IB WCS 15
HISTORY TAKING & PHYSICAL EXAM IN SURGICAL PATIENTS (1)
Dr NG Patil
Surgery
Wed 04-09-02
GROUPS OF SURGICAL PATIENTS
Obvious signs: lumps, swelling, etc
Symptoms and pain - most Pt's complain of pain (eg. Start in right epigastrium then moving to right iliac fossa - usually appendicitis) (Loin pain - kidney)
Blood: haemoptysis, PR bleeding haematuria, haematemesis
Infections: pain, fever, lump (eg. Abscess, cellulitis)
Referrals: GP, psych, O&G have all seen Pt but cannot find problem, therefore refer to surgeon; most referrals on Friday afternoon =)
Therefore can make clinical Dx in surgery in >95% of cases
CASES
R pendulous breast
- L prominent nipple
- Lump found in L breast
® ca breast
Swelling of R leg
- Present for wk-mth
- Developed cellulitis
- Lymphangitis
Elderly Pt with obvious varicose veins (dilated tortuous abnormal veins)
- Present for 5 yr
- Note: Varicocele: in scrotum!
- Veins started bleeding so Pt presented at A&E
- Pt's have benign condition but present when there is some change
Small lump on ulnar side of forearm
- Pt worried it may be cancer
- Pt's have cancer phobia: worry that any lump and bump is cancerous
Mass in neck noticed by Pt
® enlarged LN
- Oral cavity examined - ulcer on tongue
- Dx: carcinoma of tongue with secondaries in LN
- Enlarged LN: (1) Infection (2) Malignancy: must look for primary focus
Pendulous mass on posterior aspect of thigh
- Not extra testicle! (as some previous MBBS said)
- Close to groin - therefore Pt embarrassed
- Genital area and breasts: Pt's present later because they are embarrassed, also tend not to present if they think it's benign
- Hx: important to know how long someone has had a lump for
- Pt's will tell you they have had it for less time than they actually have
MAKING DX IN SURGERY
Anatomical: eg. Lump originating from liver, skin, back (retroperitoneal), headache (from head)
Pathological:
CHINA: Congenital: look at Pt's age
TRAM: Trauma: Hx of trauma?
TRAIN: Tumour: benign, malignant
INFORMATION: Inflammation: bacteria, other causes?
OFFICE: Other: cyst, stones (biliary, gall, kidney), autoimmune disease
SCENARIOS
SCENARIO 1
- Miss Chan, 23-year-old lady was admitted to Accident and Emergency Department with lower abdominal pain, mainly on the right side.
- Medical Officer on call who examined the patient thought it was appendicitis; and she was taken to operating theatre for emergency appendectomy.
- However on operating table it was revealed that appendix was normal and the patient had right-sided ruptured ectopic pregnancy.
Q: What might have happened that led to this misdiagnosis?
A: Forgot to ask about menstrual history; if Pt says she missed period, perform pregnancy test
SCENARIO 2
- Mr. Law, 65-year-old gentleman was seen by his general practitioner for bleeding per rectum.
- He was told that his problem must been due to 'haemorrhoids' and was given suppositories and advised to have high fibre diet.
- Three months after this episode, Mr. Law was admitted to Queen Mary Hospital with hepatomegaly due to secondaries from carcinoma of rectum.
Q: What might have happened?
A: Should perform PR examination
"Pt with abdominal problem - if you don't put your finger in it (ie. PR) you'll put your foot into it!"
SCENARIO 3
- Mr. Li, 80-year-old gentleman was admitted to surgical ward with obstructed inguinal hernia.
- Mr. Li's granddaughter asked the surgeon, "How serious is granddad?"
- "Not too serious!" said the surgeon.
Q: How did he come to this conclusion?
A: Hx and P/E (performed above P/E: pulse, RR, conjunctiva etc and all signs were OK)
FORMAT FOR HISTORY TAKING & PHYSICAL EXAMINATION
HISTORY
6-minute consultation: should have some idea of what is wrong with Pt
Introduction and permission for examination
Identification of the patient
Know the Pt
Writing notes
Cross-matching blood
History of present illness (HPI)
What have you come to hospital / see doctor?
- Chief complaint - OPD (out-Pt dept)
Origin
Progress: what change, what did you do?
Duration: how long have you had it?
- Relevant questions related to chief complaint: eg. Br lump: nipple discharge, change in size, any other swellings, when did menopause start?
Hx: Beware of Pt's who are story-tellers
Past History
Any operations?
Any major illness or hospitalisation
History of diabetes, hypertension, TB (elderly) etc.
Family History
Relevant / Specific Fam Hx only
Eg. Elderly: who is supporting that Pt?
Eg. Ca breast: mother, sister, aunt have ca br?
Personal & Social History
Smoking
Alcohol SAD
Drugs
Drugs: stimulants, depressants, HT, DM
PHYSICAL EXAMINATION
- Permission: can have a chat and then come back 1/2 hr later
- Privacy: curtains
- Presence of escort: for female patients
Genital / Breast problem: be specific in saying to Pt that you need to examine that part
General Examination
- General condition of Pt - ie. Has Pt's disease affected that Pt? Eg. Advanced cancer: malnourished
- Pallor / Jaundice / Cyanosis
: conjunctiva, nails, tongue
- Vital signs
: pulse, BP, RR, temp
- Legs: any bilateral ankle oedema: hypoproteinaemia, cardiac failure, liver failure, kidney failure
- LN
: cervical commonly
Eg. General condition of Pt looks good. On examination of tongue, nails and conjunctiva, no evidence of pallor, jaundice or cyanosis. The pulse is 60 bpm, BP 120/80, I have not measured the RR and temperature
Local
Medicine: examination by systems
Surgery: local examination
IPPA
Regional / Systematic
Depends on observations in general and local examination