Procedures

Question 1

Outline examination of thyroid gland?

Answer 1

Inspect - gland itself, swelling, distended neck veins, scars, neck contour etc
Assess clinical thyroid status - hypo, eu or hyperthyroid
Palpate neck, assess if discrete or diffuse swelling
Check with water swallow and tongue movements
Examine LN chains
Evaluate for retrosternal extension - percuss lower border of neck and upper chest
Pemberton’s manouevre
Auscultate gland for bruit

Question 2

What other examination would you like to include in overtly hyperthyroid patients?

Answer 2

Cardiovascular examination - look for failure

Question 3

Differentials for diffuse swelling thyroid + hypothyroidism?

Answer 3

Iodine deficiency

Hashimoto’s

Question 4

Differentials for diffuse swelling thyroid + hyperthyroidism?

Answer 4

Graves, Hashimoto’s

Question 5

Differentials for diffuse swelling thyroid + euthyroid?

Answer 5

Anaplastic cancer
Lymphoma
Medullary cancer

Question 6

Differentials for discrete thyroid nodule and euthyroidism?

Answer 6

Follicular cancer
Papillary cancer
Non-functioning adenoma
Cyst

Question 7

Differentials for discrete thyroid nodule and hyperthyroidism?

Answer 7

Functioning adenoma

Question 8

Differentials for multiple thyroid nodules and euthyroidism/hyperthyroidism?

Answer 8

(toxic) multinodular goitre

Dominant nodule within MNG

Question 9

Describe how to examine the parotid gland? Specific nerve to check?

Answer 9

Inspect from front to back of face, looking for obvious mass lesions
Lesion at angle of madible - consider parotd
Look at interior oral cavity - poor dentition, pharyngeal extension of mass, discharge from parotid duct
Palpate mass and comment on consistency, mobility etc
Palpate regional lymph nodes
Test facial nerve function

Question 10

Most likely differential for mandibular angle swelling with no facial nerve involvement? What about with facial nerve invasion?

Answer 10

Pleomorphic adenoma

Facial nerve involvement suggests malignancy

Question 11

Outline procedure for breast examination? Specific things to remember incl nerves?

Answer 11

Inspect with arms by sides and hands behind head
Palpate under areola and all regions of breast - normal then abnormal, express discharge if able
Examine axilla
Examine function of long thoracic (wing scapula - serratus anterior) and thoracodorsal nerves (lat dorsi)

Question 12

Why is it important to examine the thoracodorsal nerve in breast exam? How do this?

Answer 12

Innervates latissimus dorsi - if considering latissimus dorsi pedicled flap but nerve impaired could cause atrophy of muscle and compromise prosthesis coverage

Question 13

Why might there be impaired sensation in the axilla post-mastectomy?

Answer 13

Axillary node clearance - intercostobrachial nerves injured or divided

Question 14

4 indications for mastectomy in treatment of breast cancer?

Answer 14

Patient choice
Large tumour where removal with conservation approach would give poor cosmesis
Multifocal lesions
Lobular cancers unless very small and focal

Question 15

What scars may be easy to miss in breast examination?

Answer 15

Circumareolar, sentinel node scars, scars from reconstructive surgery e.g. lat dorsi (posterior), TRAM/DIEP at base of abdomen - may be hidden by underwear

Question 16

What does distortion of breast on raising arms suggest?

Answer 16

Pectoral involvement with mass lesions

Question 17

What is the difference between a TRAM flap and a DIEP flap?

Answer 17

TRAM = transverse rectus abdominis musculocutaneous - tissue from abdominal muscle and soft tissue
DIEP = deep inferior epigastric perforators - spares abdominal muscle, only uses soft fat tissue and local blood vessels

Question 18

If breast lesion suspected as malignant on examination, what other areas should you examine?

Answer 18

Chest - effusions
Abdomen - hepatomegaly
Vertebral column - bony tenderness
Axilla - nodes

Question 19

What other hint should you look for if breast Ca patient has had wide local excision?

Answer 19

Radiotherapy tattoo

Question 20

Describe how to perform chest drain insertion with open technique?

Answer 20

Check equipment, ensure 30-34 Fr drain with underwater drainage system prepared and set up, 10ml 1% lidocaine for local
Position at 45 degrees if injuries permit
Safe triangle of affected side, infiltrate with local prep and drape
2cm transverse incision
Blunt dissection to pleural cavity
Finger sweep to ensure correct location and no underlying adhesions
Remove introducer from drain tube and guide into pleural cavity towards lung apex with clamp
When in satisfactory position use purse string sutures and anchor sutures with 1/0 silk
Connect drain to underwater system and apply dressing
Check drainage tube swinging and bubbling
Chest x-ray

Question 21

5 complications of chest drain insertion?

Answer 21

Damage to neurovascular bundle
Parnechymal lung injury
Injury to great vessels
Dislodgement or kinking of tube with re-development of tension
Not opening vent port of underwater seal system, revelopement of tension

Question 22

What is the safe triangle for insertion of a chest drain?

Answer 22

Midaxillary line of 5th intercostal space
Bordered by anterior edge of latissimus dorsi posteriorly
Lateral border of pectoralis major anteriorly
Line superior to horizontal level of nipple inferiorly and apex below axilla

Question 23

Where and how would you decompress a tension pneumothorax emergently? With what?

Answer 23

14G needle into second intercostal space, midclavicular line

Question 24

What is the cut off between large and small spontaneous pneumothorax and how does this influence management?

Answer 24

2cm at level of hilum
Small spontaneous can be left alone if no compromise
Consider aspiration of large pneumothorax, underlying lung disease or significant compromise - chest drain

Question 25

What is the difference between chest drains used for spontaneous and traumatic/tension pneumothorax?

Answer 25

Small seldinger type drains for spontaneous rather than large 30-34Fr drains for trauma

Question 26

Describe management of needle stick injury?

Answer 26

Immediate - wash wound carefully and encourage bleeding
Identify virology status of origin of needle
Determine risk
Take blood from source patient and clinician for virology
Discuss PEP with micro/occ health

Question 27

What BBV has highest seroconversion risk following needlestick? What about HIV/Hep C?

Answer 27

Hep B - 30% for percutaneous, non immune
HCV - 0.5-1.8%
HIV - 0.1-0.3%

Question 28

4 highest risk factors for seroconversion following needlestick injury?

Answer 28

Deep injury
Terminal HIV illness in source patient
Visual blood on device causing injury
Injury with needle that has been in artery or vein

Question 29

Describe how to assess foot and ankle?

Answer 29

Look feel move
Look both sitting and standing, exposure so can see knee and below - e.g. surgical stigmata, arches, genu valgum/varum, intoeing
Palpate main bony prominences and pulses, sensation
Move - plantar and dorsiflex
Subtalar joint inversion and eversion
Midtarsal/tarsometatarsal joints - hold heel still and grip forefoot in eversion and inversion
Toe movements
Walk - look at gait

Question 30

What are the 2 phases of the gait cycle? Which lasts longer?

Answer 30

Stance - heel strike to toe off - 62%

Swing - toe off to heel strike - 38%