Take Charge! General Surgery and Urology

A practical guide to patient management

Alexander Trevatt, Richard Boulton, Daren Francis

• Publisher: CRC Press
• Year: 2020
• ISBN:
  9781351651912
• Edition: 1
• Topic: Medizin
• Subtopic: Medizinische Theorie, Praxis & Referenz

As a junior doctor starting a surgery or urology rotation, you are expected to take charge of referrals from - and give specialist advice to - A&E, GPs and other specialties. Often you will have had very limited surgical experience and only an off-site registrar for support. This pocket-sized book provides a quick, reliable reference guide for the initial management of the common surgical referrals, with guidance as to what complaints require admission and which can be sent home for outpatient or GP follow-up. It will help relieve the stressful experience of being on-call, alleviating some of the anxiety and making shifts more bearable.

Part I

Abdominal Examination

Chapter 1

Abdominal examination and surgical scars

Jason Hol-Ming Wong

A comprehensive abdominal examination is an essential part of diagnosing and managing surgical patients. This chapter will guide you through a complete ‘exam style’ abdominal examination.

The key points to consider when examining the surgical abdomen are:

•To correlate the clinical findings with the history to make a diagnosis

•To assess whether the patient has an ‘acute abdomen’

•To assess the need for surgery and how urgently this is required

Examination

Always: Introduce yourself, explain the procedure, check for pain and ask for permission to examine the patient. Wash your hands and don a pair of gloves if appropriate.

Tip: Keep a stethoscope as your registrar is unlikely to be wearing one and keep a supply of lubricant in your pocket; your time is too valuable to search A&E (accident and emergency) when it is needed.

•Exposure

⚬Ask the patient to lie supine

⚬Expose the patient adequately in order to examine them appropriately, whilst maintaining dignity

Offer a chaperone where appropriate.

Tip: Document the name of the chaperone present or if one has been declined. For male colleagues it may be appropriate to insist on a chaperone for your own medical legal protection.

•General inspection

⚬Look around the bed for clues (i.e. infusions, catheters, drains, etc.)

⚬Assess the patient’s general condition

◼Glasgow coma scale (GCS) including breakdown if reduced (eyes, voice, motor) – see Chapter 22

◼Breathlessness or obvious discomfort

◼Jaundice or pallor

⚬Abdominal distension

⚬Any scars/masses/stoma/skin changes

⚬Visible hernias: Ask the patient to cough/lift head off the bed

•Inspection

⚬Hands

◼Nails: Koilonychia (iron deficiency)/leuconychia (hypoalbuminaemia)

◼Capillary refill time (normal <2 seconds)

◼Palmar erythema (decompensated liver disease)

◼Finger clubbing (e.g. malignancy, inflammatory bowel disease, suppurative lung disease)

◼Dupuytren’s contracture (decompensated liver disease, mechanical)

◼Asterixis (decompensated liver disease, uraemia)

⚬Eyes and mouth

◼Jaundice (decompensated liver disease)

◼Pallor (anaemia)

◼Angular stomatitis (iron deficiency)

◼Glossitis (B12 deficiency)

◼Ulceration (e.g. Crohn disease)

⚬Neck

◼Virchow’s node (left supraclavicular node – GI [gastrointestinal] malignancy)

◼L...