ANAMNESIS & PHYSICAL

EXAMINATION SURGERY
dr. Muhammad Rustam HN,M.Kes,Sp.OT
 Rule Of Status

1. History Taking (Chief Complain)

2. Physical Examination
3. Special Test
4. Clinical Findings
5. Differential Diagnosis
6. Additional Examination (Lab, X – Ray, CT – Scan, MRI, USG)
7. Diagnosis
8. Treatment
9. Prognosis
10.Follow Up / Rehabilitation
How to determine the Diagnosis

Physical
Anamnesa Examinatio
(80%) n
(20 %)

DIFFERENTIAL
DIAGNOSIS
How to determine the Diagnosis

Anamnesa
(80 %)
Physical Additional
Examinatio Examinatio
n n
(10 %) (10 %)

DIAGNOSIS
EMERGENCY
TRAUMA STATUS

Primary Survey

Traum < 24 Hours Secondary survey

a > 24 Hours General Status

Local Status
 TRAUMA < 24 Hours

PRIMARY SURVEY
A : Patent
B : RR = 22 x/min,symmetrical spontaneous,thoracoabdominal type.
C : BP = 110/70 mmHg, PR = 88 x/min regular, strong.
D : GCS 15 (E4M6V5), pupil isochors ø 2,5 mm, light reflex +/+
E : T = 36.70 C (axillar)
 SECONDARY SURVEY
Thorax region:
I : haematoma and swelling at right and left shoulder,excoriated
wound at right upper hemithorax, chest expansion assymetric (right
side delayed).
P : Tenderness(+)
TRAUMA > 24 Hours
General status

Moderate illness/poor nourish/Conscious

BP =110/70 mmHg
PR =72 x/min
RR = 20 x/min
T = 36,30 C (axillar)
 Localized status
Right Shoulder Region :
I : Lump sized 32 cm x 25 cm x 17 cm, more shiny than vicinity,
venectation (+), wound (-),hematoma (-)
P : Tenderness (+), Flat surface, immobile, solid, temperature
warmer than environment
A : Bruit (+) at lateral aspect
ROM : Active and passive motion at shoulder joint are limited due to
pain
NVD : Sensibility is good., radial artery is palpable, capillary refill < 2”
 CHIEF COMPLAIN

• KELUHAN UTAMA : Yang paling dikeluhkan pasien sehingga

pasien datang ke dokter atau RS

Nyeri (80 %)
Keluhan Utama
(Poliklinik)
Dll (20 %)
 POLA ANAMNESA
(LOTDYKA)
• Location
• Onset ( suddenly, progressive dll)
• Type (burning, electric, parasthesia dll)
• Duration ( intermitten, by position, continuous dll)
• Yang memberatkan & meringankan
• Kronologis ("please tell me your stories")
• Aktivitas harian yang terganggu ( Toilet, walking,
wearing clothes, eating dll)
 POLA ANAMNESA
(CINTA)
• Congenital: milestone, family history,
Prenatal,natal,postnatal.
• Infection: fever, edem, redness
• Neoplasma: lump, Weight loss, Night pain
• Trauma: MOI, Associated injury, commorbid
• A/Other: AHIM (Aging-Haemathologic/Haemophilic-
Inflamation-Metabolism) .PAST IMM(illness-medicine-
medical)
 Physical Examination

< 24 Jam > 24 Jam

• Primary survey • Primary survey
• Secondary • Secondary
Survey Survey
• Special Test (-) • Special Test (+)
• Clinical Finding • Clinical Finding