exam with miss tan

1. Differentials of RIF pain
a. In male : acute appendicitis, torsion of testis, epidiymitis, cystitis, diverticulitis, mesenteric ischemia, cecal cancer with obstruction, constipation colic
b. In female: to add on PID(tuboovarian abscess), ectopic pregnancy, torsion of ovarian cysts
c. In peads: to add on mesenteric adenitis, age
2. Investigation: twbc, ufeme, upt for female, pt, inr if suspect coagulopathy, buse ( asses dehydration)
3. Others: radiological axr: fecal loaded, dilated small bowel in caes of i/o 2 cecal cancer, in female , us gynae esp if upt positive
4. Size of bowel dilated: small bowel: 3cm, large bowel : 6cm, cecum iis 8cm
5. In acute appenditis: do u give painkiller yes, because if pt have peritonitis, the pain is always there
6. In appedicectomy: what layers: skin, subcutaneous fat, sup fascia, deep faschia, ext oblique, int oblique, transversalis fascia, peritoneum
7. What is the area for op: 2/3 rd upper from the umbilicus to asis . mac burneys point, via the lanz incision
8. How the pain is like: paraumbilical(gen peritonitis) to rif ( local peritonitis)
9. What is rovsing sign: press thelif, the have pain at rif ( d/t reffered pain: T10 innervation)
10. Pr in acute appendicitis: can see if fecal loaded, can feel for tenderness of the lateral wall in cases of pelvic appendicitis

11. Diffential of epigastric pain: surgical , non surgical

a. Surgical-
i. Acute abdomen: panreatitis, cholecystitis, cholangitis, reffered pain?, acute diverticulitis, mesenteric ischemia, volvulus, peptic ulcer disease, h.pylori infection.reflux oesophagitis, deudenal ulcer, intestinal obstruction: colon carcinoma
b. Non surgical- right lower lobe pneumonia, myocardial infarction, dka, adisonian crisis, crest syndrome ( scleroderma)

12. How to investigate: x ray, chest erect, us abdomen
a. X ray: abdomen calcification of pancrease in chronic pancreatit, erect axr: step ladder sign in i/o
b. Erect chest: air ender diaphragm

13. Ugib, pt come to ed . how do u manage: ABC:airways, removed the dentures, suction any blood, and remove foreign body obstruction, head tilt, chin lift
14. B: breathing
15. C: circulation: crystalloids: ns and hartman,. Hartman may cause lactic acisdosis, but still can be used in resus as acidosis is a later complication
16. How do u divide hypovolemic shock: stage 1-4
17. What is the 5 parameters: bp, pr, rr, urine output, mental status ( the other 2: vol of blood loss and % of the blood loss)
18. If after resus: what u proceed : take blood, hb, correct coagulopathy
19. Ask his: taking nsaids, trad meds, dengue: look for heamoconcentartion, look at platelet(ITP, hemophilia, von wille brand disease), aspirin, on warfarin
20. Examination: crt, peripheries, pulse vol, bp, lungs: any crackels, cvs: any gallop, p/a: any tenderness, how is bowel sound, pr
21. In pr: fresh melena: marron calor, stale melena: black to dark green
22. Then , how do u proceed: with ogds, can inject adrenaline, clips, of if have varices banded
23. If varices cannot band: pt bleeding: put sensteken blackmore tumes
24. Explain about sengtaken blackmore
a. 3 ports, one suction, and the other 2 are ballons port. The re are two ballons, gastric ballon and oesophangeal ballon,
b. The is also a gastric aspirate
c. The gastric ballon is filled with: 250 cc air(water?)
d. The osephangeal ballon is filled with: air pressure 30-45 mmhg(never exceed 45 mmhg)
e. Leave the tube for maximum 24 hours
f. If still bleed, and cannot control by endoscopy: for sclerotheraphy or tips(transjugular intrahepatic postcaval shunt
25. How to insert it?
a. First , consent. Make sure pt intubated, or not must be sedated
b. Check patency of tube
c. Insert the tube via: oral or nasal until the 50 cm mark
d. Pump in air, and listen to the air sound to indicate tube is already in the stomach
e. Then , aspirate all the gastric content , to prevent aspiration
f. Inflate the gastric ballon with 250 cc air
g. Then apply traction
h. If still bleed, inflate the oesophangeal ballon
i. Connet the free end oesophangeal port with the manometer, and inflate the oesophangeal ballon to maximum 45 mmhg of air
j. Keep for 24 hrs. if fail: for scleroptheraphy, tips
26. Indication of sengsteken blcakmore tube:
a. While waiting for endoscopy
b. Fail endoscopic band ligation
c. While awaiting for TIPS
27. Mva: u are at casualt y, pt come gcs: 5/15, how u proceed: withABC initial resuscitation
28. D:
29. E: exposure , log roll the pt , to look at any other injury
30. How do u asses gcs
31. Then, : to proceed with ct brain: edh: lentiform, sdh: cresent, sah: lightening? Of sulci and gyri
32. What is the life threatening chest injury: tension pneumothorax, flail chest,injury of great vessels, cardiac tamponade, open sucking chest wound
33. What is flail chest: when 3 or more ribs fracture , and at least at 2 sides
34. How do u insert chest tube
a. Get consent
b. Use open technique, lie pt down
c. Prepare set, prepare underwater seal
d. Use lignocaine to infiltrate ( maximum lignocaine is 3 mg.kg)
e. Locate: at the safety traingel
f. Pect major, lattissimus dorsi, 5 th rib
g. Use blade to nick the skin
h. Use hand to open in up
i. Then use artery to separate the muscles
j. Then, u will feel a give awayin penumothorax (air), or water comes out ( in hemothorax)
k. Clamp the chest tube, the insert
l. Conncet to the underwater seal
m. Secure with purse string suture
n. Chest x ray post chest tube insertion
35. If chest tube too deep, can pull out, if too superficial, never push in, off the chest tube, and insert a new ones
36. How do u insert cvp?
a. Take consent
b. Decide: subclavian, internal jugular, external jugular, branchiocephalic
c. Subclavian
i. Location. Medial third of clavicle
ii. Easiet rt side, as the lobe of the rt lungs, lower than the right
iii. The subclavian arteries lies superior and posterior to the subclavian vein
iv. Insert the needle, at the medial third clavicle, aim towards the sterna notch
v. Insert the subcalavian line as usual
vi. Cxr post insertion
d. Internal jugular
i. At the between the sterna head and clavicular head of scm muscle
ii. The apex is the clavicle
iii. Aim the needle to laterally, carotid arteries lies medial to the internal jugular vein.
iv. When aiming needle , aim it towards the nipple line.
v. Once gush of blood, insert the catheter as usual
vi. Cxr post procedure.
e. External jugular
i. Easier in this people where the external vein are prominent
ii. Pulsation can beseen, but cannot be palpated
iii. Compress the clavicle , to expose the ext jugular to be distended
iv. In other words, can put pt in tredelenburg position: to prevent catheter embolus , and to distend the vein
f. branchocephalic
37. The use of cvP
a. Use for measuring central venous pressure
b. For tpn insertion
c. To give medication
d. To give inotropes
e.
38. How do you do you proceed with incison of drainage of an abscess?
a. Example of breast abscess
i. Do an incision below the breast nipple( good cosmetic reason)
ii. Take pus c+s , drain the abscess, if can , use curret
iii. wash with povidone iodine
iv. then , pack with povidone gauze
v. wound inspection cm, or as outpt
39.