Procedures Flashcards
Outline examination of thyroid gland?
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
What other examination would you like to include in overtly hyperthyroid patients?
Cardiovascular examination - look for failure
Differentials for diffuse swelling thyroid + hypothyroidism?
Iodine deficiency
Hashimoto’s
Differentials for diffuse swelling thyroid + hyperthyroidism?
Graves, Hashimoto’s
Differentials for diffuse swelling thyroid + euthyroid?
Anaplastic cancer
Lymphoma
Medullary cancer
Differentials for discrete thyroid nodule and euthyroidism?
Follicular cancer
Papillary cancer
Non-functioning adenoma
Cyst
Differentials for discrete thyroid nodule and hyperthyroidism?
Functioning adenoma
Differentials for multiple thyroid nodules and euthyroidism/hyperthyroidism?
(toxic) multinodular goitre
Dominant nodule within MNG
Describe how to examine the parotid gland? Specific nerve to check?
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
Most likely differential for mandibular angle swelling with no facial nerve involvement? What about with facial nerve invasion?
Pleomorphic adenoma
Facial nerve involvement suggests malignancy
Outline procedure for breast examination? Specific things to remember incl nerves?
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)
Why is it important to examine the thoracodorsal nerve in breast exam? How do this?
Innervates latissimus dorsi - if considering latissimus dorsi pedicled flap but nerve impaired could cause atrophy of muscle and compromise prosthesis coverage
Why might there be impaired sensation in the axilla post-mastectomy?
Axillary node clearance - intercostobrachial nerves injured or divided
4 indications for mastectomy in treatment of breast cancer?
Patient choice
Large tumour where removal with conservation approach would give poor cosmesis
Multifocal lesions
Lobular cancers unless very small and focal
What scars may be easy to miss in breast examination?
Circumareolar, sentinel node scars, scars from reconstructive surgery e.g. lat dorsi (posterior), TRAM/DIEP at base of abdomen - may be hidden by underwear
What does distortion of breast on raising arms suggest?
Pectoral involvement with mass lesions
What is the difference between a TRAM flap and a DIEP flap?
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
If breast lesion suspected as malignant on examination, what other areas should you examine?
Chest - effusions
Abdomen - hepatomegaly
Vertebral column - bony tenderness
Axilla - nodes
What other hint should you look for if breast Ca patient has had wide local excision?
Radiotherapy tattoo
Describe how to perform chest drain insertion with open technique?
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
5 complications of chest drain insertion?
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
What is the safe triangle for insertion of a chest drain?
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
Where and how would you decompress a tension pneumothorax emergently? With what?
14G needle into second intercostal space, midclavicular line
What is the cut off between large and small spontaneous pneumothorax and how does this influence management?
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
What is the difference between chest drains used for spontaneous and traumatic/tension pneumothorax?
Small seldinger type drains for spontaneous rather than large 30-34Fr drains for trauma
Describe management of needle stick injury?
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
What BBV has highest seroconversion risk following needlestick? What about HIV/Hep C?
Hep B - 30% for percutaneous, non immune
HCV - 0.5-1.8%
HIV - 0.1-0.3%
4 highest risk factors for seroconversion following needlestick injury?
Deep injury
Terminal HIV illness in source patient
Visual blood on device causing injury
Injury with needle that has been in artery or vein
Describe how to assess foot and ankle?
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
What are the 2 phases of the gait cycle? Which lasts longer?
Stance - heel strike to toe off - 62%
Swing - toe off to heel strike - 38%
