Difference between purpura and ecchymoses

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PBL 1 - Structure of synovial joints

Common postoperative problems

Postoperative complications are common, despite good pre-op assessment, surgical technique and perioperative management.

Complications can be minimised by regular and close postoperative patient observation. Managing complications effectively requires quick diagnosis and treatment before the complication gets out of hand.

Postoperative pain

• Pain from surgical wounds should subside over the first few days, and should be controlled by planned analgesia. Some types of wounds (e.g. vertical abdominal incisions) are more painful than others.
• Postoperative pain can be reduced by:
  
  • Preoperative counselling - letting the patient know in advance what to expect after the operation in terms of wounds, IV lines, catheters, extent of pain, plans for pain relief and degree of mobility.
    
  • Peroperative measures - preemptive analgesia to ensure pain does not become established after operation e.g. long acting analgesics, local anaesthetic infiltration into the sound edges, regional nerve blocks, morphine epidurals etc.
    
  • Postoperative analgesia - better to prevent pain than to react to established pain!
    
  
  
• Patients vary in their tolerance for pain and need for analgesics. Anxiety, exhaustion and sleep deprivation all reduce pain tolerance.
  
• If the pain is not controlled by what seems to be a normal dose and frequency of analgesia, complications should be suspected.
  
  • Review dose in relation to expected severity of pain and the weight of the patient.
    
  • Consider local postoperative complications such as haematoma -> wound pain, bleeding into fascial compartment -> compartment syndrome, wound infection -> pain increasing after 48 hours.
    
  
  

Pyrexia

• Infection is not the only cause of postoperative pyrexia, however it should always be considered and investigated as a cause.
• Common postoperative infections include superficial and deep wound infections, chest infections (pneumonia), UTIs and IV cannula site infections.
• Infection is not likely to be a cause in fever developing within 2 hours of surgery - it normally takes longer to develop.
  
• Common non-infective causes of pyrexia include transfusion reactions, drug reactions, wound haematomas, DVT and pulmonary emboli.

Tachycardia

Tachycardia can be benign or malignant.
Benign causes of postoperative tachycardia:

• pain
• anxiety

Malignant causes of postoperative tachycardia:

• infection
• circulatory disturbances
• thyrotoxicosis
• Mild tachycardia can be a sign of incipient hypovolaemic shock resulting from haemorrgahe or dehgydration.
• Cardiac failure.
• AF or flutter.
• Anastomotic leakage - after bowel surgery.
  

Week 2 eve

Well I've officially been in the OC for just over a week. It feels like a lot longer. My emotions tonight are very different to how I felt sitting here at my desk this time last week.

I'm not really nervous about tomorrow (except about getting grilled about pyloric stenosis). I'm actually looking forward to it, although I'm not looking forward to the 6:30am start. The main thing I'm worried about is mucking up my timetable and inadvertently missing a teaching session in the afternoon. I think the only session I have on is a procedural skills one, but I wouldn't bet my life on it.

I'm hoping that this week I can start working out how to come home at the end of the day and do something productive in the afternoon. The main problem so far is in working out what to do. Let's see how tomorrow goes, one day at a time!

Pyloric stenosis

Congenital hypertrophic pyloric stenosis

• Seen in infants as a disorder that affects males three to four times more often than females, occurring in 1 in 300-900 live births.
  
• Familial occurrence implicates a multifactorial pattern of inheritance; monozygotic twins have a high rate of concordance of the condition.
• May occur in association with Turner syndrome, trisomy 18, and esophageal atresia.
  
• The stenosis from hypertrophy, and possibly hyperplasia, of the muscularis propria of the pylorus. Edema and inflammatory changes in the mucosa and submucosa may aggravate the narrowing.

• Regurgitation and persistent, projectile, nonbilious vomiting usually appear in the second or third week of life.
  
• Physical examination reveals visible peristalsis and a firm, ovoid palpable mass in the region of the pylorus or distal stomach.
• Investigations include barium swallow to look for narrowing, blood tests to check for electrolyte imbalances.
  
• A pyloromyotomy - surgical muscle splitting - is curative.

• After surgery, most babies are able to return to normal feedings quickly. The baby starts feeding again 3 to 4 hours after the surgery, and the baby can return to breast-feeding or the formula that he was on prior to the surgery. Because of swelling at the surgery site, the baby may still vomit small amounts for a day or so after surgery. As long as there are no complications, most babies who have undergone pyloromyotomy can return to a normal feeding schedule and be sent home within 48 hours of the surgery.

Acquired pyloric stenosis

• Seen in adults.
• One of the long-term risks of antral gastritis or peptic ulcers close to the pylorus.
  
• Carcinomas of the pyloric region, lymphomas, or adjacent carcinomas of the pancreas are more ominous causes. In these cases, inflammatory fibrosis or malignant infiltration narrow the pyloric channel, producing pyloric outlet obstruction.
  
• In rare instances, hypertrophic pyloric stenosis is the result of prolonged pyloric spasm.

New kids on the block

I’ve got absolutely no idea where to start in describing day 1 in hospital. The morning, and indeed most of the day up until 4pm was the usual orientation stuff – getting id issued, hospital tour etc

I’m doing General Surgery for my first rotation, along with another student, who I’ll call Kate here (all names changed to protect the guilty, remember).

At around 4pm myself and Kate paged our registrar to say hello and find out what time we should turn up tomorrow. He asked if we were close by, and when I said we were in the student’s quarters across the road he asked could we meet him in the ED in 5 mins. We were free for the rest of the afternoon, so why not?

The next few hours we were thrown in the deep end taking histories and doing abdominal physical exams of patients in the ED. Although we had just done this stuff last year, I felt so ill-prepared.

Our reg is a lovely, lovely guy, more than a little crazy and I have no doubt that in the next 4 weeks we are going to learn a hell of a lot, and have fun in the process. He is not of the old-school humiliate-your-students-into-learning way of teaching, but will teach us what we are seeing on the day, and expect us to go and learn about it that night, instead of drilling the crap out of us when it’s the first time we are seeing a given case.

Things were off to an eeirily rosy start, right up until we met our consultant. This week is not a good week to get sick because the teams across the state are basically rebuilt from the ground up: brand new interns first week out of uni, new registrars etc. Chaos.

Our reg hadn’t even met his consultant right up until the consultant walked into the room where I was interviewing a patient who presented earlier that day with a palpable mass and right groin pain. Not long after the consultant walked in, our reg walked in. Not long after he walked in, Kate walked in. Our consultant had obviously had enough of people walking in the room, because he then yelled at us all to get out. The reg was mortified and apologized that we had to witness that. He’d never seen anyone act like that before.

Since then he has talked to the consultant who has calmed down and is apparently apologizing to us tomorrow morning. Talk about drama. Let’s see how this unfolds tomorrow!

New beginnings

The first two years of college are vocabulary lessons.
The second two years are spent learning who to ask and where to look it up.
--Bill Austin

Today was my second day of 3rd year.

Yesterday was spent at uni, in a lecture theatre full of our entire 200-and-something person cohort hearing all about the structure of this year - our rotations, our assessments, how to do Honours, what forms we have to have filled in and hoops we have to have jumped by the end of this year. All this information is summarised in a 70 page handbook. After 6 hours of that, it was all a bit much.

Today was spent at hospital, finding out in more detail where we are expected to be when, what rotations we will be doing, which groups we are in for the different course components, all of which was laid out in a mere 120 pages.

Talk about information overload. I still have no clue exactly what I should and will be doing next week, and I'm still petrified I'll get to the end of this year and realise that I haven't completed some important task such as witnessing an autopsy or performing a PR.

I was alarmed to hear from several speakers that this year is the toughest year of our course. In a lot of ways I feel like I only made it through last year by the skin of my teeth - both in academic terms, and in terms of motivation and sanity. I'm not sure if I have recovered even now.

It's a bit disheartening to hear that even after this year everyone still feels like they are below the curve, despite that fact that this in the year in which we develop most of the clinical skills that will take us through our career. We have been warned finishing this year with big gaps will leave us no future chance to gain the knowledge we missed this year. This is our chance and we need to work our assess off to make the most of it.

In a lot of ways I am exhausted already. I have no idea how I am going to feel next week once this caper gets going properly, let alone 6 months from now when another barrier exam starts looming large.

Today we were encouraged to spend time every day reflecting on what we have seen and learnt in the hospital, and to make a log of it if we can. To remember the patients we see as people, to see the human side of the diseases we learn about. That's how to learn and remember it, how to make it important to us.

Although this is no easy task, that’s why I'm starting this new blog. It's going to be both my log book, and my developmental portfolio.

All names and particulars will be changed to protect both the guilty and the innocent.