- Published on
Surgery - Abdominal Investigations
Fecal occult blood testing may be chemical or immunological/quantitative—specifically, the quantitative fecal immunochemical test (qFIT). The primary application is as the initial community test for colorectal carcinoma, as outlined in the National Bowel Cancer Screening Programme.
Flexible sigmoidoscopy
• Minimal risk (perforation <1 in 10,000), typically conducted without sedation. • should visualize up to the descending colon. facilitates small therapeutic interventions (polypectomy, biopsy, injection). commonly employed for: diagnosis and evaluation of colitis colonic neoplasia, investigation anorectal hemorrhage.< />pan>
Colonoscopy: Low risk (perforation 1 in 1000); conducted with or without intravenous sedation or Entonox®; necessitates bowel preparation.
• The entire colon should be visualized in over 95% of cases. Permits minimal therapeutic interventions—polypectomy, including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), injection, tattoo marking, and biopsy. Applicable when comprehensive colonic evaluation is warranted or when colonic and/or terminal ileal pathology is suspected.
Transabdominal ultrasonography
Simple, secure, non-invasive, and eliminates radiation exposure. Common applications encompass: • 1° examination of the biliary tree for gallstones, bile duct dimensions, and liver parenchymal characteristics. • Detection of ovarian pathology, for instance, in cases of suspected appendicitis. Evaluation of the hepatic and splenic parenchyma. Detection of free fluid in abdominal trauma.
Computed Tomography scanning
• Simple and non-invasive; necessitates considerable radiation exposure and intravenous/oral contrast.
• Common applications encompass:
• Initial evaluation of all intra-abdominal masses.
• Staging of intra-abdominal and pelvic neoplasms.
• Examination of acute stomach pain (gaining prevalence).
• Examination of potential intestinal blockage.
• Assessment of probable postoperative sequelae.
MRI scanning
• Eliminates radiation exposure.
• Can be conducted using specific contrast agents.
• Commonly employed for: • Examination of suspected bile duct pathology—magnetic resonance cholangiopancreatography (MRCP).
Evaluation of hepatic pathology and potential metastases. Evaluation of the pancreatic.
Evaluation of pelvic and retroperitoneal soft tissue pathology, such as pelvic malignancies and intricate perianal sepsis.
• Evaluation of the small intestine where radiation exposure should be minimized (magnetic resonance enterography)
Standard abdominal radiograph
• may detect intestinal blockage, urinary tract calculi, free intra-abdominal air, and intra-abdominal fluid.
The Barium/Gastrografin® enema can be performed as either a single contrast, where contrast material fills the colon to detect strictures and blockages, or a double contrast, which involves a dilute contrast and air to cover the mucosal surface of the colon, however the latter is currently hardly utilized.
Computed Tomography Colonography • Necessitates comprehensive bowel preparation and rectal catheter placement; entails considerable radiation exposure with intravenous or oral contrast.
• Generally employed as an alternative to colonoscopy when it is contraindicated or unfeasible, such as in cases of advanced age, frailty, known strictures, or unsuccessful colonoscopy attempts. Studies on intestinal transit
• Serial abdominal X-rays (AXR) are utilized to monitor the progression of ingested radio-opaque markers.
• They are employed to evaluate intestinal motility and transit duration. PET scanning involves the injection of a radioactive metabolic substrate to identify metabolically active tissues, such as malignancies or areas of inflammation/infection. It is combined with high-resolution CT scanning to accurately locate 'hot spots.' Commonly employed to detect unrecognized metastatic tumor deposits or to distinguish fibrosis from remaining tumor following surgery.
Physiological assessment
• Manometric evaluation of the esophagus, encompassing the lower esophageal sphincter and the anal canal. Pressure sensitivities of the esophagus and anal canal. pH assessment of the esophageal contents (either isolated or continuously over 24 hours).
• used to evaluate anorectal function, esophageal motility and function, and gastroesophageal reflux
Fecal occult blood testing may be chemical or immunological/quantitative—specifically, the quantitative fecal immunochemical test (qFIT). The primary application is as the initial community test for colorectal carcinoma, as outlined in the National Bowel Cancer Screening Programme.
Flexible sigmoidoscopy
• Minimal risk (perforation <1 in 10,000), typically conducted without sedation. • should visualize up to the descending colon. facilitates small therapeutic interventions (polypectomy, biopsy, injection). commonly employed for: diagnosis and evaluation of colitis colonic neoplasia, investigation anorectal hemorrhage.< />pan>
Colonoscopy: Low risk (perforation 1 in 1000); conducted with or without intravenous sedation or Entonox®; necessitates bowel preparation.
• The entire colon should be visualized in over 95% of cases. Permits minimal therapeutic interventions—polypectomy, including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), injection, tattoo marking, and biopsy. Applicable when comprehensive colonic evaluation is warranted or when colonic and/or terminal ileal pathology is suspected.
Transabdominal ultrasonography
Simple, secure, non-invasive, and eliminates radiation exposure. Common applications encompass: • 1° examination of the biliary tree for gallstones, bile duct dimensions, and liver parenchymal characteristics. • Detection of ovarian pathology, for instance, in cases of suspected appendicitis. Evaluation of the hepatic and splenic parenchyma. Detection of free fluid in abdominal trauma.
Computed Tomography scanning
• Simple and non-invasive; necessitates considerable radiation exposure and intravenous/oral contrast.
• Common applications encompass:
• Initial evaluation of all intra-abdominal masses.
• Staging of intra-abdominal and pelvic neoplasms.
• Examination of acute stomach pain (gaining prevalence).
• Examination of potential intestinal blockage.
• Assessment of probable postoperative sequelae.
MRI scanning
• Eliminates radiation exposure.
• Can be conducted using specific contrast agents.
• Commonly employed for: • Examination of suspected bile duct pathology—magnetic resonance cholangiopancreatography (MRCP).
Evaluation of hepatic pathology and potential metastases. Evaluation of the pancreatic.
Evaluation of pelvic and retroperitoneal soft tissue pathology, such as pelvic malignancies and intricate perianal sepsis.
• Evaluation of the small intestine where radiation exposure should be minimized (magnetic resonance enterography)
Standard abdominal radiograph
• may detect intestinal blockage, urinary tract calculi, free intra-abdominal air, and intra-abdominal fluid.
The Barium/Gastrografin® enema can be performed as either a single contrast, where contrast material fills the colon to detect strictures and blockages, or a double contrast, which involves a dilute contrast and air to cover the mucosal surface of the colon, however the latter is currently hardly utilized.
Computed Tomography Colonography • Necessitates comprehensive bowel preparation and rectal catheter placement; entails considerable radiation exposure with intravenous or oral contrast.
• Generally employed as an alternative to colonoscopy when it is contraindicated or unfeasible, such as in cases of advanced age, frailty, known strictures, or unsuccessful colonoscopy attempts. Studies on intestinal transit
• Serial abdominal X-rays (AXR) are utilized to monitor the progression of ingested radio-opaque markers.
• They are employed to evaluate intestinal motility and transit duration. PET scanning involves the injection of a radioactive metabolic substrate to identify metabolically active tissues, such as malignancies or areas of inflammation/infection. It is combined with high-resolution CT scanning to accurately locate 'hot spots.' Commonly employed to detect unrecognized metastatic tumor deposits or to distinguish fibrosis from remaining tumor following surgery.
Physiological assessment
• Manometric evaluation of the esophagus, encompassing the lower esophageal sphincter and the anal canal. Pressure sensitivities of the esophagus and anal canal. pH assessment of the esophageal contents (either isolated or continuously over 24 hours).
• used to evaluate anorectal function, esophageal motility and function, and gastroesophageal reflux
- Published on
Anatomy - “Temporoparietalis
Latin, tempus (temple); parietalis (pertaining to the walls of a cavity)”
Origin: Fascia superior to the ear.
Insertion Lateral margin of the galea aponeurotica. Facial nerve (VII), temporal branch.
Action Constricts the scalp.
Elevates auditory organs
Latin, tempus (temple); parietalis (pertaining to the walls of a cavity)”
Origin: Fascia superior to the ear.
Insertion Lateral margin of the galea aponeurotica. Facial nerve (VII), temporal branch.
Action Constricts the scalp.
Elevates auditory organs
- Published on
Surgery - Assessment of peripheral vascular disease
Placement and examination The patient ought to be assessed in a heated setting while at rest. Ensure to assess the pulse and blood pressure, inspect the belly for aneurysms and scars, and conduct a comprehensive cardiovascular examination, including all peripheral pulses, heart sounds, and carotid auscultation.
Examine the leg in the supine position, subsequently elevated (passively), and ultimately in a dependent position. Fully expose the leg, encompassing the foot or hand, to facilitate a comprehensive examination and eliminate any bandages. The patient should be assessed in an upright position for venous disease. During supine examination,
observe the following:
Appearance Are there any regions with confirmed skin necrosis (dry gangrene, such as the tips of fingers or toes, interdigital spaces, or the heel of the foot)? Are there alterations in chronic venous stasis (such as varicosities, venous dermatitis, lipodermatosclerosis, or leg ulcers)?
Color - Waxy white indicates critical or acute ischaemia; blue and mottled coloration denotes potentially irreversible acute ischaemia; dark red or purple signifies chronic ischaemia.
Color alterations occur with positional modifications. Observe the angle at which the skin of the limb becomes pale when lifted passively (Buerger’s test). Normal extremities may have no blanching whatsoever. An angle of 15° or less indicates significant ischaemia. Observe the occurrence and latency of color change when the limb is in a dependent position. Ischaemic limbs gradually assume a vivid scarlet hue (reactive hyperaemia).
Ulcers-What is the site (digital or pedal) indicative of arterial disease? Ensure to examine the areas between the toes and fingers, as well as the plantar surface of the foot, particularly in cases of diabetes.
• Examination of venous structures. Assist the patient in standing upright. Examine for varicose veins. Are they located within the long saphenous or short saphenous distribution?
Palpation
• Temperature. Is the skin seen as chilly or warm? Is there a transitional phase? Compression and filling of skin capillaries. The standard is 2 seconds or fewer. A delay over 5 seconds indicates markedly diminished perfusion.
• Peripheral pulsations. Commence with the most proximal (major) vessels and go distally. Document whether the pulse is normal (++), diminished (+), or missing (–). Document any discernible excitement.
• In venous pathology, assessments of venous competence may be conducted (% Varicose veins). Surgical grafts. Examine the pathway of any surgical grafts and document the existence or nonexistence of pulses. Auscultation Assess for bruits. Are there bruits in the proximal vessels indicative of stenosis?
Inquiries Handheld Doppler (at the bedside), followed by Duplex ultrasound or CT angiography, are the primary modalities for examining vascular disease.
Portable Doppler ultrasonography • A simple and portable "bedside" assessment for preliminary evaluation. • used to: • Verify the existence of flow within a vessel or graft. • Assess the ankle-brachial pressure index (ABPI). Assess the existence of venous reflux.
Duplex Ultrasound (USS) • Integrates two-dimensional (2D) ultrasound imaging with Doppler-derived flow, shown in color and superimposed in real time. • Arterial duplex: utilized for the evaluation of stenoses and occlusions. Venous duplex: utilized for evaluating reflux or thrombosis in deep and superficial veins.
Computed Tomography Angiography Requires a multi-slice rapid acquisition ('helical'/'spiral') scanner. Images obtained during the arterial and/or venous phase following intravenous contrast administration.
Three-dimensional (3D) reconstruction facilitates the generation of 'virtual angiogram' images. This process is rapid, non-invasive, and comparatively safe. Utilizes iodinated contrast, which is nephrotoxic (relatively contraindicated in renal impairment) and poses a minor risk of allergic reaction. The presence of vessel wall calcification may hinder the visibility of the lumen.
Digital subtraction angiography (DSA) involves X-ray imaging subsequent to the injection of contrast material into the target vessel, effectively eliminating background structures (such as bone) to render the vessel lumen in black. This technique is primarily employed when endovascular intervention is necessary during the same procedure or when prior investigations yield inconclusive results. It is an invasive procedure that necessitates arterial puncture, which carries inherent risks, including the potential for false aneurysm or retroperitoneal hemorrhage associated with groin puncture. • Necessitates iodinated contrast, necessitating vigilance in cases of renal impairment and allergies.
Magnetic resonance angiography produces images of the arterial network by detecting arterial flow throughout the scanning process. • Safe and non-invasive: does not necessitate iodinated contrast, typically employing gadolinium to accentuate circulating blood. • Often overestimates the extent of stenosis due to the underrepresentation of very low flow.
Placement and examination The patient ought to be assessed in a heated setting while at rest. Ensure to assess the pulse and blood pressure, inspect the belly for aneurysms and scars, and conduct a comprehensive cardiovascular examination, including all peripheral pulses, heart sounds, and carotid auscultation.
Examine the leg in the supine position, subsequently elevated (passively), and ultimately in a dependent position. Fully expose the leg, encompassing the foot or hand, to facilitate a comprehensive examination and eliminate any bandages. The patient should be assessed in an upright position for venous disease. During supine examination,
observe the following:
Appearance Are there any regions with confirmed skin necrosis (dry gangrene, such as the tips of fingers or toes, interdigital spaces, or the heel of the foot)? Are there alterations in chronic venous stasis (such as varicosities, venous dermatitis, lipodermatosclerosis, or leg ulcers)?
Color - Waxy white indicates critical or acute ischaemia; blue and mottled coloration denotes potentially irreversible acute ischaemia; dark red or purple signifies chronic ischaemia.
Color alterations occur with positional modifications. Observe the angle at which the skin of the limb becomes pale when lifted passively (Buerger’s test). Normal extremities may have no blanching whatsoever. An angle of 15° or less indicates significant ischaemia. Observe the occurrence and latency of color change when the limb is in a dependent position. Ischaemic limbs gradually assume a vivid scarlet hue (reactive hyperaemia).
Ulcers-What is the site (digital or pedal) indicative of arterial disease? Ensure to examine the areas between the toes and fingers, as well as the plantar surface of the foot, particularly in cases of diabetes.
• Examination of venous structures. Assist the patient in standing upright. Examine for varicose veins. Are they located within the long saphenous or short saphenous distribution?
Palpation
• Temperature. Is the skin seen as chilly or warm? Is there a transitional phase? Compression and filling of skin capillaries. The standard is 2 seconds or fewer. A delay over 5 seconds indicates markedly diminished perfusion.
• Peripheral pulsations. Commence with the most proximal (major) vessels and go distally. Document whether the pulse is normal (++), diminished (+), or missing (–). Document any discernible excitement.
• In venous pathology, assessments of venous competence may be conducted (% Varicose veins). Surgical grafts. Examine the pathway of any surgical grafts and document the existence or nonexistence of pulses. Auscultation Assess for bruits. Are there bruits in the proximal vessels indicative of stenosis?
Inquiries Handheld Doppler (at the bedside), followed by Duplex ultrasound or CT angiography, are the primary modalities for examining vascular disease.
Portable Doppler ultrasonography • A simple and portable "bedside" assessment for preliminary evaluation. • used to: • Verify the existence of flow within a vessel or graft. • Assess the ankle-brachial pressure index (ABPI). Assess the existence of venous reflux.
Duplex Ultrasound (USS) • Integrates two-dimensional (2D) ultrasound imaging with Doppler-derived flow, shown in color and superimposed in real time. • Arterial duplex: utilized for the evaluation of stenoses and occlusions. Venous duplex: utilized for evaluating reflux or thrombosis in deep and superficial veins.
Computed Tomography Angiography Requires a multi-slice rapid acquisition ('helical'/'spiral') scanner. Images obtained during the arterial and/or venous phase following intravenous contrast administration.
Three-dimensional (3D) reconstruction facilitates the generation of 'virtual angiogram' images. This process is rapid, non-invasive, and comparatively safe. Utilizes iodinated contrast, which is nephrotoxic (relatively contraindicated in renal impairment) and poses a minor risk of allergic reaction. The presence of vessel wall calcification may hinder the visibility of the lumen.
Digital subtraction angiography (DSA) involves X-ray imaging subsequent to the injection of contrast material into the target vessel, effectively eliminating background structures (such as bone) to render the vessel lumen in black. This technique is primarily employed when endovascular intervention is necessary during the same procedure or when prior investigations yield inconclusive results. It is an invasive procedure that necessitates arterial puncture, which carries inherent risks, including the potential for false aneurysm or retroperitoneal hemorrhage associated with groin puncture. • Necessitates iodinated contrast, necessitating vigilance in cases of renal impairment and allergies.
Magnetic resonance angiography produces images of the arterial network by detecting arterial flow throughout the scanning process. • Safe and non-invasive: does not necessitate iodinated contrast, typically employing gadolinium to accentuate circulating blood. • Often overestimates the extent of stenosis due to the underrepresentation of very low flow.
- Published on
Anatomy -Occipitofrontalis
Latin, frons, the forehead, the anterior part of the head; occiput, the posterior part of the head. The occipitofrontalis has two muscular bellies, the frontal and occipital, interconnected by an aponeurosis known as the galea aponeurotica, named for its resemblance to a helmet (Latin galea).
Source Frontal belly: epidermis of the eyebrows.
Occipital belly: lateral two-thirds of the superior nuchal line of the occipital bone. Mastoid process of the temporal bone. Insertion: Galea aponeurotica. Facial nerve (VII), including the posterior auricular and temporal branches.
Action : The frontal belly elevates the eyebrows and creates horizontal creases on the forehead.
Occipital belly: retracts the scalp posteriorly. Fundamental functional movement Enables facial expressions, such as displaying surprise or frowning.
Latin, frons, the forehead, the anterior part of the head; occiput, the posterior part of the head. The occipitofrontalis has two muscular bellies, the frontal and occipital, interconnected by an aponeurosis known as the galea aponeurotica, named for its resemblance to a helmet (Latin galea).
Source Frontal belly: epidermis of the eyebrows.
Occipital belly: lateral two-thirds of the superior nuchal line of the occipital bone. Mastoid process of the temporal bone. Insertion: Galea aponeurotica. Facial nerve (VII), including the posterior auricular and temporal branches.
Action : The frontal belly elevates the eyebrows and creates horizontal creases on the forehead.
Occipital belly: retracts the scalp posteriorly. Fundamental functional movement Enables facial expressions, such as displaying surprise or frowning.
- Published on
Surgery - Antibiotic administration in surgical procedures
The tenets of effective antibiotic prescription Over the past 40 years, antibiotic resistance has escalated significantly. The development of new antibiotics is limited, and there is an urgent necessity to preserve the effectiveness of current antibiotics. The UK Department of Health has released a 'Start Smart – then Focus' systematic strategy to guarantee the effective and optimal use of antibiotics.
Start smart
Commence antibiotics only in the presence of unequivocal evidence of infection. Conduct a comprehensive medication allergy history assessment. Examine regional antibiotic prescribing protocols. Commence early and effective antibiotic therapy within one hour of diagnosis (or as soon as feasible) in patients with severe sepsis or life-threatening illnesses. Refrain from the improper application of broad-spectrum antibiotics• Record the clinical indication (including disease severity), drug name, dosage, and administration route in the drug chart and clinical notes. • Include a review or cessation date, or specify the duration. Acquire cultures before initiating therapy where feasible (but do not postpone therapy). • Administer single-dose antibiotics for surgical prophylaxis in instances where their efficacy has been demonstrated. • Specify the precise indication on the medication chart for clinical prophylaxis instead of referring to long-term prophylaxis.
Subsequently, concentrate on evaluating the clinical diagnosis and the ongoing necessity for antibiotics at 48–72 hours, while establishing a definitive plan of action—the 'antibiotic prescribing decision.' All intravenous antibiotics have should be evaluated at 48 hours.
The five alternatives for 'antibiotic prescribing decisions' are: Discontinue antibiotics in the absence of infection evidence. Transition antibiotics from intravenous to oral administration. Alter antibiotics, preferably to a narrower range, or broader if necessary.Proceed to record the subsequent review and cessation date.
Outpatient parenteral antibiotic therapy (OPAT) involves administering parenteral antibiotics to patients outside of an inpatient environment.
Antibiotic prophylaxis in surgical procedures
Antibiotic prophylaxis is an efficacious measure for mitigating surgical site infections (SSI) in specific surgical procedures.
Numerous additional risk variables also influence the occurrence of SSIs. When prescribing antibiotics for surgical prophylaxis, it is essential to weigh the associated risks against the advantages of treatment.
Factors influencing the incidence of SSIs
Patient Extremes of age
Poor nutritional status
Obesity (>20% of ideal body weight)
Diabetes mellitus (DM)
Smoking
Coexisting infections at other sites
Bacterial colonization (e.g. nasal colonization with
Staphylococcus aureus)
Immunosuppression
Prolonged post- operative stay
Operation
Length of surgical scrub
Skin antisepsis
Preoperative skin preparation
Length of operation
Antibiotic prophylaxis
Operating theatre ventilation
Foreign material in surgical site
Surgical technique
Post- operative hypothermia
Advantages of antibiotic prophylaxis
The efficacy of antibiotic prophylaxis in surgical procedures correlates with the frequency and severity of surgical site infections (SSIs).
Surgical site infections can elevate the likelihood of patient morbidity and prolong hospital stays.
The duration of hospitalization related to SSIs is contingent upon the type of surgery performed on the patient.
Evidence suggests that preventing wound infections correlates with reduced durations of stay and expedited patient recovery.
Risks associated with prophylaxis (and antibiotic usage in general)
Optimizing surgical antibiotic prophylaxis is essential to mitigate the unexpected repercussions of antibiotic utilization.
Significant concerns linked to antibiotic prescribing encompass: penicillin allergy, Clostridium difficile infection (CDI), and antibiotic resistance.
Penicillin allergy—penicillins and cephalosporins are the most frequently utilized kinds of antibiotics. Mislabeling patients as penicillin-allergic can jeopardize their antibiotic treatment.
Obtaining a comprehensive medical history, encompassing the specifics of the patient's reported reactions to penicillins or other antibiotics, is a crucial step in determining the patient's allergy status.
Individuals with a confirmed penicillin allergy should not receive β-lactam antibiotics due to cross-sensitivity with penicillins.
Examples of antibiotics in penicillin allergy
Antibiotics that must be avoided in serious
penicillin allergy
Amoxicillin (e.g. co- amoxiclav/ Augmentin® HeliClear®)
Ampicillin (co- fluampicil/ Magnapen®) Benzylpenicillin/ penicillin G
Flucloxacillin (co- fluampicil/ Magnapen®)
Phenoxymethylpenicillin/ penicillin V
Piperacillin- tazobactam (in Tazocin®)
Pivmecillinam
Ticarcillin (in Timentin®)
Antibiotics to be avoided in serious penicillin
allergy and used with caution in non- severe
penicillin allergy (e.g. minor rash only)
Cephalosporins: cefaclor, cefadroxil, cefalexin, cefixime, cefotaxime, cefpirome, cefpodoxime, cefprozil, cefradine, ceftazidime, ceftriaxone, cefuroxime
Other β-lactam antibiotics: aztreonam, imipenem, meropenem, ertapenem
Antibiotics considered safe in penicillin allergy
Amikacin, ciprofloxacin, clarithromycin, clindamycin, colistin, co- trimoxazole, doxycycline, erythromycin gentamicin, linezolid, metronidazole, nitrofurantoin,
minocycline, rifampicin, sodium fusidate, teicoplanin, tetracycline, tobramycin, trimethoprim, vancomycin
The risk of getting C. difficile infection is elevated in patients who have undergone recent gastrointestinal surgery,had an extended hospitalization. Are administered proton pump inhibitors (PPIs),Are aged individuals. Patients now receiving or who have recently received antibiotics, particularly broad-spectrum antibiotics, are at an increased risk of Clostridioides difficile infection (CDI).
The prevalence of antibiotic resistance is rising worldwide, particularly in healthcare environments. The emergence and proliferation of antibiotic resistance within a population is associated with the population's exposure to antibiotics. Inappropriate and excessive use of antibiotics might result in antibiotic resistance. Not all surgical procedures necessitate antibiotic prophylaxis. The NICE recommendations advise against the routine use of antibiotic prophylaxis for uncomplicated clean non-prosthetic surgeries.
Three Prophylaxis is necessary for the following surgical procedures: Clean surgeries that involve the insertion of a prosthesis or implant. Clean-contaminated surgical procedure. Operative intervention on a contaminated or infected wound necessitates antibiotic therapy, alongside prophylactic measures.
Selecting an antibiotic for prophylaxis
A diverse array of bacteria can induce infections in people. Selecting the suitable antibiotic will depend on patient-specific characteristics, the probable site of infection, and local susceptibility patterns.
Initially, consult your local hospital's antibiotic prescribing guidelines. These policies are formulated by MDTs and are grounded in the most reliable evidence and clinical competence. Timing of antibiotic treatment for surgical prophylaxis The route, dosage, and pharmacokinetic characteristics of antibiotics determine the duration required for an antibiotic to attain effective concentrations in particular human tissues. Administering prophylactic antibiotic dosages either too late or too early can diminish their effectiveness and elevate the risk of surgical site infections (SSIs).
Intravenous prophylactic antibiotics for surgical patients should be administered within 60 minutes prior to skin incision, as near to the time of incision as feasible.Three Vancomycin, when warranted, should be administered by IV infusion commencing 90 minutes before the skin incision.Three In most cases, a solitary preventive dose of antibiotic is adequate—always consult the local policy to ascertain the appropriate amount and frequency of administration.
The tenets of effective antibiotic prescription Over the past 40 years, antibiotic resistance has escalated significantly. The development of new antibiotics is limited, and there is an urgent necessity to preserve the effectiveness of current antibiotics. The UK Department of Health has released a 'Start Smart – then Focus' systematic strategy to guarantee the effective and optimal use of antibiotics.
Start smart
Commence antibiotics only in the presence of unequivocal evidence of infection. Conduct a comprehensive medication allergy history assessment. Examine regional antibiotic prescribing protocols. Commence early and effective antibiotic therapy within one hour of diagnosis (or as soon as feasible) in patients with severe sepsis or life-threatening illnesses. Refrain from the improper application of broad-spectrum antibiotics• Record the clinical indication (including disease severity), drug name, dosage, and administration route in the drug chart and clinical notes. • Include a review or cessation date, or specify the duration. Acquire cultures before initiating therapy where feasible (but do not postpone therapy). • Administer single-dose antibiotics for surgical prophylaxis in instances where their efficacy has been demonstrated. • Specify the precise indication on the medication chart for clinical prophylaxis instead of referring to long-term prophylaxis.
Subsequently, concentrate on evaluating the clinical diagnosis and the ongoing necessity for antibiotics at 48–72 hours, while establishing a definitive plan of action—the 'antibiotic prescribing decision.' All intravenous antibiotics have should be evaluated at 48 hours.
The five alternatives for 'antibiotic prescribing decisions' are: Discontinue antibiotics in the absence of infection evidence. Transition antibiotics from intravenous to oral administration. Alter antibiotics, preferably to a narrower range, or broader if necessary.Proceed to record the subsequent review and cessation date.
Outpatient parenteral antibiotic therapy (OPAT) involves administering parenteral antibiotics to patients outside of an inpatient environment.
Antibiotic prophylaxis in surgical procedures
Antibiotic prophylaxis is an efficacious measure for mitigating surgical site infections (SSI) in specific surgical procedures.
Numerous additional risk variables also influence the occurrence of SSIs. When prescribing antibiotics for surgical prophylaxis, it is essential to weigh the associated risks against the advantages of treatment.
Factors influencing the incidence of SSIs
Patient Extremes of age
Poor nutritional status
Obesity (>20% of ideal body weight)
Diabetes mellitus (DM)
Smoking
Coexisting infections at other sites
Bacterial colonization (e.g. nasal colonization with
Staphylococcus aureus)
Immunosuppression
Prolonged post- operative stay
Operation
Length of surgical scrub
Skin antisepsis
Preoperative skin preparation
Length of operation
Antibiotic prophylaxis
Operating theatre ventilation
Foreign material in surgical site
Surgical technique
Post- operative hypothermia
Advantages of antibiotic prophylaxis
The efficacy of antibiotic prophylaxis in surgical procedures correlates with the frequency and severity of surgical site infections (SSIs).
Surgical site infections can elevate the likelihood of patient morbidity and prolong hospital stays.
The duration of hospitalization related to SSIs is contingent upon the type of surgery performed on the patient.
Evidence suggests that preventing wound infections correlates with reduced durations of stay and expedited patient recovery.
Risks associated with prophylaxis (and antibiotic usage in general)
Optimizing surgical antibiotic prophylaxis is essential to mitigate the unexpected repercussions of antibiotic utilization.
Significant concerns linked to antibiotic prescribing encompass: penicillin allergy, Clostridium difficile infection (CDI), and antibiotic resistance.
Penicillin allergy—penicillins and cephalosporins are the most frequently utilized kinds of antibiotics. Mislabeling patients as penicillin-allergic can jeopardize their antibiotic treatment.
Obtaining a comprehensive medical history, encompassing the specifics of the patient's reported reactions to penicillins or other antibiotics, is a crucial step in determining the patient's allergy status.
Individuals with a confirmed penicillin allergy should not receive β-lactam antibiotics due to cross-sensitivity with penicillins.
Examples of antibiotics in penicillin allergy
Antibiotics that must be avoided in serious
penicillin allergy
Amoxicillin (e.g. co- amoxiclav/ Augmentin® HeliClear®)
Ampicillin (co- fluampicil/ Magnapen®) Benzylpenicillin/ penicillin G
Flucloxacillin (co- fluampicil/ Magnapen®)
Phenoxymethylpenicillin/ penicillin V
Piperacillin- tazobactam (in Tazocin®)
Pivmecillinam
Ticarcillin (in Timentin®)
Antibiotics to be avoided in serious penicillin
allergy and used with caution in non- severe
penicillin allergy (e.g. minor rash only)
Cephalosporins: cefaclor, cefadroxil, cefalexin, cefixime, cefotaxime, cefpirome, cefpodoxime, cefprozil, cefradine, ceftazidime, ceftriaxone, cefuroxime
Other β-lactam antibiotics: aztreonam, imipenem, meropenem, ertapenem
Antibiotics considered safe in penicillin allergy
Amikacin, ciprofloxacin, clarithromycin, clindamycin, colistin, co- trimoxazole, doxycycline, erythromycin gentamicin, linezolid, metronidazole, nitrofurantoin,
minocycline, rifampicin, sodium fusidate, teicoplanin, tetracycline, tobramycin, trimethoprim, vancomycin
The risk of getting C. difficile infection is elevated in patients who have undergone recent gastrointestinal surgery,had an extended hospitalization. Are administered proton pump inhibitors (PPIs),Are aged individuals. Patients now receiving or who have recently received antibiotics, particularly broad-spectrum antibiotics, are at an increased risk of Clostridioides difficile infection (CDI).
The prevalence of antibiotic resistance is rising worldwide, particularly in healthcare environments. The emergence and proliferation of antibiotic resistance within a population is associated with the population's exposure to antibiotics. Inappropriate and excessive use of antibiotics might result in antibiotic resistance. Not all surgical procedures necessitate antibiotic prophylaxis. The NICE recommendations advise against the routine use of antibiotic prophylaxis for uncomplicated clean non-prosthetic surgeries.
Three Prophylaxis is necessary for the following surgical procedures: Clean surgeries that involve the insertion of a prosthesis or implant. Clean-contaminated surgical procedure. Operative intervention on a contaminated or infected wound necessitates antibiotic therapy, alongside prophylactic measures.
Selecting an antibiotic for prophylaxis
A diverse array of bacteria can induce infections in people. Selecting the suitable antibiotic will depend on patient-specific characteristics, the probable site of infection, and local susceptibility patterns.
Initially, consult your local hospital's antibiotic prescribing guidelines. These policies are formulated by MDTs and are grounded in the most reliable evidence and clinical competence. Timing of antibiotic treatment for surgical prophylaxis The route, dosage, and pharmacokinetic characteristics of antibiotics determine the duration required for an antibiotic to attain effective concentrations in particular human tissues. Administering prophylactic antibiotic dosages either too late or too early can diminish their effectiveness and elevate the risk of surgical site infections (SSIs).
Intravenous prophylactic antibiotics for surgical patients should be administered within 60 minutes prior to skin incision, as near to the time of incision as feasible.Three Vancomycin, when warranted, should be administered by IV infusion commencing 90 minutes before the skin incision.Three In most cases, a solitary preventive dose of antibiotic is adequate—always consult the local policy to ascertain the appropriate amount and frequency of administration.
- Published on
Surgery – Post Operative Nausea and Vomiting
One challenging and unpleasant side effect of anesthesia and surgery that can lengthen recovery is post-operative nausea and vomiting (PONV). The type of operation and case mix have an impact on the incidence of PONV. According to estimates, the incidence of PONV without prophylaxis is 30% when General Anesthesia is used with inhalational medicines. In addition to being a side effect of post-operative opioids, PONV is also caused by patient-specific variables, especially a history of PONV
Apfel PONV prediction system
Opioids used after surgery (1 point)
Gender - female (1 point) ♀
Non-smoker (1 point)
Motion sickness/PONV history (1 point)
The baseline risk of PONV can be decreased using a number of effective treatments. Among these are:
Steer clear of nitrous oxide (N2O)
avoiding anesthetics that are volatile
reduction of opioids used during and after surgery
Drink enough water.
Ondansetron, unless contraindicated, is one of two antiemetics with distinct mechanisms of action that should be administered to patients at risk for PONV. Usually administered orally (PO)
Preoperative antiemetics can also be administered intravenously. Ondansetron 8–16 mg PO is one preoperative antiemetic that can be administered as a single dosage. Prochlorperazine 3–6 mg buccal or 5 mg tablets PO; Cyclizine 50 mg PO. With the exception of dexamethasone, which is administered at induction.
Intraoperative antiemetics can be administered intravenously (IV) at the conclusion of the procedure: • Dexamethasone 3.3–6.6 mg IV (at induction). • 4 mg of ondansetron. Cyclizine (20–50 mg). • 625–1250 micrograms of droperidol.
Post-operative antiemetics: routinely evaluate patients to identify PONV.
Regular intravenous antiemetics should be administered to individuals who are vomiting.
Only mild to moderate nausea can be treated with oral and buccal antiemetics, such as ondansetron 4 mg 6 hours per day, cyclizine 50 mg 8 hours per day, and buccal pro-chlorperazine 12 hours per day.
One challenging and unpleasant side effect of anesthesia and surgery that can lengthen recovery is post-operative nausea and vomiting (PONV). The type of operation and case mix have an impact on the incidence of PONV. According to estimates, the incidence of PONV without prophylaxis is 30% when General Anesthesia is used with inhalational medicines. In addition to being a side effect of post-operative opioids, PONV is also caused by patient-specific variables, especially a history of PONV
Apfel PONV prediction system
Opioids used after surgery (1 point)
Gender - female (1 point) ♀
Non-smoker (1 point)
Motion sickness/PONV history (1 point)
The baseline risk of PONV can be decreased using a number of effective treatments. Among these are:
Steer clear of nitrous oxide (N2O)
avoiding anesthetics that are volatile
reduction of opioids used during and after surgery
Drink enough water.
Ondansetron, unless contraindicated, is one of two antiemetics with distinct mechanisms of action that should be administered to patients at risk for PONV. Usually administered orally (PO)
Preoperative antiemetics can also be administered intravenously. Ondansetron 8–16 mg PO is one preoperative antiemetic that can be administered as a single dosage. Prochlorperazine 3–6 mg buccal or 5 mg tablets PO; Cyclizine 50 mg PO. With the exception of dexamethasone, which is administered at induction.
Intraoperative antiemetics can be administered intravenously (IV) at the conclusion of the procedure: • Dexamethasone 3.3–6.6 mg IV (at induction). • 4 mg of ondansetron. Cyclizine (20–50 mg). • 625–1250 micrograms of droperidol.
Post-operative antiemetics: routinely evaluate patients to identify PONV.
Regular intravenous antiemetics should be administered to individuals who are vomiting.
Only mild to moderate nausea can be treated with oral and buccal antiemetics, such as ondansetron 4 mg 6 hours per day, cyclizine 50 mg 8 hours per day, and buccal pro-chlorperazine 12 hours per day.
- Published on
Surgery - Terminology in surgery
How to describe an operation
The terminology used to describe all operations is a composite of basic
Latin or Greek terms.
First, describe the organ/ area to be operated on
•
lapar- , abdomen (laparus = flank).
nephro- , kidney.
pyelo- , renal pelvis.
cysto- , bladder.
chole- , bile/ biliary system.
ileo- , small bowel (distal).
col(on)- , large bowel.
hystero- , uterus.
thoraco- , chest.
rhino- , nose.
masto/ mammo- , breast.
Second, describe any other parts involved
docho- , duct.
angio- , vessel (blood- or bile- carrying).
litho- , stone.
Third, describe what is to be done
•
otomy, to cut open.
ectomy, to remove (cut out).
plasty, to change shape or size.
pexy, to change position
raphy, to sew together.
oscopy, to look into.
ostomy, to create an opening in (stoma = mouth).
paxy, to crush.
graphy/ gram, image (of).
Lastly, add any terms to qualify how or where the procedure is done
percutaneous, via the skin.
trans- , across.
antegrade, forward.
retrograde, backward.
Examples of terms
Choledochoduodenostomy. An opening between the bile duct and the
duodenum.
Rhinoplasty. Nose reshaping.
Pyelolithopaxy. Destruction of pelvicalyceal stones
Bilateral mastopexy. Breast lifts.
Percutaneous arteriogram. Arterial tree imaging by direct puncture
injection.
Loop ileostomy. External opening in the small bowel with two sides.
Flexible cystourethroscopy. Internal bladder and urethral inspection
How to describe an operation
The terminology used to describe all operations is a composite of basic
Latin or Greek terms.
First, describe the organ/ area to be operated on
•
lapar- , abdomen (laparus = flank).
nephro- , kidney.
pyelo- , renal pelvis.
cysto- , bladder.
chole- , bile/ biliary system.
ileo- , small bowel (distal).
col(on)- , large bowel.
hystero- , uterus.
thoraco- , chest.
rhino- , nose.
masto/ mammo- , breast.
Second, describe any other parts involved
docho- , duct.
angio- , vessel (blood- or bile- carrying).
litho- , stone.
Third, describe what is to be done
•
otomy, to cut open.
ectomy, to remove (cut out).
plasty, to change shape or size.
pexy, to change position
raphy, to sew together.
oscopy, to look into.
ostomy, to create an opening in (stoma = mouth).
paxy, to crush.
graphy/ gram, image (of).
Lastly, add any terms to qualify how or where the procedure is done
percutaneous, via the skin.
trans- , across.
antegrade, forward.
retrograde, backward.
Examples of terms
Choledochoduodenostomy. An opening between the bile duct and the
duodenum.
Rhinoplasty. Nose reshaping.
Pyelolithopaxy. Destruction of pelvicalyceal stones
Bilateral mastopexy. Breast lifts.
Percutaneous arteriogram. Arterial tree imaging by direct puncture
injection.
Loop ileostomy. External opening in the small bowel with two sides.
Flexible cystourethroscopy. Internal bladder and urethral inspection
- Published on
Surgery -medical history and case presentation
Fundamentals
Begin with the individual's name, age, occupation, and the mode of presentation, such as Accident and Emergency (A&E), general practitioner referral, or admission from a clinic.
• Address all key aspects of the comprehensive medical history, as outlined below. Chief complaint This is a concise statement of the patient's primary symptoms, such as "right iliac fossa (RIF) pain," "abdominal pain and vomiting," or "bleeding per rectum (PR)."
• Do not record a diagnosis here in emergency admissions (e.g. ischemia leg). The referral diagnosis may prove to be incorrect. In elective admissions, it is appropriate to state, for example, 'elective admission for anterior resection for rectal cancer.' Chronology of presenting complaint This is a comprehensive delineation or examination of the primary symptom(s) and must encompass the pertinent systems inquiry
. • Begin with pertinent historical context to provide the framework for the presenting issue.
• Prioritize significant positives, such as "right-sided lower abdominal pain, exacerbated by movement and coughing, accompanied by anorexia."
• Include pertinent negatives, such as "no vomiting, no rectal bleeding." Clearly delineate the sequence of events. In a complex history or with numerous symptoms, utilize titles such as 'Previous Episodes/Operations for This Issue,' 'Current Episode,' and 'Results of Investigations.' Systematically summarize the findings of prior investigations: hematological analyses, microbiological assessments, histopathological examinations, radiological evaluations, and specialist diagnostic procedures. Previous medical history
• Enumerate particular medical diagnoses. • Include pertinent negatives, as it is prudent to inquire about cardiorespiratory and renal conditions that influence the patient's operative and anesthetic risk, such as ischemic heart disease (IHD), heart failure, chronic obstructive pulmonary disease (COPD), and renal impairment, in addition to those specific to the presenting complaint, such as neurological diagnoses in neurosurgery or ear, nose, and throat (ENT) conditions, as well as risk factors for atherosclerosis in vascular surgery. •
• Enumerate and date all prior operations. Inquire whether any prior complications associated with anaesthesia. Methodical investigation This is crucial, however frequently overlooked—it is essential to exclude alternative diagnoses (e.g., gynaecological etiology for lower abdomen pain) and to evaluate the patient's surgical and anaesthetic risk
. • Cardiovascular. Chest pain, exertional dyspnoea, orthopnoea, nocturnal dyspnoea, palpitations, edema of the ankles, strokes, transient ischemic attacks (TIAs), claudication.
• Respiratory. Dyspnea, cough, sputum production, wheezing, hemoptysis.
• Gastrointestinal. Anorexia, alteration in appetite, weight reduction (specify the amount and duration).
• Genitourinary (GU). Sexual activity, dyspareunia (intercourse-related pain), abnormal discharge, and last menstrual cycle (all female patients). Neurological. Three Fs: fits; fainting; humorous episodes. Nil by mouth (NBM) duration: what was the last time they consumed food or beverages? for urgent admissions Societal history Inquire regarding the individual responsible for the patient's care. Do they require assistance with mobility and/or activities of daily living?
• History of smoking and alcohol consumption. •
profession.
Two Recommendations for Case Presentation
• Engage in practice. Each instance represents a potential presentation to an individual. Consistently establish the context appropriately. Commence with the individual's name, age, occupation (if elderly, include general fitness and independence), pertinent medical history, mode of referral, and presenting complaint, e.g., ‘78-year-old male, typically fit and well, with a previous history of open anterior resection for rectal adenocarcinoma, presents with a 3-day history of abdominal pain and vomiting.’ • Adhere to a chronological order. Commence with the onset of any pertinent prodrome or accompanying symptoms, as they are likely to constitute a significant aspect of the presenting history, e.g., 'He was in good health until... when he began suffering... the current symptoms commenced...
• Summarize the past medical history succinctly. Only elaborate on aspects that you genuinely believe may be pertinent to the diagnosis or management. •
• Initially, summarize the overall look and vital signs. Present the most critical findings initially, adhering to a methodical approach, such as 'upon examination . . . , during palpation . . . , upon percussion . . . , and by auscultation.'
• Concisely outline further systemic observations. Elaborate on them if they are directly pertinent to the diagnosis or treatment.
• Ultimately, condense and integrate. Attempt to categorize symptoms and indications into clinical patterns that inform the proposed diagnoses or differential diagnosis list.
• Be prepared to discuss which diagnostic or additional evaluation tests may be required.
Fundamentals
Begin with the individual's name, age, occupation, and the mode of presentation, such as Accident and Emergency (A&E), general practitioner referral, or admission from a clinic.
• Address all key aspects of the comprehensive medical history, as outlined below. Chief complaint This is a concise statement of the patient's primary symptoms, such as "right iliac fossa (RIF) pain," "abdominal pain and vomiting," or "bleeding per rectum (PR)."
• Do not record a diagnosis here in emergency admissions (e.g. ischemia leg). The referral diagnosis may prove to be incorrect. In elective admissions, it is appropriate to state, for example, 'elective admission for anterior resection for rectal cancer.' Chronology of presenting complaint This is a comprehensive delineation or examination of the primary symptom(s) and must encompass the pertinent systems inquiry
. • Begin with pertinent historical context to provide the framework for the presenting issue.
• Prioritize significant positives, such as "right-sided lower abdominal pain, exacerbated by movement and coughing, accompanied by anorexia."
• Include pertinent negatives, such as "no vomiting, no rectal bleeding." Clearly delineate the sequence of events. In a complex history or with numerous symptoms, utilize titles such as 'Previous Episodes/Operations for This Issue,' 'Current Episode,' and 'Results of Investigations.' Systematically summarize the findings of prior investigations: hematological analyses, microbiological assessments, histopathological examinations, radiological evaluations, and specialist diagnostic procedures. Previous medical history
• Enumerate particular medical diagnoses. • Include pertinent negatives, as it is prudent to inquire about cardiorespiratory and renal conditions that influence the patient's operative and anesthetic risk, such as ischemic heart disease (IHD), heart failure, chronic obstructive pulmonary disease (COPD), and renal impairment, in addition to those specific to the presenting complaint, such as neurological diagnoses in neurosurgery or ear, nose, and throat (ENT) conditions, as well as risk factors for atherosclerosis in vascular surgery. •
• Enumerate and date all prior operations. Inquire whether any prior complications associated with anaesthesia. Methodical investigation This is crucial, however frequently overlooked—it is essential to exclude alternative diagnoses (e.g., gynaecological etiology for lower abdomen pain) and to evaluate the patient's surgical and anaesthetic risk
. • Cardiovascular. Chest pain, exertional dyspnoea, orthopnoea, nocturnal dyspnoea, palpitations, edema of the ankles, strokes, transient ischemic attacks (TIAs), claudication.
• Respiratory. Dyspnea, cough, sputum production, wheezing, hemoptysis.
• Gastrointestinal. Anorexia, alteration in appetite, weight reduction (specify the amount and duration).
• Genitourinary (GU). Sexual activity, dyspareunia (intercourse-related pain), abnormal discharge, and last menstrual cycle (all female patients). Neurological. Three Fs: fits; fainting; humorous episodes. Nil by mouth (NBM) duration: what was the last time they consumed food or beverages? for urgent admissions Societal history Inquire regarding the individual responsible for the patient's care. Do they require assistance with mobility and/or activities of daily living?
• History of smoking and alcohol consumption. •
profession.
Two Recommendations for Case Presentation
• Engage in practice. Each instance represents a potential presentation to an individual. Consistently establish the context appropriately. Commence with the individual's name, age, occupation (if elderly, include general fitness and independence), pertinent medical history, mode of referral, and presenting complaint, e.g., ‘78-year-old male, typically fit and well, with a previous history of open anterior resection for rectal adenocarcinoma, presents with a 3-day history of abdominal pain and vomiting.’ • Adhere to a chronological order. Commence with the onset of any pertinent prodrome or accompanying symptoms, as they are likely to constitute a significant aspect of the presenting history, e.g., 'He was in good health until... when he began suffering... the current symptoms commenced...
• Summarize the past medical history succinctly. Only elaborate on aspects that you genuinely believe may be pertinent to the diagnosis or management. •
• Initially, summarize the overall look and vital signs. Present the most critical findings initially, adhering to a methodical approach, such as 'upon examination . . . , during palpation . . . , upon percussion . . . , and by auscultation.'
• Concisely outline further systemic observations. Elaborate on them if they are directly pertinent to the diagnosis or treatment.
• Ultimately, condense and integrate. Attempt to categorize symptoms and indications into clinical patterns that inform the proposed diagnoses or differential diagnosis list.
• Be prepared to discuss which diagnostic or additional evaluation tests may be required.
- Published on
Surgery- Prevalent surgical manifestations
Discomfort Any pain should exhibit identical characteristics. This can be encapsulated by the acronym SOCRATES:
Sites - What is the location of the pain? Is it specific to a region or generalized?
Onset- Progressive, swift, or abrupt? Intermittent or continuous?
Character- Acute, penetrating, blunt, throbbing, constricted, painful?
Radiation. Does it disseminate to other regions? Ureteric pain radiates from the loin to the groin; diaphragmatic irritation extends to the shoulder tip; retroperitoneal pain manifests in the back; and myocardial discomfort is referred to the jaw and neck.
Associated symptom-. Nausea, emesis, dysuria, icterus?
Timing-. Does it transpire at a specific time? Factors that exacerbate or alleviate.
Exacerbation of symptoms with respiration, movement, or coughing indicates peritoneal or pleural irritation; alleviation through the application of hot water bottles implies deep inflammatory or infiltrative pain.
Surgical history- Is the pain associated with surgical procedures?
Dyspepsia refers to epigastric discomfort or soreness, typically occurring postprandially. What is the frequency? Is it triggered by eating or does it occur spontaneously? Do milky beverages or foods provide any relief? Is it determined by position?
Dysphagia (impairment in the swallowing process)
Is the symptom recent or chronic? Is it deteriorating rapidly or remaining reasonably stable? Is it more detrimental with solids or fluids? Increased severity with fluids indicates a motility issue rather than a stenosis. Can it be alleviated by any means, such as warm beverages? Can the patient indicate a certain 'level' of obstruction? This frequently corresponds to the degree of an obstructive lesion. Is it linked to 'spluttering' (indicating a tracheoesophageal fistula or aspiration of food/fluid)?
Gastroesophageal reflux
(bitter or acidic fluid in the pharynx or oral cavity). What is the frequency? Which color? Green indicates bile, while white signifies only stomach contents. When does it manifest (exclusively while supine, upon bending, or spontaneously in an upright position)? Is it linked to coughing?
Haematemesis refers to the presence of blood in vomit.
What is the color of blood? (Dark red-brown 'coffee grounds' indicates old or low-volume gastric bleeding; dark red may suggest venous bleeding from the esophagus; brilliant red signifies arterial bleeding, typically from significant gastric or duodenal arteries.) What volume has transpired throughout what duration? Did the blood manifest with the initial episodes of vomiting or only subsequent to a duration of extended vomiting? Indicates a traumatic esophageal etiology.
Abdominal distension
Symmetrical distension indicates one of the '5 Fs' (fluid ascites, flatus from ileus or blockage, fetal presence, adipose tissue, or a substantial mass). Asymmetrical distension indicates a confined bulk. What is the duration of the process? Does it fluctuate? Is it altered by vomiting? Defecation or flatulence?
Alteration in bowel habits
Alterations in frequency or consistency (i.e., increased frequency and looser stools are more likely attributable to a pathogenic etiology). Is it enduring or temporary? Prolonged alteration in bowel habits beyond six weeks necessitates additional examination. Defecation frequency and urgency The recent onset of urgency in feces is typically indicative of a medical condition. What is the level of urgency—how long can the patient postpone treatment? Is there accompanying discomfort? Is the stool normal?
Rectal hemorrhage
What is the color of blood? Pink-red coloration, observed solely on the paper during wiping or splashing in the pan, indicates a potential origin from the anal canal. The presence of bright crimson on the stool's surface indicates a lower rectal origin. Darkened blood with clots or marbled appearance in the stools indicates a colonic origin. Blood thoroughly integrated with the stool or modified indicates a proximal colonic origin.
Tenesmus is the need to defecate accompanied by either an absence of results or a sensation of incomplete evacuation. Indicates rectal pathology.
Jaundice (yellow pigmentation of the skin, sclera, or uvula resulting from hyperbilirubinemia;) What was the rate of jaundice development? Is there accompanying pruritus? Are there any indications of discomfort, fever, or malaise? Indicates infection
Haemoptysis (the presence of blood in sputum). What is the color of blood? Pale pink froth indicates pulmonary edema.) Are there clots or dark blood indicative of infection or an endobronchial lesion? What is the volume of blood? Moderate hemorrhages rapidly jeopardize airways—seek assistance promptly.
Dyspnea (difficulty in or awareness of breathing) When does dyspnea manifest? Assess the magnitude of exertion. Is it determined by position?
• Orthopnea. Assess the difficulty in breathing that arises when supine; quantify it by inquiring about the number of pillows the patient need at night to be asymptomatic.
• Paroxysmal nocturnal dyspnea. Nocturnal intermittent dyspnea. Orthopnoea and paroxysmal nocturnal dyspnoea indicate heart failure.
Claudication (muscle soreness in the calf, thigh, or buttock induced by physical activity and alleviated by rest). At what level of exercise does the pain manifest, considering both flat distances and inclines? What is the rate at which rest alleviates pain?
Rest pain (pain in a limb at rest without substantial exertion). What is the duration of the pain's presence? Is it sporadic? Does it primarily transpire during the nocturnal hours? Is it alleviated by the reliance of the affected limb?
Dysuria (discomfort during urination). At what point does the discomfort manifest (initially, at conclusion, or continuously along the process)? Is the sensation localized to the penis or the suprapubic region? Is it correlated with frequency? Is the pee discolored or does it contain particulate matter?
Hematuria (the presence of blood in urine). Does the hematuria manifest at the onset (indicating a bladder source), during, or at the conclusion (indicating a prostatic or penile source) of the urinary stream? Is there concomitant pain (indicative of infection or nephrolithiasis)?
Discomfort Any pain should exhibit identical characteristics. This can be encapsulated by the acronym SOCRATES:
Sites - What is the location of the pain? Is it specific to a region or generalized?
Onset- Progressive, swift, or abrupt? Intermittent or continuous?
Character- Acute, penetrating, blunt, throbbing, constricted, painful?
Radiation. Does it disseminate to other regions? Ureteric pain radiates from the loin to the groin; diaphragmatic irritation extends to the shoulder tip; retroperitoneal pain manifests in the back; and myocardial discomfort is referred to the jaw and neck.
Associated symptom-. Nausea, emesis, dysuria, icterus?
Timing-. Does it transpire at a specific time? Factors that exacerbate or alleviate.
Exacerbation of symptoms with respiration, movement, or coughing indicates peritoneal or pleural irritation; alleviation through the application of hot water bottles implies deep inflammatory or infiltrative pain.
Surgical history- Is the pain associated with surgical procedures?
Dyspepsia refers to epigastric discomfort or soreness, typically occurring postprandially. What is the frequency? Is it triggered by eating or does it occur spontaneously? Do milky beverages or foods provide any relief? Is it determined by position?
Dysphagia (impairment in the swallowing process)
Is the symptom recent or chronic? Is it deteriorating rapidly or remaining reasonably stable? Is it more detrimental with solids or fluids? Increased severity with fluids indicates a motility issue rather than a stenosis. Can it be alleviated by any means, such as warm beverages? Can the patient indicate a certain 'level' of obstruction? This frequently corresponds to the degree of an obstructive lesion. Is it linked to 'spluttering' (indicating a tracheoesophageal fistula or aspiration of food/fluid)?
Gastroesophageal reflux
(bitter or acidic fluid in the pharynx or oral cavity). What is the frequency? Which color? Green indicates bile, while white signifies only stomach contents. When does it manifest (exclusively while supine, upon bending, or spontaneously in an upright position)? Is it linked to coughing?
Haematemesis refers to the presence of blood in vomit.
What is the color of blood? (Dark red-brown 'coffee grounds' indicates old or low-volume gastric bleeding; dark red may suggest venous bleeding from the esophagus; brilliant red signifies arterial bleeding, typically from significant gastric or duodenal arteries.) What volume has transpired throughout what duration? Did the blood manifest with the initial episodes of vomiting or only subsequent to a duration of extended vomiting? Indicates a traumatic esophageal etiology.
Abdominal distension
Symmetrical distension indicates one of the '5 Fs' (fluid ascites, flatus from ileus or blockage, fetal presence, adipose tissue, or a substantial mass). Asymmetrical distension indicates a confined bulk. What is the duration of the process? Does it fluctuate? Is it altered by vomiting? Defecation or flatulence?
Alteration in bowel habits
Alterations in frequency or consistency (i.e., increased frequency and looser stools are more likely attributable to a pathogenic etiology). Is it enduring or temporary? Prolonged alteration in bowel habits beyond six weeks necessitates additional examination. Defecation frequency and urgency The recent onset of urgency in feces is typically indicative of a medical condition. What is the level of urgency—how long can the patient postpone treatment? Is there accompanying discomfort? Is the stool normal?
Rectal hemorrhage
What is the color of blood? Pink-red coloration, observed solely on the paper during wiping or splashing in the pan, indicates a potential origin from the anal canal. The presence of bright crimson on the stool's surface indicates a lower rectal origin. Darkened blood with clots or marbled appearance in the stools indicates a colonic origin. Blood thoroughly integrated with the stool or modified indicates a proximal colonic origin.
Tenesmus is the need to defecate accompanied by either an absence of results or a sensation of incomplete evacuation. Indicates rectal pathology.
Jaundice (yellow pigmentation of the skin, sclera, or uvula resulting from hyperbilirubinemia;) What was the rate of jaundice development? Is there accompanying pruritus? Are there any indications of discomfort, fever, or malaise? Indicates infection
Haemoptysis (the presence of blood in sputum). What is the color of blood? Pale pink froth indicates pulmonary edema.) Are there clots or dark blood indicative of infection or an endobronchial lesion? What is the volume of blood? Moderate hemorrhages rapidly jeopardize airways—seek assistance promptly.
Dyspnea (difficulty in or awareness of breathing) When does dyspnea manifest? Assess the magnitude of exertion. Is it determined by position?
• Orthopnea. Assess the difficulty in breathing that arises when supine; quantify it by inquiring about the number of pillows the patient need at night to be asymptomatic.
• Paroxysmal nocturnal dyspnea. Nocturnal intermittent dyspnea. Orthopnoea and paroxysmal nocturnal dyspnoea indicate heart failure.
Claudication (muscle soreness in the calf, thigh, or buttock induced by physical activity and alleviated by rest). At what level of exercise does the pain manifest, considering both flat distances and inclines? What is the rate at which rest alleviates pain?
Rest pain (pain in a limb at rest without substantial exertion). What is the duration of the pain's presence? Is it sporadic? Does it primarily transpire during the nocturnal hours? Is it alleviated by the reliance of the affected limb?
Dysuria (discomfort during urination). At what point does the discomfort manifest (initially, at conclusion, or continuously along the process)? Is the sensation localized to the penis or the suprapubic region? Is it correlated with frequency? Is the pee discolored or does it contain particulate matter?
Hematuria (the presence of blood in urine). Does the hematuria manifest at the onset (indicating a bladder source), during, or at the conclusion (indicating a prostatic or penile source) of the urinary stream? Is there concomitant pain (indicative of infection or nephrolithiasis)?
- Published on
Medical Terms -Autistic Behaviour
Amplified egocentric conduct characterized by an absence of receptivity to others. It is defined by highly individualized speech and acts that lack significance to an observer. For instance, the patient may sway their body or repeatedly strike their head on the floor or wall. Autistic behaviors may manifest in children and adults with schizophrenia.
Amplified egocentric conduct characterized by an absence of receptivity to others. It is defined by highly individualized speech and acts that lack significance to an observer. For instance, the patient may sway their body or repeatedly strike their head on the floor or wall. Autistic behaviors may manifest in children and adults with schizophrenia.
