OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
SURGERY – OSCE FOLEY’S TWO WAYS URINARY CATHETER
Blunt end
x Balloon(Prevent self retaining) x
1. What is the use of this object? Drainage of urine from bladder. Fluid management of patient. Measure urine output. 2. What is x for? Passage of distil water through x & inflate the balloon located at the end of the tube in order to keep the catheter inside the bladder. So we call it “self retaining catheter.”(silastic catheter change every 3 months.) 3. What are the indications? Gastrostomy Pt, loss of ANS functions, in cardiac failure. 4. Disadvantages: Connect the external and internal environment. Therefore infection can be spread to exterior to interior. Have to change daily 5. Advantages: Balloon prevent self retaining Blunt end prevent irritation to mucous membrane
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OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
A NASOGASTIC TUBE
1. What is the use of this? For nasogastric feeding. To aspiration gastric secretions or contents before emergency surgeries & in bowel obstruction. Gastric empty because emergency surgery( Road traffic accident)
2. Why is the end of the tube blunt? o To make the tube easy to pass through airway. o To prevent mucous entering the tube & blocking the way – use of two opening in suction tube.
o There are metal boalls in the end to ensure the tube in correct place by using Xray o By applying air we have to auscultate the bubbling sound to ensure the possition
INTERCOSTAL DRAINAGE WITH TROCAR
a Air tube (metal tube) Around this there is a rubber tube
1.
What is the use of this? To do intercostals drain in pneumothorax, haemothorax, haemopneumothorax, pleural effusion & for peritoneal dialysis. 2. What are the advantage of “a” ? “a” is the trocar . a can be pass through a small cut in the skin to pleural space without damaging much tissues. 3. What is location you introduce it? 4th intercostals space in mid axillary line. 2|P a ge
OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
THE AMBU BAG e a c
b d
1. What are “a “s indications? To give oxygen to a Pt. in emergencies lick, Pulmonary oedema. Acute asthmatic attack. Post operative Pt. Pt. with chest injuries. E.g.:- pneumothorax Anaphylactic shock Pt. Head injury Pt. To rehabilitees asthmatic Pt. To ventilate Pt. with respiratory depression. Eg: Morphine overdose To recover from anesthesia. 2. What is “b” for? To connect the ambu bag to the oxygen cylinder. 3. What is “c”? It is face mask it is use to give O2 from the cylinder or ventilate from the ambu bag and also to obtain a good seal. 4. Name “d” & “e” d- Valve to put air into the mask to it inflates. To obtain a good seal around the mouth. e- Connecter.
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OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
CUFFED ENDOTRACHEAL TUBE
a
What are the uses of this tube? To maintain Pt. air way in injured or unconscious Pts. To ventilate unconscious Pts. To give anesthetic drugs.
What is the use of “a”? Inflation of “a” with air helps to keep the tube in position & prevent aspiration. How does this tube an adult differ from that of a young child? In children’s endotracheal tube is a 3.5 mm area which is radio opaque that help to detect the position of the tube in x-rays.
e.g.:-halothane To ventilate pts. In intra oral surgeries. To prevention by use of cuff.
THE TRACHEOSTOMY TUBE a
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OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
1. What are the indications? Acute airway obstruction. e.g.:-forging body. To ventilate Pts following surgeries including oral cavity. To protect the lower airway e.g.:-aspiration of saliva in unconscious Pts. For Pt requiring artificial respiration – respiratory insufficiency. Who has dead space depression 2. What are the advantages? Anatomical dead space is reduced. Work of berating is reduced. Alveolar ventilation is increases. Level of sedation needed for Pts comfort, is reduced. Conscious pts also can apply Not damage to the vocal cords 3. What are the disadvantages? Loss of heat & moisture exchange performed in upper airway. Desiccation of tracheal epithelium. Loss of ciliated cells & metaplasia. Over production of mucous. Mucocilliary stream arrested.(Mucous secretion increase due to irritation) Increase mucous may block the tube. Splitting of the larynx prevent normal swallowing and lead to aspiration. 4. How do you manage tracheostomy post operatively? Suction. Humidification. Change of the inner tube & remove mucous plugging. Physiotherapy. Position the tube & the Pts. 5. What is “a” & what is the use of it? Introducer. Used to insert the tube – reduce tissue damage |& insert to the tracheal hold more easily.
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OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
ANESTHESIA MASK & OXYGEN MASK
Anesthesia mask
Oxygen mask
Its color is black.
It is green and translucent (Simple mask / open mask)
What are the uses of each? To give oxygen from cylinders and inhalation anesthetics (Halothane) To ventilate a pt in an emergency (to a breathing Pt) ex: pulmonary oedema, head injury, shock
IV CANULA Use to establish IV drips, Blood transfusion, Fluid transfusion, Nourishment
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OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
LARYNGOSCOPE
Use to examine the larynx, intubation( placing of tube in to hollow organ), removal of foreign bodies obstructing from larynx
THREE WAY TAP What are the use of this tap? To aspirate blood from the pleural cavity as well as fluid without leaving any where. To give 2 IV drips together To measure central venous pressure To measure arterial blood gases To drain liver abscesses To drain pleural effusion
A
B
Pt
Can be A = Saline, B= Drugs or can be closed one tap
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OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
FLEXIBLE SUCTION CATHETER/ TUBE
1. For what is it use? To suck out secretion from trachea and bronchi To remove the secretion in post operative sites 2. What is the location you introduce it? 5th 6th 7th intercostals space in the mid axillary line Bulbous end present
BLOOD TRANSFUSION SET
A
1. Used for Transfusion of blood 2. What is “a”? The filter 3. What is the advantage? Remove clot and clump formed due to breakdown of cells and rouleux (stock of RBC/ blood clot) formation 4. What is empty chamber? Estimate the rate
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OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
OROPHARYNGEAL AIRWAY What are the uses of it? To depress the tongue preventing the tongue falls back To maintain a pts airway To keep air way pt until recovering from anesthesia
Berman airway
NASOPHARYNGEAL TUBE Keep to pt’s airway empty Indication Epileptic pt(don’t put in mouth) Contraindication Fracture of skull (Bone septa may damaged)
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OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
LARYNGEAL MASK To keep a pt’s airway Ex: In an emergency
IV DRIP SET/INFUSION SET 1. What is it usage? To give electrolytes, colloids, antibodies 2. What is the use of empty chamber? To observe and estimate the amount going in a period of time 3. Why do you an IV drip? To keep the circulating volume constant (roughly 15 drop for 1ml)
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OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
TONGUE DEPRESSOR It is used for lowering down the tongue during oral surgeries or when the need is to visualize oropharynx
PERITONEAL DIALYSIS SET 1. What is the use? To dialysis the peritoneum (semi permeable membrane) in poisoning, acute renal failure, snake bite 2. Advantages Large amount can insert rapidly
Haemodialysis- Use a machine in chronic renal failure
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OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
PACK OF SUTURE MATERIALS WITH NEEDLE Sterile 4/0 cat gut absorbable suture material with round body needle 18G contain conditioning fluid
1. What are the uses of it? Cat gut:
Soft tissue suturing Tracheostomy Mucous membranes Intestine Highly vascular tissue
Needle: Soft tissue suturing Blood vessel Oral tissue 2. What are the advantage and disadvantage of suture material? Advantages Can use in tissues where removal of suture is not done, in young children Disadvantages Can not suture tough tissue like bone and cartilage, can not use in tension tissues like skin Inflammatory tissue elicit a high tissue reaction
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OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
A SYRINGE WITH A NEEDLE Giving drug by injection Subcutaneously or intradermally Withdrawing blood
URINARY THREE WAY CATHETER Used for irrigation of the bladder by using normal saline after surgery Metal catheter used in maternal ward Also used as gastrostomy tube Distil water to inflate Distil water input
Distil water output
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OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
DEXTROSE What are the indications of this? 5% dextrose To replace water deficits post operatively (Dehydration) Fluid management Fasting
50% dextrose To produce with parental nutrition Infuse through CV catheter (Central venous catheter) to ovoid thrombosis, hypoglycemia, hyperkelemia, with insulin To reduce cerebral edema
Identify this described abnormality? This is a skull x ray of a man with a bone eating malignant tumor. This kind of tumors are mostly metastases of thyroid carcinoma , breast cancer.
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OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
1. Name two natural & synthetic osmotic products. Natural:o Fresh Frozen Plasma (FFP) o Albumin 25% Synthetic:o gelatin solutions. E.g.:- gelafundin, haemocoal. o
Dextrans.
a. what are the indication for use? Sevier burns. Hypovolemic shock. Hemorrhage.
b. What are the disadvantages? FFP; risk of disease transmission. Gelatin; allergic reactions. So that>2.5 l/d not infused. Dextrans: interferes with cross matching of blood.
2. What are the indications? Hypovolemia.GI losses. Vomiting. Diarrhea.
0.9%
HS
NaCl
Hartman’s solution
Contra indications: Hypertensive patients. Cardiac failure Renal failure Colloid: crystalloid = 1:3
When crystalloid given only 20% of fluid remains in the vascular comportment after 10 minutes.
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OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
a. By using 25% dextrose how to make 500 ml of 15% dextrose solution.
500ml vial 100ml-25g 500ml-125g
25% D 500× 75=300 125
Needed 15g- 100ml 75g-500ml -300ml contains 75g -Dilute until 500ml
b. How do you make 500ml at 20% dextrose out of this vial using both? 20% dextrose in 500ml 100ml – 29g 500 – 100g
25%D
25%D
c. How do you manage an anemic pt.? Pre operative. Take blood for testing & cross matching. Check for Hb , WBC, platelets. Normal Hb level:-10-15 mg/dl Blood film:- MCV, MCHC, PCV Treat according to the cause: Nutrients – Fe deficiency anemia Drugs FeSO4 200mg 8 hly 4-10 weeks orally Normal Hb level continue for 6 months. B12 & Folic acid can be given for emergency surgery. Can give blood packed cells emergency surgery blood grouping & cross matching – transfusion. 16 | P a g e
OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
d. Pre- operative management of Diabetic pt. Blood – check for sugar levels. If oral hypoglycemic – convert to iv short acting insulin
Take first for surgery. Admit before few days. Maintain blood glucose above normal. Control with drugs. Before surgery give small amount glucose as liquid. Emergency- give insulin IV with dextrose & maintain it.
e. I.
30 g ×1.5 used for infuse, Insulin Reduce pain Minimized mescal damage. Reduce risk of touching other vessels. Used to give subcutaneously or intradermally.
II.
19G × 1.5 used to transfuse blood reduce rupturing of cells for rapid infusion. To give large amount.
III.
25G*1.5 fine needle aspiration (biopsy) when the gauge increases the needle become smaller. e.g. In LA Insulin Vaccines. Adrenaline. Large needle used for: Lumbar puncture. Aspiration fluid from cavities. To withdraw blood. Biopsy. 17 | P a g e
OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION f.
SUMITH & HASHAN
Describe a malignant ulcer
Site Size Shape Margie Edge
Floor Base Regional lymph nodes Surrounding areas
g. O2 & N2O cylinder
O2 cylinder
N2O cylinder
Green in color
h. A 40 year old man patient presented with an ulceration lesion on his right leg above the ankle Take history Onset Duration
Pain Fever Associated diseases
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OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION i.
SUMITH & HASHAN
70 kg man had an operation to remove a part of his mandible due to cancer. How do you maintain fluid and electrolyte balance for the second day after surgery? Fluid and electrolyte balance and fluid replacement For 1st 10kg=100ml/kg So 1st 10kg require 100X10=1000ml For 2nd 10kg =50ml/kg So 10-20 kg require 50X10=500ml Rest of the body weight require 20ml/kg For 50kg 20X50=1000ml Total fluid requirement =25000ml Electrolyte balance Na+ 1-2mmol/kg/g 70kg = 1-2X 70 = 70mmol/d 0.9%NaCl 500ml contains 70mmol of NaCl So 5000ml of 0.9%NaCl is enough to replace Na+ requirement Remain fluid requirement is replaced by 5% dextrose 2000ml KCl 80-100need KCl comes as vials which contain 20mmol of KCl given for 500ml Total vial requirement = 4 vial for 2000ml dextrose Pt at ICU does not give K because due to tissue destruction it can be released to out
j.
How do you insert an endotracheal tube? 1st give suxamethonium Give emla cream or lignocaine spray Depress the tongue with the use of the laryngoscope Turn the tongue to left lateral position Then put the endotracheal tube and inflate the cuff
BUTTERFLY NEEDLE What is used for? To deliver IV drug to children Use in pneumothorax for emergency
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OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
k. I. o
What is and what are the use of this? Monnitol is a diuretic Used to replace depleted volume specially a head injury pt where there is increased intra cranial pressure- to keep the fluid in the intravascular compartment After a crush injury there is extensive muscle damage and release of myoglobins from tissues. they can block the renal tubules. Monnitol push the myoglobin and relieves obstruction.
o
To measure glomerular filtration rate.
o o
What are the contraindications? Less than 5 month babies Because Monnitol tend to accumulate in the body.
II.
l.
Adrenaline-1:8000 concentration I. What are the uses? Cardiac arrest pt 1:1000 Anaphylactic shock pt 1:1000 Local anesthesia 1:8000 (dental procedure) As a treatment of glaucoma Hypertensive pt are not given II. How it give? IM III. Why? IV administration cause arrhythmias m. Atropine-Antimuscarinic parasympathetic blocker
What are the uses? Premedication for anesthetic procedure to reduce secretion Organophosphate poisoning Arrhythmias
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OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
n. I.
II.
What are the complications of giving dextrose? Infections Thrombosis Electrolyte imbalance How do you prevent them? (IV drip infections) Do not give only for one hand Change the site other hand Should give IV nutrition or vitamins
o. Ulcer Site Margin Base
Discharge- present, absent, color, smell Size Edge
Surrounding areaslymph nodes Shape Floor
p. Calculate the 1st 12 hours fluid requirement in this pt Normal daily requirement Fluid loss from burns
= 2.5l =2 X bodyweight X surface area of burns =2 X 70 kg (18+6+1+9+9+9) =2 X 70 X46
9%
=8940ml Total requirement per day
= 25000+ 6440
38%
= 8940ml For the 1st 8 hours
= ½ X 8940ml
9%
1%
9%
=4470ml Next ½ is for the next 16 hours So for the next 4 hours = 4470/16 X 4 = 1117.5ml st So for 1 12 hours = 4470 + 1117.5ml
18%
18%
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OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
q. How many calories do 25ml of 5% dextrin caries energy? 100ml of dextrose =5g So in 25ml = 5/100 X 25 = 1.25g 1g of sugar carries 4 Kcal So 1.25g = 1.25 X 4 = 5 Kcal Ampule Vial
r.
How many vials do you need to replace daily requirement of calories for a 50kg weight pt? 5Kcal/kg/day needed Total daily calorie requirement =calories /kg/day X weight =35 X 50 =1750 Kcal One vial of 50% dextrose carries o 50g dextrose in 100ml o In 25ml – 50/100 X 25 = 12.5g o 1g = 4 Kcal o So that 12.5g = 50Kcal Require number of vials = 1750Kcal/50Kcal =35 vials
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OBJECTIVE STRUCTURE OF CLINICAL EXAMINATION
SUMITH & HASHAN
s. What are the differences between crystalloids and colloids?
Crystalloids (normal saline) o Cheap o No allergic reaction o Do not interfere with blood o Grouping and direct testing o Require volume is more o Risk of pulmonary edema
t.
Colloids ( Monnitol) o Expensive o Elicit allergic reaction o Interferes with blood o Get blood and match before infusion o Fever amount needed o No risk of pulmonary edema
How to recognize a fracture? Eg mandible See along lower border and upper border If there is any discontinuing of the border There is a fracture
Sumith Ruwan Gunawardane
Hashan Lakshitha Wijethunge
D/07/023
D/07/091
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