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RECOMMENDED TEXT BOOKS
& Love's Short Practice of Surgery Concise Textbook of Surgery by S. DAS
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 .
GASTROintestinal GASTROintestinal SURGERY SURGERY .
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. .
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).
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.
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 .
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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