All India Institute of Medical Science Surgery Syllabus

OBJECTIVES Knowledge

At the end of the course, the student shall be able to:

1. Describe aetiology, pathophysiology, principles of diagnosis and management of common surgical problems including emergencies, in adults and children:
2. Define indications and methods for fluid and electrolyte replacement therapy including blood transfusion:
3. Define asepsis, disinfection and sterilization and recommend judicious use of anatibiotics:
   1. Describe clinical features and risk factors of common malignancies in the country and their management including prevention.
   2. Enumerate different types of anaesthetic agents, their indications, mode of administration, contraindications and side effects.

Skills

At the end of the course, the student should be able to:

1. Diagnose common surgical conditions both acute and chronic, in adult and children;
2. Plan various laboratory tests for surgical conditions and interpret the results;
3. Identify and manage patients of haemorrhagic, septicaemic and other types of shock;
   1. Be able to maintain patent air-way and resuscitate a –

(i)       a critically injured patient;

(ii)     patient with cardio-respiratory failure;

(iii)    a drowning case.

1. Monitor patients of head, chest, spinal and abdominal injuries, both in adults and children;
2. Provide primary care for a patient of burns;
3. Acquire principles of operative surgery, including pre-operative, operative and post operative care and monitoring;
4. Treat open wounds including preventive measures against tetanus and gas gangrene;
5. Diagnose neonatal and paediatric surgical emergencies and provide sound primary care before referring the patient to secondary / tertiary centers;
6. Identify congenital anomalies and refer them for appropriate management.

COURSE CONTENT

A combination of system-based model and the spiral model is recommended for the MBBS course:

Pathogenesis, causes, epidemiology, Clinical Presentation, Investigations, and management of the diseases in the following systems:

1. Skin: ulcers and wounds, wound infections, burns, skin infections (boils, carbuncle, abcess), cysts (epidermoid cyst, dermoid),skin tumors(basal cell carcinoma, squamous cell carcinoma, melanoma).
2. Head and Neck region: congenital anomalies (cleft lip, cleft palate, branchial cyst and fistula, thyroglossal cyst) swellings of parotid and submandibular glands, oral ulcers, leukoplakia, submucous fibrosis, lichen planus, common jaw tumors, squamous carcinoma of oral cavity, pharynx & larynx. Thyroid swellings (adenomatous goitre, Graves’ Disease, papillary and follicular thyroid cancer).Swellings of lymph nodes (tuberculosis, lymphoma, metastatic carcinoma)
3. Arteries: Features of limb Ischaemia, noninvasive vascular diagnostic tests, obliterative atheromatous disease, aneurysms, Raynaud’s syndrome, arterial emboli.
4. Veins: varicose veins, deep vein thrombosis , pulmonary embolism.
5. Breast: mastalgia, ANDI, fibroadenoma, cyst, breast abscess, cancer of the breast.
6. Oesophagus: dysphagia, reflux, hiatus hernia, benign and malignant tumours.
7. Stomach and duodenum: Peptic ulcer- stomach and duodenum, carcinoma of the stomach, gastritis.
8. Small intestine: Small bowel obstruction, intestinal tuberculosis.
9. Colon and rectum: Amoebic colitis, Ulcerative colitis, colorectal cancer.
10. Appendix: Acute appendicitis.
11. Anus: Haemorrhoids, Pruritus ani, Fissure-in-ano, Anorectal abscesses, Fistula-in-ano, cancer of the anus.
12. Peritoneum and intraperitoneal abscesses: peritonitis.
13. Liver: Hepatic trauma, abscesses, cancer.
14. Biliary tract: gall stone disease, carcinoma of the gallbladder.
15. Pancreas: Acute panacreatitis, pancreatic cancer.
16. Acute abdomen
17. Hernias of the abdominal wall: Inguinal hernias, femoral hernia, umbilical and epigastric hernia.
    1. Urology: Diagnostic studies and techniques in the urinary tract, trauma to the urinary tract, urinary calculi, urinary tract infection, prostatic hyperplasia, tumours of the kidney, epididymo-orchitis, hydrocele, tumours of the testicle, carcinoma of the penis.

TEACHING LEARNING METHODS

The following strategy is used for organizing teaching learning activities:

a)       Lectures are used for teaching the basic principles for 4^th semester students of surgery viz. infection, wound healing, shock, trauma.

b)       Integrated seminars are utilized during the 6^th and 8^th semester for teaching system based surgery viz. thyroid and endocrine disorders, GIT, urinary, head and neck and vascular disorders.

c)        Clinical teaching to a group of 12 students on surgical Inpatient Wards and OPD’s.

d)       Clinical skill training- We teach basic surgical skills to our final year students and interns in minor OT, casualty theatre and main theatre. In the department we also organize yearly workshop on suturing & knot tying where students get an opportunity to acquire hands-on experience on these important skills.

Guidelines for students posted in Department of Surgery 3^rd – 4^th Semester

This is the first introductory posting in surgery to provide orientation, towards the general functioning of the Department and the nature of clinical work performed in the Department of surgery. You will be posted in the surgical Out-patients department. This is a five weeks posting. The learning objectives for this session are to learn :

• the art and science of history taking,
• general evaluation of overall health;
• basic principles of examination of a lump;
• examination of hernia, hydrocoele and abdomen;
• examination of breast;
• examination of head and neck;
• evaluation of wounds, ulcers and sinuses.

You will be required to attend the surgical Out-patient clinic from 9.15 A.M. to 12.00 noon. Be punctual as any person coming to clinic after 9.30 A.M. will be marked absent. Attendance register will be sent to the Dean.

You are required to be properly dressed, wear a white coat, with a name plate (no jeans and no sneaker shoes please!). You are required to bring the following:-

A pen torch with metal tip, measuring tape, Vernier callipers, stethoscope, patella hammer;

Please read “ Norman Browse- An Introduction to the symptoms and signs surgical diseases” or “Hamilton Bailey- Physical signs”, in order to acquire theoretical background of clinical examination. A book by “ S.Das ” has many mistakes, and therefore, not recommended.

5^th Semester

The learning objectives for this session are honing the skills of physical examination. You are again posted in the Out-patient surgical department. The timings are 9.15 A.M. to 12.00 A.M.. Attendance is compulsory. For this semester utilize your time in examining as many patients as possible. Visit the consultation rooms of all the consultants and senior registrars. Remember there is no substitute for seeing the patients.

You cannot acquire the practical skills by sitting in the Library.

A famous physician of USA, Sir William Osler said” To study the phenomena of disease without books is to sail an uncharted sea whilst to study books without patients is not to go to sea at all”

Besides seeing patients you should also acquire the following basic surgical skills- wound dressing, debridement , abscess aspiration and drainage, excision biopsy of skin lesions, lipoma and epidermal cysts, skin suturing and knot tying, proctoscopy, rubber banding of piles.

Please attend minor surgical operation theatre situated at the end of the surgical OPD corridor to acquire the above skills. Please maintain a record of cases seen and surgical skills learnt in a diary/log book. You will be assessed on this.

Assessment of III – V Semesters

A weightage of 15 marks for III semester and 25 marks for IV & V semester will be given in the form of viva questions with short case presentations.

6^th Semester

The learning objectives in the 6^th semester are to master the skills of surgical diagnostic evaluation. You are advised to follow a problem based approach (PBL).

Greet the patient cheerfully with a smile and introduce yourself. Seek patient’s permission for

interrogation and examination (e.g. “ I am________ , a 6^th semester student of MBBS. Can I ask a few

questions about your illness and can I examine you. This will help me in learning the diagnosis and in becoming a good doctor so that I may serve the society well). Be extremely polite in your approach. If patient refuses simply thank him and go to a next one. Ask presenting symptoms along with duration.

Formulate a diagnostic hypothesis (e) based on the patient’s age, gender, place of living and initial symptoms. This is essentially a list of differential diagnoses. Think about pros and cons of each possibility.

Now ask details of the present and past history focused on the initial diagnostic hypothesis. For example-in a patient with bleeding P/R at age 40. If you have consider piles and cancer rectum as your diagnostic hypothesis, your interrogation should revolve around these two conditions with the objective of proving one and refuting the other.

After interrogation revise your diagnostic hypothesis(e) on the basis of historical facts. Perform a quick general exam and make a note of overall health status.

The next step is to carry out a detailed physical exam of the lump, swelling or ulcer. Remember no exam of a swelling or ulcer is complete without checking the draining lymph nodes.

Make a diagrammatic representation of your findings with colour felt pens on your diary/log book. Go through the following checklist while seeing any lump: number, site, size, shape, margin , surface, skin over it, structures superficial and deep to it, temperature over it, tenderness, consistency, transillumination, thrill or bruit and the regional nodes.

Once again revise your diagnostic hypothesis. Generate a diagnostic workup plan (Diagnostic decisions).

Allocation of Units

Find which unit you are posted with? The first 12 students of the batch go with Surgical Unit 1 and Unit 3, while the remaining students are posted with Unit 2 and Unit4. Reverse this order during the 8^th semester posting.

You will get 3 beds allotted to you. You are responsible for seeing all the patients admitted to these beds during your stay of 6 week with us. Record the history, exam findings and results of any investigations.

Assessment: OSCE = 12 marks with 3 clinical skills stations. Portfolio= 5 marks. Total=17 marks. Note these marks are added in the final MBBS exam result.

8^th Semester Posting: This is again 6 weeks long posting on surgical wards. The learning objectives of this final session is to develop the competency in making a diagnosis, generating a diagnostic decision plan and outlining the therapeutic decision. During this period you have to accompany the patient to the operation theatre, assist in the operation, write postoperative orders and follow the postoperative recovery of the case. Write down the daily progress in your case records till the patient is discharged.

Perform dressings, I.V. line insertion, catheter and nasogastric tube insertion on your cases.

Assessment: OSCE= 13 marks with 3 clinical skills stations, diary/log book= 5 marks, Total =18 marks.

Objectives of Clinical Training

At the end of clinical posting in surgery, a student should be able to:

• Elicit a detailed & relevant history
• Carry out a physical examination
• Identify patients’ problems
• Reach a differential diagnosis
• Formulate appropriate investigations
• Interpret the results of investigations
• Plan appropriate management
• Undertake some aspects of management
• Demonstrate adequate communication skills

TEXTBOOKS RECOMMENDED

(1)     Short Practice of surgery- Bailey & Love

(2)     ASI Text book of surgery Ed.A.K. HAI

(3)    An introduction to the symptoms and signs of surgical Disease-Norman L. Browse

(4)     Hamilton Bailey’s Physical Signs in Surgery.

(5)     Principles and Practice of Surgery Eds-Garden, Bradbury Forsythe.

(6)     Pye’s Surgical Handicraft.

ASSESSMENT AND EXAMINATION

The total weightage of 600 marks to Surgery comes from both internal and external assessment, viz., final professional examination in theory as well as practical. Since surgery included several specialties, the weightage often gets distributed amongst the specialties: Ophthalmology, E.N.T., Orthopedics, Anesthesiology, besides a little weightage for postings in Dental and Casualty. The distribution of marks can be divided in to four components as follows:

Theory:

Final Professional Examination – Theory and viva voce – Internal Assessment derived from allied specialties:

Practical:

Final Practical and Clinical examination with Long and Short cases Consisting of allied surgical specialties:

Internal marks derived from allied specialties, and end semester Examination marks

Grand Total

Final Professional Exam in Surgery – Theory

Theory and viva-voce:

(a)     Paper I – General Surgery

(including specialities)

(b)     Paper-II Part I-General Surgery

(including specialities) Part II-Ophthalmology

Otorhinolaryngology

(These shall include questions in Traumatic Surgery. Questions in other specialities, e.g. Orthopaedics and Anaesthesiology may also be included).

(c ) Viva-Voce

(including Surgery and its specialities, Orthopaedics,

Ophthalmology, Otorhinolaryngology and Anaesthesiology)

Class work

(This shall include Surgery, Ophthalmology, Otorhinolaryngology, Orthopaedic surgery, Anaesthesiology and End Semester Examination)

Total 300

Practicals and Clinical

(a)     Class work                                                                                                                                150 (including surgery, Otorhinolaryngology, Orthopaedics, Anaesthesiology

and End Semester Examination)

(b)     Clinical cases                                                                                                                           150 Long and short

(These shall include clinical cases in Ophthalmology and Otorhinolaryngology which shall be assigned 30% of the total marks for clinical cases. Clinical cases in other specialities e.g. Traumatic Surgery, Orthopaedic Surgery and Anaesthesiology may also be included).

Total 300

Types of Questions suggested

Theory :

Modified Essay Questions, Simulated Patient Management Problems (SPMP), Short Answer/ Short Notes, and MCQs;

Practical / Clinical Assessment:

Long Case, Short Case, Objective Structured Clinical Examination (OSCE)

Notes on OSCE

Objective Structured Clinical Examination (OSCE) has proved to be a valid, reliable and objective modality of assessment for assessing clinical skills. This involves breaking up clinical competence in to a series of clinical skills (history taking, performing physical examination, interpreting lab data, differential diagnosis, treatment & follow up), and testing each skill in a separate ‘station’. Each station is provided with a real or simulated patient, mannequin, equipment, X-Ray, or even a question which should be tackled by a student within a prescribed time limit say, 2 – 5 minutes, on rotation basis. The performance is observed by an observer using a predetermined check list for assigning marks. A detailed discussion on the preparation of OSCE is beyond the scope of this book. However, a few tips have been given for initial introduction.

Principles of Designing OSCE Define skill to be tested

• Break into steps
• 3-5 minutes to perform each task
• Observation by examiner

Scoring based on vital components of skill and precautions to be observed

• Provision for negative score, if necessary

Two types :Procedure stations (needs observer) and Question stations Skills that can be tested using OSCE

• History taking
• Physical examination
• Analysis of clinical data
  • Observation and ability to recognize disease patterns
  • Interpretation of investigations
  • Performance of a procedure

–          Diagnostic

–          Therapeutic

• Problem solving skill
• Communication skill
• Others

–           Surgical/clinical instruments

–           Surgical specimens

–          Procedures on models/dummy

–          Patient education

A model OSCE for our 8^th semester students is given below :. Conduct of an OSCE in surgery using 7 stations

Station 1 (History taking skill)

• Take the history of this patient who has sudden onset right lower abdominal pain

Marks :6

Checklist

The student questions the patients about

history of pain                                                                                        1

history of vomiting                                                                                1

history of fever                                                                                      1

history of previous surgery 1

Attitudes and communication (gentle approach)                           1

General proficiency                                                                               1

Station 2 (Physical Examination skill)

Examine the neck swelling of this patient. You are being observed by the examiner for your skills in physical examination and your attitude towards the patient.

Marks:10

Checklist

Student looks for the following parameters

a) movement with swallowing                                                                     1

b)	examination of each lobe of thyroid	1
c)	relationship with sternocleidomastoid	1
d)	testing for retrosternal extension	1
e)	palpation of carotids	1
f)	elicitation of signs for airway obstruction	0.5
g)	examination of cervical lymph nodes	0.5
h)	auscultation over the swelling	0.5
i)	Positions patient properly to examine neck swelling	1.5
j)	correct sequence of procedures	0.5
Attitude towards patient
k)	. explains procedure	0.5
l).	causes minimal discomfort to the patient	0.5

General proficiency                                                                                       0.5

Station 3 (Procedural skill)

Apply a Pressure bandage to stop bleeding from cut wrist Check-list

Explains the procedure to the patient Follows properly the steps of the procedure:

• a) positioning of the patient: supine
• b) positioning of the limb: straight
• c) properly tying the bandage
• Performs the procedure confidently and gently
• Explains the following aftercare to the patient a) finger movements
• b) warns about swelling of fingers & to report

immediately if severe pain or swelling occurs

Station 4

Palpate the abdomen of this patient (Has a generalised liver enlargement)

Marks: 7

Check list:

1. Explains the procedure and approaches to him gently                   1
2. Inspects the abdomen first                                                                   1
   1. Starts palpating from lower abdomen first                              1
   2. Palpates the whole of anterior surface of liver and its

entire lower border                                                                                2

1. Percusses for dullness over liver and its upper border 2

Station 5

Questions based on station 5: Marks : 5

Q1. Describe your findings (if correctly described)                         1

Q2. Enumerate 2 most probable causes of this condition (mentions obstruction of common bile duct, congestive heart failure)                                                    2

Q3. Mention : one blood test ( mentions LFT)                                1

: one imaging technique for this patient (mentions Ultrasound)  1

Station 6

Skill Station: Problem: An adult male met with an accident on the road and has come to the casualty with a clean lacerated wound on the abdomen. Demonstrate suturing of this wound using the skin simulator provided. Put 3 interrupted sutures. Note that skin edges have a tendency to invert.

Marks: 19

CHECK LIST FOR SKIN SUTURING INSTRUCTIONS TO CANDIDATES

Suture the clean incised wound with interrupted sutures

1. Number of knots taken
2. Knot is square or not.
3. Knot is too tight or too loose.
4. Suture breaks or not
5. Knot is on the incision line or on one side
6. Distance of cutting the suture from the knot
7. Suture board moves or not
8. Skin edges are everted or inverted
9. Inter sutural distance – 0.5 to 1cm.