Medical Scenarios: Exam Clues

00:01 In the exam if you are getting a history along these lines, go for venous.

00:31 Diabetes. You know these are all the terminologies they use. The patient with ulcers at the tips of the toes, neuropathy, renal compromise, blah blah blah, diabetic. Okay, that's it.

00:45 Right. We’re done now. Now just to summarize, as you know, a lot of things we had to rush through. Despite that, we have finished by six o'clock. Now what you need to do is go back, revise all these things what we've discussed, things which I haven’t covered or we haven’t covered are the different types of cancers. Out of the cancers, we have covered melanoma in quite a bit detail, skin cancers are done. Colorectal cancers, we did. Breast, prostate and thyroid. Three things read up. Okay. Read about microbiology, it comes up. Other thing we haven't covered is diathermy.

01:37 Where would you suggest that we read up on microbiology, because you know none of the MRCS books have that and they are specifically asking what type of organisms, how does it work, what are the things going to be in there. You know, it’s not one question. It’s four or five usually.

02:04 My god.

02:05 Yeah, it’s like, what’s the organism or the inflammatory cell acting as well? Granulomas and -- Well, if you take, what if I take TB or something.

02:22 Well, this is it, if you read the scenario or something. It then asks you what type of inflammatory cell is most likely to be there. Okay.

02:31 So the microbiology, getting back to the point. Which reference book would you suggest? I don't think there's any book as I said. The only book we suggest is for part B, which is also applicable for part A is David Lowe's Surgical pathology book, which has got a section of microbiology. David Lowe. L-O-W-E. I think the book has been around for about ten years, David Lowe. He is a pathologist but he has covered the basics of microbiology in that section. We should use this for paper 2? No, no it is good for paper 1 as well. But definitely, it is used for paper 2. Have you guys have Andrew Raftrey’s book? Applied Basics Surgical, yes, and that has got a slightly good microbiology section. That's quite useful. I really can't think of any other book.

03:28 Anything else? I don't know when you do you do angioplasty over by-pass? Angioplasty, let’s take the femoral artery.

04:00 If you have a narrowing of the femoral artery, this is classically, you have little bit of flow there. You can do an angioplasty there just to dilate the blockage. But imagine you have an embolus blocking it completely. You can't do an angioplasty.

04:24 If there's no peripheral pulses palpable? Then angioplasty won't probably won't work.

04:28 There is reduced flow in the angiogram, then you can try to dilate, similar to the coronary angioplasty. You're just trying to dilate the blood vessel. But if it is completely blocked, either by an acute embolus, or a thrombus, then the only thing you can do is a by-pass. So if the options here are fem by-pass, or a fem distal by-pass.

04:52 You still do embolectomy? Yes, yes, embolectomy is classically done for the acute embolus, which is in one area. You're diagnosing it or seen it by either angiogram or CT or one of the investigations, and you just take the embolus out.

05:13 In an acute ischemic condition with no peripheral pulses palpable? Acute ischemic limb, no peripheral pulses palpable, then embolectomy. Embolectomy.

05:21 Definitely. And if there's femoral’s palpable. And they've decresead flow on the Doppler? Yeah. No, no, no, no, they'll give Doppler.

05:34 The other contraindication for angioplasty is diffuse disease. So patient has got disease there, disease here, disease here, then there's no point doing angioplasty, by-pass is the best option. But, if it’s three vessel disease? You can't. Well, triple vessel disease, you're really -- the only way -- No, in this situation, the only thing you can do is you can do that's when you go for distal bypass. Bypass from above the popliteal and go and anastomose to the posterior tibial or the dorsalis pedis or the anterior tibial. But triple vessel disease, diabetics who pretty much, it will end up in amputation, isn't it? Very unlikely. Axillary femoral by-pass, that's when you have iliac diseases. When you have high disease, aorto-iliac disease, so this is your aorta, iliac, femoral. Now this is diseased. What's the option? You can't go above the diaphragm, because you're opening the thorax. You won't do that, so the only other option is going from the axilla. So you're going to do an axillo-femoral bypass.

07:09 So axillo-femoral bypass is done for diffuse aorto-iliac disease.

07:19 From crossover bypass graft is, that you do quite higher up, just above the symphysis pubis. So this is here, the femoral artery.

07:54 It depends on the disease. You can't, you can't go back. Embolectomy is for acute. And a fem distal bypass is usually for a triple vessel disease. Okay.