ShortTests

Chest tube (Thoracostomy tube)

--is a tube placed through the chest wall into the pleural fluid to drain an air or fluid collection
from the pleural space and can be used to install medication.

--location-triangle of safety(b/n 4th and 5th ICS in the anterior axillary line)

1. Lateral border of the pec. Major

2.MAL

3.Nipple line

2nd ICS for pneumothorax.

Indication

Pneumothorax--spontaneous and tension,traumatic

Haemothorax--chest trauma--only if massive (>1L)

Pleural effusion-sterile effusion, infectedeffusion (empyema), par pneumonic effusion,malignant

effusion)

Chylothorax

Pleurodesis--installation of sclerosing agents (talc...)

Contraindication

Anticoagulation

Coagulopathy

Pleural effusion due to liver failure

Pleural adhesion from an infection

Techniques for tube thoracostomy

1. Blunt dissection

2. Selderger technique
Complication

Malposition

Infection

Organ injury

Reexpansion pulmonary edema

Materials--- silicon andPVC

Chest tube care

--when transportation is needed clump the tube,

Keep the bottle underbed and static.

Check functionality (Oscillation)

Change when the bottle becomes full/ every 6hrs.

Removal

Symptoms resolved, Take control X ray for lung inflation

Drainage <50ml/hr. of serous fluid. If Blood/chyle don’t remove.

Remember

Fluid collects at the dependent side while air at the non-dependent.

The radiopaque line --for a radiological purpose.

Oscillation in the bottle--movement of fluid column with respiration.

Ask the patient to cough.

Remove the tube rapidly during inspiration!!

All holes in the plastic tube should be in the pleural space.

Don't clump when there is air leak.

Colostomy
-is a procedure in which the colon is pulled through a hole surgically made on the abdomen.

Stoma-the area of the abdomen where the new opening to the colon sits--where waste material now
exits the body.

Ostomy-bringing of the opening of an internal organ to the outside surface of the body

E.g. Ileostomy is bringing opening of the ileum onto the surface of the skin to form a stoma.

• Permanent—e.g. APR, Recto vaginal/vesical fistula, Gangrenous sigmoid, anal ring incontinence.
• Temporary--e.g. in trauma-to stop stool from passing to the affected area,giving it time to
properly heal, cancer, diverticulosis, sigmoid volvulus, perianal fistula.

Post-surgery--hospital stay--2-7 days. The stoma at first looks large and a bit dark in color. Over time the
size goes down and obtain a pinker or light red tone.

Types

• Based on surgical Construction

Loop Colostomy- sum stool can pass distally due to intact Posterior wall

End Colostomy- b/c we need complete diversion of fecal matter.

Spectacle Colostomy- for fistula mainly

Double Barrel Colostomy

• Based on segment of bowel involved

Transcending

Ascending

Descending

Sigmoid

Remember-Differentiate where the stoma is,the consistency of the waste material,types of conditions
responsible.
1. Descending--most frequently performed

Location-last 3rd section of the colon

Waste-firmer and less watery

Single or double barrel variety

Location--lower left side of the abdomen.

2. Transverse-in the transverse colon

Location-middle of the abdomen to the right side of the abdomen

Waste-loose and watery

Two types

A. Loop transverse colostomy-looks large but its b/c it has two openings--one is to expel fecal and waste
and the other is to drain the naturally occurring mucus that is used for self-protection.

B. Double barrel-colon is divided into two sections and two distinct stomas are formed

3. Ascending

Location-at the very start of the colon near the small intestine.

Waste-very loose and usually contains digestive enzymes in liquid form which have greater risk for skin
irritation.

--is the least common.

Loop colostomy

In-penetrating abdominal injury

Descending colon diverticula

Perianal injury

Congenital mega colon.

In gangrenous volvulus we do end colostomy

Complications

Bleeding

Infection

Prolapse

Retractions

Colostomy Hernia--parastomal hernia

Colostomy diarrhea—Acute gastroenteritis

Fecal impaction

Necrosis of the distal end

Excoriations (Skin irritation)--the more up

Psychological

Closure of colostomy

6-12 weeks if late adhesion makes surgery difficult

Remember ileostomy--95% bile so skin irritation.

NG tube
-insertion of a plastic tube through the nose past the throat into the stomach.

Indication

Dx

1.UGI bleeding

2. Aspiration of gastric fluid content

3. Identification of chest and abdomen through chest radiography

4. Radiologic contrast to GIT.

RX

1. Gastric decompression

2. Relief of symptoms and bowel rest in small bowel obstruction

3. Administration of medications

4. Feeding

5. Bowel irrigation

Contraindication

Obstructed airway

Midface trauma

Gastric bypass surgery

Comatose patient

Hx of caustic/acid ingestion or esophagus burns

Recent nasal surgery

Relative C/I--coagulation abnormalities,esophageal varices and alkaline ingestion

Types of NG

Levin tube

Salem samp tube

Miller abbot

Cantor

Size--16+age/2 French

Care

Secure the tube--keep it out of patient's vision

Meet the patients comfort needs

Insertion-@ High Fowler's position--Sniff and swallow--anesthetize

Measure-tip of the nose-ear-xiphoid

Infant till the umbilicus

Checking for placement

1 auscultation for air

2 get glass of water--bubble--Lungs??!!??

Complication

Nose bleed sinusitis and sore throat

Esophageal perforation

Pulmonary aspiration

Intracranial placement of the tube

Catheterization
--is a tube inserted into the bladder through the urethra to allow the urine in the bladder to
drain out.

Indication

• Retention of urine
• Monitor urine output
• Pre/Peri/Post surgery
• Assessment and investigation
• Rx-to install chemotherapy
• Irrigation of the bladder
• By pass an obstruction
• Mgt of incontinence
• Unconscious patient

Mode

Urethral

Suprapubic

Clean intermittent Self catheterization

Types of catheter

1. Condom catheter

2. Straight catheter

3. Foley/indwelling catheter

4. Suprapubic catheter

5.3 way catheter for CBI

Complication

• Infection
• Injury to the urethra
• Stricture

Care

Drainage bag lower than the person's bladder

Empty when full

Catheter strap(adhesion tape) loosely connected to the persons' body

Assess comfort

Characteristics and amount of urine

Closed system-bed ridden

Link system-ambulatory

Contraindication

Urethral stricture(it can’t get through) and Urethral trauma(Foley is contraindicated)

Tracheostomy
--Air way access

Types

• Metal (no cuff)--permanent, 2 lumen, not obstructed, if obstructed u can take out the inner
tube, prevent fistula,easily get distorted.
• PVC(cuffed)--prevent aspiration
Indication

• For Upper air way obstruction

-foreign Body

-tumor

-infection

-trauma

-Burn

-Laryngeal diphtheria, Tetanus

-severe head injury

-prolonged intubation (>10days)

-b/c it decreases dead space (by removing nose and oropharynx)

-tracheomalasia

-for Congenital Problems (atresia, web formation…)

• To improve respiratory function

• For respiratory failure

-pulmonary toilet in comatose

---remember the normal dead space is 150ml.

Complication

Bleed--anterior jugular vein,thyroid isthmus

Obstruction by post membranous trachea--immediate,fatal

Infection--pneumonia

Long term tracheal stenosis

Tracheoinominate fistula--massive bleeding

Subcutaneous emphysema

What is the most common cause of upper airway obstruction in eth?

-->papilloma, mass and croup

Contraindication

Age<15(in up-to-date)

Uncorrectable bleeding diathesis

Gross distortion of neck due to hematoma

Infection in the soft tissues of the neck

Cervical spine instability

Care

Humidified air

Air suction. If dry sputum may form crust

Prevent dislodgment

If obstruction is late remove, early suction

Mucolytic in our country-just saline.

Change tube (30 days)

Advantage of tracheostomy over intubation

1. Speech

2. Mobility

3. Ease of suctioning

4. Patient comfort

Intubation is good in that there is no surgical procedure required+lack of stoma complications.

ORTHO SHORT
POP
-plaster of Paris

Is hemi-hydrated calcium sulphate

Used as a splint-2 forms-plaster slab and cast

Indication

-as a splint

-to hold #

-correct deformity

-prevent pathological fracture

Complication

Pressure sore

Obstruction of circulation-compartment syndrome

Joint stiffness

Osteoporosis

Remember POP is poor choice in the treatment of acute fractures and soft tissue complications.

--padding is important.

--in forearm casts-MCP should be free(only till the proximal palmar crease, opposition should be intact)

--below knee cast-freedom of toes, build up heel+

--above knee-knee flexion at 5-20 degrees)

Traction
-applied distal to the # to create a continuous pull in the long axis of the bone

Methods

By gravity

Skin traction-only in children because it has small weight,and after surgery b/c we may not find app
instruments

Skeletal traction

Complication

Circulatory embarrassment

Nerve injury

Pin-site infection

Skin traction-limited force(not exceeding 10lbs),can cause soft tissue problems esp. in old.

Skeletal traction

-More powerful+ with greater control

-Permit pull up to 20% of the body weight

Indication

Long bone

Pelvic

Acetabular fractures

Pin inserted on the proximal tibia-insertion is from lateral to medial not to damage the peroneal nerve

If on the distal femur-medial to lateral not to damage the adductor canal.

Remember we don't put pin in these parts in children due to the fear of physeal injury

Internal fixation
Screws

Wire

Plate

Intramedullary nail

Indication

Closed methods failed

Unstable #

Pathological #

Malreduction/interposed soft tissue

Multiple trauma

Displaced intraarticular fracture.

Complication--u remove it

Infection

Non-union

Implant failure

External fixation
-fracture held by pins above and below the #,attached to external frame.

Indication

-compound #with severe soft tissue damage

-severe multiple #

-pelvis#

Complication

-damage to ST

-over distraction

-pin track infection.

Complication of fracture

1. General

Shock, fat embolism,tetanus

2 Early-compartment syndrome,neurovascular injury, infection

3. Late-delayed union, Malunion,non-union, joint stiffness.

The 6P's of compartment syndrome-pulsnessness, pallor,pain, paresthesia, poikilothermic, paralysis

Hemorrhoid
--aka lump, pile

Dilated or enlarged veins in the lower portion of the rectum or anus.

Internal and external

4 grades

-1. Only bleed

-2. Prolapse but reduce spontaneously

-3. Require replacement

-4. Permanently prolapsed.

Peak age-45-65 years

In pregnant common but is temporary

Symptoms-painless bleeding(bright red blood), itching,prolapse, pain during bowel movement

P/E-DRE,proctoscopy,prolapse.

Causes are-constipation,diarrhea,pregnancy,heavy lifting,sitting or standing for a long time

Complication

1. Blood in the enlarged veins may clot and form necrosis--painful lump

2. Iron deficiency anemia from bleeding excess

Rx
1 mild-prevent constipation,stool softeners,drinking fluid and high fiber diet

2. Painful,persistent-Sclerotherapy,tying(banding), laser therapy, surgery (hemorrhoidectomy)

Risk-bleeding, pain,anal stenosis, urinaryretention, infection.

Hernia
--protrusion of organs through an opening.

PE

-The patient should be standing and facing the examiner

-Visual inspection may reveal a loss of symmetry in the inguinal area or bulge

-Having the patient perform valsalva’s maneuver or cough may accentuate the bulge

-A fingertip is then placed in the inguinal canal; Valsalva’s maneuver is repeated

-Differentiation between indirect and direct hernias at the time of examination is not essential

Boundaries of the inguinal canal

1. ant-external oblique Apo neurosis

2.post-transversalis fascia

3.sup-conjoint muscle

4. Inf-inguinal ligament

Contents

1. Spermatic cord

2. Genital branch of genitofemoral nerve

3. Ilioinguinal nerve

4. Round ligament in females

5. Vestigialremnant of processes vaginalis

Direct hernia most common in the HasselBach triangle

Med-lateral border of rectus abdominis

Lat-inferior epigastric artery

Inf-inguinal ligament

defence mechanism of inguinal canal- its obliquity and the conjoint tendon

indirect hernia-protrusion of the intraabdominal organs through the deep ring into the inguinal canal

types

1.complete--to the bottum of the scrotum.

2.funicular--to the roof of the scrotum.

3.bubunocele--confined to the inguinal region

covering

the external spermatic fascia

thecremasteric fascia

the internal spermatic fascia

content

-omentocele--the omentum

-enterocele--the intestine

-littre's hernia--meckel's diverticulum

-richters hernia--part of the wall of the gut is involved.

--direct hernia is almost always acquired.

i.e weakness of the transversalis fascia-- in elderly,BPH,chronic cough and constipation,smoking....

femoral hernia

herniation of the intraabdominal contents through the femoral opening

mostly in females

mostly unilateral(R>L)

femoral canal is from femoral ring to the saphenous ring

content-fat fascia lymphatics

necer congenital, it can be after pregnancy or wide canal

most strangulate.

femoral canal boundaries--

ant-inguinaliigament

post-cooper ligament

lat-thin septa that sep fem canal from the fem vein

med-lacunar ligament

inguinal hernia-above and medial to the pubic tubercle

femoral hernia is below and lateral to the pubic tubercle.

incisional hernia

also K.a post op hernia is herniation through a weak scar.

factors-infection,obesity,persistent post-op cough,ascitis,wrongly placed incision,anatomic site.

CL-serosanguious discharge on the 4th postop day,infection,bulge or swelling in the r'n to the scar and
expansile impulse.

spegelian hernia
-interstiitial hernia which occurs in the spegelianfascia(9th costal cartilage to the pubic tubercle, mostly
occur at the umblicusbc its wide there.

-pregnancy,advancingage,obesity,

round soft reducible swelling below and lateral to the umblicus

--interparietal hernia.

Incisional(ventral/post op hernia-hernia that occurs through a weak scar.) common in females,

Precipitating

-infection

-anatomical site(midline-lower abdomen b/c of absence of post rectal sheath below the arcuate line)

-obesity

-faulty sutures

-ascites

-distension

-persistent post op cough

-wrongly placed incisions

Complication

-Irreducible-adhesion

-Incarcerated

-Strangulate-blood supply goes down.

Examination of neck and abdominal mass
Abdominal mass
Inspection

• Shape-scaphoid,protuberant,gen distention with flank mass(in ascites).

• Peristalsis-step ladder peristalsis indicates SBO. If gastric peristalsis-pyloric stenosis, right to left-
colonic obstruction.
• Umbilical nodule(SisterMary joseph-intraabdominal malignancy (colon,stomach,pancreas).
• Detail about the mass-site, shape,size,surface,border, movement with respiration; if mass is not
clear say there is fullness, also skin color change, pulsation,movement with
deglutition,movement with cough,if ulcer or discharge.
• Male genitalia-badokehone undescended testis.

Palpation

• Superficial-flatten the hand to detect superficial lesion(lipoma,neurofibroma,fibroma)

• Deep-flexion of knee is good. Started from quad opposite to site of pain.
Remember to palpate the renal angles.

-Tenderness, temprature,shape,size,consistency(hard,firm,soft,cystic),pulsation or thrill,fixation to

skin,mobility,growth line(in abdominal mass), Hernial examination.

-Consistency-hard-malignancy(say firm to hard). Firm-ileocecal TB,

Remember-upper border not made out in liver,spleen, renal. Lower cant in pelvic mass(like ovarian
cyst).

Do leg raising or head raising test to diff intraabdominalfrom abdominal wall swellings. When rectus
abdominis muscles contract the abdominal masses become more prominent.eg.
Fibroma,lipoma,neurofibroma.

Rememberalso a swelling which moves with respiration is always intraabdominal.

Percussion

Mildascites-dull

Splenic and liver masses are dull to percuss.

Retroperitoneal mass are resonant b/c the intestine is anterior to them.

Hydatid thrill by putting Ur three fingers and percussing the middle.

In neck mass retrosternal extension

Auscultation

Bruit,bowel sound(hernia),friction rub.

---don’t forget to look for lymph nodes(esp. left supraclavicular--due to GI lymph draining to thoracic
duct--internaljugular and subclavian vein on the left)

Time for differentials

• First neck mass

-congenital

-acquired(inflammatory,neoplastic,vascular,traumatic)

1. Congenital

Midline--Thyroglossal duct cyst

--Dermiod-A tumor consisting of displaced ectodermal structures along lines of embryonic

fusion, the wall being formed of epithelium-lined connective tissue, including skin appendages and
containing keratin, sebum, teeth, and hair.

Lateral--Brachial cleft cyst

-Anatomy--C1,hyoid

-muscular-torticollis-A contraction, often spasmodic, of the muscles of the neck, chiefly those
supplied by the spinal accessory nerve; the head is drawn to one side and usually rotated so that the
chin points to the other side--aka twisted neck.

2. Inflammatory

-Infection-bacterial (streptococcus/bartonella,TB), fungus(actinomycosis),protozoa(toxo),virus(HIV,EBV)

-Inflammatory--granulomatous (sarcoidosis),reactive.

-Salivary lesions-at the angle of mandible and ant to tragus.

Most common is benign pleomorphic adenoma of parotid,sjogren's.

--neural origin-neurofibroma,schwannoma, paraganglionoma (CBT).

--lymphoma-Hodgkin and Non-Hodgkin.

--metastatic cervical LN-head and neck primary(upper aero digestive tract),remote

primary(Virchow),malignant melanoma,skin cancer,unknown primary

Neck physical exam-Complete head and neck examination,including ear, nose, thyroid, facial nerve and
including examination of oral cavity

With mirror and by palpation Assessment for other nodes, liver, spleen Examination of skin of the
scalp/neck for lesions or scars

triangles of the neck

anterior and post by SCM.

anterior-submental,submandibular,carotid,muscular, while post-occipital and supraclavicular

submandibular-LN(NHL,TB,Acutelymphadenitis,secondaries),salivary gland(bimanually
palpable),dermoid,plungingranula

carotid triangle(SCM,digastric,omohyoid)-brachial cyst,LN swelling(cold abcess-TB(caseous

necrosis)),aneurysm of carotid artery,thyroid gland
enlargment,CBT,laryngocele,SCMtumor,Neruofibroma of vagus,lipoma,lymphangioma.

short note on brachial cyst-arises from the vestigealremenant of the 2nd

branchialpouch.it'ssoft,cystic,fluctulant and transillumination neg.

in SCM contraction test the swelling becomes less prominent.is partly covered by the SCM.

--when u feel some pulsations over a lymph node in the carotid triangle--it's carotid body tumor!!

--killian's dehiscence -herniation or protrusion of mucosa of the pharyngeal wall-through potential area
of weakness in between the two parts of the inferior constrictor muscle(oblique and horizontal)

posterior triangle--
lymphangioma,hemangioma,coldabcess,lymphoma,cervicalrib,pancoasttumor,aneurysm,it's also the
commonest area of metastasis.

hemangioma is swelling due to congenital malformation of blood vessels. it can be capillary,Venous or

arterial.it'ssoft,cystic,pulsatile swelling.
lipoma-arise from fat cells of adults.with soft consistency,

histologic types of lipoma--

1.fibrolipoma-hard

2.neurolipoma--painful

3.naevolipoma-vascular

rhabdomyosarcoma-arise from striated muscles. common site head neck and genitalia.

cystic swellings

congenital

1.dermoid cyst--

2.branchial cyst--

3.thyroglossal cyst

4.lymphangioma

5.parasitic cyst--hydatid cyst&cysticerciasis

ranula--cystic swelling arising from sublingual salivary gland and from accessory salivary glands which
are present in the floor of the mouth.

abdominal mass

differential

1.1 mass in right iliac fossa

1 parietal swelling

-parietal wall abcess in females-ovarian cyst,fibroid of the

uterus

-desmoid tumor

2.intra abdominal from abnormal stru-unascendedkideny,undescended

testis

A.from normal stru

-appendicular mass

-appendicular abcess

-ileocecal TB

-carcinoma of cecum

-intucesseption

-amoeboma

-actinomycosis

-lymph node mass

-retroperitoneal sarcoma

-aneurysm(iliac artery)

-ileopsoasabcess

1.2 mass in the umblical region

a. arising from the lymph nodes

-metastasis or secondaries

-lymphoma

-TB--para-aortic lymph nodes

b.retroperitoneal sarcoma

c.carcinoma of body of pancreas-cystadenocarcinoma

d.carcinoma of the transverse colon-vertical mobility

cystic masses on the abdomen

1.pseudocyst of the pancreas

2.hydatid cyst of the liver

3 mesenteric cyst-moves at right angles to the direction of mesentry.

-- types-chylolymphatic cyst and enterogenous cyst.

4.hydronephrosis--with bulge in the loin(bimanually palpable)

5.ovarian cyst-

6.encystedascitis

7.AAA-expansile pulsation in hypertensive elderly males.

8.rare cyst--omentalcyst,large mucocele of the bladder.

1.3 mass in the epigastrium

-:-consider mass arising from the liver and stomach first.

a.mass arising from abdominal wall-lipoma,neurofibroma,desmoid tumor. rem hernia is not a mass.

b,intraperitoneal mass

from liver

-hepatoma

-hydatid cyst

-simple cyst

from stomach

-carcinoma of the stomach-hard irregular moves with respiration

c. retroperitoneal mass

-pseudopancreatic cyst

-pancreatic ca

-abdominal aortic aneurysm

1.4 mass in the right hypochondrium

a.parietal-on head raising test the mass becomes more prominent

-lipoma,neurofibroma(pain and pigmentation)

-if hard-secondary deposit in the skin or subcut tissue

-cold abcess

b. intra abdominal

-liver-secondaries,hepatoma,polycystic disease of the liver,hydatidcyst,cirrhosis of

liver,lymphoma,congenitalriedel lobe,

-GB mass-carcinoma of bladder,back pressure due to obst(papillary ca),mucocele(non

tender),empyema(very tender),acute cholecystitis(tender mass).

-colon-carcinoma of the hepatic flexure,largeileocecal TB.

-renal and suprarenal mass.

char of liver mass-location in the hypochondrium and epigastrium,moves with

respiration,dullness,fingerinsuniation below costal margin not possible.
Varicose vein
-Varicosity is a penalty for verticality against gravity.

-are tortuous, dilated,elongated superficial veins of the limb.

--example-long saphenous,short saphenous,hemorrhoid, varicocele (abnormaldilatation of veins of the

spermatic cord), vulva and ovarian varix.

--primary-congenital weakness of vein wall,congenital abscess of the valves,klippel trenuany

syndrome(valvless syndrome).

--secondary-pregnancy n pelvic tumor(proximal obstruction to the blood flow),pill,AV fistula, DVT and
RTA can result in destruction of the valves.

--anatomy-superficial,perforators and deep system of veins. All have valves.

--long saphenous vein starts from tributaries of dorsal venous arch to SF junction (1 and half inches
lateral and below the pubic tubercle),it has 15-20 valves,

--perforators are veins which connect long saphenous vein with deep system of veins, they perforate the
deep fascia,5 in medial side of lower limb.

--u have to know the 3 perforators-Dodd (thigh), Boyd (knee),cockett(ankle)...Imp for multiple
tourniquet test.

--deep venous system comprises the femoral,popliteal, and the venae commutatesaccompanying the
ant and post Tibial and peroneal arteries.

--it's the powerful calf muscle contraction that returns the blood to the heart.

--Blood is returned to the heart via-

1. Calf muscle

2. Competent valves

3. via-a-Trego-pressure from the arterial pulse, also negative intrathoracic pressure

Remember IVC and common iliac vein have no valves.

Symptoms

-dilated veins on the leg

-Dragging pain on the leg--in varicose it's relieved on exercise, while in arterial disease pain get worse on
exercise.

-DVT-sudden pain, fever,edema of the ankle.

-also ulceration,eczema,dermatitis,bleeding.

Signs

Inspection(on standing position)

Dilated vein-medial aspect of the leg

Saphena varix-single dilated varix at the SF junction.

Ankle flare is a group of veins near the medial malleolus

Complications such as ulceration,bleeding,eczema and dermatitis may be present

Palpation

1. Cough impulse test(Morrissey test)

2. Trendelberg test

3. Multiple tourniquet test

4. Perth's test

Answer

1. Which system is involved?MSV or LSV

2. Is SF junction incompetent- trendelberg 1 positive?

3. Is there perforator incompetence- trendelberg 2 positive

4. Which groups of perforators are incompetent-multiple tourniquet test

5. Is there DVT?-Perth’s test positive

6. Is there any abdominal mass--pelvic tumors

7. Any complications-eczema,dermatitis,ulcer

8.Is it unilateral or bilateral?

Investigations

1. Doppler ultrasound

2. Duplex ultrasound imaging--images of the veins+ flow+origin+can detect a thrombus

3. Venography-

4. Plethysmography--volume changes in the leg