TEALE FENNING

Nick Raine-Fenning · Posted: Sun Jul 23, 2006 7:28 pm Post subject:

That's a nice question.

We set a similar one last year but that was puerperal pyrexia (amazing how many missed the breast!).

I think you are more likely to get pain after a laparoscopy and pyrexia after a laparotomy as questions in the exam.

I'll leave this to you to bubble for now. I am immersed in EMQs Crying or Very sad

_________________
"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

bronwyn · Posted: Sun Jul 23, 2006 8:34 pm Post subject:

Nothing a pinot grigio sundowner on the beach can't solve Cool

concept
management

category
Gynae surgery

+
29
36 hr post-op
DSU lap adhesiolysis
pyrexia 38

intro

morbidity with op lap: 1.3%
mortality 3-8:100000
cause of litigation
diff diagnosis: gynae (wound infection, endometritis from uterine manipulation, wound infection), urological (UTI/ pyelonephritis, bladder/ ureteral injury), surgical (bowel injury, paralytic ileus), other (DVT/ thrombophlebitis, atelectasis/ LRTI), not related to surgery (appendicitis)

history
Pre-op risk factors (prev abdo surgery, bowel/pelvic adhesions, severe endometriosis/PID, obesity/ excessive thinnes)
Fever/ rigors (infection, bowel injury)
abdo/ suprapubic pain (vowel injury/ UTI)
bowel symptoms/ abdo distension/ N+V
leg/ ggroin pain (DVT)
chest symptoms (atelectasis/ LRTI/ PE)
anorexia & RIF pain (appendicitis)
operative notes (exact nature of procedure, possible complications)
previous medical, surgical and anaesthetic history

examination
general (pallor: haematoma; pyrexia: infection/ bowel injury; tachycardia: infection/ bowel injury; hypotension: septic sock)
Abdo (peritonism: bowel injury/ appendicitis; bowel sounds: ileus; mass: haematoma/ pelvic collection; renal angle tenderness: pyelonephritis)
VE: cervical excitation/ tenderness: infection
PR: bowel/ appendix
calves and groin: DVT/ phlebitis

Investigations
urinalysis/ MSU: infection
AXR: air under diaphragm not reliable as laparoscopic gas still present, dilated bowel loops
CXR: atelectasis/ LRTI/ PE
Bloods: raised WCC, low HB, CRP, UKE, blood cultures
PV swabs: chlamydia and HVS
wound swab
USS pelvis/ abdo
dupllex doppler calves and V/Q scan
IVU; renal tract injury

Treatment
Conservative: IV, IV fluids, NBM, NGT if paralytic ileus suspected
Medical: Antibiotics following septic screen, analgesic, anti-emetic, thromboprophylaxis
Surgical: laparotomy for suspected bowel/ renal tract injury; ureteral stent

follow-up
GOPD 6 months: review initial symptoms and debrief complications and follow up management plan for unresolved and new symptoms

GAPS
multidisciplinary: early surgical/ urological input
document
info: RCOG consent doc for lap surgery
guidelines & audit

Think that's about it! Done for the day now.....exhausted
Need to get down the gym and work on my physical endurance for the exam Embarassed

_________________
Bronwyn Bell
SpR
Portsmouth

Nick Raine-Fenning · Posted: Sun Jul 23, 2006 9:10 pm Post subject:

Pretty good effort after a weekends work - well done.

You certainly seem to have got the right approach and are planning well.

You need to get the plans down to 6 minutes - both you and Raj are saying you are taking 10 minutes.

That's actually pretty good.

You have a few weeks left to practice.

One important lesson from the first few days of this site is to be ultra careful how you read a question. There is no point in formulating a detailed plan and writing a great essay if you miss big areas as you will invariably be limiting your potential mark. You saw on the Essay Writing Technique Course how several marks are awarded for acknowledging and addressing key facts that are provided or not provided in the question.
_________________
"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

bronwyn · Posted: Sun Jul 23, 2006 9:48 pm Post subject:

Have I missed some big areas in this? Or is it just too busy?
Maybe this one's better answered looking at a few important diff diagnosis' and then out lining history, examination etc seperately?
The answer would be similarfor post-op pain, wouldn't it?

Getting Confused

Think I need a nice long theatre list tomorrow for some distraction Sad

_________________
Bronwyn Bell
SpR
Portsmouth

Nick Raine-Fenning · Posted: Sun Jul 23, 2006 10:08 pm Post subject:

No - it's good Exclamation

I've not looked in depth but will do.

I think pain and pyrexia are different. The emphasis in a post-operative pain question would be sinister causes and intra-operative trauma whilst pyrexia is more likely to be benign and require conservative management.

You are probably right in that with such broad topics you should probably take the most common causes and the sinister ones and addess these individually.

Tired myself, but more of EMQs than a lack of energy - they are killing me Evil or Very Mad

_________________
"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

Xerxes I · Posted: Sat Apr 05, 2008 7:53 am Post subject:

Had a similar case last week, On my last day in the previous hospital. did a rather challenging adhesiolysis as daycase, went well we thought. 19 YO, had appendicectomy at 15, chronic pelvic pain.

Came back day2 with T38 and pain. Got a call from the cons who was in theatre with me, saying "thank u for ur f*** present!" in a nice way, I actually thought he is thanking me for the bottle of wine I left for him. He's a very nice guy though.

Anyway, had a CT and I had to read te report three times and didn't understand it, minimal free gas which was expected, no apparent perf, moderate amount of fluid in pelvis and lots of "abnormal tissue planes".

Surgeons decided to take her to theatre, as they don't know how to do a laparoscopy, did their usual up and down incision to find absoloutely NOTHING. Now she's got a lovely scar with all that comes with it Mad

Nick Raine-Fenning · Posted: Sat Apr 05, 2008 8:40 am Post subject:

Xerxes I · Posted: Sat Apr 05, 2008 8:48 am Post subject:

I was being sarcastic but at least in our hospital only two of our surgeos were up to speed with their lap skills and the registrars generally weren't allowed to do lapappendix out of hours.

Would be good to look with a lapx first in the above case but on the other hand, they wouldn' b able to rule out bowel injury with certainty.

I was trying to find out what the role of peritoneal lavage is in this case. I am making this up but could they not have done a lapX, send sme washing to pathology to look for fecal material intraoperatively. I'd imagine if that is negative, you can be sure you haven't got a perf. I might be cmpletely wrong, any thoughts on that? have you seen anyone doing that?