Consent Flashcards
What are 4 particular risks to consent for in laparoscopic surgery?
Damage to viscera
Damage to vessels
Conversion to open
Iatrogenic injuries missed at time of surgery
Specific risks for consent in appendicetomy?
Normal appendix
Wound infections
Pelvic abscesses - higher risk if laparoscopic
Need for bowel resection / stoma
Explain 2 methods of obtaining pneumoperitoneu,?
Open hassan technique - incision around imbilicus, dissect down under direct vision to peritoneum, blunt trochar in, lap port inserted and CO2 attached
Veress needle - stap incision, needle down into peritoneum, that is spring loaded and stops when hit peritoneum. can put drop of saline down to make sure in
2 non-radio opaque renal stones?
Xanthine
Urate
Semi opque renal stone?
Cystine
2 kinds of coupling complications in lap surgery?
Direct
Capacitance
Why do post op haematoma thyroid patients get airway obstruction?
Laryngeal oedema secondary to reduced venous return
Rarely due to direct compression unless concurrent laryngomalcia
What is Stenson duct?
Parotid duct
What 2 veins form the EJV?
Retromandibular (maxilalry and STV)
Posterior auricular
What does the EJV drain into?
SCV
Waht forms the boudnaries of the quadrangular space and whats in it?
Long head tricep (lat border) Teres major below Teres minor above Humerus laterally Axillary artery and posterior circumflex humeral nerve
What forms the boundaries of the triangular space and whats in it?
Long head tricep (med border)
Teres major below
Teres minor above
Circumflexx scapular artery
What muscle is inbetween the quad and trinagular space?
Long head triceps
What forms the boundaires of the tirnagular interval and what is in it?
Long head tricep (med border) Teres major above Lateral head tricep laterally Radial nerve Profunda brachii
Where is the canal of Guyon? Borders
Ulnar aspect of wrist just superficial to carpal tunnel (floor)
Palmar carpal ligaments is roof
Hook of hamate is radiail border
Pisiform is ulnar border
4 nerves innervated by superior gluteal nerve?
Glut med
Glut min
Tensor fascia latae
Piriformis
What RFs are there of wounds for tetanus?
Heavy contamination w soil/faeces
Devitalised tissue
Old neglected wound
Puncture wounds
What is the vaccine schedule for tetanus?
2, 3 and 4 months
Boosters at 4 and 14
What is the full treatment for tetanus - 3 things?
Penicillin, metronidazole and tetanus Ig
Discuss role of tetanus in wound management?
If fully vasccinated less than 10 years ago - doesnt need anything
If fully vaccinated more than 10 years ago give booster, plus Ig if dirty / high risk wound
If unvaccinated - start immunisation and give Ig if dirty/ high risk
Clinical features and pathology of tetanus?
Caused by C tetani from dirty wounds
Produces spores and tetanospasmin, a neurotoxin that inhibits release of inhibitory GABA / neurotransmitters
Retrograde axonal transport once diffused to spinal cord
Widespread tetany, autonomic disturbance, dysrhythmias
What is the most common GAS implicated in e.g. nec fasc, toxic shock, impetigo and pharnygitis?
Strep pyogenes
Give 3 virulence factors associated w severe GAS infection?
Streptokinase, hyaluroindase and streptolysins
What may the concern be if an area of severe dysplasia is picked up on biopsy for Barretts?
That there is already invasive cancer somewhere else that hasnt been picked up due to sampling error
Give 3 treatment options for barretts with severe dysplasia?
Photodynamic therapy
Laser ablation
Segmental resection
Describe how abscesses are formed?
Large site of pus where centre becomes hypoxic, impeding clearance of pus by phagocytes
Contained in anatomical area
What is the definition of an empyema?
Collection of pus within a hollow viscus
What is a spore?
Single celled reproductive unit capable of giving rise to new individuals without sexual fusion
What are the 3 channels for in an endocscope?
Instrumentation
Aspiration/suction
Irrigation
What are the physis, diaphysis, metaphsis and epiphysis?
Physis = growth plate Epiphysis = end of bone next to growth plate Diaphysis = body of bone Metaphysis = bit next to physis on body side
What is an osteoclastoma otherwise known as? Benign or malgiannt?
Giant cell tumour of bone
Benign usually
What scoring system can risk striatfy potential for path fractures in bony mets?
Mirels scoring system - 9 or more = impending fracture so fix, 7 or less = dont fix
Which branchial cleft is most commonly implicated in cysts?
Second
What investigation can be done for structures with a sinus tract to the surface
Sinogram
What classically is found if aspirate a branchial cyst?
Choelsterol granules
4 reasons why surgery is recommended for branchial cysT?
High risk of infection
Dont spontaneously regress
Risk of mass effect etc
Low risk malignant potential
Describe how you woudl examine a neck lump?
Wash hands, introduce, consent etc
Sat up away from wall
General inspection
Neck inspection
Insecpt on tongue protrusion and drinking
Palpate - each level (anterior triangle, SCM, post triangle, LNs)
Asuculate
Offer to examine ENT system and systemic LNs
Specifically examine SM gland if indiicated including milking it, or facial nerve if parotid, or systemic for thyroid
Investigations for ?submandibular sialolithiathisis?
US
Sialogram
Management options for submandibular gland?
Conservative Sialogram may be thereapeutic Lay open duct and retrieve stone (leave open to avoid stricutirng) Silaendoscopy Sumbandmibular gland excision
How to examine CV system?
Wash hands, indtroduce self General insecption Hand inspection - stigmata of IE etc Radial pulse, radio radial delay Central pulse JVP - hepatojugular reflex Eyes - cholesterol Mouth - IDA Chest - scars etc Heaves and thrills Apex beat Each valve area ausculatate - diaphgram for systolic murmurs, bell for diastolic Leaning forward for AR, on side for MS Into axilla for mitral, carotid for aortic Peripheral odedemma Offer to eamine rest of pulses and respiratory system
How to examine pperipharl vascular system?
Wash hands, consent, expose Inspect around, hands, face + eyes, abomen/thorax and LLs Feel radial pulses and for RR delay Central - brachial and carotid Aorta Femoral - and radio femoral delay SFA over hunters canal Popliteal DP Post tib Examine feet for temp, NV status, CRT, oedema Asuclautate carotids, aorta, femoral, popliteal Buegers test ABPI
How to do Buegers test?
Lift each leg off bed in turn and keep elevated
Angle that goes white = buegers angle - over 20 suggests PVD
then hang over bed and watch go red/dusky purple
ABPI values?
Over 1 - ?diabetes
0.4-0.7 = intermittent cluadication
less than 0.4 = critical ischaemia
What i the normal doppler artieral waveform? What is abnormal?
Triphasic normal
May be mono or biphasic
What is diagnostic of critical limb ischaemia?
ABPI less than 0.4
Rest pain, or tissue loss (gangrene/ulcers)
Describe how to do a venous examination of the lower limb?
Wash hands, consent, exposure and positioning
Inspect - varicose veins, skin discolouration, scarring etc
Palpate - for temperature, saphena varix, LNs
Tap test, cough test and tourniquet tests
Doppler assessment
Complete by doing abdo and arterial eaxms
How wwould you do a cough impulse test in varicose veins?
Palpate saphenofemoral junction jjust med to femo artery
Ask patient to cough
How would you do a tap test in varicose veins?
Tap above and below and feel for upwards/downard transmission of tap
Retrograde tap transmission is a sign of venous impcomtpetne
How would you do a doppler venous assessment of the lower limbs?
Standing
Probe over SF junction
Compress calf listening for whoosh - if second woosh suggests imcompetence of SFJ
Repeat over short saphenous and popliteal junction
Ix for venous insufficiency with skin changes?
Venous duplex scan
What causes varicose veins?
Usually - valve incomepetence resulting in elevated superficial venous pressure as deep comes back into superficial
Also DVT, pregnancy, hormonal changes
Management of varicose veins?
For mild - mod - consider conservative with weight loss, compression stockings, exercise, leg elevation
For severe / skin changes - consider surgical intervention incl surgical avulsion, sclerotherapy or endovenous/radiofreuqency ablation
How to examine respriartory system?
Wash hands, introduce self, consent and position/exposure
General inspection
Hands inspection and feel pulse, check for CO2 flap
Check face + mouth
Inspect chest for scars, expansion etc
Palpate - chest expansion, tactile fremitus, trachea and cervical LNs
Percuss - chest throughout
Asuculate - lung fields throughout incl apex, vocal fremitus
Offer to examine LNs, cardio system
What does disparity ain active and passive shoulder movements suggest?
Rotator cuff tear
What special tests are there for rotator cuff fucntions?
Jobes test for supraspinatus - thumb down and abduct
Gerbers lift off test for subscapularis
Infraspinatus/teres minor - resisted external rotation
What test is there for recurrent anterior shoulder dislocation?
Shoulder apprehension test
What is anterior shoulder discloation usually associated with in younger people?
Labral tear - bankart lesion
What is anterior shoulder disolcation usually assoicated with in older people?
Rotator cuff injury due to degerenative changes
What is a bankart lesion?
Injury to anterior glenoid labrum, capsule and ligaments of shoulder due to recurrent dislocations
What is a hill sacks lesion?
Indentation on posterolateral humeral head caused by impaction against anteroinferior glenoid rim during anterior dislocation
How would you examine the spine?
Wash hands, introduce self, consent and exposure / position
Inspect each part in turn - from front sides and back
Watch gait
Adams forward bend test for scoliosis
Feel all the way down
Chest expansnion if kyphoscoliosis
Assess movement of cervical spine
Then thoracolumbar (thoraco only really rotation)
Schobers test for flexion (or measure fingers - floor distance
Spurlings test
How would you perform Schobers test?
Mark iliac crest level and 10cm above, 5cm below
Bend forward to touch toes without bending knees
Remark differences - if over 5cm normal, if under 5cm abnormal
What is Spurlings test?
For cervical stenosis - ear to shoulder then apply axial load
What is lasegues sign?
Like SLR for sciatica
Causes of acquired kyphosis?
Osteoporsis and fractures Spondylosis Bad posture Cancer infilitration TB
How woudl you examine a stoma?
Inspect with bag off - number of lumens, position, spouted vs unspouted, skin changes
Check for parastomal hernia
Finger in for ?stenosis
Light in for ?mucosal health
What is a left upper quad stoma likely to be?
Transverse loop colostomy
Things to consider when siting stoma?
Bony prominences, skin folds and scars Belt/bra line Patient can get to it easliy No local lesions or infections Within rectus abdomins muscle (if poss) Mark sitting and standing
How to examine submandibular region?
Wash hands, introduce, consent and exposure
Inspect neck itself
Inspect oral cavity incl with tongue depressor
Palpate the neck and gland areas, and LN areas
Bimanually palpate gland through mouth - ballot - also duct
Test tongue sensation and movement
Coplete by examining parotids, rest of ENT system
How can you test mylohyoid muscle?
Push tongue to roof of mouth
How to do AMTS?
Age? Time? Remember 42 west street Year? Name of this palce? My job? This persons job? DOB? When did WW2 end? Who is the current PM/monarch? Count 20-1? Recall address?
Prep for colonscopy?
Couple days befroe - low fibre diet, drink plenty of fluids
Day before - clear fluids and bowel prep
Day of - NBM 6 hours, sips until 2 hours before
Omit BP medications perioperatively
Ensure have adequate social support
Do you need to stop anticoagulation for a colonscopy?
Nope
Alternatvies to OGD/colonscopy?
For OGD - barium swallow/XRs
For colon - CT colonography
What is a Bartons fracture?
Fracture of the distal radius with involvement of joint surface and radiocarpal dislocation
What is a fracture of the distal radius with involvement of joint surface and radiocarpal dislocation called?
Bartons fracture
What is a Bennetts fracture?
Fracture of the thumb - base of metacarpal
What is a fracture of the base of the thumb called?
Bennetts
What is a boxer’s fracture?
Fracture of the neck of the 5th metacarpal
What is a chance fracture?
Horizontal fracture of the veterbal body
What is a horizontal fracture ofht evebertal body called?
Chance fracture
What is a Chauffeur’s fracture?
Intra-articular fracture of radial styloid
What is an intra articular fracture of the radial styloi called?
Chauffers fracture
What is a Colles fracture?
Distal radial fracture with dorsal angulation - FOOSH
What is a distal radial fracutre with dorsal angulation called?
Colles
What is a galleazi fracture?
Radial shaft fracture with dislocation of the radio ulnar joint
What is a radial shaft fracture with dislocation of the radio ulnar joint called?
Galleazzi
What is a Hangmans fracture?
Fracture through both pedicles of C2
What is a fracture through both pedicles of C2 called?
Hangmans fracture
What is a Jefferson fracture?
Burst fracture of C1 due to axial loading
What is a lisfranc injury?
Fracture disocatino of the midfoot - forced plantar flexion or weight through midfoot
What is a monteggia fracture?
proximal ulna fracture with dislocation of radial head
What is a proximal ulna fracture with dislocation of radial head called?
Monteggia
What is a Rolando fracture?
Intra articular comminuted fracture of the base of the 1st metacarpal
What is a Intra articular comminuted fracture of the base of the 1st metacarpal?
Rolando fracture
What is a Smiths fracture?
Opposite of a colles - distal radial fracture with volar displacement (fall with flexed wrist)
What is a distal radial fracture with volar displacement called?
Smiths
What are the Salters Harris fractures?
1 - straight through grwoth plate 2 - above 3 - lower 4 - through everything 5 - rammed (crush fracture)
What is the most common salter harris fracture?
2 - above
What are the Weber ankle fractures?
A = least bad - below syndesmosis - boot B = at level of syndesmosis - variable C = most bad - proximal fib so unstable - fix
What nerves come off the brachial plexus - not the main ones?
Long thoracic nerve of bell - C5-7
Dorsal scapular - C5
Nerve to subclavius - C5/6
Suprascapular - superior trunk
Lateral cord - lat pectoral nerve
Posterior cord - upper and lower subscapular, thoracodorsal nerves
Medial cord - med cut nerve of arm and forearm, medial pectoral nerve
Contents of hunters canal?
Femoral artery and vein
Saphenous nerve
Nerve to vastus medialis
