BOOK
Hunt & Marshall's Clinical Problems in Surgery - eBook
Julian A. Smith | Jane G. Fox | Alan C. Saunder | Ming Kon Yii
(2017)
Additional Information
Book Details
Abstract
Is surgery required? Is the patient effectively communicating symptoms to make the correct clinical diagnosis? Clinical Problems in Surgery, 3rd Edition supports medical students in applying clinical reasoning to problems they encounter in a clinical setup.
Individual chapters are dedicated to specific regions of the body where surgeons encounter most of the problems. The content structure follows the logical step-by-step process of introducing a clinical problem; seeking history and conducting physical examination; diagnosing the patient and devising a treatment plan based on this informed diagnosis.
- Each chapter discusses the clinical presentations with which surgeons are most commonly faced.
- Each chapter is dedicated to a range of such problems within a particular region of the body.
-
Incorporation of the latest RACS guidelines on surgery
- A new Chapter 14, titled Ophthalmological Problems, expands the latest advancements in surgical treatments of such problems.
- Many line drawings from the previous edition have been replaced with clinical photos to emphasise real-life clinical scenarios which surgeons encounter on a daily basis.
- This edition will be available as a Student Consult eBook along with the print book. The eBook will include enhancements to the images within the book, as enabled by the Inkling platform.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | cover | ||
| Inside Front Cover | ifc1 | ||
| Hunt & Marshall's Clinical Problems in Surgery | i | ||
| Copyright Page | iv | ||
| Table Of Contents | v | ||
| Foreword | ix | ||
| Preface | x | ||
| Acknowledgements | xi | ||
| Editors | xii | ||
| Contributors | xiii | ||
| Reviewers | xiv | ||
| Introduction | xv | ||
| The problem-oriented clinical approach | xviii | ||
| 1. Collect and record the database | xviii | ||
| Take a history and examine the patient | xviii | ||
| Record the data in a systematic manner | xix | ||
| History of the presenting complaint | xix | ||
| Subjective data (S) | xix | ||
| Objective data (O) | xix | ||
| 2. Constructing a problem list | xx | ||
| 3. Assessment and plan | xx | ||
| 4. Progress notes | xxi | ||
| 5. Discharge summary | xxii | ||
| Medical record | xxii | ||
| Discharge summary | xxiii | ||
| Student case presentations | xxiii | ||
| Suggested format | xxiv | ||
| What to put on visual aids such as computer presentation packages | xxiv | ||
| Suggestions | xxiv | ||
| Example case presentation | xxiv | ||
| Format of bedside presentations | xxv | ||
| ISBAR | xxv | ||
| 1 Integument problems | 1 | ||
| 1.1 Introduction | 1 | ||
| The clinical history of a lump or ulcer | 2 | ||
| 1. Onset and duration | 2 | ||
| 2. Change and progression | 4 | ||
| 3. Other symptoms | 4 | ||
| 4. Multiplicity | 4 | ||
| The physical examination of a lump or ulcer | 4 | ||
| 1. Situation and depth | 5 | ||
| 2. Size | 5 | ||
| 3. Shape and surroundings | 5 | ||
| 4. Colour | 6 | ||
| 5. Contour | 6 | ||
| 6. Consistency | 6 | ||
| 7. Temperature | 7 | ||
| 8. Tenderness | 7 | ||
| 9. Transillumination | 7 | ||
| 10. Fluctuation and percussion | 7 | ||
| 11. Fixity | 8 | ||
| 12. Fields | 8 | ||
| 1.2 Focal skin lesions | 8 | ||
| Clearly benign lesions | 8 | ||
| Common causes of benign skin lesions | 9 | ||
| In children | 9 | ||
| In adults | 9 | ||
| Clinical features, diagnostic and treatment plans | 9 | ||
| Children | 10 | ||
| Port-wine stain | 10 | ||
| Strawberry naevus (capillary haemangioma) | 10 | ||
| Benign mole | 10 | ||
| Intradermal, junctional and compound naevus | 10 | ||
| Blue naevus | 10 | ||
| Freckles (ephelides) | 11 | ||
| 2 ENT, Head and neck problems | 30 | ||
| 2.1 Introduction | 30 | ||
| History | 30 | ||
| Examination of the head and neck | 30 | ||
| Ear | 30 | ||
| Nose | 30 | ||
| Nose and sinuses | 30 | ||
| Throat | 31 | ||
| Mouth | 31 | ||
| Oropharynx | 31 | ||
| Hypopharynx | 31 | ||
| Nasopharynx | 31 | ||
| Head and neck lumps | 31 | ||
| Regional and developmental anatomy | 33 | ||
| 2.2 Ear | 33 | ||
| Role of the ear | 35 | ||
| Nearby blood vessels | 35 | ||
| External ear | 35 | ||
| Wax and otitis externa | 35 | ||
| Management | 35 | ||
| Middle ear | 35 | ||
| Otitis media | 35 | ||
| Inner ear | 36 | ||
| Hearing loss | 36 | ||
| Vertigo | 37 | ||
| Tinnitus | 37 | ||
| 2.3 Facial weakness | 40 | ||
| Trauma | 40 | ||
| 2.4 Nose and sinuses | 41 | ||
| Anatomy/physiology | 41 | ||
| Blood supply | 41 | ||
| Nerve supply | 41 | ||
| Olfactory nerve – cranial nerve I | 41 | ||
| Paranasal sinuses | 42 | ||
| Epistaxis | 42 | ||
| Nasal obstruction | 42 | ||
| Sinusitis, nasal polyps, allergy | 43 | ||
| Investigations | 43 | ||
| Treatment | 43 | ||
| 2.5 Throat | 43 | ||
| Tonsils and adenoids | 43 | ||
| Anatomy | 44 | ||
| Microbiology/pathology | 44 | ||
| Infectious mononucleosis | 44 | ||
| History and examination | 44 | ||
| Diagnosis | 44 | ||
| Medical treatment | 45 | ||
| Surgical treatment | 45 | ||
| 2.6 Airway emergencies and tracheostomy | 45 | ||
| Tube types | 46 | ||
| Complications | 46 | ||
| Avoiding complications | 46 | ||
| 2.7 Snoring and obstructive apnoea | 46 | ||
| Treatment | 47 | ||
| 2.8 Voice, dysphonia, hoarse voice | 47 | ||
| Anatomy | 47 | ||
| Nerve supply | 47 | ||
| Dysphonia | 47 | ||
| 2.9 Dysphagia | 48 | ||
| 2.10 Congenital anomalies | 48 | ||
| Thyroglossal cysts | 48 | ||
| Branchial cysts | 48 | ||
| Vascular malformations | 49 | ||
| Nasolabial cyst, dermoids, cleft lip and cleft palate | 49 | ||
| 2.11 Foreign bodies | 49 | ||
| Ear | 49 | ||
| History | 49 | ||
| Examination | 49 | ||
| Investigation | 49 | ||
| Treatment | 49 | ||
| Nose | 50 | ||
| 3 Breast problems | 65 | ||
| 3.1 Introduction | 65 | ||
| History | 65 | ||
| Physical examination | 65 | ||
| Diagnostic tests | 68 | ||
| Imaging techniques: mammography, ultrasound | 68 | ||
| Cytology and histology | 68 | ||
| 3.2 Breast pain | 68 | ||
| Common causes | 68 | ||
| Clinical features and diagnosis | 68 | ||
| Treatment plan | 70 | ||
| 3.3 Breast lump | 70 | ||
| Causes | 70 | ||
| History and physical examination | 70 | ||
| 1. Carcinoma | 70 | ||
| 2. Involutional change with stromal hyperplasia | 72 | ||
| 3. Fibrocystic change (breast cyst) | 72 | ||
| 4. Fibroadenoma | 72 | ||
| 5. Mammary duct ectasia | 72 | ||
| 6. Less common causes | 72 | ||
| Diagnostic plans | 72 | ||
| 1. Fine needle aspiration cytology | 72 | ||
| 2. Mammography | 73 | ||
| Treatment plan | 73 | ||
| 1. Clinical staging | 73 | ||
| 2. Curative surgical treatment for early disease | 73 | ||
| 4. Stage IV disease and advanced local disease | 73 | ||
| 3.4 Nipple discharge | 73 | ||
| Common causes | 74 | ||
| Diagnostic plans | 74 | ||
| Discharge from many duct orifices (often bilateral) | 74 | ||
| Unilateral bloody discharge from a single duct | 74 | ||
| Mammary duct fistula | 75 | ||
| Diagnostic plan | 75 | ||
| Treatment plan | 75 | ||
| 3.5 Gynaecomastia | 76 | ||
| Common causes | 76 | ||
| Clinical features | 76 | ||
| 1. Puberty and old age | 76 | ||
| 2. Systemic disease | 76 | ||
| 3. Carcinoma of the lung and other tumours | 76 | ||
| 4. Drug-induced gynaecomastia | 76 | ||
| Diagnostic plan | 77 | ||
| Treatment plan | 77 | ||
| 4 Chest and chest wall problems | 78 | ||
| 4.1 Introduction | 78 | ||
| History | 79 | ||
| Physical examination | 80 | ||
| General inspection | 80 | ||
| Examination of the periphery | 80 | ||
| Examination of the pulse | 80 | ||
| Examination of the head and neck | 80 | ||
| Jugular venous pressure and pulse | 81 | ||
| Examination of the heart | 81 | ||
| Examination of the chest and lungs | 82 | ||
| 4.2 Acute chest pain | 83 | ||
| Causes | 83 | ||
| Clinical features | 84 | ||
| 1. Angina pectoris, myocardial infarction and oesophageal spasm | 84 | ||
| 2. Pneumothorax | 84 | ||
| 3. Pleurisy and pneumonia | 84 | ||
| 4. Pulmonary embolus and infarction | 84 | ||
| 5. Musculoskeletal disorders | 84 | ||
| 6. Less common causes | 84 | ||
| Diagnostic plans | 85 | ||
| Chest x-ray | 85 | ||
| Electrocardiogram | 85 | ||
| Serum enzymes | 86 | ||
| Plasma D-dimers | 86 | ||
| Arterial blood gases | 86 | ||
| Ventilation/perfusion (V/Q) scanning | 86 | ||
| Echocardiography | 86 | ||
| Computed tomography pulmonary angiography (CTPA) | 86 | ||
| Lower limb venous Doppler | 86 | ||
| Gastrografin swallow | 86 | ||
| Treatment plans | 86 | ||
| 1. Myocardial infarction (and oesophageal spasm) | 86 | ||
| 2. Pneumothorax, tension pneumothorax, cardiac tamponade | 87 | ||
| 3. Pleurisy and pneumonia | 87 | ||
| 4. Pulmonary embolus | 87 | ||
| 5. Musculoskeletal pain | 87 | ||
| 6. Other causes | 87 | ||
| 4.3 Pleural effusion | 87 | ||
| Common causes | 87 | ||
| I. Transudate | 87 | ||
| II. Exudate | 87 | ||
| Clinical features | 87 | ||
| Investigations | 87 | ||
| Treatment plans | 88 | ||
| 4.4 Chronic cough and haemoptysis | 88 | ||
| Causes | 88 | ||
| Clinical features | 88 | ||
| 1. Smokers’ lungs | 89 | ||
| 2. Carcinoma of the lung | 89 | ||
| 3. Postviral bronchitis | 89 | ||
| 4. Foreign body | 89 | ||
| 5. Tuberculosis | 90 | ||
| Diagnostic plans | 90 | ||
| Imaging | 90 | ||
| Endoscopic studies | 90 | ||
| Treatment plan | 92 | ||
| 1. Smokers’ lungs | 92 | ||
| 2. Carcinoma of the lung | 92 | ||
| 3. Postviral bronchitis | 92 | ||
| 4. Foreign body | 92 | ||
| 5. Tuberculosis | 92 | ||
| 6. Less common causes | 92 | ||
| 4.5 Chest wall problems | 93 | ||
| Common causes | 93 | ||
| Clinical presentation and management plans | 93 | ||
| 1. Congenital deformities of the thoracic cage | 93 | ||
| 2. Soft tissue swellings | 93 | ||
| 3. Bony swellings | 93 | ||
| 4. Costochondral swellings | 93 | ||
| 5. Infections | 93 | ||
| 5 Back and related limb neurological problems | 94 | ||
| 5.1 Introduction: the back and spine | 94 | ||
| History | 94 | ||
| Examination | 95 | ||
| Neurological system | 98 | ||
| History | 98 | ||
| Examination | 98 | ||
| Motor nerve function | 98 | ||
| Sensory nerve function | 99 | ||
| Reflex function | 99 | ||
| Gait | 100 | ||
| 5.2 Back pain | 101 | ||
| Causes | 101 | ||
| Special tests in the assessment of spinal pain | 101 | ||
| Chronic lumbar ligamentous strain | 101 | ||
| Degenerative disc disease, spondylosis and osteoarthritis | 101 | ||
| Spondylolisthesis | 102 | ||
| Osteoporosis | 102 | ||
| Secondary carcinoma of the vertebral body | 102 | ||
| Spinal infection | 103 | ||
| Referred pain | 103 | ||
| Less common causes | 103 | ||
| Diagnostic plan | 103 | ||
| Treatment plan | 104 | ||
| 5.3 Limb weakness and numbness – peripheral neuropathies | 104 | ||
| Clinical assessment of specific nerve palsies | 105 | ||
| Upper limb nerve palsies | 105 | ||
| Lower limb nerve palsies | 105 | ||
| Median nerve | 105 | ||
| Common causes | 105 | ||
| Ulnar nerve | 106 | ||
| Common causes | 106 | ||
| Radial nerve and posterior interosseous nerve | 108 | ||
| Common causes | 108 | ||
| Axillary (circumflex) nerve | 109 | ||
| Common cause | 109 | ||
| Brachial plexus | 109 | ||
| Common causes | 109 | ||
| Spinal nerve root lesions (cervical) | 110 | ||
| Lower limb: common peroneal nerve | 110 | ||
| 6 Limb problems | 116 | ||
| 6.1 Introduction | 116 | ||
| Arterial circulation | 116 | ||
| History | 116 | ||
| Examination | 116 | ||
| Inspection | 116 | ||
| Palpation | 117 | ||
| Auscultation | 118 | ||
| Venous circulation | 118 | ||
| History | 118 | ||
| Examination | 118 | ||
| Inspection | 118 | ||
| Palpation | 118 | ||
| Neurological system | 119 | ||
| 7 Abdominal and gastrointestinal problems | 184 | ||
| 7.1 Introduction | 184 | ||
| History – analysis of abdominal pain | 184 | ||
| Location and migration | 184 | ||
| Onset and duration | 185 | ||
| Type and intensity | 185 | ||
| Radiation | 185 | ||
| Associated symptoms | 186 | ||
| Offsetting factors | 186 | ||
| Past history | 186 | ||
| Physical examination | 186 | ||
| Examination of the periphery | 186 | ||
| Abdominal examination | 187 | ||
| Anorectal examination | 188 | ||
| 7.2 ‘Acute abdomen’ (acute abdominal surgical emergency) | 191 | ||
| Common causes of the ‘acute abdomen’ | 191 | ||
| History and physical examination | 191 | ||
| 1. Acute appendicitis with perforation (see also acute right iliac fossa pain) | 192 | ||
| 2. Severe acute pancreatitis | 192 | ||
| 3. Perforated peptic ulcer | 193 | ||
| 4. Diverticulitis with perforation | 193 | ||
| 5. Strangulating intestinal obstruction | 193 | ||
| 6. Vascular catastrophes | 194 | ||
| 7. Ruptured ectopic pregnancy | 194 | ||
| 8. Gastroenteritis | 194 | ||
| 9. Less common causes | 194 | ||
| Diagnostic plan | 195 | ||
| Urine examination | 195 | ||
| Haematological examination | 195 | ||
| Biochemistry | 195 | ||
| Imaging techniques | 196 | ||
| Treatment plan | 197 | ||
| 1. Acute appendicitis with perforation | 198 | ||
| 2. Severe acute (haemorrhagic) pancreatitis | 198 | ||
| 3. Perforated peptic ulcer | 198 | ||
| 4. Perforated diverticulitis | 199 | ||
| 5. Strangulating intestinal obstruction | 200 | ||
| 6. Vascular catastrophes | 200 | ||
| 7. Ruptured ectopic pregnancy | 200 | ||
| 8. Gastroenteritis | 201 | ||
| 7.3 Acute upper abdominal pain | 201 | ||
| Causes | 201 | ||
| History | 201 | ||
| 1. Acute gastritis and non-ulcer dyspepsia | 201 | ||
| 2. Acute exacerbation of duodenal ulcer | 201 | ||
| 3. Biliary ‘colic’ and acute cholecystitis | 201 | ||
| 4. Acute (oedematous) pancreatitis | 202 | ||
| Examination | 202 | ||
| Gastritis and duodenal ulcer | 202 | ||
| Cholecystitis | 202 | ||
| Acute pancreatitis | 202 | ||
| Diagnostic plan | 202 | ||
| Haematological and biochemical examination | 204 | ||
| Radiology: plain erect film of chest and abdomen | 204 | ||
| Ultrasound and CT scanning | 204 | ||
| Radionuclide excretion scan | 204 | ||
| Gastrograffin swallow and meal | 204 | ||
| Late endoscopy and ERCP | 205 | ||
| Treatment plan | 205 | ||
| 1. Acute gastritis and non-ulcer dyspepsia | 205 | ||
| 2. Acute exacerbation of duodenal ulcer | 205 | ||
| 3. Biliary ‘colic’ and acute cholecystitis | 205 | ||
| 4. Acute (oedematous) pancreatitis | 205 | ||
| 5. Less common causes | 205 | ||
| 7.4 Acute right iliac fossa pain | 206 | ||
| Causes | 206 | ||
| History and physical examination | 206 | ||
| 1. Acute appendicitis | 206 | ||
| 2. Acute mesenteric adenitis and acute Meckel’s diverticulitis | 208 | ||
| 3. Non-specific acute right iliac fossa pain | 208 | ||
| 4. Gynaecological disorders | 208 | ||
| 5. Urinary tract stone, infection or hydronephrosis | 208 | ||
| Diagnostic plan | 209 | ||
| Full blood count | 209 | ||
| Urine examination | 209 | ||
| Cervical swab and culture | 209 | ||
| Plain x-ray | 209 | ||
| Ultrasound | 209 | ||
| CT scan | 209 | ||
| Laparoscopy | 209 | ||
| HCG pregnancy test | 209 | ||
| Treatment plan | 209 | ||
| 1. Acute appendicitis | 209 | ||
| 2. Acute mesenteric adenitis and Meckel’s diverticulitis | 210 | ||
| 3. Non-specific acute right iliac fossa pain | 210 | ||
| 4. Gynaecological disorders | 210 | ||
| 5. Acute urinary tract stone, infection or hydronephrosis | 210 | ||
| 6. Less common causes | 210 | ||
| 7.5 Acute lower abdominal (pelvic) pain | 210 | ||
| Causes | 211 | ||
| History and physical examination | 211 | ||
| 1. Diverticulitis | 211 | ||
| 2. Carcinoma of the colon | 211 | ||
| 3. Pelvic appendicitis | 212 | ||
| 4. Gynaecological disorders | 212 | ||
| Diagnostic plan | 213 | ||
| Full blood count, blood grouping and pregnancy test | 213 | ||
| Urine microscopy and analysis | 213 | ||
| Plain x-ray of the abdomen | 213 | ||
| Pelvic ultrasound | 213 | ||
| Laparoscopy | 213 | ||
| CT contrast study | 213 | ||
| Colonoscopy | 214 | ||
| Treatment plan | 214 | ||
| 1. Diverticulitis | 214 | ||
| 2. Carcinoma of the colon | 214 | ||
| 3. Pelvic appendicitis | 214 | ||
| 4. Gynaecological disorders | 214 | ||
| 5. Less common causes | 214 | ||
| 7.6 Chronic epigastric pain | 214 | ||
| Causes | 215 | ||
| History | 215 | ||
| 1. Non-ulcer dyspepsia | 215 | ||
| 2. Gallstones and chronic cholecystitis | 215 | ||
| 3. Duodenal ulcer | 215 | ||
| 4. Gastric ulcer | 216 | ||
| 5. Carcinoma of the stomach | 216 | ||
| Examination | 216 | ||
| Diagnostic plan | 217 | ||
| Full blood examination | 217 | ||
| Ultrasound | 217 | ||
| Endoscopy | 217 | ||
| Contrast radiology | 217 | ||
| MRCP, CT cholangiography and ERCP | 217 | ||
| Treatment plan | 217 | ||
| 1. Non-ulcer dyspepsia | 217 | ||
| 2. Gallstones and chronic cholecystitis | 217 | ||
| 3. Duodenal ulcer | 218 | ||
| 4. Gastric ulcer | 218 | ||
| 5. Carcinoma of the stomach | 218 | ||
| 6. Less common causes | 219 | ||
| Non-gastrointestinal causes | 219 | ||
| Gastrointestinal causes | 219 | ||
| 7.7 Chronic lower abdominal (pelvic) pain | 221 | ||
| Causes | 221 | ||
| History and physical examination | 222 | ||
| 1. Chronic pelvic inflammatory disease | 222 | ||
| 2. Pelvic congestion syndrome | 222 | ||
| 3. Endometriosis | 222 | ||
| 4. Functional bowel disorders and diverticular disease | 222 | ||
| Diagnostic plan | 222 | ||
| Full blood examination | 222 | ||
| Radiological examination | 222 | ||
| Microbiological examination | 223 | ||
| Laparoscopy | 223 | ||
| Treatment plan | 223 | ||
| 1. Pelvic inflammatory disease | 223 | ||
| 2. Pelvic congestion syndrome | 223 | ||
| 3. Endometriosis | 223 | ||
| 4. Functional bowel disorders and diverticular disease | 223 | ||
| 5. Less common causes | 223 | ||
| 7.8 Bowel obstruction | 224 | ||
| Initial assessment: small or large bowel obstruction? | 224 | ||
| Small bowel obstruction | 225 | ||
| Common causes | 225 | ||
| History | 225 | ||
| 1. Adhesive obstruction | 225 | ||
| 2. Hernias | 225 | ||
| 3. Malignancies | 226 | ||
| 4. Sigmoid diverticulitis and intraperitoneal abscess | 226 | ||
| 5. Gallstone ileus and enteroliths | 226 | ||
| Examination | 226 | ||
| Diagnostic plan | 227 | ||
| Haematological and biochemical examination | 227 | ||
| Radiology | 227 | ||
| Treatment plan | 228 | ||
| Nasogastric drainage and decompression | 229 | ||
| Resuscitation | 229 | ||
| Surgical intervention | 229 | ||
| Management of other causes | 230 | ||
| Large bowel obstruction | 230 | ||
| Common causes | 230 | ||
| History and physical examination | 230 | ||
| 1. Colonic carcinoma | 230 | ||
| 2. Sigmoid or caecal volvulus | 231 | ||
| 3. Diverticular disease | 231 | ||
| 4. Colonic pseudo-obstruction | 231 | ||
| 5. Faecal impaction | 231 | ||
| Diagnostic plan | 232 | ||
| Treatment plan | 232 | ||
| 1. Colonic carcinoma | 232 | ||
| 2. Sigmoid or caecal volvulus | 232 | ||
| 3. Diverticular obstruction | 233 | ||
| 4. Colonic pseudo-obstruction | 233 | ||
| 5. Faecal impaction | 233 | ||
| 7.9 Abdominal mass | 233 | ||
| General assessment | 233 | ||
| 1. Confirm a mass is present | 233 | ||
| 2. Categorise the mass | 233 | ||
| Right upper quadrant mass | 235 | ||
| Common causes | 235 | ||
| History and examination | 235 | ||
| 1. Single mass in the liver | 235 | ||
| 2. Mucocele of the gall bladder | 235 | ||
| 3. Right renal swelling | 235 | ||
| 4. Carcinoma of the right colon | 235 | ||
| Diagnostic plan | 235 | ||
| Treatment plan | 236 | ||
| Hepatomegaly | 237 | ||
| Common causes | 237 | ||
| Smooth regular liver enlargement | 237 | ||
| Irregular or nodular liver enlargement | 237 | ||
| Symptoms and signs | 237 | ||
| Diagnostic and treatment plans | 237 | ||
| Haematological tests | 237 | ||
| Liver function tests | 237 | ||
| Scanning | 238 | ||
| Biopsy | 238 | ||
| Left upper quadrant mass | 238 | ||
| 8 Groin, scrotum and abdominal wall problems | 306 | ||
| 8.1 Introduction | 306 | ||
| History | 306 | ||
| Physical examination | 306 | ||
| Examination: patient standing | 306 | ||
| 1. Is a hernia present? (Box 8.2) | 308 | ||
| 2. Is the hernia inguinal or femoral? | 308 | ||
| Examination: patient supine | 309 | ||
| 3. Is the hernia reducible? | 309 | ||
| 4. Is the hernia strangulated? | 309 | ||
| 5. Is a scrotal lump present? | 310 | ||
| 6. Can one get above the scrotal lump? | 310 | ||
| 7. Is the lump arising from the testis or epididymis? | 310 | ||
| 8. Does the lump arise from the coverings or from appendages? | 310 | ||
| General examination | 311 | ||
| 8.2 Inguinoscrotal lumps | 311 | ||
| Scrotal lumps | 311 | ||
| Causes | 311 | ||
| 9 Urogenital Problems | 323 | ||
| 9.1 Introduction | 323 | ||
| History | 323 | ||
| Physical examination | 323 | ||
| Diagnostic tests | 324 | ||
| 9.2 Loin Pain | 324 | ||
| Causes | 325 | ||
| Clinical assessment | 326 | ||
| 1. Renal pain (ureteric colic) | 326 | ||
| 2. Pain referred from the ovary or other abdominal viscera | 326 | ||
| 3. Musculoskeletal pain | 326 | ||
| 4. Less common causes | 326 | ||
| Diagnostic plan | 326 | ||
| Treatment plan | 327 | ||
| Ureteric colic | 327 | ||
| Management of urinary calculi | 328 | ||
| Management of recurrent urinary calculi | 329 | ||
| 9.3 Painless Haematuria | 329 | ||
| Causes | 330 | ||
| Clinical assessment and urine microscopy | 330 | ||
| Diagnostic and treatment plan | 330 | ||
| 9.4 Lower urinary tract symptoms | 333 | ||
| Common causes | 333 | ||
| Clinical features and diagnostic plan | 333 | ||
| Urinary tract infections | 334 | ||
| Lower urinary tract infections | 334 | ||
| Upper urinary tract infections | 335 | ||
| Storage LUTS | 335 | ||
| Urinary tract pain | 335 | ||
| Voiding LUTS | 335 | ||
| 9.5 Poor Urinary Stream | 335 | ||
| Common causes | 335 | ||
| Symptoms and signs | 336 | ||
| Benign prostatic obstruction | 336 | ||
| Carcinoma of the prostate | 336 | ||
| Diagnostic plan | 336 | ||
| Treatment plan | 338 | ||
| 1. Prostatic obstruction | 338 | ||
| 2. Urethral stricture | 340 | ||
| 3. Phimosis and meatal stenosis | 340 | ||
| 9.6 Urinary Retention | 340 | ||
| Causes | 340 | ||
| Clinical assessment | 340 | ||
| Diagnostic plan | 340 | ||
| Treatment plan | 340 | ||
| 9.7 Urinary Incontinence | 342 | ||
| Types of urinary incontinence | 342 | ||
| Clinical features | 342 | ||
| 1. Stress incontinence | 342 | ||
| 2. Urge incontinence | 342 | ||
| 3. Continuous or total incontinence | 342 | ||
| Treatment plan | 343 | ||
| 1. Stress incontinence | 343 | ||
| 2. Urge incontinence | 343 | ||
| Management of complex cases of incontinence | 343 | ||
| 9.8 Penile Lesions | 344 | ||
| Common causes | 344 | ||
| Clinical assessment and diagnostic tests | 344 | ||
| 1. Disorders affecting the foreskin | 344 | ||
| 2. Disorders affecting the urethral meatus | 344 | ||
| 3. Disorders affecting the glans | 344 | ||
| 4. Disorders affecting the shaft | 345 | ||
| 5. Sexual and functional disorders | 345 | ||
| 6. Sexually transmitted infections | 345 | ||
| Treatment plan | 346 | ||
| References | 347 | ||
| 10 Preoperative medical problems in surgical patients | 348 | ||
| 10.1 Introduction | 348 | ||
| 10.2 Assessing patients for surgery | 348 | ||
| Grading of surgical and anaesthetic risk | 350 | ||
| Evaluation of the healthy patient | 350 | ||
| Evaluating elderly asymptomatic patients | 350 | ||
| Investigations and diagnostic (screening) tests before surgery | 350 | ||
| Urinalysis | 350 | ||
| Body weight | 351 | ||
| Temperature | 351 | ||
| Full blood examination | 351 | ||
| Blood typing | 351 | ||
| Chest x-ray | 351 | ||
| Electrocardiogram | 351 | ||
| Preoperative blood transfusion planning | 351 | ||
| Other tests | 351 | ||
| 10.3 Cardiac disease | 351 | ||
| History | 353 | ||
| Physical examination | 353 | ||
| Diagnostic and treatment plan | 353 | ||
| Non-invasive monitoring | 353 | ||
| Invasive monitoring | 353 | ||
| Common cardiac problems | 353 | ||
| Congestive cardiac failure | 353 | ||
| Ischaemic heart disease (coronary artery disease) | 354 | ||
| Valvular heart disease | 354 | ||
| Arrhythmias (and conduction defects) | 354 | ||
| Hypertension | 354 | ||
| 10.4 Respiratory disease | 354 | ||
| History and physical examination | 355 | ||
| Diagnostic plan | 355 | ||
| Prevention and treatment plan | 356 | ||
| 10.5 Cerebrovascular disease | 356 | ||
| 10.6 Chronic liver disease | 356 | ||
| Complications arising from chronic liver disease | 356 | ||
| History and physical examination | 357 | ||
| Diagnostic plan | 357 | ||
| Treatment plan | 357 | ||
| Alcoholic liver disease | 358 | ||
| 10.7 Chronic renal disease | 358 | ||
| Diagnostic plan | 358 | ||
| Treatment plan | 359 | ||
| 10.8 Haemostatic and haemopoietic disorders | 360 | ||
| Common causes | 361 | ||
| Clinical assessment | 361 | ||
| Diagnostic plan | 361 | ||
| Whole blood clotting time | 361 | ||
| One-stage prothrombin time | 361 | ||
| Partial thromboplastin time | 361 | ||
| Thrombin time | 361 | ||
| Tests of platelet function | 361 | ||
| Tests of fibrinolysis | 362 | ||
| Treatment plan | 362 | ||
| 1. Patients on oral anticoagulants or antiplatelet agents | 362 | ||
| 2. Liver disease | 362 | ||
| 3. Platelet disorders | 362 | ||
| 4. Consumption coagulopathy | 363 | ||
| 5. Haemophilia, Christmas disease and Von Willebrand's disease | 363 | ||
| 10.9 Anaemia | 363 | ||
| Causes of anaemia | 363 | ||
| Clinical features and diagnostic plan | 364 | ||
| Treatment plan | 364 | ||
| 10.10 Diabetes mellitus | 364 | ||
| Diagnostic and treatment plans | 365 | ||
| 10.11 Mental health problems | 366 | ||
| Clinical states | 366 | ||
| Anxiety disorders | 366 | ||
| Depressive disorders | 366 | ||
| Somatoform disorders | 367 | ||
| Organic mental syndromes | 367 | ||
| Confusion | 367 | ||
| Delirium | 367 | ||
| Dementia | 367 | ||
| Causes of dementia | 368 | ||
| Drug dependence and abuse | 368 | ||
| Diagnostic and treatment plans | 368 | ||
| Anxiolytics, sedatives and hynotics | 368 | ||
| Antipsychotics | 368 | ||
| Antidepressant drugs | 369 | ||
| 10.12 Additional preoperative preparation | 369 | ||
| Reference | 370 | ||
| 11 Postoperative problems | 371 | ||
| 11.1 Introduction | 371 | ||
| 11.2 Pain | 371 | ||
| 11.3 Fever | 373 | ||
| 11.4 Tachycardia | 375 | ||
| 11.5 Shortness of breath and tachypnoea | 375 | ||
| Common causes | 375 | ||
| 1. Basal lung atelectasis, bronchitis and bronchopneumonia: ‘the postoperative chest’ | 375 | ||
| 2. Adult respiratory distress syndrome – acute respiratory failure | 376 | ||
| 3. Tension pneumothorax | 377 | ||
| 4. Pulmonary embolism | 377 | ||
| 5. Acute pulmonary oedema | 377 | ||
| 11.6 Low urine output | 377 | ||
| Common causes | 377 | ||
| Clinical features and management plan | 377 | ||
| 1. Prerenal – acute vascular insufficiency | 377 | ||
| 2. Renal – acute intrinsic renal failure (from acute tubular necrosis) | 378 | ||
| 3. Postrenal – obstructive renal failure | 378 | ||
| 11.7 Sudden collapse or rapid deterioration | 378 | ||
| 11.8 Nausea and vomiting | 380 | ||
| 11.9 Confusion and altered mental state | 381 | ||
| 11.10 Wound care problems | 382 | ||
| 11.11 Abnormal investigations | 383 | ||
| Hypokalaemia | 383 | ||
| Hyperkalaemia | 383 | ||
| Hydrogen ion (acid–base) disorders | 384 | ||
| Metabolic acidosis | 385 | ||
| Metabolic alkalosis | 385 | ||
| Respiratory acidosis and alkalosis | 385 | ||
| 12 Problems in surgical intensive care | 386 | ||
| 12.1 Introduction: What is intensive care? | 386 | ||
| 12.2 Patient selection | 386 | ||
| Post elective surgery | 386 | ||
| Post emergency surgery | 387 | ||
| Unplanned admission from the surgical ward | 387 | ||
| Scoring systems | 387 | ||
| 12.3 Throughput and efficiency | 387 | ||
| 12.4 ICU versus high dependency unit care | 387 | ||
| 12.5 Postoperative ICU care | 387 | ||
| Monitoring – an overview | 387 | ||
| Invasive monitoring | 387 | ||
| Intra-arterial blood pressure monitoring | 387 | ||
| Central venous access and monitoring | 387 | ||
| Pulmonary artery (Swan-Ganz) catheters | 388 | ||
| Non-invasive monitoring | 389 | ||
| Nursing care | 389 | ||
| Organ preservation | 389 | ||
| Wound healing in the ICU | 389 | ||
| Pain management | 390 | ||
| Nutrition | 390 | ||
| Enteral feeding | 390 | ||
| Parenteral feeding or total parenteral nutrition | 390 | ||
| 12.6 Recovery and discharge from the ICU to the surgical ward | 391 | ||
| 12.7 General management of ICU patients | 392 | ||
| 12.8 Cardiopulmonary arrest | 392 | ||
| 12.9 Common problems in the ICU | 392 | ||
| Fever | 392 | ||
| Systemic inflammatory response syndrome | 392 | ||
| Sepsis | 392 | ||
| Hypoxia and hypercarbia | 393 | ||
| Hypotension and shock | 394 | ||
| Inotropes and vasopressors | 394 | ||
| Hypertension | 395 | ||
| Metabolic and electrolyte disturbances | 395 | ||
| Acid–base disorders | 395 | ||
| Metabolic acidosis | 395 | ||
| Metabolic alkalosis | 395 | ||
| Respiratory acidosis | 395 | ||
| Respiratory alkalosis | 396 | ||
| Other metabolic disorders | 396 | ||
| Electrolyte disorders | 396 | ||
| Sodium and water (disorders of tonicity) | 396 | ||
| Hyponatremia | 396 | ||
| Hypernatremia | 396 | ||
| Disorders of potassium | 396 | ||
| Magnesium | 397 | ||
| Oliguria/renal dysfunction and renal replacement | 397 | ||
| Hepatic and gastrointestinal dysfunction | 398 | ||
| Neurological dysfunction | 398 | ||
| Peripheral causes | 398 | ||
| Haematological dysfunction and haemorrhage | 398 | ||
| Massive haemorrhage | 399 | ||
| Multiple organ dysfunction syndrome (MODS) | 399 | ||
| 12.10 The dying patient | 399 | ||
| 12.11 Limitation of treatment/not for escalation of care orders | 399 | ||
| 12.12 Withdrawal of treatment | 400 | ||
| 12.13 Brain death and organ and tissue donation | 400 | ||
| Brain death | 400 | ||
| Organ and tissue donation | 400 | ||
| References | 400 | ||
| 13 Problems in injured patients | 402 | ||
| 13.1 Introduction | 402 | ||
| 13.2 Managing injured patients | 403 | ||
| Initial assessment | 403 | ||
| Primary survey and resuscitation | 403 | ||
| A. Airway and cervical spine | 403 | ||
| B. Breathing and ventilation | 404 | ||
| Oxygenation | 405 | ||
| C. Circulation and control of haemorrhage | 406 | ||
| Fluid resuscitation | 408 | ||
| D. Disability and neurological assessment | 409 | ||
| E. Exposure and environmental control | 409 | ||
| Diagnostic peritoneal lavage | 409 | ||
| Secondary survey | 409 | ||
| History | 409 | ||
| Examination | 410 | ||
| Neurological: Glasgow coma scale | 410 | ||
| Investigations and procedures following the secondary survey | 410 | ||
| Re-evaluation | 411 | ||
| Pain relief and splinting | 411 | ||
| Definitive care and transfer | 411 | ||
| Interhospital transfer | 411 | ||
| Medical records and documentation | 411 | ||
| Shock | 411 | ||
| Clinical features of haemorrhagic shock | 413 | ||
| Diagnostic and treatment plan | 413 | ||
| 13.3 Soft tissue injury and wound care | 413 | ||
| Classification of wounds | 413 | ||
| 1. Clean wounds | 413 | ||
| 2. Clean–contaminated wounds | 413 | ||
| 3. Contaminated wounds | 415 | ||
| 4. Dirty–infected wounds | 415 | ||
| Principles of wound healing | 415 | ||
| Phases in wound healing | 415 | ||
| Factors adversely affecting wound healing | 415 | ||
| Local factors | 415 | ||
| General factors | 415 | ||
| Definitive care | 416 | ||
| Wound care – debridement | 416 | ||
| Wound closure | 416 | ||
| Timing of wound closure | 416 | ||
| Wound closure techniques and materials | 417 | ||
| Closed soft tissue (sporting) injuries | 418 | ||
| 13.4 Burns | 419 | ||
| History | 419 | ||
| Types | 419 | ||
| Pathophysiology of burns | 419 | ||
| Local response to burns: Jackson’s burn zones | 420 | ||
| Systemic response to burns: SIRS and MODS | 420 | ||
| First aid | 420 | ||
| Initial assessment | 421 | ||
| Extent of burns | 421 | ||
| Classification of burn depth | 422 | ||
| Assessment of burn depth | 422 | ||
| Burns to the respiratory tract | 423 | ||
| Subsequent assessment and definitive care | 423 | ||
| General management | 423 | ||
| Monitoring | 424 | ||
| Burn wound management | 424 | ||
| 13.5 Head injury | 426 | ||
| Classification and definitions | 426 | ||
| Primary injury: focal lesions | 426 | ||
| Primary injury: diffuse lesions | 428 | ||
| Secondary injury | 428 | ||
| Initial assessment | 428 | ||
| Primary survey and resuscitation | 428 | ||
| Secondary survey | 429 | ||
| Examination of the scalp and face | 429 | ||
| Abnormal neurological signs | 429 | ||
| History | 429 | ||
| Re-evaluation | 429 | ||
| Investigations | 429 | ||
| Plain x-ray | 429 | ||
| CT scan | 434 | ||
| Lumbar puncture | 434 | ||
| Magnetic resonance imaging | 434 | ||
| Cerebral angiography | 434 | ||
| Definitive care | 434 | ||
| General principles of management | 434 | ||
| Management of mild head injury (GCS 14–15) | 435 | ||
| Management of moderate head injury (GCS 9–13) | 435 | ||
| Management of severe head injury (GCS 3–8) | 435 | ||
| Management of specific complications | 435 | ||
| 13.6 Facial injury | 437 | ||
| Initial assessment | 437 | ||
| Le Fort classification | 438 | ||
| Mandibular fractures | 438 | ||
| Adjuncts to initial assessment | 438 | ||
| Definitive care | 438 | ||
| 13.7 Eye and orbital injury | 439 | ||
| Introduction | 439 | ||
| History taking | 439 | ||
| Examination | 439 | ||
| Chemical injury | 440 | ||
| First aid | 440 | ||
| 14 Ophthalmological problems | 473 | ||
| 14.1 Introduction | 473 | ||
| 14.2 Who’s who in eye care | 473 | ||
| Ophthalmologist | 473 | ||
| Optometrist | 473 | ||
| Orthoptist | 473 | ||
| 14.3 Basic anatomy of the eye | 473 | ||
| 14.4 Ocular symptoms | 473 | ||
| 14.5 The basic eye examination | 474 | ||
| Visual acuity | 474 | ||
| Distance visual acuity testing and recording | 474 | ||
| Pupils | 476 | ||
| Visual fields | 476 | ||
| Eye movements | 477 | ||
| Gross examination of the eye and adnexae | 477 | ||
| Eyelids and surrounding tissue | 477 | ||
| Gross inspection of the eye | 479 | ||
| Additional tests | 479 | ||
| Direct ophthalmoscope | 479 | ||
| Operating a direct ophthalmoscope | 479 | ||
| Clinical examination using a direct ophthalmoscope | 479 | ||
| Slit lamp examination of the eye and adnexae | 480 | ||
| 14.6 Diagnosis of common problems | 481 | ||
| Loss of vision | 481 | ||
| Differential diagnosis | 481 | ||
| Acute loss of vision | 481 | ||
| Transient visual loss | 481 | ||
| Persistent visual loss lasting more than 24 hours | 481 | ||
| Gradual painless loss of vision | 481 | ||
| Binocular visual loss | 481 | ||
| History | 481 | ||
| Duration of symptoms | 481 | ||
| Associated symptoms | 481 | ||
| Previous ophthalmic history | 481 | ||
| Previous medical history including drug history | 481 | ||
| Family history | 482 | ||
| Social history | 482 | ||
| Examination | 482 | ||
| Visual acuity | 482 | ||
| Pupils | 482 | ||
| Visual fields | 482 | ||
| Eye movements | 482 | ||
| Anterior segment examination | 482 | ||
| Fundoscopy | 483 | ||
| Primary management | 483 | ||
| Ongoing management | 483 | ||
| 14.7 Double vision – ‘diplopia’ | 483 | ||
| Monocular diplopia | 483 | ||
| Differential diagnosis | 483 | ||
| Binocular diplopia | 483 | ||
| Differential diagnosis | 484 | ||
| History | 484 | ||
| Nature of the double vision | 484 | ||
| Associated symptoms | 484 | ||
| Examination | 484 | ||
| Visual acuity with pinhole | 484 | ||
| Pupil examination | 484 | ||
| Inspection | 484 | ||
| Cover test | 484 | ||
| Eye movements | 484 | ||
| Cranial nerve examination | 484 | ||
| Primary management | 484 | ||
| Neuroimaging | 484 | ||
| Bloods | 484 | ||
| Ongoing management | 485 | ||
| 14.8 Red or painful eye | 485 | ||
| History | 485 | ||
| Duration of symptoms | 485 | ||
| Description of pain | 485 | ||
| Associated symptoms | 485 | ||
| Previous ophthalmic history | 485 | ||
| Previous medical history | 485 | ||
| Primary management | 485 | ||
| 14.9 Common lumps and bumps around the eye | 487 | ||
| Eyelid swelling | 487 | ||
| Causes | 487 | ||
| 14.10 Selected ophthalmic conditions | 487 | ||
| Preseptal and orbital cellulitis | 487 | ||
| Preseptal cellulitis | 487 | ||
| Picture Credits | 502 | ||
| Chapter 1 | 502 | ||
| Chapter 2 | 502 | ||
| Chapter 3 | 502 | ||
| Chapter 4 | 502 | ||
| Chapter 6 | 502 | ||
| Chapter 7 | 502 | ||
| Chapter 9 | 502 | ||
| Chapter 10 | 503 | ||
| Chapter 13 | 503 | ||
| Chapter 14 | 503 | ||
| Index | 504 | ||
| A | 504 | ||
| B | 506 | ||
| C | 507 | ||
| D | 510 | ||
| E | 511 | ||
| F | 512 | ||
| G | 512 | ||
| H | 513 | ||
| I | 514 | ||
| J | 516 | ||
| K | 516 | ||
| L | 516 | ||
| M | 517 | ||
| N | 518 | ||
| O | 519 | ||
| P | 520 | ||
| Q | 522 | ||
| R | 522 | ||
| S | 523 | ||
| T | 524 | ||
| U | 525 | ||
| V | 526 | ||
| W | 527 | ||
| X | 527 | ||
| Z | 527 |