Writing of principles for ghana college exams

medicine

1. The Principles Question
JCB Dakubo
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2. DISCUSS THE MANAGEMENT OF ………
Just write what is normally done and how it is
done, describe what is normally done, narrate
and explain only where necessary

3. Discuss the PRINCIPLES of ……..
Lists in logical order the stepsthat are taken
giving the scientific, proven, or accepted
explanationfor those steps.
This question is trying to find out whether you
understand the scientific reasoning behind
what you have been doing every day

4. 3. Plan
Introduction
History
Examination
Investigations
Resuscitation/patient preparation
Treatment including surgery
Post Op. complications
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5. DISCUSS THE PRINCIPLESGOVERNING
ONCOLOGICALRESECTIONSOF THE COLON
AND RECTUM FOR ADENOCARCINOMA

6. General principles:
1.Intra-operative diagnosis –exploration to
determine resectability, peritoneal seedlings,
metastasis to other organs (liver). Findings
must be part of the surgical notes
2.Resection must be En-block resection of
bowel and mesocolonor mesorectum
3.In colon cancer division of the
lymphovascularpedicle is at the point where
the feeding vessel braches off from the main
vessel

7. 4. Labelling and or tatooing portions of the
specimen
5. Resection should achieve R0 for both bowel
and lymph nodes

8. Colectomies
-The bowel should be resected at 5cm from both
sides of the tumour –reason here the tumour
does not extend beyond 2cm on both sides of
the tumour
-At least 15 lymph nodes should be harvested in
the mesocolon.
-The lymph node at the highest point of ligature
should be specially labeled for the pathologist

9. -Any enlarged lymph node outside the area of
resection should be harvested and labeled for
the pathologist
-Because the resection is based on the feeding
vessel along which the lymphatics run when a
tumour is equidistant from two feeding
vessels the two must be sacrificed –hence the
origin of extended right hemicolectomy
-The ends of the resected bowel should be
appropriately labeled to help the pathologist
in orienting it

10. Rectal resections
-Resections are based on the location of the
tumour relative to the anal verge
-As much as possible effort should be made to
preserve the anal sphincter
-Excision of the mesorectal envelope is
mandatory because it has lymph nodes and
can also harbour tumour in nerves and
connective tissue

11. -In the bowel wall tumour does not spread
beyond 1.5cm inferiorly so a 2cm resection
margin is enough
-In the mesorectum inferior spread of tumour
is about 3cm so the inferior resection of the
mesorectum should be at least 4cm
-For proximal third tumours anterior resection
accomplishes an 5cm inferior margin fot both
bowel and mesorectum. Total mesorectal
excision is not necessary

12. -Middle third tumours to help save the anal
sphincter and also prevent diarrhoea and
incontinence ( which requires at leas 2cm cuff
of distal rectum) a 2cm resection of the bowel
wall inferiorly is adequate oncologically. If the
mesorectum is to be transected at 4cm diatal
of the tumour is done less than 2cm
mesorectum will be left distally. Also this can
cause annoying bleeding so it is advised that
the reminant mesorected be filleted out

13. For distal third the following can be done
a.Ultra-low. It has a lot of problems
b.Inter-sphincteric
c.Abdomino-perinealresection
All of these with TME
-If a tumouris adherent to or has invaded
another organ that organ must be resected
en-block with the tumour
-No Pelvic exenteration. Rather enlarged
pelvic wall lymph nodes are excised and
labeled for the pathologist

14. Conclusion
I have enjoyed the question I have written on
THANK YOU
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15. Discuss the principles(Subject) in the
management(Action verb) of a 65 year old
woman with an early breast cancer.(Object)
Standard SVO strong, active form of writing.
This is principles so you are going to take the
steps in managing a patient with breast cancer
and adapt them to the elderly patient
specifically giving the reasoning behind them.
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16. Answer
Introduction
What is an early breast cancer? And why?
What are the issues with a 65year old woman
a. Increased incidence of co-morbidities
b. Decreases reserves, physiological,
metabolic, immunological etc
So what will determine the fitness of the patient
for treatment? Is it the physiological or the
performance or functional status of the
patient which must be assessed.
How is this done? Not needed here any way
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17. Diagnosis of the tumour
Triple assessment
The history will not be different; bloody nipple
discharge, skin changes, itching or pain in the
breast, asymptomatic but lump was found
during screening mammography.
Examination; Lump in breast, size 0-2cm,
features of malignancy but in the elderly the
features may be like those of a benign lesion
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18. Confirmation of diagnosis
Same for all, FNAC or core biopsy. Remember that
incision biopsy and excision biopsy don’t come in
here
Treatment.This is where the essay starts proper
a.Neo-adjuvant or Not why?
b.Oncoplasticexcision of the lump with shave
margins, or partial mastectomy with breast
reconstruction or total mastectomy, which and
why?
c.Sentinel lymph node biopsy, standard now
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19. Chemotherapy or no chemotherapy, reduced
dose or normal dose, and why?
Radiotherapy, to be given or not to be given if
breast conservation was done. What could
prevent it and why?
Hormonal treatment. Can it be given solely in
place of Chemotherapy if the latter is contra-
indicated and why?
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20. Which anti-estrogen agent should be used here
and why?
Herceptinuse. What could prevent its use and
why?
Can the patient be denied any of these
treatments based on the age alone ? No and
why?
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21. Discuss the Principles(Subject)in the
management(Action Verb) of infections in
surgery(Object)
1. Introduction
What is Infection?
What is a surgical infection?
Why are surgical infections important?
What are the DDs of surgical infections
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22. 2. Diagnosis of surgical infections
-Local symptoms and signs
-Systemic symptoms and signs
3. Investigations to diagnose surgical infection
-WBC
-Cultures; blood, swabs, aspirates, biopsies
(Why each of them)
-X-Rays
-Ultrasound
-CT Scans
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23. Principles of treatment
-Reduction of oedema, why is it important
-Antibiotics, prophylaxis, emperical, based on
culture results, De-escalating, Why, why, why?
-Incision and drainage, lavage, why?
-Debridement/desloughing, why?
-Amputation, why?
-Hyperbaric Oxygen, why?
-Immunization, Tetanus etc, why?
-Nutritional support, why?
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24. Discuss the principlesof managingthe
chronically unconscious patient
Introduction
Who is the chronically unconscious patient?
Why does this person need special care?
Which areas of special care does this person
need?
Enumerate them and give reasons.
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25. 1.Managing the respiratory tree, clearing the
throat and suctioning, bronchial lavage,
tracheostomy
2.Nutrition, NG tube feeding, Feeding
gastostomy, Feeding jejunostomy, Parenteral
Nutrition-Supplementary or total
3.Sphincters, Urinary bladder and Anal
4.Hygiene and skin care
5.Muscle activity
6.DVT prevention
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