A guide to the Practical Section of the Surgery State Exam

Introduction

The State Exam in Surgery (held in Sixth Year at MU Pleven) is a lengthy, challenging and difficult exam. However, with a focus on the right tips and a little bit of confidence, the exam can be a successful and rewarding experience. This article focuses on some high yield tips to get you prepared for the practical section of the exam in a systematic and structured manner, including an overview of the exam itself.

Exam Overview

The State Exam in surgery is composed of three sections. The first section is the practical exam where you are expected to examine a patient and report the findings and suggest a treatment and investigations pathway, along with a tentative diagnosis. The second section is the written section, where you will have a Multiple Choice Question Paper along with essays from topics selected from all areas of Surgery (General Surgery 3rd Year, General Surgery 5th Year, Orthopedics, Urology and Vascular Surgery). The third section is an oral interview section, which, arguably, is the most difficult section of all the three sections.

Tips for the practical section of the State Exam in Surgery

The practical section of the State Exam in Surgery is the first section and is the test of your clinical judgement in surgery. It is a test to see if you are familiar with the process of diagnosis for surgical patients.

Examining Patients

Note: It is imperative that you speak to and examine patients in a precise but complete manner. This means that you need to take an adequate history (Anamnesis) and perform a full surgical physical exam. Below is a simplified structure to aid you in your approach to the patient.

1. Anamnesis and Presenting Complaint

   1. Name and Age of the patient

   2. Their chief complaint that brought them to the hospital.

   3. Remember the SOCRATES method for pain

      1. Site

         1. Where is the Pain?

      2. Onset

         1. When did the pain start?

      3. Character

         1. Is the pain dull or sharp?

      4. Radiating

         1. Does the pain radiate to any other part of the body?

      5. Associations

         1. Does the patient have any other symptoms, such as fever, nausea, vomiting, diarrhoea, dehydration, etc

      6. Time course

         1. Does the pain change with time, is the pain worse in the mornings or evenings?

      7. Exacerbating or Relieving Factors

         1. Exacerbating factors: Does something worsen the pain? For example, does eating make the pain worse? Does movement make the pain worse?

         2. Relieving Factors: Is there anything that reduces the pain? For example, does eating, or changing positions relieve the pain?

      8. Severity

         1. On scale of 1 to 10, how would you rate the pain?

   4. Relevant History

      1. It is essential to ask the patient for a relevant history.

      2. Surgical History

         1. Does the patient have constipation, or diarrhoea?

         2. Does the patient have changes in bowel habit, and if so, what kind of changes are they? (It is helpful to show them the Bristol Stool Chart)

         3. Has the patient undergone any operations?

         4. Does the patient have a prior diagnosis of any kind of surgical pathology? The most common ones are listed below:

            1. Cancer

            2. Gallstones

            3. Pancreatitis

            4. Constipation

            5. Ileus

      3. Medical History

         1. In this section, it is important to ask the patient if they have any medical conditions and if they are taking any medications

         2. Most commonly there are two types of medical history that you should always ask about

            1. Cardiac History

               1. Does the patient have any cardiovascular diseases and if so what medications do they take?

               2. Do they take any Anti-coagulants?

                  1. This is relevant anti-coagulants affect the bleeding risk of patients.

            2. Medical History of Diabetes

               1. Ask the patient if they have been diagnosed for Diabetes and if so what medications do they take.

               2. A very important question to ask if they take insulin for their diabetes.

2. Examining the patient

   1. Perform a full General Surgical Examination

      1. Examine the abdomen thoroughly and note any physical signs.

      2. Examine the Cardiovascular System

         1. Auscultate the heart and lungs and report your findings.

   2. A focussed examination of the limbs

      1. To examine the limbs, it is important to note changes in the skin over the limbs and assess whether there are ulcers, inflammations or lesions.

      2. It is very important that you palpate the Dorsalis Pedis Artery in the lower limb to assess whether there is adequate blood flow there.

3. Reporting on the patient

   1. To report on the patient, it is important that you report the findings in a succinct manner. A template is given below:

      1. Name, Age and Presenting complaint. A brief word on their history.

      2. Physical Examination findings

         1. Abdominal Exam findings

         2. Cardiovascular and Respiratory exam findings

Algorithms to remember

This section has some algorithms to remember that will help you with reporting on the patient and presenting an investigation and management plan to the attending surgeon.

1. Patients with Abdominal Pain

   1. Blood Tests

      1. Complete Blood Count

      2. Urine

      3. Electrolytes

      4. A full biochemical panel

         1. ALT, AST

         2. Bilirubin

         3. Amylase, Lipase

         4. Alkaline Phosphatase

         5. Urea and Creatinine

      5. Inflammatory Markers

         1. CRP

         2. D-Dimer (if the patient has a history of stroke or other Cardiovascular Diseases)

      6. Albumin and Proteins

   2. Imaging Work-up

      1. Chest X-Ray

      2. Abdominal X-Ray

      3. Abdominal Ultrasound

   3. Endoscopic Investigations

      1. Fibrogastroduodenoscopy

      2. Fibrocolonoscopy

2. Patients with Melaena

   1. Note: Patients with Melaena will describe their stools as dark, almost black. Melaena is vastly different from Rectorraghia which is bleeding per rectum

   2. Physical Exam: You should recommend or perform a Digital Rectal Exam and report the colour of the stool.

   3. Blood Tests

      1. Complete Blood Count

      2. Urine

      3. Electrolytes

      4. A full biochemical panel

         1. ALT, AST

         2. Bilirubin

         3. Amylase, Lipase

         4. Alkaline Phosphatase

         5. Urea and Creatinine

      5. Inflammatory Markers

         1. CRP

         2. D-Dimer (if the patient has a history of stroke or other Cardiovascular Diseases)

      6. Albumin and Proteins

   4. Imaging Work-up

      1. Chest X-Ray

      2. Abdominal X-Ray

      3. Abdominal Ultrasound

         1. Abdominal Ultrasound in patients with Melaena is performed to investigate the presence of free fluid within the abdominal cavity.

   5. Endoscopic Investigations

      1. Fibrogastroduodenoscopy

      2. Fibrocolonoscopy

   6. Patient with Rectorrhagia, or Bleeding Per rectum

   7. Note: In patients who are bleeding per rectum, it is important to assess whether they have a fissure, hemorrhoids, or if they are bleeding due to a more serious Colorectal Pathology such as Large Bowel Cancer.

   8. Physical Exam: You should recommend or perform a Digital Rectal Exam and report the colour of the stool.

   9. Blood Tests

      1. Complete Blood Count

      2. Urine

      3. Electrolytes

      4. A full biochemical panel

         1. ALT, AST

         2. Bilirubin

         3. Amylase, Lipase

         4. Alkaline Phosphatase

         5. Urea and Creatinine

      5. Inflammatory Markers

         1. CRP

         2. D-Dimer (if the patient has a history of stroke or other Cardiovascular Diseases)

      6. Albumin and Proteins

   10. Imaging Work-up

       1. Chest X-Ray

       2. Abdominal X-Ray

       3. Abdominal Ultrasound

          1. Abdominal Ultrasound in patients with Rectorrhagia is performed to investigate the presence of free fluid within the abdominal cavity.

   11. Endoscopic Investigations

       1. Fibrogastroduodenoscopy

       2. Fibrocolonoscopy

3. Patients with Acute Pancreatitis

4. Note: The treatment of Acute Pancreatitis is largely supportive with bowel rest. Bowel rest implies that the patient is Nil By Mouth (Nil per oral). It is important to grade the severity of pancreatitis according to the Ranson Criteria (once at admission and then 48 Hours after Admission)

5. Physical Exam: You should ask the patient if the abdominal pain radiates to the back on the left side. This is specific for Acute Pancreatitis. If the pain is relieved by sitting forward, it is confirmation that the patient has acute pancreatitis. It is also important to assess for intra-abdominal blleding. Check for Cullen’s Sign: Periumbilical Bleeding, and Frank-Turner Sign: Retroperitoneal Bleeding evidenced by bruising or ecchymosis over the flank.

6. Blood Tests

   1. Complete Blood Count

   2. Urine

   3. Electrolytes

   4. A full biochemical panel

      1. ALT, AST

      2. Bilirubin

      3. Amylase, Lipase

      4. Alkaline Phosphatase

      5. Urea and Creatinine

   5. Inflammatory Markers

      1. CRP

      2. D-Dimer (if the patient has a history of stroke or other Cardiovascular Diseases)

   6. Albumin and Proteins

7. Imaging Work-up

   1. Chest X-Ray

   2. Abdominal X-Ray

   3. Abdominal Ultrasound

      1. Abdominal Ultrasound in patients with Acute Pancreatitis is to assess whether the cause of pancreatitis is Biliary Obstruction

      2. Abdominal Ultrasound can also assess for Intra-abdominal free fluid collections

   4. CT Scan Abdomen

      1. This is performed to assess whether the patient has necrotizing pancreatitis or if the patient has a pancreatic cyst. These are potentially life-threatening conditions and need to be assessed early.

Resources for further reading.

1. Oxford Handbook of Clinical Surgery

2. Surgical Recall

3. Clinical Algorithms in General Surgery

Lectures for last minute prep:

1. Stomach and Colorectal Surgery Essential Review

   1. Youtube Link

2. Colorectal Surgery Essential Review

   1. Youtube Link

3. HPB Surgery Essential Review

   1. Youtube Link