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Today we will take about history and physical examination in general surgery and anesthesia (because its included in pre-operative procedure). *General rules in history taking : 1- Welcome the patient - ensure comfort and privacy 2- Know and use the patient's name - introduce and identify yourself 3- Set the Agenda for the questioning (history taking) 4- Use open-ended questions initially 5- Negotiate a list of all issues - avoid excessive detail initially Chief complaint(s) and other concerns Specific requests (i.e. medication refills) Clarify the patient's expectations for this visit - ask the patient "Why now?"

6- Elicit the Patient's Story

Its differ than history of disease which means: the progression of a disease .

7- Return to open-ended questions directed at the major problem(s) 8- Encourage with silence, nonverbal cues, and verbal cues 9- Focus by paraphrasing and summarizing

*patients: root of administration

Ex: if pt. has been transferred from ICU in basma hospital to ICU in king Abdulla Hospital >> outer transfer Ex: if pt. Has been administered to the medical care >surgical care >surgical Team >> internal transfer.

*You have two types of presentations : 1- Cold present./complain > When pt. comes in out clinic and u begin ur examination by take history (elective cases ) - in office long duration of complain

2- Hot present. / complain > When pt. are in emergencies, so u have 1st to control his conditions then go u take history when he becomes stable in emergency short duration of complain .

Usually vomiting ,sever pain , mass can bring pt. to emergency .

How do I know if my pt. is stable? Looking to him, body language, language contact, nonverbal language. if my pt. is obeying my commands so he is at least 50%consiounes >> which Indicates for normal wake up science.

*Components of the History 1- Chief complaint This is why the patient is here in the emergency room or the office (out clinic). U should concern about the duration and onset of it. Examples: Shortness of breath for 2 days Chest pain of 3 hours Pt. with right upper quadrant colic pain from 2 horse, maybe its gallbladder stones but it form in 2 h. So we think about other diseases. 2- History of Present Illness This is the detailed reason why the patient is here

We analysis the chief complain to know its effect on effected organ, system of the whole body.

It is the why, when and where, etc Use the OPQRSTA approach to cover all aspects of information OPQRSTA <> Onset When did the chief complaint occur <> Prior occurrences of this problem <> Progression Is this problem getting worse or better Is there anything that the patient does that makes it better or worse Using scaling system can help u to draw the line of pain presentation. <> Quality Is there pain, and if so what typehow would the patient describe it is words Chronic pain = discontinuous = such as obstruction of lumen GIT , biliary tract , urinary track

Continuous pain = dental caries, Abscess <> Radiation Do the symptoms radiate to anywhere in the body, and if so, where? To know the side of presentation and from which organ or system is come <> Scale On a scale of 1 to 10, how bad are the symptoms <> Timing When do the symptoms occur? At night, all the time, in the mornings, etc <> Associated symptoms Ask if there is anything else that the patient has to tell about the chief complaint To know other symptoms goes parallel with chief complain

Location Length of time Severity Qualit 3- Past Medical History These are the medical conditions that the patient has chronically and that they see a doctor for. Examples: Hypertension, GERD, Congestive heart failure, Diabetes, Asthma, Thyroid problems, etc 4- Past Surgical History These are any previous operations that the patient may have had Make sure to put how old the patient was when they occurred Include even those that occurred in childhood It will guide u to other investigations and help u to rule out others Examples: Tonsillectomy, Hysterectomy, Appendectomy, Hernias, Cholecystectomy Pt. with upper and lower right quadrant abdominal pain , his may be abdominal appendicitis , but if he had already appendectomy so I should rule out this option .

5- Allergies Make sure to ask about medication allergies and the reaction that the patient has to them so u can think in other disease. Ask about latex, food and seasonal allergies 6-Medications Include all meds the patient is oneven over the counter meds and herbals Try to include the dosages if the patient knows them Include how often the patient takes them

7-Social History Things to include: Occupation Marriage status Tobacco usehow much and for how long Alcohol use Illicit drug use Immunization status

8-Family History Ask if the patients parents, grandparents, siblings or other family members had any major medical conditions Examples: Heart disease, heart attacks, hypertension, hyperlipidemia, diabetes, sickle cell disease, breast and colon cancer. 9- Review of Systems The review of systems is just that, a series of questions grouped by organ system including: General/Constitutional Skin/Breast Eyes/Ears/Nose/Mouth/Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Neurologic/Psychiatric Allergic/Immunologic/Lymphatic/Endocrine

*physical examination : To improve or rule out the differential diagnosis that we had thought of. Pt should be in supine position .

Pt. must feel comfort, privacy while we are diagnosing. U must be smart enough to look around pt. environment and know some of complains (when u go to pt. home)

ex: if u found basket >> he may complain of vomiting it includes : General Heart Lungs Abdomen (most important) Extremities Neck GU if pertinent to the chief complaint So u had to examine all that first then focused about ur target . Make sure to include vital signs as part of this Develop a systematic approach for doing the physical exam

How to exam pts. ? Neck >> expose the upper third of the body from the mid midline and up Abdomen >> expose the middle line to the mid high line Lower limbs > expose both of them and keeping in mind we are going to compare both of them ( sorry , its not clear !! )

*Component of physical examination : For some disease we have some disease to be performed to reflect something 1- Inspection 1st: I check my anatomical layer, we usually start with the skin and focuses on the hidden areas . Ex: while examining lower limbs, u should check nails and websites between fingers and toes,

Color Vascularity Lesions Temperature Turgor Texture Wounds

Clubbing of Fingernails

2nd : I go to the subcutaneous layer which composes of fat and veins (no arteries), I may found dilated vein, or superficial mass. If pt have a dressing > so for sure he had traumatic injury , I can ask him to remove it for good diagnosing .

3rd : to the Abdomen Contour Size Bowel sounds Tenderness Palpate bladde the abdominal wall .

All these >> increase the intraperitoneal pressure > then hernia will be shown >> this is called : visible cough impulse

In Some cases, hernia is not shown such as obstructed or complicated one , so pt. in this case is directed to emergency Ex: we have found a mass >> u should check five (s) :{ shape sites - side surface } and the overlaying structure of that mass, surrenders and edges . *the surface could be smooth , nodular , non nodular - charge discharges , * if the mass is connected to the skin > so there if no overlaying structures *We should check the symmetry of right side with left side of the abdomen, contour of abdomen, if it flat or descended or scaphoid

Another way to check the abdominal wall:

*We should check Pattern of respiration: while respiration, our abdominal wall moves specially in female . If I have inflammatory process inside my peritoneal cavity, then any movement of the abdominal wall will irritate the peritoneum > feeling pain Thats mean pt. with acute abdominal inflammation cant use his ant. Abdominal wall in respiration, this indicates malignancy (sever not cancer) > so pt. have periodontitis > need surgery in most cases

Peritoneal content ( content of the abdomen ) , u may found intestinal obstruction . I can see huge mass in peritoneal cavity by examining symmetry

Retroperitoneal content , pt with huge liver or spleen . Then retroperitoneal organs : aorta and pancreas. Ex : hemorrhagic pancreatitis, and it will give a sign as subcutaneous bleeding In aorta , we can check epigastric area by pulsation . 2- Palpation This is the 1st time we touch the pt. We can check his temperature (although checking temp. is a verbal cues that should be checked before physical examination ) Its divided into:

Light / superficial Definition To examine the wall

Deep to examine the content Deep tenderness masses

What to check?

Tenderness masses - Muscle tone - Wall defect

ABOUT LIGHT PAPLATION Ex : pt with subcutaneous lipoma , then when pt. cough the ant. Abdominal wall will be contracted and the lipoma will pushed up and thats what called visible cough impulse >> u may think that its hernia, but it is not, why ?? >> if

u pulped it again and again , there will be no pulpal cough impulse and no Fascial defect >> so its not hernia Hernia: its a primary pathology in the fascia of ant . Abdominal wall . ABOUT DEEP PALPATION U can divide it into 4 major area or nine sub-ones, but keep in mind u had to examine clockwise or counter clock wise In any cases that u found a mass u have to write the five( s ).

3- Percussion Its specific test that is done for the pt. to give him a cue about hidden content in the peritoneal cavity , we divided the sound result into : tympanic , resonance ,hyperesonance , dullness , flatness

Then u can complete ur examination using telescope until u reach target organ . (49:5 49 :34) !!! *When u hear the sound u have to know : Site intensity duration frequency of it >> these are called general survey


*General Survey Age, sex, race Body build, height, weight Posture and gait If pt have acute appendicitis and he his obese , this fat will act as isolator to the syndrome to appear , so pt. will only feel abdominal pain and loss apatite , also he will have abnormal gait Hygiene and grooming Signs of Illness Affect Cognitive Processes

*Head and Neck examination Inspect scalp and hair Facial Symmetry Ears Inspect Nose Mouth Checks the skin over the neck and head, u know that the Sternocleiodmastoid muscles divided the neck into ant. And post. Triangle Neck ROM

Lymph Nodes Palpate trachea Palpate carotids Auscultate carotids Assess for JVD

*This is superficial lymph node enlargement. *Post. Triangular lymph node or lymphopathy is more serious than ant. Ones because in most cases the ant. Lymph node are infectious but the post ones either TP or malignant. By looking to the external jangler vein and palpate it , we can take a cue about the hemodynamic static of the pt. how ? All the body veins are valved veins except the portal and head and neck veins , so if u lay down and hang ur head below ur heart then u will feel pressure inside ur head because blood rushed to ur heads . In most of the times, ur head is above ur heart, in this status, the blood will be drop dynamically down to ur heart .

*Chest examination We should calculate the respiratory rate Respirations labored unlabored Chest shape

Chest symmetry Breath sounds

These are the sites in which we put our telescope in order to hear the respiratory sounds; it should be symmetrical in right and left

*Extremities ROM present ( rang of movement ) Strength Capillary refill > it will reflect the perfusion to the target Peripheral pulse > help in knowing if pt. have peripheral vascular disease Edema Nails

*Assessment and Plan This is what you think is wrong with the patient, and what you plan to do initially during admission so u may need to change ur primary deferential diagnosis after physical examination .

Example: -A/P: 1. Chest pain. We will admit the patient to the chest pain protocol. We will get EKG every 8 hours times three, and cardiac enzymes every eight hours times three, get a CBC, KFT, Lipid Profile, etc -I may think of acute appendicitis then when I found a scar and re - ask the pt. again about it , my diagnosis will change into appendicostomy .

After sitting ur 2nd deferential diagnosis , this will lead u to ask for 59:22 ., then this will lead u to prepare ur pt to anesthesia I may need chest x ray as a part of pre-operative assessment for anesthesia , sometimes I cant ask pt .to have x- ray such in pregnant female . classify ur pt into : 1- Pt fit for surgery and pre surgical intervention case 2- pt. is not fit for surgery

pt comes to emergency room in top of surgical intervention and have acute appendicitis , and sometimes if we didnt do surgery then pt may have another consequences. **** so this case is divided into : fit for surgery and not fit If the case is sever and the life life-threating , so we had to make the agreement of the pt and this called conformed concept ,we should tell the pt about his status and what may happen if we do or not do the surgery .

we may found pt beyond surgical intervention , And also these either to be fit or not fit Example : pt with metastatic breast cancer , and female start to complain from this Brest mass , Is she fit for surgery while the malignancy is over her body ? this is what we called : the beyond surgical intervention

-we can make the surgery for cosmetic fake but this isnt radically -the mass is in her Brest will not kill the pt. but the malignance spread will do.

*History and Physical This will all become like second nature after you have done a few. Just stick to the same way you do the H and P each time, and you will do all right.

>> Present and absent is important , we have 10 marks on attendance

Forgive me for any mistake, I tried my best . Made by : Farah Salem