (PVS) Examination
Begin by washing your hands.
a general observation of the patient
general appearance of the legs
muscle wasting
scars.
patient’s legs, feet and toes

36. Ulcers (venous or arterial )
painless or painful
Any skin changes
varicose eczema
sites of previous ulcers
varicose veins (seen best with the patient standing.)

37. palpating the legs temperature of each leg(Starting distally)
Check capillary return
If abnormal perform Buerger’s Test, This involves raising the patient’s feet to 45 degrees. In the presence of poor arterial supply, pallor rapidly develops

38. you should feel abdominal aorta peripheral pulses: Femoral Popliteal
Finally for palpation,
you should feel
abdominal aorta
peripheral pulses:
Femoral
Popliteal
Posterior tibial
Dorsalis pedis

39. auscultate in a peripheral vascular examination.
Listen for femoral and abdominal aortic bruits

51. “beak-like” appearance
Achalasia
“beak-like” appearance

52. Heller’s Myotomy

53. barium study of the upper GI tract
Para esophageal hernia

54. HIATAL HERNIA

57. DDx 75% of patients of perforated peptic ulcer
Post operation (laparotomy or laparoscopy)

58. Perforated peptic ulcer
Graham patch technique

59. control of bleeding ulcer

64. asking the patient to rest her hands on her thighs
general inspection of both breasts
skin changes (peau d’orange, eczema).
any asymmetry, scars, obvious lumps or swellings and any nipple abnormalities (e.g. inversion or discharge)
Ask the patient to place her hands above her head and repeat the inspection
Again perform a general inspection, this time with the patient placing her hands on her hips and pushing inwards to tense the pectoralis muscles
Ask the patient to lie down with her arms by her side, and again repeat the general inspection.

65. Examine each breast individually
Examine each breast individually. If you have been told about any abnormality then start on the “normal” side. Ask the patient to place her hand behind her head on the side you are examining
Systematically examine all areas of the breast with your hand laid flat on the breast. Start from outside and work towards the nipple. Imagine that the breast is a clock face and examine at each ‘hour’.
Don’t forget that the breast tissue extends towards the axilla in the ‘axillary tail’.
Palpate the nipple and the tissue deep to it to check for any lumps.  If the patient has reported a nipple discharge you could ask her to try and reproduce this at this stage.
Swapping which hand is behind the patient’s head, you should now examine the other breast in the same manner.
Examine both axillae for any enlarged lymph nodes (you may wish to put on gloves for this part of the examination).

66. Whilst examining the patient’s axilla, you should fully support the weight of that arm with yours. Examine the axilla with your other hand ensuring that you feel all four walls (anterior, posterior, medial and lateral) as well as feeling into the apex of the axilla.
Palpate the supraclavicular fossa on both sides to check for lymphadenopathy.

67. An extension to this station would be the investigation of a breast abnormality such as a lump.  For this you should understand what is meant by “triple assessment” , which is usually performed at an outpatient clinic.
Clinical examination
Imaging
Biopsy
Imaging modality will primarily depend upon the patient’s age. Younger women have denser breast tissue and so the use of mammography is of limited use; in these patients ultrasound is the best first form of imaging. Older patients may undergo both mammography and/or ultrasound.
If there is any abnormality detected in the examination, or imaging, then biopsies are taken. This can be in the form of FNAC (Fine Needle Aspiration Cytology) or a core (Tru-Cut) biopsy. If neither of these provide a reliable answer then an open surgical biopsy may be required.

68. Cullen’s
Grey-turners

70. Corkscrew O. in diffuse O. spasm