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I tried to squeeze all your experience. I've started to record it from now because a lot of people ask about recording and hopefully we'll have uh one candidate to jump in here. It is. And I will work for a, for admitting people and recording and you are in the chart. You uh you start record. Yes. Yes. We'll start the recording when we start. Yes. OK. OK. Do, do you like to introduce yourself doctors? Uh Yeah, my name is uh I was working the cause by the leg and OK, your, your voice, your voice is little bit low if you're able to improve your voice. Yeah, that's much better. Ok. And we have another candidate, Doctor Abderrahman Shahat. Although if you would like to start the the station, the examiner today is Professor Sein Hariri. Uh I have a little bit of problem with net connection and electricity. So he will be in charge from Malaysia. Do you like to start the doctor say uh from which, which country are uh speaking? Ok. Uh II think the connection is not very good. Yeah, we can see we can shift to Doctor Abderrahman. Are you with us? Doctor Abderrahman. Ok. Very good. Uh, try to speak in English because it will be recorded and broadcasted. And Professor Sherin, you can start with Doctor Abh. Ok. Ok. I uh uh one second please. I will uh grab uh Evan and Vigo. Ok, take your time. No problem. Ok. Uh we can start. Ok. Hello. Uh uh good evening. Uh It's supposed to be the scenario about difficult to swallow for a patient, male, patient. 65 years old have difficulty to swallow. So you have uh 10 minute to start by taking a history. You take a history about seven minute and after that, the examiner ask you some question. Ok. Can we start? Yeah, I can, I can play the actor if you want uh up to up to you. No, I I'm, I'm not sure if my connection is good or not, but ok, I will start. I will start. No problem. Oh, ok. So you can start professor. She OK. Go ahead. All right. Ok. So uh uh doctor Abbra, you can start to take a history. So again, the scenario is 65 years old male patient and have difficulty to swallow. Yeah. Mm uh Good afternoon. I'm doctor a surgical team uh of the hospital. Um Could I confirm your name? I need you, please? Yeah, I am uh Mister Man and I am 65 years old. Hello, Mister man. Nice to meet you. Uh Could I know what brought you here? To visit. What brought you to do? Uh, I have difficulty to swallow. Ok. I'm sorry for that. Uh, could ask you some questions about that. Ok. Ok. Uh, so 100 30. Ok. It is, uh, just, uh, two weeks ago, two weeks ago. Ok. Uh, so, uh, can you tell me more how it started? How, how it started? Uh, no, you can, you can ask me. Ok. Mm. Uh, it's increasing, uh, or, uh, or the same as it's, uh, it is increasing. It has become worse. It's increasing. Uh, it's more for fluids or, or for food on only, or it is, no, it is only for solid, only for food. Ok. Uh, but it, those, uh, loads, right? I can, if I drink it can be. Ok. Uh, is associated with any pain. Uh, no, be, no, we, uh, uh, did you notice any, uh, bad smelling or bad odor of your, uh, mouth? No, no. Uh, do you notice any, uh, gurgling, uh, during eating, uh, reflux or what? Uh, no, II mean, like, uh, you feel some s, uh, in your neck, uh, making sound when you swallow? No, no, no, no, no, no, no. Ok. And did you, uh, three minutes, three minutes? You did, did you notice any fever recently? A low fever? Got you. Uh, so, uh, how it affect your daily life? Uh, no, it is. Ok. How my daily life is? Ok. Uh, you? Ok. Uh, so, uh, did you lose weight unintentionally recently? Uh, yes, I lost about 5 kg in the last 12 months. Ok. I'm sorry. Uh, so, uh, do you, do you, do you visit your, uh, GB for any medical condition, like hypertension, uh, diabetes, uh, asthma or something like that? Uh, no, but I visit him, uh, many years ago because of have reflux. Ok. You have deflux, uh, ok. Yeah, that, the GERD, ok. Did you, uh, underwent any surgery before? Uh, no surgery. But I take a treatment only for one month and, uh, I don't complain. Ok. Um, uh, do, uh, do you smoke, uh, I smoke, uh, 10 cigarettes per day for the last 30 years. Ok. Do you drink alcohol? Yes, I drink alcohol. One can of alcoholic beer every day. Ok. Uh, so, uh, uh, could I ask you about your family, uh, any of your family, uh, had, uh, a condition like that before? Uh, no, but my father died from heart attack. Uh, I'm sorry for that. Ok. Now, six minutes have passed. So, no, we can, we can wait one minute. Uh, don't wait. Ok. It's like, ok, if it's like, uh, exam, I, yeah, II want it to go like the exam as I have, you can have one minute, uh, you can, uh, because examiner can stay 10 minutes. You can tell you to take a history in seven minute, eight minutes after that. He ask you some questions. Ok. Ok. Ok. Uh, anything can I do I need to add? Ok. Ok. Uh, let me ask you some, uh, some other questions. Uh, we live in. Uh, no, I live with my wife. Ok. Uh, what do you do for a living? Uh, I am retired, uh, Lorry Driver. Ok. Uh, do you see any back pain recently or, uh, neck pain? Uh, no back pain, no back pain. Uh, uh, any, any, any shortness of breath or coughing, no shortness of breath, no coughing. Ok. Ok. Uh, do it any, uh, a change in your bowel habits? Uh, no alter bowel habit? Ok. Ok. Uh, any heartburn, no heart to, yeah, I have heart to be regularly since the last five years. Ok. Uh, uh, do you take, uh, drugs for them? I think a bump inhibitor, but I want to continue on it. Ok. Uh, I'm thankful for you, Mister Man. Uh, all right. Ok. So, now what's your diagnosis? Uh, Doctor Abbra? So you take about 60 minutes? Ok. So you still have four minute in exam. So, what is your diagnosis? Uh, ii, will, my language will be, uh, cancer, esophagus, cancer esophagus. Ok. If it is a cancer esophagus, which type of cancer esophagus do you think? Mm. Uh, adenocarcinoma, mostly adenocarcinoma. Ok. So why you think it is adenocarcinoma? Not squamous cell carcinoma, for example. Mm, the patient, uh, had, uh, a history of five year reflux. Ok. Uh, it was, uh, what happened to your or what is, or what is met. Uh a change in the, it's a cancer is a change in the uh form of, in the form of cells to another type of cells for which type of cell to which type of cell uh in the, in this, in this, it will be from uh um squamous cell carcinoma from squamous to uh to columnar cell to columnar cells. OK. All right. What is the first investigation you need to do for this patient? Uh for submission, you will need the first or the golden, the golden for it will be uh endoscope and the biopsy, endoscope. And the what does biopsy mean? Uh What does this mean by biopsy? What do you mean by biopsy? I think of the a from the, ok. You take bart or punch from esophagus. So what is, is uh assembly of the tissue uh from uh uh I did so biopsy is take a sample. All right. OK. All right. Uh All right. So if this patient have cancer esophagus, uh what do you offer for him as a surgical treatment, surgical treatment? Uh if it, if it predictable, uh it will be a, a resection or area with, with an an so how to know it is resectable or not? Uh grading by, by the biopsy is not resectable ultrasound. Uh Actually, in my country, we don't have endoluminal ultrasound. There can be something of C uh C scan. Uh and c uh ct abdomen and chest? Ok. Good. All right. So if it's resectable, what operation will do? What uh again, please, what operation you make anastomosis? OK. So after that, if you need to have this patient have early feeding, what type of feeding you give to him? Um It, it, it what? Ok. Uh It will be uh So this is regional but actually this is difficult because you make anastomosis. So what is the other way of? Uh So uh s uh OK. So sy usually one of the step. OK. Thank you. I think we finish. So uh thank you doctor. Uh A II. Want, I want to come to one going to be Yeah. Yeah. Actually, actually II II had recently uh get scrubbed and Omy for ab patient to uh with a cancer esophagus. Uh But uh the I didn't uh remember. OK. So first uh general knowledge just it is important to do what you are available. Uh by the way, uh uh we have all students from all nationality but we are we all all background of you, whatever your nationality because this is international exam. So if you say to me in or indo uh sonography or indo, so sonography, I know that it is not done in your hospital. OK. OK. I know that most of you are Egyptian, uh 90% of the examiner in the Royal Colleges from Egypt, by the way, whatever the word. So don't do something. The, the he, he had, he sure that it is not in your hospital. Uh After that all you start, you start about this patient have difficult to swallow, which is the seizure. You ask about duration. Uh You ask about it become worse but it is better to start. The first bar. Is this dysphagia or difficult to swallow to solid or fluid? After that, you ask, it is uh, uh easy or worse or not worse. You ask about pain. You ask about bad odor and the GG may be not important. Uh But uh you ask about loss of weight is ok. You ask about smoking, alcohol is ok. But what you miss, you need to ask more detail about reflux. See this patient have reflux for five years. So why he stopped the treatment is any endoscopy done in this five years can be yes, can be. No. Uh he change his type of food. So you need to ask about type of food because in some countries like India, they eat the spicy food in some country like or they eat alcohol, drink alcohol. So type of food, spicy food or smoked uh food like in Japan or South Korea can be increased uh percentage of cancer, colon, uh cancer esophagus and stomach. Uh So you need to consist to ask more detail about reflux. Uh You ask about the smoking and alcohol. You ask about what fevers is OK. You ask about the figure to solid and the flare which, which is good. Uh You asked doctor Z about uh with whom you are live, you think this is important in this scenario? No, no. Uh After I ask you that, uh so it's not important for her. OK. So not if you think is important. Like for example, if this patient is a female, it's not necessary to ask about minister history or all this. So uh uh with who you are live, no need to ask uh why you ask about back ache or back pain. It is just a general survey or some in your mind about uh I it for cervical uh uh for cervical or back pain uh for uh uh in if there is a, a chance of uh no uh it is not common. But if you ask as general body survey, you can no problem like you asked about short of breath and the cough. But if you need to ask some more specific religious conditions, so it's better to ask about for or for lymph node can, can be important. You can ask, for example, about anemia can occur in some uh patient. You can ask about hematosis or vomiting. I think uh you don't ask about vomiting. No, no. OK. But overall is ok except you are not concentrate on the reflux in today or type of food, which is important after that differential diagnosis is cancer esophagus. Yes, it is adenocarcinoma. And it is metaplasia and it is esophagus and the metabol changed from to become columnar eil with go cell. Uh if it is resectable, of course, uh we do resectability by ct scan of sox and the abdomen and the pelvis just to exclude and to know the extent. And uh see the lymph node metastasis in the liver. And usually we resect it and make stomach up if you make a stomach up. So it is difficult to have gastrostomy for feeding, uh whatever the technique. So we have two option either in terms uh total brain nutrition by central line or nowaday. We started by Omy as a as a feeding way of feeding because the surgeon or the nutrition, I notice that the patient is fasting for a long time. The bacteria or flora in the intestine become flare up to pose into to uh endotoxic toxemia or septicemia in some patients. So they prefer to start feeding by urostomy. So nowadays, Urostomy is one of the operation. Ok. Uh I think when I ask you, what is the investigation you start? Uh the first investigation in inhibition is not, it is a full blood count. Uh Yeah, but I think the good standard uh to make it uh to know, usually we actually have a step bladders, whatever the condition you start by full blood count, looking for leukocytosis, looking for hemoglobin, maybe the patient have hemoglobin low due to cancer or due to bleeding you have bleeding. So usually it is overall is OK. So uh no problem, uh any comment from other about the scenario. OK. So uh we can uh have the same scenario. Uh but usually, uh by the way, you know, the scenarios in history taken in the exam is fix it maybe more than 16 years, we don't change it. Uh We just changed a little. So this patient, you have dysphagia to uh solid so we can make it dysphagia to something else like uh like fluid and this become another. Ok. Can, can you ask anyone uh just to have the same scenario? But we have a little change. Mhm. Ok. If not, we can use doctor Abderrahman again. No problem you. Ok. So uh we started by you, Doctor Abbra again. I am a female patient migrate and I am 45 years old and I have uh difficult to swallow. Can you start? Uh will you move a minute also? Yes, you can start. I am Margaret. I am 45 years old. Ok. Again, uh uh surgical team. Uh Could I confirm your name and age, please? Yeah, I am Mar Mar, I'm 45 years old. Uh Hello, MS Margaret. Could I call you Margaret later? You can don't waste your time in exam. What you and what is your IC number? Ok. So can I ask you what brought you here today? Uh act actually uh the doctor uh the GP transferred me to her? Uh ok. Uh So I see in your file that uh you have been transferred. Oh, please again, II will ask you II will take uh and this, I have been able to swallow. So I have difficulty to swallow. Yeah. Ok. Mm. So uh on the third. Yes. Good. Ok. Uh When did it start? Is that uh swallowing the problem? No, it is just two weeks. Uh No, it is maybe more than two months. More than two months. Ok. Yes. Uh, it started, uh, abruptly or gradually. Uh, and, uh, no, it is, uh, gradually gradually. Uh, and it's increasing or it is the same as it. So, no, it has become worse now. Uh, it's, I'm sorry. Uh, uh, so it is for solid or fluid the first? Ok. Uh, so it's for solid or fluid. No, it is for fluid. Solid is ok, but only for solid. I have difficulty to, to swallow, uh, any drink. Ok. Um, uh, did you have any unintentional weight recently? Uh, no weight loss at all? Uh, any heartburn, uh, no heart pain. I just have any to swallow any fever and no fever, uh, pain with swelling, no pain with swallowing. Ok. Uh, ok. Um, how do, how does it affect your life? Uh, uh, it's ok. Uh, not much affected by, I have difficulty to swallow fluid only. Ok. Uh, do you, do you vomit, uh, after you eat or choke or choking? No, vomiting and no, uh, vomiting or blood. Ok. Uh, feeling of choking going, uh, drunk. No, no. Uh, so, uh, do you have any, uh, other medical condition? You, you follow up with the G before, uh, like what, like, uh, diabetes like hypertension, uh, like, uh, heart problems? No, uh, any problems or your, or your, uh, um, I feel, uh, it was your bowel, your, uh, no, no, no diarrhea, no constipation. I am normal. Ok. Ok. Uh, did you underwent any surgery before? Uh, no surgery? No admission to, do you underwent any indication for your, uh, foot, like, uh, for the drug? No, a actually, uh, act as a doctor. Uh, do OO GD endoscopic endoscopy and he don't found anything. Ok. Uh, so, uh, do you underwent any surgery before? Uh, no surgery? Ok. Uh, uh, do you notice any problem, uh, like any other problem in your body like rash, uh, or, uh, no, no skin, right? Or, uh, joint pain or, uh, no, uh, skin skin lesions like, uh, in your nails? Something like that. Any, no, no, no. Ok. Um, do you smoke or drink alcohol? Yeah, I smoke about five cigarettes per day and drink alcohol in weekend. Ok. Uh, any of your, uh, family under, uh, good, good around like that before. Uh, no, but my father died from car accident. Uh, I'm sorry. Uh, no. So, uh, I finished, uh, I II am not allergic to any medication. Ok. So uh uh what is the investigation you will do for this patient? O GD done is normal. What other investigation in your mind can give us a clue for that. Mm. Uh It's a manometry. Uh So manometry severe me good. So the good answer is Mery. Ok. So what, what are you looking for? What is the possibility for this condition? Mm. It, it might be achalasia or no. A what does achilles mean? Aia uh is a problem. Uh was uh lo lo the loses its uh my blood cells. Uh So uh so in ba it is under which category of disease? It is inflammatory, malignant. Uh No, it is what? Yeah, it sounds uh uh no, it is congenital presented late but it is under uh which I will tell you inflammatory, inflammatory in no, no, not inflammatory. OK. All right. OK. Not inflammatory. OK. In the past uh how was he diagnosed before manometric study? How does he diagnosed it? I know? No, no, the ari swallow, but peak appearance by swallow. OK. It's historical. But OK. So this patient is proved by manometric to cardiac, what you will do for her. Um We have a one here. We have to. OK. All right. So I, yes, esophageal dilatation or no dilatation and myotomy done by laparoscope. OK. So you take a history good. You ask about dysphagia. You need to ask about first is what difficulty you feel? So I have difficulty with fluid, you need also to ask about reflux. You ask, uh in the old item, but I don't know uh why you ask about skin rash. Uh II assume ailia, uh achalasia and, and symptoms like that, uh sometimes are treated with uh another autoimmune diseases like scleroderma, uh, or scleroderma. Is, is it, it might be, is this, this, uh, uh scleroderma or disease? It is not Ayia, it is, have a spasma and they also diagnosed by, yeah, but don't think for something very odd is ok. All right. No problem. Uh, your history is OK, how to treat this condition? Of course. Um, so we can diagnose and uh what we will do it is just, uh, pneumatic dilatation or balloon dilatation or sometimes we do myotomy and this myotomy in the past done open surgery. Now a day is done by laparoscopy, just myotomy or os myotomy. Ok. Uh, as you see, the scenario is the same dysphagia can come as a cancer. Uh, dysphagia can come as akinesia. And again, as we mentioned many times, it is not important to know the diagnosis. The diagnosis may be one mark, but we, we ask you about family history, social history, all this I think doctor, uh he forget to ask about allergy. It is important, but from this, the overall is. Ok. Ok. So doctor, uh uh I got, uh, I got sometimes like, uh a blackout in my mind, uh, during you, at least at least forget what you asked. But don't forget uh you know that social history, family history, uh allergy, one mark, one mark, one mark, other disease like hypertension diabetes. All these, all these you can collect a mark. Of course you ask about other system. You collect the mark. So sometimes uh you, you have, you don't reach the diagnosis but have good, good mark because the we collected the mark at the end. Ok. So it is uh it is different from case to case. But again, the scenario or the headache of the scenario is usually fixing. Ok. Ok. Uh By the way, uh yesterday you had exam in Mumbai. Mumbai is a country in India and they have two cases, one is shorting of breath and another case is unilateral tons nerve swelling. And if you remember if you go to any recall, you found this treated many, many times, maybe more time. Ok. Uh Second scenario we have today, if no one has comment on dysphagia is about bleeding, the baricum, which is common and they can have many possibility. So anyone is volunteer, we ask him about bleeding the bar rectum. Ok. Anyone to, to uh again, I am I am ready. Ok. Hello. Uh Yes. Uh so I am a Mr uh man also, I am 65 years old and I have uh altered bowel habit so you can start. Hi, I'm doctor H one of the surgical doctor. Can I can I confirm your name and age, please. Yeah, I am mister man and I am 65 years old, 65 years old. Uh by the way, usually in exam we use the name men, but actually it is not English name, it's not name even, but just to be easy for some Indian and uh nationalities over the world. Ok. Ok. Tell me what brought you into the hospital today. Uh Yo I just came because I have a habit being sometimes constipation, sometimes diarrhea. Ok. Sorry to, sorry to hear that. Can I ask you several questions regarding your complaint? I can. Yes, no problem. Uh Could you please, you, have you, you told me you have, you have sometimes the, the area and sometimes you have, you have consideration, right? Yes. Yes. Uh Could you tell me please how many in the time in the, in the last uh I usually I go to washroom is 11 time per day. Uh But uh in the last uh three months I found one month, I take it twice or one every two days. And uh another month I found I go to washroom or toilet is five times a day. Ok. Last, so last week, how many times a day? The last five times each, each, each day? Ok. Uh Does it include a good time? No, it is and no, no, it is the same. It is alternative. Some like this, some like this. Do you do you have abdominal pain and no abdominal pain? Uh, when, uh, ok. Uh, could you, could you please characterize the, the, the stool? Do you, do you have, do you have like watery stool or solid or semisolid? No, it is. Uh, sometimes there is sometimes constipation. D don't ask, minor in exam. It's not important. Uh, can they have blood or mucus in the stool? Uh, yes. Sometimes I have, uh, some, uh, red color or stool mixed with blood. Ok. Do you have like the, the stool? Do you have full s smell stool? No, no. Do you have fever? Uh, no fever, no fever. Uh, did you have, do you have weight loss? Yes, I lost about 5 kg in the last 12 months. Do you have joint pain or back pain, joint pain. Uh, no joint pain. Did you travel recently? To any, to abroad? Did you, did you travel abroad recently? Uh, no, but II, live in ma, I was always ok. Uh, do you go to the, to your GB, uh, for any other medical condition? Uh, no. Do you have allergy to any drug? No allergy? Do you take, uh, uh, uh, drugs at all? Uh, what do you mean by the drug? Like, what, for what drugs, any type of drug do you take? Like, uh, you need to ask about any chronic disease, for example, like what, like what, like, what do you have diabetes or do you have, uh, ischemic heart disease and no diabetes. No ischemic heart, no hypertension did. Ok. Uh, did you have any surgery? Any, any surgery in the past? No surgery? Ok. Tell me, uh, tell me please. What is your occupation? Uh, I am retired lurid driver. Ok. Who, who live with, who live with you at home? Uh, I live with my wife. Do you go, do you go shopping alone or independently? Uh, no, I make delivery. Uh, do you take alcohol or reactional drug? I id, I drink alcohol. Yes. Uh, I drink alcohol and kind of alcoholic beer in the, every day. But I want to know what you mean by recreational drug, uh, drugs, uh, which you take it, which you should take them. Like, uh, uh, uh, uh, what do you mean by drug first medication or? Sorry? You, you mean illegal drugs, illegal drugs? Uh, uh, like what, like, uh, cocaine, for example. Uh, no, no, we don't have it in my country. Ok. Does any of your family experience such, such a medical condition? Uh, no, but my father died from heart attack. Sorry to hear that. Uh, what do you think? Uh, what do you think the cause of your medical condition? Ok. It is good question but you know that I am not a doctor. So why are you asking me what you expected from me to know? I usually lory driver and even, I don't read except some newspaper. So how do you expect it to me? I know my condition. I am not a doctor, correct? Ok. Uh uh, ok. Do you have, uh, do you have chest pain? Uh, no chest pain? Do you have, uh, do you hear, do you, do you feel your, your, uh, heartbeat? No. Do you have cough or difficulty breathing? No. Do you have any problem with the, with the water work? What do you mean the water? What do you have like uh by the urine when you go to the bathroom? Urine, urine? You mean urine? So what do you mean by what you need to ask about urine? If you have any problem with that? You have like burning sensation or bad leg sensation. What else? No. OK. Uh Do, do you have dizziness or visual disturbance? I don't know you ask about urine. What else do you need to ask in urine? You ask about dysuria or pain? What else you need a little bit dribbling? For example, uh color change pain. You ask about pain, color, increased frequency, no frequency. Mhm. Ok. Do you have dizziness or visual, visual disturbance? Uh No, but I wear glasses because it's myopia. Do you have dizziness? No dis what you mean by this? Yeah, it's, it's uh like uh in normal movement or something. Yes. No, no, thank you. Thank you. OK. Uh Thank you, Doctor Hakim. Ok. Uh Usually in the college uh we consider as you are one of the mater fellow, you know. Doctor Mat. No. No. Ok. All right. So, uh, uh, you, you, you did yourself in many mistakes? Ok. So I was, I started it, but after that, what's your diagnosis? You can have blood in the, in the stool? Yes. Uh, but, uh, you don't have any abdominal pain. Yes. You have weight loss. Don't know. You give me the diagnosis or differential diagnosis, don't tell me. Do you think it is? It is it can be a colon cancer or diverticular disease? Ok. Colon cancer. Yes. Uh What is the second? It may be diverticular disease, diverticular disease. But actually from your question, you exclude diverticular disease. OK. So what, what is question you ask you to exclude, you already asked it. But uh uh uh what, what is this question? You ask it to exclude diverticular disease or diverticulitis? Uh Sorry, you have the. Yes. OK. So you also remember the question. No problem. Uh Because in your history taking you exclude diverticulitis by asking me some questions. All right, we're back to this. So, uh what is the investigation we need to do for this patient? Uh You need to do a stool analysis, stool analysis looking for. Ok. Uh what else? Colonoscopy? OK. All right. II, think you can start uh start by lab investigation first. So what else? Lab investigation we need to do? You do need to do complete blood count. You need to do uh what's what, what you expected in full blood count. Uh It can be uh can be anemia. Which type of anemia are you expected to find in this patient? Uh It can be iron deficiency. It can be, you look like your chronic chronic. Uh It's, it's chronic anemia. It's chronic. Uh it's the enemy of chronic disease can be uh what look like under microscope. It is microcytic microcytic hypo. Uh What else do you need to, to, to do you mentioned colonoscope? Looking for? What? OK. Uh You mentioned colonoscope looking for what uh for any like uh for, for cancer, for, for, for polyp uh for polyp and tape biopsy from this polyp or so, what you expected if this is a cancer, which your type of cancer adenocarcinoma? Ok. What is the common site of adenocarcinoma in the colon? Which part of colon? I think it is in sigmoid, left colon, rectosigmoid, 65% rectosigmoid. What is the common side of spread of the tumor in cancer? Colon human of metastasis. What is the c of me to deliver? Uh why it is go to the liver cause the venous venous drainage to the liver, uh your bo bo circulation. So for example, the upper part of the rectum is drainage to which, to which vein suboral to with sever to the uh inferior mesenteric, inferior mesenteric and joins aboral vein. Ok. If you have a tumor in the colon invading nearby organ like in the bladder or uterus in female. W what is this stage? T what you have? Tea and aging? So, if the tumor invading urinary bladder or uterus, so it is tea. T four, I think T four. Yes. R four at four, T four. Yes. Ok. Uh So what is the level you, you will know that it is T 2 to 3? Which muscle, what is the name of muscle? We say if it is just a touch, it is T two. If it penetrated T three, what is muscle in the colon called? You're welcome the mucosa mucosa submucosa and the CSA. Uh No, no, it is vascular piro. It's a muscular Respi. OK. Doctor, thank you. All right. So uh this is a way of speaking your answer. I heard it about 100 times, maybe 1000 times. So it is a chemical, it is typical way of uh some group of a student uh for my background, we call it mat group. But doctor Mat is one of my friend. By the way, I just asked uh I come to you one by one. OK. So first the question you say it is cancer colon, which is correct, but why it is not diverticulitis and diverticulitis? Uh You have, first of all, you start with uh it's, it's, it's like it started with constipation at the area, the constipation and the fever, fever. No, no fever. Because if you remember you ask about fever, you didn't interact to you you ask about fever. If you ask about fever and they say to you it's no fever. So it is cold first. And also diverticulitis is of care in the left side and have been. Yes. Ok. In this patient have no abdominal pain. So it is not diverticulitis. Of course, in full blood count, looking for leukocytosis, we don't have leukocytosis. So this is not diverticulitis, of course, in both case cancer, colon and the cancer. Uh and the diverticulitis, you need to ask about the type of food he eat fast food or something like that. All right. Uh We uh uh from the beginning, it is important. The cancer colon is very, very important in England diverticulitis is the same. Uh You need to ask about six equation. You need to ask. We mentioned to you ter bowel habit, don't predict yourself. What is the color of the stool? What is the smell? All this? We are not in gastroenteritis case. So ter bowel habit finish after that. You ask about bleeding rectum. It is OK. Just ask, it makes it a lot. You ask, you don't ask about fecal incontinence, which is indicated if the patient have fecal incontinence, which part of colon? He have a cancer? Ok. Fecal incontinence like uncontrol of the muscle. So the tumor is in anus and usually to diagnose it, you need to do MRI to, to see infiltration of muscle and you have something called 10, which is incomplete evacuation of the, you need to ask. So you need to ask about inter bowel habits already given bleeding incontinence. And after that loss of weight loss of appetite, you already answered. Ok. So of course you have abdominal pain. You ask about fever. You ask about joint Tibet. I don't know why you ask about joint Tibet. I asked II it's, it's like I thought about the, the IBD colitis IBD inflammatory IBD inflammatory bowel disease. Ok. No problem. Uh, I think, uh, you asked about your traveling abroad. Uh, what, what, what is value of traveling abroad? Uh, it's like to, to exclude if you have, if you, if you have, uh, it, it can be in gastroenteritis maybe. Uh, you, you actually gastroenteritis is, is not common in, uh, in England. But if you are in examine in India, we can accept that if you, if you work in India or exam in India, we can accept that. Uh, we don't ask about traveling. Sometimes you ask in Southeast Asia about traveling if we're looking for sexual transmitted disease because of the sex of tourists, especially to country like Thailand. But in the Middle East and England, we don't ask about traveling. You ask about allergy. You ask about diabetes, mellitus ischemia and, uh, ask about chest pain, palpitation, your dizziness, use some medical term. You have the, the same typical, uh, two common mistake. What is called? We call in college. I ce I ce means that in uh concern, expectation and, and the expectation and the concern and the idea. And uh this is according to our culture. So, you know, we have the background of every student come to the exam. Uh So uh in your practice, you ask as a student, you ask as a patient, what you expected from us to do to you or not? Mm No, if, if you're in your, in, not in your culture. So don't ask it because it is give negative mark to you. OK? Because when we examine you, doctor, we examine you from your background. OK. So anyone in the college, anyone who's a college, he can expect it from you from whoever you study, not for your nationality, we can expect it from who your source of a study. Actually, it is very common in India. We found the student asked about I ce but it is not expected from British, not expected from a student who book like Hampton be or no Brown or even clinical normal books. So in this condition, we will ask you from which clinical book you study? I have notes. II just I'm sitting from I have notes. OK? But in medical school you don't have traditional books like be and love there. Even even local book in your country. Where are you from? He sure then Jordan. OK. All right. So good. So it is not uh uh don't tell the patient what you expected from us to do. All right. OK. Second you ask about recreation, drugs and diseases in England Asia is not accepted uh simply because it is like or heroin or heroin or other drugs. And this is the drug used in America. Uh Usually British culture, Irish culture, Southeast Asia culture is conservative. If you ask something like this, it's not, not good. So just you can ask a direct, you take any illegal drug can be OK. Uh You ask about, uh family cancer colon, in particular colonoscope. Of course, if you ask about the investigation, I will go for blood count, looking for hemoglobin, looking for leukocytosis. And this is type of anemia is microcytic hypochromic anemia due to bleeding. And I, uh of course, if the blood is less than eight, I can correct it. OK. Yes. All right. So I think someone raised his hand. So any comment, anything you need to ask the doctor say? Ok. All right. So we'll repeat the same scenario and this time we'll make it another disease, but it is the same colonic case and the same patient have bowel habit or make it bleed in the rectum. So, can Doctor Hakim again? You can start, we just have 10 minutes or something. So can I, can I or anyone, can I can up here? Doctor Ahmed? Can, can. All right. Uh I started in the same scenario, uh, same scenario, but this time it's breathing, breathing. Uh Doctor Hakim, if you know doctor S uh uh what is called SAPA. Just tell him hello if you are working in the hospital in. Ok. Uh back to doctor Ahmed Naser. So I am uh mister uh man, also 65 years old and I have bleeding. Ok. Start from now. Yes. Good afternoon, sir. Good afternoon. What's your name? Yeah, I am Mister Man. I'm 65 years old. Yes. Hello, Mister man. Can I call you Mister Man? Yeah, I can. My name is doctor. I am one of the surgical trainer. Uh Yes, could I ask you some uh, questions? Ok. Can ask, you can ask. Ok. Uh, do you have any uh any uh, any, uh, any past medical history, like diabetes, mellitus hypertensive? No, you start by past history first, you need to start the analysis. I will start uh, in my country, the history, uh, start the name, age and uh both medical history and uh complain and, uh, and personal history. My, in my country. Uh Which country you are in my, in my? Is that which college you are university? Ok. No, I think it's not accepted because usually if you have debate, supposed to be as the doctor Mohammed Omar Faro have a debate. We go to normal just as a, as a reference. So first I have bleeding, you can start by. Ok. Ok. How many do you have? It? Is, it is uh, just uh, three times I have bleeding Deb start from when, uh, just, uh, two week ago, two weeks ago. Do you, do you notice that it's, uh, have a relation with, uh, any type of food? Uh, not related to food? Not related to food? Ok. Uh, how many times per day, how many, 33 times per day? Three times per day? Uh, yes. Uh, uh, could you tell me the amount of bleeding it? Uh, no, it is not, not, not the fresh blood. It is mixed with the stool, mix it with a stool, mix it with a stool. Do you have any loss of weight? Uh, no loss of weight, no loss of weight. Uh, no loss of weight. Ok. Uh, if there is any abdominal pain, no abdomen. Uh, yes. Sometimes I have pain in the, my left side of my lower abdomen on your left side. Uh, did the pain, uh, could you, uh, tell me the character of pain? Uh, it is called in nature and not radiated, not to inside of your body? Yes. Ok. Are you a smoke? Uh, I smoke five cigarettes per day for the last 20 years. Uh, you take alcohol? Yeah, I take alcohol, one can of alcoholic beer every day. Ok. Uh, do you have any illegal drugs? Do you take any illegal drugs? Uh, no. Ok. Uh, uh, there is no loss of weight, no loss of weight, no loss of weight. Uh. Ok. Uh, do you love spicy food? Uh, yeah. In my country. I am from Malaysia. So we, it is normal to have a spicy food. Ok. Do you have any surgical history? Uh, no, past history of surgery. Uh, what about, uh, medical history, hypertensive diabetes? Uh, no hypertension, no diabetes. No, just lipidemia. Ok. Uh, has this been, uh, common in your family? No, but my father died from heart attack but no one of your family have this, uh, same attack. No, no, just my father died from heart attack. Ok. Ok. Uh Is there, is there is any pain with the uh uh sometimes, sometimes, uh is this committed to this uh bleeding or uh normally how long uh it's sever? Yes. Ok. Uh Do you have any, uh do you have any signs of uh gastro reflex disease? Uh uh No. Ok. Uh Do you have any problem in urination? Uh What do you mean by urination if there is any change in color change in color? There is a baby, no pain, no change in color, no increase in frequency. Ok. So this is the main basic just to ask about color, uh frequency and uh dysuria. No. Ok. Ok. Ok. Uh So what's your, your diagnosis doctor? What else do you need tosis? But you don't ask any question about colonic symptom and you don't ask any question about fever. So first I have, but I have asked you about the abdominal pain. Yes. But II tell you it, it's a chronic case, you need to ask first if I tell you bleeding rectum. So you need to ask about bowel habit. You need to ask about fecal incontinence. You need to ask about 10 after that loss of weight loss of appetite after that fever. Because the, the, the key, the key of this diagnosis is if you have a fever, pain, diverticulitis, good. No loss of weight. If you have loss of weight, no fever, no pain. It is cancer. Ok. Ok. Ok. Uh When, when uh I tell you that my father died from heart attack, what you expected to, to tell me? Sorry for that. Sorry for that. Ok. Uh By the way for uh uh for trying to share with you, uh I II will get this more to uh to improve my skills. OK? No problem. It will be OK. Uh By the way, what you mentioned that we mentioned the past history, it is OK. If you write a case report, if you write a case report for publication, we write yes male patient, 25 years old, well known diabetic hypertension, but in present in the history taking of exam is different. Ok. Ok. Uh You ask uh of course, again, if it's a chronic case, you ask about chronic symptom, you ask about them, you ask about fever, you ask about smoking, you ask about alcohol. It is important for both Doctor Hakim and you, you need to ask about diet. So I eat fast food. Usually patient with diverticular disease and cancer colon. He like pasta, food less vegetables. This is Hawaii diverticulitis common or not common in Southeast Asia or Middle East. And this is also explains the high risk of cancer in some country. Ok. Ok. We, we just have five minute. Uh I just, when you ask about urine because Doctor Hakim asked about urine. You need to ask in any patient about the from state, you need to ask about dysuria befol in urination, color of urine increased frequency. OK. Of course. Uh Again, the scenarios is fix it. And in the exam, you don't find any new scenario. It is the same scenario repeated many, many, many times. We run the exam about uh 20 times per year. So we don't change the question. But the way presentation, the way you're asking is important, Doctor Ahmed your, your way of asking you miss the main target of the, of the question which is asked about colonic symptom. OK. Ok. So it is very important but although you ask a lot of question, you have a mark, but the main target you don't ask. Ok. Uh Any question, Doctor uh Mohammed Omar. Uh Al Far is any question from your side? Uh I enjoy it very, very much. Uh You're OK. Thank you. Yes, thank you very much. And uh we will record it and hopefully everyone will benefit from it. Thank you very much. OK, so tell we have two minutes to just explain to him. History taking is easy. Uh We, we know that the students come from different cultures. We examined the student all over the world, but at least if you found different, maybe I see something wrong just to go to the text book is a billion Glove Hampton billion Normal Brothers if you are in is as you can use this. II know that many books because what we notice as examiner we notice is that all the student asked what you expected from us to do, which is not logic in most of the country. Of course, I don't know your background. Maybe in Gordon do that. Maybe in Egypt to do that. I don't know. In Gordon you asked about expectation. Doctor Hakim or not? I think we close the control. Oh, ok. You can speak. OK. Go ahead. Ok. No, I didn't ask. Ok. All right. So if you something you don't to do in your country don't ask because you usually we know your background. II tell them all over the world. Yeah, it is. Please don't say so. Then don't to do something. You found it. What do you want me to do or what do you expect? It is not, it is not totally accepted if we ask about past medical history in the first to if I am the examiner because it is I check, I have check list. So II check it but, but you give me the I that you finish. No, no, we don't have an idea. You know that OS is a checklist. What you mention, make it you ask about fever.