Podcast
Questions and Answers
What is informed consent?
What is informed consent?
The patient has received the relevant information in a way they can understand, to enable them to make an informed decision and they voluntarily give permission.
Which of these principles must be fulfilled for informed consent to be valid? (Select all that apply)
Which of these principles must be fulfilled for informed consent to be valid? (Select all that apply)
Verbal consent is a form of express consent where a patient acknowledges agreement to healthcare.
Verbal consent is a form of express consent where a patient acknowledges agreement to healthcare.
True
What must written consent be supported with to ensure it is valid and informed?
What must written consent be supported with to ensure it is valid and informed?
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Informed consent requires communication that is _____ and involves two-way exchange.
Informed consent requires communication that is _____ and involves two-way exchange.
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What are the three areas that the process of surgery can be broken down into?
What are the three areas that the process of surgery can be broken down into?
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When is surgery indicated?
When is surgery indicated?
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The American Society of Anaesthesiologists (ASA) Physical Status Classification System describes a patient's __________ to undergo anaesthesia.
The American Society of Anaesthesiologists (ASA) Physical Status Classification System describes a patient's __________ to undergo anaesthesia.
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What grade of surgery is indicated for minor operations such as nail surgery?
What grade of surgery is indicated for minor operations such as nail surgery?
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Which of the following conditions is NOT indicated for nail surgery?
Which of the following conditions is NOT indicated for nail surgery?
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What should be monitored before nail surgery in patients with autoimmune diseases?
What should be monitored before nail surgery in patients with autoimmune diseases?
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HIV patients have the same post-operative risks as the general population if their CD4 count is above 200 cells/mm3.
HIV patients have the same post-operative risks as the general population if their CD4 count is above 200 cells/mm3.
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In what condition is unstable angina characterized?
In what condition is unstable angina characterized?
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What is a contraindication for performing nail surgery in sickle cell disease patients?
What is a contraindication for performing nail surgery in sickle cell disease patients?
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What should be ensured regarding a patient's HbA1c level before nail surgery in diabetic patients?
What should be ensured regarding a patient's HbA1c level before nail surgery in diabetic patients?
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What is the risk of performing surgery on a patient with hepatic diseases?
What is the risk of performing surgery on a patient with hepatic diseases?
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Patients with severe anaemia can generally undergo elective surgery without concern.
Patients with severe anaemia can generally undergo elective surgery without concern.
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Malnutrition has a higher incidence in the elderly.
Malnutrition has a higher incidence in the elderly.
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Match the following conditions with their considerations for nail surgery:
Match the following conditions with their considerations for nail surgery:
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What are some non-modifiable risk factors for nail surgery? (Select all that apply)
What are some non-modifiable risk factors for nail surgery? (Select all that apply)
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Which of the following conditions may indicate that nail surgery should not be performed? (Select all that apply)
Which of the following conditions may indicate that nail surgery should not be performed? (Select all that apply)
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What does ACM stand for?
What does ACM stand for?
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Who should be consulted before proceeding with nail surgery if a patient is taking anticoagulants?
Who should be consulted before proceeding with nail surgery if a patient is taking anticoagulants?
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The presence of severe ischaemia and infection creates a high immediate risk of __________.
The presence of severe ischaemia and infection creates a high immediate risk of __________.
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Informed consent is not required for medical treatment if the patient does not understand the treatment.
Informed consent is not required for medical treatment if the patient does not understand the treatment.
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An advance health directive is also known as a __________.
An advance health directive is also known as a __________.
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What should be done if a patient under 18 can make an informed decision about their medical treatment?
What should be done if a patient under 18 can make an informed decision about their medical treatment?
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Which of the following medications may need to be adjusted before nail surgery? (Select all that apply)
Which of the following medications may need to be adjusted before nail surgery? (Select all that apply)
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Study Notes
Patient Assessment for Surgery
- Evaluation of clinical history and physical examination is essential for clinical decision making and anesthetic administration.
- High-level clinical judgment and technical skills are necessary for performing effective podiatric surgery.
Importance of Patient Assessment
- Effective patient assessment directly influences surgical outcomes and patient satisfaction.
- Nail surgery outcomes are improved with thorough pre-operative assessments.
Pre-operative Assessment Process
- The surgical process is divided into pre-operative, intra-operative, and post-operative phases.
- Strong outcomes depend on assessment and management at each stage.
Indications for Surgery
- Surgery is indicated if conservative treatments have failed or if conservative treatment is not suitable.
- Surgical grading:
- Grade 1: Minor procedures (e.g., nail surgery)
- Grade 2: Intermediate procedures (e.g., knee arthroplasty)
- Grade 3: Major procedures (e.g., hysterectomy)
- Grade 4: Major+ procedures (e.g., total hip replacement)
Assessment for Nail Surgery
- Painful nail conditions warrant surgical intervention:
- Onychocryptosis
- Painful onychauxis/gryphosis
- Painful onychomycosis
- Trauma-related painful conditions
Patient Suitability Assessment
- The American Society of Anesthesiologists (ASA) Physical Status Classification System helps assess patient fitness for anesthesia:
- ASA 1: Normal healthy patient
- ASA 2: Mild systemic disease
- ASA 3: Severe systemic disease
- ASA 4: Severe disease that poses a constant threat to life
- ASA 5: Moribund patient not expected to survive without surgery
Pre-operative History Considerations
- Comprehensive medical history should include:
- Immune function and blood diseases
- Cardiovascular, endocrine, and neurological conditions
- Previous surgeries and current consultant care
- Evaluate for potential contraindications to local anesthesia (LA) use.
Managing Autoimmune Diseases
- Autoimmune diseases increase post-operative infection risk and affect healing.
- Patients may require altered DMARDs dosage pre-surgery.
- Procedures should be avoided during disease exacerbations or cold weather.
Diabetes Management Prior to Surgery
- HbA1c level must be below 9% for surgical appropriateness.
- Surgery remains a risk-benefit decision; careful patient agreement and clear documentation are crucial.
Considerations for Hepatic and HIV Issues
- Hepatic diseases correlate with immunosuppression and potential blood coagulation issues.
- HIV patients with a CD4 count > 200 cells/mm3 have similar post-operative risks as the general population.
Cardiac Conditions and Surgery
- Stable angina poses low perioperative myocardial infarction (MI) risk if managed correctly.
- Unstable angina requires stabilization before considering surgery.
Respiratory Diseases and Risks
- Patients with pulmonary disease experience higher post-operative morbidity and mortality.
- Smoking cessation is advised at least one week prior to surgery.
Blood Dyscrasias and Hematological Issues
- Severe anemia may hinder elective foot surgery; evaluate hemoglobin levels pre-operatively.
- Consider platelet count and coagulation status in patients with bleeding disorders.
Pregnancy Considerations
- Establish pregnancy status during pre-operative assessment; check again on surgery day.
- Use local anesthetics with caution during the first trimester.
Nutritional and Obesity Factors
- Obesity is linked to increased post-operative complications such as DVT and infection risks.
- Malnutrition in elderly patients heightens surgical risks.
Allergy History
- Document patient allergies or sensitivities, especially to local anesthetics, latex, or medications.
Vascular Assessment
- Perform a lower limb vascular assessment to identify significant peripheral vascular disease (PVD).
- Establish modifiable (e.g., smoking, hypertension) and non-modifiable (e.g., age) risk factors.
Venous Assessment
- Assess for varicose veins, history of DVT, and previous venous surgeries.
- Non-invasive vascular investigations are indicated for suspected peripheral artery disease (PAD) prior to nail surgery.### Nail Surgery Considerations
- Nail surgery in patients with non-severe PAD requires careful evaluation of risks and benefits alongside patient, GP, and vascular team.
- Severe or critical limb ischaemia necessitates vascular team consultation before considering nail surgery.
Vascular Findings That Contraindicate Nail Surgery
- Do not perform nail surgery if ABPI is less than 0.6 or if ankle systolic pressure is below 70 mmHg.
- Indication for urgent vascular opinion: ABPI greater than 1.4 with non-palpable foot pulses or toe systolic pressure under 40 mmHg.
Critical Risks in Ischaemia with Infection
- Severe ischaemia combined with infection increases risk of sepsis, tissue necrosis, gangrene, and potential amputation.
- Prompt communication with the vascular team is crucial for urgent triage of infected nail issues.
Neurological Assessment
- Neuropathy can lead to foot deformities and abnormal plantar pressures, significantly delaying healing.
- Assessment methods include 10g monofilament, neurosthesiometer, or 128 Hz tuning fork to determine levels of neuropathy.
Anticoagulant Medications (ACMs)
- Common anticoagulants: warfarin, aspirin, clopidogrel; newer options include rivaroxaban, dabigatran, apixaban, and edoxaban.
- Patients on ACMs may have conditions like DVT, stroke, CAD, and must be informed that post-op bleeding may be prolonged.
INR Monitoring and ACM Management
- Adjustments to ACMs should be considered but stopping them is not generally justified.
- INR typically ranges from 2 to 3 for warfarin users, indicating clotting takes two to three times longer than normal.
Cytokine Inhibitors (CytIs)
- CytIs, like adalimumab and etanercept, are used for autoimmune conditions and may require dosage adjustments prior to surgery.
- Stopping CytIs 2-8 weeks before surgery is recommended, along with prophylactic antibiotics during healing.
Oral Retinoids (ORs)
- Used for acne and psoriasis, ORs may lead to skin fragility and delayed healing post-surgery.
- Establish duration of therapy and reason for use, with special attention to increased infection risks.
Psychosocial Considerations
- Evaluate patient’s health beliefs, self-efficacy, and locus of control to adapt treatment communication and planning.
- Consider patient’s domestic support, including transportation for surgery and post-operative care assistance.
Impact of Occupation and Hobbies
- Understand patient’s working situation; inability to take time off may rule out surgery.
- Emphasize the need for cessation of sports during the healing process and convey typical post-op advice.
Importance of Comprehensive Assessment
- Inadequate information can lead to unsafe surgery and higher post-operative morbidity.
- Factors like systemic pathologies (e.g., unstable angina or rheumatoid arthritis) heighten the risk of clinical emergencies.
Legal and Ethical Considerations for Consent
- Adults over 18 can consent if they understand the treatment; enduring power of attorney can act on their behalf if they lose capacity.
- Minors require guardian consent, though those over 16 may consent if they demonstrate understanding of the treatment.
Obtaining Informed Consent
- Informed consent requires clear communication and understanding of treatment, risks, and rehabilitation implications.
- It is the patient’s right to decide what healthcare is received, and no treatment should occur without consent.
Consent Types
- Verbal consent is an express agreement, while written consent must be reinforced with detailed treatment information to ensure validity.
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