PACES Flashcards
Antalgic gait
Antalgic- decreased time on painful leg
Leg length
True - asis to medial malleolus
Apparent - umbilicus to medial malleolus
Indications for joint replacement:
Pain not controlled by conservative or medical therapies
Significantly disability patient
Severe osteoarthritis, rheumatoid arthritis,
Avascular necrosis, NOF fracture, pathological fractures from metastatic disease, congenital joint diseases
Failure of previous surgeries/ non union
De quervains tenosynovitis
Painful condition affecting tendons on the thumb side of your wrist
Hurts when you make a fist, grasp anything,
Swelling and pain at base of thumb and wrist
Cause: Direct blow to thumb lifting something heavy eg. Child, shopping Repetitive movements eg. Gaming Rheumatoid arthritis
X ray HF acute
A - alveolar oedema (bat wing opacities) B - Kerley B lines C - cardiomegaly D - dilated upper lobe vessels E - pleural effusion
Acute pul oedema And hypotensive patient Mx
Cpap - push lung fluid out and into pulmonary vessels
Will allow IV diuretics to work without risk of further hypotension
Then oxygen
Whipple’s procedure
Pancreatic head
Gall bladder
Part of the duodenum
Stoma exam
Site
Spout or flush
Number of lumens: loop (2 holes), double barrelled vs end
Consistency - does the stoma look healthy, prolapse, and contents of bag
Para stoma- herniation, skin,
Palpate - cough (herniation)
digitalise the lumen for stenosis and assess latency
Examine the rectal stump if necessary
What is a stoma?
Examples
External opening to a luminated organ
Allows discharge of the luminal contents to outside the body
Gastrostomy, duodenostomy, jejunostomy Ileostomy Colostomy Nephrostomy Urostomy
Complications of stomas
Specific
- ischaemia, haemorrhage
- infection, necrosis
- skin erosions
- retraction, prolapse, herniation
- stenosis
General
- stomal diarrhoea resulting in hypoK
- stone disease incl gall stones and renal stones more common following ileostony
- residual disease
- psychological disease
- psychosexual disease
- risks of operation
stoma indications
loop (temporary, reversal intended, relieve the distal bowel for healing), end (permanent)
feeding - percutanoues endoscopic gastrostomy
infection - severe necrotised fascitis, fournier’s gangren, abdominal tuberculosis
inflammation - severe irritable bowel disease, diverticular disease, radiation enteritis, familial adenomatous polyposis
perforation, complex fistulas
malignancy with resection
trauma - gun shot/ stabs
congenital - imperforate anus, hirschprung disease, necrotising enterocolitis, intestinal atresias
hartman’s procedure
surgical resection of the rectosigmoid colon with closure of the anorectal stump and formation of an end colostomy
*occasionally reversed
indications:
- Localized or generalized peritonitis caused by perforation of the bowel secondary to the cancer
- Viable but injured proximal bowel that, in the opinion of the operating surgeon, precludes safe anastomosis
- Complicated diverticulitis
colorectal cancer operations
anterior resection - loop stoma for later rejoining to allow the distal anastomosis to heal
Hartman’s procedure - removal of rectosigmoid colon, anorectal stump, formation of an end colostomy
right or left hemicolectomy
suspected bowel perforation, which imaging modality?
If bowel perforation is being considered, you don’t usually require an abdominal film, instead you need an erect chest X-ray, as this allows free gas under the diaphragm to be identified (the patient needs to have sat upright for at least 15-20 minutes prior to the X-ray to allow time for the air to rise).
structure for abdominal X ray
erects vs supine AXR
BBC
Bowel & other organs
- small intestine: middle, valvulae conniventes transverse the entire width
- large intestine: peripheral, haustra DO NOT transverse entire width
- faeces (usually a mottled/ thumb print appearance)
- upper limit of bowel diameter: 3cm (small in), 9cm (caecum), 6cm (colon)
Bones - fractures, sclerosis (white), mets
Calcifications - renal stones, gall stones
small bowel obstruction x ray findings and causes
coiled like appearance as valvulae conniventes are more prominent
>3cm diameter
causes: adhesions, abdominal herniation, intrinsic or extrinsic cancers
Reversible causes cardiac arrest
4 “Ts” and 4 “Hs” causes (hypoxia, hypokalaemia/hyperkalaemia, hypothermia/hyperthermia, hypovolaemia, tension pneumothorax, tamponade, thrombosis, toxins),
When to use terlipressin for upper GI bleed
Intravenous terlipressin is used in variceal bleeds for its effect on the splanchnic circulation causing a lowering of portal pressure, and slowing or stopping bleeding. However, in ulcerative bleeding the vessel is commonly arterial rather than from an abnormally dilated vein.
causes of high anion gap
Carbon monoxide, cyanide
Aminoglycosides
Teophyline
Methanol Uraemia Diabetic ketoacidosis, starvation/alcohol ketoacidosis Paracetamol Isoniazid, inborn errors of metabolism Lactate acidosis Ethylene glycol, ethanol Salycylates (aspirin)
which x ray allows you to measure heart size
PA - it is POSSIBLE
AP - no
type 1 vs 2 causes of respiratory failure
type 1 - hypoxic
- pneumonia
- PE
- pulmonary oedema
- pulmonary hypertension
- ARDS
type 2 - hypercapnic
- COPD
- asthma
- upper airway obstruction
- neuromuscular disorders, paralysis, spinal cord, central respiratory depression
colonic obstruction
causes: volvulus, colon cancer, diverticular strictures, hernias
volvulus - bowel twists on its mesentry –> ischaemia –> necrosis –> perforation
Sigmoid volvulus: ‘coffee bean’ appearance.
Caecal volvulus: fetal appearance
Causes of pneumoperitoneum
perforated abdominal viscus (e.g. perforated bowel, perforated duodenal ulcer)
recent abdominal surgery
signs of perforation
Rigler’s sign - double walled lumen
pneumoperitoneum - air under diaphgram
IBD AXR findings
Thumbprinting: mucosal thickening of the haustra due to inflammation and oedema causing them to appear like thumbprints projecting into the lumen.
Lead-pipe (featureless) colon: loss of normal haustral markings secondary to chronic colitis.
Toxic megacolon: colonic dilatation without obstruction associated with colitis.
what is toxic megacolon
nonobstructive colonic dilatation larger than 6 cm and signs of systemic toxicity
causes: IBD, infections (c.diff), colon cancer
Non invasive ventilation types and indications
CPAP
- sleep apnoea
- acute pulmonary oedema
BIPAP
- exacerbation of COPD
- ARDS
What is fluoroscopy
Use serial x rays to create real time moving images
Contrast enemas
Single contrast (barium) Used when patients unable to turn quickly as required in double. No real contraindications
Double contrast (barium positive contrast and CO2 gas negative contrast) - black and white image
- visualise the mucosa
CI: colonic perforation, toxic mega colon, anaphylaxis to barium, imminent or recent rectal biopsy within 7 days
What is an enema
Administration of liquid into the rectum to relieve constipation
The liquid softens the stool
The enema nozzle loosens the stool
Causes of GI obstruction
Mechanical
- intraluminal: foreign bodies, faecal impaction, gall stones
- intra mural: stricture (IBD), malignancy
- extramural: adhesions, hernias, volvulus, intussception
Non- mechanical (pseudo obstruction)
- paralytic ileus: medications (opioids), post surgery, inflammation (appendicitis, diverticulitis), haematoma (AAA rupture), intestinal ischaemia, electrolyte abnormalities, pneumonia, MI
- mesenteric vascular occlusion
