Transcript Document

Fundamental principles in
examination and clinical
diagnosis in surgery
Anamnesis – Case History
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assurance
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Patient must feel that hepl exist.
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Surgeon must have an interest about patient.
Anamnesis
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First – ask patient about the problem, let him
to speak alone
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Second – doctor ask patient slightly more
Offtake anamnesis
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Crime story
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Bleeding from anus
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Haemmorhoides
colorectal cancer
Appearances - Surgical diseases
PAIN
where started? when started?
how it continued?
how is the character of pain?
intensity of pain?
permanet – intermitent?
Patient reaction to pain
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
Vomitus
What is vomitus?-blood, food, juice-gastric, bile
How offten is vomitus?
Chance for doctor to see vomitus.
Change bowel activity
alternation – diarrhoe + constipation- colorectal
cancer
sporadically stools - travelling
Bleeding – hematemesis - enterorhoea
Blood
red, blood digestion – coffee grounds
melena
Trauma
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
Anamnesis
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Family
Personal
Medicamentous
Allergic
Epidemiologic
Social
Actual disease
New situation
Chronic disease – change acut
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
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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
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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
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docho-, duct;
angio-, vessel (blood- or bile-carrying);
litho-, stone.
Third describe what is to be done
 -otomy, to cut (open);
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-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
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percutaneous, via the skin;
trans-, across;
antegrade, forward;
retrograde, backwards.
Examples of terms
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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
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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
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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
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Always record name, age occupation,
method of presentation.
Cover all the principal areas of medical
history:
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
Tips for case presentation
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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.
Tips for case presentation
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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.
Tips for case presentation
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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
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Pain
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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?
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Common surgical symptoms
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Pain
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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?
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Common surgical symptoms
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Pain
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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?
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Common surgical symptoms
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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?
Common surgical symptoms
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Dysphagia
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(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 l˜evel 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).
Common surgical symptoms
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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?
Common surgical symptoms
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Haematemesis
(the presence of blood in vomit).. What colour is the
blood (dark red-brown ˜coffee grounds is old or smallvolume 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).
Common surgical symptoms
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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?
Common surgical symptoms
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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?
Common surgical symptoms
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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?
Common surgical symptoms
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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.)
Common surgical symptoms
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Tenesmus
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(desire to pass stools with either no result or
incomplete satisfaction of defecation).
Suggests rectal pathology.
Common surgical symptoms
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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.)
Common surgical symptoms
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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.
Common surgical symptoms
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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.
Common surgical symptoms
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Paroxysmal nocturnal dyspnoea is
intermittent breathless at night. Both
orthopnoea and paroxysmal nocturnal
dyspnoea suggest cardiac failure.
Common surgical symptoms
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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?
Common surgical symptoms
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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!