Gateway to Success in Surgery MD Ray
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1GATEWAY TO SUCCESS IN SURGERY2
3GATEWAY TO SUCCESS IN SURGERY
(Long and Short Cases, Commonly Asked Questions and Answers, Short Notes and Viva Tips)
MD Ray MBBS (Cal) MS (Surgery) DU Senior Research Fellow (Oncosurgery) ICMR Assistant Professor Army College of Medical Sciences New Delhi, India Forewords Sanjay Kapoor VSM AN Sinha
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This book has been published in good faith that the contents provided by the author contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the author specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the author. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device.
Gateway to Success in Surgery
First Edition: 2012
9789350252246
Printed at
5Dedicated to
My Parents and Guides Teachers, Friends, Followers and Students
Present, Past and future
6
7Foreword
It is heartening to see Dr MD Ray, compiled the book Gateway to Success in Surgery for the surgery residents and MBBS students as well. It is one of the greatest moments of my life, as he has been my student, and I feel really proud of him. Even at this young age, he has done what many of us want to do, but do not, since we suffer from a writer's block.
Academics has three stages, learning, teaching and writing and it is great to see him reach the third and final stage, so soon and I am sure that the book, meant for surgery residents and medical students, will be highly useful.
These three years of PG in the life of a surgeon are the most important, tough and full of struggle, long working hours and the pressure of work is killing, but most come out of it brilliantly, in spite of repeated thought of quitting on innumerable occasions. Resident means one who lives, and a resident practically has to live under the roof of the hospital during this period.
Postgraduation is multitasking. We have to learn many things. To assess a patient and reach a diagnosis, learn to operate and to study to pass examinations while working gives experience, but that is never enough. To pass examinations and even for assessing patient, one needs to know theory, studies are mandatory, as the eyes do not see what the mind does not know. I have innumerable books, but much of what we need in practice is not mentioned in it, and much of what is written is not practised, hence a balanced blend of work and reading are essential to pass examinations and to be a good surgeon—what this book is.
We may know the latest article and the most recent advances in a subject, but we fumble at the basics and these can only be cleared by bedside clinics, and I am really happy to see, that the short book has those simple, but important and commonly asked questions and answers and other tips to present a case successfully and to pass exams which are very useful for undergraduate and postgraduate students too.
Knowing theory is like making a skeleton, practices add flesh, but it is only experience that puts the soul. So learning is an ongoing process. First we learn when and how to operate, but we become good surgeons, only when we can also decide when not to operate.
I wish Dr Ray, the book and all the budding surgeons, who read this, all the best.
Brigadier Sanjay Kapoor vsm
Consultant, Professor
Surgery and Surgical Oncology
Indian Army
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9Foreword
It is my pleasure to write a foreword for Dr (Major) MD Ray's book Gateway to Success in Surgery. I know him for a couple of years but I feel, I know him for more than a decade. He worked with me for a few months and proved his worth.
I have gone through the proof of the book. I am very much sure that the book will help a lot both the undergraduate and postgraduate students. It is really a fantastic book for case presentation and truly it is the Gateway to Success in Surgery to pass out the surgery examinations, i.e. MBBS, MS, DNB, BAMS, BHMS, etc.
I also believe that general practitioners and surgeons will also be benefited to assess different common cases effectively.
I am sure that his book will be highly appreciated by the entire community of medical students and medical faculties too.
Professor (Dr) AN Sinha ms fais fics
DNB Examiner
Senior Consultant Surgeon and Former Head, Department of Surgery
VMMC and Safdarjung Hospital, New Delhi, India
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11About the Principal Editors of the Book
The principal editor of the book Dr (Colonel) Chandra Kishor Jakhmola, MBBS, MS, GI Surgery from AIIMS. He is one of the renowned GI surgeons of Indian Army. He is the most senior advisor in GI Surgery in the Army Medical Corps.
He has performed maximum number of advanced laparoscopic surgeries in Armed Forces. He has got more than 22 years vast experience in the surgical field, especially in GI surgery, advanced laparoscopic surgery, emergency and trauma surgeries.
He has also published a lot of papers in national and international journals. He is a renowned DNB teacher and examiner for the long time. He has been awarded different prestigious awards like Army Commander Award, VSM for his excellence in works.
Presently, he is working as a Professor, Army College of Medical Sciences and as a Senior Advisor, GI Surgery, Base Hospital, Delhi, India.
Despite of his busy schedule, he took a great interest to edit the book sincerely. The writer is ever grateful to him for his kind attention to make this book more rational and useful.
Dr GC Bhattacharya, MD (Pathology) 83 years old, a renowned pathologist, served Indian Air Force for decades. My recent friendship with Dr MD Ray, is an episode of “Love at first sight”. In age he is slightly elder than my grandson, but in professional knowledge he appears to be my “grandpa”. I pray his potential genius blossom into a future a Dr Bidhan Chandra Roy. In my versatile experience in every field of medical sciences and extraordinary knowledge of human physiognomy as a first pilot Doctor of Indian Air Force have been of some help to encourage him as a friend, philosopher and guide. I shall consider myself fortunate.
The book is a product of a genius, first of its kind in my knowledge. This is a pioneer venture with all sincerity and dedication under Dr MD Ray's command. I feel the name Gateway to Success in Surgery coined by him is appropriate and suitable. I prophecy and forecast that many many budding surgeons, medical students will feel fortunate to enter through this gateway into the kingdom of surgery.
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13Preface
Most people, the vast majority in fact, lead the lives that circumstances have thrust upon them, and though some repine, looking upon themselves as round pegs in square holes and think that if things had been different they might have made a much better showing, the greater part accept their lot, if not with serenity, at all events with resignation, I think they are like tram, cars travelling for ever on the self same rails. They go backwards and forwards inevitably, till they can go no longer and then are sold as a scrap iron.
My sincere effort to write the book is to make you an exceptional personality in the field of surgery through this Gateway to Success in Surgery. I feel the book will help all the medical students both undergraduates and postgraduates to present cases, better in examination and which is very very important to get through the exam door; I mean that is the Gateway to Success in Surgery.
I have also tried to include all the possible examination type questions and answers which will help the students to get through the exam very much. I will tell, there is no alternate way of hard work. So keep studying standard textbooks, and try to understand the subject and learn little but learn accurately forever.
Lastly, I will say, prove William Shakespeare's word in Macbeth wrong “it (life) is a tale told by an idiot, full of sound and fury, signifying nothing”.
Say with me, life is a tale told by a wise full of joy and merry signifying many things. Welcome for constructive criticism always.
All the best always.
MD Ray
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15Acknowledgments
I am ever and ever grateful to the following personalities for this book and for my career forever:
  1. Brigadier (Dr) Professor Sanjay Kapoor, a great oncosurgeon. He is overall a super human being and my research guide in oncosurgery under ICMR, New Delhi and he is my teacher always. His valuable lecture, notes are included in the book. Without his writing the book would have never been completed. He is a man of confidence in his professional as well as personal front of life too. He knows how to become an ideal guide always in life.
  2. Professor (Dr) AN Sinha, Senior Consultant Surgeon, and former Head, Department of Surgery, VMMC and Safdarjung Hospital, New Delhi, India, one of the editor of the book and my well-wisher all the way.
  3. Colonel (Dr) CK Jakhmola, GI Surgeon, the Principal Editor of this book who took a great pain to correct the book all the aspects. The way he encouraged for the book it showed his greatness and great heartedness. As a surgeon as well as a human he is really a big man. I am ever grateful to him.
  4. Professor (Maj General) RP Choubey, GI Surgeon, my MS guide and teacher. He was literally excited to see the publishing of my book. I am ever grateful to him also.
  5. Dr Amar Bhatnagar, MCh (Oncosurgery), Senior Consultant and Head, Department of Cancer Surgery, VMMC and Safdarjung Hospital, New Delhi, India, an excellent cancer surgeon, my teacher and guide in my path of career.
  6. Group Capt (Dr) Sharan Choudhuri, a great Oncosurgeon. To tell the truth, I have never seen such type of marvelous surgeries in my life. I am very much grateful to him for his exceptional teaching of standard surgery in my PG days and early days in Army College of Medical Sciences, New Delhi, India.
  7. Dr Pinaki Ranjan Debnath, Pediatric Surgeon, my constant inspiration to do well in life.
  8. Dr Suddhaswatya Chatterjee, Physician, who took special interest to complete this book at the earliest by guiding his wife to get the book typed very sincerely and Dr Sanjiv Kumar Gupta, Laparoscopic Surgeon, who took pain to correct the proofs of the book many times.
  9. Base Hospital, New Delhi, India, I am thankful to Col CK Jakhmola, Col SS Jaiswal, Wing Commander P Chatterjee, Maj Amit Agarwal, Lt Col Manoj Talreja, Col BC Nambiar, OT Metron, Capt Pactesia and specially Lt Col (Dr) Manish Nakra, Anesthesiologist and Intensivist, for their enthusiasm towards my book and me. I must give special thanks to them.
  10. Dean, Brig SS Anand, Dr Dibyajyoti Bora, Dr Prakash Rana, Dr Mitalee, Dr Sindhu, Dr Chitralekha, Lt Col S Ghatak, Dr Lalit Garg, Lt Col D Bandopadhyay, Lt Col Shusil Sharma, Dr SK Sharma, Dr Dayal, Dr Revthy, Dr Suchi, Dr Paras Gupta, Dr S Mata, Army College of Medical Sciences, New Delhi, India for their ever encouragements in all of my social and academic activities. Lab Assistant, Mr Gulav for assisting in paper work.
  11. Recently, a surprise fatherly figure joined in the list of friends mentioned above and became my friend, philosopher and guide all the way, he is Dr Gopal Chandra Bhattacharya, a renowned pathologist, a young man of 82 years who loves to encourage with all his versatile experiences in all field of life to all the talented persons he meets. His constant companionship was a welcome help to me in the publication of the book. I cannot but remember him forever.
My sincere thanks to Dr Garima Kapoor, Dr Sindhu Chandra (Gynecologists), Assistant Professors, ACMS for their contribution in the chapter ‘Pelvic Mass’ and Dr Amit Goyel for contributing in the short note ‘Laparoscopic Surgery – Recent Trends.’ My sincere thanks to all of my Doctors' friends, Baljinder Kaur, Himanshu, VK Mishra, Abhijit, Mohan, Sanjoy, Biswajit (Bishu), Manoj, SR Sahoo, Akash for their ever encouragements in all of my social and academic activities.
I am very thankful to my loving mother Saralashree Ray and my beloved wife Anisha Ray, Graded Classical Artist, All India Radio, for their constant sufferings and support to make this hard work possible. I am also very much thankful to my seven-year-old naughty son Mayukhraj, who is my astrologer and guide all the time. He always gives a positive astrology to get my every hardwork done. And definitely I am thankful to all of my family members and relatives, especially Mr PK Das, 16Mrs Urmimala Das, Amit Da, Boudi, Sima Das and elder sisters Mrs Kavita Bhattacharya, Kalpana, Suparna, Archana, Bandana, sisters Munny, Alpana, Dhriti, Chandrima, Sampa, Pampa, Tumpa, Tunu, Dr PK Chakraborty, Biswajit, Uttam, Sasanka, Subhas Da, Sibu, Subho, Santu, Tutun, Veltu, Swachhatoya, Munai, Diya, Kakima Sipra and Masima Partima Mukherji, dr Narayyan Bhattachaya for their ever encouragements in all events in my life.
I am very much thankful to Mr BC Dey more than my elder brother and Mrs Panchali Chatterjee, Mrs Bhawna Sharma, PK Yadav, Biswas Da, Mr Partha Gupta, who took a great pain to type this book very sincerely. Mr Swadhin Roy, artist and my students of ACMS especially Nandishwar, Rahul Ranawat, Pankaj Tiwary, Sumit Sachan, Pawan Kumar Gaba, Elly Verma put their sincere efforts in linediagrams and various aspects to complete the book. Without their sincere efforts the book cannot be handed over to the publisher.
My sincere thanks to Shri Jitendar P Vij (Chairman and Managing Director), Mr PG Bandhu (Senior Director–Sales), Mr Tarun Duneja (Director-Publishing), Mr KK Raman (Production Manager), Seema Dogra, Sunil Dogra (Production Executive), Neelambar Pant (Production Coordinator), Ms Samina Khan (PA to Director-Publishing), Akhilesh Kumar Dubey, Sarvesh Kumar Giri, Ankit Kumar, and Hemant Kumar of M/s Jaypee Brothers Medical Publishers (P) Ltd, for bringing this book to light. I will always welcome all the constructive criticisms from the sincere readers of this book.
Overall I am deeply indebted to all of my patients—present, past and future.
Thank you all very much.
21Basic Tips for Viva
  1. Proper dressing, simple, sober clothes
    Full sleeve apron—well written Exam Roll No over it, and don't forget to wear SMILE AND CONFIDENCE always, Think at the exam hall “I tried my level best—nothing to get tense. I know better than anyone else”. Take long breaths frequently to avoid anxiety and fear.
  2. Take the following things in exam hall:
    • Two pens
    • Stethoscope, Sphygmomanometer
    • Measuring tape
    • Torch
    • Gloves and Lignocaine Gel
    • Roll made X-ray film
    • 4 tourniquets
    • Hammer
  3. Be gentle and polite in exam hall. Never argue with the examiners—never and never. Not only in examination it is applicable in all the fields of life too.
  4. When you are given a case, go to the patient smiling and introduce yourself. Give him/her a packet of biscuit and tell “this is my very important exam. Cooperate with me and don't get annoyed please”. Make him/her comfortable and friendly. Take relevant history. Request him/her; tell the same story/words to the examiner also, if he/she is asked by the examiner please.
  5. Take proper history. You know, perfect history taking will take you through the Gateway to Success in Surgery. Remember the points for the specific case and write down the long case till case summary and provisional/differential diagnosis.
  6. Examination of patient and its findings should be perfect. Don't try to make it as per book, make it whatever it is. Examiners like the truth, not the bookish knowledge or the manipulation. You know he is more than hundred times experienced than you.
  7. Be confident to see the examiners. Say ‘Good morning sir,’ ‘Thank you sir’, etc.
  8. If examiner asks to tell history it is always better to speak history without seeing case sheet. Have eye-to-eye contact with examiner. If he asks the summary/diagnosis tell that thing only. First you listen what examiner is asking you. Take a pause then start speaking—speak in proper speed, not very fast, not too slow. Give a common diagnosis first. Remember diagnosis of a rare disease will be rarely correct.
  9. Always avoid speaking uncommon words, uncommon terms or syndromes.
  10. Think for a second which you are going to tell. In exam hall each word is important which takes you through or may not take you through the ‘Gateway’.
  11. Maintain basic things. If you don't know the answer, say, ‘I don't know sir’. Never stand dumb. And never try to fool examiner by giving irrelevant answers. If required quote a standard textbook not any guidebook or note Pl.
  12. Lastly I would say the same, ‘practice makes perfect.’ Practice case presentation in Clinical Meeting, in front of teachers, friends and above all at home in front of a mirror repeatedly.
Wish you easy overcome the Gateway to Success in Surgery
All the best-ever and always.
MD Ray
22Concise Information About Health  
ACCORDING TO WHO
“Health is a state of complete physical, mental and social well-being and not merely an absence of disease or infirmity”.
Physical dimension: Physical health implies the notion of perfect functioning of body. Signs of physical health—a good complexion, a clear skin, bright eyes, lustrous hair with a body well clothed, firm fresh not toe fat, a sweet breath, a good appetite, sound sleep, regular activity of bowels and bladder and smooth easy coordinate bodily movements.
Mental dimension: It is a state of balance between individual and the surrounding world, a state of harmony between oneself and other with coexistence between the realities of the self and that of other people of that of the environment.
Signs of mental health: Free from internal conflicts, he is not at ‘war’ with himself.
He faces problems and tries to solve them intelligently, i.e. coping with stress and anxiety.
Social dimension: It is quantity of quality of an individual interpersonalities of the extent of environment with the community. Social dimensions include the level of social skills one possesses, social functioning and the ability to see one self as a member of a large society.
Well-being—indicates standard of living and lifestyle.
Maintain your perfect health and be happy forever.
 
SUGGESTIONS FOR SUCCESS
23What is Surgery?
Surgery is an art of learning not only when to cut but it is more important to learn when not to cut.
Surgery is such an act which once done, cannot be reversed.
Surgery is a science as well as an art. Try to be artistic in surgery and life too.
Surgical triad
i.
Measure thrice
ii.
Think twice
iii.
Cut once.
The lesser the indication, the greater the complication.
In surgery as well as life too there is no question of ‘Short Cut’.
Many very skillful operators are not good surgeons.
 
 
HOW TO START THE STUDY
  1. Start practicing meditation before you start studying, i.e. concentrate your mind first please.
  2. Start with anatomy of specific topic you are going to read. I will advise the following anatomy books—BD Chaurasia's Human Anatomy/Lee McGregor's Surgical Anatomy/Snel's Anatomy and Last's Anatomy, etc. for reference.
 
REMEMBER ONE THING
If you know the road map you can drive properly.
You know the anatomy, you do the surgery perfectly.
  1. Go through the standard textbook for same topic which you are going to read
    1. Bailey and Love's Short Practice of Surgery (the book is enough for undergraduate students)
    2. Schwartz's principle of surgery or
    3. Sabiston textbook of surgery
    4. Maingot's abdominal operations.
  2. Read Clinical Surgery—Dr S Das—A Manual on Clinical Surgery/Dr ML Saha's—Bedside Clinics in Surgery/SRB's— Bedside Clinics in Surgery.
  3. Read this book Gateway to Success in Surgery for case presentation and questions-answers for the same topic.
  4. Read Nyhus Mastery of Surgery or at least Farquharson's Textbook of Operative General Surgery for Operative Steps.
  5. If you make notes on specific topic, get it attached in your textbook in the same page of the topic or right down in your textbook about the notes where it is written. Try to study the notes in the same time when you feel required.
    I can assure you will cross the Gateway to Success in Surgery very easily without any doubt.
24How to take History in Surgical Cases?  
GENERAL GUIDELINE
History taking is an art that helps you to reach the diagnosis in more than 90% cases. History taking in the surgical cases is slightly different from medical history taking. You have to give importance to special important points in surgical cases as below.
  1. Patient's particulars
    1. Name: Ask the patient by name. Patient will always be happy. He/She will feel that, “my doctor knows my name like my relatives”.
    2. Age: Age is important aspect to establish the diagnosis. Examples: congenital anomalies appear usually since birth like cleft palate, phimosis, cystic hygroma, etc.
      Solitary nodular, multinodular colloids goiter occurs in 20–30 years. Papillary carcinoma in young girl. Follicular carcinoma in middle aged women, medullary carcinoma 58–70 years.
      Sarcoma in younger age group, i.e. teenagers and early third decade people are usually the victim. Choledochal cysts usually in young adults around 20 years of age.
      Carcinoma usually occurs in the elderly after 50 years, so many exceptions are there like Wilms' tumor occurs at the age of 2–4 years.
      Few disease are bimodal e.g. Hodgkin's lymphoma occurs pick at around 20 years and another pick at 50 years and above. Benign breast disease occurs below 35 years and another pick is above 60 years. Carcinoma breast occurs in 45–55 years.
      So from the age you can have a primary idea about the disease which helps you to reach the diagnosis.
    3. Sex: Few diseases are very common in male like lung, kidney, stomach diseases, carcinoma lip, tongue, etc. Few diseases are very common in female like thyroid, breast, Raynaud's disease, varicose vein, cystitis, urinary tract infection, pyelonephritis, etc.
    4. Residence: Residence is important aspect of history taking. Few diseases predominantly occurs in certain areas like gallbladder diseases are common from Delhi to Patna belt, Southern and Eastern regions of our country especially in Gangetic belts.
      Thyroid disorders like goiter are common in rocky mountains area, i.e. Himalayas, Vindhyas belts known as goiter belts in India.
      Urinary bladder stone disease is common in Punjab and Rajasthan. Other examples are Kangri Cancer in Kashmiri people due to carrying burning charcoal (Kangri) at their abdomen to keep them warm during cold. Chronic pancreatitis is more common in Kerala, Karnataka. In Tamil Nadu, practice of reverse smoking (burning site of bidi/cigarette inside the mouth) causes palatal cancer.
    5. Occupation: Occupation plays an important role to cause different diseases like—Varicose vein is very common in tram on driver, traffic police, rickshaw puller, bus conductors where job demands for a long standing.
      Housemaid knee (prepatellar bursitis) common in housemaid as the work involves kneel down position to clean the floor.
      Bladder cancer is common in the factory workers who are working with aniline dye, gas, printing, rubber, textile, leather, etc.
      Thyroid disease is commonly associated with stress and strain
      Carcinoma lip is commonly seen in a man of outdoor activities, that's why it is called ‘Countryman lip’.
      25
      Peptic ulcer is commonly seen with the business executives, civil servants, clerks, and those who are habituated to take tea, coffee frequently and smoke excessively.
      (Other points you have to highlight when required in surgical cases like)
    6. Religion in case of carcinoma penis; as carcinoma penis commonly occur in Hindus, not commonly in Jews and Muslims owing to their religious custom of circumcision in infancy and early childhood.
    7. Social status—Carcinoma breast, appendicitis are common in high social status people; whereas tuberculosis, portal hypertension, renal, vesicle calculus, peptic perforation, etc. usually common in low social status group.
    8. Bed number and
    9. Date of admission, etc.
  2. Chief complaints: Write patient's main complaints in brief and in patient's own language. If multiple complaints are there, write it in a chronological order, i.e. longer duration to shorter duration.
    If the problems start simultaneously write it in order of severity.
    Minor complaints should not be mentioned in chief complaints.
    Examples are given in subsequent disease presentation part.
  3. History of present illness (the sequence of events from the time of onset of the chief complaints to the time of patient's visit to the doctor)
    Starts like this way my patient was apparently symptomatic 6 months/1 year back then, describe the details of chief complaints with OPD.
    1. O-Onset
    2. P-Progress
    3. D-Duration (Remember OPD).
    If patient complains of pain, describe onset, progress, duration site, nature, radiation/referred, aggravating, relieving factors, etc.
    Describe the treatment part related with the disease. Exclude the expected symptoms (related with the disease) by asking gastrointestinal, respiratory, cardiovascular, urinary, neurological or muscular skeletal systems. These are called negative history (i.e. these symptoms may be present with the disease but not present in this case).
  4. Past history: Mention all the major disease that patients are suffering from and major disease in the past like hypertension, diabetes, tuberculosis, chronic obstructive pulmonary disease (COPD). Others like jaundice, autoimmune disease psychiatric illness, if any.
    History of similar disease in the past.
    History of any significant operation and its complications in the past.
    Past history of any allergy to any drug, etc.
  5. Personal history: Dietary habits
    Addiction to alcohol, cigarette/bidi, tobacco, betel, betelnut, etc. Marital status, socioeconomic background, bowel, bladder and sleep habits.
    In case of female along with the above—menstrual history is very important (like breast carcinoma details menstrual history is important) Menarche cycle, duration, amount of blood loss, LMP (Last menstrual period), etc.
  6. Family history: Ask about the same and any significant illness his/her family especially in patients, siblings, children and first/second degree relatives.
    Examples: Carcinoma breast is familial—Fissure in ano, hemorrhoids are familial also.
  7. Physical examination: Physical examination includes:
    1. General Survey: Write like this way—The patient is cooperative, comfortable looking having smiling/anxiety/(faces), average build, well/averagely/poorly nourished.
      Next comment on pallor, icterus, edema and generalized lymphadenopathy (clubbing, cyanosis, pigmentation, neck vein engorgement, etc. if these are prominently marked only)
      Next Pulse—details only in specific cases like thyrotoxicosis, etc.
      Blood pressure right arm spine.
      Temperature Respiration
      26
    2. Local examination: It includes—(i) Inspection, (ii) Palpation, (iii) Percussion and (iv) Auscultation
      Example—In lump abdomen—On inspection you have to mention, shape of abdomen—scaphoid/flat/protruded, any obvious swelling/bulge is there or not.
      Position of umbilicus—central/deviated.
      Movements of abdomen—all quadrants move with respiration or not.
      Skin over the abdomen—any venous engorgement, scar marks, pigmentation.
      Flanks/Renal angle are full or not.
      Hernial sites, external genitalia are normal or any abnormality is there.
      On Palpation: temperature (first), tenderness of the lump and describe the lump in details—Site, size, surface, consistency margins, movement with reception, relation with underlying or overlying structures, etc.
      Liver, spleen palpable or not, fluid thrill, renal angle, and palpation of lymph nodes.
      Percussion: Very important like supraclavicular lymph nodes.
      • – General note over the abdomen—tympanitic/dull
      • – Shifting dullness
      • – Upper border of liver dullness, etc.
      Auscultation:
      • – Bowel sounds (see for one minute)
      • – Any added sound, etc. Next do not forget.
      • – Digital per rectal examination (DRE) and paravaginal examination in case of female.
      (In exam hall, ask the examination when it is very much essential, at least try to do DRE)
    3. Systematic examination
      1. Respiratory—write bilateral air entry equal. Bronchovesicular sounds breath sound, there is no adventitious sound heard.
      2. CVS—SI, SII (normal) no murmur heard
      3. Neurological examination—higher motor functions are normal, no neurodeficit is found. Other examinations are essentially normal.
(Mind that if any abnormality is detected in above system, write in details please).
Summary of the case:
Write in two paragraphs: First paragraph—brief history, Second paragraph—only positive clinical findings to reach the diagnosis.
Provisional diagnosis: From history and clinical examination which you think is the most possible disease. Next differential diagnosis, i.e. other possibilities think why you are thinking the other possibilities. What are the positive points in favor of them and what are points not in favor.
It is always better to tell the history to the examiner without seeing the casesheet, so practice case presentation repeatedly and you know it is the Gateway to Success in Surgery.