PA 729 General Surgery Syllabus

COURSE CONTACTS: Beverly Speece, MTS, PA-C Director of Clinical Education 1260 HSLC, 750 Highland Ave. Madison, WI 53705 608-265-6723 [email protected]

Lauren Trillo, MMS, PA-C Clinical Faculty 1264 HSLC, 750 Highland Ave. Madison, WI 53705 608-263-5199 [email protected]

Rosa Retrum, MSE Clinical Coordinator 1262 HSLC, 750 Highland Ave., Madison, WI 53705 608-265-6457 [email protected]

PA PROGRAM OFFICE 1278 HSLC, 750 Highland Ave., Madison WI 53705 Toll Free: 1-800-442-6698 FAX: 608-265-4973

PA Program Website: http://www.fammed.wisc.edu/pa-program/ PA Program Preceptor Resources: http://www.fammed.wisc.edu/pa- program/preceptors/

COURSE OVERVIEW: The General Surgery rotation is a required, 8-credit module that occurs over a two- month period. The student will learn in a community-based outpatient, inpatient, and operating room setting. The general surgery rotation is designed to provide the second- year PA student with the knowledge and skills necessary to perform in the ambulatory setting.

GENERAL SURGERY PRECEPTORSHIP COURSE GOALS:

1. Provide the student with the opportunity and access to a diverse population of patients and a variety of diseases and injuries commonly encountered in an inpatient, outpatient and OR setting. 2. Support ongoing development and mastery of the student's ability and skill in obtaining a patient centered medical history, conducting a physical examination, recommending diagnostic studies and discussing and recommending treatment plans with the guidance of a preceptor. 3. Provide ongoing interactive opportunities for the student to deepen their knowledge regarding various diagnostic studies used in the evaluation of disease and injury and disease prevention. 4. Provide supervised patient care based opportunities, which foster the development of the student's ability to recommend, select and interpret (where applicable) appropriate diagnostic methods in the evaluation of a patient. 5. Provide clinical based opportunities to continue to develop the student's ability to generate differential diagnoses.

GENERAL SURGERY PRECEPTORSHIP LEARNING OUTCOMES:

At the end of this eight-week experience students will be able to:

1. Complete a problem-oriented history and physical examination specific to the patient’s chief complaint. 2. Complete a pre-op full history and physical exam (both male and female). 3. Appropriately document patient encounters using SOAP note format (Subjective, Objective, Assessment and Plan). 4. Accurately order and interpret laboratory evaluations/diagnostic studies essential to determining the patient diagnosis (es). 5. Formulate a reasoned differential diagnosis for a patient problem. 6. Formulate an appropriate treatment plan, based on the patient’s H&P, and laboratory results/diagnostic findings, with emphasis on problems commonly seen in general surgery. 7. Participate actively in patient care and management under preceptor supervision. (The level of engagement will be logged in WisPAAR.) 8. Educate and counsel patients with common acute and chronic diseases across the lifespan that are commonly seen in a general surgery setting. 9. Educate, counsel and promote patients in healthy lifestyles and illness prevention across the lifespan. 10. Synthesize and apply medical knowledge and treatment in an evidence-based manner in the care of patients. 11. Understand continuity of patient care in a community setting and to participate in care of families. 12. Attend to the emotional as well as physical health needs of the patient and family, with consideration of individual sociocultural and psychosocial factors. 13. Work as an effective member of an interprofessional health care team and participate in coordinated, quality, team-based care. 14. Develop relationships with and participate in clear, succinct, positive, respectful communications and interactions with all peers and related staff. 15. Participate in positive, respectful communications and interactions with all patients and their families, including effectively eliciting patient complaint, utilizing good listening skills, and practicing confidentiality. 16. Understand of the challenges and rewards of a career in General Surgery.

GENERAL SURGERY ROTATION -SPECIFIC OBJECTIVES:

These objectives are to guide the student in preparing for the Post Rotation examination by defining areas of content to be emphasized and studied as well as the clinical skills and professional behavior required and expected during this practicum.

Outline to this information is as follows: • Alignment to the PA Core Competencies • Organ system based conditions

Alignment to the PA Core Competencies • Interpret the clinical features, differential diagnosis, and management of common acute and chronic medical conditions Medical Knowledge seen in the ambulatory medical setting. • Recognize the impact of disease on individuals and societal levels • Compare preventive strategies for common acute and chronic medical conditions seen in the ambulatory setting, in the clinic, and at the population level . • Perform focused histories and physical exams relevant to Patient Care common acute and chronic medical conditions. • Perform comprehensive wellness exams relevant to patient’s age and comorbidities. • Formulate treatment plans for common acute and chronic ambulatory medical problems. • Use test characteristics, predictive values, and likelihood ratios to enhance clinical decision making. • Distinguish preventive screening tests for individual patients, acknowledging prevalence, risk factors, and outcomes. • Formulate answerable clinical questions from patient interactions • Practice life-long learning skills, including the use of evidence Practice-Based Learning and based medicine at point of care. Improvement • Differentiate and appraise preventive service guidelines and recommendations from various organizations. • Identify individual learning goals, and self-assess knowledge and behaviors • Present cases to preceptor in a patient-centered manner, Interpersonal and Communication integrating further testing recommendations, diagnostic Skills probabilities, and evidence-based treatment recommendations as indicated. • Document clinical encounter in written SOAP note form. • Establish effective relationships with patients and families. • Ascertain patient and family beliefs regarding common acute and chronic medical conditions. • Educate patients and families regarding common acute and chronic medical conditions. • Demonstrate the process of negotiating management plans with patients, incorporating patient needs and preferences into care. • Check for patient’s understanding of follow-up plan, including treatments, testing, referrals, and continuity of care. • Identify community assets and system resources to improve the System Based Practice health of individuals and populations. • Demonstrate a clinical perspective that recognizes the impact of multiple systems on patient health. • Recognize and address self-care and personal issues that affect Professionalism one’s ability to fulfill the professional responsibilities of being a physician. • Assume responsibility, behave honestly, and perform duties in a timely, organized, respectful, and dependable manner. • Seek, accept, and apply constructive feedback appropriately.

Learning Objectives for Organ based Conditions:

Know etiology, prevention, signs and symptoms, diagnostic workup, treatment plan and patient education for (Table 1)

Table 1. Acute and Chronic Presentations with Common Diagnosis, Serious Diagnosis and Preop/Post op Considerations

Topic Symptoms Common Diagnosis Serious Diagnosis Pre- op/post op care/ risk assessment GI/nutritional Abdominal pain, Hernias (inguinal, Carcinoma anorexia, femoral, incisional, (colorectal, small heartburn/dyspepsia, umbilical), bowel, gastric, nausea/vomiting, internal/external pancreatic, jaundice, hematemesis, hemorrhoids, anal esophageal, and diarrhea/constipation/ disease (fissures, hepatic) toxic obstipation/change in abscess, fistula), megacolon, bowel habits, bowel obstruction appendicitis, melena/hematochezia (small, large, acute/chronic volvulus), pancreatitis, diverticular disease, pancreatic inflammatory bowel pseudocyst, disease, pancreatic cholangitis, pseudocyst, peptic cholelithiasis/choled ulcer disease, hiatal ocholithiasis, hernia, esophageal acute/chronic stricture, pilonidal cholecystitis, pyloric cyst, polyps stenosis, intussusception, incarcerated or strangulated hernia, Hirschsprung’s disease Cardiovascular Chest pain, syncope, Peripheral artery Aortic Hx of MI, dyspnea on exertion, disease, aneurysm/dissection, unstable claudication arterial/venous arterial angina, ulcer disease, embolism/thrombosi valvular varicose veins s disease, hypertensio n, arrhythmias , heart failure, deep vein thrombosis Endocrinology Tremors, fatigue, Hyperparathyroidis Thyroid carcinoma, Hx of palpitations, heat/cold m, hyperthyroidism, adrenal carcinoma, diabetes, intolerance thyroid nodule pheochromocytoma adrenal insufficienc y Urology/renal Edema, dysuria Orthostatic Testicular carcinoma, Fluid and hypotension, urinary Wilms tumor, electrolyte retention, chronic bladder carcinoma, disorders, renal failure, renal renal cell carcinoma, acid/base vascular disease, testicular torsion disorders nephrolithiasis, varicocele Neurology Change in vision, Vascular disorders Subarachnoid change in speech, (carotid disease) hemorrhage, motor and/or sensory subdural hematoma, loss epidural hematoma Dermatology Rash, Cellulitis, burns, Squamous cell Wound redness/erythema, pressure ulcers, carcinoma, infections, discharge, pilonidal cyst, melanoma drug dermoid cyst, eruptions hidradenitis (post-op), suppurativa, basal urticarial cell carcinoma (post-op) Pulmonology Shortness of breath, Pleural effusion, Pulmonary Hx of hemoptysis, weight pneumonia embolism, lung asthma, loss, fatigue, carcinoma, chronic pneumothorax obstructive pulmonary disease, tobacco use/depend ence Hematology Easy bruising/bleeding, Anemia Hemorrhage Hx of fatigue clotting disorders, anticoagula nt use, fluid/volum e disorders (volume overload/de pletion) OB/GYN Pain, skin changes, Cervical dysplasia, Breast, ovarian, Postpartum nipple discharge, cystocele, uterine cervical, and hemorrhag axillary prolapse, rectocele, endometrial cancer, e, perineal lymphadenopathy endometriosis, vaginal/vulvar laceration/e ovarian cyst, neoplasms, ovarian pisiotomy leiomyoma torsion care, Breast abscess, Abruptio placentae, gestational breast ectopic pregnancy, diabetes, fibroadenomas, placenta previa, preeclampsi fibrocystic disease, gestational a/eclampsia mastitis trophoblastic disease Psych Substance abuse Other Post-op fever

LEARNING OBJECTIVES FOR SURGICAL PROCEDURES AND SKILLS

• Proper sterile surgical technique in regard to gowning, gloving, scrubbing and in creating and maintaining a sterile surgical field (MK) [PsyM] B3.03

• Knowledge and utilization of surgical instrumentation and surgical imaging as a member of the surgical team (MK) [L1] B2.02

• Proficiency in surgical wound closure, application of surgical dressings and post- operative wound care (MC, PC, ICS) [PsyM] B2.02, B2.04, B2.05, B2.07, B2.09

• Knowledge and competency in using local and regional anesthesia and understanding appropriate utilization and monitor when general anesthesia is utilized (MK, PC) [L1, L2] B2.02, B2.07, B3.03, B3.04

• Order and interpret diagnostic evaluation of surgical patients in pre-operative, intra- operative and post-operative settings (MK, PC) [L1, L2] B2.05, B3.03, B3.04

• First assist and utilize advanced skill level in general surgical procedures in the operating room (MK, PC, ICS) [PsyM] B2.02, B2.03, B3.02, B3.03, B3.04, B3.07

• Assist and perform placement and removal of surgical drains (MK, PC, ICS) [PsyM] B2.02, B2.07

• Be familiar with the common surgical procedures listed in table 2

Table 2. Common Surgical Procedures

Organ system Surgery Breast Axillary lymph node dissection Core needle biopsy Lumpectomy or partial mastectomy Modified radical mastectomy Needle-localized biopsy or excision Sentinel lymph node biopsy Simple mastectomy Skin-sparing and/or nipple-sparing mastectomy Colon and Rectal Abdominoperineal resection Appendectomy Fistulostomy Hemorrhoid banding Hemorrhoidectomy Ileocolic resection Iliostomy/colostomy creation or take down Partial and Total Colectomy Sigmoid resection Lateral internal sphincterotomy Pilonidal Cyst Excision Small bowel resection Total proctocolectomy Transanal proctosignmoidectomy Femoral hernia repair Inguinal hernia repair Hiatal hernia repair Ventral hernia repair

Hepatobiliary Bile duct resection Caudate resection Cryoablation Liver Cyst Fenstration Liver resection Obstructed pancreatic duct drainage Pancreaticoduodenectomy (Whipple Procedure) Pancreatic pseudocysts drainage Pancreatic resections Radiofrequency ablation Cholecystectomy Dermatologic Melanoma completion lymph node dissection Melanoma sentinel lymph node biopsy Melanoma wide local excision and skin closure Excision of lipoma Sebaceous cyst removal Subcutaneous tumor removal Esophageal and Gastric Endoscopic mucosal resection of Barrett’s Esophagus Partial or Total Gastrectomy Transoral incisionless fundoplication (TIF) Heller Myotomy Nissen Fundoplication Bariatric Laparoscopic Adjustable Gastric Band (Lap Band) Roux-en-Y Gastric Bypass Vertical Sleeve Gastrectomy Laparoscopic lysis of adhesions Endocrine Central neck dissection Fine needle aspiration (FNA) Adrenalectomy Parathyroidectomy Modified radical neck dissection Resection of substernal goiter Subtotal parathyroidectomy Total thyroidectomy Thyroid lobectomy Vascular Phlebectomy Sclerotherapy AAA repair

Recommended Resources

1. Fauci A. Harrison’s Principles of Internal Medicine. McGraw-Hill.

2. Doherty, G. CURRENT Surgical Diagnosis & Treatment (LANGE CURRENT Series). McGraw-Hill.

3. Townsend: Sabiston Textbook of Surgery. W. B. Saunders Company.

4. Hamilton RJ. Tarascon Pharmacopoeia. (Pocket or PDA version)

5. Gilbert DN, Chambers HF, Eliopoulos GM. Sanford Guide to Antimicrobial Therapy 2014. (Pocket or PDA version)

6. Netter, FH. Atlas of Anatomy. Saunders.

7. Blackbourne, LH. Surgical Recall, North American Edition (Recall Series). Lippincott Williams & Wilkins.

8. Trott, AT. Wounds and Lacerations: Emergency Care and Closure. Elsevier/Saunders.

Recommended Websites Address UpToDate www.uptodate.com Guide to Clinical Preventive http://www.ncbi.nlm.nih.gov/books/NBK16363/ Services American Society of General Surgeons www.aafp.org American College of www.facs.org Surgeons American Medical www.theasgs.org Association (AMA) American Academy of www.aapa.org Physician Assistants (AAPA)