PACES Surgery Flashcards
(191 cards)
1
Q
Aneurysm: definition
A
This is the pathological localised permanent dilatation of an artery to more than 1.5 times its original diameter involving all 3 layers of its parent wall.PSEUDOANEURYSM DOESN’T INVOLVE ALL THREE LAYERS OF THE ARTERIAL WALL.
2
Q
Causes of bowel obstruction
A
Small bowel obstruction is more common than large bowel. The most common causes of small bowel obstruction are - adhesions- hernias- cancersThe most common causes for large bowel obstruction are:- cancers- diverticular disease- volvulusThe causes of bowel obstruction can be divided into mechanical and non-mechanical causes.Mechanical causes can be classified according to their relation to the bowel wall:- luminal: gallstones, meconium, impacted faces, …- extramural: adhesions, cancers, hernia, volvulus- in the wall: congenital stenosis, strictures, IBD, diverticulitis, cancer…Non-mechanical causes, known as paralytic ileus, are due to - postop abdo surgery, - mesenteric ischemic- metabolic causes (hypokalemia, uremia, hypoglycemia and hypothyroidism)
3
Q
Causes of clubbing
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The most common cause of digital clubbing is idiopathic. However, there are many causes of clubbing and they can be classified into:- GI causes: IBD, PBC, coeliac- Resp causes: Lung Ca, bronchiecstasis (suppurating lung disease), CF, Mesothelioma, fibrosing alveolitis - cardiac causes: congenital cyanotic heart disease, endocarditis- other causes: familial, idiopathic, graves’ diseaseShamroth’s test
4
Q
Ix for acute abdomen
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!!! simple bedside tests:- ECG (to rule out ischemic/MI)- urinalysis (hematuria in renal calculi, UTI, or pregnancy test)- BM: blood sugar levels, if suspected DM presenting as abdo pain!!! Blood tests:— Simple tests- FBC (raised WCC in infection or anemia if GI bleed)- U&E: look for dehydration, renal failure, raised urea in case of acute GI bleed, electrolyte imbalance secondary to massive fluid shifts in pancreatitis or cases of bowel obstruction- LFT: for acute cholecystitis, or obstructive jaundice- Amylase: compulsory in acute abdomen. Raised in acute pancreatitis to at least greater than 3 times the upper limit of normal - G&S: if expecting an operation or if there is blood loss- Cross-match: if expect pt will need operation and will require blood transfusion (eg upper GI bleed taken to theatre)- ABG: if pt particularly sick, will help to gauge how sick he is. Lactate and pH are helpful indicators of level of shock and can help unmask conditions like mesenteric ischemia.— specialist tests (for pancreatitis for example: do BM, Ca levels, liver transaminases and CRP to score severity).!!! Imaging— plain films- erect CXR: if suspecting perforated intra-abdominal viscous…then looking for air under diaphragm. Film taken while patient sitting upright for at least 20 min prior to film taken, because air will need time to rise and demonstrate a pneumoperitomeum. Sign only present in 80% of cases- AXR: if bowel obstruction thought- Contrast films: gastrograffin enema if bowel obstruction or IVU for ureteric colic.— Ultrasound- USS liver: to scan biliary tree for evidence of gallstones or to measure size of common bile duct in suspected obstructive jaundice— CT scans:- CT KUB: first line Ix for renal calculi- CT abdo/pelvis: depends on the case but useful in pts not responding to ttt and in whom urgent Sx exploration is not mandated.
5
Q
Question about discussing the management
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Start with stating Hx, examination, Ix, differential diagnosis and ttt options.Ttt options can be either:- conservative: includes anything non-surgical. May be in the forms of IV fluids, NG tube for drainage of stomach contents and urinary catheterisation. Includes as well MDT approach (OT, PT, clinical nurse specialists) in chronic debilitating conditions such as OA or cancers- medical: any drugs (eg analgesia, antibiotics…). May also take form of more invasive but non-surgical ttt options, such as injection sclerotherapy in varicose veins or injecting Hemorrhoids. Some surgeons argue that endoscopic ttt options fall under this category.- surgical: any surgical procedure performed
6
Q
Discussing surgical complications
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2 main categories1- complications from anaesthetics: 1.1 damage to local structures (mouth, pharynx, teeth) 1.2 allergic reactions to agents (minor vs major) 1.3 slow recovery (due to poor cardiac, hepatic renal function…) 1.4 malignant hyperpyrexia (caused by anesthetic gas or suxamethonium) 1.5 awareness (pt paralysed but without effective anaesthetic)2. Complications due to surgery 2.1 related to any surgical operation: pain, infection, bleeding, DVt/PE 2.2 specific to the surgical procedure 2.2.1 immediate 2.2.2 early 2.2.3 late
7
Q
Postop complications of total thyroidectomy
A
- Cpx from anaesthetics2. Cpx from surgery 2.1- general to any surgical operation 2.2- specific to thyroidectomy A- immediate (3 weeks): hypothyroidism, keloid scar formation, recurrence.FYI: primary hge or laryngeal edema compromising the airway is a surgical emergency. Surgical clips should be removed to facilitate evacuation and help relieve the immediate airway compromise (buys time before definitive surgical evacuation). Surgical clip removers always by the bedside of post-thyroidectomy pts.
8
Q
Testicular pain age groups
A
- prepubertal: mumps orchitis, idiopathic scrotal oedema, testicular torsion- adolescent (10-21): testicular torsion (most likely), epididymo-orchitis, torsion of the Hydatid of Morgagni (7-14)- adult (>21): epididymo-orchitis (most likely), testicular torsion- all age groups: trauma
9
Q
Focused Hx for Testicular pain
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- patient age- testicular pain: bilateral (mumps orchitis), unilateral (testicular torsion or epididymo-orchitis), acute onset (torsion) vs gradual onset / hours (epididymo-orchitis), sharp pain (torsion) vs dull heavy (epididymo-orchitis), pain relieved by standing up or wearing scrotal support (epididymo-orchitis), radiation to thigh groin or abdomen (t10 dermatome) implies testicle, if to penile shaft or perineum implies idiopathic scrotal edema.- Urinary symptoms: dysuria, urinary frequency and urethral discharge commonly seen in epididymis-orchitis. Nothing in torsion.- sexual HX; relevant for epididymo-orchitis- swelling: + erythema = scrotal edema or mumps orchitis / just after trauma = hemToma / swelling can occur with torsion.- previous HX: torsion (usually intermittent torsion previously) - fever/vomiting: with epididymo-orchitis, torsion or mumps. Vomit from pain in torsion.
10
Q
How to describe a scar
A
1- Identify scar: name with eponymous name or anatomically ((eg 2cm scar in R groin). Comment on whether scar recent (raised and pink/red) or old (flat and same colour as surrounding skin)2- check for incisional hernia: ask pt to cough or raise head off the bed3- suggest possible operations
11
Q
Possible operations for Midline laparotomy scarWhat about Upper midline scar and lower midline scar
A
Exploratory laparotomyHemicolectomy Hartmann’sAAA repairUpper midline scar: splenectomy (massive)Lower midline scar: para-umbilical hernia repair, colectomy
12
Q
Possible operations for Kocher’s or right subcostal scar
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Open cholecystectomyPartial liver resectionAny biliary surgery
13
Q
Reversed Kocher’s (left subcostal)
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Open splenectomy
14
Q
Possible operations for Double Kocher’s or rooftop scar (=R and L subcostal)
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Ivor Lewis (Oesophagectomy)Complex pancreatic/gastric surgery
15
Q
Possible operations for Mercedes scar or extended rooftop
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Complex upper GI surgery (eg McKeown Oesophagectomy, gastrectomy, liver transplant
16
Q
Possible operations for left nephrectomy scar or loin incision
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NephrectomySpecialist renal surgery
17
Q
Possible operations for Gridiron or McBurney’s scar
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Appendicectomy
18
Q
Possible operations for Pfannestiel scar
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- pelvic surgery: bladder resection, prostatectomy, bilateral hernia repairs- gynae: C-section, cystectomy, hysterectomy
19
Q
Possible operations for Rutherford Morrison or hockey stick scar
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Renal transplant
20
Q
(When seeing a renal transplant scar, what else would u like to examine/look for?
A
I would like to look for associated scars:eg - AV fistula at wrist, - median sternotomy scar, - CAPD (Tenckhoff) scar on abdominal wall or - infraclavicular scars from previous dialysis access (Vas Cath insertions)
21
Q
Gridiron scar vs Lanz scar
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Gridiron scar perpendicular to McBurney’s line at McBurney’s pointLanz is a transverse muscle splitting incision better for cosmetic result (incision follows Langers’s lines)
22
Q
What structures would you go through in 1- an Appendicectomy scar?2- a midline laparotomy scar?
A
Appendicectomy scar: From superficial to deep:1- skin, subcutaneous tissue2- scarpa’s fascia, Linea alba3- muscle layers: external oblique, internal oblique than transfers us abdominis4- transversalis fascia5- extra peritoneal fat then parietal peritoneumMidline laparotomy scar: From superficial to deep:1- skin, subcutaneous tissue2- scarpa’s fascia, Linea alba3- transversalis fascia4- extra peritoneal fat then parietal peritoneum
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Q
What’s a peritoneum?
A
It’s a serous membrane that forms the lining of the abdominal cavity. It covers most of the intra-abdominal organs, and is composed of a layer of mesothelium supported by a thin layer of connective tissue. The peritoneum supports the abdo organs and serves as a conduit for their blood vessels, lymph vessels and nerves.
24
Q
Pros and cons of midline laparotomy scar
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Pros: - good access- can be easily extended- speed of closure and opening- relatively avascular (Linea alba)Cons:- incision more painful than transverse incision- scar crosses Langer’s lines (poor cosmetic appearance)- Narrow Linea alba below umbilicus (therefore can damage bladder)
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What features determine the placement of laparoscopic ports?
In general, ports should be placed away from areas of high risk, such as:- previous scars, adhesions and known organomegaly- the vessels of the anterior abdominal wall should be avoided , particularly the inferior epigastric arteryThe minimum number of ports should be used (typically 3)The positioning of these ports should then allow for the target organ to be at an apex of an imaginary diamond formed by the various ports as well as the target organ itself.The 10 mm port is the camera and is useful for the removal of organs such as the gallbladder in a cholecystectomy. All other ports are typically 5mm in size.
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Pros and cons of laparoscopic surgery
Pros:- shorter hospital stay and rehabilitation- less post-op pain- better cosmetic result- less wound complications- decreased handling of organs (eg bowel)- less trauma to tissues- later reduced incidence of postop adhesionsCons:- lack of tactile feedback to the operating surgeon- longer operation times- more technical expertise required, prolonged training- expensive equipment- difficulty in controlling massive bleed- increased risk of iatrogenic injury to surrounding organs- not always feasible due to CI (eg adhesions)
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Nine regions of abdomen
From R to L:- Upper: R hypochondrial, Epigastric, L hypochondrial- Middle: R lumbar, umbilical, L lumbar- lower: R iliac fossa, suprapubic, L iliac fossa
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Underlying organs behind the 9 abdominal regions
- R hypochondrial: liver, gallbladder, R kidney, hepatic flexure of colon- R lumbar: ascending colon, small bowel, R urinary tract- R iliac: caecum, appendix, terminal ileum, R ovary and R Fallopian tube- Epigastric: Liver (left lobe), pylorus, duodenum, transverse colon, head and body of the pancreas- Umbilical: Duodenum, small bowel, abdominal aorta- Suprapubic: Bladder, uterus- L hypochondrial: spleen, stomach, splenic flexure of colon, tail of the pancreas, L kidney- L lumbar: descending colon, small bowel- L iliac: sigmoid colon, L ovary and L Fallopian tube
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Umbilical vs paraumbilical hernias
Central umbilical hernia-Clinical featuresOccurs following failed fusion of the anterior abdominal wall after birth.Often evident a few days after delivery.The hernias are usually small.The underlying defect is usually smaller than the visible hernia.A cough reflex is present. - Management:Most settle spontaneously and parents can be reassured.Surgeons are usually unhappy to operate before one year old.Strangulation never occurs in central hernias.Paraumbilical hernia- Clinical featuresOccur as a central swelling usually above or below the umbilicus.These hernias may become very large.More common in adults (especially women), than children.May be associated with obesity and weak abdominal muscles.The sac may contain both bowel and omentum.This is a true defect in the linea alba close to the umbilicus. - ManagementThese hernias will not resolve without surgical intervention.The patient should be advised to lose weight.Surgical repair is recommended because of strangulation risk.
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Striae: causes and types
Due to rupture of the reticular dermisSilver striae: signifiant changes in weightBluish striae: present in hyoercortisolism
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Abdominal signs in acute pancreatitis
Discolouration / bruising in haemoperitomeum, secondary to haemorrhagic pancreatitis or ruptured ectopic.Cullen's sign: bluish discolouration around umbilicusGrey turner's : bluish discolouration at the flanks
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Interpretation of bowel sounds: absent, increased, tinkling
- Absent bowel sounds: paralytic ileus, peritonitis, obstruction, mesenteric ischemia/infarction- increased sounds: diarrhoea, obstruction- tinkling: ileus (disruptions caused by failure of peristalsis), a later phase of obstruction
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Special tests for acute abdomen examination- McBurney's point tenderness- Psoas sign- Obturator sign- rovsing's sign- cough test- carnett' sign- succussion splash- boas' sign
- McBurney's point tenderness: acute appendicitis. Found 1/3 of the way from ASIS to umbilicus- Psoas sign: hand above R knee and apply resistance and ask pt to flex hip. If this increases abdo pain, then positive sign for appendicitis.- Obturator sign: R knee flexed, and internal rotation of hip, if increased abdo pain, then positive sign for appendicitis.- rovsing's sign: palpate in LIF. On releasing the pressure, if pt experiences pain in RIF, test positive for appendicitis.- cough test: pain experienced by pt when asked to cough in peritonitis, as this moves the peritoneum and causes pain when there is peritoneal irritation. This is another way to elicit rebound tenderness.- carnett' sign: to differentiate abdo wall pathology (eg rectal sheath hematoma) vs pain caused by intra-abdo pathology. Ask pt to lift the head and shoulders off the couch or to straight leg raise both legs.- boas' sign: pain that radiates from inflamed gallbladder in acute cholecystitis to the tip of R scapula. Leads to an area of skin just below scapula to become extremely sensitive to touch, resulting in pain (hyperesthesia)
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What is the significance of palpating a tender gallbladder?
- this elicits Murphy's sign, seen in cholecystitis. Pain on inspiration- if able to palpate a gallbladder, this is always pathological. If no coexisting jaundice, then this has resulted from obstruction of the cystic duct, resulting in mucocele or empyema- if co-existing jaundice, it implies obstruction of CBD and is thought to be caused by other causes besides gallstones. With gallstones, the gallbladder wall can become thickened and fibrosed after recurrent episodes of inflammation; but gallbladder enlargment typically arises as a result of carcinoma of the head of the pancreas, or another cause as stated in Courvoisier's law
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Courvoisier's law
in the presence of an enlarged gallbladder which is nontender and accompanied with mild jaundice, the cause is unlikely to be gallstones.
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Causes of abdominal ascites
Causes of ascites can be divided into those that can cause an exudate or a transudate exudate (>30g/l of protein)-- peritoneal malignancy-- infection (eg TB)-- obstruction of IVC-- obstruction of hepatic portal vein-- acute pancreatitisTransudate (<30 g/l)-- heart failure due to hydrostatic increase in venous return-- cirrhosis of liver as a result of increased portal hypertension-- hypoalbuminemia due to nephrotic syndrome
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Key features to look for in hepatomegaly
- site: R hypochondrium: can extend into epigastrium if very large- palpation: can't get above it- moves with respiration- not ballotable- dull to percussion- can be associated with splenomegaly
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Key features for splenomegaly
- site: L hypochondrium- can't get above it- moves down toward RIF with respiration- not ballotable- dull to percussion- palpable notch: enlarges towards the umbilicus/RIF
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Key features in kiney organomegaly
- site: L or R flank (if very large, may involve the ipsilatera Hypochondria)- L1/L2 level- can get above it- moves vertically down on inspiration- ballotable- usually resonant due to overlying bowel- if bilateral, consider polycystic kidney disease
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Causes of hepatomegaly
- jaundiced, smoothly enlarged: viral hepatitis, biliary tree obstruction, cholangitis- jaundiced, knobbly enlargment: malignancy (primary or secondary), cirrhosis, liver abscess, Hydatid cyst- no jaundice, smooth enlargment: CCF, cirrhosis, Budd-Chiari syndrome, amyloidosis - no jaundice, knobbly enlargment: primary hepatocellular Ca, cirrhosis
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Causes of splenomegaly
- infection: malaria, EBV, CMV, TB- congestion: portal hypertension, CCF- infarction: subacute endocarditis- malignancy: leukaemia, lymphoma, myeloproliferative disorders- others: felty' syndrome (RA, neutropenia, splenomegaly)
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Causes of hepatosplenomegaly
- infection: infectious mononucleosis- cellular proliferation: polycythemia rubra Vera, myelofibrosis- malignancy: lymphoma, leukemia- others: amyloidosis, sarcoidosis, cirrhosis
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What is portal hypertension
This is increased portal venous pressures to > 10 mm HgThe most common cause worldwide is post viral hepatitis, and in the UK it is alcoholic liver cirrhosis
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What is Budd-Chiari syndrome
It's a condition caused by occlusion of the hepatic veins that drain the liver. It presents with the classical triad of- abdo pain- ascites- hepatomegaly
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Causes of RIF mass
- skin and subcutaneous tissues, muscle: lipoma, sebaceous cyst, Psoas abscess, Psoas bursa- bowel: caecal carcinoma, crohn's mass, TB mass, appendix abscess or mass- urological: transplanted kidney (common in exam), ectopic kidney, bladder carcinoma- reproductive system: males (ectopic testes, u descended testes) females (fibroids, ovarian tumours)- blood vessels: iliac artery aneurysms, lymphadenopathy, sachems varix, ruptured epigastric artery, femoral aneurysm.On L side, same + diverticular abscess or carcinoma of colon.
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What are the indications for performing a DRE?
- acute abdomen assessment (appendicitis, peritonitis, lower abdo pain- prostate assessment: prostate hypertrophy or prostatic Ca- pre-procedure: before doing proctoscopy, sigmoidoscopy, colonoscopy- Dx purposes: constipation, change in bowel habit, anorectal pain or tenesmus...
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What are haemorrhoids?How are they managed?
Surgical definition: Hemorrhoids are enlarged anal cushions (dilated veins)(Typical HX of painless bright red rectal bleeding... Can be painful if thrombosed)Management: conservatively: 1- sitz bath, analgesia and dietary advice2- injection sclerotherapy: Gabriel syringe containing 5% phenol in almond oil injected above the dentate line (beware not to inject in prostate gland and cause prostatitis)3- banding: rubber band placed around pile, which causes ischemia and shrinkageSurgical1- hemorrhoidectomy
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What is dentate line (=pectinate line)?
It's an anatomical landmark that divides the sensory part of the anal canal.Above it there is no sensation, but below there is, that's why injection sclerotherapy is done above this lineThis line divides the upper 2/3 and lower 1/3 of the anal canal. Above it, we have columnar epithelium and below it's stratified squamous epithelium.
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Abdominal stoma examination
Do not remove the stoma bag in the examination unless you have been specifically directed to do so//Introduction//Inspection1- describe the site of stoma: LIF (colostomy) RIF (ileostomy) R lumbar (urostomy) (on the right because ureter is slightly shorter on R side), epigastric (gastrostomy/jejunostomy, or even loop colostomy), suprapubic (mucous fistula)2- estimate the size of lumen (large=colostomy/small=ileostomy or urostomy). Beware that if lumen is small, then this may have occurred from complications related to stomas, like stenosis or retraction. A prolapsed stoma will make the lumen look bigger.3- count number of lumens: single lumen (most cases: eg end stoma), double lumen (either looped or double stoma)4- examine for a spout: absence of spout (if lumen is flush with skin, it is probably a colostomy (unless prolapsed) vs spout present (ileostomies usually to keep irritant effluent off the skin. Urostomies as well).5- bag content: dark-green fluid and odourless (ileostomy), solid faeces and faeculent (colostomy), urine (urostomy)6- look for abdo scars: give a clue to what surgery they had (eg midline laparotomy scar in conjunction with colostomy, which can be from an abdominoperitoneal resection or Hartmann's procedure)//Complete the examination: to complete my examination I would like to examine the perineum to look for the presence of a patent anal canal and anal stump (pouch left behind after colon is diverted surgically).Differentiation of a colostomy between AP resection (abdominoperineal) (in low-lying rectal Ca or severe UC) vs Hartmann's (done as emergency for diverticulitis or bowel obstruction, secondary to colorectal Ca): Closed perineum vs patent anal canal.
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Differentiation of a colostomy between AP and Hartmann's
AP resection (abdominoperineal) (in low-lying rectal Ca or severe UC) Closed perineumHartmann's (done as emergency for diverticulitis or bowel obstruction, secondary to colorectal Ca): patent anal canal.
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What is a stoma
This is a surgically created connection between the GI or urinary tract and the skin. It can be temporary (reversible) or permanent.
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How to distinguish between ileostomy and colostomy?
1- Site: RIFT (ileostomy) vs LIF (colostomy)2- Spout : present (ileostomy) vs Flush (colostomy)3- bag effluent: odourless dark-green liquid (ileostomy) vs solid faeces (colostomy)4- effluent volume: 500 ml (low output) to 1L (high output) (ileostomy)/ day vs 300 ml/day (colostomy)
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What are the complications of a stoma?
These can be divided into general complications and complications specific to the stoma itself:- general cpx: nutritional disorders (eg vit b deficiency), renal stones, short gut syndrome, stoma diarrhea, psychological- specific complications: technical problems (such as ischemia, prolapse, parastomal hernia, stenosis or retraction). Practical problems (include malodour, skin irritation due to spillage of bag effluent).
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Causes of abdominal pain?
Localisation of pain:- R hypochondrial: biliary colic, acute cholecystitis, ascending cholangitis, empyema, hepatitis, sub phrenic abscess- Epigastric: peptic ulcer disease, leaking AAA, acute pancreatitis, perforated duodenal ulcer- L hypochondrial: splenic infarct/rupture- R lumbar: renal and ureteric colic, pyelonephritis- Umbilical: leaking AAA, small bowel obstruction- L lumbar: renal and ureteric colic, pyelonephritis- R iliac fossa: appendicitis, ureteric colic, inguinal hernia, terminal ileitis, gynae pathology- suprapubic: distended bladder, large bowel obstruction, UTI, pelvic inflammatory disease- L iliac fossa: diverticulitis, ureteric colic, gynae pathology, inguinal hernia
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How can pain be categorised?
Pain can be categorised depending on its aetiology:- visceral pain: diffuse pain that is poorly localised; usually described as being dull and aching in character---- foregut pain (described as being epigastric in site)---- mid-gut pain (usually felt in para-umbilical region)---- hindgut pain described as pain in lower abdo- parietal / somatic pain: well localised and sharp in nature, arising from peritoneal inflammation- referred pain: aching in nature and perceived as being near the surface of the body.
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Indications for various types of stomas?
- feeding: jejunostomy, gastrostomy- decompression: caecostomy, gastrostomy- diversion: urostomy (ileal conduit), ileostomy (temporary or permanent), loop colostomy (currently performed using the sigmoid colon, 2 openings, 1 functioning to release stool and gas, 1 non-functioning), double-barrelled colostomy: both ends of the colon are brought to the surface next to each other and are sutured together along the anti-mesenteric border- exteriorisation: double barrelled colostomy, end colostomy (AP resection), end colostomy and rectal stump (Hartmann's), end colostomy and mucous fistula
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Typical structure of an orthopedic examination
LookFeelMoveSpecial testsNeurovascular examinationX-Rays
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Phases of the gait cycle
1- Heel strike (heel touches the ground)2- stance phase (entire period where foot is on ground) (represents 60% of gait cycle)3- toe off4- swing phase (foot in the air for limb advancement)
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Gait examination
////Look- check for walking aids or appliances (in presentation "this patient is walking unaided" or "the patient walks aided by a Zimmer fame"). Appliances include shoe raises, orthotics or calipers- ask for pt to walk: symmetry of arm swing, presence of pelvic tilt and stride length - carefully observe the gait: looking for 1- limp (gait smooth or halted (due to abductor weakness in Trendelenburg, or leg shortening or antalgic gait)) 2- distinctive pattern of the gait, 3- arm swing, 4- how the patient turns around////Special tests- Heel-to-shin pathology- Romberg's test: if positive... Indicative of vestibular or proprioceptive problem
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Patterns of gait
-- antalgic gait: decreased stance phase and increased swing phase... Pathology=pain-- Trendelenburg lurch: shoulders and trunk lurch sideways in order to bring the body weight over the affected limb. Pathology=weak abductors-- drop foot: foot drops in swing phase, and the foot is lifted higher than normal so that the toes don't drag along the ground. The foot may slap the ground prematurely. Pathology=peripheral neuropathy or injury to the nerves L5 supplying the ankle dorsidlexors (common peroneal or sciatic nerve palsy)-- high stepping: compared to drop foot, both feet are raised here. Pathology=bilateral foot drop, proprioception or cerebellar disease-- short leg: ipsilatera hip falls when pt weight bears on short leg. Pathology: congenital shortening, previous fracture-- waddling: pt trunk moves from side to side with each step they take. Pathology=dislocation of hips, weakness of abductor muscles
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What is antalgic gait?
It's a gait with a decreased stance phase and increased swing phase, usually due to pain
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What types of walking aids are there?
Walking aids can be broadly classified into sticks, crutches and frames.Various types in each group, eg Zimmer frame, elbow crutches, or a wooden stick with crook handles
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Can u tell which side has the pathology from the position of the stick?
When using one stick, stick should be held in the opposite hand to the side of pathologyIf hip pathology, in opposite hand to reduce the weight bearing loadIf kmee pathology, usually held in ipsilateral hand
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What is the Trendelenberg sign
Sign found in people with weak or paralysed abductors of the hip, namely gluteus medius and gluteus minimus
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What to expect in examining a hip with osteoarthritis
!!! Look- Patient usually older than 50- Functional aids: walking aid, especially walking stick (held in the hands opposite to the affected hip)- Gait: obvious limp, angelic gait or Trendelenberg positive- From front: hip scar often seen in opposite hip (Patient often awaiting arthroplasty for the other hip), muscle wasting, leg length discrepancy- From the back: lumbar lordosis may be increased in those with fixed flexion deformity, scoliosis, scars from posterior approach!!! Closer inspection: affected leg will appear short, fixed flexion deformity!!! Feel: tenderness!!! Move: movements are generally restricted!!! Special tests: Thomas demonstrates a fixed flexion deformity
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What does Trendelenberg test indicate?
Weakness of the hip abductorsMore specifically, - This could be a false positive, usually due to pain or poor balance on the patients part as a result of generalised weakness- Gluteal muscle inhibition due to pain from the hip joint- Gluteal muscle inefficiency due to congenital hip dislocation or coxa vara - Gluteal muscle paralysis from polio
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How you investigate a patient with an osteoarthritic hip?
- simple blood tests such as renal function tests, because the patient is likely to be on long-term NSAID which may lead to interstitial nephritis- Specialist blood tests, particularly rheumatoid factor and ANA , to exclude a systemic cause- Imaging, which would include plain film radiographs of the affected hip with two views, AP and lateral, and views of the joint above and below
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What radiological features to find in osteoarthritic hip?
Loss of joint spaceOsteophytesSclerosisSubchondral cysts
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Radiological features of rheumatoid arthritis
Periarticular osteoporosisLoss of joint spaceMarginal erosionsAbsence of osteophytes
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Management of osteoarthritis
MDT approach with input from orthopedic surgeon, gp, physiotherapist and occupational therapistDivided in:!!! Conservative measures:- Lifestyle changes ( Functional aids to help with daily living activities)- Walking stick held in the opposite hand- Weight loss and regular physiotherapy!!! Medical treatments involve:- Pain relief ( who analgesic ladder)!!! Surgical interventions- Vary according to age: if patient>50, total joint replacement is procedure of choice- For younger patients, they will have at least one revision in their lifetime, therefore benefit from other procedures such as repositioning osteotomy until an arthroplastybecomes a viable option
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Features suggesting a total joint replacement be suitable
Intractable pain (with failure of conservative and Medical measures)Rest pain, instability or loss of mobility
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What to find in hip affected by rheumatoid arthritis
- Patient has usually an established pattern of multiple joint involvement that is typically symmetrical- There is a marked Gluteal muscle and calf wasting- Affected limb is held in fixed fixation in external rotation- All movements are generally restricted and painful, whereas in osteoarthritis the movements may be restricted but often painless with a limited range
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Hip examination... Main steps
//// Look- walking aids or appliances - observe from front: 1- level of hips and knees: symmetrical? 2- valgus/varus deformities of the knees 3- surgical scars 4- obvious leg length discrepancy?- observe from back : 1- surgical scars (don't forget posterior approach to hip), 2- any gluten muscle wasting? 3- any scoliosis? (compensory scoliosis can be seen in true shortening)- examine gait- perform trendelenburg's test//// closer inspection - measure leg length: apparent leg length (umbilicus to medial malleolus) and true leg length (ASIS to medial malleolus). If discrepancy do Galeazzi test//// Feel- palpate over bony landmarks for tenderness : (over ASIS, PSIS and greater trochanter for trochanter bursitis)//// Move- Thomas' test: for fixed flexion deformity. And assess flexion (130o) extension (10o) at same time - check abduction (45o) and adduction (30o)- check rotation internal (35o) and external (45o)//// complete examination " to complete my examination I would like to assess the neurovascular status of the lower limbs and examine the knees and back"- could ask for x-ray in 2 positions and for joint above and below
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Pes cavus and pes planus
Pes cavus: arched feetPes planus: flat feet
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Swelling in knee
- could be local effusion that may be reactive or secondary to osteoarthritis, haemarthrosis, (in tibial plateau fractures), septic arthritis (Dx with joint aspiration of the fluid and tested for MC&S and gram stain)- Prepatellar bursitis (housemaid's knee), infrapatellar bursitis (clergyman's knee- Popliteal fossa swellings (baker's cyst)
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What provides stability to the knee joint
The following ligaments:- ACL and PCL (intracapsular) stop the tibia moving anteriorly and posteriorly respectively in relation to the femur- Medial and collateral ligaments (extracapsular) provide support for the capsule of the knee.- Medial collateral attached to the medial tibial condyle and protects against a valgus force- Lateral collateral attached to the head of the fibula and protects against a varus force- Quadriceps and hamstrings are massive providers of stability to the knee joint
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What is the purpose of the fibula
Acts as a support for the tibia, so in lower limb fractures if only the tibia is fractured it can be treated in plaster alone, as it is considered to be a relatively stable injuryWhen both tibia and fibula fractured, most centres treat with an intramedullary nail of the tibia, because this is classified as a unstable fracture
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What to expect in examination of an osteoarthritic knee
!!! Look- Walking stick- Varus deformity, fixed flexion deformity- Opposite knee having a midline scar, indicating previous total knee replacement- Quadriceps muscle wasting- Antalgic gait !!! Feel- Joint line tenderness- Effusion may be present!!! Move- Crepitus on movement- Decreased range of flexion- Fixed flexion deformity of the knee may become apparent- Generalised tenderness on active and passive movement !!! Special tests- Positive McMurray's test
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What features would you look for in an X-ray of an osteoarthritic knee?
I would request a weight bearing X-ray of the knee, with AP and lateral views looking specifically for:- Loss of joint space- Osteophytes - sclerosis- Subchondral cysts Mnemonic LOSS
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How would you manage osteoarthritis of the knee
Essentially managed in a similar fashion using an MDT management approach. Details specific to the knee include:- Physiotherapy to improve quadriceps muscle strength- Simple analgesia in the form of paracetamol or co-codamol - Walking aid in form of stick or framesIntra-articular steroid injection for temporary pain relief- Partial or total knee arthroplasty
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How do you initially assess a Surgical Emergency?
It is important to state initially:"this is a surgical emergency. I will resuscitate the patient by:!!! Assessing the airways:- Give supplemental oxygen (high flow oxygen via a non rebreathable bag- Assess potency: 1)ask patient a question. If no answer, then 2) assess for evidence of airway compromise (anything blocking, blood vomits, suction using a Yankauer suction. Listen for stridor. 3) establish a patent airway by a) simple manoeuvres ( jaw thrust, chin lift, removing foreign bodies) b) airways adjuncts (oropharyngeal (guedel) or nasopharyngeal) c) secure or definitive airway (orotracheal intubation).!!! Checking the breathing- Monitoring: saturation probe or ABG - Inspection: cyanosis, check Respiratory rate, chest wall expansion, distended neck veins (pneumothorax), paradoxical chest wall movement (flail chest)- Palpation: tracheal deviation? Percussion for hyperresonance in pneumothorax or dullness in postoperative basal atelectasis or haemothorax.- Auscultate: !!! Assess circulation- Assess level of shock: cool? Clammy? Capillary refill time?- Monitoring: attach to monitor and check vital signs (HR, BP)- obtain IV access (2 large bore cannulae (grey or brown)- Resuscitation fluids: (crystalloids, colloids or blood)- Additional monitoring: urinary catheter, central line...!!! Assess disability- Neurological status: GCS, AVPU (alert, verbal response, response to pain, unresponsive)- Pupils: opiates (bilateral pinpoint pupils) or blown pupil (unilateral dilated pupil) in space occupying lesion (subdural or extradural hematoma)- BM glucose: !!! Assess environment/exposure- Exposure for bleeding..- Assess abdomen (pulsatile / expantile mass)!!! Reassess Always say that you will go back and reassess a b and c to check there is anything you have missed!!! Emergency investigations!!! Call for Senior help and advice!!! Definitive treatment (conservative, medical or surgical)Say that you will book an emergency theatre slot
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What is a definitive airway:
Is one where a cuffed tube is secured in the trachea, ensuring patency
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Atelectasis definition
Defined as the collapse or closure of the lung resulting I reduced or absent gas exchange. Alveoli are deflated. Acute onset may occur as a post operative complication or resultant of surfactant deficiency
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What emergency investigations would you confident in a surgical patient?
- simple bedside tests: EGG, pregnancy test, BM glucose- Blood tests: FBC, U&E ... ABG if critically ill- Imaging: erect chest X-ray, CT abdomen- Specialist investigations: depends on differentials (eg serum amylase in acute abdomen)- Exploratory laparotomy
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How to manage a 35 year old woman complaining of right upper quadrant pain. Serum amylase is 3500.
This is acute pancreatitis.This is a surgical emergency1- initial resuscitation: I would resuscitate the patient, ensuring the patient's airway is patent with access to high flow oxygen. I would then ensure the patient is breathing adequately. I will address the circulation by inserting 2 large bore cannulae whilst taking blood for pancreatic severity assessment at the same time. I would begin the patient on aggressive fluid resuscitation as thepatient is likely to have suffered significant third space loss.2- additional monitoring: to accurately guide fluid replacement I would like to assess the patient volume status through Clinical examination, the patient vital signs and urine output. Need for urinary catheter and a strict fluid balance chart documented in order to maintain positive balance3- call for help: at this point I would call for senior help and advice. After discussion with a senior colleague, I would like to consider the need for a central line to accurately guide fluid replacement4- assess severity: I would then like to assess the severity of this pancreatitis attack as this will help determine the level of Care the patient requires, particularly the need for an HDU bed. Using the modified Glasgow severity score, I would perform a arterial blood gas analysis on air to check for type over respiratory failure with pO2 less than 8 as this would suggest acute respiratory distress syndrome. I would also check for a Metabolic acidosis and serum lactate levels as this gives an indication of the level of shock. Other specific tests I would request include glucose levels to check for hyperglycemia as the patient may need an insulin sliding scale plus serum calcium levels and particularly a CRP as this helps to monitor and guide treatment. Other investigations include a plain abdominal radiography to check for calcified gallstones as a possible cause and a chest X-ray to check for signs of ARDS5- Definitive treatment- I would keep the patient NBM consider nutritional support (enteral or parenteral if severe) + good pain relief (PCA through a dedicated line)- I would request an USS to check for stones in the biliary
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Causes of pancreatitis
GET SMASHED- Gallstones (most common cause in the UK)- Ethanol (second most common)- Trauma- Steroids - Mumps- Autoimmune disease- Scorpion bites- Hyperlipidemia , hyperacalcemia- ERCP- Drugs (thiazide diuretics)
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What fluids to give in acute pancreatitis (surgical emergency)
The constituents ions of Hartmann's solution are very similar to the ECF compartment. As pancreatitis leads to fluid loss, which is mainly ECF , replacing with an isotonic crystalloid seems the logical choice
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How much fluid to give as resuscitation of acute pancreatitis
Patients should receive maintenance fluids plus additional losses. As this patient is likely to have suffered significant third space loss, it would not be unusual to give 6l or more in one dayHowever I would firstly need to assess the patient volume status and guide fluid replacement according to thatEmpirically I would give 1l stat followed by another 1l over the first hour, then another 1l over the subsequent 2 hours, another over the next 3 hours and then 6 hourly thereafter. This would be guided by the fluid balance chart which should be strictly kept
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How would you assess the severity of the pancreatitis attack?
Using the Glasgow prognostic score (in the first 48 hours)- P: Arterial pO2 < 8 KAps- A: Age > 55- N: Neutrophiles > 15- C: Calcium < 2- R: Raised urea > 16- E: elevated enzymes AST> 125 or LDH > 600- A: Albumin < 32- A: Sugar > 10Score of 1: mildScore of 2: moderateScore of =>3: severe and is an indication for HDU Independent from the other variables, a CRP > 150 constitutes a severe attack
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What are the different types of pancreatitis
- Oedematous (most common)- Haemorrhagic (look for Cullen's sign or Grey Turner sign)- Necrotising pancreatitis
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Would you start antibiotics in a acute pancreatitis
Use of antibiotics is controversial. Important to:- Follow trust protocol- In case of infected pancreatic necrosis, discuss with on call microbiologist and my seniors...
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What diagnosis would you consider if a patient had a persistent raised amylase?
- pancreatic pseudocyst is the likely causeIt commonly occurs in pancreatitis due to alcohol and is conformed on CT scanThose< 6 cm in size resolve within 6 weeksLarger ones may need to be percutaneously drained under radiological guidance
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How to manage a man with hematemesis?
- recognise its an emergency- Initial resuscitation: mainly assess level of hypovolemic shock- Emergency investigation: FBC, U&E (IF raised urea then recent GI bleeding), LFT, Amylase, clotting, cross match at least 4 units of blood- Additional monitoring: CVP line and catheter to accurately guide resuscitation- Call for help: "after Discussion with a senior colleague I would like to consider the need for an emergency OGD In the unstable patient.- Assess severity: rockall score (prognostic scoring system for acute GI bleeds based on the patient's medical history, current clinical Condition and endoscopic findings)- Definitive treatment: 1- consider resuscitation with blood if still hypertensive 2- PPI (if known peptic ulcer disease) 3- emergency OGD for diagnosis and treatment 3- Sengstaken-Blakemore tube if massive bleeding and the patient is still awaiting definitive treatment 4- Surgery if uncontrolled bleeding, re-bleeding, recurrent hypotension or the bleeding site is not identified as OGD.NEVER FORGET TO CROSS MATCH BLOODAND PUT TWO LARGE BORE CANNULA IN ANTECUBITAL FOSSA
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How to manage a man with hematemesis?
- recognise its an emergency- Initial resuscitation: mainly assess level of hypovolemic shock- Emergency investigation: FBC, U&E (IF raised urea then recent GI bleeding), LFT, Amylase, clotting, cross match at least 4 units of blood- Additional monitoring: CVP line and catheter to accurately guide resuscitation- Call for help: "after Discussion with a senior colleague I would like to consider the need for an emergency OGD In the unstable patient.- Assess severity: rockall score (prognostic scoring system for acute GI bleeds based on the patient's medical history, current clinical Condition and endoscopic findings)- Definitive treatment: 1- consider resuscitation with blood if still hypertensive 2- PPI (if known peptic ulcer disease) 3- emergency OGD for diagnosis and treatment 3- Sengstaken-Blakemore tube if massive bleeding and the patient is still awaiting definitive treatment 4- Surgery if uncontrolled bleeding, re-bleeding, recurrent hypotension or the bleeding site is not identified as OGD.NEVER FORGET TO CROSS MATCH BLOODAND PUT TWO LARGE BORE CANNULA IN ANTECUBITAL FOSSA
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What are the causes of an upper GI bleed
- duodenal ulcer (most common)- Gastritis, esophageal varices- Mallory-weiss tears - Malignancy
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What ate the surgical options if bleeding is due to bleeding peptic ulcer
- under-running of the bleeding vessel- Excision of the ulcer- Gastrectomy
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What are the causes of an upper GI bleed
- duodenal ulcer (most common)- Gastritis, esophageal varices- Mallory-weiss tears - Malignancy
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What ate the surgical options if bleeding is due to bleeding peptic ulcer
- under-running of the bleeding vessel- Excision of the ulcer- Gastrectomy
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What is the rockall score?
This is a prognostic scoring system for acute GI bleeding baSed on patients Medical history, current Clinical condition and endoscopic findings(Age, shock, co-morbidity, diagnosis, endoscopy)Score>8: high risk of deathSour<3: excellent prognosis
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How to manage an acutely painful pulseless leg
Key features to mention:- Recognise that this is an emergency- Initial resuscitation: include iv fluids and opiate analgesia- Emergency investigations: angiogram in incomplete ischemia, DO NOT DELAY DEFINITIVE TREATMENT IF COMPLETE ISCHEMIA- additional monitoring: CVP line and catheter to accurately guide resuscitation- Call for help: call early as time is
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What are the signs of acute limb ischemia
This is known as the 6 Ps- Pain: usually severe- Pallor: occurs in progressive stages (1- white appearance progressing to mottled but blanching 2- non blanching mottled skin 3- fixed staining and liquefaction- Perishingly cold- Pulseless (confirm with Doppler)- Paresthesiae (Assess sensation)- Paralysis (Assess motor function)PARESTHESIAE AND PARALYSIS ARE LATE SIGNS (USUALLY IRREVERSIBLE)
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what specific post Op complications to look for
- Reperfusion injury: when arterial oxygen is reintroduced, leads to oxygen free radicals causing endothelial damage- Can lead to metabolic complications such as acidosis ARDS and myoglobinemia or it can lead to a compartment syndrome which requires emergency fasciotomy
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This man was found collapsed in the street. He has a plausible expansile mass on abdominal examination. How would you manage him?
- recognise urgency- Initial resuscitation: includes blood (do not wait for cross match, give O-), maintain BP < 90, as it may destabilise a tamponading clot (permissive hypotension), two large bore cannula...- Emergency investigations: none required. Straight to theatre. 10 units needed...- Additional monitoring: CVP line and urinary catheter- Call for help- Definitive treatment: immediate Surgery to cross clamp the aorta proximal to the rupture and control the bleeding ITU care post operativelyA 60 YEAR OLD MAN WHO PRESENTS WITH RENAL COLIC CAN BE A LEAKING AAA.NEVER SEND AN UNSTABLE PATIENT TO CT SCAN. THEY MIGHT ATTEST
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5 days Post hemicolectomy (for sigmoid ca). The nurses have called you as she has spiked temperature. How to manage Post operative fever?
- Recognise urgency- initial resuscitation: involves a quick systematic examination to look for a cause (listen to chest for basal atelectasis, examine the abdomen for peritonitis, look at wounds for signs of infections and examine the legs for DVT. Assess for SIRS (systematic inflammatory response syndrome)- Emergency investigations: do septic screen (FBC, urine dipstick, CXR, and blood culture before starting antibiotics. Consider water soluble contrast study of the rectum to rule out an anastomotic leak- Call for help- Definitive treatment: depends on cause/// NBM /// If urine or chest infection: give empirical antibiotics iv and chest physiotherapy for basal atelectasis. If patient in septic shock then give fluid challenge and consider HDU/// Anastomotic leak (occur between day 3 and d 5): if patient stable and leak is small them conservative management preferred. If peritonitic, then laparotomy for wash out and plug the leak
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What is the most common cause of postoperative fever in abdominal surgery
Basal atelectasis. It can be prevented with good chest physiotherapy an nd airway adequate analgesia. That's why some patients are kept on epidural analgesia to be able to take good deep breaths.
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What are the causes of postoperative fever
- immediate < 24 hours: physiological stress response to Surgery- Early: /// < 3 days: basal atelectasis (pneumonia)/// > 3 days: pneumonia, wound infection, anastomotic leaks, subphrenic or pelvic abscess, UTI, line infection/// > 5 days: PE or DVT
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What is SIRS?
systemic inflammatory response syndrome with at least 2 of the following features:- Temperature>38 or 90 minutes- Respiratory rate: > 20 / minute- White Cell count: > 12 or < 4
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Woman returning to the Ward after having a laparotomy for acute abdominal pain. Hourly urine output<30 ml. How to manage postoperative oliguria?
- Recognise urgency- Initial resuscitation: quick systematic examination to assess volume status:/// Mental status (confusion)/// Hands (skin turgor, prolonged CRT, patient cool and clammy,?/// Vital signs: tachycardia, hypotension/// JVP: if low/// Examine: chest for signs of fluid overload, abdomen for distended bladder (in obstruction)/// Fluid balance chart assessment- Emergency investigations: renal function urea creatinine...- Additional monitoring: CVP monitoring if not responding to fluid challenges + urinary catheter...- Call for help- Definitive treatment: depends on cause/// Post renal: obstruction by large stove or BPH causing acute urinary retention/// intrinsic renal: call for expert (may need dialysis)/// Pre-renal: give fluid challenge and reassess. This is the most common cause of postoperative oliguria and is most likely due to hypovolemia secondary to dehydration.
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Man involved in rta. No obvious sites of injury.
- Recognise urgency: manage according to ATLS principles- Initial resuscitation: intubation because gcs low (endotracheal tube)... Fluids... Anesthetits- Emergency investigations: CXR, pelvic x Ray c-spine. FAST scan to look for source of bleeding. CT head chest abdo pelvis if stable.- Additional monitoring: urinary catheter- Call for help- Definitive treatment: /// Identify source of bleeding by looking in 5 places: abdomen, chest, long bones/pelvis, head and floor/// If intra abdominal bleeding this will require immediate laparotomy to diagnose and treat
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How do you assess hypovolemic shock?
Through Clinical examination and Assessment:- Stages of hypovolemia1- blood loss up to 15%2- 15-303- 30-404- > 40...Bp will only drop in phase 3
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What is a FAST scan
Focused Assessment sonogram in traumaRapid because ultrasound examination of various parts of the body where blood is likely to have collected Post trauma. Looking at: abdomen, thorax...
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Peripheral vascular examination
- General inspection: paraphernalia of disease: 1- does patient have an amputation? Describe level. Any associated walking/mobility aids or prosthesis? 2- is patient on oxygen, iv infusion of heparin, GTN spray and our cigarettes?- Upper limb vascular examination:1- examine hands: skin changes (tar staining, tendon Palmar xanthoma, purple discoloration of fingers (atheroembolism), muscle wasting (thoracic outlet syndrome), temperature, pulses, CRT, BP (less than 15 mmHg between 2 sides in absence of arterial disease)2- examine neck and face: eyes (corneal arcus, xanthelasma, conjunctivital pallor), mouth (central cyanosis & angular stomatitis), neck (prominent veins on neck, chest wall and over shoulders (indicates subclavian vein occlusion)), pulses (feel carotid pulse), bruits (auscultate for carotid bruits using bell of stethoscope).- Abdominal examination: Check for AS A- Lower limb vascular examination:1- General inspection: asymmetry (amputation, edema, muscle wasting), Surgical scars (indicative of previous varicose vein removal, or suggestive of vein harvesting for CABG, any varicosities present), skin changes (discoloration (erythema, pallor, Brown/hemosiderin deposits, purple/black from haemostasis), venous guttering, trophic changes(no hair, shiny skin, gangrene), ulcers2- closer inspection: detailed inspection of toes (amputation, purple discoloration (AAA trash foot), ulcers), focus on pressure areas where ischemic ulcers can develop (sole, lateral, heels...)3- palpation: Check skin temperature, CRT (if prolonged do a Buerger's test, Buerger's test (lift leg...). If PAD, then legs turn bluish from deoxygenated blood as it travels over ischemic tissues and then turns red from reactive hyperuremia from Post-hypoxic vasodilation. Check peripheral pulses (femoral (mid-inguinal point= halfway between ASIS and the pubic tubercle), popliteal pulse, posterior tibial pulse (posterior and 2 cm inferior to medial malleolus of tibia), dorsalis pedis pulse (lateral to extensor hallucis longus tendon, absent in 10%)4- auscultation: listen for bruits over femoral artery and over aorta and iliac barrels5- special tests: measure ABPI on both sides (>0.9 normal, 1.2 can suggest hardening of the arteries from calcification, resulting in arteries being stiffer or less compressible. Seen in patients with DM and renal failure.
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How to investigate a peripheral artery disease patient?
Investigations can be divided into bedside tests, blood tests and imaging.1- simple bedside tests: BM (see if diabetic), ECG (for evidence of coexisting heart disease because patient likely arteriopath)2- simple blood tests: FBC (anemia, polycythemia), U&E (renal function, important if undergoing contrast studies, especially in diabetics (contrast-induced nephropathy), lipid profile, clotting, esr (vasculititdes), G&S (if operative management)3- imaging: ///"cxr to look for coexisting cardio Respiratory disease, particularly as part of a pre oPerative Assessment". "I would like to request specialist imaging to assess the extent of disease and help plan operative management: duplex scan to check for the degree of stenosis. ///Spiral CT to reconstruct 3d images of vessels noninvasively. /// in some patients a digital subtraction angiogram (DSA) to demonstrate the level of blockage, runoff and presence of collateral blood supply.Management: those who undergo invasive imaging such as angiography have a catheter introduced (seldinger technique) into femoral artery and guided to site of lesion, where radio dense contrast is injected and imaged using x rays. Stenosis can be treated at same time by balloon angioplasty.
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Can you estimate the extent of stenosis from a hand held Doppler probe
- Simple hand held Doppler probe detects arterial pulsation add an audible signal.- Degree of stenosis causes turbulent blood flow which results in bruits heard on auscultation with a stethoscope- Characteristic waveforms seen:/// Normal vessels: triphasic waveforms/// Mild stenosis: biphasic waveform/// Severe stenosis: monophasic waveform
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Why are lower limbs more commonly affected by PAD compared to lower limbs
Arterial supply to legs is noir as well developed as the arterial supply to upper limbsTherefore th re lower limb arterial supply is also more susceptible to atherosclerosis than the upper limbs. So PAD is 8 times more common in lower limbs than in upper limbs
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How to treat a patient with lower limb occlusive arterial disease?
This involves an MDT management approach. Conservative and Medical management focus around modification of risk factors and Surgical measures1- Conservative measures include: stopping
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Benefits of a below-knee amputation (BKA) over an above knee amputation (AKA)
BKA are preferred:- Better mobility for patients and less likely to be ♿ bound- Physical benefits (reducing energy to mobilise)- Life expectancy better for BKA - Patients with AKA more likely to develop critical ischemia in other leg
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Reasons for amputation?
Three Ds - Dead limb (vascular (PAD)- Dangerous limb (infection (osteomyelitis)- Debilitating limb (trauma (frostbite))
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Please examine this man's abdomen as part of your vascular examination
Key features to look for:-inspection: look for abdo scars, mainly over femorals (from previous bypass surgery), obvious mass in epigastrium, visible pulsations (kneel from side to see them)- Palpation/auscultation: /// Palpate above and slightly to left of the umbilicus (before aorta bifurcates at L4 level)/// See if pulsatile and expansile (one ✋ moves laterally with each pulse)/// Estimate transverse diameter of the mass in centimeters/// Try to feel the upper border of the mass, if felt it would suggest aneurysm is infrarenal (only 1% suprarenal)/// Auscultate aneurysm for bruits/// Examine femoral and popliteal pulses
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Please examine this man's abdomen as part of your vascular examination
Key features to look for:-inspection: look for abdo scars, mainly over femorals (from previous bypass surgery), obvious mass in epigastrium, visible pulsations (kneel from side to see them)- Palpation/auscultation: /// Palpate above and slightly to left of the umbilicus (before aorta bifurcates at L4 level)/// See if pulsatile and expansile (one ✋ moves laterally with each pulse)/// Estimate transverse diameter of the mass in centimeters/// Try to feel the upper border of the mass, if felt it would suggest aneurysm is infrarenal (only 1% suprarenal)/// Auscultate aneurysm for bruits/// Examine femoral and popliteal pulses
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Please examine this man's abdomen as part of your vascular examination
Key features to look for:-inspection: look for abdo scars, mainly over femorals (from previous bypass surgery), obvious mass in epigastrium, visible pulsations (kneel from side to see them)- Palpation/auscultation: /// Palpate above and slightly to left of the umbilicus (before aorta bifurcates at L4 level)/// See if pulsatile and expansile (one ✋ moves laterally with each pulse)/// Estimate transverse diameter of the mass in centimeters/// Try to feel the upper border of the mass, if felt it would suggest aneurysm is infrarenal (only 1% suprarenal)/// Auscultate aneurysm for bruits/// Examine femoral and popliteal pulses
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potential complications of AAA
- rupture, dissection, thrombosis and embolisation from the thrombosis leading to trash foot- Fistula formation into adjacent organs, such as the colon (mainly duodenum) our vena cava
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What is a fistula?
It's an abnormal connection between two epithelial surfaces lined by granulation tissue
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What factors to make you consider elective operative treatment of an aneurysm
Depends on two features: symptomatic or not/// Asymptomatic: recommendation for repair when aneurysm diameter is >5.5 cm or if expanding at rate of > 1 cm a year/// Symptomatic patients should have their aneurysm repairedTypes of AAA repair:- Endovascular repair (can be done by interventional radiologist- Open repair
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What do you know about the NHS AAA screening programme
If you are a man aged over 65 you are more likely to have an abdominal aortic aneurysm. That is why the NHS AAA Screening Programme invites men for screening during the year (1 April to 31 March) that they turn 65.Men over 65 who have not previously been screened or diagnosed with an aneurysm can request a scan by contacting their local programme directly.Good screening programme needs to meet the Modified Wilson's criteria for screening programmes (the condition should be an important health problemthe natural history of the condition should be understoodthere should be a recognisable latent or early symptomatic stagethere should be a test that is easy to perform and interpret, acceptable, accurate, reliable, sensitive and specificthere should be an accepted treatment recognised for the diseasetreatment should be more effective if started earlythere should be a policy on who should be treateddiagnosis and treatment should be cost-effectivecase-finding should be a continuous process)
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Draw the arterial vessels of the body
....
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Draw the venous system of the body
Lower limbs: 1- superficial system: long and short saphenous veins. Responsible for draining the skin and subcutaneous tissues of the leg2- deep venous system: exists within the muscles of the leg and is covered by fascia. Receives blood from superficial venous system through the connecting perforation veins. When muscle contracts, blood pushed towards the ❤ and valves in veins are responsible for preventing backflow of blood. If valves incompetent, blood is forced from deep system to superficial system, causing veins to dilate.
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Definition of varicose veins
Dilated tortuous and prominent veins of the superficial venous system of the lower limb seen in the distribution of the short and long saphenous veins
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Risk factors for Development of varicose veins
History of dvt/pe Increasing ageObesityPositive family historyPregnancy and pelvic masses (cause increase pressure on the ivc and iliac veins)Any previous treatment to the legOCP use (needs to be stopped at least 4 weeks before any Surgical intervention due to risks of DVTAsk in history about aching legs and swellings, legs feeling heavy, pruritus, restless legs and skin changes (venous eczema, ulcers). Symptoms usually worse at night, and in occupation that requires standing o
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Clinical examination of varicose veins
ALWAYS REMEMBER TO EXAMINE PATIENT ERECT AAD VARICOSITIES MIGHT BE COLLAPSED IF SUPINE 1- introduction: patient spine initially then patient required to stand up2- inspection:/// Observe patIent lying spine: - General inspection (any obvious asymmetry, scars from previous varicose veins removal or vein harvesting for CABG, any varicosities), - signs for chronic venous insufficiency (1- swelling and brown discoloration/hemosiderin deposition, 2- telangiectasia and venous eczema, 3- lipodermatosclerosis from chronic venous hypertension causing sclerosis of skin and subcutaneous tissues from fibrin deposition 4- erythema seen in thrombophlebitis.- Look in gaiter area around medial malleolus (where venous ulcers are typically seen)- Look at groin for hernias, saphena varus or prominent lymph node/// Observe patient standing: look for tortuous varicosities (anteriorly for long saphenous and posteriorly for short saphenous). "Posteriorly I can see that there are multiple dilated and elongated veins in the distribution of the short saphenous vein". PATIENT REMAINS STANDING UNTIL TOURNIQUET TEST3- Palpation /// Palpate for a saphena varix (locate SFJ which is 2 cm inferior and 2 cm medial to femoral pulse (at mid-inguinal point). If lump found, might be a saphena varix which will be smooth with a palpable thrill and will empty on minimal pressure and refill once fingers are removed/// Cough test: place 2 fingers on SFJ while patient standing, if thrill felt then incompetence of valve. DO COUGH TEST AFTER CHECKING FOR SAPHENA VARIX./// Palpate varicosities: press and release and see refill. If pain then phlebitis. If vein feels hard, then thrombosis./// Palpate to check temperature4- special tests: to determine site of incompetence/// Tap test: find prominent varicosity. One hand over SFJ and other over varicosity. Tap over SFJ. If thrill transmitted to varicosity... Suggests incompetence at SFJ./// Trendelenberg / tourniquet test: in supine position, raise leg to comfortable angle for patient and you. Milk leg. Then tourniquet as high as possible. Patient stands. If veins refill immediately: level of incompetence below SFJ (repeat with tourniquet lower, mid-thigh, calf)). If veins do not fill: level of incompetence above tourniquet i.e. at SFJ./// Doppler probe: most reliable of the special tests. Place Doppler over SFJ. With other hand squeeze calf. And listen to the"whoosh" sound coming from probe. In normal leg: only hear noise once as blood forced proximal. In SFJ incompetence, double whoosh (second heard because blood flows backwards through valve when stop squeezing the calf). Repeat at saphenopopliteal junction.5- Auscultate: listen for bruits over varicositiesTo compete my examination, I would like to Palpate for peripheral pulses and examine the abdomen as well as perform a DRE to exclude an abdominal or rectal mass.IT'S IMPORTANT TO CONSIDER SECONDARY CAUSES OF VARICOSE VEINS, PARTICULARLY MALIGNANCIES.
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Where to locate the SFJ (saphenofemoral junction)
4 cm below and 4 cm lateral to public tubercle
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describe the course of great and short saphenous vein?
- great saphenous vein: passes anterior to medial malleolus, travels proximal in medial aspect of the calf to the popliteal fossa and then travels along medial aspect of thigh to join the common femoral vein at SFJ - Short saphenous vein: arises posterior to lateral malleolus and ascends along the midline of the calf to join the popliteal vein in SFJ in popliteal fossaDON'T SAY VEINS START AT SFJ. STAY DISTALLY
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how to investigate a varicose veins patient
- rule or secondary causes, ie abdominal/pelvic malignancies, DVT- Color duplex scanning with mating of perforators
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How do you manage a varicose veins patient
Management involves- Taking a focused history to rule or secondary causes of varicose veins- Thorough clinical examination- Tailoring of investigations depending on findings before mentioning treatment options.Treatment can be conservative, medical or surgical- Conservative: treaty underlying cause if any (e.g. weight loss in obese, constipation...), Graduated compression stockings for symptomatic relief (TED stocking: thromboembolic disease)- Surgical measures/// Injection chemotherapy for small varicosities/// Multiple stab avulsions with vein stripping and ligation of the incompetent junction/// Subfacial endoscopic perforator Surgery (SEPS)/// radiofrequency or foam ablation
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Possible differential diagnosis for varicose veins
- cellulitis, DVT - Phlebitis: inflammation of superficial veins, secondary to intraluminal thrombosis. If migratory, then raise suspicions about underlying malignancy- Osler-weber-rendu syndrome (telangiectasia, recurrent epsitaxis)
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Tell me about DVT prophylaxis for surgical patients
I will take a history to assess for the presence of risk factors such as age, ocp use, smoking, previous history of DVT/PE and high risk surgical procedures associated with DVT (eg TKR (incidence=50%)).Main DVT prophylaxis:- TED stockings- Low Molecular weight heparin
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Why is it important to check for history of DVT in patients undergoing varicose vein surgery?
- varicose veins may be secondary to thrombosis of the deep or superficial veins- If deep venous system not functioning, particularly after a DVT, patient is relying on the superficial system for venous return- Patients should have Doppler ultrasound scanning of their deep veins to confirm patency and check valve competence prior to Surgery- Clinically could perform a perthes test (put elastic bandage from toes to upper third of thigh to obliterate superficial veins. Ask patient to walk for 5 min. If deep system ok, nothing will happen. If incompetent, then pain in leg.
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If the patient with varicose veins has an unusual rash on his face, what diagnosis to consider
Varicose veins associated with a port wine stain and limb hypertrophy are signs seem in the rare Klippel-Trenaunay syndrome.
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Different types/causes of ulcers
Most common:- Arterial disease- Venous insufficiencyOther:- peripheral neuropathy- Trauma- Neoplastic causes: eg marjolin's ulcer (an scc in long standing Non healing ulcer) eg in previous trauma or wound- Systemic disease (uc, ra), leading to pyoderma gangrenosum
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Clinical examination of an ulcer
1- introduction: it's acceptable to ask the patient at this point whether the ulcer is painful (helps in diagnosis)2- inspection/// General inspection of lower limbs: ? Signs of chronic venous insufficiency, varicose veins, trophic changes, amputations or surgical scars/// Describe site of ulcers- Arterial: pressure areas, tips of toes- Venous: gaiter area- Neuropathic: heel, on the sole under the metatarsal heads/// Describe size and shape of ulcer: estimate size in cm. Check shape to see if margins well defined or irregular- Arterial: small (few cm)- shape: well defined margins with regular outline- Venous: variable in size (can be very large). Shape: irregular outline and variable shape- Neuropathic: size: variable (several cm). Shape: regular outline/// Describe edge of ulcer- Arterial: punched out- Venous: sloping or flat- Neuropathic: punched out /// Describe base of ulcer: resonate depth of ulcer (sometimes can see underlying bone and tendons). Base can be from healthy to completely avascular.- healthy: pink granulation tissue, areas of epithelialisation- Sloughy: offensive, exudative discharge, usually green or yellow in color- Necrotic: black dead tissue- Avascular : shiny paleIF YOU SEE DISCHARGE, SAY TO EXAMINER THAT YOU WOULD TAKE SWABS FOR MC&S (MICROSCOPY CULTURE AND SENSITIVITY)AND START TOPICAL ANTIBIOTICS3- Palpation/// Check if painful (Neuropathic: no pain/ arterial and venous painful, but usually arterial more painful and require opiate analgesia)/// Check temperature of surrounding skin: Arterial: if colder than rest of leg. Venous: if warmer than rest of leg/// Check CRT: Arterial: prolonged crt /// Check peripheral pulses (mainly distal pulses)To complete my examination I would like to perform a complete peripheral vascular examination, looking particularly at sensation.
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Definition of gaiter area
It's the distal one third of the leg along the medial aspect, above the medial malleolus
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What is granulation tissue (in the vascular context)
Granulation tissue is a heterogeneous structure that forms within the extracellular matrix at the end of the proliferative phase of wound healing. It consists of fibroblasts, macrophages and endothelial cells with a rich capillary network
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What is a sloughy tissue (in vascular context)
This is most necrotic tissue
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Please examine the lesion on this patient's leg (Venous ulcer on gaiter area)
Key features to look for:- Inspection:/// Associated paraphernalia: treatment on table (topical antibiotic), for of bed raised (part of ulcer treatment), patient's last bandage next to bedside/// General inspection of leg: patient usually an arteriopath, look for signs of chronic venous insufficiency or varicose veins. "On general inspection, the lower limbs are Oedematous with loss of hair, areas of hemosiderin deposition and lipodermatosclerosis. Site: gaiter area, size/shape: variable in size, can be extremely large, irregular margins. Edge: sloping. Base: shallow and sloughy with underlying pink granulation tissue./// Palpation: temperature: skin surrounding ulcer is warmer than the rest of the leg. Usually painless./// Completion: offer to examine for varicose veins as an associated feature. Offer ABPI. An index of >0.8 is prerequisite top compression bandaging. "I would like to check the patient's ABPI to ensure the index is greater than 0.8 as the patient is likely to require four layer compression bandaging as part of his treatment".i
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What is lipodermatosclerosis and hemosiderin ?
It's a skin and connective tissue disease. Known as chronic panniculitis with lipomembranous changes. An inflammation of the layer of fat under the epidermis.Hemosiderin deposition: common late complication of untreated superficial venous insufficiency or venous reflux resulting in chronic venous hypertension. Buildup of venous pressure in the superficial dilated veins leads too leakage of red blood cells from the capillaries into the surrounding tissues under the skin. Over time, breakdown of haemoglobin content of the red blood cells in these tissues lead to accumulation of hemosiderin, resulting in long term and potentially permanent brown pigmentation of the overlying skin. (Potential treatment: intense pulse light (IPL) and tattoo removal lasers)
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What is compression bandaging
This is part of the treatment for venous ulcers and most ulcers heal within a year with this treatmentEvidence based medicine proves that compression bandaging works, it should be offered to all patients with an ABPI>0.8 (because they could otherwise compromise arterial flow to the limb. It's a four layer bandaging technique (Non adherent dressing over the ulcer, followed by crepe bandage, blue lien bandage and finally an adhesive bandage).
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What to consider if venous ulcer fails to heal
"The great majority of ulcers heal by 12 weeks and most heal by a year. So if an ulcer fails to heal, I would need to consider the possibility of malignant transformation of a long-standing ulcer and arrange for a biopsy to exclude a marjolin's ulcer.Always say MDT management (including wound Care Nurse, OT, district Nurse Care...)In conservative management: patient advised to rest and keep limb elevated to reduce venous hypertension. Once ulcers are healed, patient advised to wear graduated elastic compression stockings.Surgical: skin graft may be used with excitation of the underlying dead skin.
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Please examine the lesion on this patient's foot (Arterial ulcer)
Key features to look forInspection://// Associated paraphernalia: patient may be on prostaglandin infusion/// General inspection of the leg: patient usually arteriopath. If amputation on opposite limb them mention it./// Site: usually on pressure areas of feet, around the toes)/// Size/shape: well defined regular margins, size no more than several cm/// Edge: classically punched out/// Base: no granulation tissue due to poor blood supply. May be necrotic or Avascular. Can be deep. Even potentially see tendons and bone. "The ulcer appears deep and I cam see the underlying bone"- Palpation: temperature (surrounding skin cold and grayish blue discoloration), painful ulcer (may be masked by peripheral neuropathy in diabetics. Peripheral pulses absent (offer to use a Doppler probe, loss of triphasic waveform seen in arteriopath).Completion/management:Management similar to those for peripheral vascular disease. PAIN RELIEF IS KEY (WHO pain ladder). Use of vasodilators such as prostaglandins or surgical techniques such as lumbar sympathectomy.
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How to distinguish ivc obstruction from portal hypertension
, look at veins below umbilicus
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When to consider pleuridesis
2 or more spontaneous pneumothorax
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Tell me about bone scan
Radioisotopes caught by more metabolically active...
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Definition of laparotomy
Inspection of.... Check
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Difference between arterial claudication and neurological claudication (spinal stenosis)
Other types of claudicationNeurological: spinal stenosis (numbness, worse on bending forward),
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What do claudication patients die of
Mi cva renal failureMortality 5y 60%Give antiplatelets and statin
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Definition of critical ischemia
3 parts Greater than 2 weeks Rest pain unremittingTissue lossAbpi less than 0,5
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Acute ischemia
PalePulselessPerishing coldPainfulParasthesiaParalysis
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How do aneurysms present
Incidental findingNerve compression/painVein compression/dvt (popliteal aneurysm)Embolisation or thrombosisFistula (aorta enteric fistula, aorta cutaneous fistula, aorto cava fistula)
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Screening for aaa
> 65One of uss of abdomen
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Complications of aneurysms
RuptureEmbolisation (trash footThrombosis (acutely ischemi, leg)Pressure DVTFistularion acutely unstable usually
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Thoracic outlet syndrome
Venous: upper limb dvt and long term swellingArterial: raynaud, claudication embolisationNeurological: pain radiculipathyIx: mri, mra MarcDuplex in abductionNerve conduction studies
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Why do diabetics get ulcer
Pvd Small vessel diseaseNeuropathyInfection
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What is a charcot joint
Painless... Check definition
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Causes of raynaud
CrestThoracic outlet syndromeIdiopathic (Primary) most common white blue redLarge vessel diseaseVasculiticOccupational: vibrating toolIatrogenic: anthocyaninsHaematological: polycythemia, cold affliction.
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How to estimate area of body surface burntWhy is it important to know
Rule of 9If more than 15% them start fluid resuscitationManagement with split-skin graft taken from thigh
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Common nerve lesions in carotid artery Surgery
Hypoglossal nerve palsy (tongue towards lesion)Recurrent laryngeal 9 (cough)...8710
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Describing fracture radiograph
See photo
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Management of fractures
ResussReduce restrict/hold Rehabilitate
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Smith and colles fracture
Smith's fracture, also sometimes known as a reverse Colles' fracture or Goyrand-Smith's, is a fracture of the distal radius.[1] It is caused by a direct blow to the dorsal forearm[2] or falling onto flexed wrists, as opposed to a Colles' fracture which occurs as a result of falling onto wrists in extension. Smith's fractures are less common than Colles' fractures.The distal fracture fragment is displaced volarly (ventrally), as opposed to a Colles' fracture which the fragment is displaced dorsally. Depending on the severity of the impact, there may be one or many fragments and it may or may not involve the articular surface of the wrist joint.
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Most likely cause of postoperative pyrexia, tachycardia and dyspnea
Postoperative pulmonary collapse. Extremely common following thoracic abdominal or groin Surgery.Pyrexia unlikely from wound infection our PE so soon after surgery.Cause: retention of plugs of mucus in bronchial tree.Managed Physio, vigorous breathing exercises, coughing in upright position, passion management pca, antibiotic
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Burst abdomen = abdominal wall dehiscenceFactors- causes
FolloWing colectomy...Usually preceded by pink fluid sign, serous peritoneal exudate from wound several days before complete dehiscence.Factors:Preoperative factors: vit c deficiency, protein deficiency, jaundice, uremia, anemia, chronic cough, abdominal distensionOperative factors: faulty techniquePostoperative factors: cough abdominal dissension, wound sepsis
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Managing burst abdomen
Reassure patient or relativesIv morphine as sedation and pre anesthetic medication and antiemeticCover exposed viscera and transfer to theatre with General anesthesia
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What happens with incisionsal hernia
Deep layers of abdominal wound give eau but skin sutures hold
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Definition of fistula
Pathological communication between two epithelial surfaces
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Fistulogram
Injection of radioopaque contrast fluid gastrograffin through fine catheter into the fistula
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Definition of cellulitis
Spreading infection of cellular tissues. May involve superficial fascia, overlying skin...Symptoms: heat pain redness swellingComplications: abscess + homogeneous ,+ systemic features like Pyrexia ill Management: swab blOod culture antibiotics
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Definition of abscess
It's a localised collection of pus. Pus is defined as living and dead phagocytes usually containing living and dead bacteria.
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General manifestations of an abscess
Swinging PyrexiaTachycardiaMalaiseAnorexiaSweating Polynorph leucocytosisSometimes pus seen around a piece of suture: stitch abscess
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Carbuncle
Area of subcutaneous necrosis that discharges onto the surface through multiple sinuses. Most commonly neck from collar excoriatingUsually staph aureus Common in diabetics
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Indications of renal transplant
Check
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Sister Marie Joseph nodule
Intra abdominal and ovarian cancer
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Recti
Lines alba
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Hydrocele
Fluid in tunica vaginalis
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Hematuria causes
Check
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Bladder cancer
Majority transitional Cell cancerScc: shistosomiasis
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JJ stent
A ureteral stent, sometimes as well called ureteric stent, is a thin tube inserted into the ureter to prevent or treat obstruction of the urine flow from the kidney. The length of the stents used in adult patients varies between 24 to 30 cm. Additionally, stents come in differing diameters or gauges, to fit different size ureters. The stent is usually inserted with the aid of a cystoscope. One or both ends of the stent may be coiled to prevent it from moving out of place, this is called a JJ stent, double J stent or pig-tail stent.
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Definition of urinary retention
Painful palpable our percussavle bladder when the patient us unable to pass any urine Inability of passing urine
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Contents of spermatic cord
Arteries: testicular artery, deferential artery, cremasteric arteryNerves: nerve to cremaster (genital branch of the genitofemoral nerve), testicular nerves (sympathetic nerves) and the ilio-inguinal nerve- Ilio-inguinal nerve not inside spermatic cord, but runs along the outside.Vas deferens (ductus deferens)Pampiniform plexusLymphatic vesselsTunica vaginalis (remains of the processus vaginalis)
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Borders of inguinal canal
Superior wall (roof): 2 Muscles:internal oblique Muscletransverse abdominus MuscleAnterior wall: 2 Aponeuroses:Aponeurosis of external obliqueAponeurosis of internal obliqueLower wall (floor): 2 Ligaments:inguinal Ligament·lacunar LigamentPosterior wall: 2Ts:Transversalis fasciaconjoint Tendon
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Hesselbach triangle
RIPMedial border: Lateral margin of the rectus sheath, also called linea semilunarisSuperolateral border: Inferior epigastric vesselsInferior border: Inguinal ligament, sometimes referred to as Poupart's ligament
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Midline laparotomy
Skin, fat, linea alba and peritoneum
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Femoral triangle
The femoral triangle is bounded:superiorly by the inguinal ligament.medially by the medial border of the adductor longus muscle.laterally by the medial border of the sartorius muscle.[2]
