Surgical

Examiner check list

2015 – 2016

Edited by:
Zaid Fadhil Jawad Dr.Hussein Ali
Stager F.I.C.M.S
College of Medicine / College of Medicine /
Wasit University Wasit University
Station 1 : Thyroid ; focused examination :
1 Greet the patient , introduce yourself , establish a plan
2 Inspection
3 Asked patient to swallow
4 Asked patient to protrude tongue
5 Moist palms ,skin
6 Tremor
7 Eye sign ( lid lag , lid retraction , exophthalmos , ophalmoplagia & chemosis )
8 Palpation from the front
9 Palpation from the back (size , shape , surface consistency , mobility )
10 Tenderness
11 Position of the trachea & examined for possible retrosternal extension
12 Cervical lymphadenopathy
13 Auscultation (bruit)
14 Thanks the patient

Station 2 : This 55 y. old male had history of loss of weight .Take a focused history :
1 Greet the patient , introduce yourself
2 duration
3 How many Kg/week or month was lost
4 Loss of appetite , weakness & easy fatigability
GI symptom ( dysphagia , vomiting , diarrhea ,constipation & change of bowel
5
motion )
Chronic bleeding ( hematemesis , melena , hematuria , vaginal bleeding &
6
hemoptysis )
Thyrotoxicosis symptom (intolerance to hot weather , sweating , tachycardia ,
7
palpitation& nervousness )
8 Past medical history ( D.M , Chronic illness )
9 Past surgical history ( previous surgery , tumor , chemotherapy & radiotherapy )
10 Psychological status
11 Thanks the patient

Station 3 : Difficulty of swallowing ; focused history :

1 Greet the patient , introduce yourself , establish a plan
2 Asked about onset of dysphagia
3 Asked about dysphagia to solid & liquids
4 Hematemesis or melena
5 Asked about site of sticking of food
6 Asked about regurgitation
7 Asked about position that aggravate regurgitation
8 Asked about smell ,taste & nature of regurgitation material
9 Asked about aspiration & chalking spills
10 Asked about history of respiratory infection
11 Asked about weight loss
12 Painful or painless dysphagia
13 Asked about previous hospitalization , medical illness & drugs
14 Family history & social history
15 Thanks the patient
Station 4 : obstructive Jaundice , focused history :
1 Greet the patient , introduce yourself , establish a plan
2 Asked about onset of Jaundice
3 Duration
4 Fluctuation
5 Progression
6 Fever & rigor
7 Loss of weight , loss of appetite
8 Pruritus
9 Change in urine color
10 Change in stool color
11 Past medical history , drug
12 Past surgical history
13 Family history & social history , smoking & alcoholic
14 Thanks the patient

Station 5 : Risk factor of breast cancer :

1 Greet the patient , introduce yourself
2 Age
3 Gender
4 Family history of breast cancer
5 Late menopause
6 Nullipaity
7 Age <35 at first birth
8 Hormone replacement
9 Post-menopausal obesity
10 Previous benign breast disease
11 Radiation exposure
12 Alcoholic use
13 Prior breast carcinoma
14 Atypical hyperplasia , carcinoma in situ
15 Thanks the patient

Station 6 : Causes of post operation fever :

1 Greet the patient , introduce yourself
2 At the same time ; transfusion reaction
3 At the same time ; drug reaction
4 Day 1 ; inflammation response to surgical truma
5 Day 2 ; atelectasis of the lung
6 Day 5 ; superficial and deep wound infection
7 Day 5 ; chest infection including viral respiratory tract infection
8 After day 5 ; intra-abdominal abscess
9 2 week ; urinary tract infection
10 2 week ; DVT
11 Any day ; thromboembolism
12 Thanks the patient
Station 7 : Repeated vomiting ; focused history :
1 Greet the patient , introduce yourself
2 Duration
3 Frequency
4 Vomitus ( amount , content , character )
5 Regurgitation
6 Bile stained
7 Blood , clot
8 Relation to meal ( intermediately , after , projectile any time )
9 Bowel motion ( diarrhea , constipation & melena )
10 Abdominal pain ( character , site , ……)
11 Jaundice
12 Fever , rigor
13 Weight loss
14 Past history ( PU , gall stone , endoscopy , previous surgery )
15 Drug history ( anticoagulant , aspirin )
16 Social history ( smoking , alcoholic )
17 Thanks the patient

Station 8 : DVT ; focused examination :

1 Greet the patient , introduce yourself
2 Inspection ( redness , pallor , other skin changes )
3 Leg swelling , edema
4 Trauma( wound , bruises )
5 Varicose vein , ulcer , pigmentation
6 Palpation ( temp. ,compare side )
7 Percussion of tenderness
8 Presence of tenderness
9 Arterial pulses ; dorsalis pedis
10 Femoral and popliteal pulses
11 Hoffman's sign
12 Examination of both leg
13 Thanks the patient

Station 9 : Differences between Crohn disease & Ulcerative colitis :

UC CD Done Not
1 colon Any part
2 Smoking is protective Smoking is risk factor
3 Mucosal disease Full thickness of the bowel
Confluent disease in the colon and Skip lession
4
rectum
5 No Structuring and fluctuation
6 No granuloma Granulomas
7 no Perianal disease
8 Watery diarrhea with blood Symptom mimicking appendicitis
9 Resection cure Stricture-plasty
10 No Recurrence is common
Station 10 : Change in bowel motion ; focused history :
1 Greet the patient , introduce yourself
2 Nature of bowel habit ( diarrhea , constipation )
3 Duration
4 Onset (sudden or gradual )
5 Tenesmus
6 Mucus
7 Weight loss
8 Nausea / Vomiting
9 Blood in the stool ( Bright red , mixed with stool , dark )
10 Past medical history of previous episodic , Drug history
11 Past surgical history
12 Social history
13 Thanks the patient

Station 11 : Post-operative examination :

1 Greet the patient , introduce yourself
2 Asked about pain , nausea , vomiting & mobility
3 Facial appearance , dehydration
4 Vital sign ( Pulse , Temp. , B.P , Resp. rate )
5 Chest examination ( infection )
6 Abdominal examination ( distension , bowel sounds )
7 N/G tube
8 I.V line fluid
9 Urine output
10 Dressing
11 Drains & other ( colostomy )
12 Thanks the patient

Station 12 : Focused examination of a subcutaneous mass :

1 Greet the patient , introduce yourself
2 Site , size , shape
3 Surface ( smooth or irregular ) , edge ( distinct or not )
4 Change of overlying skin ( inflamed , sinus )
5 Temp.
6 Tenderness
7 Consistency ( solid , cystic )
8 Mobile or fixed
9 Fluctuation & fluid thrill
10 Trans-illumination
11 Pulsation or not ( expansible & transmitted pulsation )
12 Compressibility & reducibility
13 Auscultation ( Bruit )
14 Regional lymph node ( palpable or not , tender , soft , firm or hard )
15 Thanks the patient
Station 13 : Acute cholecystitis ; History taking :
1 Greet the patient , introduce yourself
2 Site of the pain
3 Duration , onset , course , nature of pain
4 Referred , radiation
5 Nausea , vomiting
6 Aggravating or relieve factors
7 Fever , chills
8 Bowel motion , flatus
9 Bleeding per-rectum , melena
10 Previous attack
11 Previous medication ( NSAID )
12 Change in urine color
13 Previous surgery or endoscopy
14 Family history and social history
15 Thanks the patient

Station 14 : Examination of stoma in the abdominal wall :

Introduction
1 Greet the patient , introduce yourself , permission
2 Hand washing
3 Ask about any pain
4 Positioning and exposure
Inspection
5 Asked the patient to cough
6 Site of stoma
7 Shape ( spout or flush )
8 Lumen ( single or double )
9 Content ( liquid faces or solid faces or urine …. )
10 State of stoma mucosa ( healthy , ulcerative ischemic )
11 Surrounding skin ( normal , excoriated , erythematous )
12 Parastoma hernia
13 Prolapse or retraction
14 The previous surgery scar
Palpation
15 Any stenosis
16 Confirming weather single or double lumen
Finishing
17 Thanks and cover the patient

Station 15 : Chest tube ( Evacuation for removal ) :

Introduction
1 Greet the patient , introduce yourself , permission
2 Hand washing
3 Ask about any pain
4 Positioning and exposure
Inspection
5 Site of the insertion of the tube
6 Tissue surrounding of the insertion site (infection)
7 Under water seal position to the patient
 8 Checking the function of the chest tube
9 Type of fluid drained
Auscultation of both side
10 Anterior Auscultation
11 Lateral Auscultation
12 Posterior Auscultation
Indication for removal
13 Clinical
14 Mechanical
15 Radiological
Finishing
16 Thanks and cover the patient

Station 16 : Post-operative examination :

Introduction
1 Greet the patient , introduce yourself , permission
2 Hand washing
3 Ask about any pain
4 Positioning and exposure
Vital sign
5 Pulse rate
6 Blood pressure
7 Respiratory rate
8 Temperature
examination
9 Hydration state
10 Checking for the color change ( pallor , jaundice , cyanosis )
11 Auscultation of the chest anterior
12 Auscultation of the chest posterior ( lung base )
13 Inspection of the abdomen
14 Auscultation for the bowel sound
15 Examination of the lower limps for DVT ( pitting edema )
Tube checking
16 I.V access examination
17 Drain , NG tube
Finishing
18 Thanks and cover the patient

Station 17 : Abdominal pain/female ; History taking :

Introduction
1 Greet the patient
2 Introduce yourself
3 permission and establishing a plan for the visit
Pain history
4 Site
5 Radiation
6 Onset
7 Duration
8 Character
9 Severity
10 Aggravating factor
11 Relieving factor
12 Similar previous attack of pain
Associated symptom
13 Nausea
14 Vomiting
15 Change in bowel motion
16 Blood in stool
17 Urinary symptom
18 Fever
19 Jaundice
20 Vaginal discharge ( if the patient is female )
21 last period and possibility of being pregnant
Related history
22 Any systemic illness
23 Any medication
24 Any previous surgery
25 Family history
26 Alcoholism
27 Occupation
Finishing
28 Thanks and cover the patient

Station 18 : Examination of abdomen :

Introduction
1 Greet the patient , introduce yourself , permission
2 Hand washing
3 Ask about any pain
4 Positioning and exposure
Inspection
5 Movement with respiration
6 Position of umbilical
7 Ask the patient to cough ( visible cough impulse ? )
8 Description of colostomy
9 Site of stoma
10 Content of the collecting bag
11 Presence of the scar
Palpation
12 Asked the patient about painful area and starting away from it
13 Superficial palpation ( tenderness , guarding or rigidity , mass )
14 Deep palpation ( tenderness , masses , organ palpation )
Percussion
15 Over the mass
Auscultation
16 Bowel sound
Extra test ( only mentioned by the candidate )
17 groin
18 Gentalia
19 DRE
20 The back
21 Left supraclavicular lymph node
Finishing
22 Thanks and cover the patient

Station 19 : Examination of the lower limp :

Introduction
1 Greet the patient , introduce yourself , permission
2 Hand washing
3 Ask about any pain
4 Positioning and exposure
Inspection
5 The shape of the limp ( any amputation or gross joint or bone deformity )
6 Nail change ( brittle nails )
7 Skin change ( hair , color , dryness , thickening )
8 Ulcer or scar or sinuses
9 Muscle wasting
10 Edema
Palpation
11 Temp.
12 Pitting edema
13 Capillary refill
14 Abdominal aorta pulse
15 Femoral pulse
16 Popliteal pulse
17 Posterior tibial artery
18 Dorsalis pedis artery
Auscultation
19 Abdominal aorta bruit ( abdomen )
20 Femoral artery bruit ( groin )
21 Adductor canal
Neurological examination and special test
22 Sensory ( light and prick )
23 Motor
24 Ankle brachial pressure index ( ABPI )
25 Burger test
Finishing
26 Thanks and cover the patient

Station 20 : Breast mass ; History taking :

Introduction
1 Greet the patient
2 Introduce yourself
3 permission and establishing a plan for the visit
Breast mass history
4 Age of the patient
5 Site (which quarter and relation to the nipple )
6 Duration ( when the lump was discovered )
7 Onset ( how the lump was discovered )
8 Size ( any change in size )
9 pain
10 Skin change
11 Nipple change ( shape or discharge and color of discharge )
12 Breast size or shape change
13 Axillary lymph node
Associated symptom
14 Fever
15 Headache
16 Shortness of breath
17 Backache
18 Weight loss
Menstrual & obstetrical history
19 Age of menarche
20 Menses ? menopausal ?
21 Contraceptive pills or hormonal therapy
22 Parity
23 Breast feeding
24 Family history
Finishing
25 Thanks and cover the patient

Station 21 : Examination of thyroid :

Introduction
1 Greet the patient , introduce yourself , permission
2 Hand washing
3 Ask about any pain
4 Positioning and exposure
Thyroid goiter
Inspection
5 Swelling , scar , dilated vein
6 Asked the patient to swelling
7 Asked the patient to protruded the tongue
8 Arm raising for retrosternal goiter
Palpation
9 Tracheal position
10 Thyroid gland (anteriorly)
11 Thyroid gland (posteriorly)
12 Carotid pulse
13 cervical lymph node
Percussion
14 Clavicle and manubrium for retrosternal goiter
Auscultation
15 Over the upper pole of thyroid gland for bruit
Thyroid status
Hand signs
16 Outstretching the patient hand and finger for tremor
17 For temp. & sweating
18 Radial pulse
Eye signs
19 Lid retraction
20 Exophthalmos
21 Lid lag
22 Ophthalmoplasia
Legs signs
23 Pretibial myxedema
24 Ankle reflex delayed in hypothyroidism
Finishing
25 Thanks and cover the patient

Station 22 : Examination of hernia :

Introduction
1 Greet the patient , introduce yourself , permission
2 Hand washing
3 Ask about any pain
4 Positioning and exposure
Inspection ( in standing position )
5 Lump ( describe the lump )
6 Scar
7 Cough 1 for the affected side
8 Cough 2 for the contralateral side
Palpation
9 Can get above the swelling
10 palpation of the contralateral spermatic cord
11 Cough 3 for expansile palpable cough impulse
12 Cough 4 for any palpable impulse on the other side
13 Lump size
14 Lump shape
15 Lump overlying skin
16 Lump surface
17 Lump consistency
18 Lump tenderness
19 Lump reducibility
Auscultation
20 Bowel sound over the lump
Inspection ( in supine position )
21 Cough 5 for seeing the expansile impulse
Palpation ( in supine position )
Occlusion test ( land mark are ASIS , pubic symphysis , pubic tubercle , mid-point
22
of inguinal ligament , internal inguinal ring )
23 Three finger test
Finishing
24 Thanks and cover the patient

Station 23 : Examination of groin mass :

Introduction
1 Greet the patient , introduce yourself , permission
2 Hand washing
3 Ask about any pain
4 Positioning and exposure
Inspection
Asked the patient to breath ( from the right side of the patient ; movement with
5
the breathing ? )
 6 Asked the patient to cough ( from the end of the bed )
7 Inspection of the right groin with cough
8 Inspection of the left groin with cough
9 Head rising test ( to accentuate any hernia or diverticulum )
Palpation
10 Site
11 Margin
12 Shape
13 Can get above it or bellow it
14 Surface
15 Consistency
16 Temp.
17 Tenderness
18 Pinch the skin over it
19 Head rising test to establish the depth of the mass
20 Reducible
21 Compressible
22 Thrill or pulsation
Percussion
23 Over the mass
Auscultation
24 Over the mass
Finishing
25 Thanks and cover the patient

Station 24 : Communication skill :

A 65 y. old man present with recurrent vomiting and loss of weight for the last month , he recovered
after conservative management .His work-up investigation prove the presence of carcinoma of
stomach in the prepyloric region .you decided to plan for subtotal mastectomy. you are going to tell
him in Arabic word and convince him to accept our plan .
Self-introduction and greeting
Setting
1 Privacy
2 Ask for presence of family member or friend
3 sit down
Perception
4 Ask the patient what he knows about this condition
Invitation
5 Obtaining over permission
6 Respect patient right to know ( or not know )
Knowledge
7 Give your patient a warning that bad news are coming
8 Avoid technical or scientific language
Empathy
9 Downplay severity and give a more hopeful prognosis
Strategy and summery
10 Summarize the information in your discussion
Station 25 : Intestinal stoma :
Give 3 type of intestinal stoma
1 Colostomy
2 Ileostomy
3 Caecostomy or gastrostomy
Tell the potential immediate & long term complication of stoma
1 Bleeding
2 Ischemia & necrosis
3 High output & electrolyte disturbance
4 Obstruction
5 Retraction
6 Prolapse
7 Stenosis
8 Parastomal hernia
9 Skin excoriation
10 Fistula formation
11 Stone ( renal & gall ) formation