Gsur 302

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Gsur 302

  1. 1. GENERAL SURGERY - 302 - SUMMARY PREPARED BYSABRI KHALIL SHAMALI College of medicine 2011 2nd versionbîuìÛìäØnÛaë@âìÜÈÜÛ@‹—ß@òÈßbu@‡vß@ÝibÔß@M@oíýnŽ@òjnØß@À@bèã뇤@
  2. 2. Start by putting the patient at ease: ( )• Greet the patient by name: "Good morning, Mrs Jones"• Introduce yourself and explain that you are a medical student.• Shake the patients hand, or if they are unwell rest your hand on theirs.• Ensure that the patient is comfortable.You should always begin the physician-centered phase of the interview with "WH"questions (where? what? when?) directed at the chief complaint(s). Build on theinformation the patient has already given you. Flesh out areas of the story you dontfully understand. Try to quantify whenever possible (pain on a scale of 1 to 10,number of days instead of "a while," etc.). Be as specific as possible and try to recordwhat the patient says accurately, without interpretation A.Personal history:1- Name: Medical registration To be familiar with patient2-Age: Why we ask about age: "age related diseases as: " Infant (0-2 yrs) --- congenital diseases Childhood (2-12 yrs) --- Parasitic infection mumps Adolescence (12-20 yrs) --- Trauma, TB Adulthood (20-40yrs)--- Hernia ) Middle age (40-60yrs) --- Gall bladder diseases, Atherosclerosis Old age (above 60rs --) --- Malignancy, vascular disease)3. Sex: Why sex: "sex related diseases" emale Breast cancer Gall bladder stones Femoral Hernia Goiter SLE "Systemic Lupus Erythematosis" ale Hypertension Inguinal hernia Peptic ulcer Gastric and bladder carcinoma4- Residence: íÚ^Î÷]<á^ÓÚ Farmer ---- Malnutrition and parasitic infection "bilharziasis" Endemic diseases: Oases ---goitre Bilharziasis---Egypt stomach cancer Japan Burketts lymphoma central Africa, esophageal cancer china1
  3. 3. 5. occupation :‫ﺍﻟﻤﻬﻨﺔ‬ Porter ‫ --- ﺍﻟﻌﺘﺎﻝ‬hernia teachersurgeon ‫ﺟﺮﺍﺡ‬barber ‫ --- ﺣﻼﻕ‬Varicose vein Vibration --- vascular diseases Radiation --- Bone marrow depression 6. Marital status: Single, married, divorced or widow, offspring. the age of the youngest 7. Menstrual History: regularity of menstruation, age of menarchemenopause 8. Special Habits: Smoking:"number of cigarette and period of smoking" Lung cancer, Lip cancer , Urinary bladder cancer Atherosclerosis Respiratory tract infection Emphysema, chronic bronchitis Alcohol Abuse: Peptic ulcer Liver cirrhosis Drug Abuse and addiction.--- injection lead to hepatitis and AIDS B. Complaint: 1-Written in patient words "only translation without medical terms" 2- only one complaint the most sever and recent"(distressing one) 3- in brief 4-Duration of complaint 5-Complaint may be swelling , pain or disturbed function 6- one complain one system C. present History:1-history of pain:If the history of the presenting complaint includes pain, ask about it using themnemonic SOCRATES Site - where exactly is this pain? Onset - when did the pain start, did it start suddenly or gradually? • sudden "trauma > hematoma" ( MCQ ) • gradual "neoplasia" • acute "inflammation , infection" • Accidental "discovered by patient"2
  4. 4. Character – describe the pain - sharp? knife-like? gripping? burning? crushing? • Colic pain • Throbbing pain - infection with pus • dragging "heaviness" – varicose vein • Radiation - "Referred pain " extension-of pain to another site" does the pain spread anywhere? To the arm, jaw, groin etc? Renal pain back pain ,radiate to inguinal region and testicular o Gall bladder pain mid-epigastrium and tip of right scapula o appendicitis pain around the umbilicus • Associated symptoms - is the pain accompanied by any other features? o like oedema, hemoptysis , vomiting • Timing duration - does the pain vary in intensity during the day? ( ) o Short "inflammation" o Long "benign lesion" • Exacerbating srotcaf gniveiler dna - does anything make the pain better or worse? • Severity - does the pain interfere with daily activities or with sleep? o Mild o Moderate o Sever " life stopping" 2-History of swelling : ( ‫) ﺍﻭﻝ٦ ﻧﻘﺎﻁ ﻟﻠﺘﻮﺿﻴﺢ-ﺗﺘﺤﺪﺙ ﻋﻦ ﻃﺮﻳﻘﺔ ﺳﺆﺍﻝ ﺍﻟﻤﺮﻳﺾ‬Some key questions to be asked regarding a swelling (generally)1. When do you first notice the lump? REMEMBER, first noticed the lump 3 months ago is not the same as first appeared 3months ago.2. How do you notice it? Below are the 3 commonest answers : a) Its painful b) I noticed it accidentally c) Others told me about it Generally, if the lump is painful, the commonest aetiology is inflammation. Most of the patients thought that only painful lumps are cancerous.3. How does the lump disturbs you? Basically, the question is asking about the associated symptoms. It can be pain, discharge, dysphagia, dyspnoea, cosmetically disfiguring, fear ofmalignancy, etc.4. Any changes to the lump since you first notice it? The commonest change is the size. Whether the lump has increased or decreased in size, or its size fluctuates.5. Has the lump ever dissapears before? Does the lump dissapears when the patient is lying down supine? or any other activities6. Do you ever had any other lumps before this? Asking for multiplicity 3
  5. 5. 1. Onset: o Sudden "trauma hematoma" _MCQ_ o Gradual "neoplasia" o Acute "inflammation, infection" o Accidental "discovered by patient or others" 2. Course: o Progressive rapid "malignant lesion" or slow "Benign lesion" o Regressive acute infection o Stationary cysts or benign lesion o Intermittent jaundice due to obstruction 3. Duration: o Short "inflammation o Long "benign lesion" 4. Relation to pain: o Swelling then pain --malignancy o Pain then swelling- inflammation 5. Relation of onset to constitutional manifestation: o Fever , redness, headache, malaise 6. effect on body function and nearby structures 7. possible cause (aetiology): o Carrying Heavy object -- hernia o Trauma -› hematoma 8. Special character: o Move up and down with deglutition thyroid swelling o increase size with food pharyngeal diverticulum o Pulsations aneurysms or vascular swelling o Impulse on cough and reduce on laying down hernia D.past history: ê•^¹]<<»<˜è†¹]<äe^‘]<‚Î<^Ú<<àÂ<Ù^ŠÞ< The past medical history is essentially background information related to the patients health and well being. A brief past medical (and social) history often includes these elementsGeneral question: • Have you suffered from any previous illness? 1. Allergies and Reactions to Drugs (What happened?) 2. Current Medications (Including "Over-the-Counter") 3. Medical/Psychiatric Illnesses (Diabetes, Hypertension, Depression, etc.) 4. Surgeries/Injuries/Hospitalizations (Appendectomy, Car Accident, etc.) 5. Immunizations 6. smocking/Alcohol 4
  6. 6. 7. Reproductive Status for Females o Last Menstrual Period o Last Pelvic Exam/Pap Smear o Pregnancies/Births/Contraception 8. Birth History/Developmental Milestones for Children 9. Exposures:lufpleh DAERHT cinomenm eht dnif yam uoY • Tuberculosis • Hypertension (myocardial infarction and strokes) • Rheumatic fever • Epilepsy • Asthma, anxiety and arthritis • Diabetes and depression E. Family History:• Are your father, mother, brothers, sisters alive? - If they have died, at whatage did he/she/they die? What did he/she/they die of?• Do they have any current illnesses?• Do any illnesses run in your family? Similar cases in family "hereditary disease Consanguinity ‫ا رب‬ relevant - cancer breast and hemolytic anemia goiter , varicose veins irrelevant-hernia5
  7. 7. Local examination of swellinga- inspection: <ì‚â^Ž¹^e< o 1- solitary or multiple o 2- site (anatomical) o 3- Size ( in cm) o 4- Shape (rounded, oval, etc.) o 5. Surface: • - Smooth • - Irregular : granular (<0.5 cm), nodular (1-2 cm), lobulated (>2 cm) o 6. Surrounding structures: ( relation & effect of swelling in the surrounding structures ): Relation to muscle: (ask the patient to contract the muscle and see if the swellings): - decrease in size --> deep to muscle - Increase in size - superficial to muscle -No change- muscular swelling Relation to surrounding structures as arteries and veins o 7-Other Swelling: draining lymph nodes o 8-Special sings: • Move up and down with deglutition > thyroid swelling • increase size with food > pharyngeal diverticulum • Pulsations > aneurysms or vascular swelling • Impulse on cough and reduce on laying down > hernia o 9.skin overlying: • Normal • Sings of inflammation (redness, dilated veins) • Sings of malignancy (skin retraction , dilated veins) • Scars 6
  8. 8. B) palpation ‚éÖ^e<Œ^Šu÷]< 1-tenderness ‫اﻻﻟﻢ ﻋﻨﺪ اﻟﻠﻤﺲ‬ 2-Temperature- by dorsum of hand which is more dry 3-consistency : solid : • Hard like bone • Firm like tip of nose • Soft like lobule of ear Systic : fluctuant "presences of fluid" (MCQ ) Can be detected by: • fluctuation test : - - cross fluctuation test - Bipolar fluctuation test- for swelling have 2 place NB . fluctuation test uses > 2 cm Pagets test uses < 2 cm 4-Edge: well defined edges or ill defined edges remember . comment on edge by palpation ( MCQ )C) Percussion: • Resonant: gaseous swellings • Dull: cyst and solid swellingsD) Auscultation: • Systolic murmurs in aneurysm • Contentious murmurs in A/V fistula • Venous hum in portal hypertention • Intestinal sounds in hernias 7
  9. 9. - Sutures - Def: Surgical suture is a medical device used to hold body tissues together after an injury or surgery. Uses: wound closure (Wound healing) : 1ry intention 2ry intention – granulation tissue/leave scar and doesnt look nice 3ry intention – infection wound sutured after wound healing Type of sutures:1-absorbable: o Not for skin o For abdominal layer o Intestine , stab knife (NB. We can use non-absorbable but prone to infection)2- non-absorbable: For skin suture : / multifilament fix drain (natural) prolene (polyprolene) suture/ (synthetic) ( mcQ) BN . Prolene {inert} the body doesnt react against itUses: 1- for suture tough structure, we suture linea alba , rectus sheath at midline with prolene 2- repair of hernia: protrusion of a sac Sac = -omentum – intestine Prolene mesh non absorbable for treatment of hernia :erutus elbabrosba fo epyT (every thread has tensile strength) A) chromic catgut (natural) • induce very severe immune reaction • has tensile strength remain 90 days (loss of tensile strength after 3 weeks) B) synthetic vicryl : • not much severe immune reaction at natural • monofilament (monocryl) mcq • multifilament (vicryl) : mcq o More tensile o More liability to infection o Absorbed after 70 days 8
  10. 10. :Chromic Catgut suture: is an absorbable, sterile, surgical suture composed of highly purified connective tissue (mostly collagen) derived from either beef or sheep intestines Application: General Closure , Urology , Plastic Surgery : Silk Suture Natural Non-absorbable Suture (braided) Indications: Eye and lip skin surgery , Intraoral surgery Advantages: Best handling and tying of any Suture Material Disadvantages: - Least tensile strength of any Suture Material - High tissue reactivity (similar to CatgutSuture) - Increases risk of infection due to high capillarity :esoohc ot woH ‫ﻛﻞ ﻣﺎ ﺍﺯﺩﺍﺩ ﺭﻗﻢ ﺍﻟﺨﻴﻂ ﻛﻠﻤﺎ ﻗﻠﺖ ﺳﻤﺎﻛﺘﻪ‬Example : Face : 0.4 and late Scalp : 1 Vascular non absorbable – prolene : 6.0 BN . Cartilage (not sutured) lead to ISCHEMIA Precaution to ensure increase intention healing : A) approximate not strangulate cut of blood supply of edges no wound healing B) don t increase number of sutures more than needed (wound 5 cm need 4 sutures) Every needle in for out lead to trauma Every suture will contain foreign body / bacteria BN . If there is skin loss ; leave to heal natural –skin graft C) no tension on wound D) suture memory ♦ ability of suture material to regain its normal shape 9
  11. 11. complication of suturing a wound 1- infection : ♦ tools not clean ♦ disease transmission (as AIDS) ♦ inflammation ( auto immune Reaction) 2- scar ♦ wound healing but leave mark ♦ not raised / not elevated ♦ respect edges of wound 3- , keloid (occur more with natural) ♦ spread out of wound edges ♦ itching ♦ raised 4- improper healing (opened the wound)BN .(radiotherapy) : ( endarteitis obliteranis ) i.e small vessels are blocked lead to impair healingBN . Human glue ( skin stripsskin dips) @ @ZÛíjïÑÜa@ôÝÈ@bäíØŠb’ < <†’Ú<íÃÚ^q<»<|^rßÖ]<Ðè†ŞÖ<Ôu^jËÚ <www.facebook.com/dr.alshamali < <ÜÓñ^<gé<àÚ<^ÞçŠßi÷10

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