Integration of Medical and Surgical Skills
Taken patient history
Swelling/lump
Goitre- likely an enlarged thyroid gland
Enlarged lymph node
Hernia- protrusion of organ or part of an organ through the wall that contains it
Incisional hernia and groin (inguinal) hernia
How to take a history of swelling
Onset, course, duration
Painful or painless
Other lumps
Effect of general condition
Cause
Does the lymphatic system disappear
Onset gradual onset- likely benign
Rapid-inflammatory (over 1-2 days)
Acute-bleeding into cyst (in hours)
Accidental-most lumps
Incidental is what a medical professional found, accidental what the patient found
Course - increasing, decreasing or stationary in size
Progressive- benign, malignant, inflammatory
Regressive- resolving inflammation
Stationary - no change
Duration for how long, malignancy is unlikely with long duration (years)
However recent change in size in a longstanding swelling might indicate malignant change
Benign lumps can turn into malignant lumps
Painful or painless if painful take detailed history of pain
Painless- most lumps
Painful- traumatic, inflammatory
Malignant
Late
Indicate infiltration of local nerves or surrounding structures
Other lumps
Effect of General Condition benign/early malignant lumps
Malignant lumps- S&S of metastases: eight loss, loss of appetite
Cause - history of trauma, history of previous surgery, history of heavy lifting - usually makes hernia
Does the lump disappear
If you increase intra abdominal pressure, hernia will come out if you decrease it; will go back
How to examine a swelling?
General examination
local examination -inspection -palpation -percussion -auscultation
Inspection : site , size, shape
Surface- smooth, lobulated/irregular
Skin overlying-normal
Special signs- movement with swallowing (seen in thyroid swelling)
-movement with protrusion of the tongue (seen in thyroglossal cyst)
-pulsations (seen in swellings related to arteries)
-cough impulse
Palpation -tenderness : check if swelling is painful BEFORE you touch it
-skin temperature : compare with normal area
Size
Surface - smooth - irregular
Edge -well defined -ill defined
Consistency -cystic: fluid containing swelling :positive cross fluctuation in 2 perpendicular directions
- solid :soft :firm :hard :indurated
Relation to surrounding structures -skin -muscles-arteries -others
Draining lymph nodes
Special signs
Relation to surrounding structures : skin
is the lump separate from overlying skin -pinch the skin over the lump
Is the lump tethered to the skin-the lump can move within a range
Is the lump fixed to the skin-lump and skin move together
:muscle
Superficial to the muscle -more prominent
Deep to the muscle -not felt
Inside the muscle -less prominent and fixed
Special signs- transillumination
Common Findings on Surgical patients
Incisions
Stoma’s- artificial opening made into the surface of the body leading to the gut
:ileostomy :colostomy
Nasogastric tube- decomposition of stomach & small bowel
-to prevent vomiting and aspiration
Nutritional support -enteral feeding (fine pore NG tube)
Percutaneous endoscopic gastrostomy (PEG)
Feeding jejunostomy tube
TPN = total parenteral nutrition
Urinary catheters -suprapubic catheter
Chest drain
Surgical sub speciality’s
General surgery- upper GI surgery (oesophagohastric) -lower GI surgery (colorectal)
HBP (hepatic, biliary & pancreatic) surgery
Breast surgery
Neurosurgery, cardio thoracic surgery, urology , orthopaedics, plastic & reconstructive surgery, maxillofacial surgery
Open surgery
-somatic pain : sharp, more severe, localised
-visceral pain: vague, less severe, poorly localised
laparoscopic makes port incisions and extraction site, smaller cuts compared to open surgery
Limitations of laparoscopy
-camera controlled by assistant
-2D vision
-limited retraction
-limited dexterity
-limited ability to do high precision tasks
Robotic surgery
-camera controlled by surgeon
-3D vision