Surgery Guidelines for Patient Evaluation and Example H&P

Learn how to listen: This is a dictum that will serve you not only in history taking but also throughout
life. Inability to listen is a fault of many senior physicians and surgeons who prejudice their work by
simply not knowing how to listen to others. Remember you have, as a student, two goals. The first is to
learn how to do a history and physical primarily from the patient directly at the bedside. Second, but an
equally important goal, is to gather information that pertains to the patient from other sources as well.
You will be judged and graded in both these areas. Your history and physical will be signed and
reviewed and your information gathering ability will be reviewed when you make case presentations.
History and physical: Remember who, what, where, when, and why as the general categories for each
datum. Try to use the patient's own words when giving his chief complaint. It is not inappropriate to
insert in parentheses your own interpretation of the best meaning of what the patient said as long as
this is clearly identified. As to general information gathering, the following may prove useful. When a
patient is transferred from another facility, it is helpful to obtain all pertinent transfer notes, laboratory
and x-ray. In regards to records, the fax machine is very helpful in this day and age. For a patient who
has been recently admitted and treated, the most useful items are the discharge summary, operative
reports, pathology reports, and sometimes x-ray reports or the x-rays themselves if they are very
specific, such as arteriograms. Taking the effort to pull up the patient's previous chart and documenting
prior admissions to the particular hospital where he is at is also helpful. The student will be given an
access and verify code to pull up patient information from the computer. A call to the referring
physician "when approved by the attending surgeon of record" can provide a wealth of information.
Knowing which tests and x-rays have been done recently can be valuable to prevent needless repetition
of same. Remember to locate the attending of record and have your history and physical signed usually
within 24 hours before entering it into the record. Similarly, orders that are written will not be executed
by the nursing staff unless countersigned by the attending physician of record.
Meeting the patient for the first time is extremely important. The first impression is often the lasting
impression and certainly many times cannot be undone. Being well dressed, friendly, and courteous will
help not only the student obtain a good history and physical, but will provide a good reference both for
the attending surgeon of record and for the hospital in general.
Patient questions that are very general can certainly be answered by the student. Specific questions
from the patient may, in most instances, be best deflected by referring them to the attending surgeon.
Most certainly, the patient should not be confused by conflicting statements given by the student as to
specific tests, x-rays and surgical procedures to be performed. Working through and with the attending
surgeon of record as part of the team is the best way to avoid prejudicial comments to the patient.

Example:
CC: Abdominal pain x 2 months. (Chief complaint and duration)
HPI: (All items regarding present illness including pertinent ROS and negatives. First line- age, gender,
race or ethnicity, parity, and occupation) the patient is a 64 y.o. obese African American female
nulliparous dental hygienist who presents with a 2 month history of back and abdominal pain. The pain
is described as dull, constant, and a feeling of fullness in the abdomen. The pain does not seem to have
progressed over the past 2 months. Patient has noticed some abdominal swelling. The pain is mostly

localized to the RLQ of the abdomen and the lower back in the midline. The pain does not radiate and
nothing seems to make it better. Patient has noted an approximately 10 pound weight loss over the last
2 months. Patient denies nausea, vomiting, or a change in bowel habits. Patient also notes occasional leg
cramps and some occasional swelling. Patient notes occasional numbness and tingling in the extremities,
as well as joint stiffness. Patient denies fever, chills, or night sweats. Patient also complains of occasional
frequent urination. Her PCP had ordered a CT scan which was suggestive of a retroperitoneal mass. She
is admitted for exploration and excision of the tumor.
PMH: Hypertension, Diabetes Mellitus type 2, and Asthma.
PSH: Partial Hysterectomy, for fibroids with metamenorrhagia
Social History: Patient is single, denies tobacco or drug use, and drinks alcohol rarely.
Family History: One aunt with type 2 diabetes, a brother with colon cancer, two aunts with breast
cancer, and a maternal cousin with breast and ovarian cancer.
Allergies: Penicillin manifested as rash, but no hx of anaphylaxis.
Medications: Norvasc 500 mg daily, Lasix 40 mg daily, Flonase inh prn, Advair inh 250 mcg daily, Spiriva
inh prn, Metformin 100 mg daily, Albuterol inh prn.
Review of Systems: The review of systems was negative except for those items already mentioned and:
the patient has worn corrective lens for myopia since age 14.
PE:
Vital Signs: BP 120/80, Pulse 70
General: Awake, Alert, NAD, Alert and Oriented x 3
HEENT: PERRLA, EOMI, Mucous membranes moist
Neck: Supple, no lymphadenopathy, smooth thyroid
Heart: RRR, no murmurs, no JVD
Lungs: CTA bilaterally, no wheezing or retractions
Abdomen: Soft and non-distended with a palpable mass on the right side that measures approximately
15 x 20 cm by palpation. The mass is not mobile. The right side of the abdomen is mildly tender and the
left side is non-tender. Bowel sounds are audible.
Extremities: Radial pulses 2+ bilaterally. dorsalis pedis pulse 2+ bilaterally
Pelvic: patient refused.
Rectum: patient refused.
Differential Diagnosis:
1. Retroperitoneal tumor, etiology undetermined
2. Sarcoma (such as liposarcoma or leiomyosarcoma)
3. Lymphoma
4. Tumor of a retroperitoneal organ (i.e. kidney, duodenum)
5. Germ cell tumor
Labs and Imaging Orders: (If not listed in HPI)
Discussion:
The patient presented with nonspecific dull abdominal pain and a palpable mass (which was very large,
approximately 15 x 20 cm). Given the large size of this mass, the most realistic next step is to
immediately obtain a CT scan to determine the location and involvement of internal organs. As I wrote
in the H&P, at the time we saw this patient, we already had a CT scan and a biopsy showing that she had
a mass, most consistent with leiomyosarcoma. Given the diagnosis of sarcoma, I would proceed with

surgery to excise the mass. The ideal margins for a sarcoma removal are >2cm. Given the large size of
this mass, the resection may have to include internal organs. Neoadjuvant and/or adjuvant
chemotherapy and radiation for retroperitoneal sarcomas is being studied, but there is no evidence to
warrant the use of either in our patient.
Retroperitoneal sarcomas are dangerous because they can get quite large without being noticed
(especially in an obese patient). These sarcomas do not have systemic effects until they compress other
structures in the abdomen. If you obtain a CT that demonstrates a retroperitoneal mass that does not
arise from an internal organ (i.e. - kidney, duodenum), your differential needs to include a
retroperitoneal sarcoma, lymphoma, germ cell tumor, or testicular cancer. Therefore, it is very
important to ask about fevers and night sweats/chills to help identify lymphoma. The likely next step is a
biopsy of the mass. If the mass is <3 cm, you should do an excisional biopsy. If it is >3 cm, an incisional
biopsy is the method of choice. In our case, an incisional core biopsy was done, confirming a
retroperitoneal sarcoma (leiomyosarcoma).
Once you have a diagnosis of a retroperitoneal sarcoma, it is important to know that the only potentially
curative treatment is complete surgical resection. Retroperitoneal sarcomas tend to have a poor
prognosis due to their large size at time of diagnosis and therefore it is anatomically difficult to get 2 cm
clear margins on resection. Without obtaining 2 cm clear margins, there is a greater likelihood of tumor
recurrence. It is also important to check for metastases with sarcomas as they spread hematogenously
to the lungs. Of note, retroperitoneal sarcomas more commonly metastasize to the liver.
In conclusion, retroperitoneal sarcomas are difficult to diagnose early because they cause few patient
symptoms until they exert pressure on other organs. This underscores the importance of performing
comprehensive abdominal exams on each patient in the primary care setting.