Surgery a short intro

1. SURGERY
Dr Fahim Akbar

2. Society Self
Work Family
B a la nc
e

3. p ro fe s s io na l
s kill
Pe rs o na l
re la tio ns hip
S c ie ntifi
c
re s e a rc h
Te a c hing
a b ility

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

5. The Anatomy

6. The Surgical Technique

7. Grey’s Anatomy
The Emergency Room

9. The History
Present illness, previous history, family history
The physical examination
Inspection, palpation, percussion, auscultation 1. Correct Diagnosis
2. Therapy schedule
The laboratory examination 3. Good relationship
Laboratory examination, imaging exams
Other examination
All kinds of endoscopes, angiography

10. Medical Record
 Chief complains
 Present illness
 Past history
 Review of systems
 Personal history
 Bearing history
 Family history

11. The history——how to begin
 gentle  Gain confidence
 Considerate  Give confidence
 Sympathy  Establish relationship
 Understanding  Effective communication
 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

12. 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

13. 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

14. 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

15. Building the history— Pain
How to evaluate/rate pain
Wong—Baker face

16. 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

17. Pain: reaction
 Purpose ： To find the cause
 Do not believe all patients saying
 Overreactor:
 Mild pain: Mosquito Bites
 Moderate pain: gastric ulcer
 Severe pain: vascular pain, renal or biliary colic
 Restore confidence
 Anagelsia

18. Vomiting
 What
 How much
 How often Pathogeny
 Smell diagnosis
 Color
 Projectile:
○ Intracranial hypertension

19. 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

20. Hematemesis or Hematochezia
 Hematemesis  Hematochezia
 From rectum
 From throatmouth
 Character of blood
 Character of blood
 Clot
 Clot  Bright or dark red
 Bright or dark red  Tarry stool
 Coffee-ground  hemorrhoids

21. 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

22. Trauma
 Car/vehicle accident injury
 Sport injury
 Gun shot

23. Past history
 Never overlooked important histories
 Do not expend to much time
 Do with the physical examination
 Accord to different systems
 System review

24. 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.

25. 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

26. Family history
 Many disease are familial hereditary
 familial adenomatous polyposis FAP
 Hypertension
 Heart disease
 diabetes mellitus
 Colon cancers
 Have the same genes
 Have the similar enviroment

27. 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

28. Examination
 Physical examination
 Laboratory examination
 X-ray
 CT scan
 MRI ( Magnatic Resonance Imaging)
 Endoscopy
○ Gastroscopy
○ Esophagoscopy

29. Remember
 Necessary examination
 Painful and inconvenient
examination
 No excessive examination

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

31. Physical examination
 Ordinary system
 Inspection
 Palpation
 Percussion
 Auscultation
 locomotor system
 Movement
 measurement

32. Inspection
 Facial features
 Expression
 position  Observe by purpose
 Pupil  Compare with the normal side
 Consciousness
 Steps
 Droop eyelid
 Breast disease

33. Palpation
 Gentle and skillful
 Careful, gentle and precise
 Fingertip is most sensitive
 Mass (benign, malignant)
 Boundary, tenderness, size, pain, movements

34. Auscultation
 Important in both medicine and surgery
 Pneumothorax
 Great vessels disease
 Ileus
 Vascular lesions
 Heart disease

35. Movement and measurement

36. 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

37. Emergency
 Primary consideration:
 consciousness
 Breathing
 Airway open
 Palpable pulse
CPR?
 Heart beating

38. How to deal with
 Airway obstruction
 Massive bleeding
 Tension pneumothorax
 Cardiac tamponade
 Bone fracture
 Blunt trauma to the brain/ head

39. 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

40. 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

41. Imaging studies—X ray
 Chest radiograph
○ Pneumonia
○ lung cancer
○ Tuberculosis
○ Rib fracture
○ Pneumothorax
- (lung marking)

42. Imaging studies—X ray
Abdominal X-Ray
Rupture
Obstruction

43. Imaging studies—X ray
Bone Fracture

44. Imaging studies——CT
 Why do a CT

45. Imaging studies——CT
CT will show the nidus
more specific than X ray

46. Imaging studies——MRI
Why do a MRI

47. Imaging studies——MRI
MRI can display Softtissue

48. Basic exams
 Complete blood test
 Stool examination
 Urine examination
 Chest X-ray
 ECG: electrocardiograph
 Old patient （ >60 ）：
○ Ultrasonic cardiography
○ blood gas analysis

49. Medical consultation
Why

50. Thank You!