Compiled Explanations

EXPLANATIONS &
CONSENTING
PROCEDURES
1
GLOSSARY
Consent Template
3
BEDSIDE PROCEDURES
Injection – MANDY LAW
Venepuncture – JULIAN HUA 4
IV Cannulation – JULIAN HUA 5
Suturing – CHRISTL YONG + SARAH QIAN 6
Catheterisation – VICKI CHAN 7
PR – VICKI CHAN 9
Nasogastric tube – DAVID THOMSON 10
Pap smear – OLIVIA LEAHY 11
Lumbar Puncture – DAN TRAN 12
Pleural Tap – DANIELA SAY 13
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SPECIALISED PROCEDURES
Colonoscopy – KATHRYN CONNELLY
Gastroscopy – KATHRYN CONNELLY 15
Bronchoscopy – KATHRYN CONNELLY 16
Cardiac Catheter/Angiogram – ERICA CHAN 17
Renal biopsy – ALEX SHUEN 18
Cardiac stress test – SOH PEI QIAN 19
Bone Marrow Biopsy – SHRAVYA KARNA 20
ERCP – NINA CHIANG 21
FINE NEEDLE ASPIRATION 22
CORE BIOPSY 23
24
IMAGING
ECHO – SARAH LLOYD
CT (with contrast) –SARAH QIAN 25
MRI – MAMIE CHEN 26
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SURGICAL
Anaesthetic – GENNA VERBEEK
Laparotomy – ARIEL LASHANSKY 28
CABG – MAHSA JAFARI 29
TURP – KATHRYN CONNELLY 30
Thyroidectomy – PRADEEP KANDIAH 31
Resection colon ca – CHRISTIANNE TAN 32
Hernia repair – PHOEBE GAO 34
Hip/knee replacement – FERN MCALLAN 35
36
DRUGS
NSAIDs – SOO-MIN CHO
Warfarinisation – SHIVANI DURAI 39
Steroids – OLIVIA LEAHY 40
The Pill – MEI GOH 41
42
CHRONIC DISEASES
BSL monitoring – GAYA MATHAN
Insulin – LUCY DANG 43
Chronic complications of DM – ALISON PUNG 45
Asthma devices - DAN TRAN 46
Peak flow – DAN TRAN 47
Osteoarthritis + management – DAN TRAN 49
Osteoporosis + management – DAN TRAN 49
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INFECTIOUS DISEASES COUNSELLING

HIV testing – SU-WEI KHUNG
Counselling a prospective traveller – CHRISTL YONG 50
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CONSENT TEMPLATE
INTRODUCTION
STEP 1: EXPLAIN WHY THE PROCEDURE NEEDS TO BE PERFORMED

STEP 2: EXPLANATION OF THE PROCEDURE

 Enquire about prior experience
 General description
o
 Step-by-step explanation of before, during and after procedure
 BEFORE
o
 DURING
o
o Estimation of duration:
o Estimation of pain/discomfort:
 AFTER
o
STEP 3: BENEFITS AND RISKS

 BENEFITS OF UNDERGOING PROCEDURE
o
 RISKS OF UNDERGOING PROCEDURE
o Common risks: Bleeding, infection, anaesthesia (if used), and allergic reactions for invasive procedures
o Specific risks

 CONTRAINDICATIONS
o
 RISKS OF NOT UNDERGOING PROCEDURE
o
STEP 4: ALTERNATIVES (if any)(mention drawbacks)


STEP 5: CHECK UNDERSTANDING

 Ask patient to describe what they understand about the procedure, and correct any misunderstandings
STEP 6: OBTAIN CONSENT
 Verbal and/or written consent
STEP 7: PROVIDE WRITTEN INFORMATION
STEP 8: DOCUMENT IN NOTES
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INJECTIONS MANDY LAW
INTRODUCTION
 Dependent on the type of injection. For example:
o Morphine – pain relief
o Local anaesthetic for suturing – pain relief
o Enoxaparin (Clexane) – anti-thrombotic, to prevent clotting (DVTs and PEs) in immobile patients etc
o Cortisone injections – reduce inflammation and symptom relief
o Procaine penicillin – antibiotic for faster resolution of illness and symptom relief
o Thiamine injections – thiamine levels are low, will resolve neurological symptoms

o Will clean area with a swab
o ‘Sharp prick’ as needle goes in, but should not hurt thereafter
o Cotton bud and apply pressure to prevent bleeding
 BEFORE
o Adequate exposure of injection site
 DURING
o Relax
o Estimation of duration: not more than a few seconds
o Estimation of pain/discomfort: sharp prick, should not hurt thereafter
 AFTER
o Cotton bud and apply pressure to prevent bleeding
o To wait in waiting room/in patient bed and monitor for any side effects

o Therapeutic effects – ie. symptoms relief, pain relief
o Specific risks
 Allergic reactions (esp if never had it before)
 Injection into artery or vein (rare)
 Nerve injury
 Risks specific to the type of injection – categorise into common, unlikely, and rare but important
 Ie. Morphine
o Common – nausea, vomiting, drowsiness, constipation, dizziness
o Rare but important – respiratory depression, ‘mood changes’
 Ie, Local anaesthetic (lignocaine)
o Nausea, vomiting, dizziness, prolonged anaesthesia, nerve injury etc
 Ie. Enoxaparin – easy bruising and bleeding, pain, irritation, thrombocytopaenia, headaches
o Allergies
o Adverse side effects previously
o C/I specific to the type of injection
o Morphine and cortisone injections: Lack of pain relief or symptom relief
o Procaine penicillin: protracted and prolonged illness
o Enoxaparin: tendency and increased likelihood of clotting, leading to DVTs and PEs which are potentially fatal

 Alternative medications


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CONSENT FOR VENEPUNCTURE JULIAN HUA

INTRODUCTION

 To obtain blood for diagnostic purposes
 To monitor blood component levels to assess severity of the disease

o Venepuncture involves inserting a needle into a large vein on the arm to obtain blood
 BEFORE
o You (patient) should attempt to be well hydrated
o Explain to the doctor if you’re known to have difficult veins or locate previous sites blood has been taken from
o Patient should notify if any allergies are present (E.g Latex)
 DURING
o You will be either sitting or lying in bed with your arm extended to form a straight-line from shoulder to wrist.
o The doctor will apply a tourniquet to your arm and ask you to “pump a fist” to locate a suitable vein to insert the
needle.
o The area is cleaned with an alcohol swab
o A needle is then inserted into the vein
o Depending on what is needed; multiple, small vials may be used to collect the necessary samples
o The entire procedure should take about 5 minutes
o There will be a sharp sting when the needle is inserted but only when it is entering (I.e. when it’s in, it should not be
painful). There may be some discomfort after the procedure
 AFTER
o The doctor will apply a gauze pad/cotton ball and ask the patient to apply pressure for at least 2 minutes.
o When bleeding stops, the bandage is secured by the doctor

o Very useful and minimally invasive diagnostic tool
o Guides management
o Specific risks
 Minor bruising (12% most common)
 Persisting pain (mild but common)
 Excessive sweating with BP (3%)
 Infection (minimised by sterile technique)
 Fainting (<1 %)
 Seizures (rare)
 Arterial puncture (rare and minimised by good technique and location)
o Local skin infections over puncture site, bleeding disorders/anticoagulation, allergies to equipment
o May incorrectly diagnose/assess the patient
o Treatment hindered by this lack of information.


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CONSENT FOR IV CANNULATION JULIAN HUA
INTRODUCTION
 To provide temporary venous access for various uses. (E.G Fluid management, medications, transfusions)

o IV cannulation involves inserting a small plastic tube into a vein to allow continuous access to the venous system for a
short period of time.
 BEFORE
o You (patient) should attempt to be well hydrated
o Explain to the doctor if you’re known to have difficult veins and locate previous sites from which you’ve been
cannulated.
o Patient should notify if any allergies are present (E.g Latex)
 DURING
o You will be either sitting or lying in bed with your arm extended to form a straight-line from shoulder to wrist.
o The doctor will apply a tourniquet to your arm and ask you to “pump a fist” to locate a suitable vein to insert the
needle.
o The area is cleaned with an alcohol swab or another antiseptic (Chlorhexadine)
o The smallest needle necessary is then inserted into the vein. (the needle is encased in a plastic tube)
o There will be a sharp sting when the needle is inserted but only when it is entering (I.e. when it’s in, it should not be
painful). There may be some discomfort after the procedure
o The needle is then removed, and a small one-way seal (bung) is placed over the end, leaving the plastic tube inside the
vein and a seal on the outside to allow access when required.
 AFTER
o The doctor will apply a clear adhesive dressing and secure the seal with tape.
o The cannula should stay there for at most 72 hours and will be removed by a health practitioner.
o Another IV cannula may be inserted at a different site if ongoing treatment is required

o IV cannulation can be a lifesaving procedure by resuscitating fluids or blood products
o It is a well-suited way to administer certain drugs
o Specific risks
 Bruising
 Infiltration/Accumulation of fluid in subcutaneous space (minimised by frequent checking of insertion site)
 Inflammation of the vein (minimised by aseptic technique)
 Infection (minimised by aseptic technique)
 Air embolus (minimised by proper flushing technique)
o Local skin infections, burns, cellulitis over puncture site, presence of ateriovenous fistula
o No suitable alternative in some life-threatening conditions
o Oral treatment may not be as effective

 Oral fluid resuscitation (relatively slow and not suitable for emergency situations or where gut absorption compromised)
 Other drugs with different routes of administration (other options may not always exist, not as effective)


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CONSENT FOR SUTURING CHRISTL YONG + SARAH QIAN
INDICATIONS
 Wound requiring sutures to bring skin edges together or else it won’t heal properly

 DURING
o Will inject local anaesthetic into wound to numb the area
o Will stitch edges of wound together by putting sterile thread (suture) through the skin
o How many sutures?
o Will only take 20 minutes
o Stay nice and still
o Distraction: think about your favourite place
 AFTER
o How long till the sutures are taken out
 Face: remove within 5-7 days
 Hand: 7-10 days
 Limbs: 14 days
o 3 days: scab
o 1 week: 50% strength, scab may have fallen off, scar tissue/erythema
o 2 weeks:  redness
STEP 3: COMPLICATIONS (AFTER SUTURING)

 Pain
 Infection: tell pt to look for signs of pain, erythema, warmth, pus
o Dirty wound: prophylactic antibiotics, anti-bacterial inside the wound
 Scarring
o Tension
o Infection
 Bleeding
 Dehiscence
 Arrhythmia/Seizure from local
o Metal taste
o Headache
o Blurred vision
o Seizure: refractory to normal
o Arrythmia
CAUTIONS
 Ask/check for:
o Tetanus
o Tendons, Arteries/Nerves: document beforehand
o Foreign objects: ultrasound (wood etc), X-ray (glass)
o Allergies
SET UP
 WASH HANDS!!!
 Ergonomics: lighting, expose wound, wound positioning
 Collect Equipment
o Sterile dressing pack
o (Alcohol: chlorhexidine) iodine not as good
o Local anaesthetic + syringe/tourniquet  stop bleeding
o Adrenaline
o Lignocaine + adrenaline: on everywhere except people
o 25/26 gauge for local
o 200ml water to clean the wound: volume important
o Drawing up needle: hissing sound means the right amount of pressure
o Wash under tap if it’s really big/dirty
o Drape
o Sterile gloves
 Wash wound
 Drape
 Glove
 Prepare
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 Don’t put chlorhexidine/iodine into the wound, just water
PERFORMANCE
 Local anaesthetic
o Nerves run just under the skin
o Go through wound edge on a diagnal and inject into the skin
o Don’t inject so much that it distorts the skin
o Delicate area: 2%, concentration
o Large aea:  volume
o Lignocaine: 3mg/kg
 If adrenaline in it, you can give 7mg/kg
 Lasts 20mins to 1hour, but acts quickly
 Bupivicaine: 8-24 hours, lasts longer but takes 2 minutes to work (stings)
 2mg/kg
o As few jabs as possible
o Inject then advance needle (so you push through anaesthetised tissues)
 SUTURE!
o Rule of halves - begin in centre, then quarters, etc.
o 0.5cm from edge, insert perpendicular to skin
o 1st tie: 3 turns
o 2nd tie: 2 twists
o 3rd tie: 2 twists back
 short end swaps sides , loose
 if you pull it too tight, it causes scarring
 pull it to the other side
 pull it parallel to wound
 SUTURE TYPES
o Monofilament, braided
o Degradable ones: children, deep wound
 SIZES
o Face: 6o, remove within 5-7 days, heals quickly remove so no infection
o Hand: 5o, 7-10 days
o Limbs: 3o, 14 days
o Over a knee/elbow: thicker
CLEAN UP
 Sharps bin, clean up
 Pain relief
 Bleeding
 When to go to GP
DOCUMENT
 Advised on wound care
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CONSENT FOR URINARY CATHETER PLACEMENT VICKI CHAN
INTRODUCTION

 Indications: Urinary retention, urinary outlet obstruction, emptying bladder before another procedure, careful monitoring
of urinary input and output, bladder lavage, urinary tract instrumentation or treatment, immobility, incontinence,
neurogenic bladder, during surgical procedures under GA, collection of uncontaminated urine samples.
 The reason is usually very clear.
 It will be removed again.

 Enquire about prior experience and complications
o It involves inserting a catheter into your urinary opening and inflating a little balloon on the end for it to stay in.
 BEFORE
o No significant preparation
 DURING
o You will be lying on your back with your legs slightly apart.
o This is a sterile procedure, so I will be putting sterile drapes around your genital area and using gloves.
o You will feel me holding your penis/spreading your labia and cleaning the area with sterile solution.
o **I will insert a small amount of anaesthetic gel into the urethral opening to make it more comfortable
o Then I will insert the catheter. You may feel some slight pressure with this. The catheter would be lubricated so it
glides easily but may be cold.
o Once the catheter is in place, I will inflate a balloon on the end of the catheter which keeps it from falling out.
o Altogether it will take around 5- 10 minutes
 AFTER
o The catheter will be taped to your leg and there will be a bag to catch the urine on the side of your bed.
** optional

o Confirms the diagnosis
o Guides therapy
o Common risks: Bleeding (small amount of blood in urine immediate post procedure), infection, anaesthesia (if used),
and allergic reactions
o Specific risks
 Damage to sphincter and trauma to the urethra or prostate if wrong sized catheter or too much force
 Damage to sphincter and trauma to the urethra or prostate if removed without first deflating balloon
 Skin breakdown with long term use
 Blockage of the catheter
o If there is suspected trauma to the lower urinary tract
o Directly related to the reason having it. i.e. urinary retention
STEP 4: ALTERNATIVES (mention drawbacks)

 Suprapubic catheter (more invasive)


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Appropriate terms: Penis, urethra, urinary outlet/opening, labia/lips, foreskin
Inappropriate terms: any slang term for penis or vagina

9
CONSENT FOR PR EXAM VICKI CHAN
INTRODUCTION

 Indications: bleeding per rectum, rectal pain, bowel habit change, constipation, tenesmus, abdominal pain, urinary
hesitancy in men, sexual dysfunction in men, incontinence, coccygeal pain, others.
 There are a number of things that can be causing the symptoms. It could be simply haemorrhoids or there could be an
infection or something more serious going on.

 Enquire about prior experience and complications
o Involves insertion of finger into anus and feeling around the area for any abnormalities.
 BEFORE
o No specific preparation required.
 DURING
o You will lie down on your left side with your knees bent.
o I will first inspect the area around you buttocks and anus, then insert one gloved and lubricated finger into your back
passage to feel for abnormalities.
o This involves me rotating my finger so that I can feel all the way around, including feeling for your prostate. (men)
o I may then ask you to squeeze my finger or bear down before removing my finger and checking the stool.
o During the exam you may feel some discomfort or pressure like you have to go.
o The whole process takes around 1 minute usually.
o Usually no pain. If there is any significant pain during the exam then I will stop.
 AFTER
o Patient can get dressed and leave straight after

o Guides therapy
o Bleeding: trauma from the exam, rupture of haemorrhoids or varices.
o Infection: as the area is not sterile. It is possible to transfer organisms to other areas if there is active infection.
o Anaesthesia: usually not necessary. Topical anaesthetic may be applied if there is significant rectal pain.
o Allergy: to anaesthetics if used or to latex gloves (switch to other gloves)
o If extremely painful and inflamed and hence impossible to insert finger.
o May misdiagnose life-threatening condition
o Treatment may not be as effective

 Nil. Others would be more invasive.

 If patient seems apprehensive, ask if there are any particular worries not addressed.

***********************
Appropriate terms: anus, back passage, bottom, buttocks, rectum
Inappropriate terms: bum, fanny, arse, rear end, butt cheeks, backside
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CONSENT FOR NASOGASTRIC INTUBATION DAVID VYPER THOMSON
INTRODUCTION: check patient name, age, HOPC; ensure patient understands English

 Purpose of procedure
o Diagnostic: (1) Evaluation of upper GI bleed (presence, volume); (2) Aspiration of gastric content; (3) Identification of
esophagus & stomach on CXR; (4) Administration of contrast to GIT
o Therapeutic: (1) Gastric decompression; (2) Relief of symptoms & bowel rest in SBO; (3) Aspiration of recently
ingested toxic material; (4) Administration of meds; (5) Feeding; (6) Bowel irrigation; (7) Prevent vomiting & aspiration

 Previous experience? Adverse reactions?
o “Nasogastric intubation is the insertion of a soft plastic tube into the stomach via the nasal passage to provide access
to the stomach for diagnostic & therapeutic purposes.”
 BEFORE: no preparation needed on patient’s part
 DURING:
o Estimation of duration: Process (excluding CXR) may take up to 30min
o Estimation of pain/discomfort: Can be uncomfortable if inadequate anesthesia or patient doesn’t follow instructions
(head position; holding breath then sucking water)
o Position: sitting up, in patient’s bed
o Anaesthetic: gel anesthetic (viscous lignocaine 2%) & oral analgesic spray (benzocaine spray) – no sedation
o “First we will place a local anesthetic gel into your nostril & mouth. Then we will lubricate the tip of the tube &
advance it into 1 nostril until it lies in the stomach. Inserting the tube may be a little uncomfortable, but to enable us to
do it more easily, we will ask you to drink water through a straw while we work.
o If at any time you experience trouble breathing, are unable to speak, develop a blood-nose or if we cannot advance
the tube, we will stop & withdraw it immediately.
 AFTER
 Following the insertion of the tube, we will need to ensure the device has been inserted correctly, & [this will either involve
us injecting air through the tube, sucking up some fluid & testing it, or] we may need to take an XR of your chest. Once its
position has been confirmed, the tube will be secured to your nose & left in place until the diagnostic/therapeutic purpose
has been satisfied (if for aspiration of content, the end of the tube will be connected to the wall for suction).”

 BENEFITS OF UNDERGOING PROCEDURE: investigation for diagnosis; alleviation of symptoms; allow meds to be
administered; allow feeding; allow bowels to rest
o Common risks: bleeding, infection, anaesthesia (if used), and allergic reactions for invasive procedures
o Specific risks:
Risk Preventative measures
 Ptnt discomfort  Generous lubrication, topical anesthetic, gentleness, anesthetic
lozenges (eg. benzocaine lozenges [Cepacol]) prior to procedure
 Epistaxis  Generous lubrication, gentleness
 Pulmonary hemorrhage, empyema, or pneumonitis from malpositioned  Withdrawal at slightest indication (unable to speak, resistance), listen
tube to injection of air, test acidity of aspirate, CXR
 Perforation of nasal, pharyngeal, esophageal or gastric tissue from  Gentleness
respiratory tree intubation
 Necrosis or erosion of this tissue
 Vomiting/aspiration  Have suction ready
o Absolute: severe midface trauma (esp. cribiform plate damage) – possibility of inserting tube intracranially; recent
nasal surgery
o Relative: obstruction of nasal passages – patient blows nose first; coagulation abnormality; esophageal
varices/stricture; recent banding/cautery of esophageal varices; alkaline ingestion
 RISKS OF NOT UNDERGOING PROCEDURE: particular to patents’ situation
STEP 4: ALTERNATIVES (if any)(mention drawbacks): particular to patient’s situation
STEP 5: CHECK UNDERSTANDING: ask patient to describe what they understand about the procedure, correct any
misunderstandings & allow the chance to ask questions
STEP 6: OBTAIN CONSENT: verbal and/or written consent

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CONSENT FOR PAP SMEAR OLIVIA LEAHY
INTRODUCTION

 A Pap Smear is a quick and simple screening test to detect changes in the cells of the cervix, including early cancer changes
 The importance of this test cannot be over-emphasized as there are no symptoms or visible changes in the stages before
cervical cancer.
 Being immunized with Gardasil or any other cervical cancer vaccine does not replace the need for regular pap smears
 If this is her first pap smear, it is important to take time to explain the reason & the procedure

o It involves the collection of cells from the surface of the cervix which will be sent for analysis
 BEFORE
o There are no requirements, however, it can’t be done while you have your period as this affects results/ recollect
o You will be asked to disrobe from the waist down and asked to lie on the examination table with a sheet covering you
 DURING (include duration and pain)
o Your Dr will talk you through the procedure, it is generally painless (but may be uncomfortable/awkward)
o You can stop at anytime and may have a chaperone with you (there may be a nurse assisting the Dr too)
o Using a lubricated speculum (or hollow cylinder, similar in shape to a duck’s beak to visualize the cervix), a smear of
cells is collected using a cotton tipped applicator. This sample is then smeared by the nurse/Dr onto a glass slide for
analysis in the laboratory. It may take 1-2 weeks for the results to get back to your doctor.
 AFTER
o It is a minor procedural test and there are no post test activity restrictions
o (‘praise patient’ for having their pap smear and remind them of followup in 2 years)

o Changes can be detected and treated early
 There is slight discomfort with the procedure but this is usually tolerable.
 The Pap smear does not check for other problems in the reproductive system. It is not a check for sexually transmitted
infections. Women who are worried that they may have a sexually transmitted infection should talk to their general
practitioner about the tests and treatments available
 It is NOT diagnostic – if changes are detected, further tests may be required
o It is advisable not to have a pap smear if you have your period or if there is a concurrent infection such as an STI or
thrush (affects the results/ recollect and makes procedure more uncomfortable/painful)
o Avoid douching, use of vaginal creams or sex 24 hours before.

o If there are abnormal changes, they cannot detect them early. Treatment is more aggressive in advanced disease
o If a cancer present, it may be very advanced before there are any symptoms

 Nothing is able to examine the cell changes as reliably. Blood tests and ultrasounds are not sensitive
 More invasive detection may not be offered without abnormal pap smear results.

 Ask if she has any questions or if she would like any part of it explained further – a ‘bad experience’ can be traumatic and
may mean than she does not return for another pap smear!

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CONSENT FOR LUMBAR PUNCTURE DAN TRAN
INTRODUCTION
 Meningitis is a life-threatening condition
 Lumbar puncture can confirm the diagnosis and guide subsequent treatment

o LP involves placing a needle in the lower back to obtain fluid that bathes the brain and spinal cord (this fluid is called
cerebral spinal fluid or CSF).
 BEFORE
o Blood tests to ensure clotting is normal
o Go to the toilet prior to the procedure
o You will lie on a bed on your side with your knees drawn up toward your chest. This position helps widen the spaces
between the bones of the lower spine so that the needle can be inserted more easily
o The doctor will mark your lower back (lumbar area) with a pen where the puncture will occur (at a level below the
spinal cord where there is less risk of damaging any nerves)
o The area is cleaned with antibacterial soap and draped with sterile towels. A numbing medicine (local anaesthetic) is
put in the skin.
o Then a long, thin needle is put in the spinal canal
o The doctor then measures the pressure of the CSF and takes several samples of fluid to send for analysis
o The entire procedure takes about 30 minutes
o There is not usually a lot of pain because a local anaesthetic is used but some patients feel a slight pressure and
soreness when the needle goes in.
 AFTER
o After the procedure, the doctor covers the site of the puncture with a sterile bandage
o Patients usually lie flat for several hours after the procedure (NB. no evidence that this actually prevents headache)

o Guides therapy
o Specific risks
 Headache (most common complication; can last up to several days)
 Backache (common, but transient)
 Leg pain, weakness or numbness (rare)
 CNS infection – minimised by sterile technique
 Bleeding from site of needle insertion or into spinal canal (usually harmless)
 Brain Herniation or Coning – minimised by CT brain beforehand
 Failure to obtain CSF
o Local skin infections over puncture site, bleeding disorders/anticoagulation, raised ICP (as suggested by CT brain)
o May misdiagnose life-threatening condition
o Treatment may not be as effective

 Blood cultures (not as good as LP at confirming diagnosis)
 Empirical antibiotic therapy (not as effective as targeted antibiotic therapy guided by LP results)


13
CONSENT FOR PLEURAL TAP/THORACOCENTESIS DANIELA SAY
INTRODUCTION
 To Dx/Rx a pleural effusion (fluid accumulation in the pleural space – ‘around lungs’) or Rx a pneumothorax
 Build up of fluid can lead to increased pressure in the chest and severe difficulty breathing
 Diagnostic tap (pleural aspiration) – diagnosis and initial assessment of fluid – blood, pus, microscopy (malignant cells), bugs
 Therapeutic tap (intercostal drainage) – removes larger amours of fluid to help relieve extreme breathlessness or drainage
of an empyema

 An invasive procedure where a needle is inserted into the back to remove fluid or air from around the lungs. The procedure
is done in the pt’s hospital room. The sample is taken to the lab for testing.
 BEFORE
o Blood tests (Coagulation screen) and CXR
o Full aseptic precautions to prevent infection – sterilise skin (iodine/chlorhexidine), gloves, cap, gown and mask
o Pt sits on the edge of the bed, arms folded in front of body and leaning forward across a table
o The procedure can also be done with the pt lying on the back or side
 DURING
o Under local anaesthetic (5-10mL of 2% lignocaine)
o Needle is inserted between the ribs through the skin, into the fluid around the lung
o Diagnostic tap/pleural aspiration uses a small bore (21G) needle attached to a syringe (20mL)
o Therapeutic tap/intercostal drainage uses a larger bore (16G) needle attached to a 3-way bung
 Fluid is drained under gravity through tubing or it can be withdrawn with a large syringe (50mL)
o For small or loculated effusions, ultrasound can be used to guide aspiration and drainage
o Estimation of duration: depends on the flow rate, viscosity and amount of fluid – a few minutes
o Estimation of pain/discomfort: moderate discomfort occurs with inserting the needle or if more LA is needed
 AFTER
o Once 1-1.5L of fluid has been drained the needle can be removed and a
gauze pad held over the site for 1min
o CXR – to check for pneumothorax, if the fluid has been removed and if
the lung has re-expanded

o Diagnosis and relieves difficulty breathing
o Common risks: Bleeding, infection, anaesthesia (if used), and allergic
reactions for invasive procedures
o Specific risks
 Failure to aspirate(dry tap) – may need to start again/use ultrasound guidance
 Coughing - as the lung re-expands and occurs if a large amount of fluid has been removed
 Mediastinal shift – can cause changes in autonomic tone (vasovagal response - fainting) or shock
 Collapsed lung – chest tube may need to be inserted into the chest cavity to reinflate the lung
 Pneumothorax (3-30%)
 Reexpansion pulmonary oedema
 Infection in the pleural space causing an empyema
 Fluid may not be drained completely and it may build up again – requiring the procedure again
o Bleeding risk – anticoagulated, coagulopathy, thrombocytopenia
o Respiratory distress
STEP 4: ALTERNATIVES
 Leave it to resolve – risk of respiratory distress
 Chest tube insertion
 Surgery – more invasive and more complications

14
CONSENT FOR COLONOSCOPY KATHRYN CONNELLY
INTRODUCTION

 Screening for cancer
 Diagnose or exclude certain conditions (depends on patient’s symptoms)
 Can take samples of tissue for testing and remove polyps that could go on to become cancer

o Doctor feels for abnormalities around anal area then puts a flexible tube up back passage and into large bowel.
o Look for any abnormalities and take samples/remove things as required
 BEFORE
o Bowel preparation (buy from chemist) the day before
o Clear fluids (important to stay hydrated) and low fibre diet
o No solid food after breakfast of day before
o Procedure takes about 15-30 minutes
o It is a day procedure
o You will be under sedation – you will be drowsy and be given pain relief
 AFTER
o Recover from the sedation and can then go home
o Unsafe to drive due to sedation – recommend having someone pick up
o Follow up results with doctor

o Catch cancer at an earlier stage – better prognosis. Can remove pre-cancerous polyps
o Common risks: bleeding, infection, anaesthesia
o Specific risks
 Abdominal discomfort
 Discomfort defecating for a short while after
 Perforation (1/1000)
 Reaction to bowel preparation
o Active IBD or other acute colitis
o Cancer goes undetected and untreated. Precancerous polyps progress to cancer

 Sigmoidoscopy, virtual colonoscopy (CT), Double Contrast Barium Enema – but colonoscopy would give the most accurate
results and has the ability to take samples of tissue and remove polyps.


15
CONSENT FOR GASTROSCOPY KATHRYN CONNELLY
INTRODUCTION

 Investigate symptoms (e.g. abdominal pain, reflux, haematemesis)
 Provide treatment for certain conditions (e.g. peptic ulcer disease, varices)

o Throat sprayed with anaesthetic
o Tube with camera down food pipe into stomach to look inside
o Doctor may take samples of tissue or give certain treatments if this is required
 BEFORE
o Stop anti-acid therapy 2 weeks before
o Nil by mouth 4 hours before
o Procedure takes about 15-30 minutes
 AFTER
o Follow up results with doctor

o Same as reason for doing procedure
o Specific risks
 Sore throat
 Aspiration  lung infection
 Perforation (1/1000)
 Cardiac or respiratory arrest (very rare)
o Massive bleeding where surgery would be more appropriate
o Hypotension or shock
o Depends on the indication for the procedure – but risks would include missing diagnosis

 Depends on reason for undergoing procedure – but gastroscopy would give the most accurate results


16
CONSENT FOR BRONCHOSCOPY KATHRYN CONNELLY
INTRODUCTION
 Diagnosis – mainly cancer or infection (depends on patient’s clinical presentation and results of previous investigations)
 Treatment – mainly relieving symptoms of obstruction (foreign body, mucus plug)

o Throat and nose sprayed with anaesthetic
o Flexible tube put through nose or mouth and down windpipe into lungs.
o Doctor may take samples of tissue, cell scrapings or sputum which are tested in the lab
 BEFORE
o Nil by mouth from 6 hours before
o Procedure takes about 30 minutes
 AFTER

o Specific risks
 Sore throat, headache
 Respiratory depression
 Coughing up blood
 Pneumothorax (puncturing the lung)
o None really except obvious things like if the patient is having a cardiac arrest in front of you
o Depends on the indication for the procedure – but risks would include missing diagnosis

 Depends on reason for undergoing procedure – but would not be as accurate in diagnosing


17
CONSENT FOR ANGIOGRAPHY/ANGIOPLASTY ERICA CHAN
INTRODUCTION
 Coronary artery disease is when plaque (fatty deposits, cholesterol and calcium) builds up and causes narrowing of the
arteries supplying your heart, resulting in less blood flow to your heart. Sometimes these narrowings can cause clots to form
and give you a heart attack.

o Angiography can diagnose coronary artery disease and guide the treatment
o It involves inserting a catheter into an artery in your groin and a wire is threaded up to your heart. Dye will be inserted
into your coronary arteries and we will be taking pictures of this by x-ray If narrowing are found, a balloon can be
inflated to widen the narrowing and a metal coil (stent) can be inserted to keep the narrowing open
o Your cardiologist will also be able to measure the blood pressure within your heart to ensure your heart is pumping
correctly.
 BEFORE
o Bloods tests, ECG, chest x-ray
o Fast the night before (don’t have anything to eat after dinner, fast for 8hrs)
o Take you to the cath lab o Angiography takes about 30 minutes
o Lie on your back o Can be performed as an outpatient
o Inject some local anaesthetic in your left groin o If we find a narrowing in your arteries, we can
o Give you some sedation : medazolam inflate a balloon to widen it
o The area is cleaned and draped with sterile drapes  And we might insert a metal coil to keep the
o Small incision, left groin artery open
o Insert a catheter into your artery  thread a wire  This will take longer >30 mins (depends on
to the left side of your heart how many coils need to be inserted)
o Inject some dye into your coronary arteries  If stents are inserted, expect to stay
o You may feel warmth in your head or face as the overnight
dye goes through o If there are complications  emergency cardiac
o We take some x-rays as the dye is going through surgery may be needed
o Compress the incision site for 15 minutes
 AFTER
o Angiography  Go home the same day
o Angiography + stent  Stay overnight

o We will be able to see the narrowing in your arteries
o We can blow up a balloon and insert a stent that will fix the narrowing/blockage
 Relieve your symptoms: chest pain, shortness of breath
 Treats heart attack: stops further heart muscle from dying
o We can also measure the blood pressure in your heart to ensure your heart is pumping properly
o Specific risks
 CV: tachycardia, ↓ BP
 Mortality: 1 in 1000
 Stroke
 Arrhythmias (VT, VF) tx with cardioversion
 Arterial trauma
 Hypotension: allergic reaction to dye or perforation of chamber
 At the incision site: infection, haemorrhage, pain
o This procedure allows us to visualise and treat the narrowing in your artery. If we do not fix this narrowing, it will
progressively get more and more narrow. Eventually when the artery gets completely blocked, it may give you a heart
attack. Some heart tissue will not be getting any oxygen, and this will result in your heart not being able to pump
properly
 CABG (still preferred for left main stenosis)
o Drawbacks: cardiac surgery (more invasive, more complications)

18
CONSENT FOR RENAL BIOPSY ALEX SHUEN

INTRODUCTION

 To find the cause of the kidney disease and tell what is the best treatment option.

o Involves taking a piece of kidney tissue.
 BEFORE
o Avoid aspirin or other blood-thinning medication 1 to 2 weeks before the procedure.
 DURING
o Lying face down with a pillow under your stomach.
o The skin over the kidney will be cleaned with antiseptic wash and a local anaesthetic will be injected to numb the skin
and the kidney.
o You will be asked to hold your breath as breathing moves the kidney.
o A biopsy needle with ultrasound guidance will be used to extract a piece of the kidney which makes a clicking sound.
o The doctor may need to insert the needle 3-4 times to collect the needed samples.
o The procedure should be painless.
o Estimation of duration: 30 minutes
o Estimation of pain/discomfort: minimal
 AFTER
o Bed rest for at least 6 hrs (on their stomach) and vital signs will be monitored. Urine will be tested for bleeding.
o You can eat and it is advised to drink plenty of fluids.
o As the local anaesthetic wears off, you make feel some pain in the back.
o You can go home on the day or the following day if you feel well after the biopsy
o Avoid exercise for 48 hours and if you develop sever pain over the kidney or any blood in urine, contact the doctors
straight away.

o Diagnosis of the kidney disease. Better outcome for management.
o Specific risks
 As above
o None.
o Renal failure

 None


19
CARDIAC EXERCISE STRESS TEST SOH PEI QIAN
INTRODUCTION
 Determine whether it is likely that you have heart disease
 To estimate the likelihood of coronary artery disease in people with high risk factors
 To measure exercise capacity in people with known coronary artery disease (severity of the blockage as well as response of
the heart to physical exertion)
o After angioplasty or stent insertion
o After modification of medications
o After Coronary Artery Bypass surgery

o An ECG is recorded at rest, and then whilst walking on a treadmill
 BEFORE
o Do not stop taking any medications prior to the test unless you have been advised to do so by your doctor
o Do not have any caffeine or nicotine 2 hours prior to the test
o Wear comfortable footwear
o Have a light meal only prior to your test
 DURING
o You will need to undress to the waist, but will be allowed to wear a surgical gown. Women will not be able to wear a
bra, as this impedes the placement of electrodes that will be placed on the chest. Men may require part of the chest to
be shaved
o The treadmill begins at a very low speed that is increased every few minutes.
o You will be asked to exercise until you exceed a target heart rate that is determined by your age
o Your blood pressure, pulse rate and electrocardiogram will be monitored continuously
o A technician and a doctor will be there to supervise you
o Estimation of duration: 30mins including a few minutes on the treadmill
o Estimation of pain/discomfort: Patient may experience some shortness of breath, chest pain or dizziness.
 AFTER
o You will receive some feedback about your result after the test
o Your doctor will also be sent a full report

o Non-invasive way of determining the likelihood of heart disease
o Able to assess how your heart responds to physical exertion
o Specific risks
 Patient with pre-existing severe heart disease may suffer a heart attack (LOW RISK)
 Risk is the same as you would expect from any strenuous exercise such as jogging or running
 This is why a Cardiologist is in attendance to manage the rare complications
o Acute myocardial infarction within 48 hours
o Unstable angina not yet stabilized with medical therapy
o Uncontrolled cardiac arrhythmia, which may have significant hemodynamic responses (e.g. ventricular tachycardia)
o Severe symptomatic aortic stenosis, aortic dissection, pulmonary embolism, and pericarditis
o Multivessel coronary artery diseases that have a high risk of producing an acute myocardial infarction
o Unable to tell how heart will respond or cope with physical stress
o Unable to determine exercise tolerance
 Nuclear stress test
o More invasive (injection of radiotracer)
o As the tracers used for this test are carcinogenic, frequent use of these tests carries a small risk of cancer
 Encourage patient to ask questions
20
BONE MARROW BIOPSY SHRAVYA KARNA
INTRODUCTION
 This is a procedure used to diagnose leukemia, infections, some types of anaemia, and other blood disorders.
 It may also be used to help determine if a cancer has spread or responded to treatment.

o A bone marrow biopsy is the removal of soft tissue, called marrow, from inside bone. Bone marrow is found in the
hollow part of most bones. It helps form blood cells.
o The procedure performed in the outpatient clinic procedure room or at the hospital bedside. Two needles are
introduced into your bone marrow cavity and cells are taken for analysis.
 BEFORE
o You may receive instructions about not eating food or drinking liquids before the procedure
o Before the procedure, you will be asked to change into a patient gown. Your vital signs-blood pressure, heart rate,
respiratory rate, and temperature-will be measured.
o Depending on your doctor, you may have an IV placed or your blood drawn. Then you will be given some medicine to
help you relax.
o You may be asked to position yourself on your stomach or your side depending on the site the doctor chooses to use.
 DURING
o The doctor will choose a place to withdraw bone marrow. Often this is the hip (pelvic bone), but it also can be done
from the breastbone (sternum), lower leg bone (tibia), or backbone (vertebra).
o The chosen site will be cleaned and sterilised with the cleansing agents betadine and alcohol and anaesthetized with
lidocaine (similar to what a dentist uses). After the skin is clean, sterile towels will be placed around the area.
o When the area is numb, a small incision is made. The bone marrow aspiration needle is inserted through the skin into
the bone marrow cavity to obtain a sample of the liquid part of the bone marrow. It is then removed.
o Another needle which is larger, called the bone marrow biopsy needle, is inserted in the same way in order to obtain a
small sample of bone biopsy.
o The wound site may bleed a small amount, so pressure is applied for a few minutes. A sterile bandage is then applied.
o Estimation of duration: 20 to 30 minutes
o Estimation of pain: You may feel some brief pain as the local anaesthetic is injected, and as the samples are removed
 AFTER
o Sedative medication will continue to make you feel drowsy for a while. After the local anaesthetic wears off over the
next few hours, you may have some discomfort at the biopsy site. Pain medication will be offered for better comfort.
o You must remain lying down for at least one hour, whereby your vital signs shall be observed. You should be able to
leave the clinic and resume most normal activities immediately.
o You may feel some tenderness for a week or more after your bone marrow exam. Pain medication can be used to
reduce discomfort and ice for swelling. The bandage should be kept on for 48 hours.

o Confirms diagnosis
o Guides therapy
o Specific risks
 Bleeding at site: usually controlled with external compression and gauze.
 Infection: rare, but can require oral antibiotics
 CONTRAINDICATIONS (very few)
o Presence of a severe bleeding disorder
o If there is a skin or soft tissue infection over the hip (a different site can be chosen)
o Not knowing the cause or the extent of the haematological problem

 None
21
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) NINA CHIANG
INTRODUCTION
STEP 1: EXPLAIN WHY ERCP NEEDS TO BE PERFORMED
 ERCP is used primarily to diagnose and treat conditions of the bile ducts, including gallstones, inflammatory strictures
(scars), leaks (from trauma and surgery), and cancer

o ERCP combines the use of x rays and an endoscope, which is a long, flexible, lighted tube
o Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject dyes into the ducts
in the biliary tree and pancreas so they can be seen on x-rays
 BEFORE
o Patient will not be able to eat or drink anything after midnight the night before the procedure, or for 6 to 8 hours
beforehand, depending on the time of your procedure
o The physician will need to know about allergies, especially to iodine, which is in the dye
o Patient removes all jewellery and wears a gown
 DURING
o Patient lies on their left side on an examining table in an x-ray room
o Medication given to known the back of the throat (spray), and sedation given intravenously to help patient relax during
exam.
o A mouth guard is put in patient’s mouth. The physician then guides the scope through the esophagus, stomach, and
duodenum until it reaches the spot where the ducts of the biliary tree and pancreas open into the duodenum
o At this time, the physician will pass a small plastic tube through the scope. Through the tube, the physician will inject a
dye into the ducts to make them show up clearly on x rays. X rays are taken as soon as the dye is injected
o If the exam shows a gallstone or narrowing of the ducts, the physician can insert instruments into the scope to remove
or relieve the obstruction. Sometimes a sphincterotomy is carried out during the ERCP. This involves passing a small
instrument through the endoscope and making a tiny cut in the lower part of the bile duct. This will allow the surgeon
to remove any
o Tissue samples (biopsy) can be taken for further testing.
o Estimation of duration: 30 minutes to 2 hours
o Estimation of pain/discomfort:
 There may be some discomfort when the physician blows air into the duodenum and injects the dye into the
ducts. However, the pain medicine and sedative should keep patient from feeling too much discomfort.
 AFTER
o After the procedure, patient needs to stay at the hospital for 1 to 2 hours until the sedative wears off.
o If any kind of treatment is done during ERCP, such as removing a gallstone, overnight hospital stay may be arranged.
o Patient must arrange for somebody to take them home as they are not allowed to drive because of the sedatives.

o Diagnosis the therapy!
o Specific risks
 Bloating due to air used to inflate the stomach and bowel
 Sore throat from sedation
 Reaction to dyes : symptoms like nausea, hives, burning sensation, blurred vision, and urine retention.
 Perforation of the bowel
 Pancreatitis – inflammation of the pancreas, which can be very serious
o Contrast allergy
o Gall Stones :
 Bile trapped in these ducts can cause severe damage or inflammation in the gallbladder, the ducts, liver or
pancreas, which are very painful and life-threatening conditions.

 Diagnosis (but no therapy possible)
o Computerized tomography (CT) scan - noninvasive x ray that produces cross-section images of the body.
o HIDA scan - The patient is injected with a small amount of nonharmful radioactive material that is absorbed by the
gallbladder, which is then stimulated to contract. The test is used to diagnose abnormal contraction of the gallbladder
or obstruction of the bile ducts
22
 Therapy: Laparoscopic cholecystectomy – more invasive, anaesthetic and surgical risks
FINE NEEDLE ASPIRATION (THYROID) DAN TRAN

INTRODUCTION
 You have been referred for a Fine Needle Aspiration biopsy (FNA).
 This is because a lump was discovered (e.g. in your thyroid or ) and your doctor needs a sample of the tissue to determine
what that lump is (namely, whether it is cancerous or not)

o We take samples of cells from the lump using only a thin small needle which will leave a mark no bigger than a needle
stick from a blood test.
 BEFORE
o You will have to remove any clothing covering the lump, or change into a patient gown
 DURING
o The doctor will clean the skin overlying the lump with a pad or swab prepared with an antiseptic solution
o The doctor may inject local anaesthetic into the skin to numb the area, although this injection itself causes pain
o Holding the lump with one hand, the doctor will precisely sample the lump with a thin needle
o Usually, 2 to 3 samples will be required from the lump to provide an accurate diagnosis.
o In some cases, the lump or mass from which the cells are to be taken is not easily felt through the skin. If this is the
case, the doctor collecting the sample may use ultrasound, where the needle can be seen on the ultrasound monitor
and guided to the area. This may make the procedure take a little longer.
o Estimation of duration: Each sample will only take about 10 seconds to obtain. The whole procedure from start to
finish usually takes no more than 10 to 15 minutes.
o Estimation of pain/discomfort: There is usually minimal discomfort felt during an FNA, comparable to that of giving a
blood sample. This should be relieved by paracetamol or the application of an ice-pack for short periods following your
return home.
 AFTER
o Most people are able to continue with their regular daily activities straight after their procedure.

o Quick, and minimally invasive way of obtaining a sample of the tissue from the lump
o Specific risks
 The most common complication is a slight bruising or tenderness of the area for a few days following the
procedure.
 Other complications such as bleeding and infection are very rare. Contact your doctor if you notice any excessive
bruising or swelling, persistent pain or fever
o Cannot definitively determine whether your lump is cancerous or not

 Core biopsy and open surgical excisional biopsy (both more invasive, though may be used if lump turns out to be cancerous)

23
CORE BIOPSY (BREAST OR LYMPH NODE) DAN TRAN
INTRODUCTION
 You have been referred for a Core biopsy
 This is because of your lump(e.g. breast lump or lymph node) and your doctor needs a sample of the tissue to determine
what that lump is (namely, whether it is cancerous or not)

o The procedure involves making a small cut in the skin and removing cylindrical tissue samples from a lump or the area
of concern. This is done using a specifically designed core biopsy needle.
 BEFORE
o Because the procedure may cause some localised bleeding, it is important that you let the doctor know if you have a
bleeding disorder or if you are on any medication to thin the blood e.g. Warfarin.
 DURING
o The doctor will clean the skin overlying the lump with a pad or swab prepared with an antiseptic solution
o They will then inject local anaesthetic into the skin to numb the area where the needle is inserted
o A small incision (cut) is made in the skin over the lump, and a needle is inserted through the incision.
o When the tip of the needle is in the area to be examined, the specially-designed hollow needle is used to collect a
sample of the cells that are present
o The needle is then withdrawn, and the sample extracted.
o This may be repeated up to 5 times, until an adequate sample has been collected.
o In some cases, the lump or mass from which the cells are to be taken is not easily felt through the skin. If this is the
case, the doctor collecting the sample may use ultrasound, where the needle can be seen on the ultrasound monitor
and guided to the area, or stereotactic mammography (for the breast) which uses two mammograms at different
angles and a computer to locate the correct area. This may make the procedure take a little longer.
o Estimation of duration: Overall, core biopsy usually takes between 30 minutes to 1 hour to complete.
o Estimation of pain/discomfort: Because local anaesthetic is used, core biopsy should not be painful, though it may be
uncomfortable
 AFTER
o Once the test is completed, a small dressing or some tape will be placed over the biopsy site. This can be removed the
next day.
o A small ice pack can be applied to the affected area of the breast to reduce any swelling and bleeding.

o Core biopsy is a quick and effective tool in evaluating and diagnosing suspect lumps or masses
o Core biopsy is also very good at determining whether a lump is malignant (cancerous) or benign (non-cancerous)
o Specific risks
 Core biopsy may leave a very small, fine scar, which usually fades with time
 There are generally no complications with this procedure, though you may experience some tenderness or
bruising over the needle insertion site.
 If you experience any bleeding, swelling, fever or pain that is not relieved with paracetamol, contact your doctor
immediately.
o Cannot definitively determine whether your lump is cancerous or not
STEP 4: ALTERNATIVES (if any) (mention drawbacks)

 Fine needle aspiration biopsy is slightly quicker and less invasive than core biopsy. Fine needle aspiration biopsy does not
require local anaesthetic as the needle is much finer. However is more difficult to interpret than core biopsy. This is because
the same of cells collected by the fine needle appears under the microscope as a disorganised jumble. It is not possible to
distinguish between in situ and invasive cancer on the basis of fine needle aspiration biopsy alone.
 Open surgical biopsy (more invasive, though may be used if lump turns out to be cancerous)

24
TRANSTHORACIC ECHOCARDIOGRAM SARAH LLOYD

INTRODUCTION
 Tests for underlying problems in heart structure and function

o ECHO uses a specialised machine that uses high frequency sound waves (ultrasound) around the heart to see its
structure and function
o A technician uses a hand held transducer placed to the chest to allow the sound waves to pass through the heart
o A thick gel is used to assist transmission of sound waves
o A computer processes this information to make an image of your heart and the way the blood flows through it
 BEFORE
o Pt will have to take off any clothing on the their chest
 DURING
o Pt lies on a bed while technician performs procedure
o Estimation of duration: 15-45mins
o Estimation of pain/discomfort: slight pressure from probe
 AFTER
o Patient can re-dress and go home immediately

o Will allow identification of heart problems
o Painless
o Non invasive
o Carries virtually no risks
o Specific risks
 Bruising from transducer
o May not be as accurate in people with a thick chest wall
o This is safest method of determining underlying problems with heart structure/function

 TOE (see below) – more invasive

25
TRANSOESOPHAGEAL ECHOCARDIOGRAM SARAH LLOYD
INTRODUCTION
 Tests for underlying problems in heart structure and function

o a special tube is passed down the throat into oesophagus (food pipe)it is placed near the heart allowing clear
pictures to be taken
 BEFORE
o Pt will have to fast for at least 6hrs before procedure
 DURING
o Children may be put under a general anaesthetic while in adults a local anaesthetic is sprayed on the throat
o An IV sedation is also given before the tube is passed
o Estimation of duration: 15-45mins
o Estimation of pain/discomfort: throat pain may be present after procedure but no pain will be felt during procedure
 AFTER
o Pt will be returned to recovery room and can return home when sedation wears off. Someone else must drive you
home
o Will allow identification of heart problems
o More accurate the TTE
o Better viewing of heart
o General: bleeding, sedation, infection
o Specific risks
 Post op pain: pressure/heat injury
 Nausea/vomiting
 Oesophageal bleed
 Bacteraemia 3-12%
 Perforation of oesophagus 1/10000
o Oesophageal problems: stricture, perforation, spasm, diverticular (Zenkers)
o May not find info needed

 TTE (see above) - less accurate

26
CONSENT FOR CONRAST CT SARAH QIAN
INTRODUCTION
 Obtain extra information regarding *insert illness*
 Visualise important anatomy/pathology,

 Key History Points
o Pregnant
o Breast feeding: do not breast feed for 24 hours after the contrast injection
o Asthma, allergies
o Diabetes, kidney failure
o Anaemia
 General description: Test using X-ray and computer to produce images of internal body parts
 BEFORE
o Most require no preparation
o If contrast required: Fasting from fluids/food from 3 hours beforehand
o Insertion of IV cannula (small plastic tube) into yoru arm
o IV contrast: iodine based colourless liquid
 Delivered by pump injector
 30-120ml depending on your size and CT type
 Not radioactive
o Into machine: lie on table which moves into the machine, the camera revolves around you
o Painless, but you have to stay very still, may be asked to hold the breath
o Duration: 30 minutes
 AFTER
o You can leave once the doctor’s have okayed the images
o You can eat and drink normally
o Results will be sent to your doctor

 Accurate
 Excludes life threatening conditions, i.e. cancer
 Highlight difference between tissue that would otherwise look the same
RISKS OF UNDERGOING PROCEDURE
Common Minor Allergic Reaction Rare
 Small radiation exposure  Itching, sneezing  Shock

 Metallic taste  Hives, eye swelling, wheezing  Kidney Failure
 Warm Sensation  Cardiac arrest
 Nausea  Fatality: 1/20,000-75,000
procedures
ALTERNATIVES, these are not as accurate

 CT without contrast
 Ultrasound
 MRI
Discuss these options with your doctor


27
CONSENT FOR MRI MAMIE CHEN
INTRODUCTION
 Non-invasive medical imaging of soft tissues using radio waves and magnetic field
 Commonly used in investigations for following systems: Neurological, Musculoskeletal, Cardiovascular, Oncological
 The MRI scan consists of a table that slides into a large cylinder. Inside the cylinder is a magnet that, when operated, creates
a powerful magnetic field.
 BEFORE
o Nil orally for at least 5 hours prior procedure in pelvic/abdo MRI
o Pt asked to remove all metal objects (wristwatches, keys, jewellery, etc.) to be left outside scan room
o Asked to undress and put on a cotton gown.
o Pt lies on scanner table; table slides into cylinder. Intercom inside scanner to talk with radiographer.
o Important to lie very still for good images
o Scanned area of body may feel a little warm
o May take up to an hour
o No pain, may feel uncomfortable in enclosed space
 AFTER
o Patient asked to wait whilst radiographer reviews pictures

o MRI fantastic at imaging soft tissues and therefore often gold standard investigation for many neurological/
musculoskeletal/ cardiovascular/oncological diseases. Gives good quality high standard pictures of patient’s internal
pathology in minimally invasive manner.
o Specific risks
o Anxiety/claustrophobia/discomfort
o Allergic reaction to contrast dye
o Radiographer will assess quality of pictures & if poor, may need rescanning
o During scan, scanner will make noises such as knocks, loud bangs and clicks – earplugs or music will usually be offered
o Rare: Hyperthermia, Peripheral nerve stimulation
o Should pt consent, ask pt to fill out a form to assess whether they are eligible to be imaged with an MRI scan. In the
interest of pt’s own safety, ask to please answer form with as much detail and as truthfully as possible.
 Possible serious complications include trauma/injury/death
o Metals
o Claustrophobia (not always absolute)
o Allergy to contrast dye
o Renal disease (if using contrast)
o May not detect pathology as quickly or at all; may slow down Dx, treatment & hence patient recovery
 STEP 4: ALTERNATIVES (mention drawbacks)
o Other imaging
 CT (incl. CTA, etc.)
 X-ray (+/- contrast)
 US/Echo
 Nuclear med/PET
 Angiogram

• Ask patient to describe what they understand about the procedure, and correct any misunderstandings
• Verbal and/or written consent
28
CONSENT FOR ANAESTHESIA (INCLUDES GENERAL, SPINAL/EPIDURAL, LOCAL) GENNA VERBEEK
INTRODUCTION
 Based on a surgical request, anaesthesia is to allow the patient to be pain free during the operation (they may be awake or asleep depending on the type of
anaesthesia (technique))
 Therefore, patient must be sure they would like to go through with the surgery (all medical and other options explored) with appropriate management of
risks

 Enquire about prior experience – assess understanding, address fears/previous experiences (also inquire about side effects – intra/post op N&V, difficult
intubation, dreams/awareness, hypotension, malignant hyperpyrexia, post op jaundice), also ask about FHx
 BEFORE
o Pre-op assessment 4-6weeks before – may do blood tests, ECGs, x-ray – will check all comorbidities (ASA risk stratification)
 Especially discuss medications – diabetic, warfarin/heparin/clexane, herbal meds ceasing, all other drugs to continue as normal
o Fasting – nil food for 6 hours before, with only clear fluids (ie. apple juice/water) up until 2 hours before the procedure, then nil oral intake allowed
o Bring an overnight bag (even if it is a day procedure, must be organised in case of complications)
o Arrive early (eg. 7am for am list/11am for pm list – depends on hospital)
o Change into gown and lie on a bed prior to seeing the surgeons/anaesthetists
 DURING
29
Patient is wheeled into anaesthetic room, drip is
placed in hand (may be painful/uncomfortable)
Monitoring placed
Local anaesthetic - ECG, BP, pulseGeneral
Spinal/epidural oximetry
anaesthetic
To numb the pain anaesthetic The patient goes to
May be given
in a small area
some pre-medication
Single injection into
– for anxiety,
sleep and may/may
N&V,
(eg. Onpain, or other health
the back issues (eg.
(with the ↑BP)
not require a muscle
hand/finger/in a patient sitting/lying relaxant
cut – for down) Oxygen will be
stitching) Local injected into supplied through a
Painful as it goes skin first mask prior to
through the skin Will feel pressure as induction to increase
(small injection), needle goes in, but oxygen in all of the
then gradually very important not to tissues
goes numb move as is near spinal Induction (going to
May feel cord (requires sleep) – may have
pressure, but support person to be some drugs put into
should not feel present) drip which may sting,
pain Spinal – takes a few but will make the eyes
Will be awake for minutes to work, lasts feel heavy, cloud the
the procedure up to 2 hours mind a little, until the
Epidural – takes up to patient cannot
30 mins to work, can remember – becomes
be used for hrs/days unconscious
as pain relief by If the IV line is difficult
leaving cannula in to get in, some
place and reinjecting patients will have a
pain meds via this mask placed over the
method face and go to sleep
Again, via this method (IV line
pushing/pressure may placed later)
be apparent, but A tube will be placed in
should not be able to the airway and a
feel pain machine may help the
Will check numbness patient breathe whilst
using ice they are asleep –
Requires the insertion therefore an itchy/sore
of a urinary catheter throat may be
May have a headache apparent aftewards
afterwards, or Drugs may be given
tingling/shocks on throughout the
insertion procedure to keep the
Patient will be awake patient relaxed and
for procedure, a sheet under anaesthetic, for
will be put up btw pain relief, to prevent
them and the N&V, to prevent
operating space infection (antibiotics),
or other drugs may
need to be given if
something unexpected
occurs (like heart
attack/aspiration/PE
etc)
o Estimation of duration: Depends on the surgical procedure
30
 AFTER
o Will wake up/be wheeled into recovery –
 if it was a local/spinal/epidural pain will be managed and patient will be made comfortable
 if it was a general anaesthetic, the patient may wake up in recovery/ICU with a tube still in the throat, they may have an oxygen mask on over
mouth/nose, may have a sore throat, may have a urinary catheter inserted, may feel cold/shaky (blankets available)
o May feel nauseated or may vomit – medications will be given to prevent this/will be available to access
o If it is a day case, the patient cannot drive, must have someone come and collect them
o Pain will be managed at this point as the pain medications from in the begin to operation wear off

o Minimise pain during procedure, make the operation more comfortable, allow patient to lie still and therefore prevent surgical complications
o Common risks
 Complications of bleeding (may require a blood transfusion – be aware of patients beliefs), infection from surgery/at IV site + other surgical
risks (depends on the specific surgery)
 Minor – failed IV access, pain at IV site, sore throat, headache, post op N&V, urinary retention, hypotension
 Major – Aspiration of gastric contents (fasting for prevention), hypoxic brain injury (pulse oximetry for prevention), AMI/CVA (minimise risk
factors, resuscitation equipment serviced and ready for use), nerve injury (ie. due to insertion of endotracheal tube – minimise by visualising
the vocal cords), chest infection (minimise risk factors, surgical time), DVT/PE (minimise surgical time, ?use clexane, wear TEDs stockings),
anaphylaxis (if occurs, antidotes are available)
o Specific risks
 Dental – cut lip, damage to teeth/caps/crowns (if tube is to be placed in the throat)
 PRECAUTIONS
o Pre-existing heart disease, HT, diabetes, hyperlipidaemia, pregnancy, renal failure, hepatic failure, PVD, obesity, CVA, smoker, ↑alcohol
consumption, ↓fitness, OSA, IVDU

 Different modalities – see above under explanation of the procedure

CONSENT FOR LAPAROSCOPIC SURGERY ARIEL LASHANSKY

INTRODUCTION
 Diagnostic: To explore abdomen to discover cause of disease
 Therapeutic: To surgically repair or remove organ which is causing disease

o Surgery performed via small cameras and tools inserted through several small incisions in the abdomen
 BEFORE
o Directly preceding the surgical procedure, an intravenous (IV) line will be placed so that fluids and/or medications may
be administered to the patient during and after surgery. A catheter will be inserted into the bladder to drain urine. The
patient will also meet with the anaesthetist to go over details of the method of anaesthesia to be used.
o You will be asked not to have anything to eat, chew or smoke for at least 6 hours before your operation. You should
have nothing to drink for 3 hours before surgery. You will be advised of the actual times.
 DURING
o The patient is usually placed under general anaesthesia for the duration of surgery.
o The skin over the abdomen is cleaned to remove any bacteria
o The surgeon makes 3-5 small incisions (portholes)
 These are for the surgeon to place instruments (cameras & tools)
o Your abdomen may also be filled with a gas to expand it
 Makes it easier for the surgeon to see inside
o Estimation of duration: depends on type of surgery
o Estimation of pain/discomfort: Under general anaesthesia during surgery, so will be unconscious. Will be some
pain/discomfort after surgery
 AFTER
o The patient will remain in the postoperative recovery room for several hours where his or her recovery can be closely
monitored. Discharge from the hospital may occur in as little as one to two days after the procedure, but may be later
if additional procedures were performed or complications were encountered.
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o This operation allows the doctor to look inside your stomach to find out what may be causing your
problems and if necessary, carry out the surgery to treat it. RISKS OF UNDERGOING PROCEDURE
o Specific risks
(a) Damage of the bowel may occur which may cause leakage of bowel fluid. This may need further surgery.
(b) Deep bleeding in the abdominal cavity could occur and this may need fluid replacement or further surgery.
(c) Infections such as pus collections can occur in the abdominal cavity. This may need surgical drainage.
(d) The bowel movement may be paralysed or blocked after surgery and this may cause building up of fluid in the
bowel with bloating of the abdomen and vomiting.
(e) A weakness can occur in the wound with complete or incomplete, bursting of the wound in the short term, or
a hernia in the long term.
(f) In some people healing of the wound may be abnormal and the wound can be thickened and red and may be
painful.
(g) Adhesions (bands of scar tissue) may form and cause bowel obstruction. This can be a short term or a long
term complication and may need further surgery.
o Those who have had generalised peritonitis or repeated laparoscopies
o The underlying disease might progress and ultimately afford the patient a worsened prognosis when discovered
 Various diagnostic tests may be performed, such as x ray, computed tomography (CT) scan, and magnetic resonance
imaging (MRI) to try explore the nature of any unknown disease, however these tests are not as sensitive and don’t have
therapeutic capabilities.

CONSENT FOR CORONARY ARTERY BYPASS GRAFT MAHSA JAFARI

INTRODUCTION
 A large degree of blockage in the main arteries supplying your heart.
 In order to improve your symptoms and reduce the risk of a heart attack occurring, we are able to perform open heart
surgery where we take a vessel graft (from your leg, arm or chest) and bypass your heart’s own blocked arteries. The new
vessels will provide a better blood supply to your heart and reduce the symptoms you are currently experiencing.

o This procedure involves open heart surgery and replacement of your blocked coronary vessels with blood vessels from
your arms or legs, or artificial vessels
 BEFORE
o You will need to fast the night before the surgery
o On the day of surgery you will come into hospital
o You will be guided down to theatre where you will be dressed in a patient gown
o You will be met by the anaesthetist who will explain what you might expect coming out of surgery.
o The anaesthetist will insert some IV lines and inject you with general anaesthetic which will put you to sleep and you
will not remember or feel anything for the duration of the operation.
o Then the surgeons will come in and clean your skin over the operating site to remove any bacteria
o They will harvest vessels from you arms/legs/ chest to use as grafts during the operation.
o At the same time other surgeons will make a large incision through the middle of the chest and cut through the
breastbone to get to the heart.
o Once the heart is reached, in order to stop the heart pumping, you will be put on the heart-lung machine which will
transfer blood from your heart to the machine and divert it away from the heart to prevent excessive bleeding during
the operation.
o The surgeons will then stitch the harvested blood vessels to your heart, bypassing the area of blockage
o They will then take you off the heart-lung bypass machine and close up the chest wall with wires and sutures.
32
 AFTER
o After the operation you will be transferred to ICU, where you will be closely monitored and awakened from the
anaesthetic.
o You will be closely monitored in ICU for 24 hours, after which you will be transferred to the cardiac ward for further
recovery and monitoring.
o You should expect to experience some pain after surgery from the site of the incision and may take a few days to get
out of bed and eating and drinking.

o The symptoms you are currently experiencing, angina/SOB, will improve significantly
o You will reduce the chances of suffering from a heart attack or heart failure in the future and prolong your life
expectancy and have better QOL.
o Common risks: Bleeding, infection, reaction to anaesthesia
o Specific risks: AMI, arrhythmia, stroke, death
o Co-existing non-cardiac conditions with poor prognosis (cancer, chronic lung disease)
o Non-viable myocardium
o Lack of viable artery to use as a graft
o Advanced age
o Worsening symptoms or heart attack, potentially leading to death
STEP 4: ALTERNATIVES (if any) (mention drawbacks)

 Medical therapy (nitrates, statins, aspirin, antihypertensives, β-blockers) – not as effective as surgery
 Angioplasty +stenting (not suitable for extensive CAD)
CONSENT FOR TURP KATHRYN CONNELLY

INTRODUCTION
 Relieves symptoms and prevents complications from having a big prostate

o Surgeon puts a tube with a camera through the tube in the penis, looks in the bladder and around the prostate and
scrapes out part of the prostate so it no longer obstructs the flow of urine
 BEFORE
o Fast from midnight the night before (or >6 hours)
o Procedure takes about 1 hour
o Under general anaesthetic – asleep, no pain
o Catheter will be put in
 AFTER
o Usually stay a night or two in hospital
o Remove catheter after a day or so with trial void
o At first may need to urinate more frequently before improve
o May get red urine for 2wks
o Avoid sex 2 wks post-op

o Specific risks
33
 Retrograde ejaculation (implications for fertility)
 Incontinence
 Erectile dysfunction
 Urethral trauma
 TURP syndrome (rare)
 Regrowth – may need re-doing
o Unreasonable anaesthetic risk
o Recent radiotherapy of area
o Prostate cancer
o Current UTI
o Certain neurological conditions affecting bladder and sphincter
o Symptoms will continue
o May develop complications such as infection, bladder distension (which can later lead to incontinence), bladder
stones, complete obstruction (leading to kidney failure)

 Medication e.g. tamsulosin – but this is not a cure (may have already been tried)



CONSENT FOR THYROIDECTOMY PRADEEP KANDIAH

INTRODUCTION
 Hyperthyroidism is a serious condition which can result in a ‘thyroid storm’ or crisis
 Thyroid cancer is a potential lethal cancer
 Ask about previous experience with surgery and anaesthetic and if there were any complications from either
o Pt. placed under general anaesthetic; an incision is made in the neck and the thyroid exposed and then cut out
 Step-by-step explanation of before, after and during procedure
 BEFORE
o Blood tests to measure thyroid hormone levels
o Nuclear medicine scans of thyroid
o Needle biopsy of thyroid
o May need to take anti-thyroid medications of iodides
o Fast from midnight
o Come in morning of operation
o Vocal function tested before procedure (recurrent laryngeal nerve)
o IV line inserted into back of hand
 DURING
o Put under general anaesthetic
o Incision made at the base of neck
o Important structures identified (laryngeal nerve and parathyroid glands)
o Gland and arteries (middle and inferior thyroid arteries) removed
o Incision sutured closed
o Normally takes 1-2 hours
 AFTER
o Drain may be placed in the area to train excess fluid
o Wake up in recovery room after anaesthetic wears off
34
o Discharged normally after 2 or 3 days
o Stitches still in place and removed by GP
o Maybe started on thyroxine therapy if complete thyroidectomy
o Follow up by endocrinologist and surgeon
 BENEFITS OF DOING PROCEDURE
o Symptom relief
o Cures hyperthyroidism or can cure thyroid cancer
 RISKS OF DOING PROCEDURE
o Permanent hypothyroidism – easily treated by giving thyroxine tablets
o Thyrotoxic crisis
o Recurrent laryngeal nerve injury
 If unilateral, hoarse voice, impaired cough
 If bilateral, mute with tracheostomy
o Transient hypoparathyroidism
 Can be permanent in some patients
o Haemorrhage/Haematoma
 More risky in this procedure because a haematoma can compress the trachea
o Infection
o DVT and PE due to immobilization
o If any surgery is contraindicated e.g. patients with ASA scores of 4, patients with extreme IHD or COPD
 RISKS OF NOT DOING PROCEDURE
o Continuation of symptoms + hyperthyroidism can lead to potential fatal thyrotoxic crises
o Thyroid cancer can metastasize
STEP 4: ALTERNATIVES
 Anti thyroid medications
 Radioactive iodine for thyroid cancer
 Ask if the patient to describe what they understand about the procedure and correct misunderstandings
 Verbal/written consent
CONSENT – SURGICAL RESECTION OF COLORECTAL CARCINOMA CHRISTIANNE TAN

INTRODUCTION
 Colorectal cancer – potentially deadly disease
 Surgical Removal of the cancer is the best choice

o The part of the bowel affected by the cancer will be removed
o Some of the surrounding bowel & tissues (lymph nodes) will also be removed to reduce the chance of the cancer
recurring
o The bowel ends are then joined together
o A temporary or permanent colostomy may be performed – Surgeon brings part of the bowel up to the skin
 BEFORE
o Usually admitted to hospital the day before surgery
o Do not eat or drink anything (even water) at least 8 hours before surgery
 Ask your doctor which medications should be stopped and which should continue to be taken
 If your medications need to be taken, take them with a small sip of water
o The evening before, the bowel is cleansed using a bowel preparation solution (3L)
o Some tests may be performed before the surgery
 Colonoscopy
 Physical examination
 Blood tests
o A catheter may be placed for urine, as well as several IV lines for fluids
o The anaesthetist or doctor may visit you to check on you
 DURING
35
o Anaesthetist gives you a general anaesthetic so you go to sleep
o A tube is placed into your throat to assist breathing
o Open surgery: Midline incision is made (about 15-20 cm); or laparoscopic surgery: several small incisions through
which instruments and cameras are inserted, abdomen filled with gas to expand it to make it easier to see inside
o The tumour is localised and other organs may be inspected for spread of the tumour
o The tumour is then removed, together with surrounding bowel & glands that cancer cells may have affected
o If there is enough healthy bowel remaining, both bowel ends are stitched together
o Estimation of duration: 2 hours
o Estimation of pain/discomfort: will be unconscious during operation
 AFTER
o You will wake up in the recovery room and be transferred to the ward
o You may feel drowsy, nauseated and may have a sore throat due to the tube
o You may feel pain
 Pain relief will be given
 Patient controlled analgesia (PCA) – you control the amount of medication given
 Pethidine injections, suppositories, IV medication
o Your intestines need to recover from the surgery
 No food is given for 4-5 days
 IV infusions will provide you with fluids and minerals your body needs
o Once you have passed flatus, you can drink
o Once the intestines resume their normal function, liquid food is given for the first few days before you can have solids
o While recovering, you may be given heparin or anticoagulants to stop clots from forming in your legs
 These can travel to your lungs and cause problems
o A stoma nurse or physiotherapist may also visit you to help improve your recovery
Colostomy
Temporary
A temporary colostomy may be performed to give the bowel enough time to rest and recover
The bowel is brought up and through the abdominal wall to the skin
The edges of the bowel are stitched to the surface of the skin
A stoma bag is secured around the opening to allow stool to drain
Once your body has fully recovered, another surgery is performed to close up the stoma & reattach large bowel
This is usually done after about 12 weeks, if there are nor complications
Permanent STEP 3:
Sometimes, if there is not enough bowel remaining to stitch together, a permanent colostomy may be performed
A permanent colostomy is where the healthy end of the bowel is brought through the abdominal wall to the skin
A stoma bag is secured around the opening to allow stool to drain
The other end is stitched up
 A few days following the surgery, there may be mucous discharge from the anus
 This is normal and due to normal secretions
People with colostomies usually can do activities that normal people can do
BENEFITS AND RISKS
o If the cancer is completely removed and there is no distant spread, the cure rate is very high
 Depends on the stage of the cancer
o Common risks:
 Anaesthesia – Risk is very small
 Allergic reaction
 Breathing problems
 Surgery
 Blood clots in the legs that may travel to the lungs
 Breathing problems, heart attack or stroke during the surgery
 Infection
 Bleeding
o Specific risks
 Damage to nearby organs
 Wound infections – treated with antibiotics
 Bleeding inside your abdomen
 Incisional hernia – Bulging tissue through the incision site
 Adhesions – Scar tissue may form in your bowel which can cause blockage of your intestines
 Recurrence of the cancer, which may occur locally
36
o The risk of not undergoing the procedure is the spread of the cancer
o Colorectal cancer can spread to nearby glands, and most commonly spreads to the liver
o When cancer spreads to other organs, the cure rate decreases
 Chemotherapy
o Can be used for patients unsuitable for surgery or in patients with cancer that has spread
o Have many side effects
 Radiation therapy
o Only indicated in rectal cancers
 Both chemotherapy & radiation therapy may be used after surgery to reduce the risk of spread
STEP 5: RECOVERY & FOLLOW UP

 During your recovery
o Avoid lifting heavy objects
o Follow a high-fibre diet
o Ensure care of the colostomy to prevent infections
 Follow up
o You will need to have regular colonoscopies to ensure the cancer does not recur
 3 months after surgery
 1 year after surgery
 Every 3 years after first 2
o Regular stool occult blood tests every year
o Tumour marker screening
 CEA is a protein found normally in small quantities the blood
 It is present in increased amounts in people with colon cancer
 Should be measured before colon cancer surgery & then at intervals of 2-3 months

CONSENT FOR HERNIA REPAIR PHOEBE GAO

INTRODUCTION
 Hernia: a hole in the muscle wall of the abdomen that allows part of the gut to protrude through
o Bowel can become strangulated (stuck through gap and lose blood supply)
 Reasons for procedure:
o Prevent strangulation from occurring
o Improve cosmetic appearance
 BEFORE
o Fast from midnight prior to operation
 DURING
o General anaesthetic (no pain/consciousness during operation)
o Tube put down throat to facilitate breathing
o IV line and urinary catheter may be used
o May need blood transfusion
o The operation
 Bowel is pushed back through hole in muscle and a mesh is stitched into place over the hole to prevent it from
protruding again
 Laparoscopic (keyhole) procedure – three small cuts made in skin, air is pumped in to inflate the abdomen,
telescope and instruments inserted into small cuts and used to perform operation
o May need to be converted to open procedure (bigger single scar)
o Estimation of duration: 1-2 hours approximately
o Estimation of pain/discomfort: General anaesthetic (no pain/consciousness during operation)
 AFTER
o May be drowsy post-op due to anaesthesia/painkillers
o Stay in hospital for monitoring for 1-2 days
o Avoid heavy lifting (5-10kg) and strenuous activity (~6 weeks)
37
o Avoid driving (1 week)
o Prevents hernia from getting larger
o Prevents strangulation from occurring in future
o Gets rid of bulge
o Specific risks
 Bleeding at site
 Perforation/infection of abdominal cavity
 Infection of the mesh graft (requires redo)
 Bleeding/fluid accumulation in groin or scrotum
 Damage to (ilio-inguinal) nerve supplying parts of groin, penis and scrotum – pain/loss of sensation
 Testicular atrophy (0.1%) due to damage to testicular artery
 Prostatism/urinary retention
 Recurrence (3%)
o None specific to hernia repair
o General medical fitness for surgery (cardio/resp/coagulation etc.)
o Hernia can enlarge
o Pain
o Strangulation – part of bowel dies, need major operation to remove it, may have problems with bowel function in
future
 Watch and wait (risk of strangulation)
 Reduce worsening hernia by avoiding straining/heavy lifting (risk of strangulation)
HIP AND KNEE REPLACEMENT FERN MCALLAN

INTRODUCTION
 Explain how a healthy joint works (cartilage, +/- menisci, synovial fluid etc)
 Conditions for which a joint replacement might be an option:
o “The indications for hip arthroplasty are incapacitating arthritis of the hip combined with appropriate physical
and x-ray findings.”
o Conditions not necessarily involving arthritis, such as:
 Fractures that won’t heal properly (e.g. NOF)
 Avascular necrosis
 Previous septic joint damage
 Cancer in or near a joint
 Symptoms (validated Hip and Knee Questionnaire) no longer relieved by non-surgical Mx:
o Pain (primary reason!): effect on sleep interruption and while resting
o Limitations to ADLs, including walking and self care
o Psychological health: psychological well-being, carer roles
o Economic impact: ability to perform paid work
o Recent deterioration

o During the operation, the ends of the damaged bones are removed, and the artificial components are fixed in place.
 Damaged joint surgically replaced with artificial joints made of metal, ceramic, or plastic.
o Type: The choice of procedure is primarily based on considerations of the lifestyle requirements of the patient and the
condition of the affected joint.
o Types of hip replacement: Total arthroplasty, Hemi arthroplasty (Often develop acetabular disease and need THR)
o Types of knee replacement: high tibial osteotomy (break and re-align tibia), unicompartmental knee arthroplasty, total
knee arthroplasty
38
 Aim for replacement only of part affected by OA, results in less invasive surgery with quicker recovery
 BEFORE
o Ways to improve your outcomes from surgery:
 Lose wt if you’re overweight
 Exercise or hydrotherapy (irrespective of weight)
 STOP SMOKING!
 Optimise Mx of co-morbidities
 Meds: NSAIDs and some herbals: inc bleeding, may need to be stopped.
o Before admission – clinic a week to ten days prior to the operation, to help with admission paperwork and planning,
plus working out any changes that might be needed around home
o At hospital, before the operation: FFMN (fast at least 6 hours), May need some more tests (ECG, CXR), Anaesthetics r/v
 DURING
o You will be given some medications: antibiotics and anticoagulants
o You lie on your back on the operating table and your leg is cleaned and prepared for surgery.
o Mechanical devices (stockings or pumps) will be used to reduce the risk of clots
o Anaesthetic: GA or epidural.
o Surgery:
 Incision will be about 30cm long, Soft tissue, such as muscle, will be moved to expose the joint
 The bones are cut, diseased section removed. Further bone may need to be removed to ensure the prosthetic
joint sits in the correct position
 Often, a special type of glue – bone cement – is used to anchor the prosthesis to the bones
 Knee: if needed, the patella can be replaced with a prosthetic ‘button’
 The ligaments and muscles are rearranged, drain tube is inserted into the wound and closed with stitches or clips.
o Estimation of duration: two to four hours
o Estimation of pain/discomfort: general anaesthetic during procedure, some discomfort post-procedure
 AFTER
o Recovery:
 Tubes: IV, drain tube from site of operation, urinary catheter
 Activity is encouraged EARLY (day two) to prevent stiffness, muscle wasting and DVT. (Drain tube should be
removed at about one day post op to make this easier).
 Mobility: you’ll need some help with mobility and will likely need some form of gait aid for about 6 weeks.
 Physio and OT will help you with some exercises to perform and advice to modify your ADLs – this is useful to
help you achieve the maximum benefit from the operation.
 Food: You can start eating on day 2 post-op
o Discharge: It might take MONTHS before you get the full benefit
 Someone else at home? You may need to plan to be in a rehab unit after leaving hospital, If you live alone, plan
to have someone visit daily or live with you to help with ADLs.
 Keep the wound clean and dry. Check it for Sg of infection.
 Follow the instructions on how to safely walk, climb stairs and get in and out of chairs.
o Review: clinic at about 6 weeks. Appointments may continue out to ten years after replacement.
o Long term: 90% of hip and/or knee replacements survive for 10 to 15 years, some have lasted up to 25 years.

o In most cases, it will reduce pain, improve mobility, make ADLs easier and improve quality of life. Eventually you
should be able to do activities such as walking, swimming and gardening. High impact activities and sports involving
running, jumping and twisting should be avoided.
o Remember, the prosthesis is good, but can’t hope to function as fully as a healthy joint
 DVT + PE [mechanical measures are adequate prophylaxis if pt is mobilised quickly, anticoagulate otherwise]
 Infection – up to about 3/12 is considered due to the op, Rarely amputation due to severe wound infection
 Failure of procedure - Persistent pain or stiffness after the operation
o Specific risks
 Revision surgery is associated with a higher risk of complications and further device failure.
 Nerve palsies: (Mx: generally conservative)
 Fracture: Typically around prosthesis, may be in other areas (fatigue fractures) due to inc activity with pain relief.
 Joint dislocation: (RFs: female pt, non-union, revision surgery; Can reduce risk with compliance with post-surgical
guidelines, such as physio)
 Other bone Cx: Leg-length discrepancy (longer or shorter), Non-union, Prosthesis may become loose, break or
undergo wear
 Effusion (‘build up of fluid in the joint’)
o After discharge, see your GP if: Sg infection, Sx PE/DVT
39
o Absolute: Septic joint, Remote source of ongoing infection, Severe vascular disease
 Knee: poor extensor function
o Relative
 Medical conditions precluding safe anaesthesia and impairing rehabilitation, Skin conditions within the surgical
field (e.g. psoriasis), PHx of osteomyelitis around the joint, Neuropathic joint/ neurological disorders affecting
musculature or joint, Obesity
o “Without surgery, a severely osteoarthritic joint will continue to deteriorate until it is impossible to go about your
normal daily activities.”
o Impact = Sx as described above (pain, ADLs, psychological health, financial disadvantage)

 Other, less effective, treatments include
o Conservative Mx, e.g. walking aids, such as frames or sticks, NSAIDs, Corticosteroid injections
o Other surgery: e.g. osteotomy (diseased bone is cut away in an attempt to properly align the malformed joint).
 #NOF:
o Extra-capsular – dynamic hip screw
o Undisplaced intra-capsular – pinned, with hope supply to head is preserved and AVN won’t develop
o Displaced intra-capsular – joint replacement: in older generally hemiarthroplasty (Moore’s), in younger or those
expected to rehabilitate to a higher level usually a THR.
 Knee
o Arthroscopy: two portals are made, one for visualisation and one for ‘working’.
 Indicated in OA pts with mechanical Sx rather than pain
 Debridement of labral tears, loose body removal, chrondral lesion debridement, osteophyte resection, biopsy,
synovectomy

http://arthritisaustralia.com.au/images/stories/documents/info_sheets/english/colour/Joint_Replacement.pdf
http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Knee_replacement_surgery
NSAIDS SOO-MIN CHO

INTRODUCTION
 Mainly for mild to moderate pain management

 Enquire about prior experience - any allergies? Check for contraindications
o 3 actions of NSAID
 anti-inflammatory effect
 analgesic effect
 antipyretic effect
o commonly used NSAIDS
 Short term: Aspirin, Paracetamol, Ibuprofen
 Chronic pain: Naproxen, Diflunisal, piroxicam

 DURING
o Aspirin and ibuprofen - po
o Paracetamol - po or IV
o Selective COX-2 inhibitors – IV or IM
o Estimation of duration: should relieve pain in 30 minutes
o Estimation of pain/discomfort: should relieve pain/discomfort

o Manage your pain to a level that can be controlled and less distressing
o Used in conjunction with narcotic analgesics to limit the dose of narcotics used
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 RISKS OF UNDERGOING PROCEDURE/SIDE EFFECTS
o Gastric irritation – dyspepsia, diarrhoea, sometimes gastric bleeding or ulceration
o Effect on renal blood flow
o Prolong bleeding through inhibition of platelet function
o Rash, only with specific drugs (5~15%)
o Much less common: CNS effects, bone marrow disturbances, liver disorders
o Aspirin
 Large doses: Salicylism - dizziness, deafness and tinnitus in large doses
 Toxic doses: respiratory acidosis with metabolic acidosis
 Linked to postviral encephalitis (Reye’s syndrome) in children
o Paracetamol overdose: liver failure (hepatotoxic)
o Gastric ulcer
o Aspirin: drug interactions
 warfarin (increases effect)
 probenecid (reduce urate excretion  C/I in gout)

 Find alternative analgesics – steroids, opioids

WARFARINISATION SHIVANI DURAI

INTRODUCTION- Name, establish rapport
 AF-you have an irregular heart rhythm
 DVT/PE-anticoagulation
 Mechanical heart valve
STEP 2: CHECK SUITABILITY/CONTRAINDICATIONS

o Current meds
o PHx stroke
o PUD
o Subacute bacterial endocarditis
o Pregnant/breastfeeding
o Recent surgery
o HTN

 EXPLAIN BENEFITS OF WARFARIN USE
 Role of warfarin- a medication that thins your blood and prevents clotting
o Why patient needs it
 RISKS OF WARFARIN USE
o Common risks: Bleeding/bruising, skin rashes, N&V, diarrhea, jaundice, alopecia
 PRECAUTIONS
1. Trauma: avoid contact sports
2. Diet
a. Avoid vit. K-rich foods – liver, green veggies. Eating an increased amount of foods rich in vitamin K can lower
the prothrombin time and INR, making warfarin less effective, and potentially increasing the risk of blood clots.
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b. Alcohol – may ↑ coagulation effect, ≤2 standard drinks/24
3. Pregnancy & breast feeding: stop taking warfarin immediately & see GP (warfarin can be teratogenic in 1 st trimester)
4. Drug Interactions
a. NSAIDs are not safe (but paracetamol is)
o Many drugs interact with warfarin & pharmacist should be consulted before taking OTC meds
 MONITORING
DOSE:
o To be taken at the same time each day (with or without food)
o Suggest patient marks off a calendar for every dose taken
o If a dose is missed, take it ASAP or if it is time for the next dose, do NOT take the previous dose
(e.g do not take both at the same time) – just inform the doctor
INR(International Normalized Ratio): If the INR is below the target range (ie, under-anticoagulated), there is a risk of clotting. If,
on the other hand, the INR is above the target range (ie, over-anticoagulated), there is an increased risk of bleeding.
BLOOD TESTS: Regular blood tests to tailor dose to patient by measuring INR(target:2-3)
o Every day for 1 week
o Every week for 3 weeks
o Every month for 3 months
WARFARIN BOOK
o Give patient book to record doses & results of blood tests
o Explain patient should show it to their doctors
STEP 4: ADDITIONAL POINTS

BRACELET: Recommend in case of an emergency or accident
DENTIST: Ensure patient tells dentist prior to any dental procedure
SEEK HELP: If there are obvious or subtle signs of bleeding, including the following, patients should call their healthcare
provider immediately.
 Provide leaflets
CONSENT FOR STEROIDS OLIVIA LEAHY

INTRODUCTION
STEP 1: EXPLAIN WHAT STEROIDS ARE AND WHY PATIENT NEEDS THEM
 Some steroids, such as the hormone cortisol, occur naturally in the human body.
 Steroids are very effective against swelling and inflammation which would make your condition worse if left untreated.
 They only suppress the disease and do not cure it.
 The type of steroids used to treat disease are called corticosteroids which are different to the 'anabolic' steroids
STEP 2: EXPLANATION OF TAKING STEROIDS

 Enquire about prior experience taking steroids
o Dose is usually taken regularly, once a day, preferably in the morning, with or after food.
o Enteric-coated tablets should be swallowed whole (not crushed or chewed)
o If you miss a tablet, take one as soon as you remember BUT NEVER take two doses at the same time
 You should not stop taking your steroid tablets or alter the dose unless advised by your doctor. It can be dangerous to
stop steroids suddenly
 This can cause various 'withdrawal' symptoms until your body resumes making natural steroids over a few weeks.
 The withdrawal symptoms can be serious, even life-threatening and include: weakness, tiredness, feeling sick,
vomiting, diarrhoea, abdominal pain, low blood sugar, and low blood pressure which can cause dizziness, fainting
or collapse.
o Store in a cool dry place, away from children. If many are taken at once, esp by a child, call an ambulance
o Carry a ‘Steroid card’ with you if taking a long course – this tells the dose & type of steroid in case of emergency
 BEFORE taking steroids, you must tell your Dr if you: have had any sick infectious contacts (shingles, chickenpox), a recent
MI, PHx/FHx of: HTN, DM, glaucoma, PUD, hypothyroidism, TB, mental illness (esp severe depression), vaccinations (last
3months), heart/kidney/liver disease, taking other medicines OCP, insulin, NSAIDs, antibiotics etc

 BENEFITS OF STEROIDS
o A short course of steroids usually causes no side-effects and can induce remission (halt disease/ take away symptoms)
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 RISKS OF LONG TERM or REPEATED STEROID USE
o Unfortunately steroids can have serious side-effects that are more likely to occur if you take a long course of steroids
(more than 2-3 months), or if you take short courses repeatedly.
o The higher the dose, the greater the risk of side-effects. We’ll use the lowest possible dose which controls symptoms
o A common treatment plan is to start with a high dose to control symptoms.
Often the dose is then slowly reduced to a lower daily dose
o The length of treatment can vary, depending on the disease. Sometimes the
steroid treatment is gradually stopped if the condition improves. However,
steroids are needed for life for some conditions as symptoms return if the
steroids are stopped.
o Common side effects:
Weight gain Thin bones/fractures Muscle weakness Mood changes
↑appetite Indigestion Stomach ulcer Central Obesity
Easy bruising Thin skin + striae acne Dry skin
Menstrual changes Baldness hirsutism ↓ libido, Impotence
High BP High glucose High cholesterol ↓calcium
Cataracts/Glaucoma ↑ risk infection Poor healing ↑ blood clots
o Immunosuppression, malignancy, current infection (or latent e.g. TB)
o Do not take NSAIDs whilst taking steroids  PUD
o No live attenuated vaccinations whilst on steroids
o Minimise use of alcohol. DO NOT take if pregnant w/o consultation
o Beware: Drug/OTC interactions – e.g. exacerbation of hypokaliemia; Digoxin toxicity
 RISKS OF NOT TAKING STEROIDS
o Treatment may not be as effective, the disease may progress/death...depends on the indication

 Depends on if there is another option; surgery, DMARDs/steroid sparing agents, chemotherapy agents

 Ask patient to describe what they understand about steroids, and correct any misunderstandings.

THE ORAL CONTRACEPTIVE PILL MEI GOH

- Introduction
- Consent
- Name, age, occupation
- Hx/Ex if indicated
 Before prescribing the pill, usually conduct:
- Breast Ex
- Pelvic Ex
- Urine + blood tests
- BP check (hypertension is a contraindication)
- Explain the different types of contraception available – OCP, condoms, diaphragm, IUDs, progesterone only pills
(POP), Billings Method, sterilization etc. Include pros/cons; consider specific patient circumstances/preferences etc.
1. What is the OCP?

 Pill contains 2 hormones – oestrogen and progesterone
 Sometimes referred to as combined oral contraceptive pill (COP)
2. How does it work?

 The hormones prevent ovaries from releasing eggs and ovulation
 Progesterone: –ve feedback results in ↓ pulse frequency of GnRH from hypothalamus, which ↓ FSH
secretion and ↓↓ LH secretion
 ↓ FSH stops follicular development, stopping a rise in oestrodiol levels
 Oestrogen: -ve feedback also ↓ FSH secretion, which decreases follicular development and hence stops
ovulation
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 Pill also causes changes in the lining of the uterus and mucus of the cervix, further discouraging pregnancy
3. How do I take the pill?

The pill is based on a 21-day cycle – the pills are taken everyday at the same time, then stopped for 7 days during which time
there should be withdrawal bleeding  not the same as menstrual bleeding.
– During the 7 days, “sugar” pills (non-active) are taken so the patient can remember the timing. I.e. Start with
active pills for 21 days, then 7 sugar pills.
– Remember: To stop ovulation, a woman must take 7 consecutive active pills (7 day Rule). Therefore, if > 7
days are missed (> than the 7 sugar pill days), you are at risk of ovulation + pregnancy.
– Explain to the patient that it takes at least 7 days on active pills to shut down the ovaries.
Starting the pill:
– Start your first pack of pills on the day your period begins (take the pill that is labeled that day of the week).
– Take one pill everyday, at around the same time – discuss with patient when is the best time to establish a
routine (Eg. After brushing your teeth or before you go to bed).
– It will take at least 7 days on the active pill to ensure contraception, however, during the first month, it is
safest to use backup contraception, such as the condom.
What if you miss taking the pill:
– If you miss the pill within 12 hours of set time
 Take the pill you missed immediately, and then take the pill for the next day at the set time. Do NOT take
extra pills in one go.
– If you miss the pill past 12 hours, always apply 7 day Rule  use alternative method + active pills for 7 days
in a row.
– Don’t have to explain to patient but… Missing the pill near the 7 day pill free interval (sugar pill interval) may
mean the woman has not taken enough pills to prevent ovulation in the next month (> 7 days missed). This
usually happens when an active pill is missed at the end or beginning of a packet, as this lengthens the time
the woman is not taking an active pill.
 Use alternative method of contraception + apply 7 day rule
4. Benefits
 Regular, lighter periods
 Improvement of acne
 Improvement or absence of PMS
5. Disadvantages/side effects
 Sore breasts, nausea, breakthrough bleeding (first few months of use)
 May cause weight gain, mood changes, loss of sex drive in some women
 Doesn’t protect you against STIs
 Increased risk of DVTs
6. Contraindications
 Migraine
 Hx of blood clotting
 Liver problems
 Unusual vaginal bleeding
 Smoking – increases the harmful effects of the pill
 May precipitate/worsen hypertension, liver disease
Pill does not work well if:

- Not taken regularly (poor compliance)
- Diarrhoea, vomiting
- Taken with antibiotics or other drugs
7. Effectiveness
If used correctly and consistently – 0.3% of pregnancy (Actual/typical use – 8%)
OBTAIN PATIENT CONSENT
PROVIDE WRITTEN INFORMATION
DOCUMENT IN NOTES
44
BSL MONITORING GAHA MATHAN
INTRODUCTION
 Uncontrolled diabetes can be life threatening. Extremely high sugars can lead to DKA or HONK both of which can make you
very sick and require hospitalisation. Extremely low sugars can put you into a coma.
 Overall, poorly controlled sugars can accelerate the pathway to many diabetic complications including the big ones like
heart attack and stroke, as well as kidney and eye disease and peripheral vascular disease which can lead to loss of
sensation in your arms and legs and later down the track amputation of a senseless limb.
 Blood sugar monitoring reveals individual patterns of blood sugar changes, and helps in the planning of meals, activities, and
at what time of day to take medications. It keeps both you and your doctor aware and in control allowing for better
management of your diabetes.

o BSL monitoring involves a quick finger prick and a drop of blood placed onto a strip attached to a little machine that
tells you in a few seconds what the level of sugars in your blood.
o Most people with Type 2 diabetes test at least once per day.
o Diabetics who use insulin (all Type 1 diabetes and many Type 2s) usually test their blood sugar more often (3 to 10
times per day), both to assess the effectiveness of their prior insulin dose and to help determine their next insulin
dose.
 Blood glucose targets should be
o Fasting: < 6
o Random: 4-8
 High blood sugars are regarded as being higher than 10, but symptoms (increased thirst, increased urination and blurred
vision) may not start to become noticeable until even higher values such as 15-20 at which stage it would be wise to take
insulin or if on oral medications call an ambulance.
 Chronic levels exceeding 7 can produce the organ damage we discussed before.
 Low blood sugars are regarded as being symptomatic below 3; symptoms are unique to each individual though some
common ones are sweating, pale, shaky and anxious. At this point you should eat a jelly bean or something starchy and if
family see that you are unconscious and unable to eat or drink they should call an ambulance.

 BEFORE
o Clean your hands/fingers before handling electrodes or obtaining blood as dirt or grease from fingers can alter the
reading
o Meters use electrodes that are inserted into the machine to measure blood glucose.
o Electrodes are made for particular machines and can only be used ONCE.
o Machines are normally calibrated for every new box of electrodes (calibrator- special electrode comes with each new
box)
o Prior to calibrating compare the calibrator strip number with the number on the box, electrode insert sheet number
and number on the electrode packet (ALL should be the same) and ensure that the expiration date has not passed.
o Insert the calibrator strip into meter – see that appropriate display occurs to ensure meter has been programmed.
o Once the machine is calibrated, insert an electrode into the sensor of the meter.
o Check the meter display indicates that it is ready to record/measure.
o When a drop of blood is applied to the end of the electrode, the glucose in the blood combines with chemicals on the
electrode to produce very small electrical currents that are measured by the sensor of the meter.
o The meter converts this signal into a blood glucose reading
o Disposable lancets (and a lancing device) are used to obtain a drop of blood from your finger.
o Touch the drop of blood on the target area of the electrode until sufficient blood has been drawn up.
o A blood glucose reading is displayed 10-30 seconds later depending on the meter.
 AFTER
o Dispose of the used lancet and electrode.
o Hold pressure to the pricked area (especially if you are on blood thinners) to stop the bleeding.

 BENEFITS OF UNDERGOING PROCEDURE – keeps you out of the trouble that we mentioned before.
45
 RISKS OF UNDERGOING PROCEDURE – not many at all, perhaps a little bleeding and bruising over the pricked site especially
if you are on blood thinners. Patients do say that their fingers get sore so try to switch them around.
 CONTRAINDICATIONS- Local skin infections over pricking site
o Run the risk of over- or under-medicating leading to extremes in blood sugars and the severe consequences
mentioned.
STEP 4: ALTERNATIVES – a ‘continuous monitor’ located under the skin that determine the blood sugar level every few minutes.
The down side is that it still requires calibration twice a day with finger pricks and there is a lag time between the real blood
glucose and that measured which is not good in severe highs or low where treatment has to be immediate.

STEP 6: OBTAIN PATIENT CONSENT
USE OF INSULIN LUCY DANG
Why:
T1DM-Without insulin, the sugar levels in your blood will get too high, you will be very sick over several days and this may lead
to death. Don’t want to scare you but I must highlight the importance.
When:
This involves giving 4 injections per day of insulin: one 30min before breakfast/lunch/dinner and one before bed (basal)
Where:
Injections can be given in the thigh or abdomen (pinch skin and apply pressure after 30s)
Remember to change location of injection site (>3cm clockwise fashion) to maintain good absorption to prevent fat
atrophy/hypertrophy
How much:
Adjust amount according to BSL. Ie if you are ill, more insulin may be required; if planning to exercise, less insulin is required. In
order to this, a DIARY is recommended to keep track of BSL throughout the day.
Types of insulin
Rapid-acting (e.g. Humalog, NovoRapid, Actrapid)- onset 10-30min, last 3 to 5 hours, peaks at about 1-3 hours
46
Short-acting, intermediate acting (e.g. Humulin, Humulin NPH respectively), onset 30min to 1 hour, lasts 4 to 12 hours, peaks
after about 2 hours
Long acting (Lantus, Levemir)- provide slow, steady insulin release, peakless basal insulin, used once a day, helps control BGL for
a full 24 hours
Mixed (mixture o short-acting and intermediate-acting) e.g. Mixtard 30/70 contains 30% short-acting & 70% intermediate-acting
human insulin
Complications:
If you give yourself too much insulin, your BSL could drop too low, giving you a hypoglycaemic attack. Features include morning
headaches, lethargy, night swearts, weight gain, seizures.
To counteract this, take lollies with you for a glucose boost when needed, lower your insulin dose, and monitor your blood
glucose levels every hour until they return to normal.
If you do not have enough insulin, you may start enter DKA. Symptoms include vomiting, feeling dizzy, difficulty concentrating
and entering a coma.
For this, you must take insulin and monitor your blood glucose levels every hour, or come to hospital.
DIABETES COMPLICATIONS ALISON PUNG

Introduction
 Diabetes is a condition where there is too much glucose, which is a type of sugar, in the blood.
 Over time, glucose builds up in the bloodstream leading to damage to small and large vessels of the body, which may
cause damage to the body’s organs.
 It is important to have regular check-ups and screening to prevent these complications from occurring/progressing.
The most common complications include:

 Damage to the large blood vessels of the heart, brain and legs (macrovascular)
 Damage to the small blood vessels, which causes problems in the eyes, kidneys, feet and nerves (microvascular)
General advice to prevent complications overall

 Stop smoking
 Limit alcohol intake – no more than 2 standard drinks/day. Have at least 2 alcohol free days in the week.
 Lose weight
 Be as active as possible
 Eat healthy food
 Test your blood sugar levels and aim to keep them as normal as possible
o Blood glucose – have an HbA1c (glycated-haemoglobin) test every 3-6 months. This shows an average of your blood
sugar levels over the last 3 months
Macrovascular
 Cardiovascular disease
o The risk of heart attacks, strokes and blood vessel disease of the legs is greater for people with diabetes.
47
o High cholesterol and blood pressure levels, combined with increased blood glucose levels can lead to cardiovascular
disease. Therefore it is important for you to have your blood pressure checked every time you go to the doctors and
have your cholesterol level checked at least once a year.
Microvascular
 Eye damage
o Damage to the blood vessels at the back of the eyes can occur without you even being aware of it. This is because your
vision doesn’t change until the damage is severe.
o Macular oedema is the specific problem that can happen in people with diabetes. The risk of cataracts and glaucoma is
more common in people with diabetes.
o It is important to have regular eye checks every 2 years, or once a year if any problems are detected. Seek help quickly
if you notice any changes in your vision.
 Kidney damage
o Changes in the small blood vessels of the kidney can cause kidney disease. This is painless and does not cause
symptoms until it is advanced.
o Screening and early detection of small amounts of protein in the urine is very important. If it is identified, the
progression of kidney disease can be slowed. Have your urine tested at least once a year.
 Nerve damage
o High blood glucose levels can cause damage to the nerves of the legs, arms, hands, chest and stomach. This results in
loss of sensation or strange sensations like pins and needles, numbness or tingling in the affected areas. Consequently,
this can lead to injury especially in the feet. You should inspect your feet everyday to avoid foot injury.
o Let your doctor know if you have experienced any altered sensations in your hands or feet. It is important to have a
foot check by your podiatrist at least once a year.
Monitoring schedule
Every three months Every six months Every year
Review symptoms and self-monitored BSL Glycaemic control
(fasting: 4-6 mmol/L, (haemoglobin A1c 7.0%) Blood lipids (total cholesterol <4.0 mmol/)
post-prandial: 6-8 mmol/L) 3-monthly if targets not being met
Microalbuminuria (morning urine
blood pressure 130/80 mm Hg Foot examination albumin/creatinine ratio M<2.5, F<3.5) and
plasma creatinine/GFR
Eye review (every two years in absence of
Weight (BMI 20-25), waist measurement
retinopathy)
Foot examination if at risk or new

symptoms
USE OF ASTHMA RELIEVER MEDICATION DEVICES DAN TRAN
METERED-DOSE INHALERS (MDI)
Most asthma medicines come in a metered dose inhaler (or MDI). It is important to use
your MDI correctly to ensure you get enough medicine into your lungs.
How to use a MDI:
1. Remove the cap and hold the inhaler upright

2. Shake the device for 10 seconds
3. Tilt your head back slightly and breathe out normally
4. Put mouthpiece in your mouth and start breathing in slowly and deeply
5. Press the canister down and continue to breathe in deeply (3-5 seconds)
6. Hold your breath for 10 seconds to let the medicine get deep into your lungs
7. Breathe out slowly
8. Wait one minute before you take another puff (if needed) and repeat steps 3-7
9. Take a maximum of 4 puffs every 4 breaths every 4 minutes
10. Replace cap and store in a cool place
Note: It may be helpful to rinse your mouth with water and spit out after using your MDI to avoidsore throat/sore
tongue/hoarse voice.
48
How to clean your inhaler:
1. Remove the canister form the inhaler. Never wet or soak the canister
2. Rinse the inhaler under warm running water
3. Dry thoroughly inside and out
SPACERS
Why use a spacer?
 Most children under 8 do not have the coordination required to use puffers
effectively.
 A spacer is easier to use than a puffer alone.
 A spacer allows more medication to be breathed in.
 A spacer results in fewer medication side effects.
 Children under 3-4 years of age will need to use a small volume spacer with a
facemask.
How to use a puffer with a spacer device
1. Assemble the spacer - Attach facemask if necessary.

2. Remove the cap from the puffer and shake it well.
3. Attach the puffer to the spacer.
4. Place the mouthpiece of the spacer in your mouth and close your lips around it. When using a spacer with a
facemask, place the facemask over mouth and nose to ensure a good seal.
5. Press down on the puffer once to release the medication into the spacer.
6. Breathe in and out normally for 4 breaths.
7. To take more medication, repeat steps 3-6.
Caring for spacers
Before initial use and then monthly, the spacer should be washed in clean warm soapy water and allowed to drip
dry. Do not rinse or wipe dry.
TURBOHALERS
Turbuhalers contain medicine as a dry powder. It is important to use your Turbuhaler

correctly to ensure you get enough medicine into your lungs.
How to use a Turbuhaler:
1. Unscrew the cap of the Turbuhaler and lift off. Hold the Turbuhaler upright
2. Load by turning the grip at the base to the right as far as it will go, then twist back to the
left until it clicks
3. Breathe out gently. Hold the Turbuhaler without occluding the air inlets and put the tip
of the mouthpiece between your lips
4. Breathe in strong and deeply through the mouth (do not breathe into the Turbuhaler)
5. Remove the Turbuhaler from your mouth and hold your breath for 10 seconds
6. Replace the cap and screw it shut
7. If another dose is required repeat steps 2-7
Note: You will get a higher dose by twisting the coloured base more than once at the same time.
Note: It may be helpful to rinse your mouth with water and spit out after using your Turbuhaler to avoid sore
throat/sore tongue/hoarse voice.
How can I tell when my Turbuhaler is empty?
49
 The Turbuhaler has an indicator (clear window below the mouthpiece). This tells you when the Turbuhaler is
empty.
How do I clean my Turbuhaler?
 It is important not to get any part of a Turbuhaler wet. If it needs cleaning, just wipe a clean dry tissue over the
mouthpiece. Always keep the cap on when not in use.
ACCUHALERS
An Accuhaler is a dry powder device. It is important to use your Accuhaler correctly to

ensure you get enough medicine into your lungs.
How to use an Accuhaler:
1. Hold the base of the Accuhaler in one hand, and with the other hand place your
thumb in the thumb grip. Push thumb around as far as possible until it clicks
2. With the mouthpiece at the top, press the lever down until it clicks
3. Breathe out gently
4. Place the mouthpiece in your mouth. Suck slowly and deeply through your mouth
5. Remove Accuhaler from your mouth and hold your breath for 10 seconds
6. Breath out slowly
7. Close Accuhaler
8. If another dose is required repeat steps 1-7
Note: Only one dose can be loaded at a time.
Note: It may be helpful to rinse your mouth with water and spit out after using your Accuhaler to avoid sore throat/sore
tongue/hoarse voice.
How can I tell when my Accuhaler is empty?
 The Accuhaler has a counter that counts backwards from 60-0 as doses are used. The last five numbers are red.
How do I clean my Accuhaler?
 It is important not to get any part of an Accuhaler wet. If it needs cleaning, just wipe a clean dry tissue over the mouthpiece.
USE OF PEAK FLOW METERS DAN TRAN
 The peak flow meter provides a quick method of assessing airway obstruction.
o The peak flow rate depends on the diameter of the airways
o Predicted normal values vary with the patient’s sex and height
 The patient is asked to take the deepest breath possible and then blow out as hard and fast as they can into the
meter. It is usual to record the best of three attempts.
o To ensure an acceptable result, the manoeuvre must be performed with maximum effort immediately
following a maximal inspiration.
 To achieve good results, carefully explain and DEMONSTRATE the procedure to the patient, ensuring that they
are sitting erect with feet firmly on the floor.
 Apply the nose clip to the patient’s nose and urge the patient to:
o Breathe in fully
o Seal their lips around the mouthpiece
o Blast air out “as fast and as far as you can” until the lungs are completely empty
 Essentials are:
o A good seal on the mouthpiece
o Vigorous effort right from the start of ht manoeuvre
o No leaning forward during the test
50
OSTEOARTHRITIS + MANAGEMENT DAN TRAN
EPIDEMIOLOGY
 Very common, about 10% of adults, and 50% of people over 60 suffer from osteoarthritis
 Osteoarthritis of the knee occurs more in older people and is more common in men than women
PATHOGENESIS
 It is a degenerative disease that mainly affects the cartilage (the lining) of the joints
 However, it also affects the bones and muscles around the joints and in some circumstances synovitis (inflammation) can be
present
 It can occur on its own (primary osteoarthritis) or as a result of another problem (secondary arthritis) such as trauma,
infection (septic arthritis), or an inflammatory arthritis
MANAGEMENT
 Non-pharmacological strategies
o Exercise (resistance training if it can be tolerated and aerobic exercise)
o Unloading the joints (holding a cane in the opposite hand to the affected knee)
o Weight loss
o Realignment strategies (braces and patellar taping and shoe insoles)
o Acupuncture (limited evidence)
 Pharmacological therapy
o Paracetamol is the first-line agent
o NSAIDS (e.g. Nurofen)
o Consider a proton pump inhibitor to prevent peptic ulcer disease
o Intra-articular steroids (injection into the joint) (benefits are usually short-lived (1-3 weeks)
o Opioids (codeine, endone)
 Surgical
o Knee replacement if severe disease, when medical management fails
OSTEOPOROSIS + MANAGEMENT DAN TRAN

PATHOGENESIS
 Osteoporosis is a condition in which the bones become fragile and brittle, leading to a higher risk of fractures (breaks or
cracks) than in normal bone.
 Osteoporosis occurs when bones lose minerals, such as calcium, more quickly than the body can replace them, leading to a
loss of bone thickness (bone mass or density). As a result, bones become thinner and less dense, so that even a minor bump
or accident can cause serious fractures
EPIDEMIOLOGY
 Osteoporosis affects both women and men.
 Women are at a greater risk of developing osteoporosis than men, mainly due to the rapid decline in oestrogen levels after
menopause. Oestrogen is an important hormone for maintaining healthy bones. When oestrogen levels decrease, the bones
lose calcium (and other minerals) at a much faster rate - bone loss is approximately 1% - 5% per year after menopause.
 Men also lose bone as they age, but their bone mass generally remains adequate until much later in life.
 However, certain risk factors such as reduced calcium intake and low levels of vitamin D can increase age related bone loss.
 Other risk factors include age, family history, low exposure to sun light, little exercise, renal disease, steroids, smoking and
endocrine problems like hyperthyroidism and Cushing’s.
MANAGEMENT
 Non-pharmacological
o Falls prevention:
 Lighting, rugs, gait aids, occupational therapist
 Alter fall-causing medications (anti-hypertensives, DM medication, sedatives, analgesics)
o Weight-bearing exercise (e.g. walking - within abilities of the patient)
o Increase dietary calcium and Vitamin D
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o Remove all risk factors
o Adequate sun exposure (20 mins per day, before 10am, after 4pm)
 Pharmacological
o Bisphosphonate
 SE: GORD – take 30 mins before breakfast, take while standing upright, take one per week
o SERM – increased risk DVT/PE
o HRT – if symptomatic menopause – increased risk of breast cancer, DVT/PE
o Strontium
o PTH
HIV PRE-TEST COUNSELLING SU-WEI KHUNG
1. INTRODUCE & GUARANTEE CONFIDENTIALITY

Tell patient that the discussion and results if the test is done will be confidential and private.
2. ASSESS RISK – varies depending on exposure, give rating of low/med/high based on:
 Current health, any suggestion of HIV/AIDS
 Sexual orientation and behaviour (no. of partners, type of intercourse, use of condoms)
 Knowledge of partner/s’ promiscuity
 Hx of STIs
 Hx or travel or country of origin and sexual behaviour
 Hx of drug abuse
 Hx of blood/blood product transfusion or organ donation
3. WHAT IS HIV/AIDS
(Check patient’s knowledge first)
HIV stands for human immunodeficiency virus. It infects T cells, a type of cell that is important in the immune system for fighting
infections. In HIV, these T or CD4 cells are gradually destroyed.
AIDS stands for Acquired Immune Deficiency Syndrome, which is a group of signs and symptoms that is caused by HIV infection
when it has become advanced and the T cell count falls. This cannot be tested for.
4. HOW IS HIV TRANSMITTED

HIV is found in blood, semen, vaginal fluids and breast milk. It can be transmitted:
 Via sexual contact with an infected person
 From infected mother to baby before/during birth or through breast-feeding after birth
 Through infected blood and blood products (blood transfusions and organ transplants)
 Through sharing of needles, syringes and other injecting equipment (inc. tattooing equipment)
5. REASON FOR TESTING

 It is important to have the test and will provide the patient with greater certainty/reassurance.
 If patient has HIV, they can be provided medical support and monitoring, and early treatment including anti-retrovirals
and prophylaxis against opportunistic infections.
 It would allow patient to alert others (partners, health professionals) of the risk of transmission.
 It is also important in terms of safe behaviour and being aware of the risk to others.
 Also mention possibly testing for other STIs
6. TIMING OF RISK EXPOSURE, AND POSSIBLE POST-EXPOSURE PROPHYLAXIS

 When did risk events happen?
 Anti-retrovirals can be used as post-exposure prophylaxis (e.g. if known exposure to HIV). Course is around 28 days.
Testing for HIV antibodies is required before, at 2-4wks, 3mo and 6mo.
7. TESTING PROCESS
52
The test involves taking a small amount of venous blood to look for HIV antibodies. When a person gets infected, the body
produces antibodies against the virus, which is called seroconversion, and the HIV test is for these antibodies. These tests are
rarely 100% sensitive/specific. Thus, whenever HIV testing is done, retesting is always required to confirm the diagnosis.
If the patient’s test is negative for HIV antibodies, this can mean one of two things:
 They are not infected.
 They are in the window period. The window period is the time between the initial HIV infection and the antibody
response (seroconversion) and is normally no more than 3 months. In this time, the patient may test negative for HIV
antibodies. Being in the window period does not mean that they are not infectious however, and the patient should be
encouraged to practice safe sex in the meantime. Some patients may opt to defer the test if they are seeking it because
of very recent unprotected intercourse and should be given the same advice. Retesting is required at 3 at 2-4wks, 3mo
and 6mo. to confirm that the patient was not in the window period. A negative result also does not mean the patient is
immune to HIV infection, and they are still able to get infected if they engage in risky behaviour.
If the patient is positive for HIV antibodies, it means that they are infected with HIV and can transmit the virus to other people if
they engage in risky/unsafe behaviours. It does not necessarily mean that they have AIDS (this cannot be tested for). There is
also a small chance that the test could be a false positive, thus retesting is required to confirm. If the patient has HIV, the lab will
be legally required to report this to the state health authorities (but anonymously w/ postcode) for statistical reasons.
There are some other implications, including contact tracing – the patient’s partner(s) must be informed and tested (this may be
done through an anonymous service). It would also be strongly advised to notify their GP and dentist, and the result would be
permanently recorded. The patient is not obliged to inform anyone else unless they choose to.
Rarely, the test may return with an indeterminate result. This does not confirm the presence/absence of HIV antibodies. It could
be due to seroconversion, cross-reactivity with something else or a prior medical condition affecting the test (e.g. arthritis,
autoimmune disease). Retest.
Tell patient that they must come back to you to receive the results in person, whether they are positive or negative.
8. CHECK PATIENT’S UNDERSTANDING/ANY QUESTIONS

9. OBTAIN INFORMED CONSENT
10. ADVICE ABOUT BEHAVIOUR PENDING TEST RESULT
 Careful to practise safe sex/drug use, etc. until the result is known.
11. ASSESS SUPPORT MECHANISMS WHILE WAITING FOR RESULTS AND IF RESULT IS +VE
 Who will they tell – friends, family, partner?
12. PROVIDE WRITTEN INFORMATION
13. DOCUMENT IN NOTES
HIV POST-TEST COUNSELLING SU-WEI KHUNG
-VE
ASK HOW THE CLIENT HAS BEEN FEELING SINCE HE OR SHE HAD THE BLOOD SAMPLE DRAWN
EXPLAIN THE RESULT
If the patient’s test is negative for HIV antibodies, this can mean one of two things:
 They are not infected.
 They are in the window period. The window period is the time between the initial HIV infection and the antibody
response (seroconversion) and is normally no more than 3 months. In this time, the patient may test negative for HIV
antibodies. Being in the window period does not mean that they are not infectious however, and the patient should be
encouraged to practice safe sex in the meantime. Retesting is required at 2-4wks, 3mo and 6mo to confirm that the
patient was not in the window period. A negative result also does not mean the patient is immune to HIV infection, and
they are still able to get infected if they engage in risky behaviour.
 The possibility of a false negative has to be considered
REINFORCE EDUCATION REGARDING SAFE BEHAVIOURS/PRACTICES
 Protected sex: always use condoms
 IVDU: sterile injecting equipment; avoid sharing needles
EMPHASIZE REPEATED RISKS ARE NOT ‘SAFE’
DISCUSS ANXIETY/RISK BEHAVIOURS
DISCUSS TESTING FOR OTHER STIS
 HPV, chlamydia, herpes simplex, gonorrhoea, hepatitis B & C, pubic lice, syphilis, trichomonas
53
DOCUMENT IN NOTES
+VE
ASK HOW THE CLIENT HAS BEEN FEELING SINCE HE OR SHE HAD THE BLOOD SAMPLE DRAWN
PROVIDE RESULTS AND NEED TO REPEAT TEST FOR CONFIRMATION
If the patient is positive for HIV antibodies, it means that they are infected with HIV and can transmit the virus to other people if
they engage in risky/unsafe behaviours. It does not necessarily mean that they have AIDS (this cannot be tested for). There is
also a small chance that the test could be a false positive, thus retesting is required to confirm.
IMMEDIATE NEEDS/SUPPORT
SAFE BEHAVIOURS – EDUCATION, INFORMATION, SUPPORT
 Protected sex: always use condoms
 IVDU: sterile injecting equipment; avoid sharing needles
MANAGING STRONG REACTIONS/EMOTIONS
OPTIONS FOR MX/TX
 There are many effective treatments for HIV, progression to AIDS is less than in the past, and prognosis is better.
 Refer to a specialist HIV physician for ongoing follow-up
 Follow-up may include regular monitoring of the immune system (viral load and CD4 count), antiretroviral therapy,
prophylactic treatment of opportunistic infections, management of common co-infections (TB, Hep B/C) and family
planning.
ONGOING THERAPY/COUNSELLING
LEGAL REQS (DISCLOSURE RIGHTS, WHO THEY SHOULD TELL AND HOW TO)
 If the patient has HIV, the lab will be legally required to report this to the state health authorities (but anonymously w/
postcode) for statistical reasons.
 There are some other implications, including contact tracing – the patient’s partner(s) must be informed and tested
(this may be done through an anonymous service). It would also be strongly advised to notify their GP and dentist, and
the result would be permanently recorded. The patient is not obliged to inform anyone else unless they choose to.
DOCUMENT IN NOTES
COUNSELLING A PROSPECTIVE TRAVELLER CHRISTL YONG

INTRODUCTION
STEP 1: RISK ASSESSMENT
 Itinerary (country / regions / dates of travel - season)
 Urban / rural
 Age
 Past vaccination Hx
 Comorbidities – altered immunocompetence due to HIV, diabetes
 Current Medications
 Pregnancy status
 Allergies
 Purpose of trip
 Risk exposures (blood, body fluids, sexual, extreme sports, outdoors)
 Types of accommodation
 Travel insurance
 Level of aversion to risk
STEP 2: VACCINATIONS
Routine vaccinations
 Measles/mumps/rubella
 Diptheria/tetanus/pertussis
 Hepatitis B
54
 Hib
 Polio
 Varicella
 Influenza
 Meningococcal
 Pneumococcal
Recommended vaccinations – depends on risk assessment
http://wwwnc.cdc.gov/travel/destinations/list.aspx - for a guide on vaccinations based on destination
 Hepatitis A (Exposure through food and water)
 Typhoid (If travelling to smaller cities, rural areas, villages where exposure might occur through food and water)
 Rabies (If contact with animals likely)
 Japanese encephalitis (If travelling to rural Asia for > 1/12)
Required vaccinations
 Yellow fever for travel to certain countries in sub-Saharan Africa and tropical South America
STEP 3: MALARIA PREVENTION

 Prophylactic therapy is typically chosen based on the area the individual is travelling to
 Common options include Doxycycline (100mg daily; begin 2/7 before travel, take daily at the same time each day while
in the malarious area and for 1/52 after leaving such areas) and Mefloquine(250mg once/week; begin 2/52 before
travel, take weekly on the same day of the week while in the malarious area and for 4/52 after leaving such areas)
 Prophylaxis does not prevent malaria, it prevents overwhelming infection and death from malaria whilst overseas
 Preventative behaviour include wearing long clothing; using insecticides, repellents and bed nets; not venturing out at
dusk and dawn
STEP 4: ESSENTIAL PREVENTIVE BEHAVIOURS

 Food and water safety
o Boiling water, using filters, chemical disinfection with chlorine, avoid beverages diluted with nonpotable water
o Eat cooked/hot food
 Protection against STDs (always use condom)
 Motor vehicle safety (wear a seatbelt, don’t drink and drive)
 Personal safety (appropriate dress, crime, recreational activities, local customs, etc.)
 Use sunscreen and insect repellent as directed
 Altitude / motion sickness / jet-lag
STEP 5: PROVIDE WRITTEN INFORMATION/TRAVEL HEALTH WEBSITE

http://wwwnc.cdc.gov/travel/destinations/list.aspx
55

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EXPLANATIONS &

INFECTIOUS DISEASES COUNSELLING

STEP 2: EXPLANATION OF THE PROCEDURE

STEP 3: BENEFITS AND RISKS

STEP 4: ALTERNATIVES (if any)(mention drawbacks)

STEP 5: CHECK UNDERSTANDING

STEP 2: EXPLANATION OF THE PROCEDURE

STEP 3: BENEFITS AND RISKS

STEP 4: ALTERNATIVES (if any)(mention drawbacks)

STEP 5: CHECK UNDERSTANDING

STEP 6: OBTAIN CONSENT

CONSENT FOR VENEPUNCTURE JULIAN HUA

STEP 1: EXPLAIN WHY THE PROCEDURE NEEDS TO BE PERFORMED

STEP 2: EXPLANATION OF THE PROCEDURE

STEP 3: BENEFITS AND RISKS

STEP 5: CHECK UNDERSTANDING

STEP 6: OBTAIN CONSENT

STEP 8: DOCUMENT IN NOTES

STEP 2: EXPLANATION OF THE PROCEDURE

STEP 3: BENEFITS AND RISKS

STEP 4: ALTERNATIVES (if any)(mention drawbacks)

STEP 5: CHECK UNDERSTANDING

STEP 6: OBTAIN CONSENT

STEP 8: DOCUMENT IN NOTES

STEP 2: EXPLANATION OF THE PROCEDURE

STEP 3: COMPLICATIONS (AFTER SUTURING)

STEP 1: EXPLAIN WHY THE PROCEDURE NEEDS TO BE PERFORMED

STEP 2: EXPLANATION OF THE PROCEDURE

STEP 3: BENEFITS AND RISKS

STEP 4: ALTERNATIVES (mention drawbacks)

STEP 5: CHECK UNDERSTANDING

STEP 6: OBTAIN CONSENT

STEP 7: DOCUMENT IN NOTES

Appropriate terms: Penis, urethra, urinary outlet/opening, labia/lips, foreskin

Inappropriate terms: any slang term for penis or vagina

STEP 1: EXPLAIN WHY THE PROCEDURE NEEDS TO BE PERFORMED

STEP 2: EXPLANATION OF THE PROCEDURE

STEP 3: BENEFITS AND RISKS

STEP 4: ALTERNATIVES (mention drawbacks)

STEP 5: CHECK UNDERSTANDING

STEP 6: OBTAIN CONSENT

STEP 7: DOCUMENT IN NOTES

Appropriate terms: anus, back passage, bottom, buttocks, rectum

STEP 1: EXPLAIN WHY THE PROCEDURE NEEDS TO BE PERFORMED

STEP 2: EXPLANATION OF THE PROCEDURE

STEP 3: BENEFITS AND RISKS

STEP 4: ALTERNATIVES (if any)(mention drawbacks): particular to patient’s situation

STEP 6: OBTAIN CONSENT: verbal and/or written consent

STEP 1: EXPLAIN WHY THE PROCEDURE NEEDS TO BE PERFORMED

STEP 2: EXPLANATION OF THE PROCEDURE

STEP 3: BENEFITS AND RISKS

 RISKS OF NOT UNDERGOING PROCEDURE

STEP 4: ALTERNATIVES (if any)(mention drawbacks)

STEP 5: CHECK UNDERSTANDING

STEP 6: OBTAIN CONSENT

STEP 7: DOCUMENT IN NOTES

STEP 2: EXPLANATION OF THE PROCEDURE

STEP 3: BENEFITS AND RISKS

STEP 4: ALTERNATIVES (mention drawbacks)

STEP 5: CHECK UNDERSTANDING

STEP 6: OBTAIN CONSENT

STEP 7: PROVIDE WRITTEN INFORMATION