SURGERY

2019-2020
STUDY GUIDE
AZRA NAHEED MEDICAL COLLEGE
SUPERIOR UNIVERSITY RAIWIND ROAD LAHORE

PRINCIPAL & HOD SURGERY

PROF.DR.MOHAMMAD ASLAM
MBBS.FCPS.MS

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LEARNING
OBJECTIVE

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General Surgery
Learning objectives:
Metabolic response to Injury.

To understand:
 Classical concepts of homeostasis
 Mediators of the metabolic response to injury
 Physiological and biochemical changes that occur during injury and
recovery
 Changes in body composition that accompany surgical injury
 Avoidable factors that compound the metabolic response to injury
 Concepts behind optimal perioperative care
Perioperative care
To understand:
 How to organise preoperative care and the operating list
 Surgical, medical and anaesthetic aspects of assessment
 How to optimise the patient’s condition
 How to take consent
 The system of postoperative care
 How to recognise and treat postoperative complications
 The principles of enhanced recovery
 The system for discharging patients
Sterilization & anti-sepsis.
To understand:
 The importance of aseptic and antiseptic techniques.
 The importance of sterilization and different methods of sterilizing
instruments.
Anesthesia & Pain management
To gain an understanding of:
 Techniques of anaesthesia and airway maintenance
 Methods of providing pain relief
 Local and regional anaesthesia techniques
 The management of chronic pain and pain from malignant disease

Trauma.
To gain an understanding of:
 The importance of time in trauma management
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  How to assess a trauma problem
 How to respond to a trauma problem
 Advanced Trauma Life Support(ATLS).
 Difference between emergency & elective orthopaedics
 Classification of fractures
 Pathophysiology & management of major orthopaedic abnormalities


Burns & its management.

To understand:
 How to assess the area and depth of burns
 Methods for calculating the rate and quantity of fluids to be given
 Techniques for treating burns and the patient
 The pathophysiology of electrical and chemical burns

Shock, hemorrhage & Blood transfusion.

To understand:
 The pathophysiology of shock and ischaemia–reperfusion injury
 The different patterns of shock and the principles and priorities of
resuscitation
 Appropriate monitoring and end points of resuscitation
 Use of blood and blood products, the benefits and risks of blood transfusion.

Wounds, tissue repair & scars.

To understand:
 Normal healing and how it can be adversely affected
 How to manage wounds of different types, of different structures and at
different sites
 Aspects of disordered healing that lead to chronic wounds
 The variety of scars and their treatment
Surgical Infections.
To understand:
 The factors that determine whether a wound will become infected
 The indications for and choice of prophylactic antibiotics
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  The characteristics of the common surgical pathogens and their sensitivities
 The spectrum of commonly used antibiotics in surgery
 Understand the concept of SIRS and MODS
 The causes of reduced resistance to infection (host response)
 The definitions of infection, particularly at surgical sites
 Special infections like MRSA, Gas gangrene.

Diagnostic Investigations (Radiological, Endoscopic, Histological)

To understand:
 The principles of different imaging techniques and their advantages and
disadvantages in different clinical scenarios
 The role of endoscopy as a diagnostic and therapeutic tool
 The indications for diagnostic and therapeutic endoscopic procedures
including endoscopic ultrasound
 The recognition and management of endoscopic complications
 The value and limitations of tissue diagnosis
 The role of histology, cytology and the autopsy
 The role of additional techniques used in clinical practice, including special
stains, immunohistochemistry and molecular methods
 The principles of microscopic diagnosis, particularly of neoplasia
Principles of oncology.
To understand:
 The principles of cancer prevention and early detection
 The principles of cancer aetiology and the major known causative factors
 The multidisciplinary management of cancer
 The principles of palliative care
Nutrition and Fluid therapy
To understand:
 The causes and consequences of malnutrition in the surgical patient
 Fluid and electrolyte requirements in the pre- and postoperative patient
 The nutritional requirements of surgical patients and the nutritional
consequences of intestinal resection
 The different methods of providing nutritional support and their
complications

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Systemic Surgery
Learning objectives:
Oesophagus

 To understand surgical anatomy of the oesophagus, describe physiology of swallowing

 To narrate the symptoms of oesophageal disease and its relevant investigations
 To define the GERD, narrate Pathophysiology of GERD, its clinical features, diagnostic
evaluation, treatment and enlist complications
 To enumerate the various causes of oesophageal injuries and describe its clinical features,
investigations and management options.
 To enlist the causes of benign esophageal strictures, give investigations and describe the
various treatment options
 To define different types of hiatal hernias and describe pathophysiology, diagnose, treatment
and enumerate list of complications of paraoesophgeal hernias
 To define barret oesophagus and describe its management.
 To recall the etiology of esophagitis, describe and identify the various clinical features of
esophagitis, explain the appropriate diagnostic testing for esophagitis, demonstrate
knowledge of the treatment strategies of esophagitis and enlist the complications of
esophagitis
 To describe the clinical features, investigations, and treatment of benign and malignant tumor
of oesophagus. Describe the treatment options for patients with esophageal cancer and
differentiate various types of oesophagectomies
Stomach & deuodenum
 To describe surgical anatomy including blood supply and lymphatic drainage; and
physiology of Stomach and duodenum.
 To enlist the symptoms of various stomach disorders and their relevant investigations
 To understand the epidemiology and pathogenesis of peptic ulcer, describe clinical features,
diagnostic investigation and pharmacological and surgical management. To enlist the various
complications of peptic ulcer
 To illustrate common gastric tumors and its differentiating features. To discuss diagnostic
imaging techniques useful in gastric cancer and various surgical options for gastric cancer
treatment
Hepatobilary system & spleen
 To describe surgical anatomy of liver and formation of bile.
 To enlist the symptoms of various liver disorders and their relevant investigations
 To identify mechanisms of liver. To describe signs and symptoms, and complications
associated with liver injuries. To grade liver trauma and accordingly management. To enlist
various techniques of hemostasis in liver trauma
 To enlist the potential complications of portal hypertension and options for managing
patients with acute variceal bleeding
 To describe the most frequent types of liver abscesses and differentiate between these, to
describe investigations and management options
 To illustrate clinical manifestation, diagnostic investigations and various management
options of liver hydatid disease in correlation with the development

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 To classify liver tumors and to discuss the treatment strategies for liver tumors
 To enlist causes of splenomegaly and postsplenectomy complications
 To describe surgical anatomy and physiology of biliary system.
 To enlist the symptoms of various biliary disorders and their relevant investigations
 To identify the risk factors and predisposing conditions associated with gallstone formation.
To understand pathophysiology of gall stones, clinical presentation of gall stones and
management of gall stones. To diagnose cholelithiasis and choledocholithiasis. To enlist
cholelithiasis complications. To revise steps of cholecystectomy
 To classify jaundice. To describe common benign and malignant causes of obstructive
jaundice. To understand common symptoms and physical signs associated with jaundice,
clinical presentation of surgical Jaundice, diagnosis and management of common bile duct
stones
Pancrease
 To enlist the causes of acute pancreatitis. To describe the diagnosis of acute pancreatitis. To
narrate the criteria of assessment of severity of acute pancreatitis. To describe the initial
management and complications of acute pancreatitis.
 To discuss the management options of pancreatic fluid collections, peudocyst, pancreatic
abscess, and pancreatic necrosis in acute pancreatitis.
 Describe the pathophysiology of chronic pancreatitis and differentiate acute from chronic
pancreatitis. To identify pharmacologic and nonpharmacologic means of preventing repeat
episodes of chronic pancreatitis. To choose appropriate pancreatic enzyme supplementation
for patients with chronic pancreatitis.
 Describe the assessment, diagnosis, and staging of the patient with pancreatic cancer. To
identify current treatment and management strategies
Thyroid & Parathyroid glands
 To describe hypoparathyroidism, its diagnosis, and clinical presentation
 To differentiate between various types of hyperparathyrodism
 To discuss the pathophysiology of primary hyperparathyroidism. To describes the clinical
presentation, diagnosis, and treatment options for primary hyperparathyroidism.
 To narrate various surgical techniques for parathyroidectomy
 To review thyroid hormone physiology including thyroid hormone synthesis, storage, release
and feedback control of thyroid function.
 To learn that the thyroid function test interpretation for various thyroid hormonal disorders.
To understand the nuclear imaging to assess thyroid function.
 To describe presenting symptoms and signs of hyperthyroidism, hypothyroidism, thyroid
storm and myxedema coma and their pharmacological and surgical management.
 To narrate various thyroiditis and their management
 To classify thyroid tumors. To understand the risk factors, symptoms, investigations and
management of thyroid carcinomas.
Adrenal glands
 To describe the roles of the various zones of the adrenal cortex in hormone synthesis.
 To describe and differentiate the various etiologies of Cushing's syndrome. To interpret the
results of laboratory tests used to diagnose Cushing's syndrome and give its management.

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 To explain the differences between primary and secondary aldosteronism. To interpret the
results of laboratory tests used to diagnose primary aldosteronism. To recommend a
therapeutic regimen for treatment of primary aldosteronism
Breast
 To describe surgical anatomy including lymphatic drainage and physiological changes of
breast.
 To enlist the symptoms of various breast disorders and their relevant investigations
 To describe the differential diagnosis of a breast lump, physical examination for a patient
with a breast lump with special emphasis on triple assessment and to investigate and treat a
breast lump.
 To discuss the possible causes of nipple discharge and treatment options.
 To give risk factors and various management options of Breast cancer.
 To identify indications for Mastectomy and narrate different types of mastectomies.
Small & large gut
 To understand the embryologic development of a Meckel's diverticulum. To review the
“Rule of 2's.” to learn the investigations of Meckel's diverticulum and its complications.
 To classify the inflammatory bowel disease. To accurately assess the severity and disease
activity of UC and CD. To design an optimal pharmacotherapy plan for CD or UC. To
develop a pharmacotherapy plan for the treatment of complications of CD or UC. To
distinguish between the signs, symptoms, and complications of ulcerative colitis (UC) and
Crohn disease (CD).
 To understand the various presentations and identify those at risk of infection or of
developing abdominal tuberculosis. To classify the intestinal tuberculosis and differentiate
between these. To give the investigations to diagnose intestinal tuberculosis and enlist the
complications and surgical management. To learn about various anti-TB treatment regimens
and their adverse effects.
 To learn the small bowel tumors, its diagnostic investigations and management.
 To review the various etiologies of small bowel obstruction, workup and evaluation of a
patient with suspected small bowel obstruction. To understand pathophysiology of dynamic
and adynamic intestinal obstruction, the clinical pictures and complications of intestinal
obstruction. To give surgical and conservative treatment of intestinal obstruction
 To describe surgical anatomy including blood supply and lymphatic drainage of colon and
rectum.
 To enlist the symptoms of various colorectal disorders and their relevant investigations
 To identify the risk factors and various types of diverticular disease. To describe the
diagnostic investigations and management. To enlist the complications.
 To discuss differential diagnosis for large bowel obstruction. To recognize the various
radiologic imaging appearances of volvulus and treatment strategies. To narrate the
management options for sigmoid volvulus.
 To explain the screening of colonic malignancy. To describe treatment strategies for various
stages of colon and colorectal malignancies. To understand the different types of colonic
surgeries for colonic tumors
 To understand hemicolectomies, various types of gut stomas, abdominoperineal resection and
hartmanns procedure
Appendix

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 To describe the clinical history and physical features in acute appendicitis.
 To discuss the appropriate diagnostic work up and the management of acute appendicitis.
 To describe the various skin incisions and steps of appendectomy
 To enlist the various complications of acute appendicitis and appendectomy.
Anal canal
 To describe surgical anatomy including blood supply and lymphatic drainage of anal canal.
 To enlist the symptoms of various perianal pathologies and their relevant investigations
 To enlist common causes of anal pain. To describe the typical history in a patient with anal
fissure. To discuss etiology and management of anal fissures
 To define hemorrhoid. To learn about symptoms, causes and grading of hemorrhoids and to
give management options according to its grading
 To understand how a perianal abscess develops. To classify it. To describe how to perform
incision and drainage of a perianal abscess
 To discuss perianal fistulas, their causes and consequences. To illustrate with relevant
imaging findings, describing their classification according to Parks and management
according to classification
 To illustrate histopathological types of anal canal tumors. To understand the various
techniques of treatment for anal canal malignancies
Vascular system
 To learn the common symptoms and signs and the treatment of acute limb threatening
ischemia.
 To describe the clinical features, diagnosis and management of patients presenting with
ruptured abdominal arterial aneurysms. To identify the risk factors for aortic aneurysms and
rupture.
 To describe indications and various types of lower limb amputation
 To understand the symptoms and signs that varicose veins may cause and diagnostic
investigations. To classify varicose veins. To describes various treatment options and their
advantages and disadvantages. To enlist complications of varicose veins
 To narrate clinical presentation of DVT and PE, including risk factors, diagnostic evaluation
of DVT and PE and standard therapy for DVT and its prevention
Lymphatic system
 To understand lymphedema, types of lymphoedema and their development.
 To diagnose and manage lymphedema
Thoracic surgery
 To discuss mechanism of injury of chest trauma.
 To discuss the management of diaphragmatic injuries.
 To classify and diagnosis a space-occupying lesion of the lung and give its management
 To understand the difference in the characteristics and treatment of non-small cell (NSCLC)
and small cell lung cancer.
 To review the classification of posterior mediastinal masses.
Neurosurgery
 To define types of trauma to the brain and classify intracranial hemorrhages. To discuss
medications used in treatment of high intracranial pressure. To describe clinical and
radiological features and emergency management of intracranial hematomas. To identify
complications of severe head injuries

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 To enlist the signs and symptoms of a brain tumor. To describe the general treatment
modalities of treating brain tumors.
Pediatrics pathologies
 To understand the embryologic basis of cleft lip and palate. To understand the types of cleft
lip and palate. To understand the various treatment for these
 To describe the different types of esophageal atresia. To review VACTERL association. To
know the complications of esophageal atresia repair and tracheoesophageal fistulas
 To describe pathophysiology, clinical features, diagnostic investigations and management of
hypertrophic Pyloric Stenosis.
 To describe the potential locations of undescended testis. To describe tests for the diagnosis
of nonpalpable testis. To describe management and complications of undescended testis
 To understand the clinical and imaging features of pediatric intussusception. To narrate
treatment strategy for it
 To understand the embryology of Hirschsprung's disease. To give clinical features,
diagnostic tests and various surgical management of the disease
 To understand embryology of the imperforate anus. To diagnose and mange imperforate anus
Abdominal wall
 To distinguish between various types of abdominal hernias.
 To describe complications of hernias
 To learn pathophysiology of obstructed hernia, clinical features and management of all types
of abdominal hernia
 To differentiate indirect from direct inguinal hernia.
 To describe various techniques of herniorraphy.
 To describe how to perform open tension-free mesh repair of inguinal hernia
 To describe clinical features and management of Femoral, Spigelian and Obturator hernia
Peritoneum, mesentry & retroperitoneal pathologies
 To describe peritonitis. To explain how germs can get into your peritoneal cavity. To identify
the signs and symptoms of peritonitis. To know how to treat peritonitis. To describe Special
forms of peritonitis
 To describe clinical features, diagnostic test and treatment of Mesenteric tumor
 To classify retroperitoneal tumors. To understand patterns of spread for soft tissue sarcoma
of the retroperitoneum. Understand prognostic factors and optimal treatment approaches for
soft tissue sarcoma of retroperitoneum.

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SHORT
CASES

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 Short case 1
History and examination of a mass
History
 Duration
 Onset
 Progression
 Features: Pain? Discharge? Persistence?
 Cause: What, in the patient’s opinion, has caused the lump?
 Past medical/ surgical history: Similar lump? Diabetes? Past
cancer? Past intervention likes surgery or radiation?

Clinical examination

I. General physical examination

II. Local examination

Inspection: Number, Size, Site, Shape, Edge, Margins, Surface,

Overlying skin (Color, Dilated veins, Ulceration), Adjacent
structures
Palpation: Location, Size, Tenderness, Temperature, Shape,
Consistency (soft, spongy, rubbery, firm, or hard), Edge, Margin,
Surface, Mobility/ fixity, Pulsation, Fluctuation, Transillumination,
Thrill, Special location features (Movement with swallowing,
tongue protrusion, Reducibility, Compressibility) ,
Percussion
Auscultation
Adjacent tissues/joints/distal neurovascular status
Regional lymph Nodes
III. Systemic Examination
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 Short case 2

Ulcer: history and examination

History

 Duration
 Onset
 Progression: Worsening? Changes?
 Features: Pain, discharge, smell.
 Other diseases
 Past medical history: Diabetes, Radiation

Clinical examination

I. General physical examination

II. Local examination

Inspection: Number, Size, Site, Shape, Edge, Margin, Floor

(Color, Granulation, Slough, Discharge), Depth, Surrounding
skin
Palpation: Size,Temperature, Floor,Tenderness,
Base, Surrounding skin (Induration, Tenderness, Warmth)
Adjacent tis sues/distal neurovascular status
Regional lymph Nodes

III. Systemic Examination

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 Short case 3

The thyroid gland: history and examination

History
 Demographic details: Age, Sex, Occupation, Residence
 Swelling: Duration, Onset, Progression, Pain, Discharge,
Persistence, Cause: What, in the patient’s opinion, has caused the
lump? Past medical/ surgical history: Similar lump? Diabetes?
Past cancer? Past intervention likes surgery or radiation?
 Ask about the effect of the swelling on the
a) Trachea, causing breathing difficulty and stridor.
b) Esophagus, causing dysphagia.
c) Recurrent laryngeal nerve, causing hoarseness.

 Hyperthyroidism and hypothyroidism

 Hyperthyroidism: Heat intolerance, raised appetite, weight
loss, sweating, palpitations, tiredness, agitation/nervousness,
dyspnea; also diarrhea, menstrual changes (commonly
amenorrhea), insomnia
 Hypothyroidism: Weight gain, loss of appetite, constipation,
cold intolerance, hoarseness of voice, decreased hearing, hair
loss, dry skin, hand pain (carpal tunnel syndrome), angina
pectoris, intellectual/ motor slowing (excessive sleeping),
muscle cramps, (commonly menorrhagia)
 Others: Medications, Family history, Dietary history
Examination
I. General physical examination
Body habit (Patients with thyrotoxicosis are usually thin and underweight.
Patients with hypothyroidism are usually obese and overweight. In case of

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 carcinoma of thyroid; signs of anaemia and cachexia may be present,
especially with anaplastic cancers), Hands (fine tremors, onycholysis, palmar
erythema, warm and sweaty palms, and clubbing. Xanthomas, cool and dry
palms, and cyanosis suggest hypothyroidism), Vital signs (Pulse and blood
pressure), Eyes (exophthalmos, chemosis, conjunctival injection, corneal
ulceration, opthalmoplegia, lid-lag, lid retraction, periorbital edema, loss of
outer third of eyebrows, and xanthelasmas near the eye), Face (dry skin and
hair)
II. Local examination: Neck
1. Mass
INSPECTION: Note the location, size, shape, surface, edges,
margins, overlying skin, pulsatility, and adjacent structures
(particularly the trachea). Dilated veins may indicate compression of
the superior vena cava.)
Four special features of neck swellings: Inspect the swelling for:
a. Look for movement with swallowing. You may need to ask the
patient to swallow some water.
b. Thyroglossal cysts (but usually not the thyroid glands) move
with protrusion of the tongue.
c. Look at the adjacent structures, especially the trachea.
d. Look for pressure on the thoracic inlet (Pemberton’s test).

PALPATION
Palpate from behind: Mass (Note the tenderness, temperature,
location, size, shape, surface, margins, edges, fixity, consistency,
and thrill. Be sure to check if you can get below the gland.
The “Lahey’s test” is a palpation of the thyroid from the front. Its
objective is to feel the posterior part of the gland.

Three special features of neck swellings

a. Examine the trachea.
b. Perform Kocher’s test.
c. Feel the carotid (Berry’s sign).

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 PERCUSSION: for a possible retrosternal extension of the goiter.
AUSCULTATION: Look for a bruit.
2. Cervical & supraclavicular lymph nodes:
3. Examination for thyroid function: pretibial myxedema,
proximal muscle weakness, tendon reflexes, mental dullness
(even coma), hearing loss.
III. Examination of the other systems: cardiovascular,
respiratory, and gastrointestinal.

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 Short case 4
History and examination of bleeding per rectum
History
 Onset
 Colour
 Location: On the toilet paper, Mixed with stools, On top of stools
 Amount
 Clots
 Mucus
 Pain

Clinical examination

I. General physical examination

II. Local examination (digital rectal examination)
Inspection: Separate the buttocks and inspect for: Skin
excoriation, Skin tags, Rashes, Haemorrhoids (are they
thrombosed?), Anal fissures, Fistulae and abscesses
Digital rectal examination
1. Lubricate the examining finger
2. Warn the patient you are about to insert the finger
3. Insert finger gently into the anal canal
4. Palpate the prostate anteriorly (in males)
5. Rotate the finger 360 degrees to assess the entirety of the rectum:
 Note location of any masses or irregularities
 Is there stool in the rectum? – soft vs impacted
6. Assess anal tone by asking the patient to squeeze your finger
7. Withdraw finger:
 Inspect for blood – fresh red vs melaena
 Inspect for stool / mucous

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 Short case 5
Peripheral artery disease: history and examination
History
 Demographics: Age, Gender (Raynaud’s disease and cervical rib are
commoner in women, while thromboangiitis obliterans (Buerger’s
disease) is commoner in males.), Profession (Persons working on
vibrating tools and those exposed to polyvinyl chloride are at risk of
developing features of Raynaud’s syndrome),
 Location (Thromboangiitis obliterans typically affects the lower limb.
Raynaud’s disease affects the upper, Arteriolosclerosis typically affects
the coronary, carotid, aortoiliac and femoral vessels),
 Side (If a limb is affected, check if the symptoms are unilateral or
bilateral)
 Onset
 Pain: claudication, rest pain, and Raynaud’s phenomenon. Onset,
character, location, severity, movement, progression, aggravating and
relieving factors, associated factors.
 Paresthesias
 Superficial phlebitis
 Limitation in activity
 Systemic features: fever, weight loss, weakness
 Involvement of other arteries: fainting, blackouts, visual defects,
chest or abdominal pain, and erectile dysfunction
 Past medical and surgical history: This includes previous
cardiovascular disease, similar symptoms, diabetes, exposure to cold,
trauma or surgery. Also ask about drug intake: ergot-like drugs can
cause severe vasospasm and even gangrene
 Personal history: Smoking
 Family history
Clinical Examination
I. General examination
II. Local examination: limb
INSPECTION: Skin Color, Edema, Nails, Muscle wasting, Lesions: Ulcers,
abscesses, and interdigital fungal infection.

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PALPATION: Temperature, Tenderness, Pulses, Vascular filling: capillary
filling (by elevating and lowering the limb), capillary nail refilling time (by
pressing the nail or finger pulp), and venous refilling (by emptying a single
vein). Buerger’s Test, Arteries of the contralateral limb, Allen’s test.
AUSCULTATION: Bruits
Others: Gait and deformity, Neuropathy, Lymph nodes
III. Systemic examination

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 Short case 6
History and Examination of varicose veins
History
 Onset
 Occupation
 Pain
 Ulcer
 Swelling in the leg
 Abdominal mass
 Past history: Ask about a history pertinent to deep vein thrombosis (a cause of
varicose veins), previous surgery (e.g. for an abdominal disorder); ask about
pregnancies (did the varicosities originate during pregnancy?). Ask about
medications (oral contraceptives that may cause venous thrombosis. Also ask if
the patient has taken any therapy at all for the varicosities (tablets, injections in
the leg, surgery)
 Family history
II. Examination
I. General examination
II. Local examination
INSPECTION: edema, pigmentation, eczema, lipodermatosclerosis, atrophie
blanche, active or healed venous ulcer, Location: Which system is affected? The
greater saphenous or its territory? The short saphenous or its territory?
Nonsaphenous veins? Are blow-outs present indicating perforator incompetence?
PALPATION:
1. Cough impulse.
2. Tourniquet test for SFJ incompetence. (Brodie-Trendelenburg test).
3. Tourniquet test for SPJ incompetence.
4. Multiple tourniquet and compression bandage test for localizing perforators
5. Tapping for valve incompetence in the GSV (Schwartz's test).
6. Deep fascia palpation for defects in the muscular layer (Fegan’s test)
7. Perthes’ test
8. Peripheral arterial examination.
9. Ankle joint. Long standing varicose veins may cause an equinus deformity.
Examine the ankle joint.
10. Regional nodes.
11. Other leg. Examine the other leg as well.
12. Abdomen. Abdominal masses can cause varicosities. In women, exclude
pregnancy.

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PERCUSSION AND AUSCULTATION: Percussion has very little role in the
leg, unless one considers the Schwartz test described above as a form of
percussion. Auscultate if you suspect an arteriovenous fistula
III. Systemic examination

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Short case 7
Breast disease: history and examination
HISTORY
 Demographic details: Age.
 Breast Lump: Duration, progression. . Pain: pain in the breast,
pain elsewhere. Nipple changes: discharge, retraction.
 Systemic features: weight loss. respiratory symptoms.
 Past history: Breast cancer, ovarian cancer, trauma, surgery.
 Personal history: Marriage, Menstrual history, Children and
lactation. Drugs, Smoking, alcohol, diet.
 Family history of breast cancer.
CLINICAL EXAMINATION
I. General examination
II. Local examination (Breast)

INSPECTION
 Symmetry
 Skin: Puckering, dimpling, retraction, thickening. Peau
d”orange. Nodules, Discoloration, Ulcer, fungation, Engorged
veins.
 Nipple and areola: Presence, number/duplication, Symmetry,
position, displacement, Ulceration, destruction, Discharge.
Depression/retraction, Color of nipple; any discoloration.
 Lump. All features of lump on inspection
PALPATION: Tenderness, Termperature, Thickening, Lump
examination, Ulcer examination, Nipple discharge, other breast
Axillary and supraclavicular lymph Nodes
III. Systemic examination

Chest, Abdomen, Bones. Palpate for bone tenderness, especially

in the spine, pelvis, ribs, sternum, femur, humerus. Bone
tenderness occurs from tumor spread.

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 Short case 8
Hernia: history and examination
History
 Demographic details: Age, occupation
 Duration
 Onset
 Progression
 Pain
 Reducibility
 Systemic symptoms: Frequently, straining (e.g. due to
prolonged cough, constipation, prolonged urinary obstruction),
lung disorders like chronic bronchitis (smoking, cough)
 Past history: Appendectomy
Clinical examination
I. General physical exam
II. Local examination: ALWAYS make the patient stand!

INSPECTION: Number of swellings, Size, Shape, Site, Surface,

Overlying skin, Reducibility and visible peristalsis.
PALPATION: Location, Size, Tenderness, Temperature, Shape,
Consistency, Edge and margin, Surface, Mobility/fixity,
Pulsation, Fluctuation, Transillumination, Thrill, Reducibility and
cough impulse, Ring occlusion, regional lymph nodes
PERCUSSION: A resonant note indicates intestine (enterocele).
A dull note indicates omentum
AUSCULTATION: In an enterocele, peristaltic sounds may be
heard
Systemic examination: Hernia may be caused by chronic cough
(examine the respiratory system), by ascites and by chronic
constipation (examine the abdomen), by chronic straining for
urination (examine the genitalia and prostate)

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Short case 9
Abdominal examination and history
Key gastrointestinal symptoms:
 Dysphagia / odynophagia – solids vs liquids, Onset,
Progression
 Nausea / vomiting – triggers, colour of vomit, haematemesis,
Frequency and volume, Projectile vomiting
 Reduced appetite, weight loss, fever, malaise or fatigue
 Jaundice: onset, duration, progression, stool color, urine color,
itching, history of blood transfusion/ surgery
 Abdominal pain – Site, Onset, Character, Radiation,
Associations, periodicity, Exacerbating or Relieving factors,
Severity, intermittent or continuous.
 Abdominal distension
 Altered bowel habit – constipation (duration, absolute or
relative), diarrhea, fresh blood, malaena , mucous

Clinical examination

I. General physical examination

II. Abdominal examination
Inspection: Symmetry, Shape, Skin, Swellings, Striae, Scars, Dilate
d veins, Pulsations, Peristalsis, Hernial sites, Umbilicus, Movement
with respiration
Palpation
Superficial: Superficial tenderness, guard, rigidity
Deep: Deep tenderness, Liver, Spleen, Kidney, Masses (all features
of mass on palpation)
Percussion: Liver, Mass if any, Fluid thrill and shifting dullness
Auscultation: bruit, gut sounds
Vaginal/ rectal examination
III. Systemic Examination
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 Short case 10
Scrotal Swellings: history and Examination

History
 Ask about pain- duration, severity etc
 Ask about any associated symptoms:e.g. features of UTI/STI (e.g.
discharge, pyuria) which might suggest epididymo-orchitis,
parotid swelling (mumps orchitis), nausea/vomiting (torsion,
rarely in epididymo-orchitis)
 Any history of trauma
 Also ask about any relevant past medical history

Clinical examination
I. General physical Examination
II. Local examination; in the standing position

Inspection: Lie (is one testis higher than other?); appearance; scars;
oedema; sebaceous cysts, ulcers or swellings; erythema
Palpate: getting above swelling, is testis palpable separately?
Transillumination, palpate all features of swelling, palpate both
testis, epididymis and spermatic cord.
III. Systemic examination

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 Short case 11
History and examination for sinus/ fistula
History
 Pain
 Fever
 Redness of the surrounding skin
 Past history of surgery/ trauma
 Family history of malignancy/ IBD

Clinical examination

I. General physical examination

II. Local Examination

Inspection: Number, Position, Opening of the sinus, Discharge,

Surrounding skin
Palpation: Tenderness, Mobility, Lump, Examination of Lymph
nodes
Examination with Probe: Direction/ depth of sinus, Presence of
any foreign body, Communication with hollow viscera, Fresh
discharge on withdrawal of probe
III. Systemic examination

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Long case: how to approach breast case (Nipple discharge, breast lump & Cyst)

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Long case: how to approach a case of acute cholecystitis/Gall stones

Long case: how to approach a case of varicose veins

Diagnosis

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Physical exam, Doppler ultrasound
Treatment
Self-care — such as exercising, losing weight, not wearing tight clothes, elevating your legs, and
avoiding long periods of standing or sitting — can ease pain and prevent varicose veins from
getting worse.
Compression stockings
Sclerotherapy. Foam sclerotherapy of large veins.
Laser surgeries.
Catheter-assisted procedures using radiofrequency or laser energy.
High ligation and vein stripping. .
Ambulatory phlebectomy
Endoscopic vein surgery.

Long case: how to approach thyroid case

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Long case: how to approach salivary gland disease (inflammation,Benign & malignant

lump)

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Long case: how to approach a case of obstructive jaundice

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Long case: how to approach a case of abdominal pain

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Long case: how to approach a case of acute appendicitis & appendicular mass

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Long case: how to approach a case of bleeding per rectum

Long case: how to approach a case of inguinal hernia

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Long case: how to approach a case of acute pancreatitis

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Long case: how to approach a case of scrotal lump

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Long case: how to approach a case of diabetic foot ulcer

Long case: how to approach a case of colorectal tumors

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Trauma management protocol

Secondary survey: look! listen! feel!

Head-to-toe
Glasgow Coma Scale Seek the following
Scalp Tenderness
Ears (including tympanic membranes) Lacerations (including entry, exit wounds)
Eyes (including pupils, acuity, fundi) Swelling (including haematoma)
Facial bones Structural deformity (i.e. bones)

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Mouth (including teeth) Discolouration (e.g. bruising)
Neck (C-spine, soft tissues, trachea) Crepitus (including subcutaneous)
Clavicles Ischaemia (i.e. limbs)
Chest: Functional impairment:
Chest wall Visceral (lungs, heart, bowel)
Chest movement Musculoskeletal neurological
Lungs
Heart
Abdomen Proceed with the following
Pelvis Digital photo (or polaroid) of major wounds
Hips Sterile pad on wounds
Thighs Pressure on bleeding sites
Knees Splint fractures
Legs Traction splints where indicated
Ankles Splinting of specific pelvic fractures (open book)
Feet Pain relief
Upper arms Tetanus prophylaxis
Elbows Antibiotics as advised
Forearms
Wrists
Hands
Fingers

Back and flanks (log-roll)

Perineum, genitalia
Rectal examination
Urinalysis

Shock management

 The main symptom of shock is low blood pressure. Other symptoms include rapid,
shallow breathing; cold, clammy skin; rapid, weak pulse; dizziness, fainting,
or weakness.
 There are several types of shock: septic shock caused by bacteria, anaphylactic
shock caused by hypersensitivity or allergic reaction, cardiogenic shock from heart
damage, hypovolemic shock from blood or fluid loss, and neurogenic shock from
spinal cord trauma.

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 Treatment for shock depends on the cause. Tests will determine the cause and
severity. Usually IV fluids are administered in addition to medications that
raise blood pressure.
o Septic shock is treated with antibiotics and fluids.
o Anaphylactic shock is treated with diphenhydramine, epinephrine and steroid
o Cardiogenic shock is treated by identifying and treating the underlying cause.
o Hypovolemic shock is treated with fluids (saline) in minor cases, and blood
transfusions in severe cases.
o Neurogenic shock is the most difficult to treat as spinal cord damage is often
irreversible. Immobilization, anti-inflammatories such as steroids and surgery
are the main treatments.

Long case: how to approach a case of fistula in ano

Total parenteral nutrition

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Indications & contraindications
Routes of administration
Nutrition & monitoring
Complications ; refeeding syndrome

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 SYSTEMIC
SURGERY
MANAGEMENT
ALGORITHYM

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GENERAL SURGERY

METABOLIC RESPONSE TO SURGERY

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SHOCK:
Pathophysiology

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BLOOD TRANSFUSION

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WOUNDS:

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SCAR

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SURGICAL INFECTION

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GAS GANGRENE

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CELLULITIS

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TYPES OF TISSUE BIOPSY

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TYPES OF ENDOSCOPY

TYPES OF BARIUM STUDIES OF GIT

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TYPES OF DIAGNOSTIC IMAGING

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POSTOP PAIN RELIEF

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POSTOP COMPLICATIONS

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NUTRITION

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ENTERAL NUTRITION ROUTES

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REFEEDING SYNDROME

PATHOPHYSIOLOGY

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TRIAGE

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CHEST TRAUMA

PNEUMOTHORAX

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