SURGERY

Dr Fahim Akbar

Balance

SocietyWork Family

Self

Personal relationship

Scientific

research

professional skill

Teaching ability

Theory basis surgical skill Sympathy and love Scientist Engineer Artist Make correct decisions

The Anatomy

The Surgical Technique

Grey’s Anatomy

The Emergency Room

The HistoryPresent illness, previous history, family history

1. Correct Diagnosis2. Therapy schedule3. Good relationship

The physical examinationInspection, palpation, percussion, auscultation

The laboratory examinationLaboratory examination, imaging exams

Other examinationAll kinds of endoscopes, angiography

Medical Record

Chief complains Present illness Past history Review of systems Personal history Bearing history Family history

The history——how to begin

Gain confidence Give confidence Establish relationship Effective communication

gentle Considerate Sympathy Understanding Personal charm

The way is different Follow your rhythm ， not the patient’s What the patient said maybe unreliability Avoid: Leading questions, wanted ， wrong answers

Building the history

Detective work: respect the facts Realize the critical problem Follow some rules Patient may tell a lie, Why? Believe your eye and mind but not your ear

Building the history—Pain The International Association for the Pain Study "Pain is an unpleasant sensory and emotional experience

associated with actual or potential tissue damage, or described in terms of such damage

The progress of pain

Why pay attention to Pain motivates the individual to withdraw from

damaging situations protect a damaged body part while it heals to avoid similar experiences in the future

Most pain resolves promptly once the painful stimulus is removed and the body has healed

sometimes pain persists despite removal of the stimulus and apparent healing of the body

sometimes pain arises in the absence of any detectable stimulus, damage or disease

Building the history—Pain

How to evaluate/rate pain

Wong—Baker face

Pain: What can we learn

How the pain begin Position Characteristics：

○ Explosive （ rupture ） or Rapid or Gradual○ Precise （ trunk ） or obscure （ viscera）○ Constant （ structural ） or intermittent （ functional）

How to relieve: naturally or medication

Associations: intermittent claudication: vasculitis or Spinal Stenosis extremity deformity: bone fracture

Pain: reaction

Purpose ： To find the cause Do not believe all patients saying Overreactor:

Mild pain: Mosquito BitesModerate pain: gastric ulcerSevere pain: vascular pain, renal or biliary colic

Restore confidence Anagelsia

Vomiting

What How much How often Smell Color Projectile:

○ Intracranial hypertension

Pathogeny

diagnosis

Bowel Habits

Habits change: common but easy to ignore

The shape and size: maybe changed with alter of diet or travel

Intermittent alternations of constipation or diarrhea

Hematemesis or Hematochezia

Hematemesis From throat\mouth Character of blood Clot Bright or dark red Coffee-ground

Hematochezia From rectum Character of blood Clot Bright or dark red Tarry stool hemorrhoids

Trauma Get the detals as precisely as possible, find

important clues○ When○ Where○ How○ Patients position○ Consciousness○ Retrograde amnesia○ Check the wounds○ Blood lose○ Get what therapy

Trauma

Car/vehicle accident injury

Sport injury

Gun shot

Past history

Never overlooked important histories Do not expend to much time Do with the physical examination Accord to different systems System review

System review

Respiratory system no pharyngalgia; no chromic cough or hemoptysis; no dyspnea and

thoracalgia;no afternoon fever or night sweats.

Circulatory system no palpitation and breathlessness on exertion: no precordial pain,

dizziness and persistent headache; no syncope and hypertension.

Digestive system no sour regurgitation and dysphagia: no chronic abdominal ache,

diarrhea and vomiting: no jaundice, hematemesis and melena

Urinary system no past history of edema and proteinuria; no pollakiuria; no urgency

and painful micturition; no visible hematuria and hypertension.

System review Hematopoietic system

pale shin, dizziness, blurred vision and tinnitus; impairment of memory; petechia and jaundic; lymph node, liver and spleen enlargement; abnormal bony pain.

Endocrine and metabolic system no irritability, hidrosis or profound fatigue and headache; no impaired vision, exceeding

thirsty and polyuria; no excessive hairiness or hair loss; no pigmentation and sexuality change.

Muscle, bone and joint system no unusual pain, redness and swelling of the joints; no deformity of joints; no

limbs and trunk limitation on motion; no myoasthenia and myoatrophy. Nervous system

no persistent headache and syncope; no memorial impairment or speaking obstacle; no insomnia and consciousness obstacle; no paresthesia of skin; no paralysis and convulsion. Mental status: no hallucination, delirium and orientation obstacle; no abnormal emotion

Family history

Many disease are familial hereditaryfamilial adenomatous polyposis FAPHypertensionHeart diseasediabetes mellitusColon cancers

Have the same genesHave the similar enviroment

Patients emotional background

Patient Depressed Nerves Fear and be afraid of the surgery Do not have confident

Amputation ， ileostomy, colostomy

Psychiatric consultation is seldom need

Surgeon is important: Explain enough Patient Professional Trustworthy

Examination

Physical examination Laboratory examination X-ray CT scan MRI ( Magnatic Resonance Imaging)

Endoscopy○ Gastroscopy○ Esophagoscopy

Remember

Necessary examination

Painful and inconvenient examination

No excessive examination

Physical examination

In a certain sequence Elective examination Complete later Be courteous and relax Suitable enviroment Let patient collaborate and at ease

Physical examination

Ordinary systemInspectionPalpationPercussionAuscultation

locomotor systemMovementmeasurement

Inspection

Observe by purpose Compare with the normal side

Facial features Expression position Pupil Consciousness Steps Droop eyelid Breast disease

Palpation

Gentle and skillful Careful, gentle and precise Fingertip is most sensitive

Mass (benign, malignant)Boundary, tenderness, size, pain, movements

Auscultation

Important in both medicine and surgery Pneumothorax Great vessels disease Ileus Vascular lesions Heart disease

Movement and measurement

Emergency

Alter to fit circumstances Make the changes History must be short and to the point Make certain the primary considerations Physical exams must be specific

Emergency

Primary consideration:consciousnessBreathingAirway openPalpable pulseHeart beating

CPR?

How to deal with

Airway obstruction Massive bleeding Tension pneumothorax Cardiac tamponade Bone fracture Blunt trauma to the brain/ head

Emergency physical exam

Life sign is stable Make a rapid survey examination 2-3minuts to evaluate:

○ Head○ Throat○ Abdomen○ Extremities○ Genitalia○ Cervical: turn the patient

Laboratory exam

Screening for asymptomatic disease Appraisal of disease contraindicate elective

surgery emergency, deadline ， elective surgery

interstinal rupture, great vessels rupture

gastric cancer, liver cancer

thyroid adenoma, inguinal hernia

Diagnosis of disorders Evaluate the paitents condition

Imaging studies—X ray

Chest radiograph○ Pneumonia○ lung cancer○ Tuberculosis○ Rib fracture○ Pneumothorax

- (lung marking)

Imaging studies—X ray

Abdominal X-RayRupture

Obstruction

Imaging studies—X rayBone Fracture

Imaging studies——CT Why do a CT

Imaging studies——CT

CT will show the nidus more specific than X ray

Imaging studies——MRI

Why do a MRI

Imaging studies——MRI

MRI can display Softtissue

Basic exams

Complete blood test Stool examination Urine examination Chest X-ray ECG: electrocardiograph Old patient （ >60）：

○ Ultrasonic cardiography○ blood gas analysis

Medical consultation

Why

Thank You!