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    History and Exam

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    Emereole Frances
    This document outlines the key components of taking a patient history and performing a physical examination in surgery. It discusses the importance of history taking in making a diagnosis and lists the parts of a surgical history, including biodata, presenting complaints, past medical history, and review of systems. It also covers performing a focused physical exam, including general examination of vital signs and regional examination of head, neck, chest, abdomen, and rectal areas. The goal is to elicit signs and symptoms that can help make an accurate diagnosis.

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    History and Exam

    Uploaded by

    Emereole Frances
    116 views27 pages
    This document outlines the key components of taking a patient history and performing a physical examination in surgery. It discusses the importance of history taking in making a diagnosis and lists the parts of a surgical history, including biodata, presenting complaints, past medical history, and review of systems. It also covers performing a focused physical exam, including general examination of vital signs and regional examination of head, neck, chest, abdomen, and rectal areas. The goal is to elicit signs and symptoms that can help make an accurate diagnosis.

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    This document outlines the key components of taking a patient history and performing a physical examination in surgery. It discusses the importance of history taking in making a diagnosis and lists the parts of a surgical history, including biodata, presenting complaints, past medical history, and review of systems. It also covers performing a focused physical exam, including general examination of vital signs and regional examination of head, neck, chest, abdomen, and rectal areas. The goal is to elicit signs and symptoms that can help make an accurate diagnosis.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    116 views27 pages

    History and Exam

    Uploaded by

    Emereole Frances
    This document outlines the key components of taking a patient history and performing a physical examination in surgery. It discusses the importance of history taking in making a diagnosis and lists the parts of a surgical history, including biodata, presenting complaints, past medical history, and review of systems. It also covers performing a focused physical exam, including general examination of vital signs and regional examination of head, neck, chest, abdomen, and rectal areas. The goal is to elicit signs and symptoms that can help make an accurate diagnosis.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 27
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    The key takeaways are the importance of taking a thorough patient history and performing a focused physical examination in order to make an accurate diagnosis. This lecture discusses the steps, components, and procedures for history taking and physical examination in surgery.

    The main steps in making a diagnosis as a surgeon are taking a thorough patient history, performing a physical examination, and ordering appropriate investigations to identify the underlying cause of the patient's problem.

    The key parts of taking a patient's surgical history are collecting their biodata, documenting their presenting complaints and history of the complaints, reviewing their past medical and surgical history, and obtaining other relevant histories like gynaecological, drug, immunization, family, and social histories.

    Lecture topic: HISTORY TAKING AND

    PHYSICAL EXAMINATION IN
    SURGERY
    • BY DR
    EZEONWUMELU T C ( FWACS ,
    FMAS )
    LEARNING OBJECTIVES
    Be able to take a structured , concise patient
    history.
    Beable to understand the basis for clinical
    examination.
    Be able to carryout a focused general and
    systemic exams in surgery with a view to making
    a diagnosis
    Introduction
    A patient presents to a surgeon with a specific
    complaint(s) called symptom(s) and surgeon’s aim
    is to make the patient better.
    To achieve this he tries to identify the cause of the
    problem(making a diagnosis) by following very
    important steps ;
    History taking
    Physical examination
    Appropriate investigations
    • Forthe purpose this lecture the first two steps
    shall be discussed
    Parts of a surgical history
    Biodata
    Presenting complaint(s) with duration, preferably
    chronologically
    History of presenting complaint(s)
    Past surgical and medical history
    Gynae history( where applicable)
    Drug history and allergies
    Immunization history (where applicable)
    Family and Social History
    Review of Systems.
    Summary
    HISTORY TAKING IN SURGERY
    History taking is the most important aspect of the
    steps in making a diagnosis
    It directs the clinician to eliciting abnormal clinical
    signs
    First introduce yourself and get consent from the
    patient
    The following are the parts of a surgical history
    BIODATA
    •NAME
    •AGE
    •SEX
    •OCCUPATION
    •RELIGION
    •ADDRESS/RESIDENCE
    •MARITAL STATUS
    •EDUCATIONAL LEVEL(HIGHEST)
    •NATIONALITY
    •INFORMANT(WHERE APPLICABLE)

    • 0
    Presenting complaints
    Alternatively called the ‘Chief complaints’
    This is what brought the patient to the
    hospital(surgical clinic or emergency)
    When there are more than one presenting complaints
    they are listed with durations chronologically eg
    C/O Groin swelling x 2/7
    Abdominal pain x 1/7
    Vomiting x 1/7
    History of Presenting Complaints
    Here, the details of each complaint is documented as
    accurately as possible mostly in patient’s words
    Preferably questions related to the system involved are asked
    and documented
    As much as possible allow patient tell his/her story and only
    guide when necessary by asking specific questions using
    terms that can easily be understood by patients
    Usually , in surgery we use the 5Cs( complaints , course ,
    cause , complications and care) as a guide.
    Past medical and surgical history
    Here, note all previous non-trivial illnesses, operations ,
    accidents , periods of admissions with dates eg hypertention
    , DM , Epilepsy , SCD , Chronic Obstructive Pulmonary
    diseases etc
    Gynaecological History
    • In
    women gynaecological history is sought for and
    documented
    Immunization History
    • This
    usually applicable to paediatric
    surgery
    Drug History and Allergies
    Note all drugs patient is taking ,their doses and duration
    Note the presence or otherwise of specific drug allergies
    and how the allergies manifested
    Family and Social History
     Patient’s family history example, the position amongst his
    sibling, number of children and family history of similar
    illnesses , any deaths in the family and likely causes of the
    deaths
    Smoking and alcohol history , including recreational drug
    use
    Assess patients economic status, where he lives , their
    source water supply etc
    Review of other systems

    History of presenting complaints encompasses


    detailed enquiry into the system(s) related to the
    presenting complaints
    However , a review of other systems entails
    enquiry into remaining systems not captured in
    the ‘body of the history’ to identify unsuspecting
    abnormalities
    GIT ; Vomiting ,Appetite ,regurgitations etc
    Resp System : Cough , hemoptysis, dyspnea
    CVS: Dyspnea ,palpitations ,chest pain etc
    UGS:loinpain/swellings,suprapubic pain,
    LUTS ,hematuria
    Musculoskeletal :muscle pains ,joint swellings
    Common presenting Complaints In Surgery
    Pain

    Pain is one of the commonest presenting complaints


    and it is an indicator disease.
    As subjective as pain is, the doctor should characterize
    the pain using this helpful acronym SOCRATES…
    Site , Onset/periodicity , Character , Associations
    ,Timing , Exercebating/Relieving factors ,Severity
    Lump

    Site
    Duration
    How it was discovered
    Changes in size/Shape
    Associated symptoms eg pain
    Other Lumps
    Preceding history of trauma etc
    PHYSICAL EXAMINATION
    Physical examination is geared towards eliciting signs that
    help in making a diagnosis
    Patient should be comfortable , reassured ,relaxed and a
    chaperone made available especially when examining an
    opposite sex.
    Adequate exposure while ensuring patients dignity is
    assured…adequate screening of patient
    Ensure minimal discomfort or inconveniences
    Appropriate patient positioning is also important.
    The examining doctor stands on the patients right
    Examination in surgery proceeds regionally
    rather than by systems
    2parts : General ( which attempts to ascertain
    patients general state of health) and regional
    examinations.
    Proceed using
    IPPA(Inspection,Palpation,Percussion and
    Auscultation)
    General examination
    Mental health status
    State of consciousness
    Pallor

    Jaundice

    Cyanosis

    Dehydration

    Nutritional status
    Febrile or otherwise
    Edema
    Digital clubbing
    Peripheral Lymph nodes
    Assessment of Vital Signs : Temperature , Pulse ,
    blood Pressure and Respiration( including SPo2)
    Regional Examination
    Examination of the Head and Neck
    Eyes : pupillary reaction to light , sclera for
    jaundice(usually during gen exam) , exophthalmos
    ,fundoscopy
    Ear ,Nose : External auditory canal ,eardrum and
    nostrils
    Chest Examinations :
    Abdominal Examination: should be performed in a warm ,
    private and well lit environment.
    Exposure is from nipple line to mid thigh.
    Remember IPPA Steps in physical examination.
    oInpect the abdomen from the foot of the and patients side at
    eye level
    oInspect for the following : size(distended,full or flat) and
    symmetry,movement with respiration,scars , distended veins,
    visible peristalsis, lumps, pigmentation ,hernia orifices
    oPalpate the abdomen for tenderness,enlarged
    solid organs(Liver,Spleen and Kidneys) and
    abdominal masses/lumps
    oCharacterise any palpable masses
    oPercuss the abdomen to elicit ascites(shifting
    dullness or fluid thrill) , and for characterization
    of certain intraabdominal masses
    oAuscultate the abdomen for bowel sounds aortic
    bruit and succession splash.

    Digital Rectal Examination


    External Gentalia
    •Thank you for
    Listening

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