Surgery Shortcut.docx

Surgery Shortcut Shortcut Lump Examination Kidney Stone BPH Varicose Veins Dupuytren

Code LUMPX KSTONEX BPHX VARIX DUPUYTRENX

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Lump Examination - LUMPXM Examination : Lump on ^ , ^ cm in diameter , round shape Smooth surface, -ve tenderness Normal temperature, -ve tansillumination Soft consistency, moves with skin -ve pulsation, -ve fluctuation, irreducible

Kidney Stones – KSTONEX Noted kidney stones on the CT scan, located on the ^ Size ^ mm. No signs of hydronephrosis, no anatomical abnormality Noted previous lab test : ^ Still complaining of pain on the ^ Urine color is clear Possible risk of stone formation : ^ -look at tool Examination : BP : ^ HR : ^ T: ^ Abdomen : soft normal active bowel sounds, -ve hepatosplenomegaly, -ve mass, -ve defans, -ve guarding, -ve bilateral CVA tenderness Diagnostic : FBE, U/E, Calcium, phosphate, Uric acid, PTH Urine MSU and pH CT scan of KUB 24h urine collection for total volume, pH, Calcium, Oxalate, uric acid, citrate, Sodium, potassium and creatinine level Medication :

Tamsulosin for 10-14 days Medical dissolution therapy Uric acid and cystine stone : Potassium citrate 40mEq and Potassium Bicarbonate 20mEmaintain urinary pH 6.5-7.0 Calcium stones : thiazide diuretic and/or potassium citrate 40meQ Management : Refer to dietician Advise to drink at least 2.5L/day with aiming urine production of 2L/day Advise to do surveillance US every 6-12 months Advise referral to urologist for further evaluation and management

BPH – BPHX Symptoms of difficulty of urination Obstructive symptoms : hesitancy, weak urinary stream, intermittency, straining to void, sensation of incomplete bladder emptying Irritative Symptoms : urgency, urge incontinence, frequency nocturia Still sexually active PMH : no prior history of recurrent UTI, no bladder stones, no urinary retention, no renal impariment FH : no prostate cancer Examination : BP : ^ HR : ^ Eyes : -ve signs of cataracts Abdomen : soft, -ve guarding, -ve defans, -ve mass, -ve CVA tenderness Rectal examination : performed with patient consent verbally : Good anal sphinter tone, prostate is firm, -ve nodules, -ve tenderness IPSS Score : ^ Noted US results : size : ^ post residual volume : ^ mL Reason for contact : BPH Diagnostic : FBE, U/E, LFT, PSA US of KUB, prostate Meds : 5 alpha reductase inhibitors – prevent conversion of testosterone to dihydrotestosterone Indication : significant enlarged gland min more than 40mL with obstructive symptoms

check pre treatment PSA then every 6 months Side effect :reduced libido, impotence, reduced ejaculate volume Finasteride 5mg/tab OD – inhibit type 2 isoenzyme only, half live 6 hours, 5mg/day Dutasteride inhibit 5alpha type 1 and 2 isoenzymes, half life 3-5 weeks, 500 ug/day

Alpha blocker – relax smooth muscle by blocking alpha-1 receptor, Prazosin, terazosin, Tamsulosin – Side effect : hypotension, intraoperative floppy iris dynrome Alfuzosin 10mg/day, tamsulosisn 400 ug/day Terazosin 1mg/day to 7 days then titrate up to 5-10mg/day Combined alpha blocker and finasteride Cholinergics Indication : predominantly storage urinary symtoms, low post void residual volume, avoid in postresidual volume >200mL Inhibit bladder contraction Oxybutynin 3.9mg/day path Oral oxybutynin2.5 mg 2-3 times daily, Propantheline 15 mg 2-3 times daily Side effect : dry mouth, Beta 3-adrenoreceptor agonist For overactive bladder syndrome Mirabegron 25mg/day, up to 50mg/day Side effect : increased BP, nasopharyngitis, UTI ADH Desmopressin 50 ug/day up to 675 m/day For men with nocturnal polyuria as predominant symptoms Reduced sodium level, need monitoring

Varicose Vein – VARIX Patient complain of varicosities on both legs since ^ Feels pain on the affected leg. There’s also report of intermittent swelling No report of bleeding, ulceration nor skin discolouration PMH : No previous leg nor pelvic fractures, no superficial nor deep vein thrombosis Obstetrics : ^ Intended future pregnancy : ^ FH : no varicose vein, no DVT nor PE SH : Work as : ^ standing ^ hours per day, ^ days per week Exercise : ^ No recent change in weight

Examination : BP : ^ HR :^ Weight : ^ Height : ^ BMI : ^ Legs : Varicose vein : ^ -ve bipedal oedema -ve skin pigmentation -ve lipodermatosclerosis, -ve fat necrosis, -ve eczema -ve atrophie blanche, -ve active nor healed ulceration Reason for contact : Varicose vein Diagnostic : Duplex ultrasound scan Management : Conservative measures explained : - Elevate foot during lying down Increase level of exercise and walking to improve calf muscle pump - Reducing weight - Avoid prolong standing unless effective hose is worn Advise to use Graduated compressions stocking below-knee with minimum compression of 20300mmHg at ankle. Medications : Advise use of simple analgesics such as Panadol or NSAID Paroven forte Advise referral to General surgeon for possible sclerotherapy, ligation or stripping Notes : Types of vein Telangiectasia (<1mm diameter, intracutaneous Venules (1-2mm) Reticular vein (2-4 mm, zigzag) Tributary varicosities Truncal varicosities : great and short saphenous trunks Dupuytren - DUPUYTRENX Complain of dupuytren contracture of ^ since ^ , gradually getting worse Catches finger at work. Unabale to wear leather gloves No Peyronie's or Ledderhose disease FHx : ^ Examination :

^ deg MCPJ contracture little finger ^ deg PIPJ contracture little finger Pre tendinous cord with pitting +++ Ulnar paresthesia noted Precentra cord to middle finger noted withouth contracture +ve Garrods Pads at BH Management : Xiaflex injection •Patients will be seen if there is a Hideflexion contracture of > 60° of the MCP joint or flexion contracture of > 45° of the PIP joint. Surgery performed when the MCP joint contracture is > 40° or when PIP joint contracture is > 20°. For practical reasons, surgery must be performed before the contracture reaches a fixed flexion deformity of 90° at MCP or 60° at PIP. Splinting and hand therapy are needed after surgery. A night splint is normally worn for 3 months.