surgery revision
DESCRIPTION
TRANSCRIPT
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OSCERevision Class
Dr. Syed Asad AliFCPS
DEPT:OF SURGERY
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Q#1.What does OSCE stands for?
• A)Objective Structured Clinical Examination
• B)Over Stimulation and Crying Event
• C)Opportunity for Showing your Competence and Excellence
• D)All• E)None
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What is OSCE?
The candidates rotate through a series of stations at which they are asked to carry out a various task(usually clinical)
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OSCE includes several "stations" examinees are expected to perform specific clinical tasks within a specified time period . students rotate through a series of stations (as few as 2 or as many as 20).
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TYPES OF OSCE STATIONS
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Osce Stations
• 1.INTERACTIVE• 2.STATIC• 3. INTERSTATION or TAG STATION
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1.Monitored station, where An EXAMINER scores the student's performance, Encounters: patient history, performing a physical examination diagnostic procedure, teaching/counseling/advising a patient. A standardized checklist is used for marking of each station.
INTERACTIVE STATIONS)
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here the student answers questions about the encounter What is your differential diagnosis? What investigations will you order? What treatment will you advise?
2. Interstation or tag station
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a student is asked to answer questions, about 1.Instruments 2.interpret findings such as lab reports x-rays,3.Clinical photographs(spot diagnosis)4.Clinical Scenarios
3.STATIC STATIONS are not observed
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Osce StationsNO:16
•1.INTERACTIVE -4.(1- INTERSTATION or TAG)
•2.STATIC-12
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REST STATIONS
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COMMON QUESTIONS ASKED IN OSCE
• INTERACTIVE STATIONS
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INTRACTIVE-1
• Simulated Patient (Hx taking)
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HISTORY TAKING STATIONS
• 1.Abdominal PAIN/MASS• -EPIGASTRIC• -HYPOCHONDRIAC REGION• -PERI-UMBILICAL /R I FOSSA•
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HISTORY TAKING STATIONS
• 2.DYSPHAGIA• 3.PAIN in the LOIN/FLANK• 4.HEMATURIA• 5.PAINFUL DEFECATION• 6.BLEEDING P/R• 7.HEMETEMESIS/MAELENA• 8.INGUINO-SCROTAL SWELLING• 9.BREAST LUMP• 10.GOITRE• 11.JAUNDICE(Surgical)
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Station Profile
A) Instruction to students: .
Mr.Mohammed is a 22-year-old, presented with sudden pain in periumblical region associated with nausea,vomiting and pyrexia for the last one day.
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Station Profile (cont)
A) Instruction to students:(cont)• You have 4 minutes to assess this patient,
by taking the proper and relevant history• An observer, using a checklist, will assess
your performance while you interact with the patient
• No questions will be asked by the examiner
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Checklist• Student greeted the patient• Introduced her/himself• Asked the patient’s name• Site of pain/• Onset• Duration of pain• Nature of pain
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ChecklistRadiation/ReferralAggravating/Alleviating factorsAssociated featuresChange in appetiteFever –typeBowel functions
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INTERACTIVE-2(Tag Station)
Here the student answers questions about the encounter on Interactive-1.
1.What is your differential diagnosis? 2.What investigations will you order? 3.What treatment will you advise?
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INTERACTIVE-3&4CLINICAL EXAMINATION
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CLINICAL EXAMINATION• 1.Exam of a SWELLING• 2.Exam of ABDOMEN• 3.Exam of THYROID• 4.Exam of PAROTID• 5.Exam of an ULCER• 6.Exam of a BREAST LUMP• 7.Exam of VARICOSE VEINS• 8.Exam of INGUINAL HERNIA• 9.Exam of SCROTUM
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Station Profile
A) Instruction to students: .
Mr.Mohammed is a 22-year-old, presented with this Lump(Swelling) in NECK,BACK,SCALP,FACE etc
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Station Profile (cont)
A) Instruction to students:(cont)• You have 4 minutes to examine this patient, • An observer, using a checklist, will assess
your performance while you examine the patient
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Check list; Examination of a LumpIntroduce self & consent
• Position• Colour and texture of
overlying skin• Temperature• Tenderness• Shape• Size• Surface• Edge
• Hardness• Fluctuance• Fluid thrill• Translucency• Resonance• Pulsatility• Compressibility• Reducibility• Mobility
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A FEW QUESTIONS
• What are your findings• What is your dignosis?• D/D• Investigation• Treatment
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BREAST EXAMINATION
• Introduction and Consent• Inspection
– With the patient sitting– With the patient leaning forward– Arms above head– Push hands into hips
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BREAST EXAMINATION
• Palpation– Start with the normal breast– Arm behind head– All 4 quadrants– Axillary tail
• Examine lymph nodes– Axillary– Cervical
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A few questions...
• What is meant by triple assessment?– Clinical examination– Imaging – mammography and ultrasound– Cytology
• What is the difference between cytology and histology?
• What are the risk factors for breast cancer? What is MRM? What are the risk factors for
breast cancer?
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OSCE SPOTTER STATION
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Spotters
• PAROTID LUMP• Jaundiced patient• Stomas• Cervical
lymphadenopathy• Lipoma• Sebaceous cyst• TG cyst• Hemorrhoid/fistula/
fissure/perianal abscess• Varicose veins
• Multinodular goitre• Diabetic foot • Ulcer-bedsore• Basal cell cancer –face• Gangrene foot/toes• Tongue ulcer/Ranula• Abdominal trauma-
liver/spleen/intestine• Appendix/Meckel`s
diverticulum• Ing:Hernia/Hydrocele
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LOOK at this picture and answer the following question:
• 1.what is your diagnosis?• 2.justify • 3.what is the underlying pathology?• 4.Name 2or 3 investigations• 4.list 3 complications.• 5.mention treatment options.
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Ostomy
•Show a normal stoma
Not painful
Always red and moist
Rose Red Bud
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Loop Colostomy
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Stomas Continued
• Complications– Early
• Haemorrhage• Stoma Ischaemia• High Output• Obstruction (adhesions)• Stoma retraction
– Delayed• Dermatitis,• Stoma Prolapsed• Parastomal hernia• Fistulae• Obstruction
Types of stoma– Temporary– Permanent– End– loop– Counselling– How to manage stomas– Stoma site avoided:
• Bony areas, umbilicus, scars, waistline skin fold & creases
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Look at this operative photograph Look at this operative photograph
-1- Dist = 1.30cm-2- Dist = 0.91cm
Look at this operative photograph
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QUESTIONS
• Identify this organ• What is your diagnosis• List 3-4 clinical features• What complications occur if treatment is
delayed
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Ranula9
• Is a term used for mucoceles that occur in the floor of the mouth.
• The name is derived form the word rana, because the swelling may resemble the translucent underbelly of the frog.
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LOOK at this picture and answer the following question:
• 1.what is your diagnosis• 2.what is the underlying pathology?• 3.list 3 complications.• 4.mention treatment options.
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Table 1 Classification of patients with renal cell carcinoma according to tumor thrombus level
Karnes RJ and Blute ML (2008) Surgery Insight: management of renal cell carcinoma with associated inferior vena cava thrombusNat Clin Pract Urol doi:10.1038/ncpuro1122
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Scar
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Figure 2Parotid lump –pleomorphicadenoma
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Presentation
• Swelling• Dragging pain• Features of complication• H/o increased abdominal • pressure
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48
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50
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Primarysquamous cell
carcinoma of tonguetongue
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CASE SCENARIOS
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QUESTIONS
• 1.What is this lesion.• 2.Name the commonest causes of this
lesion in lower leg.• 3.What are the different parts of this
lesion?• 4.How will you treat this lesion?
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CASE 1.A 28-year-old man presents to the emergency department complaining of anal and lower-back pain for the previous 36 h..The pain is progressively getting worse and he is uncomfortable to walk or sit down. ExaminationInspection of the anus reveals a 3cm 3 cm swelling at the anal margin. The swelling is warm, exquisitely tender
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Questions• What is the diagnosis?• What are the aetiological factors associated with this condition?• How are these lesions anatomically classified?• What treatment is required
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AETIOLOGY
.in 90% of cases the abscess commences as an infection of an
anal gland.
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classification of the perianal abscess:
• Perianal
• Ischiorectal
• High intersphincteric
• Submucous
• Pelvirectal.
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Treatment
1. Incision and drainage may be done under local anesthesia. packing to keep skin edges open.
2. Antibiotics .
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Case Scenario I
• 32 years old male, complaining of painless bleeding per rectum and a palpable lump while abluting. Pt sometimes has mucus discharge and pruritis.
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Scenario I
• What is your provisional Diagnosis?
• What are the investigations you need and why?
• Mention 4 complication in such pt?
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CASE SCENARIO
A 60 years old man, presented to the surgical OPD, complaining of left sided loin pain, associated with occasional hematuria.on examination his left kidney is palpable and U/S shows is mass in the upper pole left kidney,
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Q.#.1.
What is your differential diagnosis?
Q.#.2.
What investigation is now required?
Q.#.3.
Name often relevant investigations for planning management.
Q.#.4.
Mention treatment options.
Questions:Keys:
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Q.#.1. Renal CancerRenal calculusHydonephrosis/Pyonephrosis
Q.#.2. 1. CT Scan (Contrast)2. MRI
Q.#.3. 1. Blood CP2. Lft3. X-Ray Chest4. CT Scan Cheat5. Renal Angiography 6. I/V cavogram7. PET Scan8. Bone Scan
Q.#.4. 1. Minimal Invasive procedure NSS RFA Themal ablaTION1. Surgery Radical Nephrectomy1. CHTH2. RT3. Throsine Knain Inlututor (TKI)4. Inter feron/Interleukin
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50 years male with mass epigastrium moving with respiration, associated with vomiting, wt loss for two months .O/E : Left supraclavicular node palpable A Ba-meal –Ray is ordered which is shown below
CASE
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Questions
Q.#.2.
What is your likely diagnosis?
Q.#.3.
Which investigations is needed to cofirm diagnosis?
Q.#.4.Q#5.
Name any 3investigationto stage the disease.List treatment options
Q#1. Mention the finding on X-ray
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ANSWERS
Q.#.2. Cancer of StomachQ.#.3. Endoscopy/ Biopsy Q.#.4Q#5.
1.CT SCAN 2.EUS 3.PET SCAN 4.Stagging Laparoscopy1.Surgery-Gastrectomy(subtotal/total) Palliative gastrojejunostomy Lymphadenectomy.2.Radiotherapy3.aAdjuvant Chemotherapy
Q#1. Apple core appearance-body of stomach
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SCENARIO
A 62 year-old woman with chief complain of neck mass. Physical exam reveals a thyroid nodule, 2*2*2 cm. Clinically she is Euthyroid.
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Questions:
Q.#.1. What is your diagnosis.
Q.#.2. Name any 3 causes of this lesion.
Q.#.3.Q#4.
Mention any 3 signs which suggest malignancy.List any 3 investigation which will help in diagnosis of this lesion.
Keys:
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Keys:Q.#.1. Solitary Thyroid nodule
Q.#.2. 1.Thyroid cyst2.Thyroid Adenoma3.Thyroid cancer
Q.#.3. 1,Firm to hard nodule2,Fixed nodule
3.Rapid increase in size
4. local invasion -Vocal cord paralysis
-Dysphagia5.Cervica Lymphadenopathy
1.T3,TSH 2. Thyroid scan3. FNA4. Thyroid uptake of I-1315. Ultrasound
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INTERPRETING ABDOMINAL RADIOGRAPHS
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Some common X-rays
• 1.PNEMOPERITONEUM• 2.INTESTINAL OBSTRUCTION• 3.APPEDICOLITH• 4.GALL STONES
AXRs
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Note the absence of bowel gas in the right upper quadrant due to the presence of the liver
S. Rizvi, 07.08.191027th August 2007; 15.14pm
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Biliary tree
Multiple gallstones
Only 10% of gallstones are visible on plain film
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PLAIN ABDO X RAY
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“ERECT
Note the multiple fluid levels
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X-RAY
Small Bowel Obstruction is suggested by a “ladder” pattern, when obstruction occurs, both fluid and gas collect in the intestine.
They produce a characteristic pattern called air-fluid levels. The air rises above the fluid and there is a flat surface at the air-fluid interface.
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COLON
OBSTRUCTION
Distension extends to distil descending colon.
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SBO Vs LBO
Large bowel Small bowel
Peripherally placed dilated bowel
Centrally placed loops dilated bowel
Haustra (do not cross whole diameter of colon; no more than 1/3 of the way across)
Valvulae conniventes extend across whole bowel lumen
Few loops Many loops
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:Extra-luminal gas seen erect CXR.
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KUB X-RAYs• 1.RENAL CALCULUS• 2.URETERIC CALCULUS• 3.VESICAL CALCULUS
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KUB(KIDNEY- URETERS- BLADDER)
THE KUB IS USED AS A SCOUT FILM FOR MANY ABDOMINAL IMAGING STUDIES
RR
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Kidneys
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Bladder Calculus
A large calculus shown in the A large calculus shown in the bladder.bladder.
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CONTRAST X-RAYs of GIT
• 1.BARIUM SWALLOW X-RAY• 2.BARIUM MEAL X-RAY• 3.BARIUM ENEMA X-RAY• 4.CHOLANGIOGRAM
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ACHALASIA CARDIA
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A- For diagnosis:
(1) Barium swallow:(1) Barium swallow:
a.a. Fungating and ulcerative massFungating and ulcerative mass: narrowed irregular filling defect.
b.b. Annular massAnnular mass:
- If middle stricture: Apple core appearanceApple core appearance with evident shouldering
- If lower stricture: Rat tail appearanceRat tail appearance.
Apple core appearance
Cancer lower 1/3 Cancer lower 1/3
Filling defect (ulcerative Filling defect (ulcerative type)type)
Rate tail appearance
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Radiographic appearances : Gastric cancer Focal constricting lesio
n: localized infiltrating carcinoma or localized scirrhous carcinoma - circumferential irregular narrowing of the lumen with rigidity (as figure; involved body and antrum)
bodyantrumbulb
fundus
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Gastric cancer
– No ability to distinguish between malignant and benign ulcers.
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HEPATIC FLEXURE
SPLENIC FLEXURE
TRANSVERSE COLON
CECUM
ASCENDING
COLON
DESEN
DING
COLO
NTERMINAL ILEUM
NORMAL COLON
Normal air contrast barium enema shows filling of colon with air and barium retrograde to the cecum with reflux into the terminal illeum
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COLON CANCER
Barium enema showing apple-core type constricting lesion with proximal dilation of colon—”APPLE -CORE” constricting lesion
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Colonic Carcinoma
• Annular Carcinoma (green arrow) with shelf-like margin (black arrow)
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Ulcerative colitis
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T-TUBE CHOLANGIOGRAPHY
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T-TUBECholangiography : Stricture of common bile duct
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MRCP
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CHEST X-RAYs
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Pleural Effusion
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hemothorax
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Simple Pneumothorax
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Pneumothorax
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XRAY CHEST
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IVUs
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IVP (URETERIC CALCULUS)
Ureteric stone Ureteric stone causing right causing right hydronephrosis.hydronephrosis.
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OSCE-SURGICAL INSTRUMENTS
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The standard questions to be asked:
•What is this instrument?
•Name the parts. •What are its uses? •What complications can arise
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Ryle`s tube:•For gastric aspiration.
•After laparotomy
• Intestinal obstruction
• After anastomosis
Catheter
Distal (inner) end
Proximal (outer) end
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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. What are it`s different parts?
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1. What is the use of this object? Drainage of urine from bladder. Fluid management of patient. Measure urine output. 2. What is the use of 2 channels? 1,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.”2. For drainage of urine
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Used for irrigation of the bladder by using normal saline after surgery Also used as gastrostomy tube
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3. What are the indications? Gastrostomy Pt, loss of Autonomic NS functions, in cardiac failure. 4. Disadvantages: - Connect the external and internal environment. Therefore infection can be spread to exterior to interior.
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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. e.g.:-halothane To ventilate pts. In intra oral surgeries. To prevention by use of cuff.
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.
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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
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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
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2. What are the advantages? Anatomical dead space is reduced. Work of breathing is reduced. Alveolar ventilation is increases. Level of sedation needed for Pts comfort, is reduced. No damage to the vocal cords
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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
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4. How do you manage tracheostomy post operatively? Suction. Humidification. Change of the inner tube & remove mucous plugging. Physiotherapy.
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Vertical limb
Horizontal limb
T- tube
*Indications.
*Time of removal.
Therapeutic uses
Inside common bile duct
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Deaver Retractor
• Common retractor used in major abdominal procedures. Comes in several different widths. May also be used during vaginal procedures.
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Crile hemostatic forceps (curved and straight)
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Bard-Parker #3 scalpel handle
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Needle holder:
*Grasp the needle
for stitching
Blade
Shaft
Handle
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Kocher (Oschner) hemostatic forceps
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Metzenbaum scissors
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Allis tissue forceps
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Babcock tissue (intestinal) holding forceps
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Straight or curved
Doyen Intestinal Forceps
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Stone forceps
( Ureteric, biliary and Bladder):
•Used for
Stone extraction from the ureter, common bile duct and urinary bladder.
Ureteric & Billiary Bladder
Scope on blade
Shaft
Handle
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Moynihan
( Cholecystectomy forcep):
•Used in
Grasping the cystic vessels & cystic duct before their ligation during cholecystectomy operation.
Blade
Shaft
Handle
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156
Above all
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Any Questions ???
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THANK YOU