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Hello. Good evening. Good, a good day. Good morning, wherever you are in the world. And this evening we have an audience from 20 different countries. And I'd like to thank you for joining us this evening, as well as the 4230 followers on Facebook and the 457 on Instagram. My name is Dave Dori, retired cardiac surgeon in Yorkshire in the United Kingdom, and the immediate past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh and a visiting professor at Imperial College, London. This evening, we are talking about decisions before incisions and I hope you all spotted something with your eagle eye. Indeed. And can anybody state what it is in the chat room? So please put it up in the chat room and let me know what did you spot? Well, what we spotted was that incision was spelled incorrectly. I could actually say I did that deliberately to see if you are paying attention or did I? That is the question. The thing about surgery is once you've made an incision, there's absolutely no going back and you're committed. And therefore, before you make the incision, you may need to ensure that you're doing it for the right reason on the right person at the right time, on the right side, that you have the right skills, the right team, the right equipment and the right material. And if you can't answer all those in the affirmative, you should therefore stop the operation no matter what stage you are. I walked into the theater one morning did a briefing for an aortic root replacement in a man who is 6 ft two. We checked that everything was present and had all the equipment. I went off to the mortality and morbidity meeting to be cooled down and be told that the size 25 aortic root conduit was not available. They thought it was when they looked at the shelf, but the product had been incorrectly placed, of course, being six or two and looking at his BM I, there was no way I was going to proceed with an operation without a 25 millimeter conduit. Yes, this man had a central line. Yes, he had a premed. Yes, he had been catheterized and he had all been all but prepped for surgery, but I was not going to continue cos I did not have the right equipment of the operation and rescheduled him for my next list and lo and behold, yes, he did needed 25. The thing is, is that as the responsible surgeon, do not ever compromise on any of your decision prior to the incision. So the next important principle is that a surgeon, right, a good surgeon knows when to operate and an excellent surgeon knows when not to operate and can only decide that by taking a proper history and examination. So Mrs Jones turned up a clinic referred for elective choric bypass grafts and Martin who is my trainee at the time. Senior one at that took a comprehensive history from the patient and came across to our, I've seen Missus Smith in his own board, York Jack and said, she is a fit old bird. I'll come back to that good conduits with a good history of angina. She needs an operation. I said to my, I don't usually do it that way. We present the history in front of the patient and this is what general practitioners do they offer payback. So he presented the history to me in front of the patient and I look carefully at the patient and wondered at the end of a very good history. I turned to the lady and asked what her problem was and she said, doctor, my husband's got dementia, he's got dementia. I said, I see. Yes. She said, and he falls regularly. I see. I said, and when he falls, I try to pick him up. I see. I said, when I try to pick him up, I get this pain in my chest, which I'm told is Angina. Mhm. I do not want an operation doctor. I want somebody to help me look after my husband, but I think he needs to be in respite cat, but he thinks I'm trying to get rid of him. And after 55 years of marriage, he's asking for a divorce. I do not want an operation doctor. I want somebody to look after my husband. So I decided not to operate. But the letters to the general practitioner, the cardiologist, the social care worker was an interesting letter to write to summarize what mattered to this patient. And I would say to you the other principle, if the patient is hesitant, certainly in cardiac surgery, do not do it. If you unhappy, you're not, well, you're not fit, you're not comfortable. You do not feel you have the right skills emergency accepted where there's nobody else around, please do not do the operation. So the same session with you is interactive and I'd like you to populate messages in the chat room. What strikes me as rather odd is that we talk about a health service. So you and me, our customers every day, going into a shop, going to a restaurant, going into a supermarket, going into a hotel or going to a bank. I'd like you to put to chat group to decide what the term service means to you. And I'd like you to be typing away frantically. What does service mean to you? I'm looking at the chat room. I'm not seeing anything apart from hello, wrinkle greetings Carl. Good evening mister Caddy. And Gabriel's asked you to type your answers in the chat, but think about it. You and I have definite expectations when we walk into a bank, for example. And RCHO says to serve the customer or what is it to serve the customer? What do you mean by serving the customer service is about giving? Indeed. it's selfless is treating the other person as an equal, giving them help. But does it? No, which company on the planet depends on good service? Because we're all asked to rate in customer satisfaction. 0 to 5. The difference is between five out of five satisfaction and four out of five satisfaction is a 75% fall in footfall. So, can anybody name company that is dependent on a five out of five customer satisfaction? We have one correct answer. But that's for my fellow sensei. We've talked about promptness, honesty, openness. Somebody suggested Apple, interesting and Steve Jobs told you why you should buy his product and focused on how it feels and its value it gives you. But the company that actually delivers five out of five and their success is dependent on five out of five. It's Disney. So I'd like to ask you one question. Do you have a feedback form that you ask your patients? Did Mr o'regan treat me with dignity and respect? 0 to 5? Did Mr Reagan. Listen to my concerns, dear. The five. What's interesting. First, put those in your feedback. Most people go, ah, scared of the response. But I'm delighted for new or not. I ran out at a 93% 5 out of five patient satisfaction. So, the other part of the service where they come to see you as a doctor, this is a total stranger where you need to make an instant rapport with them. So there are a few rules that I call tablets of stone. Look the part. You are not going to go to a hairdresser that has a hairstyle in greasy hair like Se Snape in Harry Potter. Likewise, you're unlikely to go to a dentist that has rotting teeth and ketosis. So you do need to look smart and appropriate because you are customer facing and like it or not, people make judgment on appearance very quickly. I used to line the registrars up for ward rounds and in the old days, this is going back some checked the white coats, haircuts and fingernails and actually m march them down to laundry to get a clean white coat. Do not assume, do not judge for what they look like the size shape, whatever it doesn't matter the other is, it's what matters to the patient. That is important. And our sense caddy is asking, am I revealing my own biases pahs? But that is what I expect of a service and somebody coming to see me and that's what I would do. So what is wonderful about history and examination? It all comes down to the story behind Professor Bell, who's a professor of surgery at Royal in Family and he was the character behind Sherlock Holmes. So Conan Doyle observed the ability of Professor Bell to assimilate everything he saw and heard and smelled and put it together to deduct what was going on. So the whole thing about a history examination, you're using your senses, you're looking, you're listening, you're feeling your smelling and I can walk onto a ward and smell a pseudomonas infection. You can walk onto a ward and you can a urinary tract infection. And on a Friday afternoon having been up late all night and wanting to go home, thought I round because another prince never leave the hospital without rounding your p and I was taken to a 74 year old lady who was four days POSTOP aortic valve. The matron said that she was feeling a little nauseous. Now, the great thing about cardiac surgery is we don't operate on the gut and at day four patients are usually up and about. So a 74 year old lady being nauseous on day four is a conundrum. So went up to examine the patient feel the hand and as I grab the hand gently, I put my fingers lightly on the pulse and ask what the matter is. The lady burped af burp, indicative of a small balance, obstruction and a large amount of fluid in the stomach. I A tube and put an tube down that drained 2 L of frequent vomit. This lady was a hair's breadth away from aspiration and perhaps death. Now, why was she obstructed? Or the two common reasons are adhesions or hernias and she had never had abdominal surgery in the past. So was aa having drawn the curtains in taking back bed clothes. There was a large incarcerated umbilical hernia red and tender. Now, the funny thing is that I called the consultant general surgeon and said that she needed urgent operation because all the signs and symptoms were there. They asked for a CT scan. The CT scan took four hours to do at the time. She got to theater, they had to resect some ma. Now I do understand that CT scans are a quick way of assessing the abdomen, but I am concerned the clinical mouse inhibition is falling by the wayside. And part of your examination in particular in clinic is get up, stand up, call for the patient by the name. You wouldn't walk through your door without using a handle and every patient has a handle and a name that they prefer to be called by. I worked for a consultant breast surgeon in Oxford. We had an operation and he was extremely irritated that the nursing staff abbreviated his first name and called him Dickie. No, you greet the patient mister or missus. However, which and as you call them, watch them get up and walk to the consultation room because the ability to stand and use the quadriceps is a very good indication of frailty. On one occasion, I did ask an elderly lady to come in and she had a great deal of difficulty getting up so much so that unfortunately she had been incontinent in the chair. She was not able to get up and move around round yet she was with fat surgery. I will take the patient by the hand. It is all recognized from studies in the 19 eighties that grip strength, correlates with physical strength and wasting some of the first muscles that will disappear if you're losing weight, particularly if you ac cacic state malnourished state of the interossei and the intrinsic muscles of the hands. So therefore shaking somebody by the hand gives you an indication of the grip strength. So somebody walking in at 94 grabbing you by the hand and squeezing it tight. You know, despite the fact they're 94 their grip strength is very good and their biological age is better. Coming to see a doctor, one expert. It's scary that you need to make the patient comfortable. It's interesting the responses to the questions, please ensure that you have an interpreter present and that interpreter is not necessarily a member of the family. A colleague of mine was consenting somebody for surgery for an aortic valve and this lady could not speak English and the husband was doing the interpreting for her. Now, Pank could speak the language and was aware that the husband actually was telling his wife something different and that she had to have an operation. So do beware. I think when you examine anybody in this day and age, it is important that you have a chaperone, male or female. And some of you said, sometimes I think it's a common courtesy and I'll explain why as we go on further cos it may explain your other response about examining breasts and testicles. I would say particularly as a card a and again, this is my bias, but you're making an incision and going back to my list of right time, right person, right reasons, right. Decision making. I could ill afford to do an operation without having all the information, including an examination. So a full examination, two reasons. Many people don't regularly go to the hospital. And certainly in the UK, if they go and see a GP, the examination time or consult time is down to five minutes and it is lift the shirt stethoscopes on and that is it pertaining to the complaint. But when you come to surgery, the whole person needs to be examined format and that includes breasts and testes, particularly uh in the Asian population and elderly people, there's a degree of embarrassment there that would not be examined. And I am a trustee for British Asian Cancer Society and it is not disclosed when somebody comes into a hospital to see you for surgery. This is your opportunity to do a full M OT and for a car to run on the road in the UK. It needs a full M OT. You welcome the patient into the room. You ensure that you're on the level, you're not sitting higher, you're not sitting lower and you're keeping your eye contact and looking. Ties are no longer used for infection control purposes and reasons in the UK. And I introduced the Linac with my name, title and status embroidered on my polo neck shirt. I did what it said on the cane, a consult surgeon, consultant, cardiothoracic surgeon. For those of you going in two a room, hotel room and restaurant drawn. We wanted to look and feel warm and fresh. It's interesting that the outpatient areas are writing fish tanks and plants and some of them are playing music and why not above all else you need privacy. I think it's rather amusing, sad that we regard the curtains on the wall as soundproof curtain and reflect on my grandmother of 94 who was incarcerated in hospital was able to tell me in detail all the relating to the other patients in his bay because the curtains were drawn, but we could still hear what was going on. So the next thing is at the present moment, I think we've got tick box clock. These are pre printed sheets with prompt questions on and all too often, I've seen people sit down with a history sheet and looking at the patient or asking questions, ticking the box. This is not an inquiry. This is actually interrogation, not open questions, allowing the patient to tell their story and express that concern. So your note this evening, we don't have any slides. I'm not gonna bore you with slides. You should be able to talk and listen and maintain eye contact. Now, the whole thing of being able to take a history is to take what the patient says, their story. And you're trained as a translator to put it into medical speak and the medical speak is there to communicate with colleagues and other professionals about that patient. So your job is translation, but you got to remember that it's the patient story and understanding the nuances. So we're gonna have a little test. How long do you think it takes before a doctor interrupts a patient when he actually asks, or she asks in your own words? Tell me what is the problem? Well, doctors usually interrupt within 20 seconds. It is important to sit down and actually ask somebody in their own words to tell me what your problem is and that you listen to the patient's story as with and her husband, his understand how long the symptoms have been going on for. They are relieving and exacerbate factors, any associated symptoms. So the presenting company is the story and a story of progression, deterioration, relieving or aggravating factors all get in there. But I say telling the story, do watch what they're saying because somatic pain as you know, is applied by peripheral nerves and they can say it hurts right there and point to it. But visceral pain comes through the parasympathetic system and is represented according to derma terms in a vague sort of sensation. So I always thought it was strange that you ask patients if they get any chest pain because Angina is a squeeze, a tight, a burning a sensation anywhere from the ankle of the jaw to the tip of the elbow. It's not a pain. Visceral pain is very different and people might have different levels of pain as well. But that doesn't mean to say that you brush them off. So keep a good eye on the patient. And obviously, if it's a musculoskeletal problem, you've watched them walk in. Do they need aid where they're using a stick? Do they wince as they walk all these clues? Give you some idea all going on. Now, there are very, very few pains. They actually bring tears to the eyes and perhaps you'd like to write some down in the chat or what sort of pains bring tears to the eyes. Anybody sharp pain said his surrender. But there are emotional pain. I like that as well. Emotional pain and we treat the whole patient. But any particular pathologies, herpes zoster. Excellent. Thanks Mohammad. Anybody else, aortic dissection and cardiac specialty. And of course renal colic, groin to groin pain. And it's the distribution of pain and the story in the hand. And the indication Surinder mentions appendicitis. Certainly, if that appendix is bouncing against the peritoneum of the abdominal wall, you will get somatic severe pain. And in fact, the story of the balance on the road into hospital was very uncomfortable, is suggestive of a peritonism compartment syndrome, compressed nerve and rus childbirth and pancreatic blockage bands, second degree bands are certainly very painful. Third degree bands kill all the nerves. So with whatever pathology is going on, you then need to ask about risk factors of smoking, alcohol, drugs, family history, profession, exposure to asbestos, coal or other agents that would cause carcinogenic agents in the environment or even the sun. You then also asked about previous hospitalizations. Have there been no hospital re reason whatsoever? And I love this one too because as a register in Banbu and was on call and asked to see somebody who had all the symptoms and signs of tinnitus from app appendix. And I took them to theater. I did a full history and I'd asked them if they had any operations in the past or if they've been in the hospital, I was aghast to open up the abdomen which was pristine with no adhesions whatsoever. And trace the Taenia Coli of the ascending Colline all the way down to the caecum to find no appendix whatsoever. I've never known a congenital absence of an appendix and thought gosh, this is a paper but then looked through the abdomen and meckel and other causes of pain, didn't find any, then close the patient up, put her back to the ward and related the findings. Two days later, the notes came back. Well, we found the notes, they've been transferred from another hospital. And lo and behold, 18 months previously, she had an appendicectomy. And I asked her about this. I said, oh, that's what they did. I didn't know what was going on. He had severe stria gravidarum of pregnancy and there's no evidence whatsoever of a scar. It's a part of the sieve on previous diseases. I would ask about jaundice, rheumatic fever, TB epilepsy or stroke. But I also specifically ask about any anesthetic, any anesthetic problems. You'd make good friends with your anesthetist. If you can actually say yes, they had an anesthetic. Previously, there were problems with a particular drug or there were problems putting down an et tube. But also beware that keyhole surgery nowadays is not perceived my son has open surgery and therefore you have to be on your guard. Now, systems inquiry is a way to actually sieve through general symptoms to determine if there's anything else going on. It's important that you ask questions as open questions and pause to allow the patient to think about answer. Watching the expression because the expression couldn't, offers a degree of doubt or not quite sure and explore that further but use plain language. How far can you walk? Do you ever get short of breath? Can you lie flat at night? Do you ever get any ankle swelling? How is your breathing? Is it noisy? Do you have a cough? Do you ever cough up anything? Have you ever coughed up any blood? Do you have any problems eating? And if they say yes, what type of food is your weight stable? Do you have any difficulty or indigestion or heartburn? Have you ever ved up any blood? Any problems with the bowels? Are you regular, any blood, any mucus, any problems passing urine, any stinging or burning? How often do you need to go? Does it ever catch you short? Every you wake at night and ladies are obviously in menstrual cycles. Any problems with the front passage? Any problems with your periods? Regular ed the blood. How many towels do you use? How many days did you have to wear towels for all this is giving you ideas of what is going on. Do you have any hearing problems? Any problems with your eyesight? Any unusual headaches, any problem getting up walking around or mobility, any odd tingling sensations or numbness, anywhere or any pains in the joints and you can then translate that down into your systems? Inquiry, what tablets are you on? And that is tablets being pharmaceutical tablets or any other herbal tablets that they might be taking? Look it up if you don't know and look up what the side effects are. So, my next question to you, I'd like an answer. What is the definition of an allergy? Could somebody put that in the chat room? What is an allergy? Because too often you actually take a history from somebody and they say I'm allergic doc, you've got unwanted reaction. Immune response, surrender. Good. Do you know what type of response the thing is that we all too often put these red tags and I'm allergic badges on people without describing exactly what happened when they took the drug in some situations, patients might be told never to take an antibody again or when I was younger, I had penicillin and I was told never to have that again. Or they describe aggravated immune response to an allergen or type one. Arthur's reaction with swelling rash, laryngeal edema, a little bit of nausea and didn't feel quite a bit sick with a tablet. It is not an allergy. You can put it down as an intolerance. But if the patient required penicillin and you'd mark them as alert and a simple fact that they had a lot of nausea, you have denied them a life safe. So please be accurate and be precise. And that is exactly what taking and history is. Is taking the patient's story, asking open questions and then translating that into medical speak, which enable you to concisely document some and communicate with your colleagues. The next part of the story I think brings joy to the up what we do, talking to people and finding out who they are, what they do. I met somebody who had done troop in the car for seven years as a sergeant. Somebody else is part of a fire design team. Somebody else who designed the turbines in the Rolls Royce Gins. And when, as a junior doctor, I did a locum on a geriatric ward and this person sat on a bike plane and actually threw two bombs by hand on the a the other thing about the social history to bring out particularly in elderly patients is war events are coming up in knife. What are they living for? What are they looking forward to? And this is particularly important in elderly people. But there's another element which is the service event that hairdressers es and I think we can learn from good hairdressers are very good at gossiping and chatting and making their customers feel very special, but they would go in out the back and write on a little card that you were going to on holiday next week or you had a function coming up such that when Nick saw you, they'd look at their car and come back and say so, how was that holiday? Well, how was the wedding anniversary or the wedding? Just think how that made you feel and that is the experience element of service. It is how it made feel Fred Lee. I heard that the Association of American uh physician executives wrote a book 9.5 things you would do if Disney Manual comp company or hospital. And he related to the story of a practitioner who was p was perturbed that he was on holiday and was not available to examine the child who is unwell and ended up seeing somebody else. The difference. They noted what is this nta didn't speak to the mother but actually got down on his knees and chatted to the child, 1 to 1 and this woman never ever seen this before. As a result changed practitioners. We took my son in for an a possible appendicitis. I thought my diagnosis was correct because daddy, the bumps are very uncomfortable. The senior came to see my son and chatted to him like another human, sat on the bed and was excellent. I was so impressed. I wrote to the medical director. They said this person deserves to be a consultant in this hospital because his approach to service was exemplary. He got the job and reminded me 20 years later of the episode. So now we come to examination, you need to examine the whole page in an emergency. On a particular Thursday, the patient came down from the Cath lab straight into the Cath lab from the Cath lab to the operating theater. So I had no time to assist us and the team was scrubbing up and I went to catheterize the patient. The patient actually had penile cancer. It was not documented. And then nobody had ever looked. A few days later, I was walking around the medical ward to see another patient and the Hexagon diagram that we do West P and I'll draw exactly what they share d uh excellent. And I looked at that and thought I see there was no Amelis and for a male, there are no testicles. And I actually asked the doctor, did you examine the testicles? They said no, am I allowed to? The important thing is the patient needs to be comfortable and in the correct position and comfortable. And a family, I asked them to strip off to their underwear with a chaperone present with a blanket, the parts of the body that I'm not examining. You start with the hands, but before you examine the patient, you start with the hands by washing your hands, soap and we know gets rid of all germs, but I not only wash my hands, but I keep stethoscope as well. Some of the training would actually put gloves on to examine the patient. And I actually think to myself, what would the patient feel like if you had to put gloves on? And unless they've got a contagious disease or open sores or body fluids exposed or you've got a sore, just putting gloves on and washing your hands before and up is enough. The important thing is to look and see what is going on. I recall for my primary of as examination, being asked to go and look at it and examine an abdomen and examining and I exposing from neck to knees with the privates cupboard. And I looked and I asked them to take a deep breath in and deep breath out. And what I could see was a smooth regular mass move with inspiration up and down with expiration in the right hypochondria. Before I even put a hand on the patient, I could confidently say that this was a solitary liver cyst. In my part three examination, I was asked to see a man examine the chest. He was tattooed, he had nicotine stains on his hands, had ts in the beard as well from heavy smoking. But apart from that, there was nothing to see looking at the chest, but there was a small bruise in the second intercostal space, midclavicular line. The size of about four millimeters with ap was green. I reported a normal examination but concluded that this person probably had fine needle aspiration cytology on a right upper lobe lesion four days previously for a probable cancer. In view of his smoking, it was there the little mark. So using your eyes is important and before you touch or move anything, please ask if it's painful. So simply putting a BP cuff on and moving the arm when they got a rotator cuff or severe arthritis is not very clever as palpation as we have described in surgery. So far in our Blackbar Academy is the tips of the fingers. The palps you feel, I don't want to see prodding and blanching on fingernails as you press and prod you feel. So it's inspection palpation. And I asked you what tactile vocal femme is vocals and percussion, a clinical ultrasound to determine if there any air or fluid or solid. And of course, then we listen with the stethoscope and listen carefully. You're using all your senses. And as you're examining the patient and with your hands on the patient, don't look in your hands, look in the patient's eyes because their facial expression will tell you if you're causing any discomfort whatsoever. And as surgeons, you would have studied your anatomy. So as you're putting a hand on the patient, a stethoscope on the chest, be aware of the surface anatomy of the organs that are underneath. So when somebody is examining the chest, I expect a medical student to know the surface anatomy of the lobes of the lung, which lobe of the lung sit anteriorly, put it in the chat room, which one sits poster. But I'd expect somebody training in cardiothoracic survey to understand the broncho pery segments and the apical segment of the posterior lobe is actually heard at the spine and the scapula. And that is the only bronchopulmonary segment that is perpendicular to the airways where the patient is flat. And if there's any aspiration, it's going to go in to that segment, in particular, no, your anatomy and think of it as the sagittal planes, c six transpyloric plane. What happens at the level of the umbilicus? So I started my examination with the hands, feeling the color and temperature and comparing right and left sides, a medical student in clinic actually picked up a coarctation with feeling a difference between radial arteries that wasn't mentioned in the referral. But there was a clear difference when he felt both the pulses. When you're looking at somebody you need to decide, do they look well or unwell? It's just normal abnormal. And compared the size and as you feel no color and not the temperature mention taste in mothers would pick up cystic siders fibrosis because the Sweatt is salty, smell the urine. And of course, the physicians to the king would look at the extra in color and smell as well and tell you what is going on. You can smell clostridium difficile on the wall. That's a simple thing for the cardiovascular examination. Could somebody tell me what the minimum pulse or pressure needs to be the minimum pressure that you could feel at the foot? Could you put that in the chat room, please? Minimum pressure, you'd feel at the foot. Remember when you're feeling a pulse, you're feeling it gently, you're not pressing hard and excluding the vessel, you'd likely put your finger on the pulse. And when you fending the pulse, you got to know precise and anatomically where that artery is. So for foot pulse, there are general rules would be 100 and 20 systolic for wrist, 100 for brachial 80 for femoral 60 for carotid 40 very quickly, you can work out and assess the BP of a trauma patient coming through. I did an sy looking and I had a patient served up with a respiratory history and I was kicking myself that I had forgotten my stethoscope taking this to s so I looked at the, the left side was not moving and the ribs were constricted. There was a little scar in the neck here, there's a paramedian scar in the abdomen and there are two little blue dots on the front with evidence of uh chest drain in two places on the left side. Can anybody put that together? Well, this man had had mental radiotherapy. Hence the two dots for lymphoma that was diagnosed on removal of a node from the neck and then had a spleen removed. But the mental radiotherapy had caused bronchiectasis and collapsed of the lung and he had respiratory problems and recurrent pneumothorax. Because of that. Simply by looking, we've picked up the full history without the need for the stethoscope on that day. Remember when you examine the lymph nodes, it's from occipital postauricular preauricular juggling digastric in submental down the internal juggler, the poster triangle and everybody gets hung up about examining armpits. This an armpit is like a pyramid, anterior, posterior, medial lateral apical feel the lymph nodes because the lymph node in any of those areas could be a small melanoma on the scalp, on the back on the skin that you haven't spotted or haven't seen when examining the breast, gentle inspection hands up, symmetrical nipples, color inversal discharge. But you do need to examine that because a number of women in particular are not good at examining the breast and nobody has examined them either. And if we're doing a full history and examination, you need to actually have that information with chaperones present. Of course, remember that the eye is a very good way of looking at the microcirculation. Always impressed when I go to specs saver that not only do they test for accurate chamber hypertrophy, but they're doing screening for hypertension and diabetes with a fundoscopy looking in the ears. And of course, now with the endoscopes, we can look top and bottom and through every orifice, the bottom line then is having taken the full history and allowed the patient to tell the story. You should be able to summarize it on a single piece of paper. Now this has to be in black because it possibly it could be photocopied and every page requires the date, the time in 24 hours. But the patient's name, date of birth and ID number, if necessary are sticky, you can write it down history of presenting complaint, systems, inquiry, drugs, allergies, social history on examination. What do they look like? Are they short of breath, walking in, lying down? Are they yellow or anemic? What does the look like? And then the notes for vascular system system, abdominal system and breast, what you need to do is actually write at the bottom print your name, sign your name and then the UK recommend put the GMC number on it. A lot of junior doctors have now got a stamp. When I was a houseman, a lady came in complaining of a painful leg and was intermittent to her symptoms and she was quite vociferous and quite noisy about her pain and do beware of this. And don't judge, I listened to the story and I made the diagnosis of her Masia Cerula Dolens, a painful blue leg. In other words, an iliac vein thrombosis has symptoms whacked and and waned. I documented this clear in the notes and wrote proudly in bold my diagnosis. This was a Friday afternoon. She was seen by the senior registrar of the consultant five or six times over the weekend, but they did not document in the notes. And on the Monday, she went for a venogram and lo and behold had an a vein Thrombosis. She sued the hospital. Oh, successful. Why? Because the note keeping was poor. So the history and examination R is summarizing the patient story in the medical speak. And one of the things I do ask about patients, Queen's a in particular is how much gas they've got in the tank? Are they really up to having an operation? Because the last thing I ever want it's to do an operation and somebody turn around and say doing that. And on two occasions, two elderly gentlemen came to clinic in a fit to admit process that I introduced in my clinic. They went through the whole pre admission process with their bloods and history and examination, put their jacket and tie back on and we sat down across the diagonal of the table as equals. And he leaned forward and said, doc do I really need this operation? And I replied interesting question. Why do you ask? He said, because I only get, I only get chest pain when I go to the pub of the pub, which is better at half the distance. It's not really bothering me. And although you had three vessel disease, there is the phenomenon of stable angina in stable disease. So I said to this gentleman and there was a second one like him. A few months later, you're quite right. We do not need to proceed with an operation immediately because one of the things you've got as a surgeon and one of the tools we don't use enough is time to go back and reassess to reevaluate. Not only for you as a surgeon, but for the patient themselves. And the invitation to return should always be there in your note keeping as well. The patient for the mem prefers not to have an operation. I agree. And he's invited to return. Should the symptom change or get worse? And that is also something to be used if you're ever in the accident and emergency department. Is that all you're doing when you're seeing somebody in a busy A&E is taking a snapshot, you're not seeing the progression. So inviting them to return. Should there be a deterioration? My fellow colleague, Mister Caddy is asking so what you learn from working in a system? They ignored your meticulous documentation. I kept meticulous documentation because it helped me deliver what I thought was the best for the patient and kept the notes that way. Whereas an sh oa young 16 year old came in with a funny sort of head injury, hit, headed the ball and blacked out briefly briefly and he was admitted and I know when I was a sho in orthopedics, head injuries like this, they were sort of made pass to pass on because yeah, nobody knew quite what to do. But there's something about this lad that wasn't quite right. So I reviewed them every hour or every two hours through the night. Neurologically, he seemed conf oment in where he was, but his temperature was slowly climbing. And I spoke to the senior registrar neurosurgery and said this is, is not quite right. He is not something is amiss. And the senior registrar neurosurgery brushed me off. But the following morning came to see this young lad who then went to theater with the biggest bilateral subdural hemitoma. The senior registrar in neurosurgery had ever seen. So 1/6 sense when something is not quite right. And one of the best things you can do is developed that sense that Sherlock Holmes sense when talking to the patient, when examining the patient and remember, you could always go back and review and review and review. But each time you review, you keep an open mind and keep that attention to detail because as I've said, with the Black Belt Academy is be careful even in the smallest of matters. So when I ran a clinic every year, I gave my patients and I noted this from a clinic in America, a praise of who I was and my outcomes was I safe. In other words, mortality for the common operations was effective, the complications of the various operation. And lastly did I offer a good experience. I like to think that when pa patients came to see me S e effective e experience, they had the invasion and experienced it for themselves. And as delighted that I continued to get a 93% 5 out of five patients satisfying. And it's you want to enjoy your role as a surgeon. I don't like the concept of defense of medicine because actually if you take a good history, do a thorough examination, enjoy your contact with a patient document correctly, you will enjoy it. Your patients will enjoy it and career will be enriching. Thank you very much indeed for joining the Black Belt Academy Surgical Skills. I am very happy to take it in questions. And my fellow colleague, Nse asked me about intuition and how do you develop it? Well, this is by walking around wards and seeing lots of patients and simply asking yourself, are you using all your senses? Because intuition is really just an one form of pattern recognition. And those of you who are my age will remember the Oxford handbook of surgery which used to slip in a white coat and at the back of the Oxford handbook of surgery were all these syndromes of all these weird and wonderful diseases. But actually, if you read what the syndromes were all about and who described it? They were described by physicians who had put together a pattern of physical signs. Yeah, told, told you the story and I'm following some, what's up photographs and pictures and says, what's the diagnosis? Please? Please, please. Medicine is an art, but to practice the art, you gotta study the science. So learn the science, but practice the art and using all your senses and that is where the joy of talking to patients. The privilege of said he comes from because within a few moments, you should be able to establish a rapport with patient. They trust you and then you have the privilege of operating on them. Who else would let a total stranger cut them up? Thank you very much. Indeed. I look forward to seeing you next week as we are discussing and going back in our full cycle is like Wagner's Ring and Wagner's cycle to talking about posture. And I hope to bring a few more things to the table to stimulate your thinking and help you be the best surgeon you could possibly be. Thank you very much. Indeed.