MODIFIED BY SIDNEY NIZA

BURNS
(a) Estimate %
9 (i)..Rule of 9 in adults
Head – 9%
9 9
18 x 2 = 36 Arm- 9%
Trunk- 18x2= 36%
1
Leg – 18%
Perineum- 1%
18 18

28 (ii)..Rule of 7 in children
7 7
Head – 28%
28

Arm- 7%
2
Trunk – 28%
14 14 Perineum- 2%
Leg- 14%

(iii)..Rule of palms
Adults 1%
Children 1%
(iv)..Lund & Browder Chart
The most accurate
(b) When you are on a call, the Patient comes with burns. What 3 things would you tell the
consultant on phone about the patient? E..C..T
(1) The % ESTIMATE of the burns: as this will help in the Management of the patient ,
whether to admit or not and expected complications
(2) What CAUSED the burns
 This will help tell the depth of the burns
-Domestic burns are usually superficial
-Industrial burns are usually deep
(3) What TIME did the Patient get burnt
This will help in fluid replacement therapy
Methods for fluid replacements
(i) Barclay & Muir,
Body wt x TBSA%x0.5 = Xmls
-1st give 4hrly in 12hrs X(4hr), X(4hr), X(4hr)
-Next- 6hrly in 12hrs X(6hr), X(6hr)
-Then – 12hrly in 24hrs X(12hr), X(12hr)
Note for Barclay & Muir add maintenance fluid i.e 35mls/kg/day
(ii) Parkland,
Body wt x TBSA% x 4mls= X mls
-1st give Xmls in the 1st 8hrs from time of burnt
-2nd give Xmls in the next 16hrs
Criteria for admission
-TBSA >10%- Admit for CHILDREN
-TBSA <5% in special areas- Admit
(Face, Hands, perineum, joint)
-TBSA >20% Admit for ADULTS, also in special areas, do admit
(a) What are the complication of burns
(They are early and late complications)
EARLY
(i) Airway obstruction due to inhalation burns
(ii) Breathing difficulties as a result of respiratory distress due to eschar around the
chest
(iii) Hypovolaemia due to fluid loss as a result of increased capillary permeability
leading to renal failure.
(iv) Hypothermia As a result of loss of thermoregulatory loss of the skin due to
damage
 (v) Hypoxia due to destruction of red blood cells. Thermal injury cause coagulative
necross to the epidermis and underlying tissue
(vi) Release of inflammatory mediator to produce vasoconstriction and vasodilatation,
capillary permeability causing edema locally and distant organs
(vii) Fluid and electrolyte imbalance due to dehydration, hypernatraemia,
hypokalaemia, hypocalcaemia
(viii) Hyperglycemia, due to hypercatabolism and mobilization of glucose as a result of
release of stress hormones
(ix) Shock
- Due to systemic inflammatory response syndrome (SIRS)
- Or due to an inflammatory response causing release of cytokines which leads to
vasodilatation, vasoconstriction in burnt areas leading to toxic shock
(b) Intermediate complication
(i) Wound infection
(ii) Loss of protective’s function of the skin
(iii) Septicemia
(iv) Anemia + malnutrition due to hemocoagulation
(v) Stress ulcers( curling ulcers)
(vi) Paralytic ileus due to electrolyte imbalance
(vii) Compartment syndrome due to eschar
(viii) Poor healing, Ankylosing (joint stuffiness)
(ix) Renal failure
(x) Hypoprotenemia
(xi) Ectropion- retraction of eyelid
(xii) Amputation
LATE
(i) Contractures
(ii) Hypertrophic scar or keloids
(iii) Marjolins ulcers (malignant)
(iv) Nerve compression
(v) Psychological effects- cosmetic effect
(c) Investigations- FBC, Hct, Hb, Swab Pus
(d) Management
(i) Initial
Resuscitation
A, B, C, D, E
Fluids
Catheterize pt
Wash burnt surface
(ii) Intermediate
Directed to the wound (open/closed)
Daily wound cleaning
Silver sulphadiazine??? Resistance is developing
Wet soaks
Sloughectomy
Escharotomy
(iii) Long term
Monitoring
 Fluid replacement
 Urine output
 Pulse
 Mental status
 Edema
Wound healing
 Colour
 Pus
 Slough
 Nutritional status
 Weight
 Skin fold thickness
 Fluid/ blood
If < 10% = ORS / oral fluid
 If >10% = IVF (child) & adults > 15% IVF
If deep >20% = give blood
20%- - 70mls/KG
Unit 450mls/Kg
For each of burn give 20% of exposed blood volume for 30 min to an hour.
 Give blood on 2nd day
(i) In a child with full thickness burns of 10% or more
(ii) Adult with full thickness burns of 20% or more
Amount of blood to give
% TBSA x Wt X 80mls/Kg
100%
Treating burns
(1) Open method
Clean & leave open
Topical cream
(2) Closed method
Clean & dress wound for up to 10 days
(3) Mixed
Clean and apply wet soaks
(4) Other methods
(i) Tangential incision
(ii) Early skin grafting done on 3-4 days of blood transfusion,
(iii) Physiological dressing
Pig skin
Amniotic membranes
These release well to ---- healing
In deep burns- wait for 3 days for granulation to form then do skin graft
DDX
- Necrotising fascitis
 For every % burn deficit of water is 4mls
 There is always insensible loss
Functions of the skin
1. Thermoregulations
2. Water electrolye balance
3. Mechanical barrier
4. Cosmetic
5. Faciliatates locomotion
6. Protects against injury by having pain receptor

FRACTURES
(1) How do you classify #’s
(a) Etiologically
Traumatic #s- Direct/ indirect evidence
Pathological#s- Trival evidence/spontaneous
Stress/ fatigue #s
(b) Clinically
Simple or closed
Compound or open
Complicated
(c) Radiologically
Transverse
Oblique
Spiral
Comminuted
Segmental
Butterfly
Avulsion/ distraction
Greenstick
Impacted
Compression
(d) Anatomical site. (Falls under radiological classification)
Diaphysis
 Metaphysis
Epiphysis
(2) What are the stages of # healing
(i) Hematoma formation (immediate response)
(ii) Subperiosteal and endosteal cellular proliferation (inflammatory response) esp.
osteoblasts
(iii) Callus formation (chord material i.e calcium and iron)- 2-4 weeks (repair
response)
(iv) Consolidation
(v) Remodeling

Indications for traction

1. # femur
2. # Tibia
3. Acetabular injury
4. Septic arthritis

SKELETAL TRACTION
1. What can you see?
(i) A patient lying supine in bed with leg abducted
(ii) He/ She has fracture femur
(iii) He/ She is on skeletal traction with weights
(iv) Bed is raised with hard board

2. What are the complications of this Mx?

(i) Early (during insertion) complication
-Damage to common peroneal nerve
-Foot drop
 -Fat embolism
-# of Tibia
-Soft tissue injury
(ii) Late (during Traction) complication
-Decubitus ulcers (Bed sores)
-Pin site infection- osteomyelitis
-Pin may become loose
-Osteoporosis- bone desorption to bed bound
-Over traction – causing non- union
-Malunion
-Delayed union
-Joint stiffness (ankylosis)
-Muscle disuse atrophy
-DVT & hypostatic pneumonia
-Contractures

3. How can you prevent such complications?

Some of these complications can be prevented by Careful pin insertion and Perkins exercise.
 Careful pin insertion
Trans-tibial pin should be inserted 2 cm distal and 2cm lateral to the tibial
tuberosity __ this avoids injury to the common peroneal nerve
(i) The Pin should be inserted from lateral to medial so as to avoid common peroneal
nerve injury
(ii) Can also be pushed into calcaneum or distal femur
Apply 1/7 of body wt(adults) and for each kg of wt raise foot end by 14cm
This prevents over- traction & hence non- unions
• Perkins exercise helps to
(i) -Promote healing
-Controlled compression of bone ends encourages union
-Prevents muscle atrophy – exercise maintain the tone of quadriceps
-Prevents knees joint stiffness
-Increases blood supply
 -Prevents DVT, Decubitus ulcers and hypostatic pneumonia
-Encourages positive psychological effect on pt
Pins – Denham pin and Steinman pin
External fixators
Do daily inspection of pin site for possible infection

4. What are the indications for skeletal traction?

In the middle aged >18yrs (not young ones or elderly) pts with the following
 Shaft of femur #s – femur
 Hip dislocation after reduction
 Intertrochanteric #s
 Some supracondylar #s
 Septic arthritis in hip joint ----- denham pin pelvic

5. What is perkings traction?

Is a type of skeletal traction with patient on perkins bed and doing perkins
exercises
State of the leg during perkins traction
 Abducted = proximal femur #
 Straight = all other femur #

Gallow’s traction
When is it used and in who?
Used in shaft of femur #s in children <3 years and weighing < 15kg
What are the other indications?
(a) orthopedic
i. Hip dislocation
ii. Pelvis #s
iii. Disk prolapse
iv. Osteomyelitis
v. Septic arthritis
Non- orthopedic
 i. Perineal or gluteal burn
ii. Perineal or gluteal abscesses
iii. Hernias- obturator and umbilical
iv. Rectal prolapse
v. Contractures
vi. Scrotal swelling – congenital hydroceles
vii. Non-thrombosed hemorrhoids
viii. Spinal bifida
Complications
i. Skin avulsion
ii. Allergic rxn to strapping
iii. Compartment syndrome
iv. Joint stiffness
v. Gangrene or ischemia to distal limb
vi. Hypostatic pneumonia

Signs due to incorrect application e.g Hand can’t swipe under bullocks

ADVANTAGES
-Easy to nurse
-Prevent decubitus ulcers
-Children’s don’t find it distressing

Skins traction
1/10 patients weight
Indications
Extreme of ages
-Children between 3 to 18 years
-Old people- fragile bones
-Those reacting to pin
-Fixed flexion deformity
-Shaft of femur #s
 -Interctrochanteric #s
-Upper femoral epiphyseal separation
-An unstable hip after reduction of a discoloration
Types
(1) Gallows
(2) Lateral
(3) Boot
(4) Natural
(5) Dunlop
Complications
-Compartment syndrome
-Skin avulsion
-Allergic reaction to strapping
-Gangrene or ishaemia distal to limb
-Joint stiffness
- Hypostatic pneumonia
Descriptions of skeletal traction
-Patient lying/sitting in bed
-Foot end elevated/ not
-Pin thru tibia +/- infection
-Bearing weights
- +/- a Perkings bed

URINARY CATHETER
What is this?
It’s a 2-way Foley’s urinary catheter or
It’s a 3- way Foley’s urinary catheter
Note This applies to 2 different types of urinary catheter
What are the indications?
(i) Therapeutic
-Urine retention
 -Urine incontinence
(3) Diagnostic
-Bladder rupture
-Renal failure
(4) Pre- operative
-For monitoring urine output during operation
(5) Unconscious patients
(6) Spinal injury for
-Monitoring purposes of urine output
-Abdominal pressures
What are the Complications?
(i) Early complications
-Traumatic injury to urethra
-Bleeding by passing urine
(ii) Late complications
-Infections- UTI
-Paraphimosis
-Urethral strictures
-Incontinence (urine)
-Blockage
-Failure of balloon to deflate
-Excursion of catheter if suprapubic

Indications for Supra-pubic cystostomy

(i) Retention of urine when transurethral catheterization has failed
(ii) Rupture of the urethra due to trauma
(iii) Urethral cutaneous fistula
(iv) Perurethral abscess
(v) Extravasations of urine
(vi) Chronic retention in neurogenic bladder
PLASTER OF PARIS (POP)
(a) What is it?
Plaster of Paris cast
(b) What is it made up of?
Hydrated calcium sulphate (gypsum)
(c) What else is used elsewhere?
Fiber glass
(d) Indications for POP
-Fractures
-Dislocations
-Correction of limb deformity e.g. congenital malformation
-Prevention of pathological fractures in osteomyelitis
(e) Complication of POP
i. Early complications
-Compartment syndrome
-Burns on applying
-Allergy to POP
ii. Late complication
-Muscle disuse atrophy
-Joint stiffness (ankylosing)
-Nerve compression
-Mal-union
-Volkmann’s contracture

ICD (INTERCOSTAL DRAINAGE)

(a) What are the indications?
(i) Pleural effusion
(ii) Haemothorax
(iii) Chylothorax
(iv) Empyema thoracis
 (v) Pneumothorax
(vi) Malignant pleural effusion
(vii) Recurrent pleural effusion
(viii) Complicated parapneumonic pleural effusion
(ix) In any hypoventilated patient
(x) Tension pneumothorax
(xi) Larhe pneumatharax 2nd to spontaneous pneumothorax
(xii) Persistent recurrent pneumothorax

i. Post-operations
a. Thoracotomy
b. Oesophagectomy
c. Cardiac surgery
(i) Surprise content
-Bowel contents
-Gastric content
(b) What are the complications
Early complications
-Misplacement
-Subcutaneous
-Intraparenchymal
-Dissection of extra-pleural plane

(i) Injury to organs and other structures

-Diaphragm causes injury to the liver or spleen
-Parenchymal or hillar injuries
-Injury to the heart
-Phrenic never injury
-Neurovascular bundle injury
-Esophageal perforation- hemorrhage
(ii) Contralateral pneumothorax
Intermediate complications
-Surgical emphysema
-Re- expresanic pulmonary oedema
-Tube blockage
-Infection along the chest tube
-Pain
Late complications
-Empyema
-Abscess
-Fistula- formation
Bottles
(i) Under water vaccum
(ii) Under water seal
(iii) One way value apparatus

6. How do you tell its functional

-By moving menisci

-Ask patient to cough and check out bubbles in the bottle

7. Dow do you transfer the patient?

i. Clump the tube with an artery forcep
ii. Patient should carry it not raised above insertion
iii. When you reach the place, put it down and unclump

AMPUTATIONS
(a) What are the indications?
4 D’s
Indicated when part of the limbs is dead, deadly or dangerous, dead loss or damn
nuisance
(i) Dead (Vitality of part of limb is destroyed)
 The limb may be dead when Arterial occlusion or Stenosis causes tissue infarction
with putrefaction of macroscopic portion of tissue (gangrene) i.e gangrene due to arterial
occlusion or stenosis wet/dry gangrene.
(a) major vessels
-atherosclerotic
-embolic occlusions
(b) small vessel
-diabetes
-Buergers disease
-Raynauds disease
-Egotism
(ii) Deadly/ Dangerous (life Saving)
Limb may be deadly or dangerous
(a) When wet gangrene occurs with its accompanying putrefaction infection
(c) If infection spreads to surround viable tissue e.g. Necrotisizing fasccitis
(d) Patients with Cellulitis e.g. severe toxemia overwhelming systemic infection can
occur
(e) Gas gangrene
(f) Neoplasm like osteosarcoma, extensive melanoma(maligna)
(g) Arteriovenous fistula
Life of the limb is threatened by spread of a local condition
(iii) Dead loss
(a) Severe laceration, # with partial amputation due to trauma or burns
(b) Severe contracture or paralysis e.g. poliomyelitis
(c) Severe rest pain without gangrene in patient with an Ischaemia
(iv) Damn nuisance (deformed/ neuropathy)
a. Polydactyl
b. Severely impaired gait

SUMMARY for Amputation Indications

(a) Dead: vascular events
 -Gangrene
-Large vessels (Atherosclerosis, embolus)
-Small vessels (DM, SCD, Buergers or Reynaud)
(b) Deadly (Dangerous) life saving
-Spreading gangrene e.g. Wet & Gas gangrene
-Necrotizing fasciitis
-Spreading cellulitis
-Neoplasm
-Osteosarcoma
-Maligna melanoma
-Extensive Arteriovenous fistula
-Extensive tissue necrosis e.g. Patients with trauma
- Uncontrolled sepsis (diabetic foot) systemic infection
(d) Dead loss
-Severe trauma
-Severe contracture or paralysis
-Severe rest pain
(e) Damn nuisance
Polydacty
Impaired guit

1. What are the complications?

Early complications
(a) Associated with spinal anesthesia
-Hypotension
-High block- failure to Breath because affects phrenic nerve
-Hematoma- compression of nerve- paralysis
-Infection introduction
(b) Surgical complications
Hemorrhage (reactionary)
Hematoma
Intermediate
-Wound infection usually associated with hematoma
-Abscess formation
-Wound dehiscence
-Gas gangrene in mid-thigh stump due to fecal contamination
-Gangrene of the flaps due to ischemia
-Higher amputation
-Deep vein thrombosis (DVT)
-Pulmonary embolism
-Psychological effect – Like depression
Late complication
-Pain due to unresolved infection (sinus, osteomyelitis, and sequestrum)
-A bone spur
-A scar adherent to bone
-Amputation neuroma stump
-Phantom limb pain
-Ulceration of the stump due to pressure effects of prosthesis or increased
ischemia
2. How do you rehabilitate the patient
-Exercising proximal stump
-Mode stump for prosthesis
-Sociological care
3. Examination the limb
Always compare the two limbs
i. Ask
ii. Look (inspection)
iii. Feel (palpation)
iv. Move
Muscle power (MRC Grading)
Mo: No movement
M1: Flicker of movement only
M2: Movements with gravity eliminated
M3: Movements against gravity
M4: Movements against resistance
M5: Normal power

4. Gangrenous Toe Specimen

(a) Describe what you can see
(b) Definition
Gangrene implies death, often with putrefaction of macroscopic portions of
tissue
Give the varieties and etiology
-2˚ to arterial obstruction
-Thrombosis
-Embolus
-Arteries with neuropathy in DM
-Buerger’s disease
-Reynaud’s
-Arterial infection- drugs
Infective
-Abscesses
-Gas gangrene
-Fournier gangrene
Traumatic
-Direct injury (knife, bullet)
-Crashing injury (compression)
-Physical- pressure sores, burns
-Heat, irradiation, electrical
-Constructed grove of strangulated bowel
Venous
-Venous gangrene
Clinical features
 Look for
-Arterial pulsation
-Venous return
-Capillary filling
-Sensation
-Warmth
-Function
-Color changes: dark brown due to Hb disintegration and iron sulphides formation
Clinical types
Dry gangrene
a) Tissue desiccation by gradual slowing of the blood stream
b) Due to atherosclerotic occlusion of arteries
c) Affected part is
-dry
-Wrinkled
-Discolored from Hb disintegration
-Greasy to touch
Wet gangrene
a) Venous and arterial obstruction present
b) When artery is suddenly occluded e.g. ligature or embolus and in
diabetes
c) Infection and putrefaction are always present
d) Affected part becomes swollen and discolored

BREAST
Breast lump
History taking
(a) Demographic Hx…NASEDORAM(Name, Age, Sex, Ethnic group, Date, Occupation,
Religion, Address, Marital status)
(b) P/C
(c) Hx of P/C – lump/ ulcer-(7things)
- When it was 1st noticed?
 - What brought it to the patients’ notice?
- What symptoms does it cause e.g. pain, nipple discharge?
- Has it changed? How much has it changed since it was 1st noticed?
- Has it ever disappeared or healed?
- Does the patient have any other lumps/ulcers?
- What does the patient think caused it?
Predisposing factors
1) Age of the patient (> 40yrs)
2) Has she ever had it b4? (+ve Hx or recurrence)
3) Parity ( Null parity)
4) Did she breast feed all children & for how long ( lack of
breastfeeding)
5) When was the last time to breast feed
6) At what age did she have her 1st pregnancy or 1st child
7) Age at menarche? Early?
8) Pre or post menopause- late menopause
9) If pre-menopausal- what is the menstrual pattern ( regularity,
duration, quantity
10) What breast symptoms are there after the menstrual cycle
11) Medication i.e HRT (Hormonal replacement therapy)
12) Hx of alcohol or smoking
13) Combined oral contraceptive
14) Family Hx
15) Obesity
(d) Medical Hx
-Hx breast ca.
-Hx ca. colon
-Hx ca. ovary
-Hx radiation exposure
Metastatic symptoms
-Back pain (bone mets)
 -Dyspnoea (RS mets)
-Jaundice or Abdominal distension (liver mets)
-Hard nodules on skin (MSS mets)
-Swelling of arm (s) (axillary lymphadenopathy)
Examination of the breast
 Inspection
-Symmetry
-Site- position of lump
-Skin – color discoloration
-Puckering
-Peau’ de orange
-Ulceration
-Nipple discharge and appearance
-Edgar- Montgomery tubercle
-Calor
-Edema
Nipple (7 D’s)
-Depression
-Discharge
-Discoloration
-Duplication
-Destroyed
-Deviated
-Distracted
Ask patient to hold the waist
-Gross lumps
-Phyllodes
-Distended veins
Ask patient to raise hands
-Look for skin tethering and nipple retraction
 Palpation
 -Flat of finger
-Begin with normal side
-Palpate for
i. Tenderness
ii. Temperature
If there is a lump or mass; check
-Site
-Size
-Shape
-Consistence
-Is it fixed or freely mobile?
-Palpate axillary lymph nodes and or supraclavicular
Ask if they have a lump elsewhere also
G/E
-Arms for swelling
-P/A – -Hepatomegally
-Ascitis
-PVE-Nodules in pouch of Douglas
-Lumbar spine- hit back for tenderness and restricted movement.
Findings that suggest cancer breast
-Hard, non-tender, irregular lump in UOQ
-Tethering/fixation of the lump
-Palpable axillary LN’s
STAGING
Manchester staging
Stage1: A mobile lump in the breast
No palpable axillary nodes
No tethering or fixation
Stage 2: A mobile lump in the breast
Palpable mobile axillary nodes
Tethering & fixation
Stages 3: A fixed lump in the breast
Palpable axillary LN
Fixed & tethering
Stage 4: Distant metastases
Fixed axillary nodes
Palpable supra-clavicular node
DDx
(a) Painless lump
-Carcinoma
-Cyst
-Fat necrosis
-Momdor’s disease
-Fibroadenoma
-Lipoma of breast (intra-ductal papilloma)
-Phylloides tumor (Brodie;s tumour)
-Does not metastasize
Discharge from the Nipple
-Ductal ectasia
International TNM classification
Tumor
To- No palpable tumor
T1: Tumor 2cm, not fixed /tethering
T2- Tumor, 2.5 cm, nipple retraction or tethering
T3: 5cm (5-10cm) infiltration or ulceration
T4: Any size invading skin or chest wall (10cm), Ulceration

Node
No: - No palpable ALN’s
N1:- Mobile palpable ALN’s
N2:- Fixed palpable ALN
N3- Palpable supraclavicular LNs
Distant Metastasis
Mo: No distant metastasis
M1: Metastasis present

Classification of Ca. Breast

WHO classifications
1) Epithelial
2) Invasive
3) Ductal
4) Lobula
5) Non-invasive

Mixed CT
Miscellaneous
R4 of Ca Breast
1˚aim is to remove tumor
Medical
Surgical
Chemo or radiotherapy brachy or tele
Surgical
a. Lumpectomy
b. Quadratectromy
c. Semi- mastectomy
d. Simple mastectomy chemo
e. Radical mastectomy
f. Modified mastectomy
g. Modified radical mastectomy
Assessment
Triple assessment
i. Clinical – Hx + exam
 ii. Radiological/ imaging, Mammogram, bone scan/Ls X R – metastasis – brain, chest,
bones Solid + cysts
iii. Cytology- FNA cytology
Core needle biopsy

NGT tubes
(a) Indications
• Feeding in absence of swallow reflex of unconscious pts
• Decompression of GIT in paralytic ileus
• Gastric lavage
• Analysis of stomach content
• Physical injury to oral cavity
• Inflammation or ca oesophagus
• Premature babies to prevent aspiration
(b) Complications
(i) Early (during) insertion
-Mucosal damage
-Laryngo-tracheal obstruction?
-Oesophageal or gastric perforation
-Bleeding
-Accidental nasotracheal intubation
-Accidental transbrochial perforation
-Nausea and vomiting
During use/ late complications
-Aspiration pneumonia
-Gastro- irritations
-Pharyngitis/oeseophagitis
-Vocal cord paralysis
-Stenosis or structure of easophogus
-Ca escophgas
-Infection
-Loss of electrolytes
 -Necrosis:- retro- or nasopharynyeal
Endo-tracheal intubation
Indication
-Facilitate artificial ventilation
-Facilitate surgery around face or neck
-Protect lungs if risk of pulmonary aspiration
-Cardiac arrest
-Serious HI
-Inhalational burns
Complications
Early(during insertion)
-Accidental esophageal intubation leads to loss of airway control
-Accidental intubation of main bronchus or RT
-Trauma to larynx, tracheal or teeth
-Aspiration of vomitus during intubation
-Laryngo- tracheal perforation leading to bleeding
Late (during use)
-Disconnection
-Blockage of tube
-Infection
-Delayed tracheal stenosis due to prolonged intubation

WIDE BORE CANULA 14G

Indications
-Shock
-Blood Transfusion (BT)
-IVF
-IV drugs
-Parenteral nutrition
Commonest vein used
-Cephalic vein
Complications
-Trauma to skin
-Bleeding from the site
-Thrombosis
-Air embolism
-Damage to the nearby nerve
-Infection
-Vein (phlebitis)

Specimen bottle
a. Green (Dr Kaile i.e for Biochemical tests)
-U/E, RFTs, LFTs
- Chemical Lithium and Heparin
b. Grey - Blood sugar, ESF
- Chemical Sodium flourate
c. Red - Cross match, serology, HIV test, grouping
-Chemical Nothing
d. Purple (Dr Kolyorova Hematological tests)
- FBC, DC, ESR, Sicklin test
- Chemical EDTA
e. Blue - Prothrombin, LFTs
- Potassium citrate

Cannula

Colour size FXN

Brown 14G Rapid IVF in emergency,Shock, BT
Grey 16 G rapid IVF in emergency
White 17 G IVF, drugs
Green 18G “
Pink 20G IV drugs, IVF and slow BT
Blue 22G small fragile vein, IVF
Yellow 24G Pediatrics’

BLOOD TRANSFUSION

(a) Giving set?

(b) Indications

© Complications

i. CCF
ii. Air embolism
iii. BT RXN
-Incompartibility
-Simple pyrexia RXNs
-Allergic RXN
-Immunological sensitization
-Sensitization to leucocytes/platelets
iv. Infections due to
-Serum hepatitis
-Site of cannula- bacteria
-HIV
-Malaria
Normal Saline
i. What type of fluid
Isotonic Solution
ii. Indications

iii. Osmolarity value

iv. complications

Bone (Jar) specimen

What is it?
Dead bone – sequestrum
New bone – involucrum
Drilling points (cloaca)
In consistence with chronic osteomyelitis

Clinical presentation
-Fever
-Pain
-Swelling
-Sinus
-Pseudo paralysis

Colostomy
Examine the Abd and say what you see
i. Inspection
Seeing a stoma in
Epigastric or RIF or LIF
 It is covered by a bag: i.e in colostomy.......................
-In a bag there is
-Feacolant materials which is
-Formed, semisolid
-Watery or urine
It is not covered by a bag
-The mucosal lining looks healthy/ unhealthy
-There is a sprout or flush and skin
-It has one opening (end) 2 opening e.t.c
The rest of the abd shows
-A scar
-Midline/transverse incision
-Burnt abd not
-Wound dehiscence or and mass
-Also other drains or healed
-Stoma scar or..................................
Palpation –if allowed

What is it?
-A colostomy
- Ileostomy
What are the indications?

Congenital/ Acquired

Congenital
-Imperforate anus
-Hirchsprung disease
-Anal atresia
-Ano-rectal agenesis
-Anal stenosis
Acquired
i. Ischaemic bowed disease(IBD)/ gangrene due to strangulation
ii. Penetrating trauma to the bowel
iii. Instestinal obstruction e.g sigmoid vovulus
iv. Rectovaginal fistula prior to repair
v. Tumours
-Anal ca
-Rectal ca
vi. Protecting an anastomosis of gut resection
vii. Stenosis or stricture
Other indications
i. Bleeding
-Percutanous endoscopic gastrostomy

ii. Lavage- appendectomy

iii. Decompression
iv. Diversion
-Urinary
-Protect distal bowel anastostomy
v. Exteriorization
Complications
i. Early complications
-RXN to anastomosis
-Hemorrhage
-Stoma diarrhea- water
-Electrolyte imbalance
-Skin exconation
-Ischemic gangrene- necrosis
ii. Late complications
-Prolapsed- intussusceptions, volvulus or strangulation
-stenosis--- obstruction or constipation
 -Retraction---- peritonitis at site
-Fistula
-Parastomal hernia
-Incisional hernia later
-Nutritional disorders
-Stone formation i.e gall and renal stone
-Residual disease
-Parastoma fistula
-psychosexual problems
-Impotence in mena
-loss of libido
Types
Temporary
-Loop
-Spectacle
-Double barrel
-Hartman
Permanent
-End colostomy
Appendix specimen
(a) Describe
-Perforation in a blind ended muscular tube
(b) What is it?
-Perforation appendix
(c) What are the Signs & Symptoms?

( i) Symptoms
a. Anorexia- if good appetite not appenditis
b. Malaise
c. Fever
d. Mild diarrhea
 e. Abd – pain starts centrally and localize RIF
f. Abdominal pain caused by coughing and moving
g. Nausea and reflex vomiting
iii. Signs
-Afebrile
-Tachycardia
-Abodomen tenderness- maxima at Mcburney’s patient
-Pointing sign
-Psoas sign
-Obturator sign
-Rovsing sign
-Shake sign
Types
i. Mucosa
ii. Inflammatory
iii. Oedematous
iv. Necrotic
v. Phlegmonous
(c) Investigations
Many are normal and are non diagnostic
-FBC
-U/S
-CT scan
(d) Complications
(i) Perforation (peritonism) – local or generalized peritonitis
(ii) R/F appendicular Mass, (appendix + densely adherent cecum and omentum)
(iii)R/F abscess
(iv) Pelvic abscess
DDs
-Meckel’s diverticulitis
-Ovarian cyst/ Torsion of ovaraian cyst
 -Renal colic
-Crohn’s disease
-Pancreatitis’
-Ectopic pregnancy
-Oophoritis
-Salpingitis
-Cholecystitis
-Sigmoid volvulus
-Ovarian abscess
-Intussusception
-Psoas abscess
-Ruptured PUD
-Caecal tumours
-Caecal diverticulitis
-Rectus shealth harmatoma
Complications of Fractures
Immediate
-Haemorrhage – may – shock
Internal or external
E.g. #femur 2lts(1 -3lts) blood loss
# Tibia = ½ lts(0.1 – 0.9lts)
# Pelvis 5-8lts
-Nerve or vascular injury
-Other organ damage e.g urethra
-Fat embolism
-Compartment syndrome
-Tendon injury
-Injury to viscera
Intermediate
-Avascular necrosis
-Joint stiffness
 -Volkmann Ischemic contractors
-Osteomyelitis
-Thrombo-embolism
-Septic wound/ septecemia in compound #s
-Amputation
Late
-Mal-union
-Non union/delayed union
-Late neuropathies due to mal-union e.g valgus deformity of elbow – an
ulcer
-Osteoarthritis- common particular #s esp. displaced
-Joint instability/ deformity
-Post traumatic atrophy
-Osteochiorosis???- harden brittle
-Shortening
-Intra- articular and peri- articular adhesion
-Hypostatic pneumonia
-DVT
-Pressure sores
Causes of non- union
-Local (infection) sepsis
-Interposition of soft tissue
-Inadequate or poor local blood supply e.g # neck of femur
-Inadequate immobilization
-Bone loss or crushing
-Over traction – loss of apposition between
-Iatrogenic- wrong open reduction and internal fixation
-Local malignancy- bone destruction
-Severe communication
-Extensive opening
-Dissolution of # hematoma by synovial fluid bathing the joint
General systemic causes
-Anemia
-Poor general health
-Mineral and vitamin deficiency especially calcium and vitamins D
-Metabolic disease e.g. uncontrolled DM
-Hyperparathyroidism, acidosis help destroy the bone
-Lack of androgen/oestrogen hormones
Classification of special #S
(1) Gustilo- Anderson classification of open tibia #s
-Type 1: wound < 1 cm & not contaminated
-Type 2: wound of 1-10 cm + contaminated
-Type 3: wound > 10cm plus
3A-No. periosteal damage but contaminated
3B-With periosteal strapping
3C-Neurovascular damage
Salter- Harris classification of #s involving epiphyseal plate
 • Type I injury: complete separation at physis without damage to metaphysis or
epiphysis.
• Type II injury: The most common, triangular fragment of metaphysis attached to
displaced epiphysis.
• Type III injury: involves articular surface with separation of an epiphyseal
fragment.
• Type IV injury: fracture of articular surface with extension into metaphysis.
• Type V injury: compression fracture involving part or all of the physis.
• Type VI injury: fracture involves part of the cortex of both epiphysis and
metaphysis on the edge of the physeal plate.
These fractures should be reduced well to prevent impairment of growth.

Type1. Runs along epiphyseal plate with intact metaphysis & epiphysis, its rare
Type2: Triangular metaphysial fragment attached to displaced epiphysis, Very common with
good prognosis
Type3: Involves articular surface with separation of epiphyseal fragment
Type4: Fracture of articular surface with extension in metapiphysis , rare with poor prognosis
Type 5: Crushes/compression # involving part or all the physis. Very rare, very poor prognosis.
Type 6: Fracture involves part of the cortex of both epiphysis and metaphysis on the edge of the
physeal plate.

Shaft of femur # & classifications

a. Nature: closed or open
b. Geometry:- transverse, oblique e.t.c
c. Location: Proximal
Middle
Distal

Gartlands’ classification of supracondylar

Type1:- Undisplaced #
type2: Displaced # with intact posterior cortex
type3: Complete displacement #. Can be posteriomedial or posteriorlateral
Garden classification of neck of femur #s

Type1: incomplete or impacted, no displacement

Media trabecular intact
Vascularity preserved

Type2; complete # no displacement

Trabecular aligned
Vascularity preserved
Type3: complete # with partial Displacement of < ½ (50%)
Type 4: complete # with complete displacement
Trabercular not aligned
Vascular damage present
Boyd- Griffin classification of intertrochanteric #s

Type1: Undisplaced #
 Type2: Partially displaced
Type3: Reverse #
Type4: Displaced # subtrochanteric extension

Weber classification of Ankle #s

Type A: Below the syndesmosis
Type B: At the syndesmosis
Type C: Above the syndesmosis

Sigmoid Volvulus X-Ray

a. Describe
Contract enhanced X – ray of sigmoid colon, showing fluid air levels.
b. What is the clinical presentation?
Early -C.I.A
Constipation
Idiopathic abdominal pain
Abdominal distention
Late -T.D.F.V
Tympanic
Dehydration
Fever due to abdominal infection
Vomiting
c. Types
Subacute
Acute
Compound
d. Complication
Gangrene
Strangulation
 Perforation
Hemorrhage
Dehydration
Shock
Electrolytes imbalance
e. Investigations
FBC
Hct and Hb
ESR
W/E
X- Ray
Supine- gases
Elect- gas fluid levels

DYSPHAGIA

a. History
1. Demographic- NASEDORAM
Name, age, sex, ethnic group, date, occupation, religion & marital status
2. Symptoms
a. When did it start?
b. Is it new or long standing?
c. Is it rapidly worsening or relatively constant?
d. Was there difficulty swallowing solids or liquids from the start
e. Is it worse with solids from the start?
f. Is it worse with liquids from the start?
g. At which level does food stick?
h. Is swallowing painful?
i. Is it intermittent or is constant and getting worse?
j. Can it be relieved by anything e.g. warm drinks?
k. Is it associated with coughing?
l. Any changes in body weight?
 m. Does the neck bulge or gurge on drinking?
n. Any chest pain? Heartburn?
o. Regurgitation or substance cramp?

3. Predisposing factors
a. Hx of alcohol or smoking
b. Diet- Hx of hot foods e.g chili
c. Any gastro-oesophageal reflux disease(GORD) Hx
d. Hx of taking corrosive substance
e. Hx of surgery
f. Hx of radiotherapy
g. Immune suppression
4. Causes
According to type of dysphagia
i. Intermittent dysphagia
• Rings or webs
• Schatzkis ring
To solid foods only
ii. Diffuse easophageal spasm
To solids and liquids
iii. Progressive dysphagia
• Carcinoma and peptic stricture
Only to solids
• Achalasia and scleroderma
Solids and liquids
5. Classification
Congenital or acquired
• Congenital
• Achalasia cardia
• Pharyngeal pain
• Oesophageal diverticulum
 • Schatzki’s rings- Narrow lower oesophagus due to contraction
• Paterson- Kelly (Plummer vinson) syndrome- post cricoid web + iron
deficiency anemia, oesophageal stenosis
• Dysphagia lusoria- compression of oesophagus by a blood vessel( i.e right
subclavian artery arising from the descending aorta abnormally then passing
behind the oesophagus)

Mechanical block
• Acquired

Motility disorder

i. Mechanical block
• Ca oesophagus
• Gastric ca
• Pharyngeal ca
Bering strictures
• Peptic stricture
• Hiatal hernia
• Paraoesophageal hernia
•
Extrinsic pressure
• Lung cancer
• Mediastinal lungs
• Restrosternal goite
• Aortic aneurysm
ii. Motility
• Diffuse oesophageal spams
• Oesophageal achalasia
• Infection with candida
• Reflux oesophagitis
 • Corrosive substances
• Trauma- mattory- weills syndrome
6. Investigation
General
FBC
U/E
CX R
Specific
- Barium swallow
- Endoscopy
- Biopsy
Oesophageal manomility ( if (N) Bs)????????

7. TNM grading of Ca oesophagus

Tis: Carcinoma in-situ
T1: invading lamina propria/ submission
T2: invading muscular propria/ submission
T3: invading adventitia
T4: invasion of adjacent structure

Nx. Nodes can’t be assessed

NO.- No node spread
N1. Regional node metastates

MO. No distant spread

M1. Distant metastasis

8. Types of Ca oesophagus
(i) Adenorcarioma
• Associated with dietary nitrosamine, GORD and Barret’s oesophagitis
• Lower ½ of oesophagus
 (ii) Squamaous Cell Ca
• Associated with smoking, alcohol, diet, poor in fresh fruit and vegetables,
chronic achalasia, caustic stricture
• May occur anywhere but in upper especially
(iii) Rhabdomyosarcoma
• Skeletal muscle wall
9. Clinical features of Ca oesophagus
• Progressive dysphagia, with loss weight loss
• Rare haematemesis
• Dissemination symptoms
• Cervical lypmhadenopatty
• Hepatomegaly
• Epigastric mass due to para-aortic lymphadenopathy
• Local invasion symptoms
• Dysphonia in recurrent laryngeal nervepalsy
• Cough and hemoptysis in tracheal invasion
• Neck swellings
• Horner’s syndrome in sympathetic chain invasion
10. X-Ray
• Ca oesophagus has rat tail sign
Regular stricture
Shouldered margins
• Achalasia has beak sign
Megaoepshagus proximal to stricture
Tortuous oeso- signmoid sign

Examinations of thyroid gland

a. Inspection
Neck
i. Swelling in the anterior aspect of the neck
 ii. The swelling in the neck moves up when swallowing and does not
move up on tongue protrusion
iii. Swelling in the neck is the thyroid
iv. It is about X.. Cm and ... in shape
v. It has a smooth irregular surface to its multinodular
vi. Distended neck veins- central or deviated gland

Whole person
The young elderly woman is
 Sitting still and composed or
 Fidgeting about or
 Constantly moving finger and
 Looking nervous and agitated or slow ponderous in movement
 Looks thin than fat
 Over clothed a cold
At the hands

• Pulse- Tachy/ Brady cardia

• Moist and sweaty palms or cold
• Tremors/ no tremors- paper on his hand him
The eyes
• Exophthalmos
• Opthalmoplegia
• Swelling of conjunctiva- chemosis
• Lid retraction and lid lag
Palpation
a. From the front
• Swelling of about X cm
• .......... I shape
• Smooth irregular surface of nodular or extending ... or not
• Tender/ non tender
 • Warm/ cold to touch
• The trachea is central or deviated
From behind
• Ask patient to swallow while still palpating
• Palpate both lobes and isthmus
• Feel for thrill
Confirm
i. Temp
ii. Tenderness
iii. Consistency
iv. Shape
Percussion
• To define the lower extent of swelling
• Percuss along clavicle of sternum upper chest wall
Auscultation
• Listen over swelling for systolic bruit
Other systems
(a) CVS
(b) Legs- pretibial myoedema in graves disease or myxoedema

DDx
Goiter
(a) Epidemiology
Endemic
Sporadic
Familial
(b) Morphology
Diffuse
Nodular
Multinodular
Solitary nodules
 (c) Thyroid FXN status
• Toxic
• Non toxoic
(d) Location
• Cervical
• Retrosternal
• Intrathoracic
(e) Neoplasm
a. Benign e.g. Lipoma colloid- follicular adenoma
b. Malignant
• Papillary carcinoma- most common
• Follicular carcinoma- most common
• Medullary carcinoma- most common
• Anaplastic carcinoma- most common
• Lymphoma carcinoma- most common

(f) Inflammatory

Autoimmune
• Chronic lymphacutic thyroidits
• Hashimoto disease
Granuloma
Fibrosing
Infection
• Bacteria
• Viral
• Syphililis
• TB
Other- amyloidosis

Cysts
 • Sebaceous
• Demoid
Investigations
(1) thyroid FXN test (TFTs)
FSH
T3 or T4

(2) CXR
- Tracheal deviation
- Lung metastasis
-Retrostenal shadow

(3)Thoracic CT
• Define anatomy in patients and large
• Intrathoracic extension
• Isotope screaning
• Toxicity
Cervical spine X ray
• AP _ position of tracheal- deviated
• Gland calcification- bledd easily
Lateral X-Ray
U/S- cystic or solid
ECG- Arrhythmias
FNA- Can’t distinguish extent/site of pathology
True cut biopsy
CT
MRI

Surgical indications
• Compression
• Cosmetic deformity
 • Carcinoma
• Toxicity
Signs and Symptoms of thyrotoxisosis

a. Metabolic
• Appetite
• Loss of weight
• Heat intolerance
• Sweating
b. Neurological
• Tremor
• Nervous
• Irritability
• Insomnia
• Emotional distrurbance
• Tiredeness
• Weakness
c. CVS
• Palpitations
• Tachycardia
• Arrhythmias
d. GIT
• Appetite
• Weight loss
• Diarrhoea
e. Eyes
• Chemosis
• Exophthalmos
• Corneal ulcer
• Lid lag/ retraction
• Opthalmoplegia
Causes
Aetiological factors in Goitre
• Genetic
• Environmental
• Dietary
• Endocrine
• Puberty
• Pregnancy
• Sepsis
UROLOGY

BPH
History
Age: 50- 70
Symptoms – Luts(lower urinary tract symptoms)
Obstructive voiding symptoms

1. Hesitancy
• Do you experience difficulties to start passing urine
2. Intermittency
• When you start passing urine do you do it continuously or you experience
interruption of flow
3. Poor stream
• Do you have reduced rate of urine flow during maturation?
4. Dysuria
• Do experience pain when passing urine
5. Post- micturational dribbling
• Do you experience continued few drops for some time patient the main
stream ceases
• Or are you able to finish cleanly
6. Incomplete emptying
 • Do have a feeling of incomplete emptying
Irritative/ storage symptoms
7. (i) Frequency
• Do you have the desire to pass urine frequently
(ii)Urgency
• Do you feel the urgent need to pass urine as soon as desire arise
(iii) Nocturia
• - do you frequently pass urine at night

(iv) Urge incontinence

• Do you feel the desire to pass urine even when the bladder is not full or its
empty
(v) Hematuria (terminal)
• Do you see blood in urine at the end of maturation
Ca. Symptoms
• Age- elderly
• Rapid progression of Luts symptoms
• Any lower abdomen pain or perineum
• Have you lost weight
• Any back pain
Others – inguinal hernia
• Piles
• Constipation
How do you differentiate the 2?
By Dre

DRE
Inspection
• Piles/ polyps
• Pus
• Infection
 • Rectal tone
BPH
• Size- enlarged
• Surface- regular or smooth
• Sulci – palpable
• Consistency- firm
• Rectal mucosa over gland is Freely mobile