Showing posts with label TEST. Show all posts
Showing posts with label TEST. Show all posts
Type and Indication of Blood Transfusion
6/13/2009 09:15:00 PM | Author: fadzly
The second short note question would be about blood transfusion. Safe blood products, used correctly, can be life-saving. However, even where quality standards are very high, transfusion carries some risks. If standards are poor or inconsistent, transfusion may be extremely risky. No blood or blood product should be administered unless all nationally required tests have been carried out.


Blood component:
1 A constituent of blood, separated from whole blood, such as:
  • Red cell concentrate
  • Red cell suspension
  • Plasma
  • Platelet concentrates
2 Plasma or platelets
3 Cryoprecipitate, prepared from fresh frozen plasma: rich in Factor VIII and fibrinogen

Plasma derivative
Human plasma proteins prepared under pharmaceutical manufacturing conditions, such as:
  • Albumin
  • Coagulation factor concentrates
  • Immunoglobulins



WHOLE BLOOD
  • 450 ml donor blood
  • 63 ml anticoagulant-preservative solution
  • Haemoglobin approximately 12 g/ml
  • Haematocrit 35%–45%
  • No functional platelets
  • No labile coagulation factors (V and VIII)
Indication
  • Red cell replacement in acute blood loss with hypovolaemia
  • Exchange transfusion
  • Patients needing red cell transfusions where red cell concentrates or suspensions are not available




RED CELL CONCENTRATE
  • 150–200 ml red cells from which most of the plasma has been removed
  • Haemoglobin approximately 20 g/100 ml (not less than 45 g per unit)
  • Haematocrit 55%–75%
Indication
  • Replacement of red cells in anaemic patients
  • Use with crystalloid replacement fluids or colloid solution in acute blood loss

LEUCOCYTE-DEPLETED RED CELLS
  • A red cell suspension or concentrate containing <5>
  • Haemoglobin concentration and haematocrit depend on whether the product is whole blood, red cell concentrate or red cell suspension
  • Leucocyte depletion significantly reduces the risk of transmission of cytomegalovirus (CMV)
Indication
  • Minimizes white cell immunization in patients receiving repeated transfusions but, to achieve this, all blood components given to the patient must be leucocyte-depleted
  • Reduces risk of CMV transmission in special situations
  • Patients who have experienced two or more previous febrile reactions to red cell transfusion




PLATELET CONCENTRATES
Single donor unit in a volume of 50–60 ml of plasma should contain:
  • At least 55 x 109 platelets
  • <1.2>
  • <0.12>
Indications
  • Treatment of bleeding due to:
  • — Thrombocytopenia
  • — Platelet function defects
  • Prevention of bleeding due to thrombocytopenia, suchas in bone marrow failure



FRESH FROZEN PLASMA
  • Pack containing the plasma separated from one whole blood donation within 6 hours of collection and then rapidly frozen to –25°C or colder
  • Contains normal plasma levels of stable clotting factors, albumin and immunoglobulin
  • Factor VIII level at least 70% of normal fresh plasma level
Indications
  • Replacement of multiple coagulation factor deficiencies: e.g.
  • — Liver disease
  • — Warfarin (anticoagulant) overdose
  • — Depletion of coagulation factors in patients receiving large volume transfusions
  • Disseminated intravascular coagulation (DIC)
  • Thrombotic thrombocytopenic purpura (TTP)

CRYOPRECIPITATE
  • Prepared from fresh frozen plasma by collecting the precipitate formed during controlled thawing at +4°C and resuspending it in 10–20 ml plasma
  • Contains about half of the Factor VIII and fibrinogen in the donated whole blood: e.g. Factor VIII: 80–100 iu/ pack; fibrinogen: 150–300 mg/pack
Indication
* As an alternative to Factor VIII concentrate in the treatment of inherited deficiencies of:
— von Willebrand Factor (von Willebrand’s disease)
— Factor VIII (haemophilia A)
— Factor XIII
* As a source of fibrinogen in acquired coagulopathies:
e.g. disseminated intravascular coagulation (DIC)


HUMAN ALBUMIN SOLUTIONS
Prepared by fractionation of large pools of donated plasma

Indication
  • Replacement fluid in therapeutic plasma exchange: use albumin 5%
  • Treatment of diuretic-resistant oedema in hypoproteinaemic patients: e.g. nephrotic syndrome
  • or ascites. Use albumin 20% with a diuretic
  • Although 5% human albumin is currently licensed for a wide range of indications (e.g. volume replacement, burns and hypoalbuminaemia), there is no evidence that it is superior to saline solution or other crystalloid replacement fluids for acute plasma volume replacement

COAGULATION FACTORS

Factor VIII concentrate
  • Treatment of haemophilia A
  • Treatment of von Willebrand’s disease: use only preparations that contain von Willebrand Factor

PLASMA DERIVATIVES CONTAINING FACTOR IX
Prothrombin complex concentrate (PCC)
Factor IX concentrate
  • Treatment of haemophilia B (Christmas disease)
  • Immediate correction of prolonged prothrombin time


read more about“Type and Indication of Blood Transfusion”
, , , | comments (15) |
POSTOPERATIVE MANAGEMENT
6/12/2009 04:49:00 PM | Author: fadzly
End of Posting Written Test
Lolz.. This morning short note test come out to be complication of operation.. Damn i don't like this kinda question. I hate short notes.. really.. But nway, i've made an article for us to look what we've answer and filling all the blanks that we have.. But hey, this is not an answer scheme or what so ever. It just for our understanding and merely a revision before we get ourself into a House Officer..

The role of the junior doctor postoperatively is to check that the patient has recovered from the anaesthetic, look at their observation charts and check their fluid balance. The operation note should have a section on specific postoperative management written by the surgeon, and is a guide that should be followed. For example, following a vascular graft operation — say, to the leg — you should always check the pulses, capillary refill and toe movement in the involved leg to ensure that the graft has not blocked off. A common question for exams concerns complications of surgery.

Complications
All operations carry a risk of complications. These can be divided into general and specific.

* General complications include those pertaining to the anaesthesia itself and those that can occur after any operation, such as a chest infection or DVT.
* Specific complications are those that occur because of the individual operation itself, such as cutting a nerve.

You can subdivide this classification by time, into complications that occur immediately, within the first 24 h; early, within the first week or so; late postoperative, occurring within the first month or so; and long term.

General immediate complications include those due to the anaesthetic, such as direct trauma to the mouth when intubating and reactions to the anaesthetic (inherited disorders or idiosyncratic reactions).

Other early complications including
* Chest infections
* Urinary retention or infections
* Deep vein thrombosis
* Bed sores.

Specific complications depend on the nature of the operation. In this category haemorrhage and wound infection are important.

Haemorrhage
This can be divided into primary, reactionary and secondary haemorrhage.

* Primary haemorrhage occurs during the operation, when a vessel is cut.
* Reactionary haemorrhage is when at the end of the operation the wound looks dry, but when the patient’s blood pressure and cardiac output rise to normal levels, bleeding begins, presumably from vessels that were not properly ligated during the operation.
* Secondary haemorrhage, occurring several days after the operation, is usually attributed to infection that erodes through a vessel.

Wound Infections
These are most commonly caused by S. aureus (increasingly MRSA), although coliforms such as E. coli are also important. Wound infection is more likely if

• The operation is dirty (e.g. abdominal surgery)
• The duration of the operation is long (greater than 2 h)
• The patient is more susceptible (e.g. old age, immunosuppression, diabetes)

Minor wound infections, with a little redness and slight discharge, are relatively common and usually need just simple measures, such as regular wound dressing and perhaps antibiotics. More severe infections, common after abdominal operations, usually occur in the first week or so. The wound looks inflamed, and there may be cellulitis, discharge or localised abscess formation. The wound should be swabbed and maybe antibiotics started, but the only correct treatment for an abscess is drainage. This may mean simply removing a few of the surgical clips, and probing the wound, allowing the pus to discharge, or a further surgical procedure to open up the wound. The wound is then left to heal by secondary intention (i.e. to heal itself from within, with no further suturing).

Wound Dehiscence
This is an uncommon problem. It is usually due to an inadequate repair of the tissues (but infection, poor blood supply, malnutrition and steroids may all play a part in poor wound healing). Dehiscence usually occurs about a week after the operation. A warning sign is a serosanguinous discharge from the wound a few days before. The wound suddenly bursts open and in the case of a laparotomy the bowel protrudes outwards and is extremely alarming for the patient and the nursing staff. Sterile soaked swabs should be placed over the wound and the patient taken back to the theatre for repair.

serasenguinous discharge

An example of general and specific complications pertaining to a - gastrectomy is outlined below.

Click to enlarge

The commonest reason that a junior doctor gets called to the ward is to write up fluids or to see a patient with postoperative pyrexia or poor urine output.

POSTOPERATIVE PYREXIA
A small rise in temperature is common postoperatively. If the temperature spikes above 38'C or persists, then you should consider and look for the seven C's as potential causes. This is a common viva question.

1. Chest. Chest infection
2. Catheter. UTI
3. CVP line. Infected
4. Cannula. Superficial thrombophlebitis (solved by removing the cannula)
5. Cut. Wound infection
6. Collection. Subphrenic or pelvic abscess (may indicate a failure of anastomosis)
7. Calves. DVT (rumbling pyrexia in second postoperative week)

A chest infection is very common postoperatively, especially in patients who smoke or have pre-existing poor respiratory function. The mucus secretions are not cleared; these then clog up the smaller bronchi, which leads to collapse of the air spaces distal to the blockage (atelectasis). Inhaled organisms then infect the collapsed segments. In addition, thoracic and upper abdominal incisions cause pain and stop the patients from coughing up the secretions, and so they are much more likely to have basal atelectasis and develop chest infections. These patients should therefore be given adequate analgesia, have vigorous physiotherapy, and be encouraged
to cough up the phlegm (ideally whilst holding their wounds — applicable for chest and abdominal wounds).

Abscesses
A deep collection, such as a subphrenic or pelvic abscess, can occur after the patient has had generalised peritonitis. The patient usually presents with general malaise, nausea, pain (a subphrenic abscess may also cause pain felt in the shoulder tip), a swinging pyrexia and localised peritonitis.

A pelvic abscess often occurs 4–10 days postop., whereas a subphrenic abscess usually occurs a bit later, 7–21 days postop. Clinically, the patient appears to be recovering well, but then develops a fever and starts to feel unwell. The white cell count may be raised and a collection is identified on ultrasound or CT. Treatment is by drainage, either percutaneously under ultrasound or CT guidance, or by an open procedure. A drain is usually left in situ.

Anastamotic leak
A small anastomotic leak usually causes a localised abscess which becomes sealed off by the omentum and the bowel. Clinically, the patient is slow to recover, but usually improves with intravenous antibiotics and fluids and delayed return to food. A larger anastomotic breakdown causes the patient to be very unwell, with anything from local peritonitis through to a rigid abdomen and septicaemia. The abscess needs to be drained, the peritoneal cavity washed out, and the two ends of the failed anastomosis can be brought out as temporary stomas.

Thrombosis
A diagnosis of DVT and pulmonary embolus (PE) in the first instance is essentially a clinical one, as treatment is usually instituted before definitive diagnosis is made. A PE usually presents with pleuritic chest pain (stabbing and worse on inspiration). The textbooks tend to describe the findings you would see in a massive PE, although more commonly in the smaller PEs the findings are less impressive. Usually, the patient is tachycardic, maybe with a low-grade fever and maybe tachypnoeic, but not much else and they may even be asymptomatic. The ECG usually shows sinus tachycardia (the classic S1Q3T3, which most students know about, occurs when there is a large amount of right heart strain, in a large PE, and is rarely seen). The CXR is usually unhelpful but may show a small area of linear atelectasis.

S1Q3T3

Blood gas analysis is essential and you would expect to find a low PO2 (due to ventilation/perfusion mismatches) and a low PCO2 due to hyperventilation. Examination of the calves may or may not reveal evidence of a DVT. If a DVT or PE is suspected, a heparin infusion can be started before investigation but always check with a senior colleague before doing that, especially if the patient has had recent surgery.

To diagnose a DVT you can use duplex ultrasound (or a venogram). To diagnose a PE you can request a ventilation–perfusion scan, although the gold-standard is pulmonary angiography (note nowadays a spiral CT is used in some centres).

Other less common causes for a fever include infective diarrhoeas, drug reactions and blood transfusion reactions. If faced with a patient with a pyrexia you would obviously find out a little history and examine the patient properly. In a long case exam situation you could answer along the lines of, ‘I would listen to the chest, examine the abdomen, check the cannula sites, inspect the wound, etc. … My investigations would depend on my clinical findings but may involve sending a urine specimen, a full blood count and blood cultures, sending wound swabs or the tip of the central line for culture, etc.’

DRAINS
Collections within a wound (especially if they contain blood) are the perfect medium for colonisation of bacteria and hence infection.

A drain can be used to remove anticipated collections within a wound, but should never be used as a substitute for adequate haemostasis at the time of surgery.

Drains can be closed or open:

Closed drainage includes suction drainage (e.g. Redivac) where the collection is attracted into a container either by gravity or suction. This can then potentially reduce the risk of infection when used for large spaces or cavities, such as after a mastectomy or joint replacement. Drains are usually removed as soon as possible (usually 24–48 h) or as soon as the losses begin to tail off. Drains can also introduce infections and so they should not be left in for any longer than needed.

Open drainage (e.g. a piece of corrugated tubing with one end in the wound and the other in the dressing), allows small losses to escape from the wound. This is often employed in established abscesses after incision and drainage to allow any remaining collection a passage out of the wound. Some surgeons like to withdraw this type of drain in stages to allow the track to collapse behind it.

Other drains commonly asked about in exams include chest drains, T-tubes and percutaneous nephrostomies.

POSTOPERATIVE POOR URINE OUTPUT
This is a common exam question and can be classified as prerenal, renal or postrenal. The commonest causes of failure to pass urine postoperatively are postrenal.

Postrenal problems (commoner in males) include obstruction caused by a large prostate or a blocked catheter. Also, the patient may find initiation of micturition difficult for the following reasons:

1. Anticholinergic drugs or those with alpha adrenergic effects (e.g. the anaesthetic)
2. Pain (e.g. after a hernia repair)
3. Inhibition (e.g. because of strange surroundings or a nurse continually asking them if they have passed urine)
4. Opiates or epidural anaesthetics

Once the bladder reaches a certain volume of distension it fails to function properly and the patient goes into retention. Benign prostatic hypertrophy is an important predisposition and these patients are more likely to go into retention.

Prerenal causes are due to renal hypoperfusion because of either hypovolaemia or heart failure.

Renal causes — Acute renal failure is usually due to acute tubular necrosis.

How to handle?
Junior doctors are commonly called to see patients who have failed to pass urine postoperatively. Often this will be a patient you are covering but have not met before. It is, therefore, worth spending a little time getting a history and reading the patient’s notes. You should find out the type and date of operation and also search for clues pointing to whether the problem is prerenal or postrenal. Ask if there is any pain; an enlarged bladder causes suprapubic pain, although this is difficult to differentiate from pain in an abdominal wound (one exception is when there is an epidural in situ and there is no pain).

On examination you should look for signs of hypovolaemia (dry mucous membranes, decreased skin turgor, tachycardia, etc.), signs of heart failure (shortness of breath, tachycardia, raised CVP or JVP and bibasilar crepitations, peripheral oedema, etc.). A distended bladder palpable just above the pubis is dull to percussion and usually tender, making the patient want to pass urine, when compressed.

You can initially try conservative measures such as analgesia, privacy, sitting in a warm bath, etc., but if that fails then catheterisation is indicated. If you suspect that the cause is postrenal (i.e., distended bladder and discomfort), then the diagnosis is proven by catheterisation. A large residual volume of urine should drain (usually about 500 ml or more).

If the patient already has a catheter in situ, then the catheter should be flushed to ensure it is not blocked. If the urine coming out of the catheter is small amounts of concentrated dark urine, then the cause is likely to be prerenal anyway. You could dipstick the urine, testing for a high specific gravity (more than 1020) to prove this.

You should check the fluid balance charts (IO chart). Observe how much fluid has gone in before, during and since the operation and the measured urine output. Remember that a long laparotomy can lead to large losses of fluid by evaporation and this will not be measured on the charts. A urine output of less than about 30 ml/h is poor (oliguria). The patient should be catheterised anyway at this point to measure the hourly urine output.

U & Es should be sent; if there is a prerenal cause, the urea will be raised. If from your clinical examination and your assessment of the fluid balance charts you think the patient has a prerenal cause, then you should try a fluid challenge.

Fluid Challenge — 250–500 ml of normal saline given as a stat dose (unless you suspect blood loss as the cause, in which case the patient may be shocked and should be given colloids and blood). Then, observe the urine output over the next hour. If the urine output picks up, you have shown the patient to be in need of more fluid and the next bag should be speeded up.

If the patient has heart failure, the urine output will not pick up and the patient may become a little more breathless and the CVP might rise. If this occurs, a bolus dose of a loop diuretic, such as 40 mg of frusemide, will lead to a diuresis and a fall in the CVP. If the patient does not have a central line in at this point, you should ask a senior colleague for advice, as a central line is really necessary for knowing exactly what the state of vascular filling is and will help in the management.

Only after you have excluded a postrenal and a prerenal cause can you assume that there may be a renal problem and acute tubular necrosis has occurred. The creatinine will be raised and you should measure the urine and plasma osmolalities. The ratio of urine to plasma osmolality will be less than 1 (as opposed to prerenal oliguria, where the ratio will be more than 1). Advice from a renal physician should be sought early.

That's all folks.. Hope can help you a bit. I need a great night sleep tonight after tired using my brain for 12 hours straight. Good night.

read more about“POSTOPERATIVE MANAGEMENT”
, , | comments (6) |
The 10th day of my 6 months
4/29/2009 05:47:00 PM | Author: fadzly
Woke up early?

So? What i do today? Got up early in the morning. i mean not early, 9.10 am.. In my timetable given by department, class start at 9.30. I'm not in a rush anyway, because hospital was just nearby my college. Then later when i came, Dr Sajar was there. She claims that she was there waiting us at 8.00.. owh.. so pity.. we all except Syud was coming at 9.30am. Then the dept get one of our phone number so that in case of something happen, they will call us.. Sorry Dr Sajar, she was so busy this week because of the ongoing Master's Exam now. That's why a lot of unknown people in the college currently.

Class

This time she managed to get us a past year questions.. It seems to be simple, but i thought it was challenging. There is 3 scenario question, basically all of them can be in the paper, OSCE or long case. Ok i managed to get the question in my note, roughly let see the question!


Question One

Mrs Tan 38 years old teacher present to the clinic with a 6 months history of lower abdominal pain, bloated, increased flatulance and diarrhoea. She stated that she can pass up to three loose bowel movement per day. There is no fever loss of wt(LOW) and loss of appetite(LOA). She was recently diagnose to have diabetes melitus and is on regular follow up and treatment.

1) What futher hx would you elicit and give reason? (8 marks)
2) Give 3 differential diagnoses (3 marks)

On physical examination, she looks well, in pink, not febrile and not in pain. Her height is 163 cm, and her weight is 67 kg. Abdomen was soft and there was very mild generalized tenderness.

3) What other physical examination and investigation would you like to do? (7 marks)
4) She has went to 4 different GP for the past 6 months and on antacids and antibiotics for her current condition. She request for a scope to be done. How do you respond to her request? (4 marks)
5) Outline the management for this patient (8 marks)


Discussion

This is a typical question in paper 1 for PCM every year. It just so typical that the question will start by asking, what futher hx u would elicit and what are the differentials?

So how to answer?

Read the questions first! Patient having chronic diarrhoea for the past 6 months. What do u think in your mind? Although the first question is what futher hx you want to take, but i usually start the 2nd question. So it will be easier for me to answer the 1st question, isn't it?

The DDx in mind are:
Irritable Bowel Syndrome (IBS)
SE of drugs such antibiotics, antacids, acarbose
DM
Hyperthyroidism
Diverticulosis

So the next things is to elicit history from the DDx above, rite?
Just answer like Steps on History Taking so you wouldn't miss a thing.

History presenting Illness
1) Characteristic of the stools, is it watery, mucous, blood, malaena, soft stool?
2) Any aggravating/relieving factor such as food stressor?
3) Any associated symptom such as nausea or vomiting
4) Patient malnurish? Assess the symptom of hydration status such as cramps, very weak or lethargy, thirsty, reduce urine output.
5) Symptom of thyrotoxicosis such as heat intolerance, increase appetite, reduce weight, eye problems

Then go to past medical and past surgical hx.
DM, HPT? any thyroid surgery - past hyperthyroidism

Drugs Hx
DM- what type of drugs? acarbose, metformin can cause diarrhoea
Antibiotics? Antacids? - can cause diarrhoea also

Dietary Hx?

Family Hx - any GI malignancy in the the first degree relatives?

Social Hx - any stress event occur? such as financial prob, increase workload as a teacher? - stress can induce diarrhoea

So basically, it complete. eventhough u might miss something, but hey, the above answers already make u have 8 out of 8.

Ok 3rd question.

The question already done Abdominal, take her BMI(overweight skit). What other PE?
Hehe.. simple la.. Same principle. Start with vital sign. Temperature, BP, pulse. Then do the Hydration status such as reduce capillary refils, skin turger, sunken eye etc..
Thyroid examination jgn lupa aaa..- Goiter, thyroid eye disease, pulse - AF, thyroid acropathy, proximal myopathy and etc.
Per rectal examination!!
and because patient has DM - check the eyes, peripheral neuropathy
Investigation such as - stools for culture, ova and cyst!!
then DM - we do, urine dipstick, UFEME, renal profile etc.
Haha.. 7 marks already~!

4th question.

4 marks means 4 point to be inserted... This question basically testing your generals knowledge. Even a layman can answer it.. If you meet this type of question, it means, it is a PCM question.

TIPS: PCM will always ask about this and the answer will always rejecting the patient request! The answer should be basically like this:

Firstly i would like to like to assess the patient consern about why she want to do scope? What does the patient thinks? Did she thinks about GI malignancy?
I would tell her that currently patient is not indicated for scope yet.(be in mind what are the indications for endoscopy)
Tell her about the complication if she done the scope such as bleeding, perforation etc, and it is costly wasting your money
But, if after stopping the antibiotic and antacid, patient still having diarrhoea then we can discuss about doing the scope later

Nice isn't it? If you have another type of answer pls do not hesitate to give it at the comment section.
Last.. Outline the management.

Outline management means make it simple. First of all address the issues that the patient having now.
Issues are Diarrhoea, DM, Overweight, Stress, Multiple GP, anxious about malignancy

Diarrhoea can be settle by non pharmaco and pharmaco. Non pharmaco such as stop triggering factors and takes care of her diet and takes plenty of water. Anti-diarrhoea can be given to her.
DM - Compliance to medication, healthy lifestyle, reduce intake of sugar, fats, eat a lot of fibres, reffered her to dietician.
Overweight - Lose weight, excersize regularly 30 minutes and 3 times a week.
Stress - Reduce stress by plan management, sleep adequately.
Reassure again that this is not due to malignancy and give simple explanation about symptom of GI malignancies.

That its.. Penat menaip.. 2nd and 3rd questions will coming.. later.. i nak eat first...

read more about“The 10th day of my 6 months”
, , , , | comments (5) |