MED 698S — Senior Clerkship Surgery

• Take a focused surgical history and elicit and interpret physical signs to reach a differential diagnosis.
• Recognise surgical emergencies and begin resuscitation using a structured approach.
• Select and interpret appropriate investigations, including plain radiographs and ultrasound, with regard to cost and availability.
• Assess and prepare a patient for operation and provide safe postoperative care, including fluids, analgesia and thromboprophylaxis.
• Describe the principles of the common operations, their complications and their outcomes.
• Apply knowledge of the surgical disease burden in Ghana, including trauma, burns, late-presenting malignancy and tropical disease.
• Describe the anaesthetic assessment, fluid and transfusion therapy, pain relief and monitoring of the critically ill surgical patient.

Surgery

• Take a focused surgical history and elicit and interpret physical signs to reach a differential diagnosis.
• Recognise surgical emergencies and begin resuscitation using a structured approach.
• Select and interpret appropriate investigations, including plain radiographs and ultrasound, with regard to cost and availability.
• Assess and prepare a patient for operation and provide safe postoperative care, including fluids, analgesia and thromboprophylaxis.
• Describe the principles of the common operations, their complications and their outcomes.
• Apply knowledge of the surgical disease burden in Ghana, including trauma, burns, late-presenting malignancy and tropical disease.

Preoperative assessment

• Outline the components of preoperative assessment: history, examination, assessment of comorbidity, medication review and airway assessment
• Select preoperative investigations according to the patient, the proposed procedure and available resources
• Apply risk stratification, including ASA grading, and identify patients who need optimisation or specialist referral
• Outline preoperative preparation: fasting, consent, thromboprophylaxis, antibiotic prophylaxis and the management of anticoagulants, antihypertensives and insulin

Postoperative care and complications

• Outline routine postoperative care: monitoring, fluids, analgesia, nutrition and early mobilisation
• Classify postoperative complications as immediate, early or late, and by system
• Recognise and manage postoperative pyrexia, wound infection, wound dehiscence, atelectasis, ileus and venous thromboembolism
• Recognise the deteriorating postoperative patient and outline an escalation plan

Medical problems in surgical patients

• Describe how diabetes, hypertension, sickle cell disease, HIV, chronic kidney disease and anaemia affect surgical risk
• Outline the perioperative management of diabetes, anticoagulation and long-term corticosteroid therapy
• Recognise the perioperative complications of sickle cell disease and outline their prevention

Enteral and parenteral nutrition

• Describe the metabolic response to injury and the consequences of malnutrition in surgical patients
• Assess nutritional status and estimate energy and protein requirements
• Compare enteral and parenteral nutrition by indication, route and complications, including refeeding syndrome

Hospital infection and sterilisation techniques

• Describe the sources and routes of hospital-acquired infection and the risk factors for surgical site infection
• Compare sterilisation and disinfection methods and state where each is appropriate
• Outline prevention: hand hygiene, aseptic technique, theatre discipline, antibiotic prophylaxis and safe waste handling

Instruments and sutures

• Identify the common surgical instruments and state the use of each
• Classify suture materials (absorbable or non-absorbable, natural or synthetic, monofilament or braided) and relate the choice to the tissue
• Describe needle types, common suturing techniques, the use of drains and the principles of wound closure

Management of the patient with jaundice

• Classify jaundice as prehepatic, hepatic or posthepatic and explain bilirubin metabolism
• Elicit the history and signs that distinguish surgical (obstructive) jaundice from medical causes
• Interpret liver function tests, ultrasound and further imaging (CT, MRCP, ERCP) in obstructive jaundice
• Outline the management of obstructive jaundice, including correction of coagulopathy, renal protection, biliary drainage and the treatment of gallstone and periampullary disease

Management of the patient with dysphagia

• List the causes of dysphagia, distinguishing oropharyngeal from oesophageal and mechanical from motility disorders
• Outline investigation: upper gastrointestinal endoscopy, contrast swallow and manometry
• Outline the management of oesophageal carcinoma, achalasia and corrosive stricture, including palliation of dysphagia

Dyspepsia

• Describe the causes of dyspepsia and the alarm features that require urgent endoscopy
• Outline investigation, including testing for Helicobacter pylori and upper gastrointestinal endoscopy
• Outline initial management and the indications for surgical referral

Presentation and management of peptic ulcer disease

• Describe the pathophysiology of peptic ulceration and the roles of Helicobacter pylori and NSAIDs
• Describe the clinical presentation and investigation of peptic ulcer disease
• Recognise and manage the complications: perforation, bleeding and gastric outlet obstruction
• Outline the operations used for complicated peptic ulcer disease and their sequelae

Management of the patient with haematemesis

• List the causes of upper gastrointestinal bleeding and their relative frequency
• Assess severity and resuscitate the bleeding patient, including transfusion decisions
• Outline the role and timing of endoscopy and endoscopic haemostasis
• Outline the management of variceal bleeding and the indications for surgery or radiological intervention

Management of the patient with acute abdomen

• Describe the pathophysiology of visceral and parietal pain and the patterns of referred pain
• Generate a differential diagnosis for acute abdominal pain by site, age and sex, including gynaecological and medical causes
• Select and interpret investigations: blood tests, erect chest and abdominal radiographs, ultrasound, CT and diagnostic laparoscopy
• Outline resuscitation and the criteria for laparotomy, with reference to appendicitis, perforated viscus and generalised peritonitis

Management of the patient with intestinal obstruction

• Distinguish mechanical obstruction from paralytic ileus, and small bowel from large bowel obstruction
• List the causes of intestinal obstruction in Ghana, including adhesions, hernia, volvulus, tuberculosis and malignancy
• Recognise strangulation and closed-loop obstruction
• Outline resuscitation, nasogastric decompression and the indications for and principles of operative management

Presentation and management of large bowel tumours

• Describe the risk factors, the adenoma-carcinoma sequence and the pathology of colorectal cancer
• Recognise the presentations of colorectal cancer by site, including obstruction, bleeding and anaemia
• Outline investigation and staging: colonoscopy with biopsy, CT, MRI for rectal cancer and tumour markers
• Outline the surgical resections appropriate to each site, the role of adjuvant therapy, stomas and palliation

Management of the patient with bleeding per rectum

• List the causes of rectal bleeding according to age and the character of the bleeding
• Interpret the findings of anorectal examination and proctoscopy
• Outline investigation, including colonoscopy, and the management of massive lower gastrointestinal bleeding
• Outline the management of haemorrhoids and other benign anorectal causes of bleeding

Management of the patient with painful anal condition

• Describe the anatomy of the anal canal and its relevance to anal disease
• Distinguish anal fissure, perianal abscess, fistula-in-ano, thrombosed haemorrhoids and pilonidal disease
• Outline the management of each condition, including drainage of abscess and the principles of fistula surgery

Management of the patient with goitre

• Classify goitre and describe the surgical anatomy of the thyroid gland
• Assess a patient with goitre, including thyroid status and features suggesting malignancy or compression
• Interpret thyroid function tests, ultrasound and fine needle aspiration cytology
• Outline management, including the indications for thyroidectomy, preparation of the thyrotoxic patient and the complications of thyroidectomy

Management of the patient with breast lump and nipple discharge

• Describe the benign and malignant causes of a breast lump and of nipple discharge
• Apply triple assessment: clinical examination, imaging and pathology
• Recognise the features and staging of breast cancer and discuss the late presentation commonly seen in Ghana
• Outline the treatment of breast cancer (surgery, radiotherapy, systemic and hormonal therapy) and the management of benign breast disease

Management of the patient with cervical lymph node enlargement

• Describe the lymphatic drainage of the head and neck and its value in localising disease
• Generate a differential diagnosis for cervical lymphadenopathy, including tuberculosis, HIV, lymphoma and metastatic carcinoma
• Outline investigation, including fine needle aspiration cytology and excision biopsy, and explain when excision biopsy is preferred

Management of the patient with enlarged spleen

• List the surgical and medical causes of splenomegaly seen in Ghana
• Distinguish an enlarged spleen from other left upper quadrant masses
• Outline the indications for splenectomy and the prevention and management of overwhelming post-splenectomy infection

Management of the patient with bladder outflow obstruction

• Describe the causes of bladder outflow obstruction, principally benign prostatic hyperplasia and urethral stricture
• Assess the patient using symptom scoring and examination including digital rectal examination, and distinguish acute from chronic retention
• Interpret investigations: urinalysis, renal function, PSA, ultrasound with post-void residual volume and uroflowmetry
• Outline management: catheterisation, medical therapy and surgical options such as TURP, with their complications

Management of the patient with renal colic

• Describe the formation, types and risk factors of urinary tract stones
• Recognise ureteric colic and distinguish it from other causes of loin pain
• Outline investigation, including urinalysis, ultrasound and non-contrast CT
• Outline management: analgesia, medical expulsive therapy, urgent decompression of an obstructed infected system, ESWL, ureteroscopy and prevention of recurrence

Management of the patient with haematuria and renal mass

• Classify haematuria and list its urological and medical causes
• Outline the evaluation of haematuria, including imaging and cystoscopy
• Describe the presentation and investigation of renal cell carcinoma, Wilms tumour and bladder cancer, including the association of squamous bladder cancer with schistosomiasis
• Outline the principles of management of urological tumours

Management of the patient with urinary tract injury

• Describe the mechanisms and sites of injury to the kidney, ureter, bladder and urethra
• Recognise the features of urethral and bladder injury and explain why urethral catheterisation may be contraindicated
• Outline investigation (urethrography, cystography, CT urography) and the principles of management

Diagnosis of inguinoscrotal swelling

• Describe the anatomy of the inguinal canal and scrotum relevant to inguinoscrotal swellings
• Differentiate hernia, hydrocele, varicocele, epididymal cyst, testicular tumour and epididymo-orchitis on clinical examination
• Recognise testicular torsion and strangulated hernia as surgical emergencies
• Outline the management of inguinal hernia, hydrocele and testicular tumour

Management of the patient with multiple trauma

• Apply the primary survey (ABCDE) with cervical spine control and identify immediately life-threatening injuries
• Outline resuscitation, including haemorrhage control, use of fluids and blood products, and damage control principles
• Describe the secondary survey, its adjuncts (FAST, radiographs, CT) and the principles of triage and transfer
• Outline the assessment and initial management of abdominal and pelvic trauma, including the indications for laparotomy

Management of the patient with head injury

• Classify head injury and explain primary and secondary brain injury, raised intracranial pressure and cerebral perfusion
• Assess the patient using the Glasgow Coma Scale and pupillary findings, and recognise herniation
• State the indications for CT and for neurosurgical referral, and recognise extradural, subdural and intracerebral haematoma
• Outline management: airway protection, prevention of secondary injury and operative options

Management of the patient with chest injury

• List the immediately life-threatening chest injuries
• Recognise and manage tension pneumothorax, open pneumothorax, massive haemothorax, flail chest and cardiac tamponade
• Interpret chest radiographs in thoracic trauma
• Describe chest drain insertion and the indications for thoracotomy

Management of burns

• Classify burns by depth and mechanism and explain the pathophysiology of burn shock
• Estimate burn surface area and calculate fluid resuscitation
• Recognise inhalational injury and the other indications for referral to a burns unit
• Outline wound care, nutrition, infection control, escharotomy and the late complications of burns

Presentation and management of spinal cord compression

• List the causes of spinal cord compression, including trauma, spinal tuberculosis, tumour and disc prolapse
• Recognise the clinical features, including a sensory level, bladder involvement and cauda equina syndrome
• Outline urgent investigation with MRI and the assessment of spinal stability
• Outline emergency management and the indications for surgical decompression

Presentation and management of intracranial tumours and infections

• Describe the common intracranial tumours and their presentations, including raised intracranial pressure, seizures and focal deficits
• Describe brain abscess and subdural empyema and their sources of infection
• Outline investigation and the principles of surgical management

Presentation and management of infections of the CNS

• Describe the routes of spread and the surgical causes of CNS infection, including open skull fracture, sinus and ear disease and shunt infection
• Distinguish meningitis, encephalitis and focal suppurative lesions clinically
• Outline investigation, antimicrobial therapy and the indications for surgical drainage

Presentation and management of ischaemia of the leg

• Describe the pathophysiology and risk factors of acute and chronic limb ischaemia
• Distinguish acute from chronic ischaemia and grade chronic disease from claudication to tissue loss
• Outline assessment: peripheral pulses, ankle-brachial pressure index, duplex ultrasound and angiography
• Outline management: risk factor control, revascularisation, and the indications for and levels of amputation

Presentation and management of swollen leg

• Generate a differential diagnosis for unilateral and bilateral leg swelling, including deep vein thrombosis, cellulitis, lymphoedema and filariasis
• Outline investigation, including Doppler ultrasound and D-dimer
• Outline the management of deep vein thrombosis and of chronic lymphoedema

Management of the patient with leg ulceration

• Compare venous, arterial, neuropathic and other ulcers, including Buruli ulcer, sickle cell ulcers and malignant ulcers, by site and appearance
• Outline investigation of a leg ulcer, including assessment of the arterial supply before compression is applied
• Outline management, including compression therapy, wound care and treatment of the underlying cause

Common problems in plastic surgery

• Describe wound healing, the factors that impair it and the reconstructive ladder
• Describe skin grafts and flaps, their indications and their complications
• Outline the management of hypertrophic and keloid scars, contractures and common congenital problems such as cleft lip and palate

Presentation and management of skin tumour

• Describe the risk factors and pathology of squamous cell carcinoma, basal cell carcinoma and melanoma, including their occurrence in albinism and in chronic ulcers
• Recognise the clinical features that suggest malignancy in a skin lesion
• Outline biopsy technique, excision margins and the management of regional lymph nodes

Surgical problems in infancy

• Recognise the neonatal surgical emergencies: intestinal atresia, malrotation with volvulus, necrotising enterocolitis, anorectal malformation and diaphragmatic hernia
• Describe the presentation and management of infantile hypertrophic pyloric stenosis and of intussusception
• Describe the childhood solid tumours common in Africa, including Wilms tumour, Burkitt lymphoma and retinoblastoma
• Outline the principles of fluid, thermal and nutritional care in infants undergoing surgery

X-ray (demonstration)

• Describe a systematic approach to reading plain radiographs of the chest, abdomen and skeleton
• Recognise the key surgical signs: free gas under the diaphragm, dilated bowel loops with fluid levels, pneumothorax, pleural effusion and common fracture patterns
• State the indications for and limitations of plain radiography compared with ultrasound and CT, including radiation safety

Anaesthesia

• Describe the anaesthetic assessment, fluid and transfusion therapy, pain relief and monitoring of the critically ill surgical patient.

Management of the critically ill patient

• Recognise the critically ill surgical patient using a structured (ABCDE) assessment and early warning signs
• Outline the principles of organ support: airway, ventilation, circulatory and renal support
• Describe the criteria for intensive care admission and the principles of sepsis management

Fluid therapy and blood transfusion

• Describe the body fluid compartments and the composition of commonly used intravenous fluids
• Calculate maintenance, replacement and resuscitation fluid requirements in surgical patients
• State the indications for blood and component transfusion and describe pre-transfusion safety checks
• Recognise and manage transfusion reactions and the complications of massive transfusion

General and local anaesthesia and pain relief

• Describe the components of general anaesthesia (induction, maintenance, muscle relaxation and reversal) and the agents used
• Describe local anaesthetic agents, maximum safe doses and techniques, and the recognition and management of toxicity
• Compare regional techniques, including spinal and epidural anaesthesia, with their indications and complications
• Outline postoperative analgesia using the analgesic ladder, multimodal analgesia and safe opioid prescribing

Clinical assessment and perioperative medical problems

• Conduct a preanaesthetic assessment, including airway assessment and ASA grading
• Describe the perioperative management of hypertension, ischaemic heart disease, asthma, diabetes and anaemia
• Recognise and outline the management of common postoperative anaesthetic problems: hypoxia, hypotension, nausea and vomiting and delayed recovery

Emergency cardiac drugs

• State the indications, doses and routes of adrenaline, atropine, amiodarone and vasopressor agents in cardiac emergencies
• Explain their mechanisms of action and adverse effects
• Apply these drugs within the cardiac arrest and peri-arrest algorithms

Monitoring in the ICU

• Describe routine monitoring: ECG, pulse oximetry, capnography, non-invasive and invasive blood pressure and urine output
• Interpret monitoring data to recognise the deteriorating patient
• Describe the principles and complications of central venous pressure monitoring and of mechanical ventilation