fundamental principles in examination and clinical diagnosis in surgery

Fundamental principles in examination and clinical

diagnosis in surgery

Anamnesis – Case History

assurance

Patient must feel that hepl exist.

Surgeon must have an interest about patient.

Anamnesis

First – ask patient about the problem, let him to speak alone

Second – doctor ask patient slightly more

Crime story– Bleeding from anus

Haemmorhoides colorectal cancer

Offtake anamnesis

Appearances - Surgical diseases

PAIN

where started? when started?

how it continued?

how is the character of pain?

intensity of pain?

permanet – intermitent?

so sensitive patient-no objective treatment

agonizing pain- he looks very silent

patient flounce from pain-so reactive patient or

billiary colic, attack – renal colic, attack

so intensive pain-infection, inflammation or

vessel diseases- force patient to composednes

Patient reaction to pain

Vomitus

What is vomitus?-blood, food, juice-gastric, bile

How offten is vomitus?

Chance for doctor to see vomitus.

alternation – diarrhoe + constipation- colorectal cancer

sporadically stools - travelling

Change bowel activity

Bleeding – hematemesis - enterorhoea

Blood

red, blood digestion – coffee grounds

melena

Children – some trauma – parents don´t know

parents take care about small trauma

Syndroma hagridden child

Trauma

Conscience- loos

Retrograde amnesia

Trauma + another disease – heart attack-car accident, epilepsy, DM, hypoglycemia

Trauma

Family Personal Medicamentous Allergic Epidemiologic Social

Anamnesis

New situation

Chronic disease – change acut

Actual disease

Physical examination

Elective

Urgent

Laboratory examination

Laboratory (blood count, biochemical screening,haemocoagulation)

Roentgenology diagnostic (roentgenogram, mammography, USG, CT scan, MRI, MRCP, CT colonoscopy , PET, )

Special examination (endoscopy-gastro-, colono-, cysto-, ERCP, MR )

Terminology in surgery

How to describe an operation The terminology used to describe all

operations is a composite of basic Latin or Greek terms.

First describe the organ to be operated on

lapar-, abdomen (laparus = flank); nephro-, kidney; pyelo-, renal pelvis; cysto-, bladder; chole-, bile/the biliary system; col(on)-, large bowel; hystero-, uterus; thoraco-, chest; rhino-, nose; masto/mammo-, breast.

Second describe any other organs or things involved in the procedure

docho-, duct; angio-, vessel (blood- or bile-carrying); litho-, stone.

Third describe what is to be done

-otomy, to cut (open); -ectomy, to remove; -plasty, to change shape or size; -pexy, to change position; -raphy, to sew together; -oscopy, to look into; -ostomy, to create an opening in (stoma = mouth); -paxy, to crush; -graphy/gram, image (of).

Lastly add any terms to qualify how or where the procedure is done

percutaneous, via the skin; trans-, across; antegrade, forward; retrograde, backwards.

Examples of terms

Choledochoduodenostomy an opening between the bile duct and the duodenum.

Rhinoplasty nose reshaping. Pyelolithopaxy destruction of pelvicalyceal stones. Bilateral mastopexy breast lifts. Percutaneous arteriogram arterial tree imaging by direct

puncture injection. Loop ileostomy external opening in the small bowel with two

sides. Flexible cystourethroscopy internal bladder and urethral

inspection.

History taking and making notes

Making medical notes All medical and paramedical professionals

have a duty to record their input and care of patients in the case-notes. These form a permanent legal and medical document. There are some basic rules.

Write in blue or black ink other colours do not photocopy well.

History taking and making notes

Date, time, and sign all entries: always identify retrospective entries.

Be accurate. Make it clear which diagnoses are provisional. Abbreviations are lazy and open to misinterpretation;

avoid them. Clearly document information given to patients and

relatives. Avoid non-medical judgements of patients or relatives.

Basics

Always record name, age occupation, method of presentation.

Cover all the principal areas of medical history:– presenting complaint and past history relevant to it;– other past medical history, drug history, and

systematic enquiry;– previous operations/allergies/drugs;– family history, social history, and environment.

Presenting complaint

This is a one- or two-word summary of the patient's main symptoms, e.g. abdominal pain, nausea and vomiting, swollen leg, PR bleeding.

In emergency admissions do not write a diagnosis here (e.g. ischaemic leg). The diagnosis of referral may well turn out to be wrong.

In elective admissions it is reasonable to write: ˜elective admission for varicose vein surgery.

History of presenting complaint

This is a detailed description of the main symptom and should include the relevant systems enquiry.

Try to put the important positives first, e.g. right-sided lower abdominal pain, sharp, worse with moving, and coughing, anorexia 24h.

Include the relevant negatives, e.g. no vomiting, no PR bleeding.

History of presenting complaint

Be very clear about chronology of events. In a complicated history, or with multiple

symptoms use headings, e.g. Current episode, ˜Previous operations for this problem, ˜Results of investigations.

Summarize the results of investigations performed prior to admission systematically: bedside tests, blood tests, histology or cytology, X-rays, cross-sectional imaging, specialized tests.

Past medical history

Ask about thyroid problems, TB, hypertension, rheumatic fever, epilepsy, asthma, diabetes, and previous surgery, specifically.

List and date all previous operations. Ask about previous problems with an anaesthetic. Asking ˜Have you ever had any medical problem, or

been to hospital for anything? at the end often produces additional information.

Systematic enquiry

This is extremely important and often neglected. A genitourinary history is highly relevant in young females with pelvic pain. A good cardiovascular and respiratory systems enquiry will help avoid patients being cancelled because they have undiagnosed anaesthetic risks.

Systematic enquiry

Older patients may have pathology in other systems that may change management, e.g. the patient with prostatism should be warned about urinary retention.

Cardiovascular. Chest pain, effort dyspnoea, orthopnoea, nocturnal dyspnoea, palpitations, swollen ankles, strokes, transient ischaemic attacks, claudication.

Systematic enquiry

Respiratory. Dyspnoea, cough, sputum, wheeze, haemoptysis.

Gastrointestinal. Anorexia, change in appetite, weight loss (quantify how much, over how long).

Genitourinary. Sexual activity, dyspareunia (pain on intercourse), abnormal discharge, last menstrual period.

Neurological. 3 Fs: fits; faints; funny turns.

Social history

At what time did they last eat or drink? Ask who will look after the patient. Do they

need help to mobilize? Smoking and alcohol history.

Tips for case presentation

Practise. Every case is a possible presentation to someone!

Always ˜set the scene properly. Start with name, age, occupation, and any key medical facts together with the main presenting complaint(s).

Be chronological. Start at the beginning of any relevant prodrome or associated symptoms; they are likely to be an important part of the presenting history.


Be concise with past medical history. Only expand on things that you really feel may be relevant either to the diagnosis or to management, e.g. risks of general anaesthesia.

For systematic examination techniques see the relevant following pages.

Always summarize the general appearance and vital signs first.


Describe the most significant systemic findings first but be systematic ˜inspection, palpation, percussion, and auscultation.

Briefly summarize other systemic findings. Only expand on them if they may be directly relevant to the diagnosis or management.


Finally, summarize and synthesize don't repeat. Try to group symptoms and signs together into clinical patterns and recognized scenarios.

Finish with a proposed diagnosis or differential list and be prepared to discuss what diagnostic or further evaluation tests might be necessary.

Common surgical symptoms

Pain Pain anywhere should have the same features

elicited. These can be summarized by the acronym SOCRATES.

Site. Where is the pain, is it localized, in a region. or generalized?

Onset. Gradual, rapid, or sudden? Intermittent or constant?

Character. Sharp, stabbing, dull, aching, tight, sore?


Pain Radiation. Does it spread to other areas? (From loin

to groin in ureteric pain, to shoulder tip in diaphragmatic irritation, to back in retroperitoneal pain, to jaw and neck in myocardial pain.)

Associated symptoms. Nausea, vomiting, dysuria, jaundice?

Timing. Does it occur at any particular time?


Pain Exacerbating or relieving factors. Worse with deep

breathing, moving, or coughing suggests irritation of somatic nerves either in the pleura or peritoneum; relief with hot water bottles suggests deep inflammatory or infiltrative pain.

Surgical history. Does the pain relate to surgical interventions?


Dyspepsia (epigastric discomfort or pain, usually after

eating). What is the frequency? Is it always precipitated by food or is it spontaneous in onset? Is there relief from anything, especially milky drinks or food? Is it positional?


Dysphagia (pain or difficulty during swallowing). Is the symptom new

or longstanding? Is it rapidly worsening or relatively constant? Is it worse with solid food or fluids? (Worse with fluids suggests a motility problem rather than a stenosis.) Can it be relieved by anything, e.g. warm drinks? Can the patient point to a ˜level of hold-up on the surface (usually related to the sternum)? This often accurately relates to the level of an obstructing lesion. Is it associated with ˜spluttering (suggests tracheo-oesophageal fistula).


Acid reflux (bitter or acidic tasting fluid in the pharynx or

mouth). How frequently? What colour is it? (Green suggests bile, whereas white suggests only stomach contents). When does it occur (lying only, on bending, spontaneously when standing)? Is it associated with coughing?


Haematemesis (the presence of blood in vomit).. What colour is the

blood (dark red-brown ˜coffee grounds is old or small-volume stomach bleeding; dark red may be venous from the oesophagus; bright red is arterial and often from major gastric or duodenal arterial bleeding). What volume has occurred over what period? Did the blood appear with the initial vomits or only after a period of prolonged vomiting (suggests a traumatic oesophageal cause).


Abdominal distension Symmetrical distension suggests one of the

5 F (fluid ascites, flatus due to ileus or obstruction, fetus of pregnancy, fat, or a ˜flipping big mass). Asymmetrical distension suggests a localized mass. What is the time course? Does it vary? It is changed by vomiting, passing stool/flatus?


Change in bowel habit May be change in frequency, or looser or

more constipated stools. Increased frequency and looser stools suggests a pathological cause. Is it a persistent or transient? Are there associated symptoms? Is it variable?


Frequency and urgency of defecation New urgency of defecation is almost always

pathological. What is the degree of urgency how long can the patient delay? Is there associated discomfort? What is passed is the stool normal?


Bleeding per rectum What colour is the blood? Is it pink-red and only on

the paper when wiping? Does it splash in the pan? (Both suggest a case from the anal canal.) Is it bright red on the surface of the stool? (Suggests a lower rectal cause.) Is the blood darker, with clots or marbled into the stools? (Suggests a colonic cause.) Is the blood fully mixed with the stool or altered? (Suggests a proximal colonic cause.)


Tenesmus

(desire to pass stools with either no result or incomplete satisfaction of defecation). Suggests rectal pathology.


Jaundice (yellow discoloration due to

hyperbilirubinaemia; . How quickly did the jaundice develop? Is

there associated pruritus? Are there any symptoms of pain, fever, or malaise? (Suggests infection.)


Haemoptysis (the presence of blood in expectorate). What

colour is the blood? (Light pink froth suggests pulmonary oedema.) Are there clots or dark blood? (Infection or endobronchial lesion.) How much blood? Moderate bleeds quickly threaten airways: get help quickly.


Dyspnoea (difficulty in or increased awareness of

breathing). When does the dyspnoea occur quantify the amount of effort. Is it positional?

Orthopnoea is difficulty in breathing that occurs on lying flat: quantify it by asking how many pillows the patient needs at night to remain symptom-free.


Paroxysmal nocturnal dyspnoea is intermittent breathless at night. Both orthopnoea and paroxysmal nocturnal dyspnoea suggest cardiac failure.


Claudication (the presence of pain in the muscles of the

calf, thigh, or buttock precipitated by exercise and relieved by rest). After what degree of exercise does the pain occur (both distance on the flat and gradients)? How quickly is the pain relieved by rest?


Rest pain (pain in a limb at rest without significant

exercise) How long has the pain been present? Is it intermittent? Does it occur mainly at night? Is it relieved by dependency of the limb involved?

Thank you for your attention!

fundamental principles in examination and clinical diagnosis in surgery

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