TANES

Plan of
treatment
Final Diagnosis

Investigations

Differential
Diagnosis
Complete
History And
Clinical
Examination
1. To confirm the diagnosis
2. To assess severity or extent
of the disease
3. To assess the general
condition of the patient
(i.e. fitness for surgery).
Blood and urine
ECG
Imaging
Endoscopy
Tissue sampling
 Appropriate monitoring and repeated clinical
assessment are required, along with support
for all major organ systems, including
cardiorespiratory function, renal function and
fluid and electrolyte balance, and awareness
for signs of early surgical complications such as
bleeding and infection.
The purposes of routine pre-operative tests are
to assess whether the patient may have any
pre-existing health problems, to identify any
medical conditions unknown to the patient, the
prediction of post-operative complications.
Complete blood count (CBC)
Urinalysis (FEME)
Urea, creatinine, electrolytes,
glucose
Coagulation profile
Biochemical profiles
Pregnancy
 Pre-operative FBC also acts as a baseline for
comparison with post-operative testing.
Pre-operative serum biochemistry testing
generally includes assessment of urea &
creatinine and electrolytes.
Abnormalities of serum potassium
concentrations should be highlighted to
anaesthetic staff pre-operatively and corrected
where possible, due to a risk of cardiac arrest
with agents such as suxamethonium
 Pre-operative liver function tests should be
performed in those with established cirrhosis
or a history of liver disease, or excessive
alcohol intake.
pre-operative clotting screens should only be
performed in selective groups, namely those
with a history of a bleeding disorder, liver
disease, or malnutrition, or patients on
anticoagulants (warfarin, heparin)
 CBC:(RBCs, WBCs
and platelets)

ESR (erythrocyte
sedimentation rate)

Glucose
 Serum Bilirubin

Serum creatinine

Serum Alkaline phosphate

Serum uric acid

Serum urea
Coagulation Parameters
Prothrombin time PT 11-14 seconds

Partial thromboplastin
PTT 25-35 seconds
time

International
normalized ratio INR 0.8 to 1.2
 Glucose..........................117 mcg/dl...(80-120)
BUN (blood urea nitrogen)........24 mg/dl...(8-29)
Creatinine......................0.8 mg/dl...(0.4-1.2)
Sodium (Na)......................140 mEq/l...(139-164)
Potassium (K)....................5.2 mEq/l...(4.4-6.1)
Chloride.........................104 mEq/l...(10-118)
CO2 (carbon dioxide).............22 mEq/l...(22-285)
Calcium.........................9.6 mg/dl...(9.4-11.6)
Phosphorus.......................5.6 mg/dl...(2.5-6.2)
Total Protein (TP)...............6.3 gm/dl...(5.8-8.1)
 Albumin..........................2.9 gm/dl...(2.6-4)
Bilirubin........................0.6 mg/dl...(0.2-0.7)
Cholesterol......................204 mg/dl...(129-330)
Triglyceride.....................82 mg/dl...(36-135)
ALKP (alkaline phosphatase)......65 U/l...(20-70)
AST (asparate aminotransferase)..30 U/l...(14-42)
ALT (alanine aminotransferase)...45 U/l...(15-52)
GGT (gamma-glutamyl transferase).5 U/l...(1-12)
Amylase..........................850 U/l...(280-950)
CK (creatine kinase).............47 U/l...(0-130)
ECG & IMAGING

Priyesh Nair
 Electrocardiogram

To evaluate perioperative cardiac risk

To prevent complication during surgery
Indication

Patient > 50 years old

History of heart disease
Diabetes, dyslipidemia,hypertension
Smoking
 IMAGING MODALITIES

Plain x-ray CT scan

Contrast x- MRI scan
ray Radioisotope
Ultrasound scan
scan
 Plain x-rays
To identify intestinal obstruction, urinary
tract stones, free intra-abdominal air and
fluid
Plain x-rays
 Plain x-rays

Advantages Disadvantages

-Used widely -Soft tissues

- Not expensive poorly
visualized
-Radiation
 Ultrasound scans
Produces an image from the echoes of ultrasound
waves that are sent through tissues.
Primary investigation of the biliary tree for gall stones,
bile duct size, liver parenchyma
Investigation of suspected pelvic collection
Assessment of liver/splenic parenchyma
Identify free fluid in abdominal trauma
Ultrasound scans
 Ultrasound scan
Advantages Disadvantages
No radiation Expert
Non invasive interpretation
Investigate soft Lesions may be
tissues missed
Can assess
movement
Real time
images
 Doppler scan
Doppler imaging is widely used to evaluate blood flow
through artery and vein
Blood flowing away from the heart is red
Blood flowing towards the heart shows up as blue
Doppler scan turbulent flow
Endoscopic ultrasound
 CT scan
Computer-processed combinations of
many x-rays from multiple angles, a three
dimensional x-ray image of a part of the
body.
Uses:
Primary assessment of all intra-abdominal
masses
Staging of intra abdominal and pelvic
malignancy
Investigate acute abdominal pain from
unknown origin
In suspected intestinal obstruction
In pancreatic, biliary, visceral vessel
assessment
Suspected post operative complication
CT scan
 CT scan
Advantages Disadvantages
-Shows exact -High
anatomical radiation
details dose
-Can be
-Pt must lie
contrast
flat and still
enhanced
-Non-invasive
 Magnetic resonance imaging (MRI)

MRI depends on the way atomic nuclei resonate

when placed in a strong magnetic field.
A pulse of energy is released and this is used to
create an image.
Magnetic resonance imaging (MRI)
 Magnetic resonance imaging
Advantages Disadvantages
-Excellent soft tissue -Contraindication if metallic
contrast foreign bodies implanted
-No radiation -Expensive
-Limited
-Time consuming
 Radio-isotope Scan

Radioisotope injected and, using a gamma

camera
the uptake or concentration in a specific organ
can be charted.
It gives an idea of the functional state of the
organ.
Radio-isotope scans
 Endoscopy
By

Antony Ryan Davidson D`Cruz

BMS 12081328
 Endoscopy
Endoscopy is a procedure in which an endoscope
is introduced into an orifice of the body for
inspection. Some can also be therapeutic.

These aforementioned
orifices include
the upper and lower
gastrointestinal tract
the upper and lower
respiratory tract
the female genital
tract
the urinary tract
The upper GI Endoscopy
The lower GI Endoscopy
Laryngoscopy and Bronchoscopy
Cystoscopy
 The risks of endoscopy

Sedation related
cardiorespiratory
complications
Damage to dentition
Aspiration
Perforation or hemorrhage
Pancreatitis and cholangitis
 Indications for single/
double-balloon endoscopy

Bleeding from the GI tract of

obscure cause
Iron deficiency anemia with
normal colonoscopy and
gastroscopy
Visualization of and therapeutic
intervention for abnormalities
 Indications for colonoscopy
Rectal bleeding with looser or more
frequent stools abdominal pain
Iron deficiency anemia (after biochemical
confirmation negative coeliac
serology):
oesophagogastroduodenoscopy and
colonoscopy together
Right iliac fossa mass if ultrasound is
suggestive of colonic origin
Change in bowel habit associated with
fever/elevated inflammatory response

Chronic diarrhea (>6 weeks) after

sigmoidoscopy/rectal biopsy and
negative coeliac serology
Follow up of colorectal cancer
and polyps

Screening of patients with a

family history of colorectal
cancer

Assessment/removal of a
lesion seen on radiological
examination
Assessment of ulcerative
colitis/Crohns extent and activity

Surveillance of inflammatory bowel

disease

Surveillance of
acromegaly/ureterosigmoidostomy
 References

Bailey and Love`s short

practice of surgery

http://emedicine.medscape.c
om/article/1851864-
overview#showall
Tissue Sampling
by Mohd esmath
Definition of biopsy
Biopsy is the removal of the tissue from
the living organism for the purpose of
histopathological examination and
diagnosis.
Reasons
New diagnosis
Confirm a suspected or established
clinical diagnosis
Exclude additional diagnoses
Assist with prognosis
Help plan management
Research
Type
Incisional biopsy
Excisional biopsy
Wedge biopsy
Punch biopsy
Tru-cut biopsy
Fine neeedle aspiration
biopsy/cytology (FNAB or FNAC)
Washing/Brushing
Cervical Smears
Incisional biopsy

An incisional biopsy is a biopsy that

samples only a particular portion or
representative part of a lesion.
If a lesion is large or has different
characteristics in various locations more
than one area may need to be sampled
Indications:
Size limitations
Hazardous location of the lesion
Great suspicion of malignancy

Technique:
Representative areas are biopsied in a wedge fashion.
Margins should extend into normal tissue on the deep
surface.
Necrotic tissue should be avoided.
A narrow deep specimen is better than a broad
shallow one.
Excisional biopsy

An excisional biposy implies the complete

removal of the lesion.

Indications:
Should be employed with small lesions. Less
than 1cm
The lesion on clinical exam appears benign.
When complete excision with a margin of
normal tissue is possible without mutilation.
Technique:
The entire lesion with 2 to 3mm of
normal appearing tissue surrounding the
lesion is excised if benign.
Wedge Biopsy
An excisional biopsy in which a lesion
identified at the time of a surgical
procedure is removed, with a wedge of
normal surrounding tissue
Punch Biopsy
A punch biopsy is a diagnostic test where
a small, tube-shaped piece of skin and
some other tissue underneath are
removed using a sharp cutting tool. It can
be done anywhere on the body. The tissue
is then examined under a microscope.
 able to remove an area that includes all
the layers of skin (epidermis, dermis and
subcutaneous tissue). This is important
when a full thickness of skin is needed to
make a proper diagnosis and help plan
treatment.
Technique
The skin is cleaned and a local anesthetic is used
to freeze the area so you wont feel any pain.
Stretches the skin with one hand and places the
punch over the area with the other hand. Pushes
the punch down into the skin while twisting it
until it has cut through all layers of skin.
The tissue (called the biopsy sample) is lifted out
with a needle and cut from the area with scissors.

The wound may be closed with 1 or 2 stitches if a

large amount of tissue was removed. A bandage is
placed over the wound.
Tru-cut Biopsy
The tru-cut biopsy aims to provide the
pathologist with a core of undamaged
tissue from the lesion.
The procedure is performed using a
specially designed needle known as the
Trucut needle
Fine Needle Aspiration Biopsy
Aspiration biopsy is the use of a needle
and syringe to penetrate a lesion for
aspiration of its contents.
Indications:
To determine the presense of fluid within
a lesion
The type of fluid within a lesion
When exploration of an intraosseous
lesion is indicated
 An 18 gauge needle on a 5 or 10 ml
syringe is inserted into the area under
investigation after anesthesia is obtained.
The syringe is aspirated and the needle
redirected if necessary to find the fluid
cavity.
ADVANTAGE
Obtain cells from any sites of body
Less labour than biopsy
Fast
Permits early start of treatment
Can be done repeatedly on most masses/lesions
Enough material obtained for other studies also

DISADVANTAGE
Can be painful
Requires great skills
Needle can damage vital structure
Internal bleeding possible
Dissemination of tumor cells into damaged vessels
Washing/Brushing biopsy
biopsy obtained by abrading the surface of
a lesion with a brush to obtain cells and
tissue for microscopic examination.
Through scope
Cervical Smears (Pap smears)
A Pap smear involves collecting cells from
your cervix - the lower, narrow end of
your uterus that's at the top of your
vagina.
A Pap smear is a safe way to screen for
cervical cancer.