Prof.A.H.M. Shamsul Alam

Writing essay answers tests your ability to organize your thoughts regarding surgical issues

In most instances you provide adequate information in response to a question, as you have enough background knowledge. Yet, your answers do not always live up to the expectations of the examiners.

Focusing on some trivial issues might help finding the weak areas of an essay answer

1. Read out the question well2. Figure out the objective of the question3. Plan the answer4. Start writing with an introduction5. Write the body of the components

a. Go by the planb. Stick to relevant pointsc. Be practical- reflect real life situationsd. Give brief explanations( not just a list of

points)e. Make answers readable

6. Conclude

At the outset, it is important to read the question well. And, of course reading several times is always helpful in getting the essence of the question. Getting a wrong meaning from a frantic reading is not unusual.

Why the question has been set?Examiner has an issueGrab that core issueReflect it in writing

A 20 year old young man had a blunt trauma to his abdomen 2 months earlier, hospitalized for a week and was treated without surgical intervention before he was discharged in a comfortable state. Now over a week he has developed upper abdominal pain along with high grade fever and abdominal examination revealed a tender lump in left hypochondriac region.

a. What could be the possible causes?b. How would you evaluate the case?c. How would you treat this case?

Here, in this clinical situation, core issue is a delayed complication of blunt trauma to abdomen- most likely an abscess, until proved otherwise.

This issue involves anticipation of underlying causes (a) ability to have a diagnosis on clinical and laboratory

assessment (b) right approach in treating the condition(c)

Planning an answer is the very important step

Spending few minutes in planning can sort out the key points

Chances of missing the points can be avoided while writing goes on

The plan can be displayed in a ‘rough page’ of the answer script, preferably by pencil.

Planning time: 5 minutes, Writing time: Comp.a 7 m, Comp.b: 15 m, Comp. c:15 m, Revision:3m

Writing an introductionComp(a) Possible causes of the situationComp(b) Evaluation of the case

Clinical History-Hospital records, additional information regarding GI ,urinary and chest symptomsPhysical exam: Vital, abdominal lump evaluation and chest examination

Investigation BasicBlood: CBCUrine: urinalysisX-ray chestAbd. Sonogram: Sono-guided aspiration(if fluid collected)Gram staining of fluid, C/SAdvanced: depending on the finding of basicBlood cultureCRPCoagulation profilePancreatic enzymesCT scan

Comp. (c) TreatmentGeneral support: fluid balance

Initial antimicrobial therapy based on CBC and Gram stainMinimal invasive intervention for abscessSurgical intervention if no response

Drainage: open/Internal drainageNecrosectomy/ splenectomy

 

Starting the answer with a short introduction

Raising the core issue of the question could give the examiner a ‘first impression’ that you are in right path of thought.

It is a good step, but not a mandatory one. Be aware, a casual introduction could do

more harm than good.

Given the presenting situation the case in question could most likely to be an intra-abdominal abscess as a late complication of blunt abdominal trauma. Involved organ could be the pancreas or a haematoma from injured spleen, liver or kidney. Evaluation and treatment should be directed to locate the infective foci and drain it effectively in order to avoid fatal consequences.

Proceed according to planMark each section of plan once you

finish answering See the progress in a time-frame

Sort out the key points in the scenario Work out the relevant answer of the

components Putting information out of context not

only consumes time but also erode out the quality of answer.

In the given scenario salient points are Patient is 20 year old young man Had a blunt trauma to his abdomen 2 months earlier, Hospitalized for a week and was treated without surgical intervention He was discharged in a comfortable state. over a week he has developed upper abdominal pain along with high

grade fever On abdominal examination: a tender lump in left hypochondriac

region. Based on the above features one of the following could be

the underlying reasons of the present situation Pancreatic abscess from earlier pancreatic injury Sub-diaphragmetic abscess: in lesser sac- as infected pancreatic

pseudocyst or under the left dome of diaphragm Infected old subcapsular haematoma leading to splenic abscess Infected old perinephric haematoma leading to perinephric abscess

Writing just the cause without qualifying1. Pancreatic pseudocyst2. splenic abscess3. perinephric abscess

Writing too many causes: remotely probable, improbableDelayed intestinal perforationparietal abscesspyonephrosis Biliary stricture and cholengitis

Make your point in a practical perspective,

Consider the case was in your ward, you were the treating surgeon

Write what you would actually do in average circumstances.

Make no unrealistic suggestions

Evaluation of would be done by taking additional history, physical exam. and investigations.

History should include reviewing the previous hospital records and recent complaints.Records: Nature of trauma, hospital stay, investigations, interventions and state during dischargePattern of fever in seven daysPattern of painRespiratory difficulty, if anyUpper GI difficulty like fullness after feeding, vomitingUrinary symptoms like haematuria, if any

 Physical examinationExamination in general could reveal dehydration, pyrexia, anaemia and nutritional deficiencies resulting from the infective abdominal condition. Septicaemia could lead to features of shock.Abdomen examination is directed to evaluating the right hypochondriac mass. A poorly defined, immobile tender intra-abdominal lump is more likely to be a pancreatic abscess or an infected pseudocyst. More lateral and lumbar extension goes in favor of splenic abscess or perinephric abscess. Systematic abdominal examination might detect intra-abdominal sepsis like pelvic abscess.Respiratory system examination might detect pleural effusion particularly in left side.

InvestigationsBasic investigations

Complete blood count could show leucocytosis, anaemia or even thrombocytopenia indicating septicaemia. Urinalysis could reveal haematuria in case of involvement of kidneyX-ray chest could detect pleural effusion in response to abdominal sepsis

Diagnostic investigations that could be decisive here areUltrasonogram of abdomen for evaluation of the mass could be very helpful

by giving the anatomical location, size, echotexture and organ origin. Moreover, aspiration of a fluid filled lesion can collect sample for cytology,

gram staining and culture/sensitivity to antibiotics.Blood biochemistry for pancreatic enzymes like s, amylase and lipase could

find evidences for pancreatitis. C-reactive protein may indicate pancreatic necrosis.

Coagulation profile may indicate septicaemia induced consumption coagulopathy

 Advanced investigation like CT scan and IVU may be needed when situation

demands further evaluation. Additional investigations to assess metabolic, electrolyte, renal functions,

as a part of general assessment.

InvestigationsCBC, ESRB. sugarBlood for C/SLFTProthrombin timeD-DimarS.creatinin, BUNS. Amylase, lipaseSerum Electrolyte

I USG of abdomenCT scanIVUMRCP, ERCPCXRBarium meal X-Ray

Pus for gram stain, C/SUrine RME and C/SAngiogram

 

HistoryRecordsPainfeverSwelling

General examinationAnaemiaCyanosisJaundiceDehydrationPulseB.PLymph nodesAbdomenLump: size, shape consistTenderness, rigidityP/RSystemic examination

An examiner likes to know- what valid reason is underlying the point you have made.

Therefore, a precise explanation should accompany each point you mention- not just making a list.

Specific treatment of this case would depend on diagnosis from clinical and laboratory investigations. However, some general supportive measures are needed.

General measures: Correction of dehydration, electrolyte imbalances by IV fluid infusionsAnalgesics and antipyretics for pain and feverEmpirical antibiotic can be started after sending specimens for bacteriological studies. In this case, a 3rd generation cephalosporin along with metronidazol or Merupenum intravenously can be started.

Specific measures: Most likely, in this case, an intra-abdominal abscess would be detected either in pancreas, spleen, sub-diaphragmatic spaces. Drainage of the abscess is a mandatory step and this can be achieved byMinimal invasive method like ultrasonic guided aspiration and re-aspiration, appropriate antibiotic therapy on bacteriological study of aspirateOpen drainage by laparotomy would be needed if the abscess was large, unapproachable or there was no or little response to minimal invasive therapy.Specific operations: On laparotomy pre-operative diagnosis or situation might demand necrosectomy for pancreatic abscess, gastro-cystectomy for pancreatic pseudocyst or splenectomy for pancreatic cyst.

Follow up: Patient should be followed till infective process is evident locally or systematically.

Ex. Component (c) TreatmentAim of treatmentTreatment of diseaseTreatment of complicationsTreatment depends onGeneral conditionDiagnosispatient's choicefacilities available General treatmentNPOIV fluidBlood transfusionAnalgesic: Antibiotic-Ceftriaxo.+ metro.

Specific treatmentUSG guided aspiration+ Antibiotic according to C/S

If no improvementSplenic abscess- splenectomySub-Diaphragmetic abscess- DrainagePancreatic abscess- Necrosectoy+ drainageLiver abscess- HepatectomyPancreatic pseudocyst- gasro-cystectomy

Follow upHistory, examinationInvestigations 

Often, examiners find it difficult to read out the answers or get the points. You can avoid such a negative situation by

Making the headline of a point stand out: Bold, underlined or selected by color

Writing each point in a paragraph List the points in appropriate bullets,

check marks or numbering Keeping adequate space between lines

and paragraphs Medium sized hand writing Clear readable hand writing

Drawing a conclusion is essentially a take home message from the whole discussion.

It is not a mandatory step, but good to have one.

A casual conclusion could do more harm than good.

After taking history, physical examination and relevant investigations I will make a correct diagnosis and treat the patient accordingly.

---------------Though the patient is in early age and the whole life is still left, so, treatment should be in précised and organized manner,unless his life may be in danger

Following the general guidelines like reading the question, planning could help avoid unexpected mistakes

Sticking to core issue, making points with reasons and being realistic makes a matured response

Being superfluous and illegible would lead to a negative impression