General Principles Governing History Taking and Physical Examination of the Surgical Patient

Adam Janiak

Clinical study of disease

 History of the patient’s disability  Physical examination

„history is usually the most valuable part of the clinical examination”

Rufus of Ephesus, c. A.D. 100

Building history

    Detective work Inductive reasoning Determination of facts Search for essential clues

Stages of history creation

1.

2.

3.

Satisfactory approach to the patient Giving patient oportunity to tell the story Competent interrogation to clarify patient’s account

Approach to the patient

   Breaking barriers Self-introduction Avoiding the impression of hurry

Patient’s account

   Encouraging by prompting Attentive listening Careful interruption

Interrogation 1

  The current illness  Avoiding repeating the same questions Previous illness and state of health     Illnesses, operations, accidents Past episodes in patient’s descriptions Residence or travel abroad Previous health

Interrogation 2

   Family history   Age and health of relatives Alcoholism or mental disorders in relatives Social history  The home    Occupation Personal interests (amount of physical exercise) Habits (food, tobacco, alcohol, drugs) Psychological assessment

Surgical History Keywords

        Pain Vomiting Change in bowel habits Hematemesis/hematochezia Trauma Family history Past history Patient’s emotional background

Pain

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2.

3.

4.

Main site • • Radiation Referred pain (e.g. diaphragmatic pleurisy) Spread of pain due to extension of the disease (e.g. acute appendicitis) Character Severity

Pain 2

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6.

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Duration Frequency and periodicity Special times of occurrence Aggravating factors Relieving factors Associated phenomena

Vomiting

     What did the patient vomit?

How much?

How often?

What did the vomitus look like?

Was vomiting projectile?

Change in Bowel Habits

 Constipation  Diarrhea  Size and shape of stool

Hematemesis/Hematochezia

   Does it clot?

Is it bright or dark red?

Is it changed in any way?

  coffee-ground vomitus dark, tarry stool

Trauma

    Trauma and chief complaint relationship Accident details  What was the patient's position at the time of accident?

  Was consciousness lost?

Any evidence of retrograde amnesia?

Gunshot or stab wound direction Preexisting diseases

Family History

       Polyposis of the colon Peutz-Jeghers syndrome Chronic pancreatitis Diabetes mellitus Multiglandular syndromes Other endocrine abnormalities Cancer

Past History

 Nutritional background  Drugs

Emotional Background

   Psychiatric consultation Emotional aspects of the patient's illness (patient can be supported far more effectively by the surgeon)   patients with malignant disease those who must undergo mutilating operations (amputation of an extremity, ileostomy, or colostomy) Awareness of psychosocial factors in surgical convalescence   Recovery from a major operation Better total care of the surgical patient.

Physical Examination

 The Elective Physical Examination  The Emergency Physical Examination

Conditions of Physical Exam

   Privacy Comfort Proper illumination of the site

Tools of the Physical Exam

        Stethoscope BP cuff Otoscope Ophthalmoscope Measuring tape Torch Pin Tendon hammer       Thermometer Disposable tongue-depressors Disposable gloves Lubricant Proctoscope Weighing machine Height scale

Techniques of Physical Exam

    Inspection Palpation Percussion Auscultation

Inspection 1: Physical Appearance

       Height, Weight & Build Sexual & Physical Development Posture, Gait & Motor Activity Hair, Nails & Skin appearance Dress, Grooming & Personal Hygiene Odors Facial Expressions & Body Language

Inspection 2: Appearance & Behavior

        Posture & Motor Activity Dress, Grooming & Personal Hygiene Facial Expression Speech & Language Mood Thoughts & Perceptions Insight & Judgment Memory & Attention

Breathing Patterns

Palpation

   Skill and gentleness Laying hands on the patient One-finger examination in precise pain localization

Regions of the abdomen

Pulse Points

Percussion sounds

Auscultation

   Auscultation of the abdomen and peripheral vessels Peristalsis - the nature of ileus presence of vascular lesions (e.g. auscultation of the epigastrium in obstruction of the celiac artery.

Examination of the Body Orifices

    Ears Mouth (palpation of the mouth and tongue) Rectum (DRE, sigmoideoscopy) Pelvis

Data Obtained

    Vital Signs  Pulse    Ventilations (Respirations) Blood Pressure Temperature Height Weight Spo 2

Elements of the Comprehensive Physical Exam

      General Survey Mental Status Vital Signs HEENT Neck Chest      Abdomen Pelvis (as needed) Posterior Body Extremities   Vascular Musculoskeletal Neurologic Exam

The Emergency Physical Examination 1

   Altered to fit circumstances Limited history Primary considerations  Is the patient breathing?

    Is the airway open?

Is there a palpable pulse?

Is the heart beating?

Is massive bleeding occurring?

The Emergency Physical Examination 2

   Action without examination   Penetrating wounds of the heart Large open sucking wounds of the chest   Rapid survey examination after initial life-saving treatment (2-3 min) Additional emergency procedures following survey examination   Massive crush injuries with flail chest Massive external bleeding Control of pain Splinting of fractured limbs   Suturing of lacerations Other

Additional Diagnostic Procedures

   Laboratory tests Imaging studies Special Examinations  Cystoscopy      Gastroscopy Esophagoscopy Colonoscopy Angiography Bronchoscopy

Assessment of Acute Abdominal Pain 1

     Definition: previously undiagnosed pain that arises suddenly and is of less than 7 days' (usually less than 48 hours') duration Caused by:   intraperitoneal disorders (many of which call for surgical treatment) extraperitoneal disorders (which typically do not call for surgical treatment) Abdominal pain > 6 hours = disorders of surgical significance Primary Goal: to determine   if operative intervention is necessary when the operation should be performed

2/3 of patients w/AAP do not require surgery!!!

Assessment of Acute Abdominal Pain 2

    Diagnostic laparoscopy before laparotomy 1/3 of patients exhibit atypical features „Classic Presentations” – historical approach 1921 Sir Zachary Cope

History in Acute Abdominal Pain

          Onset Duration Frequency Character Location Chronology Radiation Intensity of the pain Presence or absence of any aggravating or alleviating factors Presence or absence of any associated symptoms

Abdominal Pain Chart

Pain Onset

   Sudden onset – intra-abdominal disease:    Ruptured abdominal aortic aneurysm (AAA) Perforated viscus Ruptured ectopic pregnancy Rapid progress, intense centering in a well-defined area, duration of a few minutes to an hour or two:   Acute cholecystitis Acute pancreatitis Gradual onset over several hours, beginning as slight or vague discomfort, slowly progressing to steady and more localized pain – subacute process of peritoneal inflammation:     Acute appendicitis Diverticulitis Pelvic inflammatory disease (PID) Intestinal obstruction

Pain Character 1

 Intermittent or cramping pain (colic)          Short period (a few minutes) Longer periods (a few minutes to 1/2 hour) of complete remission Obstruction of a hollow viscus Vigorous peristalsis in the wall of the viscus proximal to the site of obstruction Perceived as deep in the abdomen Poorly localized Patient restless, may writhe about incessantly in an effort to find a comfortable position, often presses on the abdominal wall in an attempt to alleviate the pain Intestinal obstruction – pain usually severe but bearable Obstruction of small conduits (e.g., the biliary tract, the ureters, and the uterine tubes) – often unbearable

Pain Character 2

 Continuous or constant  Present for hours or days without any period of complete relief    More common than intermittent pain Usually indicative of peritoneal inflammation or ischemia.

It may be of steady intensity throughout, or it may be associated with intermittent pain

Pain Character 3

   General burning pain – perforated gastric ulcer Tearing pain – dissecting aneurysm Gripping pain – intestinal obstruction

Character of the pain is not always a reliable clue to its cause!

Pain Location 1

Pain Location 2

Pain Location 3

Pain Radiation

Pain Intensity and Severity

       Related to the magnitude of the underlying insult

Intensity of the pain ≠ the patient's reaction to it !

Pain that is intense enough to awaken the patient from sleep usually indicates a significant underlying organic cause Peritonitis:   Pain exacerbated by motion, deep breathing, coughing, sneezing Patients lie quietly in bed and avoid any movement Acute pancreatitis  Pain exacerbated by lying down  Relieved by sitting up Duodenal ulcer disease – pain relieved by eating or taking antacids Intestinal angina  Diffuse abdominal pain  Appears 30 minutes to 1 hour after meals

Nonspecific Associated Conditions

     Nausea Vomiting   Pain often precedes vomiting in patients with conditions necessitating operation (e.g. acute appendicitis) The opposite is usually the case in patients with nonsurgical conditions Anorexia Diarrhea   Gastroenteritis Incomplente intestinal obstruction Constipation

Nonspecific!

Specific Associated Conditions

       Jaundice Melena Hematochezia Hematemesis Hematuria Fever History of trauma

Specific!

Abdominal Exam in Acute Abdo Pain

     General appearance Degree of pain Patient position Identification of the area of maximal pain Systemic evaluation for shock symptoms    Diaphoresis Pallor Hypothermia     Tachypnea Tachycardia Orthostasis Frank hypotension

Physical Exam in Acute Abdo Pain 1

       Patient resting in a comfortable supine position Inspection Auscultation Percussion Palpation of all areas of the abdomen, the flanks, and the groin (including all hernia orifices) Rectal and genital examinations Full gynecologic examination in female patients

A systematic approach is crucial: an examiner who methodically follows a set pattern of abdominal examination every time will be rewarded more frequently than one who improvises hazzardly with each patient!

The 1st Step – Careful Inspection

  WHERE?

   Anterior and posterior abdominal walls Flanks Perineum and the genitalia WHAT?

           Previous surgical scars (possible adhesions) Hernias (incarceration or strangulation) Distention (intestinal obstruction) Obvious masses (distended gall bladder, abscesses, or tumors) Ecchymosis or abrasions (trauma) Striae (pregnancy or ascites) Everted umbilicus (increased intra-abdominal pressure) Visible pulsations (aneurysm) Visible peristalsis (obstruction) Limitation of movement of the abdominal wall with ventilatory movements (peritonitis) Engorged veins (portal hypertension)

The 2nd Step – Auscultation

    Presence (or absence) of bowel sounds and their quality Absence of bowel sounds = paralytic ileus Hyperactive or hypoactive bowel sounds often are variations of normal activity High-pitched bowel sounds with splashes, tinkles (echoing as in a large cavern), or rushes (prolonged, loud gurgles) = mechanical bowel obstruction

Severe intra-abdominal conditions, even intra abdominal catastrophes, may occur in patients with normal bowel sounds, and patients with silent abdomens may have no significant intra-abdominal pathology at all!

The 3rd Step - Percussion

          Areas of dullness Fluid collections Sections of gas-filled bowel Pockets of free air under the abdominal wall Tympany Bowel obstruction Hollow viscus perforation Estimating organ size and Determining the presence of ascites Demonstrating peritoneal irritation (rebound tenderness)

The 4th Step - Palpation

    Begins far from the area of maximal pain Gradually advances toward this area, which should be the last to be palpated Determining true involuntary muscle guarding (muscle spasm) – indicative of localized or generalized peritonitis Determining the extent and severity of the patient's tenderness    Diffuse tenderness indicates generalized peritoneal inflammation Mild diffuse tenderness without guarding usually indicates gastroenteritis or some other inflammatory intestinal process without peritoneal inflammation Localized tenderness suggests an early stage of disease with limited peritoneal inflammation.

Signs 1

SIGN/FINDING Aaron sign Ballance sign Bassler sign Beevor sign Blumberg sign Carnett sign Chandelier sign Charcot sign Chaussier sign DESCRIPTION

Referred pain or feeling of distress in epigastrium or precordial region on continued firm pressure over the McBurney point Presence of dull percussion note in both flanks, constant on left side but shifting with change of position on right side Sharp pain elicited by pinching appendix between thumb of examiner and iliacus muscle Upward movement of umbilicus Transient abdominal wall rebound tenderness Disappearance of abdominal tenderness when anterior abdominal muscles are contracted Intense lower abdominal and pelvic pain on manipulation of cervix Intermittent right upper quadrant abdominal pain, jaundice, and fever Severe epigastric pain in gravid female

ASSOCIATED CLINICAL CONDITION(S)

Acute appendicitis Ruptured spleen Chronic appendicitis Paralysis of lower portions of rectus abdominis muscles Peritoneal inflammation Abdominal pain of intra abdominal origin Pelvic inflammatory disease Choledocholithiasis Prodrome of eclampsia

Signs 2

Claybrook sign Courvoisier sign Cruveilhier sign Cullen sign Cultaneous hyperesthesia Dance sign Danforth sign Direct abdominal wall tenderness Fothergill sign Grey Turner sign

Transmission of breath and heart sounds through abdominal wall Palpable, nontender gallbladder in presence of clinical jaundice Varicose veins radiating from umbilicus (caput medusae) Periumbilical darkening of skin from blood Ruptured abdominal viscus Periampullary neoplasm Portal hypertension Increased abdominal wall sensation to light touch Slight retraction in area of right iliac fossa Shoulder pain on inspiration Hemoperitoneum (especially in ruptured ectopic pregnancy) Parietal peritoneal inflammation secondary to inflammatory intra abdominal pathology Intussusception Hemoperitoneum (especially in ruptured ectopic pregnancy) Localized inflammation of abdominal wall, peritoneum, or an intra-abdominal viscus Rectus muscle hematoma Abdominal wall mass that does not cross midline and remains palpable when rectus muscle is tense Local areas of discoloration around umbilicus and flanks Acute hemorrhagic pancreatitis

Signs 3

Iliopsoas sign Kehr sign Kustner sign Mannkopf sign McClintock sign Murphy sign Obturator sign Puddle sign Ransohoff sign

Elevation and extension of leg against pressure of examiner's hand causes pain Left shoulder pain when patient is supine or in the Trendelenburg position (pain may occur spontaneously or after application of pressure to left subcostal region) Palpable mass anterior to uterus Acceleration of pulse when a painful point is pressed on by examiner Heart rate > 100 beats/min 1 hr post partum Palpation of right upper abdominal quadrant during deep inspiration results in right upper quadrant abdominal pain Flexion of right thigh at right angles to trunk and external rotation of same leg in supine position result in hypogastric pain Appendicitis (retrocecal) or an inflammatory mass in contact with psoas Hemoperitoneum (especially ruptured spleen) Dermoid cyst to ovary Absent in factitious abdominal pain Postpartum hemorrhage Acute cholecystitis Appendicitis (pelvic appendix); pelvic abscess; an inflammatory mass in contact with muscle Free peritoneal fluid Alteration in intensity of transmitted sound in intra abdominal cavity secondary to percussion when patient is positioned on all fours and stethoscope is gradually moved toward flank opposite percussion Yellow pigmentation in umbilical region Ruptured common bile duct

Signs 4

Rovsing sign Subcutaneous crepitance Summer sign Ten Horn sign Toma sign

Pain referred to the McBurney point on application of pressure to descending colon Acute appendicitis Palpable crepitus in abdominal wall Increased abdominal muscle tone on exceedingly gentle palpation of right or left iliac fossa Pain caused by gentle traction on right spermatic cord Subcutaneous emphysema or gas gangrene Early appendicitis; nephrolithiasis; ureterolithiasis; ovarian torsion Acute appendicitis Right-sided tympany and left-sided dullness in supine position as a result of peritoneal inflammation and subsequent mesenteric contraction of intestine to right side of abdominal cavity Inflammatory ascites

Rectal Examination

        Evaluation of sphincter tone Tenderness (localized versus diffuse) Prostate size and tenderness Hemorrhoids Masses Fecal impaction Foreign bodies Gross or occult blood

Genital Examination

     Adenopathy Masses Discoloration Edema Crepitus

Pelvic Examination

      Vaginal discharge or bleeding Cervical discharge or bleeding Cervical mobility and tenderness Uterine tenderness Uterine size Adnexal tenderness or masses

The possibility that a surgical condition is present should not be prematurely dismissed solely on the basis of a finding of tenderness on pelvic or rectal examination!

Assessment of Acute Abdominal Pain

Evaluation of Abdominal Masses

 Definition: palpable mass that is anterior to the paraspinous muscles and is located anywhere between the costal margins, the iliac crests, and the pubic symphysis. An abdominal mass may be noticed initially by the patient or may be discovered by the surgeon as a new finding

Clinical History

      Onset Duration Character Location Chronology Presence or absence of any associated symptoms (nausea, vomiting, anorexia, diarrhea, constipation, and a decrease in stool caliber)

Physical Examination - Inspection

 Generalized enlargement or distention of the entire abdomen:  Obesity      Tympanites or meteorism Ascites Pregnancy Fecal impaction Neoplasm

(six Fs mnemonic device: Fat, Fluid, Flatus, Fetus, Feces, and Fatal growths)

 One or more discrete masses of varying sizes (respiratory movement?)

Physical Examination - Palpation

              Location Size Shape Consistency (carcinoma may be rock-hard) Surface – smooth or nodular (smooth surface implies diffuse involvement, and a nodular surface suggests neoplastic metastases or granulomas) Tenderness (acute inflammatory process, distention of the capsule of a viscus) Temperature Color of the overlying skin Degree of mobility Fixation or attachments Pulsatility (pancreatic tumor or cyst or a gastric tumor) Fluctuation (cyst, pseudocyst, hematoma, abscess) Response to ballottement Appearance on transillumination

Evaluation of Abdominal Mass

Bibliography

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ACS Surgery: Principles and Practice by Douglas W., Md. Wilmore (Editor), Laurence Y., Md. Cheung (Editor), Alden H., Md. Harken (Editor), James W., Md. Holcroft (Editor), Jonathan L., Md. Meakins (Editor), Nathaniel J., Md. Soper (Editor), Douglas W. Wilmore, Laurence Y. Cheung, Alden H. Harken, James W. Holcroft, Jonathan L. Meakins, Nathaniel J. Soper Publisher: WebMD Professional Publishing; 2nd edition (February 1, 2003) Sabiston Textbook of Surgery: the Biological Basis of Modern Surgical Practic. Courtney M. Townsend, Jr., editor-in-chief; associate editors, R. Daniel Beauchamp, B. Mark Evers, Kenneth L. Mattox. W.B. Saunders Company 2001 Oxford Textbook of Surgery (3-Volume Set) 2nd edition (January 15, 2000): by Peter J. Morris (Editor), William C. Wood (Editor) By Oxford Press Essentials of Surgery: Scientific Principles and Practice 2nd edition (January 15, 1997): by Lazar J., Md. Greenfield (Editor), Michael W. Mulholland (Editor), Keith T. Oldham (Editor), Gerald B. Zelenock (Editor), Keith D. Lillimoe (Editor), Keit Oldham By Lippincott Williams & Wilkins Publishers Current Surgical Diagnosis and Treatment, 11th Ed 2003: Lawrence W. Way, Gerard M. Doherty By McGraw-Hill/Appleton & Lange Principles of Surgery Seventh Edition Editor-in-Chief Seymour I. Schwartz, M.D.

The McGraw-Hill Companies, Inc. 1999