Clinical Surgery Case Assessment and Viva Preparation

Posted on May 1, 2026 in Medicine & Health

1. Left Diabetic Foot Ulcer

  • HOPI: Duration, mode of onset (trauma vs. spontaneous), pain status (painless suggests neuropathy; painful suggests ischemia).
  • Positive History: Long-standing DM, numbness/burning feet, blurred vision (retinopathy), claudication.
  • Negative History: No fever (rules out osteomyelitis/cellulitis), no rest pain.
  • Examination:
    • Local: Site, size, floor (slough/granulation), edge (punched out), discharge (serous/pus).
    • Vascular: Palpate dorsalis pedis and posterior tibial pulses (Absent = PVD).
    • Neurological: Monofilament test (loss of protective sensation).
  • Differential Diagnosis: Trophic ulcer, ischemic ulcer, venous ulcer.
  • Management: Debridement, offloading, glycemic control, antibiotics.

2. Right Breast Lump (with T2DM & HTN)

  • HOPI: Duration, rate of growth, pain (usually absent in malignancy), nipple discharge.
  • Positive History: Family history of breast/ovarian cancer, nulliparity, HRT use.
  • Negative History: No bone pain or cough (rules out metastasis).
  • Examination:
    • Lump: Size, consistency (hard = malignant), mobility (fixed to pectoralis/skin).
    • Lymph Nodes: Axillary nodes (fixed/matted).
  • Interpretation: Hard, fixed lump with axillary nodes suggests breast carcinoma.
  • Management: Triple assessment (clinical + imaging + FNAC/biopsy).

3. Obstructive Jaundice

  • HOPI: Yellowish discoloration, high-colored urine, clay-colored stools, pruritus.
  • Positive History: Pain (biliary colic = stones) vs. painless (malignancy, e.g., head of pancreas).
  • Negative History: No prodromal symptoms (rules out viral hepatitis), no blood transfusions.
  • Examination: Deep icterus, Courvoisier’s Law (palpable gallbladder in painless jaundice = likely malignancy).
  • Management: LFT (increased conjugated bilirubin & ALP), MRCP, ERCP for stenting.

4. Left 2nd Toe PVD

  • HOPI: Intermittent claudication (pain on walking, relieved by rest), rest pain (critical ischemia), discoloration.
  • Positive History: Smoking (strongest link), DM, HTN.
  • Examination: Temperature (cold limb), skin changes (shiny, hair loss), Buerger’s angle (<20° = severe ischemia).
  • Interpretation: Distal pulses (popliteal/dorsalis pedis) will be weak or absent.
  • Management: Smoking cessation, antiplatelets, walking exercise, revascularization.

5. Stoma (H/o TB)

  • HOPI: Reason for stoma (e.g., bowel obstruction/perforation), duration, type of output.
  • Positive History: Weight loss, evening rise of temperature, chronic cough (abdominal TB signs).
  • Examination:
    • Stoma: Site (RLQ = ileostomy; LLQ = colostomy), color (pink/red = healthy; dusky = ischemia), protrusion.
    • Peristomal skin: Check for excoriation/redness.
  • Management: Stoma care, AKT (anti-tubercular therapy) completion, planned reversal.

6. Congenital / Left Inguinal Hernia

  • HOPI: Swelling in the groin, appears on coughing/standing, disappears on lying down.
  • Positive History: Chronic cough, constipation, straining.
  • Negative History: No vomiting or absolute constipation (rules out strangulation/obstruction).
  • Examination:
    • Impulse on Cough: Present.
    • Deep Ring Occlusion Test: If swelling is controlled = indirect hernia; if it escapes = direct hernia.
  • Management: Herniotomy (children) or hernioplasty (adults).

7. Varicose Veins (Increased HbA1c)

  • HOPI: Dilated veins, aching pain at end of day, swelling, skin darkening (lipodermatosclerosis).
  • Positive History: Prolonged standing (occupation), family history.
  • Examination:
    • Trendelenburg Test: To check saphenofemoral competence.
    • Perthes Test: To check deep vein patency (crucial).
  • Interpretation: If Perthes is positive (pain/distension), do not operate on superficial veins.
  • Management: Compression stockings, laser/radiofrequency ablation, or stripping.