Session 1 9.45 AM Anterior Abdominal Wall
Facilitator: AP Joachim Perera
Clinical Trigger I (30 minutes)
A 25-year-old man presents to a surgical clinic with a dull, ‘dragging’ pain in his left groin, which has persisted for some months. A lump is felt at the medial end of his left groin extending to the scrotum. The lump increases in size when he stands up and when coughing. The doctor diagnoses of him having an indirect inguinal hernia.
Areas of discussion:
§ Anatomy of the inguinal canal and scrotum
§ Inguinal mechanisms in preventing hernias
§ Anatomical basis of direct and indirect inguinal hernias
§ Anatomical basis of differentiating between inguinal and femoral hernias
Questions of interest:
How much of the inguinal canal is traversed by an indirect inguinal hernia?
Which structure lies immediately medial to the deep inguinal ring?
Which layer covering the spermatic cord corresponds to the Internal Oblique muscle of the anterior abdominal wall?
How would you identify the Vas Deferens clinically in the living subject?
Which anatomical structure causes femoral hernia to get strangulated very often?
Facilitator: AP Joachim Perera
Clinical Trigger I (30 minutes)
A 25-year-old man presents to a surgical clinic with a dull, ‘dragging’ pain in his left groin, which has persisted for some months. A lump is felt at the medial end of his left groin extending to the scrotum. The lump increases in size when he stands up and when coughing. The doctor diagnoses of him having an indirect inguinal hernia.
Areas of discussion:
§ Anatomy of the inguinal canal and scrotum
§ Inguinal mechanisms in preventing hernias
§ Anatomical basis of direct and indirect inguinal hernias
§ Anatomical basis of differentiating between inguinal and femoral hernias
Questions of interest:
How much of the inguinal canal is traversed by an indirect inguinal hernia?
Which structure lies immediately medial to the deep inguinal ring?
Which layer covering the spermatic cord corresponds to the Internal Oblique muscle of the anterior abdominal wall?
How would you identify the Vas Deferens clinically in the living subject?
Which anatomical structure causes femoral hernia to get strangulated very often?
Clinical trigger II (10 minutes)
Given below is a picture of a small tense and tender mass in the right groin of a 70-year-old woman.
She presented with clinical features intestinal obstruction.
Diagnose the condition. Explain anatomical reasons for the diagnosis.
Clinical trigger III (30 minutes)
A 50 years old man presented with generalized abdominal pain of one day’s duration. He has a history of constant upper abdominal pain and heartburn for last 2 years, which was often relieved by over-the-counter antacids.
An erect X ray of the abdomen was done which showed gas shadow under the right dome of the diaphragam.
What is the most proble diagnosis?
Given below is a picture of a small tense and tender mass in the right groin of a 70-year-old woman.
She presented with clinical features intestinal obstruction.
Diagnose the condition. Explain anatomical reasons for the diagnosis.
Clinical trigger III (30 minutes)
A 50 years old man presented with generalized abdominal pain of one day’s duration. He has a history of constant upper abdominal pain and heartburn for last 2 years, which was often relieved by over-the-counter antacids.
An erect X ray of the abdomen was done which showed gas shadow under the right dome of the diaphragam.
What is the most proble diagnosis?
Areas of discussion:
Based on the picture given below, discuss lesser sac, greater omentum and greater sac
Structure and blood vessels of stomach
Based on the picture given below, discuss lesser sac, greater omentum and greater sac
Structure and blood vessels of stomach
Questions of interest:
A surgical incision through fundus of stomach will require clamping of which artery?
Which artery is lying in close relation to lesser sac and is well visible because of tortuous nature?
Why ulcers are more common over lesser curvature of the stomach?
Session 2 11.00 AM Head Injuries
Facilitator: Dr Nilesh Kumar
Clinical Trigger IV (30 minutes)
A 15-year-old baseball player was hit by a baseball over the right temple area. He lost consciousness briefly but woke up after about 45 seconds and had no neurological deficits. He was taken to the emergency room and seemed to be in good condition.
Four hours later, while being observed, he complained of an increasing headache and had a seizure. On examination, the patient’s right pupil appeared dilated and reacted sluggishly to light. The neurosurgeon was concerned about the increased intracranial pressure.
What is the most likely diagnosis?
Areas of discussion:
· Anatomical explanation of the causative condition causing increased intracranial pressure.
· Arrangement of the meningeal layers in the cranial cavity
· Dural folds and intracranial venous sinuses (Related structures of importance)
· Vascular supply to the meninges
· Anatomical explanation of the causative condition causing increased intracranial pressure.
· Arrangement of the meningeal layers in the cranial cavity
· Dural folds and intracranial venous sinuses (Related structures of importance)
· Vascular supply to the meninges
Questions of interest:
What are the vessels, which carry infections from the scalp to the venous sinuses?
What is the danger area of the face? Why is it called so?
How can a scalp injury produce a black eye?
Clinical trigger V (30 minutes)
One morning, while shaving, a 65-year-old industrial worker noticed in the mirror that he was unable to elevate his left upper eyelid. The doctor found the left eyelid to be drooped (ptosis). He also told the doctor that left side of his face was flushed and felt warm but there was no sweating even in the intense heat of the factory. The doctor observed that the left side pupil was constricted and the other eye was unaffected.
The man’s medical record showed that he was a heavy smoker. The doctor advised a chest radiograph, which revealed a shadow at the apex of the left lung indicative of a cancer.
Explain the anatomical basis of the patient’s presenting symptoms.
What are the vessels, which carry infections from the scalp to the venous sinuses?
What is the danger area of the face? Why is it called so?
How can a scalp injury produce a black eye?
Clinical trigger V (30 minutes)
One morning, while shaving, a 65-year-old industrial worker noticed in the mirror that he was unable to elevate his left upper eyelid. The doctor found the left eyelid to be drooped (ptosis). He also told the doctor that left side of his face was flushed and felt warm but there was no sweating even in the intense heat of the factory. The doctor observed that the left side pupil was constricted and the other eye was unaffected.
The man’s medical record showed that he was a heavy smoker. The doctor advised a chest radiograph, which revealed a shadow at the apex of the left lung indicative of a cancer.
Explain the anatomical basis of the patient’s presenting symptoms.
Areas of discussion:
· Discussion about the structures of the head and neck affected to produce the symptoms
· Pathway of direct and consensual light reflex
· Nervous mechanism of sweating
Session 3 1.00 PM Neck Lymph nodes, Deep cervical fascia
Facilitator: Dr Daw Khin Win
Clinical Trigger VI (30 minutes)
A 50 years old farmer came to the OPD with a lump in the left side of the neck. He noticed the lump about 2 weeks ago. It was not tender nor had any discharge. He also noticed he had been salivating a lot and had a sore on the side of his tongue. He has a habit of chewing tobacco since he was 30 years old and he also used to smoke 3 to5 cigarettes daily.
On examination, the patient’s jugulo-digastric nodes were found to be enlarged. They were mobile, not fixed to the surrounding tissue, not tender but stony hard. The examining doctor also found an ulcer on the left side of the anterior two third of the tongue.
Areas of discussion:
Extrinsic and intrinsic muscles of the tongue
Nerve supply of the tongue - sensory, motor
Lymphatic drainage of the tongue
Superficial and deep lymph nodes of head and neck
MSKCC (Head and Neck Service at Memorial Sloan-Kettering Centre) method of describing nodal groups of level I to level V
Clinical trigger VII (30 minutes)
A 45-year-old labourer presented with a lump in his right axilla. It was small at first but increased in size slowly during the past one month. Now pus was coming out from a small sinus from the lump and it had become tender. He said he felt hot and sweaty in the evenings.
On taking past medical history, it was found that he had been losing weight and had sever pain in his neck when he moved his neck. He said he was under antiTB treatment regime for a swelling of neck lymph glands about 5 years ago and stopped the treatment about 3 years back.
He was admitted to drain the abscess and for further investigations.
Explain the anatomical basis for the patient’s presenting symptoms
· Discussion about the structures of the head and neck affected to produce the symptoms
· Pathway of direct and consensual light reflex
· Nervous mechanism of sweating
Session 3 1.00 PM Neck Lymph nodes, Deep cervical fascia
Facilitator: Dr Daw Khin Win
Clinical Trigger VI (30 minutes)
A 50 years old farmer came to the OPD with a lump in the left side of the neck. He noticed the lump about 2 weeks ago. It was not tender nor had any discharge. He also noticed he had been salivating a lot and had a sore on the side of his tongue. He has a habit of chewing tobacco since he was 30 years old and he also used to smoke 3 to5 cigarettes daily.
On examination, the patient’s jugulo-digastric nodes were found to be enlarged. They were mobile, not fixed to the surrounding tissue, not tender but stony hard. The examining doctor also found an ulcer on the left side of the anterior two third of the tongue.
Areas of discussion:
Extrinsic and intrinsic muscles of the tongue
Nerve supply of the tongue - sensory, motor
Lymphatic drainage of the tongue
Superficial and deep lymph nodes of head and neck
MSKCC (Head and Neck Service at Memorial Sloan-Kettering Centre) method of describing nodal groups of level I to level V
Clinical trigger VII (30 minutes)
A 45-year-old labourer presented with a lump in his right axilla. It was small at first but increased in size slowly during the past one month. Now pus was coming out from a small sinus from the lump and it had become tender. He said he felt hot and sweaty in the evenings.
On taking past medical history, it was found that he had been losing weight and had sever pain in his neck when he moved his neck. He said he was under antiTB treatment regime for a swelling of neck lymph glands about 5 years ago and stopped the treatment about 3 years back.
He was admitted to drain the abscess and for further investigations.
Explain the anatomical basis for the patient’s presenting symptoms
Areas of discussion:
Prevertebral and post vertebral muscles
Superficial cervical fascia — nerves and vessels
Arrangement of deep fascia of the neck
Investing layer of deep cervical fascia
Pretracheal layer and its importance
Fascial compartments of the neck
Prevertebral space
Prevertebral and post vertebral muscles
Superficial cervical fascia — nerves and vessels
Arrangement of deep fascia of the neck
Investing layer of deep cervical fascia
Pretracheal layer and its importance
Fascial compartments of the neck
Prevertebral space
No comments:
Post a Comment