Clinical Surgery E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 2116

Veröffentlichungsjahr: 2012

Beschreibung

Blackwell's Clinical Surgery has established itself as an excellent indispensable resource for undergraduate medical students and house officers. The first edition was Awarded 1997 BMA Certificate of Commendation. Written by an outstanding team of editors and expert contirbutors, the new updaetd and revised edition has been designed as a complete learning guide.

Unlike competing titles, Clinical Surgery covers the following all in one book!

• Symptoms and signs of surgical disease
• Diagnosis and investigations
• Treatment and procedures

The book is divided into five sections:

• Clinical Skills and Investigations
• Perioperative Care
• The Management Of Acute Surgical Illness and Trauma
• General Surgery
• Specialist Surgery

The new edition features:

• Revised chapters with updated and refreshed material, written in a systematic format to aid learning and enhance understanding
• 15 new chapters with more information providing you with everything you need to know
• Blackwell's famous At A Glance boxes for the most common surgical conditions and common clinical presentations
• Must Know/Must Do boxes - to aid learning and revision through self-assessment
• Clinically orientated information on practical procedures
• Evidence Based Medicine references for further reading and research
• Excellent full colour illustrations and a new attractive and easy to use format

The second edition of Clinical Surgery is perfect for undergraduate and junior doctors alike as well as other health professionals who need a comprehensive account of surgery in all the major medical specialities. With a strong emphasis on clinical practice and the necessary knowledge and skills, this is a must-buy for anyone going on a surgical rotation. Clinical Surgery is intended to teach you everything you need to know about surgery at the start of your career.

Pre-publication quotes

"I do not think it is an understatement to say that it is a revolutionary book. It is obviously written with integrated courses very much in mind and manages to integrate the basic sciences with clinical information very well.... Maybe above all things, this is a very practically orientated book and really attempts to mould the medical student in to a very good house officer."
SHO, Leeds

Leseprobe

Contents

Contributors

Preface

List of abbreviations

Part 1 Clinical Skills and Investigations

1 History-taking and Physical Examination

Introduction

Clinical presentation

The history

Physical examination

Examination of specific anatomical areas

2 Basic Clinical Procedures

Introduction

General principles

Consent to treatment

Aseptic technique

Scrubbing up

Gowning

Donning gloves

Local anaesthetics

Performing a simple interrupted suture (Fig. 2.1)

Excising a lesion

Maintaining the airway

Basic thoracic procedures

Urinary catheterization

Rectal examination

Taking blood from a patient

Insertion of an intravenous cannula

Arterial blood gas sampling

Nasogastric tubes

Diagnostic peritoneal lavage

3 Principles of Investigation

Introduction

Blood investigations

Microbiology

Imaging

Endoscopy

Measurement of function

Evidence-based medicine

Part 2 Perioperative Care

4 Assessment of Patients for Surgery and Preoperative Medical Management

Goals of preoperative assessment

Methods of assessment

Calculating risk

Evidence-based medicine

5 Prophylaxis

Introduction

Principles of prophylaxis

Specific prophylaxis

Evidence-based medicine

6 Transfusion of Blood and Blood Products

Introduction

Good transfusion practice

Blood and plasma products

Adverse effects of transfusion

Evidence-based medicine

7 Surgical Infection

Introduction

Pathophysiology of infection

Management of surgical infections

Specific surgical infections

Postoperative infection

Viral diseases of surgical importance

Principles of antibiotic therapy

8 Pain Relief

Introduction

Benefits of treating acute pain

Reasons for inadequate pain control

Factors affecting postoperative pain

Assessment of pain

Selection of appropriate analgesic drugs

Regular monitoring and recording

Opioids

Non-steroidal anti-inflammatory drugs

Local and regional analgesia

Non-drug analgesia

Evidence-based medicine

9 Complications following Surgery

Classification of complications

Common clinical presentations

Common or important problems

Evidence-based medicine

10 Rehabilitation

Introduction

Specific problems of rehabilitation

Gastrointestinal disorders

Part 3 The Management of Acute Surgical Illness and Trauma

11 Hypoxic States and Airway Obstruction

Introduction

Causes of acute hypoxia

Clinical features of hypoxia

Principles of treatment of the hypoxic patient

Oxygen therapy

Mechanical ventilation

Pulse oximetry

Evidence-based medicine

12 Haemorrhage, Hypovolaemia and Shock

Introduction

Classification of shock

Clinical features

Assessment and treatment of shock

Complications of shock

Gastrointestinal haemorrhage

13 Fluids, Electrolytes, pH Balance and Nutrition

Introduction

Fluid and electrolytes

Acid–base balance

Nutrition

Evidence-based medicine

14 Acute Renal Failure

Introduction

Classification

Pathophysiology

Clinical features

Management

Prognosis

Evidence-based medicine

15 The Acute Abdomen

Introduction

Aetiology (see Table 15.1)

Investigations

Peritonitis

Haemoperitoneum

Intestinal obstruction

Complications

Intestinal pseudo-obstruction

16 Systemic Inflammatory Response Syndrome

Introduction

Pathophysiology

Clinical features

Management

Prognosis

Evidence-based medicine

17 Initial Management of the Severely Injured Patient

Introduction

The golden hour

Preparation

Initial assessment

Primary survey and resuscitation

Secondary survey

Definitive care

Evidence-based medicine

18 Head Injury

Introduction

Pathology

Classification

Management

Special problems

Specific head injuries

Intracranial haemorrhage

Outcome from head injury

Rehabilitation after head injury

Spinal injury

Evidence-based medicine

19 Abdominal Trauma

Introduction

Mechanism of injury

Surgical anatomy of abdominal injuries

Management of trauma

Specific intra-abdominal injuries

Penetrating abdominal trauma

Emergency laparotomy for abdominal injuries

Pelvic genitourinary injuries

20 Chest Trauma

Introduction

Types of chest injury

21 Musculoskeletal Trauma

Introduction

History-taking after trauma

Examination of the traumatized patient (see Chapter 17)

Investigation of fractures

Management of fractures

Complications of fractures

Dislocations

Common fractures and joint injuries

22 Soft-tissue Trauma

Introduction

Injuries to specific soft tissues

23 Burns

Introduction

Epidemiology

Pathophysiology

Mechanisms of injury

Initial management of major burns

Subsequent management of burn injury

Rehabilitation

Part 4 General Surgery

24 Disorders of the Abdominal Wall

Introduction

Swellings in the wall

Common abdominal herniae

Unusual herniae

25 Disorders of the Oesophagus

Anatomy and physiology

Symptoms of oesophageal disease

Investigations

Gastro-oesophageal reflux disease

Benign oesophageal strictures

Columnar metaplasia of the oesophagus (Barrett’s columnar epithelium)

Non-reflux oesophagitis

Diaphragm

Hiatus hernia

Oesophageal motility disorders

Oesophageal diverticulae

Sideropenic dysphagia (Paterson-Kelly or Plummer-Vinson syndrome)

Oesophageal perforations

Tumour of the oesophagus

Evidence-based medicine

26 Disorders of the Stomach and Duodenum

Introduction

Dyspepsia

Investigations

Gastroduodenal disease: Helicobacter pylori infection

Acute gastroduodenal disorders

Peptic ulcer disease

Complications of gastric surgery

Gastritis

Gastric tumours

Evidence-based medicine

27 Disorders of the Liver

Anatomy of the liver

Investigations

Clinical features of liver disease

Cirrhosis

Congenital hepatic fibrosis (fibropolycystic disease)

Hepatic encephalopathy

Fulminant liver failure

Hepatic abscess

Subphrenic extrahepatic abscess

Non-parasitic hepatic cysts

Hydatid cysts

Liver tumours

Metastatic disease of the liver

Portal hypertension

Budd–Chiari syndrome

Hepatic artery aneurysm

Evidence-based medicine

28 Disorders of the Biliary Tract

Anatomy

Investigation of biliary tract disorders

Jaundice

Management of large bile duct obstruction

Cystic disease of the biliary tract

Gallstones

Acalculous chronic gallbladder disease

Ductal calculi

Cholangitis

Haemobilia

Bilioenteric fistulae

Benign bile duct strictures

Tumours of the biliary tract

29 Disorders of the Pancreas

Anatomy and physiology

Investigations

Congenital anomalies

Pancreatitis

Tumours of the exocrine pancreas

Tumours of the endocrine pancreas

Evidence-based medicine

30 Disorders of the Spleen

Anatomy and physiology

Hypersplenism

Hyposplenism

Postsplenectomy sepsis

Splenic infarction

Splenomegaly

Ectopic (wandering) spleen

Splenic cysts

Splenic tumours

Splenic vein thrombosis

Evidence-based medicine

31 Disorders of the Small Intestine and Vermiform Appendix

Physiology

Small-bowel investigations

Small-bowel tumours

Crohn’s disease

Radiation enteropathy

Intestinal tuberculosis

Human immunodeficiency virus enteropathy

Short-gut syndrome (intestinal failure)

Vascular abnormalities

Vermiform appendix and Meckel’s diverticulum

32 Disorders of the Colon and Rectum

Diverticular disease

Vascular lesions of the colon

Volvulus of the colon

Chronic inflammatory bowel disease

Colonic polyps

Carcinoma of the colon and rectum

Carcinoma of the anus

Benign anal and perianal disorders

33 Disorders of the Breast

Breast anatomy and physiology

Congenital anomalies

Benign breast disease

Breast cancer

Evidence-based medicine

34 Disorders of the Endocrine Glands

Thyroid

Parathyroid

Adrenal

Pituitary

35 Salivary Glands

Introduction

Submandibular gland

Parotid gland

Disorders of the salivary glands

Evidence-based medicine

36 Skin and Adnexae

Skin

Subcutaneous tissue

Nails

Evidence-based medicine

Part 5 Specialist Surgery

37 Cardiovascular Disorders

Introduction

Pathophysiology

ARTERIAL DISEASE

Peripheral occlusive arterial disease

Chronic lower limb ischaemia

Acute lower limb ischaemia

The diabetic foot

Thromboangiitis obliterans (Buerger’s disease)

Raynaud’s syndrome

Aneurysms

Extracranial arterial disease

Arterial miscellany

VENOUS DISEASE

Venous thrombosis

Pulmonary embolism

Post-thrombotic (postphlebitic) limb

Varicose veins

Venous miscellany

LYMPHATIC DISEASE

Lymphoedema

Tumours of lymphatics

CARDIAC SURGERY

Evaluation of the patient

Perioperative care

Cardiac surgery for specific diseases of the heart

Evidence-based medicine

38 Pulmonary Disorders

Introduction

Evaluation of the patient

Pulmonary embolism, collapse and infections

Disorders of the pleura

Bronchial neoplasms

Mediastinal lesions

Aspiration syndromes

Respiratory (ventilatory) failure

Evidence-based medicine

39 Genitourinary Disorders

Introduction

Clinical assessment

Infection of the genitourinary tract

Urinary tract obstruction

Urolithiasis

Urological malignancies

Incontinence and neuropathic bladder disorders

Disorders of the testis and scrotum

Impotence

Evidence-based medicine

40 Neurosurgical Disorders

Introduction

Evaluation of patients with neurosurgical disorders

Principles of management of neurosurgical patients

Common neurosurgical disorders

Hydrocephalus

Spinal surgery

Peripheral nerve disorders

Miscellaneous neurosurgical problems

Evidence-based medicine

41 Musculoskeletal Disorders

Introduction

Evaluation of the patient with orthopaedic disorders

Problems with joints

Knee problems

Backache and neckache

Minor adult disorders

Adult foot disorders

Orthopaedic conditions of childhood

42 Plastic and Reconstructive Surgery

Introduction

Wound healing and management

Hand surgery

Pressure sores

Lower limb trauma surgery

Surgery for congenital deformities

Facial injuries

Aesthetic surgery

43 Ear, Nose and Throat Disorders

Introduction

ENT emergencies: diagnosis and first-line management

Head and neck cancer: requirements for urgent referral

Common (non-malignant) throat and neck presentations

The ear

The nose and sinuses

Common presentations in childhood

Evidence-based medicine

44 Ophthalmic Disorders

Introduction

Evaluation of the patient

The acute red eye

Sudden loss of vision (Table 44.2)

Diabetes mellitus

Macula

Chronic glaucoma

Cataract

Squint (strabismus)

Diseases of the eyelid

45 Principles of Transplantation

Introduction

Immunology

Immunosuppression

Organ donation

Renal transplantation

Liver transplantation

Pancreas transplantation

Cardiac transplantation

Other organs

46 Surgical Conditions in Neonates, Infants and Children

Introduction

History

Physical examination

Fluid management

Neonatal conditions

Infant conditions

Paediatric conditions

Evidence-based medicine

Index

© 1996, 2003 by Blackwell Science Ltd

a Blackwell Publishing company

Blackwell Science, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USA

Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK

Blackwell Science Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia

The right of the Authors to be identified as the Authors of this Work has been asserted in accordance with the Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.

First published in 1996

Reprinted 2001

Second edition 2003

Library of Congress Cataloging-in-Publication Data

Clinical surgery/Alfred Cuschieri... [et al.]. — 2nd ed.

p.; cm.

Includes index.

ISBN 0-632-06394-7

1. Surgery.

[DNLM: 1. Surgical Procedures, Operative. WO 500 C641 2003] I.

Cuschieri, Alfred.

RD31.C643 2003

617—dc21

2003000667

A catalogue record for this title is available from the British Library

Commissioning Editor: Vicky Noyes

Managing Editor: Geraldine Jeffers

Production Editor: Alice Emmott

Production Controller: Kate Charman

For further information on Blackwell Science, visit our website:

http://www.blackwellpublishing.com

Contributors

Peter Butler

Department of Plastic Surgery, Royal Free Hospital, Pond Street, London, NW3 2QG

Author of

Chapter 23

Co-author of

Chapter 42

Graham Haddock MBChB MD FRCS(Glas) FRCS(Ed)

FRCS(Paed)

Consultant Paediatric and Neonatal Surgeon, Department of Paediatric Surgery, Royal Hospital for Sick Children, Yorkhill, Glasgow, G3 8SJ

Author of

Chapter 46

Ashok Handa FRCS FRCS(Ed)

Clinical Tutor in Surgery and Honorary Consultant Surgeon, Nuffield Department of Surgery, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU

Author of

Chapter 45

Natasha Hidvegi MBBS

Research Fellow, Department of Plastic Surgery, Royal Free Hospital, Pond Street, London, NW3 2QG

Author of

Chapter 42

Eamon Kavanagh MD FRCS(I)

Department of Surgery, Mid-Western Regional Hospital, Dooradoyle, Limerick, Ireland

Co-author of

Chapters 3, 16, 35, 37

Michael Kerin MCh FRCS(I) FRCS(Ed)

Lead Surgeon, National Breast Screening Programme, Mater Misericordiae Hospital, Eccles Street, Dublin 7, Ireland

Author of

Chapter 33

Paul Kinnear FRCS FRCOphth

Consultant Ophthalmologist, Department of Ophthalmology, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF

Author of

Chapter 44

Trottie Kirwan MB BChir

Consultant Anaesthetist, Chelsea & Westminster Hospital, 369 Fulham Road, London, SW10 9NH

Co-author of

Chapter 8

Graham Leese MD FRCP

Consultant Physician, Ninewells Hospital and Medical School, Dundee, DD1 9SY

Co-author of

Chapter 34

Mervyn Maze MB ChB FRCP FRCA FMedSci

Professor and Chair of Anaesthesia, Department of Anaesthetics and Intensive Care, Imperial College London; Director of Research and Development, Chelsea and Westminster NHS Healthcare Trust, 369 Fulham Road, London

Co-author of

Chapter 8

William Morrison MBChB FFAEM FRCP FRCS FRCA

MRCGP DRCOG

Accident and Emergency Consultant, Department of Accident & Emergency Medicine, Ninewells Hospital, Dundee, DD1 9SY

Co-author of

Chapter 17

Paraskevas Paraskeva FRCS

Lecturer in Surgery, Department of Surgical Oncology and Technology, Imperial College London, St Mary’s Hospital, 10th Floor Queen Elizabeth the Queen Mother Wing, London, W2 1NY

Author of

Chapters 13, 20, 32

Co-author of

Chapter 2

Peter Richards FRCS FRCPCH

Department of Paediatric Neurosurgery, Radcliffe Infirmary, Woodstock Road, Oxford, OX2 6HE

Author of

Chapters 18, 40

Victoria Rose MD MRCS(Eng)

Specialist Registrar, Department of Plastic Surgery, Royal Free Hospital, London, NW3 2QG

Author of

Chapter 42

David Smith MD FRCS(Ed)

Consultant Surgeon and Honorary Senior Lecturer, Ninewells Hospital and Medical School, Dundee, DD1 9SY

Author of

Chapter 34

Shawn St Peter MD

Resident in Surgery, Mayo Clinic, Rochester, MN 55905, USA

Co-author of

Chapter 45

Janet Wilson MD FRCS(Ed) FRCS(Eng)

Professor of Otolarnyngology, Head and Neck Surgery, University of Newcastle, Freeman Hospital, High Heaton, Newcastle upon Tyne, NE7 7DN

Author of

Chapter 43

Preface

Clinical Surgery in its new edition is much more than a facelift. It is the outcome of a major collective effort based on regular meetings of the five editors with the publishers at which format, content and layout were discussed. Admittedly, completion of the second edition has taken longer than anticipated, but the delay has been worthwhile. Although the basic structure of the first edition has been retained, the rewrites, alterations and new material have been based on feedback from our readers specially commissioned by our publishers before work on the second edition commenced in earnest. The needs and comments expressed by students and house officers who took part in the feedback on each and every chapter (favourable or otherwise) were kept firmly in mind by the authors and editors during the redrafting process. Consequently, the editors are confident that all defects and criticisms have been met and the second edition has no serious shortcomings.

In addition to this we have introduced some new features, which we regard as important in the continuous acquisition of medical and surgical knowledge that is based on reading, clinical observation and practice. Perhaps the most relevant of these are the Must know (core knowledge information), Must do (necessary clinical and humanistic skills) appropriate to each chapter. These provide evidence to the reader of landmark achievements of knowledge and goals in the learning process. When indicated, we have included references to evidence-based medical practice but shied away from any extensive bibliography.

New material, previously not covered or dealt with in too superficial a manner in the first edition has been added or enhanced without a material increase in the size of the book. In achieving this, we have not sacrificed any of the good features of the book including the At A Glance boxes, which have been so popular as aides-mémoire with the medical undergraduates in particular.

We trust the second edition of Clinical Surgery, like its predecessor, proves to be useful to students, house officers and senior house officers, that it will incite tham to consider a career in surgery, but if not, that they benefit as doctors from reading the book. If the second edition achieves the last, we as editors would be well pleased with the outcome of our work.

We would like to thank Alice Emmott, Senior Production Editor, for her forbearance and tact and the entire team at Blackwell Publishing. Also, the authors, you all did a magnificent and expeditious job.

Alfred Cuschieri

Pierce Grace

Ara Darzi

Neil Borley

David Rowley

List of abbreviations

AAA abdominal aortic aneurysm ABI ankle/brachial index ACTH adrenocorticotrophic hormone ADH antidiuretic hormone ADL activities of daily living AF atrial fibrillation AFP α-fetoprotein AIDS acquired immunodeficiency syndrome ALT alanine aminotransferase APACHE Acute Physiology and Chronic Health Evaluation APTT activated partial thromboplastin time ARDS acute respiratory distress syndrome ARF acute renal failure ASA American Society of Anesthesiologists AST aspartate aminotransferase ATLS advanced trauma life support ATN acute tubular necrosis AVM arteriovenous malformation AZT azidothymidine BCC basal cell carcinoma BCG bacillus Calmette-Guérin BPH benign prostatic hypertrophy CABG coronary artery bypass grafting CARS compensatory anti-inflammatory response syndrome CBV circulating blood volume CDH congenital dislocation of the hip CJD Creutzfeldt–Jakob disease CMV cytomegalovirus; controlled mandatory ventilation CNS central nervous system CO cardiac output COPD chronic obstructive pulmonary disease COX cyclooxygenase CPAP continuous positive airways pressure CPK creatine phosphokinase CPR cardiopulmonary resuscitation CRP C-reactive protein CSF cerebrospinal fluid CT computed tomography CVP central venous pressure DIC disseminated intravascular coagulation 2,3-DPG 2,3-diphosphoglycerate DPL diagnostic peritoneal lavage DSA digital subtraction arteriography DTPA diethylenetriaminepentaacetic acid DVT deep vein thrombosis EBV Epstein–Barr virus ECG electrocardiogram, electrocardiography EDTA ethylenediaminetetraacetic acid EEG electroencephalography EMG electromyography ENT ear, nose and throat EPVF extrapulmonary ventilatory failure ERCP endoscopic retrograde cholangiopancreatography ESR erythrocyte sedimentation rate ESRD end-stage renal disease ESWL extracorporeal shock-wave lithotrispsy EUS endoscopic ultrasonography FAP familial adenomatous polyposis FEV1 force expiratory volume in 1 s FFP fresh frozen plasma FIO2 fractional inspired oxygen concentration FVC forced vital capacity GABA γ-aminobutyric acid GFR glomerular filtration rate GORD gastro-oesophageal reflux disease γ-GT γ-glutamyltransferase GvHD graft vs. host disease HAFLOE high-airflow oxygen enrichment HAV hepatitis A virus HBV hepatitis B virus HCC hepatocellular carcinoma HCV hepatitis C virus HDL high-density lipoprotein HDU high-dependency unit HIV human immunodeficiency virus HLA human leukocyte antigen HPP human pancreatic polypeptide HR heart rate 5-HT 5-hydroxytryptamine HTLV human T-cell leukaemia virus ICP intracranial pressure ICU intensive care unit IL interleukin INR international normalized ratio IPSID immunoproliferative small intestinal disease ITP immune thrombocytopenic purpura IVU intravenous urogram JVP jugular venous pressure, jugular venous pulse LDH lactate dehydrogenase LDL low-density lipoprotein LHRH luteinizing hormone-releasing hormone LOS lower oesophageal sphincter LPS lipopolysaccharide LSBO long-segment Barrett’s oesophagus MALT mucosa-associated lymphoid tissue MCH mean corpuscular haemoglobin MCP metacarpophalangeal MCV mean corpuscular volume MEN multiple endocrine neoplasia MHC major histocompatibility complex MNG multinodular goitre MODS multiple organ dysfunction syndrome MRA magnetic resonance angiography MRCP magnetic resonance cholangiopancreatography MRI magnetic resonance imaging MRSA methicillin-resistant Staphylococcus aureus MUGA multiple gated acquisition NGU non-gonococcal urethritis NO nitric oxide NSAID non-steroidal anti-inflammatory drug OA oesophageal atresia OGD oesophagogastroduodenoscopy OPSI overwhelming postsplenectomy infection Paco2 partial pressure of arterial carbon dioxide Pao2 partial pressure of arterial oxygen PCV packed cell volume PCWP pulmonary capillary wedge pressure PE pulmonary embolism PEEP positive end-expiratory pressure PEFR peak expiratory flow rate PET positron emission tomography PGL primary gastric lymphoma POSSUM Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity PPI proton pump inhibitor PPV patent processus vaginalis PSA prostate-specific antigen PT prothrombin time PTH parathyroid hormone PUJ pelviureteric junction RA rheumatoid arthritis RBF renal blood flow RF radiofrequency RPLND retroperitoneal lymph node dissection RRT renal replacement therapy RTA road traffic accident SAH subarachnoid haemorrhage SBP spontaneous bacterial peritonitis SCC squamous cell carcinoma SIGN Scottish Intercollegiate Guidelines Network SIMV synchronized intermittent mandatory ventilation SIRS systemic inflammatory response syndrome SLE systemic lupus erythematosus SPECT single-photon emission computed tomography SSBO short-segment Barrett’s oesophagus SSEP somatosensory evoked potential SSI surgical site infection STD sexually transmitted disease STN solitary thyroid nodule SV stroke volume TENS transcutaneous electrical nerve stimulation TGF transforming growth factor TIA transient ischaemic attack TLC total lung capacity TNF tumour necrosis factor TNM tumour, regional nodes, distant metastases TOE transoesophageal echocardiography TOF tracheo-oesophageal fistula t-PA tissue plasminogen activator TPN total parenteral nutrition TPO thyroid peroxidase TRUS transrectal ultrasound TSH thyroid-stimulating hormone TURP transurethral resection of the prostate UTI urinary tract infection VAC vacuum-assisted closure VC vital capacity VIP vasoactive intestinal polypeptide VSD ventricular septal defect WCC white cell count WHO World Health Organization

Part 1

Clinical Skills and Investigations

1

History-taking and Physical Examination

Introduction

Clinical presentation

The history

Physical examination

Examination of specific anatomical areas

Must know Must do

Must know

Symptomatology and signs of common surgical disorders that present electively

Presentation and physical findings of common surgical emergencies

Must do

Take histories of patients with surgical disorders: learn by experience how to establish rapport with patients

Examine patients with surgical disorders: head and neck, chest, abdomen, limbs and genitalia

Perform rectal examinations under supervision

Acquire skill and experience in performing common clinical procedures, e.g. insertion of intravenous lines, insertion of nasogastric tubes, injections, setting up drips, catheterization of the urinary bladder (male and female)

Examine the locomotor system of patients

Attend outpatient general surgical clinics

Attend fracture clinics

Introduction

The mastery of clinical skills is different from knowing how the various clinical tasks are performed. This expertise has several components, including the ability to:

communicate freely and efficiently with patients and colleagues;detect abnormal physical signs, e.g. an enlarged liver, rebound tenderness;recognize acute and life-threatening situations;perform common clinical procedures with proficiency;confirm normality when present.

No amount of encyclopaedic knowledge gained from reading and lectures can ever impart clinical competence. The requirements for proficiency as a doctor are core knowledge of the common medical and surgical disorders and full clinical competence. Rare and obscure illnesses will be encountered by every clinician from time to time. One needs only to be aware of these disorders since the competent doctor will recognize that the patient does not fit any of the common disease patterns and will seek advice or expert opinion.

Clinical presentation

Patients may present in two ways: