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Medical Terms - Atrophy
Atrophy is the reduction in size or quantity of cells, leading to the shrinkage or degeneration of a tissue or organ. The etiology may be physiological, evident in atrophy of the ovary, brain, and skin, or pathological, as observed in atrophy frequently linked to neurological illnesses or abnormalities of the spleen, liver, and thyroid. This symptom is typically identified through inspection and palpation methods.
Atrophy is the reduction in size or quantity of cells, leading to the shrinkage or degeneration of a tissue or organ. The etiology may be physiological, evident in atrophy of the ovary, brain, and skin, or pathological, as observed in atrophy frequently linked to neurological illnesses or abnormalities of the spleen, liver, and thyroid. This symptom is typically identified through inspection and palpation methods.
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Medical Terms - Attention span decreased
Inability to concentrate selectively on a task while disregarding irrelevant stimuli. Anxiety, emotional distress, and any disorder of the central nervous system may diminish attention span.
Inability to concentrate selectively on a task while disregarding irrelevant stimuli. Anxiety, emotional distress, and any disorder of the central nervous system may diminish attention span.
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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.
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Clinical Surgery – Covid 19 Surgical Practice
Insights from the COVID-19 epidemic Coronaviruses are zoonotic pathogens that typically induce respiratory symptoms in humans. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease 2019 (COVID-19) were recognized as a global pandemic following the World Health Organization's (WHO) declaration of a public health emergency on January 20, 2020. This exceeded prior coronavirus epidemics, including SARS-CoV in 2002 and Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012. The majority of COVID-19 patients have moderate symptoms; however, more severe manifestations include pulmonary edema, severe pneumonia, acute respiratory distress syndrome (ARDS), and sepsis. At-risk populations encompass the elderly, immunocompromised individuals, and those with a body mass index (BMI) exceeding 40. The median incubation period is predicted to be 5.1 days, with additional symptomatic infections unlikely after 14 days of exposure without symptoms.
Severe complications and the magnitude of the disease exerted considerable pressure on global health systems, resulting in substantial compromises to surgical services during the initial wave. Certain surgical services indicated suboptimal outcomes in individuals who either presented with or developed COVID-19 during the perioperative period.
The gold standard for COVID-19 screening is a pharyngeal swab reverse transcriptase polymerase chain reaction (RT-PCR), with a sensitivity of 71–98% and generally requiring over 24 hours for results. Four Rapid testing utilizing lateral flow devices offers a more expedient option, generally within 30 minutes, exhibiting great sensitivity and specificity. A multitude of vaccines have been created, with the initial approval for usage in the UK in late 2020 granted to the Pfizer BioNTech mRNA vaccine and the Oxford AstraZeneca chimpanzee adenovirus-vectored vaccine.
Clinical prioritization
Owing to extensive disruption and bed shortages, all elective surgeries were suspended in the National Health Service (NHS). The Federation of Surgical Specialty Associations (FSSA) categorized cases based on new COVID-19 pandemic criteria
This categorization is beneficial for daily surgical practice, particularly amid ongoing strains on healthcare services, and may be advantageous for trainee doctors to consider. The impact of delays on mortality— the significance of targets The COVID-19 pandemic has underscored the detrimental effects of treatment delays in patients typically managed on an urgent approach. Cancer patients in the UK NHS are often anticipated to be seen within two weeks after referral, known as the '2-week wait (2WW) pathway,' with treatment commencing within two months. Other urgent situations, such as critical limb ischemia, have comparable treatment objectives.
The COVID-19 health care crisis resulted in the postponement of numerous procedures for urgent, life-threatening disorders. In several instances, private hospitals or designated 'COVID-19-free' zones were utilized to maintain surgical or oncological services. A balance existed between decreasing the risk of morbidity or mortality from COVID-19 and the danger posed by the underlying condition. It was established that elderly patients (>80 years) and individuals in high-risk categories had elevated perioperative risk and adverse outcomes when treated in regions with high COVID-19 transmission rates. COVID-19 was linked to increased in-hospital mortality (25–36%) and a heightened risk of thrombotic events, including end-organ ischemia in surgical patients.
FSSA prioritization system
Level
Priority 1a
Category
Emergency Operation Needed within 24h
Example
Ruptured abdominal aorti aneurysm (AAA), laparotom for peritonitis or trauma.
Ear, nose, and throat (ENT) bleeding or airway compromise
Open fracture with neurovascular compromise
Level
Priority 1b
Category
Urgent— operation needed within 72h
Example
Laparotomy for bowel obstruction
Level
Priority 2
Category
Within 4 weeks
Example
Cancer surgery
Level
Priority 3
Category
Within 3 months
Example
Colectomy— inflammatory bowel
disease (IBD)
Level
Priority 4
Category
Can be delayed for >3 months
Example
Elective total knee/ hip replacements
Conversely, preliminary evidence indicated that treatment delays for younger and medically healthier patients resulted in poorer outcomes. Patients with cancer (breast, colorectal, lung, and oesophageal) are estimated to experience an additional 5-year mortality of 6–15% due to delays in diagnosis and treatment caused by pandemic restrictions.Five For individuals with a big aortic aneurysm over 7.0 cm, a treatment delay of over 3 months correlates with a projected mortality rate of 76%, while for abdominal aortic aneurysms more than 6 cm, the rate is between 1.5% and 2%.6 This underscores the significance of prompt examination and intervention in critical situations. The implementation of designated 'pathways,' such as the 2WW system, facilitates the prioritization of such instances.
Remote consultation
To mitigate transmission risk, the majority of outpatient consultations were performed via telephone or video call, accompanied by remote triage prior to the consultation. This has facilitated the continuation of most outpatient services and the priority of urgent referrals. This novel consultation strategy is expected to persist following the COVID-19 pandemic. Investigations must be conducted over the validity of video assessment examinations; hence, a certain capacity for in-person clinics remains necessary. The Royal College of Surgeons England advises against the usage of virtual consultations. • For individuals with high-risk conditions that may require a physical examination or detailed visual assessment of a specific location. When an interior examination is necessary. When the patient's mental condition is inappropriate for a virtual consultation (e.g., dementia).
• For patients who are unable of utilizing remote technology for communication and lack caregiver support to facilitate its use. • In instances when safeguarding issues arise. In such instances, clinical spaces must be equipped with effective procedures, including personal protective equipment (PPE) and symptom screening, to ensure the safety of both patients and clinicians. Infection control protocols: hand hygiene and personal protective equipment The fundamental principles of infection control have been emphasized during the COVID-19 pandemic, yet they are also pertinent to other nosocomial infections, such as methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, and resistant enterobacteria, including vancomycin-resistant Enterococcus (VRE) and carbapenem-resistant Enterobacteriaceae (CPE). Handwashing COVID-19 can persist on surfaces for as long as 9 days.
Consequently, proper hygiene and surface disinfectants are crucial in reducing transmission. Concentrations of alcohol ranging from 60% to 95% are considered appropriate for use; however, handwashing is the preferred method when feasible. According to the WHO, efficient handwashing can prevent the transmission of COVID-19 and many infectious illnesses, including MRSA and C. difficile, by up to 50%. Seclusion Patients who test positive for, or are suspected or proven to have, COVID-19 are isolated in side rooms on the ward and during investigations or surgical operations. During surgery, specific precautions are implemented to reduce contamination of surgical equipment and personnel; post-surgery, the theatre necessitates specialized cleaning protocols. This should be considered while compiling a theatre list, with positive patients preferably deferred to the end of the list. Only essential personnel are permitted in the operating theatre for the induction of patients suspected of having COVID-19 and those with an uncertain COVID status.
Personal protective equipment (PPE) The transmission of COVID-19 via respiratory aerosols has necessitated the stringent implementation of personal protective equipment (PPE) in all clinical settings. Specialized personal protective equipment is recommended during aerosol-generating procedures, including airway intubation, laparoscopy, and specific orthopedic interventions.Training and simulation in surgery While hands-on training in theatre is irreplaceable, adjustments and redeployment during the epidemic have underscored essential complementary facets of surgical practice, such as intensive treatment unit (ITU) administration and communication with patients and their families. Furthermore, there has been an emphasis on simulation training and online education, which has demonstrated significant value in enhancing surgical training and is expected to expand in the future.
PPE types and their indications
Gloves and apron- Contact with blood or body fluids in any setting
Eye protection,mask and goggles or face shield -Risk of splashes or sprays (generally within 1m of patient)
Standard face mask Respirator mask (FFP- 3, N95) -Any clinical area dealing with respiratory fomites (e.g. COVID- 19, tuberculosis),Any surgical procedure,High- risk area or aerosol- generating procedures, e.g. operating theatre, intensive therapy unit) for respiratory formites
Full- length gown and surgical hat (-Any invasive procedure- High- risk area for respiratory fomites
Insights from the COVID-19 epidemic Coronaviruses are zoonotic pathogens that typically induce respiratory symptoms in humans. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease 2019 (COVID-19) were recognized as a global pandemic following the World Health Organization's (WHO) declaration of a public health emergency on January 20, 2020. This exceeded prior coronavirus epidemics, including SARS-CoV in 2002 and Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012. The majority of COVID-19 patients have moderate symptoms; however, more severe manifestations include pulmonary edema, severe pneumonia, acute respiratory distress syndrome (ARDS), and sepsis. At-risk populations encompass the elderly, immunocompromised individuals, and those with a body mass index (BMI) exceeding 40. The median incubation period is predicted to be 5.1 days, with additional symptomatic infections unlikely after 14 days of exposure without symptoms.
Severe complications and the magnitude of the disease exerted considerable pressure on global health systems, resulting in substantial compromises to surgical services during the initial wave. Certain surgical services indicated suboptimal outcomes in individuals who either presented with or developed COVID-19 during the perioperative period.
The gold standard for COVID-19 screening is a pharyngeal swab reverse transcriptase polymerase chain reaction (RT-PCR), with a sensitivity of 71–98% and generally requiring over 24 hours for results. Four Rapid testing utilizing lateral flow devices offers a more expedient option, generally within 30 minutes, exhibiting great sensitivity and specificity. A multitude of vaccines have been created, with the initial approval for usage in the UK in late 2020 granted to the Pfizer BioNTech mRNA vaccine and the Oxford AstraZeneca chimpanzee adenovirus-vectored vaccine.
Clinical prioritization
Owing to extensive disruption and bed shortages, all elective surgeries were suspended in the National Health Service (NHS). The Federation of Surgical Specialty Associations (FSSA) categorized cases based on new COVID-19 pandemic criteria
This categorization is beneficial for daily surgical practice, particularly amid ongoing strains on healthcare services, and may be advantageous for trainee doctors to consider. The impact of delays on mortality— the significance of targets The COVID-19 pandemic has underscored the detrimental effects of treatment delays in patients typically managed on an urgent approach. Cancer patients in the UK NHS are often anticipated to be seen within two weeks after referral, known as the '2-week wait (2WW) pathway,' with treatment commencing within two months. Other urgent situations, such as critical limb ischemia, have comparable treatment objectives.
The COVID-19 health care crisis resulted in the postponement of numerous procedures for urgent, life-threatening disorders. In several instances, private hospitals or designated 'COVID-19-free' zones were utilized to maintain surgical or oncological services. A balance existed between decreasing the risk of morbidity or mortality from COVID-19 and the danger posed by the underlying condition. It was established that elderly patients (>80 years) and individuals in high-risk categories had elevated perioperative risk and adverse outcomes when treated in regions with high COVID-19 transmission rates. COVID-19 was linked to increased in-hospital mortality (25–36%) and a heightened risk of thrombotic events, including end-organ ischemia in surgical patients.
FSSA prioritization system
Level
Priority 1a
Category
Emergency Operation Needed within 24h
Example
Ruptured abdominal aorti aneurysm (AAA), laparotom for peritonitis or trauma.
Ear, nose, and throat (ENT) bleeding or airway compromise
Open fracture with neurovascular compromise
Level
Priority 1b
Category
Urgent— operation needed within 72h
Example
Laparotomy for bowel obstruction
Level
Priority 2
Category
Within 4 weeks
Example
Cancer surgery
Level
Priority 3
Category
Within 3 months
Example
Colectomy— inflammatory bowel
disease (IBD)
Level
Priority 4
Category
Can be delayed for >3 months
Example
Elective total knee/ hip replacements
Conversely, preliminary evidence indicated that treatment delays for younger and medically healthier patients resulted in poorer outcomes. Patients with cancer (breast, colorectal, lung, and oesophageal) are estimated to experience an additional 5-year mortality of 6–15% due to delays in diagnosis and treatment caused by pandemic restrictions.Five For individuals with a big aortic aneurysm over 7.0 cm, a treatment delay of over 3 months correlates with a projected mortality rate of 76%, while for abdominal aortic aneurysms more than 6 cm, the rate is between 1.5% and 2%.6 This underscores the significance of prompt examination and intervention in critical situations. The implementation of designated 'pathways,' such as the 2WW system, facilitates the prioritization of such instances.
Remote consultation
To mitigate transmission risk, the majority of outpatient consultations were performed via telephone or video call, accompanied by remote triage prior to the consultation. This has facilitated the continuation of most outpatient services and the priority of urgent referrals. This novel consultation strategy is expected to persist following the COVID-19 pandemic. Investigations must be conducted over the validity of video assessment examinations; hence, a certain capacity for in-person clinics remains necessary. The Royal College of Surgeons England advises against the usage of virtual consultations. • For individuals with high-risk conditions that may require a physical examination or detailed visual assessment of a specific location. When an interior examination is necessary. When the patient's mental condition is inappropriate for a virtual consultation (e.g., dementia).
• For patients who are unable of utilizing remote technology for communication and lack caregiver support to facilitate its use. • In instances when safeguarding issues arise. In such instances, clinical spaces must be equipped with effective procedures, including personal protective equipment (PPE) and symptom screening, to ensure the safety of both patients and clinicians. Infection control protocols: hand hygiene and personal protective equipment The fundamental principles of infection control have been emphasized during the COVID-19 pandemic, yet they are also pertinent to other nosocomial infections, such as methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, and resistant enterobacteria, including vancomycin-resistant Enterococcus (VRE) and carbapenem-resistant Enterobacteriaceae (CPE). Handwashing COVID-19 can persist on surfaces for as long as 9 days.
Consequently, proper hygiene and surface disinfectants are crucial in reducing transmission. Concentrations of alcohol ranging from 60% to 95% are considered appropriate for use; however, handwashing is the preferred method when feasible. According to the WHO, efficient handwashing can prevent the transmission of COVID-19 and many infectious illnesses, including MRSA and C. difficile, by up to 50%. Seclusion Patients who test positive for, or are suspected or proven to have, COVID-19 are isolated in side rooms on the ward and during investigations or surgical operations. During surgery, specific precautions are implemented to reduce contamination of surgical equipment and personnel; post-surgery, the theatre necessitates specialized cleaning protocols. This should be considered while compiling a theatre list, with positive patients preferably deferred to the end of the list. Only essential personnel are permitted in the operating theatre for the induction of patients suspected of having COVID-19 and those with an uncertain COVID status.
Personal protective equipment (PPE) The transmission of COVID-19 via respiratory aerosols has necessitated the stringent implementation of personal protective equipment (PPE) in all clinical settings. Specialized personal protective equipment is recommended during aerosol-generating procedures, including airway intubation, laparoscopy, and specific orthopedic interventions.Training and simulation in surgery While hands-on training in theatre is irreplaceable, adjustments and redeployment during the epidemic have underscored essential complementary facets of surgical practice, such as intensive treatment unit (ITU) administration and communication with patients and their families. Furthermore, there has been an emphasis on simulation training and online education, which has demonstrated significant value in enhancing surgical training and is expected to expand in the future.
PPE types and their indications
Gloves and apron- Contact with blood or body fluids in any setting
Eye protection,mask and goggles or face shield -Risk of splashes or sprays (generally within 1m of patient)
Standard face mask Respirator mask (FFP- 3, N95) -Any clinical area dealing with respiratory fomites (e.g. COVID- 19, tuberculosis),Any surgical procedure,High- risk area or aerosol- generating procedures, e.g. operating theatre, intensive therapy unit) for respiratory formites
Full- length gown and surgical hat (-Any invasive procedure- High- risk area for respiratory fomites
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Medical Terms-Ballance's sign
A stationary lump or region of dullness identified through palpation and percussion in the left upper quadrant of the abdomen. This may suggest the presence of a subcapsular or extracapsular hematoma subsequent to splenic rupture.
A stationary lump or region of dullness identified through palpation and percussion in the left upper quadrant of the abdomen. This may suggest the presence of a subcapsular or extracapsular hematoma subsequent to splenic rupture.
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Medical Terms - Barlow's sign
A sign of congenital hip dislocation identified within the initial 6 weeks of life. To elicit this sign, position the newborn supine with the hips flexed at 90 degrees and the knees fully flexed. Position your palm over the infant's knee, placing your thumb in the femoral triangle adjacent to the lesser trochanter and your index finger over the larger trochanter. Position the hip in midabduction while applying gentle posterior and lateral pressure with your thumb and posterior and medial pressure with your palm. Upon detecting a click of the femoral head as it dislocates along the posterior rim of the acetabular socket, you have elicited this indication.
A sign of congenital hip dislocation identified within the initial 6 weeks of life. To elicit this sign, position the newborn supine with the hips flexed at 90 degrees and the knees fully flexed. Position your palm over the infant's knee, placing your thumb in the femoral triangle adjacent to the lesser trochanter and your index finger over the larger trochanter. Position the hip in midabduction while applying gentle posterior and lateral pressure with your thumb and posterior and medial pressure with your palm. Upon detecting a click of the femoral head as it dislocates along the posterior rim of the acetabular socket, you have elicited this indication.
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Medical Terms – Ballet Sign
Sign of ballet Ophthalmoplegia, or the paralysis of the extraocular muscles. The patient exhibits an absence of voluntary eye movement control, however demonstrates typical reflexive movements and pupillary light reflexes. This indication signifies thyrotoxicosis.
Sign of ballet Ophthalmoplegia, or the paralysis of the extraocular muscles. The patient exhibits an absence of voluntary eye movement control, however demonstrates typical reflexive movements and pupillary light reflexes. This indication signifies thyrotoxicosis.
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Surgery -Analgesia
Effectively managing a patient's pain during the perioperative period is a fundamental obligation of a surgical student. The advantages of managing acute pain encompass: • Wound healing. • Mobility. • Patient contentment. • Premature hospital discharge. • Decrease in the likelihood of thromboembolic occurrences. In instances of acute pain resulting from trauma, surgery, delivery, or a medical condition, it is crucial to ascertain the location, temporal characteristics, and intensity of the pain. Various approaches are available for evaluating the patient's pain
Techniques for Evaluating Acute Pain
Visual analogue scale (VAS)
-Scored between ‘no pain’ and ‘pain as bad as it can be’
Verbal response score (VRS)
Pain scored as a number, e.g. 4 out of 10, or verbally, e.g.
mild, severe, excruciating
Autonomic response
Sweating, tachycardia, hypertension (HTN)
Dynamic pain scores
Pain on movement; ability to take a deep breath; ability
to cough
The objective of postoperative analgesia is to reduce the dosage of analgesic drugs, hence avoiding side effects, while ensuring sufficient and efficient pain relief. The World Health Organization analgesic ladder This was initially devised for the management of persistent pain associated with cancer. The ladder is being employed to address multiple forms of pain. The technique involves the immediate prescription of analgesics upon the onset of pain and the adjustment of the regimen until the patient achieves pain relief, utilizing the ladder system
Postoperatively, patients will necessitate potent and effective analgesia. The oral route is favored whenever feasible. In the acute postoperative phase or in cases of vomiting, intravenous administration may be necessary.
The intramuscular (IM) method is unpleasant and has inconsistent absorption; it should be avoided when feasible. The analgesic regimen can be titrated down utilizing the World Health Organization (WHO) ladder as the patient convalesces in the days subsequent to the procedure. To guarantee that patients receive consistent and extended analgesia, these should be supplied routinely rather than on an as-needed basis. Adjuvant medicines are agents that augment the efficacy of analgesics, such as anticonvulsants like gabapentin utilized for neuropathic pain.
WHO Pain Relief Ladder
Mild pain
Non-opioid (e.g. aspirin, paracetamol or NSAID) +/− adjuvant
Mild to moderate pain
Weak opioid (e.g. codeine)
+/− non-opioid
+/− adjuvant
Moderate to severe pain
Strong opioid
(e.g. morphine)
+/− non-opioid
+/− adjuvant
Effectively managing a patient's pain during the perioperative period is a fundamental obligation of a surgical student. The advantages of managing acute pain encompass: • Wound healing. • Mobility. • Patient contentment. • Premature hospital discharge. • Decrease in the likelihood of thromboembolic occurrences. In instances of acute pain resulting from trauma, surgery, delivery, or a medical condition, it is crucial to ascertain the location, temporal characteristics, and intensity of the pain. Various approaches are available for evaluating the patient's pain
Techniques for Evaluating Acute Pain
Visual analogue scale (VAS)
-Scored between ‘no pain’ and ‘pain as bad as it can be’
Verbal response score (VRS)
Pain scored as a number, e.g. 4 out of 10, or verbally, e.g.
mild, severe, excruciating
Autonomic response
Sweating, tachycardia, hypertension (HTN)
Dynamic pain scores
Pain on movement; ability to take a deep breath; ability
to cough
The objective of postoperative analgesia is to reduce the dosage of analgesic drugs, hence avoiding side effects, while ensuring sufficient and efficient pain relief. The World Health Organization analgesic ladder This was initially devised for the management of persistent pain associated with cancer. The ladder is being employed to address multiple forms of pain. The technique involves the immediate prescription of analgesics upon the onset of pain and the adjustment of the regimen until the patient achieves pain relief, utilizing the ladder system
Postoperatively, patients will necessitate potent and effective analgesia. The oral route is favored whenever feasible. In the acute postoperative phase or in cases of vomiting, intravenous administration may be necessary.
The intramuscular (IM) method is unpleasant and has inconsistent absorption; it should be avoided when feasible. The analgesic regimen can be titrated down utilizing the World Health Organization (WHO) ladder as the patient convalesces in the days subsequent to the procedure. To guarantee that patients receive consistent and extended analgesia, these should be supplied routinely rather than on an as-needed basis. Adjuvant medicines are agents that augment the efficacy of analgesics, such as anticonvulsants like gabapentin utilized for neuropathic pain.
WHO Pain Relief Ladder
Mild pain
Non-opioid (e.g. aspirin, paracetamol or NSAID) +/− adjuvant
Mild to moderate pain
Weak opioid (e.g. codeine)
+/− non-opioid
+/− adjuvant
Moderate to severe pain
Strong opioid
(e.g. morphine)
+/− non-opioid
+/− adjuvant
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Surgery - Fundamentals of effective prescribing
Optimal prescribing practices The UK GMC delineates the principles of effective prescribing practice (% Duties of a doctor): Stay informed on current laws and regulations. Operate within the boundaries of your expertise—administer treatment solely when you possess sufficient understanding of the patient's condition.
• Deliver effective treatment grounded in the most reliable evidence available. Ensure that the care or treatment you administer aligns with any other therapies the patient is undergoing. Utilize the resources at your disposal, such as the British National Formulary (BNF) app/book, hospital-wide policies (e.g., antibiotic prescribing policy), the ward pharmacist, and the ward intravenous (IV) drug guide. Collaboration In the hospital, numerous healthcare specialists are often consulted for specialized prescribing guidance. Key domains pertinent to surgery encompass the prescription of:
• Analgesics:
• Acute pain team—beneficial for complex pain management requirements following surgery.
Anaesthetists possess proficiency in patient-controlled analgesia (PCA), epidural treatment, and perioperative symptom management.
• Palliative care team— for terminal symptoms.
• Antiemetics (as already mentioned). Antibiotics: for infection care, adhere to hospital antibiotic guidelines as the primary approach; for complex infections, consult with microbiologists or infectious disease specialists.
• Anticoagulants—consult a haematologist for guidance on patients with bleeding issues and the administration of perioperative anticoagulation; utilize the local anticoagulation service for long-term anticoagulation recommendations.
• Intravenous medications—ward nurses (or intensive care unit nurses). General guidance, such as medication reconciliation and interaction advisories, is provided by the ward pharmacist.
• Additional specialty-specific guidance—senior colleagues, advanced nurse practitioners.
Optimal prescribing practices The UK GMC delineates the principles of effective prescribing practice (% Duties of a doctor): Stay informed on current laws and regulations. Operate within the boundaries of your expertise—administer treatment solely when you possess sufficient understanding of the patient's condition.
• Deliver effective treatment grounded in the most reliable evidence available. Ensure that the care or treatment you administer aligns with any other therapies the patient is undergoing. Utilize the resources at your disposal, such as the British National Formulary (BNF) app/book, hospital-wide policies (e.g., antibiotic prescribing policy), the ward pharmacist, and the ward intravenous (IV) drug guide. Collaboration In the hospital, numerous healthcare specialists are often consulted for specialized prescribing guidance. Key domains pertinent to surgery encompass the prescription of:
• Analgesics:
• Acute pain team—beneficial for complex pain management requirements following surgery.
Anaesthetists possess proficiency in patient-controlled analgesia (PCA), epidural treatment, and perioperative symptom management.
• Palliative care team— for terminal symptoms.
• Antiemetics (as already mentioned). Antibiotics: for infection care, adhere to hospital antibiotic guidelines as the primary approach; for complex infections, consult with microbiologists or infectious disease specialists.
• Anticoagulants—consult a haematologist for guidance on patients with bleeding issues and the administration of perioperative anticoagulation; utilize the local anticoagulation service for long-term anticoagulation recommendations.
• Intravenous medications—ward nurses (or intensive care unit nurses). General guidance, such as medication reconciliation and interaction advisories, is provided by the ward pharmacist.
• Additional specialty-specific guidance—senior colleagues, advanced nurse practitioners.
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Symptoms and Signs – Differential Diagnosis of Excessive Weight Gain
Weight gain transpires when caloric intake surpasses the body's energy needs, resulting in augmented adipose tissue accumulation. It may also arise when fluid retention leads to edema. Weight gain due to overeating may primarily stem from emotional issues, particularly worry, guilt, and despair, as well as social influences. In the elderly, weight gain typically indicates a prolonged caloric intake despite the normal, gradual decline in basal metabolic rate. Women experience steady weight growth during pregnancy, while periodic weight gain typically happens during menstruation. Weight gain, a primary indicator of numerous endocrine illnesses, also manifests in conditions that restrict activity, particularly cardiovascular and pulmonary disorders. This may also arise from pharmacological treatments that enhance hunger or induce fluid retention, as well as from cardiovascular, hepatic, and renal conditions that lead to edema.
Medical History and Physical Assessment
Ascertain your patient's historical tendencies of weight fluctuation. Is there a familial history of obesity, thyroid disorders, or diabetes mellitus? Evaluate his dietary and exercise habits. Has his appetite augmented? Does he engage in regular exercise or any exercise at all? Subsequently, inquire about concomitant symptoms. Has he encountered visual abnormalities, dysphonia, paresthesia, or heightened urination and thirst? Has he developed impotence? If the patient is female, has she encountered menstrual irregularities or experienced weight gain during her monthly cycle? Assess the patient's mental condition. Is he experiencing anxiety or depression? Does he exhibit a delayed response? Is his recollection deficient? Which drugs is he now utilizing? During the physical examination, assess skinfold thickness to estimate adipose reserves.
Observe fat distribution, the existence of localized or generalized edema, and overall nutritional status. Examine for further anomalies, including irregular body hair distribution, alopecia, and xerosis. Obtain and document the patient's vital signs.
Etiological Factors
Acromegaly
Acromegaly induces considerable weight gain. Additional findings encompass coarse facial characteristics, prognathism, swollen extremities, hyperhidrosis, seborrheic skin, deepened voice, back and joint discomfort, lethargy, somnolence, and heat sensitivity. Hirsutism may occasionally manifest.
Diabetes mellitus
The heightened appetite linked to diabetes mellitus may result in weight gain, although weight loss may occasionally occur instead. Additional findings encompass weariness, polydipsia, polyuria, nocturia, weakness, polyphagia, and somnolence. Hypercortisolism. Significant weight accumulation, typically localized to the torso and the nape of the neck (buffalo hump), is a hallmark of this condition. Additional cushingoid characteristics encompass slender extremities, a rounded moon face, muscular weakness, purple striae, emotional lability, and heightened vulnerability to infections. Gynecomastia can manifest in males; hirsutism, acne, and monthly irregularities may manifest in females.
Hyperinsulinemia
Hyperinsulinism elevates appetite, resulting in weight gain. Emotional lability, dyspepsia, asthenia, diaphoresis, tachycardia, visual abnormalities, and syncope are also present.
Hypogonadism
Weight gain is prevalent with hypogonadism. Prepubertal hypogonadism results in eunuchoid body proportions, characterized by comparatively sparse face and body hair, as well as a high-pitched voice. Postpubertal hypogonadism results in diminished libido, erectile dysfunction, and infertility.
Dysfunction of the hypothalamus
Conditions like Laurence-Moon-Bardet-Biedl syndrome induce an insatiable appetite leading to weight gain, as well as modifications in body temperature and sleep patterns. Hypothyroidism. In hypothyroidism, weight gain transpires despite starvation. Associated signs and symptoms encompass weariness, cold intolerance, constipation, menorrhagia, diminished intellectual and motor activity, dry, pale, cool skin, dry, thin hair, and thick, brittle nails. Myalgia, dysphonia, diminished deep tendon reflexes, bradycardia, and abdominal distension may manifest. Ultimately, the visage adopts a lackluster demeanor accompanied by periorbital edema.
Assessment of Nutritional Status To evaluate a patient's nutritional condition in cases of significant weight loss or growth, measure skinfold thickness, midarm circumference, and calculate midarm muscle circumference. Skinfold measurements indicate adipose tissue mass, with subcutaneous fat comprising around 50% of the body's total adipose tissue. Midarm measures indicate the mass of both skeletal muscle and fat tissue. Utilize the outlined procedures to obtain these measurements.
Standard anthropometric measurements differ based on the patient's age and sex, as detailed in a chart of normative anthropometric values.
A triceps or subscapular skinfold measurement below 60% of the standard value signifies severe fat reserve depletion, a range between 60% and 90% suggests moderate to mild depletion, and above 90% denotes large fat reserves. A midarm circumference below 90% of the usual value signifies caloric deficiency, whereas a measurement beyond 90% denotes sufficient or abundant muscle and fat. A midarm muscular circumference below 90% signifies protein depletion, while a measurement above 90% denotes sufficient or abundant protein reserves. To assess the triceps skin fold, identify the midway of the patient's upper arm utilizing a non-elastic tape measure. Indicate the middle using a felt-tip pen. Subsequently, pinch the skin with your thumb and forefinger approximately 1 cm above the midpoint. Position the calipers at the middle and apply pressure for approximately 3 seconds. Document the measurement indicated on the handle gauge to the closest 0.5 mm. Obtain two additional readings and calculate the average of all three to mitigate any measurement inaccuracies. To assess the subscapular skin fold, utilize your thumb and forefinger to pinch the skin directly beneath the scapular angle, aligning with the skin's natural cleavage. Utilize the calipers and continue as you would while assessing the triceps skin fold. Subscapular and triceps skinfold measurements are reliable indicators of fat loss or growth during hospitalization. To assess midarm circumference, return to the midpoint previously indicated on the patient's upper arm. Subsequently, employ a tape measure to ascertain the arm circumference at this location. This measurement encompasses both skeletal muscle and adipose tissue mass, aiding in the assessment of protein and caloric reserves. To get midarm muscle circumference, multiply the triceps skinfold thickness (in centimeters) by 3.143, then remove this value from the midarm circumference. Midarm muscular circumference exclusively indicates muscle mass, serving as a more sensitive measure of protein stores.
Metabolic syndrome
Excessive weight gain, especially the accumulation of adipose tissue in the abdominal region or an imbalanced waist-hip ratio (apple shape), constitutes a risk factor for this condition. Additional risk factors encompass hypertension, heightened glucose and insulin concentrations, and irregular cholesterol, triglyceride, and high-density lipoprotein levels. It is estimated that about 50 million individuals in the United States possess metabolic syndrome. Adopting a healthy lifestyle, enhancing dietary habits, reducing weight, and augmenting physical activity are methods to mitigate or postpone the dangers linked to metabolic syndrome.
Nephrotic syndrome
In nephrotic syndrome, weight increase is attributable to edema. In extreme instances, anasarca manifests, resulting in a body weight increase of up to 50%. Associated effects encompass abdominal distension, orthostatic hypotension, and tiredness.
Pancreatic islet cell neoplasm
Pancreatic islet cell tumors induce hyperphagia, resulting in weight gain. Additional observations encompass emotional lability, weakness, malaise, weariness, restlessness, diaphoresis, palpitations, tachycardia, visual abnormalities, and syncope. Preeclampsia. Preeclampsia may present with rapid weight increase (surpassing the typical weight growth during pregnancy), nausea and vomiting, epigastric discomfort, hypertension, and visual disturbances such as blurring or diplopia. Sheehan's syndrome. Sheehan’s syndrome, prevalent in women who have significant obstetric hemorrhage, may result in weight gain.
Additional Causes: Substances
Corticosteroids, phenothiazines, and tricyclic antidepressants induce weight gain due to fluid retention and heightened appetite. Additional medications that may contribute to weight gain encompass hormonal contraceptives, which promote fluid retention; cyproheptadine, which stimulates hunger; and lithium, which can precipitate hypothyroidism.
Psychological treatment may be essential for those experiencing weight gain, especially when it stems from emotional issues or when disproportionate weight distribution affects body image. Exercises for obese patients or those with cardiopulmonary disorders should be strictly monitored. Additional investigation to exclude potential secondary causes should encompass serum thyroid-stimulating hormone assessment and dexamethasone suppression tests. Laboratory test findings for all patients should ideally encompass cardiac risk variables, including serum cholesterol, triglyceride, and glucose levels. Examine the significance of weight management and offer recommendations for suitable physical activity. Furthermore, elucidate the significance of behavior adjustment and adherence to dietary guidelines.
Weight gain in children may be attributed to an endocrine disease, such as hypercortisolism. Additional causes encompass inactivity resulting from Prader-Willi syndrome, Down syndrome, Werdnig-Hoffmann illness, advanced stages of muscular dystrophy, and severe cerebral palsy. Nonpathological factors encompass inadequate dietary practices, inactive leisure activities, and psychological issues, particularly in teens. Irrespective of the reason, dissuade fad diets and offer a comprehensive weight loss regimen. The prevalence of obesity is rising among children. Optimal weights, correlated with minimal mortality rates, rise with age.
Weight gain transpires when caloric intake surpasses the body's energy needs, resulting in augmented adipose tissue accumulation. It may also arise when fluid retention leads to edema. Weight gain due to overeating may primarily stem from emotional issues, particularly worry, guilt, and despair, as well as social influences. In the elderly, weight gain typically indicates a prolonged caloric intake despite the normal, gradual decline in basal metabolic rate. Women experience steady weight growth during pregnancy, while periodic weight gain typically happens during menstruation. Weight gain, a primary indicator of numerous endocrine illnesses, also manifests in conditions that restrict activity, particularly cardiovascular and pulmonary disorders. This may also arise from pharmacological treatments that enhance hunger or induce fluid retention, as well as from cardiovascular, hepatic, and renal conditions that lead to edema.
Medical History and Physical Assessment
Ascertain your patient's historical tendencies of weight fluctuation. Is there a familial history of obesity, thyroid disorders, or diabetes mellitus? Evaluate his dietary and exercise habits. Has his appetite augmented? Does he engage in regular exercise or any exercise at all? Subsequently, inquire about concomitant symptoms. Has he encountered visual abnormalities, dysphonia, paresthesia, or heightened urination and thirst? Has he developed impotence? If the patient is female, has she encountered menstrual irregularities or experienced weight gain during her monthly cycle? Assess the patient's mental condition. Is he experiencing anxiety or depression? Does he exhibit a delayed response? Is his recollection deficient? Which drugs is he now utilizing? During the physical examination, assess skinfold thickness to estimate adipose reserves.
Observe fat distribution, the existence of localized or generalized edema, and overall nutritional status. Examine for further anomalies, including irregular body hair distribution, alopecia, and xerosis. Obtain and document the patient's vital signs.
Etiological Factors
Acromegaly
Acromegaly induces considerable weight gain. Additional findings encompass coarse facial characteristics, prognathism, swollen extremities, hyperhidrosis, seborrheic skin, deepened voice, back and joint discomfort, lethargy, somnolence, and heat sensitivity. Hirsutism may occasionally manifest.
Diabetes mellitus
The heightened appetite linked to diabetes mellitus may result in weight gain, although weight loss may occasionally occur instead. Additional findings encompass weariness, polydipsia, polyuria, nocturia, weakness, polyphagia, and somnolence. Hypercortisolism. Significant weight accumulation, typically localized to the torso and the nape of the neck (buffalo hump), is a hallmark of this condition. Additional cushingoid characteristics encompass slender extremities, a rounded moon face, muscular weakness, purple striae, emotional lability, and heightened vulnerability to infections. Gynecomastia can manifest in males; hirsutism, acne, and monthly irregularities may manifest in females.
Hyperinsulinemia
Hyperinsulinism elevates appetite, resulting in weight gain. Emotional lability, dyspepsia, asthenia, diaphoresis, tachycardia, visual abnormalities, and syncope are also present.
Hypogonadism
Weight gain is prevalent with hypogonadism. Prepubertal hypogonadism results in eunuchoid body proportions, characterized by comparatively sparse face and body hair, as well as a high-pitched voice. Postpubertal hypogonadism results in diminished libido, erectile dysfunction, and infertility.
Dysfunction of the hypothalamus
Conditions like Laurence-Moon-Bardet-Biedl syndrome induce an insatiable appetite leading to weight gain, as well as modifications in body temperature and sleep patterns. Hypothyroidism. In hypothyroidism, weight gain transpires despite starvation. Associated signs and symptoms encompass weariness, cold intolerance, constipation, menorrhagia, diminished intellectual and motor activity, dry, pale, cool skin, dry, thin hair, and thick, brittle nails. Myalgia, dysphonia, diminished deep tendon reflexes, bradycardia, and abdominal distension may manifest. Ultimately, the visage adopts a lackluster demeanor accompanied by periorbital edema.
Assessment of Nutritional Status To evaluate a patient's nutritional condition in cases of significant weight loss or growth, measure skinfold thickness, midarm circumference, and calculate midarm muscle circumference. Skinfold measurements indicate adipose tissue mass, with subcutaneous fat comprising around 50% of the body's total adipose tissue. Midarm measures indicate the mass of both skeletal muscle and fat tissue. Utilize the outlined procedures to obtain these measurements.
Standard anthropometric measurements differ based on the patient's age and sex, as detailed in a chart of normative anthropometric values.
A triceps or subscapular skinfold measurement below 60% of the standard value signifies severe fat reserve depletion, a range between 60% and 90% suggests moderate to mild depletion, and above 90% denotes large fat reserves. A midarm circumference below 90% of the usual value signifies caloric deficiency, whereas a measurement beyond 90% denotes sufficient or abundant muscle and fat. A midarm muscular circumference below 90% signifies protein depletion, while a measurement above 90% denotes sufficient or abundant protein reserves. To assess the triceps skin fold, identify the midway of the patient's upper arm utilizing a non-elastic tape measure. Indicate the middle using a felt-tip pen. Subsequently, pinch the skin with your thumb and forefinger approximately 1 cm above the midpoint. Position the calipers at the middle and apply pressure for approximately 3 seconds. Document the measurement indicated on the handle gauge to the closest 0.5 mm. Obtain two additional readings and calculate the average of all three to mitigate any measurement inaccuracies. To assess the subscapular skin fold, utilize your thumb and forefinger to pinch the skin directly beneath the scapular angle, aligning with the skin's natural cleavage. Utilize the calipers and continue as you would while assessing the triceps skin fold. Subscapular and triceps skinfold measurements are reliable indicators of fat loss or growth during hospitalization. To assess midarm circumference, return to the midpoint previously indicated on the patient's upper arm. Subsequently, employ a tape measure to ascertain the arm circumference at this location. This measurement encompasses both skeletal muscle and adipose tissue mass, aiding in the assessment of protein and caloric reserves. To get midarm muscle circumference, multiply the triceps skinfold thickness (in centimeters) by 3.143, then remove this value from the midarm circumference. Midarm muscular circumference exclusively indicates muscle mass, serving as a more sensitive measure of protein stores.
Metabolic syndrome
Excessive weight gain, especially the accumulation of adipose tissue in the abdominal region or an imbalanced waist-hip ratio (apple shape), constitutes a risk factor for this condition. Additional risk factors encompass hypertension, heightened glucose and insulin concentrations, and irregular cholesterol, triglyceride, and high-density lipoprotein levels. It is estimated that about 50 million individuals in the United States possess metabolic syndrome. Adopting a healthy lifestyle, enhancing dietary habits, reducing weight, and augmenting physical activity are methods to mitigate or postpone the dangers linked to metabolic syndrome.
Nephrotic syndrome
In nephrotic syndrome, weight increase is attributable to edema. In extreme instances, anasarca manifests, resulting in a body weight increase of up to 50%. Associated effects encompass abdominal distension, orthostatic hypotension, and tiredness.
Pancreatic islet cell neoplasm
Pancreatic islet cell tumors induce hyperphagia, resulting in weight gain. Additional observations encompass emotional lability, weakness, malaise, weariness, restlessness, diaphoresis, palpitations, tachycardia, visual abnormalities, and syncope. Preeclampsia. Preeclampsia may present with rapid weight increase (surpassing the typical weight growth during pregnancy), nausea and vomiting, epigastric discomfort, hypertension, and visual disturbances such as blurring or diplopia. Sheehan's syndrome. Sheehan’s syndrome, prevalent in women who have significant obstetric hemorrhage, may result in weight gain.
Additional Causes: Substances
Corticosteroids, phenothiazines, and tricyclic antidepressants induce weight gain due to fluid retention and heightened appetite. Additional medications that may contribute to weight gain encompass hormonal contraceptives, which promote fluid retention; cyproheptadine, which stimulates hunger; and lithium, which can precipitate hypothyroidism.
Psychological treatment may be essential for those experiencing weight gain, especially when it stems from emotional issues or when disproportionate weight distribution affects body image. Exercises for obese patients or those with cardiopulmonary disorders should be strictly monitored. Additional investigation to exclude potential secondary causes should encompass serum thyroid-stimulating hormone assessment and dexamethasone suppression tests. Laboratory test findings for all patients should ideally encompass cardiac risk variables, including serum cholesterol, triglyceride, and glucose levels. Examine the significance of weight management and offer recommendations for suitable physical activity. Furthermore, elucidate the significance of behavior adjustment and adherence to dietary guidelines.
Weight gain in children may be attributed to an endocrine disease, such as hypercortisolism. Additional causes encompass inactivity resulting from Prader-Willi syndrome, Down syndrome, Werdnig-Hoffmann illness, advanced stages of muscular dystrophy, and severe cerebral palsy. Nonpathological factors encompass inadequate dietary practices, inactive leisure activities, and psychological issues, particularly in teens. Irrespective of the reason, dissuade fad diets and offer a comprehensive weight loss regimen. The prevalence of obesity is rising among children. Optimal weights, correlated with minimal mortality rates, rise with age.
