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01.General Surgery

01.General Surgery

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Published by: ARIF-UR-REHMAN on May 26, 2009
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 Bailey

& Love's Short Practice of Surgery  Concise Textbook of Surgery by S. DAS

Reference books
 Schwartz's Principles of Surgery  Sabiston Textbook of Surgery  Manipal Manual Of Surgery

Marks distribution .

COURSE OUTLINE COURSE OUTLINE Basic surgical principles Gastrointestinal Surgery .

Basic surgical Basic surgical principles principles .

 Approach to diagnosis: a surgical patient  History taking in Surgery  General physical examination Systemic Local or Regional  Investigations .

 Preparing a patient for surgery  Pre-operative management  Post-operative management .

 Basic Surgical skills  Nutritional support and  Critical care  Wound infection rehabilitation .


 The esophagus  Stomach and duodenum  The liver  The spleen  The gallbladder and bile ducts  The pancreas .

mesentery and retroperitoneal space  The small and large intestines  Intestinal obstruction . omentum. The peritoneum.

 The vermiform appendix  The rectum  The anus and anal canal  Hernias. Umbilicus. Abdominal wall .

Basic surgical principles .

Approach to diagnosis: Approach to diagnosis: a surgical patient a surgical patient .

 A focused physical examination is performed. and the complete medical status of the patient assessed. . This starts with the patient from whom a careful history is taken.

be that medical or surgical. and confirmed by the appropriate test. The likely diagnosis is considered on the basis of this clinical assessment. . the specific treatment. is advised.  Once confirmed.

History taking in History taking in Surgery Surgery .

 The  Two key step in surgical diagnosis types of history in surgical practice .

 Outpatient or emergency room history  To obtain a diagnosis on which the treatment is ordered  History from a patient admitted for elective surgery  To assess that the treatment planned is correctly indicated and to ensure that the patient is suitable for that operation .

. shake hands  Initiate the process by asking the patient to tell you what made him or her seek medical advice  Listen without interruption to the patient as he or she relates the history of the presenting complaint(s).  Establish a rapport with the patient: introduce yourself.Approach to historytaking.

by specific questions . During this process make a mental note of the key symptoms  Wait for the answer before asking another question  Obtain further details on specific symptoms. nature of severity and associations. including duration.

. operations and exposure to general anesthesia. including drug medication. surgical conditions. Briefly review the systems by key questions  Obtain details of past medical history.

 Past medical incidents are important because they may relate to the patient's current illness and may also influence management  Obtain details of social history and habits. including alcohol consumption and smoking  Obtain a brief family history .

Don'ts of history-taking  Do  Do  Do not interrupt the patient not use medical terminology not ask ambiguous or irrelevant questions  Do not use leading questions in the first instance  Do not be abrupt or impatient .

lump or ulcer . Surgical patient presents in the outpatient department or the emergency room with a special problem such as pain.

Diagnostic clinical information on pain  Site  Radiation  Severity  Nature  Duration  Relieving factors  Aggravating factors  Associations .

Types of pain  Colicky pain  Somatic pain  Burning pain  Intermittent claudication  Rest pain  Root pain  Referred pain .

General physical General physical examination examination .

or specific anatomical region. the lump or the pain. . Two aspects of the examination:  Systemic examination That reviewing the whole patient  Local or regional examination That concentrating on the specific complaint.

. inspection. percussion and auscultation. the process relies on four skills. Whichever system or anatomical region is examined. i. and is designed to elicit the appropriate clinical signs.e. palpation.

Inspection  Inspection requires a trained eye actively to detect abnormalities. .

conjunctival membranes and sclera. Inspection consists of a detailed and systematic scrutiny of the anatomical region and entails close observation of:  Abnormal movements and body contour  Surface abnormalities (scars. particularly . lips. lumps. bulges) and  Complexion of the skin. surface lesions.  Good lighting is essential.

lumps and enlarged organs. .Palpation  Palpation relies on the tactile sense organs in the fingers to outline surface irregularities. tension of the abdominal walls.

. the less you feel. the more you press. The exercise should be carried out by a relaxed warm hand and should be conducted gently and in an orderly fashion. the patient is hurt. and worse still.  In general.

thoracic) is stony dull to percussion.Percussion  Percussion is very useful for establishing the consistency of a swelling or organ.  Thus a solid lump or organ is dull to percussion.  A fluid-containing cyst or body cavity (peritoneal. .

 For

the same reason a distended urinary bladder is detected as a localized dull swelling in the suprapubic region.  By contrast, air-containing organs (normal ventilated lung, aircontaining hollow abdominal viscera) are resonant on percussion (much like a drum).

 When

using percussion to outline the size or margins of an organ, one should percuss from the resonant to the dull area.  The point where the note changes marks the margin of the organ.

 Auscultation

with the stethoscope requires considerable experience to recognize the normal from the abnormal, and is used to examine:  Lungs (normal and adventitial breath sounds)  Heart sounds and murmurs  Abdominal bowel sounds  Bruits over stenotic or dilated segments (aneurysms) of arteries.

Examination of aalump Examination of lump or swelling or swelling .

A lump may be visible on inspection or not be detected until palpation is carried out. .  The lump may be discrete and localized or be diffuse. when it is more properly designated a swelling.

Important characteristics of a lump  External appearance  Interior of substance  Surroundings .

External appearance of a lump  Size  Shape  Surface and  Color  Tenderness  Mobility  Ballotement edge .

Interior or substance of a lump       Consistency Reducibility Indentation Fluctuation Pulsation Trans-illumination       Compressibility Cough impulse Discharge Fluid thrill Expansion Bruit .

Test for fluctuation .

Expansile pulsation .

Trans-illumination .

Surroundings of a lump  Induration  Tethering  Invasion  Lymph nodes .

Examination of an Examination of an ulcer ulcer .

when it involves the skin and subcutaneous tissues.  Ulceration has a varied etiology and ulcers may be benign or malignant in nature. . An ulcer is defined as an area of discontinuity of the surface epithelium and may occur internally (mucosal) or externally.

its floor. In establishing the nature of an ulcer.  The duration of the ulcer. and its base and edges. including the site of the ulcer. . certain characteristics are important.  The history is also important and often provides useful diagnostic clues. history of trauma and the presence or absence of pain are all relevant.


Shape of ulcer  Round  Oval  Irregular  Serpiginous .

Edge of ulcer .

Floor of ulcer  Depth  Covering  Discharge .

Base of ulcer  Penetration  Fistulation .

Examination of specific anatomical areas  Head and neck  Breasts  Axilla  Abdomen  Inguinal region  Scrotum and external  Anus and rectum genitalia .

Investigations Investigations .

 Blood investigations  Microbiological investigations  Diagnostic imaging  Gastrointestinal Endoscopy  Tissue diagnosis .

Blood investigations  Full blood count  Coagulation screen  Baseline biochemistry  Autoantibody screen screens .

 Antibiotic sensitivity is important because it directs the use of drugs with a narrow spectrum of activity. thus avoiding the antibiotic resistance that develops from the . urine.Microbiology A septic screen consists of the collection of samples of blood. wound swabs and sometimes stool for culture and sensitivity. sputum.

Diagnostic Imaging  Conventional radiography  Contrast radiography  Fluoroscopy  Computerized tomography  Spiral CT scan .

 Ultrasonography  Doppler effect  Pulsed Doppler  Radionudide imaging  MRI .







Gastrointestinal Endoscopy  Rigid scopes  Flexible scopes .

Rigid scopes  Simply straight tubes through which light is passed from an external source into the part of the body under examination. laparoscope and arthroscope. .  Examples are the proctoscope. mediastinoscope. resectoscope. rigid sigmoidoscope.

biopsy. e.Flexible scopes  Utilize fibre-optics to give betterquality imaging that can be displayed on a video monitor. cystoscope.g. .  Examples are the gastroscope.  They may contain side channels to insert instruments for diagnostic or therapeutic procedures. ERCP sphincterotomy. colonoscope. bronchoscope and angioscope.




Tissue diagnosis  Biopsy  Incision  Excision  Needle  FNAC .

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