Surgery OSCE

Papillary thyroid cancer

●​ Presenting Complaint and Associated Symptoms:
○​ Can you describe any symptoms you've been experiencing? How long have you
noticed these symptoms? Have you noticed any lumps or swelling in your neck?
Has it changed in size since you first noticed it? Difficulty swallowing or
breathing? Have you had any changes in your voice, such as hoarseness? Have
you experienced any neck pain?
●​ General Symptoms
○​ Have you experienced any unexplained weight loss or gain?
○​ Have you noticed any changes in your energy levels or fatigue?
○​ Have you experienced any night sweats or fevers?
●​ Review of Systems:
○​ Have you experienced any other symptoms like headaches, changes in vision, or
difficulty breathing?
●​ Medical History:
○​ Have you had any previous thyroid problems or treatments?
○​ Do you have a history of radiation exposure, particularly to the head or neck
area?
○​ Have you had any other cancers or significant medical conditions?
●​ Family History:
○​ Is there a family history of thyroid cancer or other cancers?
○​ Are there any other thyroid disorders in your family?
●​ Social History:
○​ Do you smoke or have you smoked in the past?
○​ How much alcohol do you consume?
○​ What is your occupation? Have you been exposed to any hazardous materials?
●​ Explanation of Diagnosis: I'm sorry to tell you that the biopsy results indicate you have
papillary thyroid cancer. Papillary thyroid cancer is the most common type of thyroid
cancer and tends to grow slowly. The good news is that it generally has an excellent
prognosis with appropriate treatment. I understand this news can be overwhelming, but I
want you to know that we're here to support you through this journey. I understand this is
a lot to take in. Take your time to absorb this information
●​ Treatment Plan: The next step is to discuss treatment options with you. The first step in
treatment is typically surgical removal of the thyroid gland, called a thyroidectomy. Given
the size of your tumor, which is around 4 cm, we will likely recommend a total
thyroidectomy to ensure all cancerous tissue is removed. During the surgery, we will also
examine nearby lymph nodes to see if the cancer has spread and remove them if
necessary.
○​ Complications: Bleeding, hypocalcemia, hoarseness
 ○​ Radioactive Iodine Therapy: In some cases, additional treatments such as
radioactive iodine therapy or chemotherapy may be necessary. This treatment
helps to destroy any remaining thyroid tissue or cancer cells.
○​ Thyroid Hormone Replacement Therapy: Since your thyroid will be removed,
you will need to take thyroid hormone replacement pills for the rest of your life.
This medication will help maintain your metabolism and prevent
thyroid-stimulating hormone (TSH) from stimulating any remaining cancer cells.
○​ Monitoring and Follow-up: Regular follow-up appointments will be essential.
We will use blood tests to monitor your thyroid hormone levels and look for any
signs of cancer.
○​ Closing: Please don't hesitate to ask any questions you may have. It's important
that you feel informed and comfortable with the treatment plan. Let's schedule a
follow-up appointment to discuss any further questions you may have and to plan
the next steps in your treatment.
●​ Malignancy criteria? Solid, hypoechoic, highly vascular, irregular margins,
microcalcifications, taller than wide, ectopic, cold nodule
●​ Case 1 <1 cm, 1 nodule, no LAP — do lobectomy
●​ Case 2 >or= 2 cm, 1 nodule, no LAP — seeding risk — do total thyroidectomy
●​ Case 3 >or= 4 cm, 1 nodule, no LAP — total thyroidectomy + prophylactic central neck
dissection (level 6) for the lymph nodes (even though the USG didn’t show any LAP)
●​ Case 4 < 1 cm, 1 nodule, LN+ (thickened cortex, lost hilus, and irregular margins) — for
central neck LN don’t do FNAC — just do total thyroidectomy and CND
●​ Case 5 2 nodules in separate lobes; suspicious looking on the USG — do biopsy of both
and depending on the result do either lobectomy or total thyroidectomy
○​ But if there are 10 nodules, just do biopsy of the most suspicious one
●​ Case 6 Multiple nodules and CN LAP and LN LAP — do thyroidectomy and CND and
perform biopsy of the most suspicious LN in the lateral neck with thyroglobulin washout
to show metastasis
○​ If on both lateral necks then do one biopsy on the most suspicious node on each
side
●​ Case 7 < or = 1 cm, 1 nodule, only lateral neck LN — perform biopsy to lateral neck —
total thyroidectomy, CND, and LND and also later do radioiodine ablation therapy
(because there are some cancer cells that we can’t see with our eyes)
●​ If the patient is younger than 55 yo, even if there is distant metastasis, the TNM
grade is still two
●​ MEN syndromes: which type with which organs, ret mutation, calcitonin and CEA have
to be checked in medullary cancer and urine metanephrines for pheochromocytoma —
directly total thyroidectomy and CND — for lateral neck? Tg doesn’t work then what do
you? If you see suspicious LN just do LND and perform ipsilateral neck dissection even if
there is no suspicious nodule if calcitonin is >100 if >200 do bilateral LND
Acute cholecystitis (normal total bilirubin 1.2 and direct 0.3)
●​ Differentials: emphysematous, acalculous cholecystitis, necrosis, perforation and
peritonitis,
●​ Consider Gilbert’s syndrome (inherited hyperbilirubinemia) if bilirubin is high but the
stone is small and asymptomatic
●​ Acute cholecystitis summary: Severe RUQ pain radiating to back +/− scapular pain,
persistent (>4–6 hours), fever, tachycardia, Murphy’s sign; thickened gallbladder wall,
pericholecystic fluid; less pronounced elevation in bilirubin and ALP levels
●​ Acute cholangitis summary: Persistent RUQ pain, fever, jaundice (Charcot’s triad);
chills; elevated bilirubin and ALP levels, and bile duct dilation on imaging
●​ Symptomatic cholelithiasis summary: RUQ pain radiating to the back after fatty
meals, resolves within a few hours, female, multigravida, obese
●​ Chief complaint and associated symptoms:
○​ Socrates: describe, how long, constant or comes and goes, better or worse
○​ Change in urine color; like darkening
○​ Changes in stool color; pale or clay colored
○​ Any episodes of jaundice (yellowing of skin and eyes)
○​ Have you had any fever or chills
○​ Do you feel nauseous or have you vomited
○​ Have you noticed any itching
●​ Medical history:
○​ Have you had any previous episodes of similar pain?
○​ Do you have a history of gallstones or biliary tract disease?
○​ Have you had any recent surgeries, especially abdominal surgeries?
○​ Do you have any history of chronic diseases like hypertension, or diabetes? Do
you have any history of liver disease, such as hepatitis or cirrhosis?
●​ Medications and allergies:
○​ Are you currently taking any medications?
○​ Do you have any allergies, particularly to medications?
○​ Have you taken any antibiotics recently?
●​ Social history:
○​ Do you drink alcohol? If so, how much and how often?
○​ Do you use any recreational drugs?
○​ What is your diet like? Do you consume a lot of fatty foods?
●​ Family history:
○​ Do you have any history of serious or chronic disease in your family? What about
a history of liver or gallbladder disease?
●​ Review of symptoms:
○​ Do you have any other symptoms such as weight loss, fatigue, or appetite
changes? Do you have any other symptoms that concern you?
●​ Tests to order: CBC, CRP, Liver Function Tests (ALT, AST, GTT, ALP, bilirubin), may
look at amylase lipase if there is any suspicion of pancreatic pathology
○​ Cholangitis: USG first then MRCP or EUS (endoscopic ultrasonography)
EUS can see stones that MRCP might have missed in the distal ducts
 ○​ Cholecystitis: USG then Hepatobiliary Iminodiacetic Acid (HIDA) Scan
○​ Tumor suspicion: CT and painless palpable gallbladder (Courvoisier's sign)...
●​ Explanation:
○​ Based on your symptoms and the results of your tests, it appears that you have a
condition called acute cholangitis. This is an infection of the bile ducts, which
are the tubes that carry bile from your liver to your gallbladder and intestines. The
infection is usually caused by a blockage, often due to a gallstone or narrowing of
the bile ducts.
○​ Based on your symptoms and test results, it appears that you have acute
cholecystitis. This is an inflammation of your gallbladder, typically caused by a
gallstone blocking the cystic duct. This blockage leads to swelling and infection of
the gallbladder.
●​ Importance:
○​ Acute cholangitis is a serious condition that requires prompt treatment to prevent
complications such as severe infection or rupture of the gallbladder or
pancreatitis due to the blockage of the ducts. It’s important that we start
treatment immediately to manage the infection and relieve the blockage.
●​ Treatment:
○​ Cholangitis: The main components of your treatment will include: bowel rest
(NPO), spasmolytics (dicyclomine) if severe pain, antiemetics if vomiting,
antibiotics to fight the infection and IV fluids to keep you hydrated and support
your body while it fights the infection. We will provide pain relief to help manage
your discomfort (NSAIDs) but we need to address the underlying cause of the
blockage. We first have to confirm the size and location of the stone with MRCP
(magnetic resonance cholangiopancreatography). This usually involves a
procedure called ERCP (Endoscopic Retrograde Cholangiopancreatography),
where we use a flexible tube with a camera to remove the blockage. In some
cases, surgery might be needed.
○​ Cholecystitis: In most cases, the best treatment for acute cholecystitis is to
remove the gallbladder. This procedure is called a cholecystectomy and is
usually performed laparoscopically, meaning with small incisions and a camera.
This minimally invasive approach helps with a faster recovery. Within 72 hours
stabilize, do differential diagnosis then do the surgery. Also, if unstable or
unsuitable for surgery then do percutaneous cholecystostomy first (you don’t
remove for 6 weeks).
●​ Follow-up & Monitoring:
○​ We will closely monitor your vital signs, blood tests, and overall condition while
you are in the hospital. Our goal is to ensure that the infection is controlled and
that you recover as quickly and safely as possible.
●​ Questions and Reassurance:
○​ Do you have any questions about your condition or the treatment plan? We are
here to help and support you through this process. Please let us know if there is
anything you need.
●​ Closing:
 ○​ Thank you for your attention. We will keep you informed about each step of your
treatment. You are in good hands, and we are committed to helping you get
better.

If smaller than 2 cm and asymptomatic - follow up

If larger then surgery
Colon cancer (descending colon, left lower quadrant pain and rectal bleeding);
Invasive Gastric Adenocarcinoma
For metastatic colorectal cancer, start with systemic chemotherapy (targeted according
to pathology in stage 4 especially)
Must recommend lifestyle changes; obesity, malnutrition
●​ Presenting Symptoms:
○​ Can you describe the pain you're experiencing? When did you first notice the
pain? Is the pain constant or does it come and go?
○​ Does anything make the pain better or worse? How severe are your symptoms
on a scale of 1 to 10?
○​ Have you noticed any blood in your stool? If yes, what color is the blood?
○​ Have you experienced any changes in your bowel habits (e.g., diarrhea,
constipation)?
○​ Do you have any signs of gastrointestinal bleeding, such as black or bloody
stools or vomiting blood?
○​ Do you have any feelings of incomplete evacuation after a bowel movement?
○​ Do you have any pain with swallowing? What about early satiety?
●​ Associated Symptoms:
○​ Have you experienced any unintentional weight loss? How much weight have
you lost and over what period of time?
○​ Have you had any changes in appetite?
○​ Do you have any difficulty swallowing?
○​ Have you noticed any fatigue or weakness?
○​ Do you have any nausea or vomiting? If so, how often and what do you vomit?
●​ Medical History:
○​ Do you have any history of gastrointestinal disorders (e.g., irritable bowel
syndrome, inflammatory bowel disease, peptic ulcer disease, or
gastroesophageal reflux)
○​ Have you been diagnosed with any other chronic conditions (e.g., diabetes,
hypertension)?
○​ Have you had any previous colonoscopies or other gastrointestinal procedures?
○​ Do you have a history of any previous surgeries, especially abdominal surgeries
○​ Do you have any history of polyps or previous cancer diagnoses?
○​ Gastric:
■​ Are you currently taking any medications, including over-the-counter
drugs and supplements?
■​ Have you used any non-steroidal anti-inflammatory drugs (NSAIDs)
frequently?
●​ Family History:
○​ Colon:
■​ Does anyone in your family have a history of colon cancer or other
cancers?
■​ Are there any hereditary conditions in your family (e.g., familial
adenomatous polyposis, Lynch syndrome)?
 ○​ Gastric:
■​ Is there any history of cancer in your family, particularly stomach cancer?
■​ Do any close relatives have a history of gastrointestinal diseases?
●​ Social History:
○​ Do you smoke or use tobacco products?
○​ How often do you consume alcohol?
○​ What does your typical diet look like?
○​ Have you had any significant stress or changes in your life recently?
●​ Review of Systems:
○​ Have you had any recent fevers or night sweats?
○​ Have you noticed any lumps or masses in your abdomen?
●​ Differential Diagnosis for Colon:
○​ Colorectal Cancer; Diverticulitis; Inflammatory Bowel Disease (Crohn's Disease,
Ulcerative Colitis); Ischemic Colitis; Infectious Colitis; Hemorrhoids; Anal Fissure;
Colon Polyps
●​ Differential Diagnosis for Gastric:
○​ Gastric Adenocarcinoma; Peptic Ulcer Disease; Gastroesophageal Reflux
Disease (GERD); Gastritis; Esophageal Cancer; Pancreatic Cancer; Gallbladder
Disease; Lymphoma
●​ Physical Examination Findings: pallor, cachexia, jaundice, vital signs, abdominal
examination (inspection, auscultation, palpation, percussion), Check for supraclavicular
(Virchow’s node), axillary, and inguinal lymphadenopathy, rectal inspection and DRE
●​ Explanation:
SPIKESS
○​ Based on your symptoms of left lower quadrant pain and rectal bleeding, we
need to conduct further tests to understand what might be causing these issues.
These symptoms can be due to several conditions, including colorectal cancer,
which we need to rule out or confirm. The next steps will include blood tests,
colonoscopy/esophagogastric endoscopy with biopsy, and imaging studies such
as CT. And for gastric cancer endoscopic USG.
●​ Management:
○​ First, it's important to know that we have a multidisciplinary team that will be
involved in your care, including oncologists, surgeons, nutritionists, and other
specialists. Our goal is to create a comprehensive treatment plan tailored to your
specific condition and needs.
○​ Once we have our results, we can create a comprehensive management plan. If
the tests confirm cancer, the treatment plan may include: Surgery to remove the
cancerous section of the colon (or gastrectomy); Oncologist Consultation to
discuss additional treatments like chemotherapy or radiation therapy if
necessary; and Regular follow-ups will be crucial to monitor your health and
ensure the best possible outcomes.
○​ The prognosis depends on the stage of the cancer and how well it responds to
treatment. Early-stage cancers have a better prognosis, while advanced stages
are more challenging. However, treatments have improved significantly, and
 many patients respond well to therapy. We will do everything we can to provide
the best possible outcome for you.
○​ In esophageal we do chemoradiotherapy then surgery. But in gastric we just do
chemotherapy then surgery same for colonoscopy.
●​ Reassurance and Support:
○​ I understand this can be overwhelming, but please know we are here to support
you every step of the way. Early diagnosis and treatment significantly improve
outcomes, and we will ensure you receive the best care possible. Do you have
any questions or concerns about these steps?
○​ Alright. I will have my team coordinate the next steps and make sure you are
well-informed throughout the process. We are in this together.

First neoadjuvant treatment then surgery.

Appendicitis/Diverticulitis
●​ Pain Characteristics:
○​ When did the pain start?
○​ Can you describe the pain (sharp, dull, constant, intermittent)?
○​ Where did the pain start, and has it moved? (Typically, starts around the navel
and then moves to the right lower quadrant)
○​ How severe is the pain on a scale of 1 to 10?
○​ What makes the pain better or worse (movement, coughing, lying still)?
●​ Associated Symptoms:
○​ Have you experienced nausea or vomiting?
○​ Do you have a loss of appetite?
○​ Any changes in bowel habits (diarrhea or constipation)?
○​ Have you had a fever or chills?
●​ Past Medical History:
○​ Have you had any previous episodes of similar pain?
○​ Do you have any known medical conditions or previous surgeries?
●​ Medications and Allergies:
○​ Are you currently taking any medications?
○​ Do you have any allergies, particularly to medications?
●​ Family History:
○​ Is there any family history of gastrointestinal diseases or appendicitis?
●​ Social History:
○​ Do you smoke, drink alcohol, or use recreational drugs?
●​ Differential Diagnosis for Appendicitis:
○​ Gastroenteritis; Mesenteric adenitis; Crohn’s disease; Meckel’s diverticulum;
Perforated peptic ulcer; Gynecologic; Genitourinary
●​ Physical Examination: distress, discomfort, fever, abdominal exam (McBurney’s point,
rebound tenderness, guarding
●​ Imaging: Enlarged appendix (>6 mm in diameter), wall thickening, periappendiceal fat
stranding (inflammation of the fat surrounding the appendix), presence of an
appendicolith, and periappendiceal fluid collection or abscess.
●​ Management:
○​ Based on your symptoms and the findings from our examination, it appears that
you have appendicitis, which is the inflammation of the appendix. This is a
serious condition that requires urgent surgical intervention to remove the
inflamed appendix. The treatment is the surgical removal of the appendix with a
minimally invasive laparoscopic surgery which results in a faster recovery and
less postoperative pain. After the surgery, you will likely stay in the hospital for
one to two days for monitoring. Most patients can return to normal activities
within a few weeks, but we will provide detailed postoperative care instructions.
○​ Do you have any questions or concerns about the diagnosis or the treatment
plan?
○​ I will arrange for you to be admitted to the hospital immediately for surgery. The
surgical team will explain the procedure in detail and answer any questions you
may have. In the meantime, please do not eat or drink anything, as surgery may
be scheduled soon. If you have any questions or concerns, please let me know.
Our goal is to address this condition promptly and ensure your well-being.
Breast ca (maybe DCIS; maybe male w/ mammography reading and
interpretation)
●​ On mammography: suspicious areas such as bright white specks (microcalcifications)
that are in a cluster and have irregular shapes or sizes
Benign prostate hyperplasia (CVT, Glob vesicale, if infection with fever
hospitalize)

1. Initial Evaluation:

●​ History and Physical Examination: Detailed medical history focusing on lower urinary
tract symptoms (LUTS) such as frequency, urgency, nocturia, weak stream, hesitancy,
and incomplete emptying. Assessment of risk factors and impact on quality of life.
●​ Digital Rectal Examination (DRE): To assess the size, shape, and consistency of the
prostate gland.

2. Symptom Assessment:

●​ International Prostate Symptom Score (IPSS): A questionnaire to quantify the severity

of symptoms and their impact on daily life.

3. Urine Tests:

●​ Urinalysis: To rule out infections, hematuria, and other urinary abnormalities.

●​ Urine Culture: If infection is suspected.

4. Blood Tests:

●​ Prostate-Specific Antigen (PSA): To help differentiate BPH from prostate cancer.

Elevated levels may warrant further investigation.
●​ Serum Creatinine: To assess renal function and rule out obstructive uropathy.

5. Imaging Studies:

●​ Transabdominal Ultrasound: To evaluate bladder volume and post-void residual urine

(PVR).
●​ Transrectal Ultrasound (TRUS): To measure prostate volume and detect any
abnormalities.

6. Urodynamic Studies:

●​ Uroflowmetry: To measure the flow rate of urine, indicating the degree of obstruction.
●​ Pressure-Flow Studies: To assess bladder pressure during urination, helping to confirm
the diagnosis and severity of obstruction.

Differential Diagnosis

●​ Prostate Cancer: Distinguished by PSA levels, DRE findings, and possibly biopsy if
indicated.
●​ Urinary Tract Infection (UTI): Diagnosed by urinalysis and urine culture.
●​ Bladder Stones: Identified through imaging studies.
 ●​ Neurogenic Bladder: Diagnosed based on neurological examination and urodynamic
studies.

Management

Lifestyle Modifications:

●​ Reduce fluid intake before bedtime.

●​ Limit caffeine and alcohol consumption.
●​ Double voiding to ensure bladder emptying.

Medical Treatment:

●​ Alpha Blockers (e.g., tamsulosin, alfuzosin): To relax prostate smooth muscle and
improve urine flow.
●​ 5-Alpha Reductase Inhibitors (e.g., finasteride, dutasteride): To shrink the prostate
by reducing hormonal stimulation.
●​ Combination Therapy: For patients with larger prostates or more severe symptoms.

Minimally Invasive Procedures:

●​ Transurethral Microwave Therapy (TUMT): Uses microwave energy to shrink prostate

tissue.
●​ Transurethral Needle Ablation (TUNA): Uses radiofrequency energy to ablate prostate
tissue.

Surgical Treatment:

●​ Transurethral Resection of the Prostate (TURP): The gold standard for severe BPH,
involves removing prostate tissue through the urethra.
●​ Laser Therapies (e.g., HoLEP, GreenLight): Use laser energy to vaporize or enucleate
prostate tissue.

Regular follow-up appointments are necessary to monitor symptom progression and treatment
effectiveness. This includes reassessing IPSS scores, repeating DREs, and evaluating any new
or worsening symptoms. Adjustments to the treatment plan may be made based on follow-up
findings and patient feedback.
Bladder ca w/ differentials
●​ Presenting Symptoms:
○​ Could you describe the hematuria (amount, frequency, clots)
○​ When did hematuria start? How long has it been ongoing?
○​ Any pain?
○​ Constitutional: fever, weight loss, night sweats?
○​ Urinary Symptoms: frequency, urgency, or hesitancy; dysuria, ?
○​ Timing: Is the blood at the beginning, throughout, or end of urination?
○​ Triggers: Any recent trauma, exercise, or infections?
●​ Past Medical History:
○​ History of urinary tract infections, kidney stones, or renal disease
○​ Any previous episodes of hematuria
○​ History of chronic illness
○​ Previous surgeries or procedures
○​ Current medications; do you use any anticoagulants?
○​ Allergies
○​ Smoking and alcohol
○​ Occupational exposure to chemicals or dyes
○​ Recent travel history (risk for certain infections)
●​ Family History:
○​ Any family history of kidney disease, cancers (especially bladder or kidney
cancer), or hematuria

Investigations
Based on your symptoms of blood in the urine or hematuria, we need to conduct further tests to
determine the underlying cause and ensure that we address it properly. These are going to be:

●​ Urinalysis: To confirm hematuria, detect infection, proteinuria, or casts.

●​ Urine Culture: If infection is suspected.
●​ Urine Cytology: To detect cancer cells.
●​ Blood Tests:
○​ Complete blood count (CBC) to check for anemia or infection.
○​ Renal function tests (creatinine, BUN) to assess kidney function.
○​ Coagulation profile if the patient is on anticoagulants.
●​ Imaging:
○​ Ultrasound: Initial imaging for assessing the kidneys and bladder.
○​ Cystoscopy: Direct visualization of the bladder and urethra, typically done if
initial tests suggest bladder pathology.

Differential Diagnosis
There are several potential causes of hematuria, and our investigations will help us narrow
down the possibilities. Here are some of the main conditions we need to consider:

●​ Stones, Infections, Malignancy, Trauma, Coagulopathy (meds)

Management

Stones
Small : hydration and pain relief, tamsulosin, and observation
Large : it is likely to require surgical intervention like: shock wave lithotripsy, ureteroscopy or
percutaneous nephrolithotomy

Bladder Cancer
Cystoscopy w/ biopsy and CT to check for metastasis
Non-Muscle-Invasive Bladder Cancer (NMIBC): Managed primarily with TURBT,
intravesical therapy, and close surveillance.
Muscle-Invasive Bladder Cancer (MIBC): Requires more aggressive treatment with
radical cystectomy, neoadjuvant chemotherapy, and potential chemoradiation.
Metastatic Bladder Cancer: Managed with systemic chemotherapy, immunotherapy,
targeted therapy, and palliative care.

●​ Regular Monitoring: For patients with recurrent or unexplained hematuria.

●​ Specialist Referral: As needed based on the underlying diagnosis (e.g., urology,
nephrology).
●​ Imaging and Cystoscopy: Follow-up imaging and cystoscopy as required based on
initial findings and ongoing symptoms.
●​ Patient Education: Importance of follow-up and adherence to treatment plans.