Clinical Surgery: A Text and Atlas Sunil Chumber
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1History, Signs and Symptoms
  1. History of the Patient
    Anurag Srivastava, Maneesh Singhal, Sunil Chumber
  2. Symptoms and Signs
    Anurag Srivastava, Maneesh Singhal, Sunil Chumber
  3. Lump, Ulcer, Sinus and Fistula
    Anurag Srivastava, Sushma Sagar, Sunil Chumber
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History of the Patient1

Anurag Srivastava,
Maneesh Singhal,
Sunil Chumber
 
 
FIRST CONTACT WITH A PATIENT
A patient comes to a doctor when he is unwell or as a patient on a follow-up visit when he has earlier undergone treatment. Rarely, he may be a part of a study or trial.
The first contact with the patient for most doctors is in their clinics, in the outpatients’ departments (OPDs), in the Casualty (Emergency) or in follow-up or specialized clinics in hospitals. In India, the first contact may be in health camps or during medical examinations conducted prior to taking-up employment.
In this chapter, we will learn how to approach a patient from the time of his first contact or arrival at the hospital or clinic, evaluating his symptoms and examining him for signs of disease, proceed through his investigations, plan his treatment up till his discharge from the hospital. This total process is presented as a general protocol and should be applied to all patients, who come to the doctor/surgeon. Every student should learn this protocol and practice this regularly as it is the dire necessity of this profession. The description on management strategies are beyond the scope of this text.
The protocol has to be followed when attending to a patient is as under:
  • History
  • Physical examination
  • Investigations
  • Diagnosis
  • Management—both medical and surgical treatment
  • Monitoring (in the postoperative period)
  • Discharge
  • Follow-up of the patient
  • Termination of follow-up.
We have all observed senior doctors making a diagnosis of the moment, the patient enters the clinic, a reflection of the years of experience in observing patients. This skill in making a very quick on the spot diagnosis is called pattern recognition (Figs 1.1A and B). You will also (one day) acquire this competence after repeatedly observing the same condition.
Most patients come to the doctor accompanied by some close relative or friend. One should retain such persons while taking the history as they can often provide invaluable information about the patient's behavior, symptoms or signs. The accompanying person or attendant may provide crucial information on the mode of injury in patients with road traffic accidents (RTA) or spells of unconsciousness. Rarely, a patient is alone, when he will require a few grams of extra care.
 
TAKING A HISTORY
 
Details of the Patient
It is a good practice to greet the patient with words, such as namaste, etc. when he enters the clinic (Fig. 1.2). Prior to obtaining the history, the examiner should obtain the following details about the patient:
 
Name
The examiner must address the patient by his or her name with respect. It is wrong to discuss patients by their bed or ward numbers. There is no doubt that the patient is immensely pleased when addressed by his name like—Hello! Mr Lal and this practice establishes an instant rapport. When talking to children, one must address them by their names and with a smile!
 
Age
It is wise to ask the patient directly what his/her age is? Do not try to estimate the age of the patient as looks may be misleading.4A
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Figs 1.1A and B: Plexiform neurofibroma
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Fig. 1.2: Scars of smallpox acquired in childhood
A patient coming from a rural area at forty often looks very different from a patient from an urban area. This is more so for women! However, both groups of patients are often prone to the same diseases (Fig. 1.3).
Certain conditions are present from birth and are called congenital anomalies. These include cleft lip and/or cleft palate, cystic hygroma, and meningocele. Some of the congenital anomalies present later in life, e.g. branchial cyst or branchial fistula. Malignant diseases or carcinomas are seen in people often beyond their forties. Sarcomas may be seen in younger persons also. Wilm's tumor is mostly seen in infants and children. Appendicitis is commonly seen in young. Benign hypertrophy of prostate, cancer, cataract and osteoarthritis are diseases of old age and often seen together.
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Fig. 1.3: Severe jaundice in a patient with cancer of gallbladder(serum bilirubin was 28 mg/100 mL)
 
Sex
Hemophilia is exclusively seen in males. Diseases of the thyroid—multinodular goiter, thyrotoxicosis, thyroiditis and thyroid cancer are more common in women. Honeymoon cystitis is exclusively seen in women. Cancers of lung, stomach, colon and kidneys are more commonly seen in men. Some conditions like visceroptosis or mobile kidney are commoner in women, especially those who have lost weight recently.
 
Occupation
Some diseases are more often associated with certain profession, e.g. varicose veins are commonly seen among policemen, teachers and surgeons. Perineal problems 5like fissure in ano or fistula in ano are associated with vehicle-drivers. Pilonidal sinus was at one time commonly known as jeep-bottoms. Workers in industries too carry a higher risk of certain diseases. In persons working in aniline dye factories, the risk of urinary bladder carcinoma is higher. Carcinoma of the scrotum was identified with chimney-sweeps. Low-backache is more commonly seen in people working in offices requiring long hours at the desk.
Among sports injuries, injury to the medial semilunar cartilage of the knee is common among football-players. Repetitive stress injury or trauma (RSI or RST) are seen in persons working on vibration-tools or typing long hours on computers.
Inflammations of certain bursae due to repeated friction of the skin over the bursae, e.g. student's elbow or housemaid's knee are uncommon now.
 
Geographic Distribution
Certain diseases are endemic to a particular region (Fig. 1.4). Gallstone disease is commonly seen in north India whereas peptic ulcer is more common in south India. Amoebiasis is endemic in the whole country. Filariasis is common in Bihar, Odisha (Orissa) and parts of West Bengal. Leprosy is commoner in Odisha (Orissa), Andhra Pradesh and West Bengal. Bilharziasis is common in Egypt and Sleeping-sickness in Africa. Hydatid disease is seen in sheep-rearing districts of Australia, Turkey, and Iran and in north India. Kangri cancer is seen among the residents of Kashmir who have the habit of carrying the kangri (an earthenware filled with burning charcoal to keep themselves warm) inside their dress.
It must be borne in mind that certain persons are residents of certain areas but migrate to bigger cities in search of jobs or after marriage. They may still continue to carry the risk of diseases of those areas, e.g. women from mountainous north India may manifest with thyroid diseases even after migrating to the plains.
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Fig. 1.4: Geographic distribution—fluorosis of teethaffecting two generations
The student must write the full postal address of the patient, telephone or mobile number and email address, if any, for future correspondence.
 
Socioeconomic Status
Pulmonary and abdominal tuberculosis is more commonly seen in patients of poor socioeconomic status due to crowded living conditions and malnutrition. Acute appendicitis was at one time considered as a disease in individuals of high socioeconomic status.
India is overall a poor country and therefore, diseases of the poor are more common. However, it is emphasized that many rich are also afflicted with diseases of the poor. Tuberculosis is seen equally in both South Extension* and Sangam Vihar**.
 
Religion
The name of the patient often gives away the religion. Carcinoma of penis, and phimosis is not seen in Muslims owing to circumcision in infancy. On the other hand, intussusception and sigmoid volvulus is common in the month of fasting during Ramzan.
 
Presenting Complaints
The presenting or chief complaints of the patient should be recorded in the order of their appearance. The patient should be asked to clearly list the complaints that have brought him to the doctor. Sometimes, the patient may not be able to give the details, in which case, the attendant or informant may be asked about the same. The questions to be posed to the patient should be:
What are your problems or complaints? or why have you come to a doctor or what brings you here? or how can I help you?
How long have you had this or these problems?
When were you last completely well?
The answers should be recorded in a chronological order, for example,
  • Pain in the abdomen
3 years
  • Nausea and vomiting
1 month
  • Jaundice
1 week
If a few complaints start simultaneously, they should be listed in order of severity.
  • Severe pain abdomen
1 month
  • Lump abdomen
1 month
  • Weight loss
1 month
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History of Present Illness
This history of the present or current illness should begin from the onset of the first symptom and proceed to till the time of presentation to the doctor. The history of the present illness should be enquired in such a manner as to bring out the following details:
 
Onset
To know the mode of onset, the patient is asked—How did the problem start?
The onset of symptoms may be sudden or gradual. A precipitating event, if the patient can recall should be elicited.
 
Progression of Disease
To know about the progression of disease, the patient should be asked—Have you become better, remained same or deteriorated since the onset of symptoms?
The progression of the disease with evolution of symptoms in the exact order of their occurrence should be recorded. These details should be recorded in the patient's own language and not in scientific terms. The patient should be allowed to describe his own story of symptoms.
 
Direct Questioning
After eliciting the history of present illness, several direct questions may be asked to the patient. As far as possible do not ask leading questions or questions which have an answer in yes or no. The question should be such that it leaves the patient with a free choice of answers. Sometimes negative answers are more valuable in arriving at a diagnosis and should not be disregarded!
 
Past History
Any diseases that the patient may have suffered in the past should be recorded. Particular attention is paid to tuberculosis, asthma, cancer, syphilis, gonorrhea, diabetes or bleeding tendencies. The patient should be questioned about any admission to the hospital for a long illness, any major trauma that he may have sustained or any operation that he may have undergone. The dates and the types of operations should be mentioned in a chronological order.
During the course of the illness, the patient would have consulted some doctor or received some form of treatment. One must find out this information and how the patient has responded to the treatment.
 
Treatment History
The patient should be questioned about any drugs or medications that he may be taking. This should include information on any alternative medicine prescriptions or Ayurvedic or Unani preparation. A large number of patients attending the hospitals may be on medications for some other illnesses such as oral hypoglycemics, insulin, antihypertensives, diuretics, aspirin, steroids, hormone replacement therapy (HRT) or contraceptive pills. This history may provide some valuable clues about the current illness.
This is also useful subsequently when planning the operation and the postoperative care. The patient should also be asked about allergies to any medicine or diet. The allergy to any named drugs should be noted on the medical and bedside records. All of these are of special relevance during litigation.
 
Personal History
Several patients over their lifetime have acquired vices or habits that may be directly or indirectly contributory to the illness. Hence, the examiner must enquire about:
  • Smoking: Cigarettes, cigar or pipe or hookah and the quantity and frequency. *
  • Intake of alcohol: Quality and quantity and duration. **
  • Dietary habits: Regular or irregular, vegetarian or non-vegetarian, takes spicy food or not.
  • Marital status: Whether married or single, divorced or widowed or in a relationship or not.
  • Pets: Whether the patient has any pets at home, e.g. dogs or lives in the vicinity of animals, e.g. cattle with farmers.
 
Work and Hobbies
What sort of work does the patient do?
If retired, what do they do to stay busy?
What are his hobbies? Is he physically active?
These questions do not necessarily reveal information directly related to the patient's health. However, it is nice to know something about their personal life to understand and about the disease process better. This may help improve the patient-physician bond and convey that you care about them as a person. It also gives you something to refer back 7during later visits, letting the patient know that you paid attention and really remember them.
 
Gynecological and Obstetric History
In a female patient, the menstrual history must be recorded as follows:
  • Periodicity: Whether the patient is having regular menstrual cycles or not, the number of days of menstruation.
  • Associated pain: Whether any pain is associated with menstruation or not.
  • Last menstrual period (LMP) and last date of last menstruation.
The number of pregnancies and miscarriages should be recorded year wise. If the patient has undergone Cesarean section, the reasons of this should be enquired into.
 
Sexual Activity
This subject is considered as a taboo in our society and most practitioners are uncomfortable with this line of questioning. However, it can provide important information and should be pursued. It is not possible, by looking at a person, to decide who is sexually active and in what type of activity. The process will be less awkward if all the patients are asked the following questions:
  • Are they married or involved in a stable relationship?
  • Do they participate in intercourse?
  • Has there ever been with same sex also? (very carefully)
  • Do they use condoms or other means of birth control?
  • How is the health of spouse?
  • Any history of sexually transmitted diseases in the past?
  • Do they have children? If so, are they healthy?
 
Family History
Several diseases are seen in other members of the family also. Diabetes, hypertension, hemophilia, multiple endocrine neoplasia and breast cancer are noted in other family members also. The health of all other family members should be enquired and if any of them have died, the cause of this should be noted.
 
History of Immunization
Immunization for major illnesses like tuberculosis, diphtheria, tetanus, pertussis (DPT) or whooping cough and poliomyelitis should be enquired, especially in children and elderly.
 
PHYSICAL EXAMINATION
The physical examination, in fact, starts the moment the patient enters the clinic. The examination should be conducted in a separate adjacent room, in a quiet atmosphere with good lighting, preferably with sunlight coming in. The examination should be unhurried. Only then will you get the cooperation of the patient.
When examining a child, the mother or the father should be present. An infant is best examined in the mother's lap. The examination of a female patient should be conducted with a female attendant or nurse. If a female doctor is examining a male patient, then also, a nurse should be present.
For complete examination, the patient should be asked to take-off all his clothes and covered only by a dressing gown. For examination of young persons and children, the patient's parents/guardians should be explained about the examination. In some countries, written permission is needed for the same.
The examination of the patient is divided into three parts:
  1. General examination.
  2. Systemic examination.
  3. Local examination.
 
GENERAL EXAMINATION
The general examination elicits information about the patient as indicated below:
 
Mental Status and Intelligence
Most often, the patient who attends the clinic is conscious and alert about his surroundings, and is well-oriented in time, place, and person, i.e. he knows the date and the time as well as the fact that he is with a doctor because he needs help.
A chronically ill patient may be depressed due to his illness and seem unconcerned or aloof. In a similar situation, in a patient with a malignancy, this could be indicative of disease disseminated to the brain. Hence, one should always assess the mental state and the level of intelligence of every patient. Only an alert and intelligent patient can provide a good history and cooperate in the examination. If the patient is not alert, the level of consciousness should be evaluated by using a coma scale. The grading of level of consciousness is most useful in patients with head injury where the Glasgow Coma Score is employed. This GCS score is now regularly used in other conditions also (see later).
 
Build and Nutrition
The build of a patient is often influenced by heredity, race and region. North Indians are usually taller than south Indians. People from the hills in eastern India are often shorter. These may have no bearing on the disease till it is correlated with the nutritional status of the patient (Fig. 1.5).8
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Fig. 1.5: Xanthelasma
Table 1.1   Indicators of nutritional status
  • Clinical history
  • Physical examination
  • Social history
  • Gastrointestinal function tests
  • Calorimetry
  • Plasma proteins
  • Tests of carbohydrate metabolism
  • Tests of lipid metabolism
  • Tests of endocrine function
  • Water-soluble vitamins
  • Fat-soluble vitamins
  • Calcium metabolism
  • Phosphorus metabolism
  • Magnesium metabolism
  • Zinc balance
  • Copper balance
  • Selenium balance
  • Anthropometry
  • Nonspecific immunocompetence
  • Specific immunocompetence
Table 1.2   Clinical evidence of malnutrition
  • Hair
Easy pluckability and hair loss
  • Skin
Thin shiny skin, petechiae or purpura
  • Face
Nasolabial seborrhea
  • Lips
Angular cheilitis
  • Tongue
Atrophy of papillae
  • Glands
Enlargement of salivary glands
  • Extremities
Dependent edema
Some endocrine abnormalities are followed by alteration of build (Tables 1.1 and 1.2).
Cachexia is observed in patients with gastrointestinal disease like carcinoma of esophagus or stomach and chronic diarrhea (Fig. 1.6). Significant weight loss (defined a loss of more than 10 percent of patient's weight in a short period) is generally seen in chronic illnesses, malignant and endocrine diseases.
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Fig. 1.6: Emaciation in a patient with carcinoma of esophagus
 
Attitude
A patient generally occupies the position of ease when lying down in the bed. A patient with pain due to peritonitis often lies still in bed, while one with colicky pain is tossing.
A patient in severe pain and depression assumes a fetal position, i.e. curled up with knees flexed and almost touching the chin.
 
Gait
Gait of the patient constitutes the entire mechanism of walking. Abnormal gait on walking may result from pain, diseases of bones and joints and muscular or neurological disease. Trendelenburg gait is seen in poliomyelitis, unilateral coxa vara and arthritis of the hip. Waddling gait is typical in bilateral congenital dislocation of hip and bilateral coxa vara.
 
Facies
A good clinician may find a diagnosis in the look of the face. Certain conditions and diseases lead to specific look of the face called facies. The typical appearance of Cushing's syndrome is called moon-facies. Adenoid facies are seen in children with hypertrophied adenoids. Hippocratic facies are seen in patients with generalized peritonitis, mask facies in Parkinsonism and risus sardonicus in tetanus.
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Fig. 1.7: Severe pallor in shock (the examiner's hemoglobin was 13 g 100 mL, but the patient was only 6 g 100 mL)
 
Posture
This means the position of the patient in bed or decubitus, e.g. in cerebral irritation, the patient lies curled upon his side away from light. A patient with pancreatitis bends forwards and a patient with Buerger's disease is seen clutching his ischemic leg both during the day or night.
 
Pallor
Shocking pallor of the skin is seen in hemorrhage with acute loss of blood or in patients with hemolytic anemias due to intrinsic defects in the red blood cells (Fig. 1.7). Pallor should be assessed by examination of the lower palpebral conjunctiva, mucous membrane of the lips, palmar creases and nail bed. Pallor is graded as follows:
Mild: It is usually noticed by the examiner on comparing the palms of the patient with his/her own palms. The mucous membranes and the palpebral conjunctiva also are pale. This may correlate with hemoglobin levels between 10 and 13 g percent. Patients with hemoglobin levels below 10 g percent are usually not taken-up for major operations (Figs 1.8A and B).
Moderate: This may correlate with hemoglobin levels between 8 and 10 g/100 mL.
Severe: A deathly pallor involving the skin, mucous membranes, nail bed and the palm. The palmar creases stand out as if drawn on a white paper. The hemoglobin levels are far below 8 g/100 mL (see Fig. 1.1).
 
Cyanosis
This is the bluish discoloration of the skin or mucous membrane resulting from the presence of large amounts of reduced hemoglobin in the underlying blood vessels. Cyanosis is of two types—peripheral and central.
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Figs 1.8A and B: (A) Examination for icterus. Lift up the upper eye lid and tell the patient to look towards her toes; (B) Examination for pallor
 
Peripheral Cyanosis
It results from poor perfusion of the tissues. Peripheral cyanosis is noted in the nail bed, skin of the palm and toes. It may also be seen in extremities exposed to cold due to vasoconstriction.
 
Central Cyanosis
It results from inadequate oxygenation of circulating blood. Central cyanosis should be looked for in the tongue, lips and also on palms and soles. In severe anemia, cyanosis cannot be seen as it requires a critical minimum amount of deoxygenated hemoglobin.
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Jaundice
Jaundice or icterus is a yellowish-discoloration of the eyes, skin and mucous membrane. The discoloration depends on the intensity of jaundice varying from a yellowish-tinge in hemolytic anemias to almost green in severe obstructive jaundice. It results from the presence of excess of bile pigments in the plasma. Jaundice is looked for in the sclera of the eye, the nail-bed, lobule of the ear, tip of the nose, and undersurface of the tongue and hard palate (see Fig. 1.2).
In obstructive jaundice, due to the deposition of bile salts in the skin, the patient complains of itching or pruritus and develops itch-marks. A yellow discoloration of the skin may also be seen in hypercarotenemia, due to intake of a large amount of raw carrots.
 
Skin Eruptions
These are discussed in the Chapter on Skin.
 
Vital Signs
The pulse, blood pressure, respiration and temperature are called the vital signs of the patient. Most examiners are only informed about the first three by the student and assume that the temperature is within normal range.
 
Pulse
The pulse of the patient is an important indicator of disease. The following are noted in the examination of the pulse:
  • Pulse rate: Tachycardia or increased pulse rate is seen in infections and inflammatory conditions like acute appendicitis, acute cholecystitis and acute pancreatitis, and in physiological states like pregnancy. It is also seen in thyrotoxicosis, shock and fever. Bradycardia is seen in typhoid, and jaundice. Physiological bradycardia may be seen in athletes. Hence, count it for full 60 seconds.
  • Rhythm of pulse: Regular or irregular.
  • Volume of pulse: This indicates the pulse pressure.
  • Character of pulse: For example, water-hammer pulse in aortic regurgitation and thyrotoxicosis and pulsus paradoxus in pericardial effusion.
The pulse is a good indicator of the cardiovascular status of the patient. Abnormalities of the heart and the vascular system are also revealed by pulse.
 
Blood Pressure
It is a good idea to record the patient's blood pressure at the first examination. Several of them may be first time discovered hypertensives and can be started on treatment. The blood pressure of the patient varies with age and should be recorded with an appropriate sized cuff. This is even more important in infants and children (Fig. 1.9).
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Fig. 1.9: Blood pressure is commonly obtainedby an electronic instrument
 
Respiration
The respiration is a good guide to the assessment of the condition of the patient. Increased respiratory rate or tachypnea is seen in fever, shock, metabolic acidosis, hypoxia and hysteria. Slow and deep respiration is seen in cerebral compression. Irregular respiration is seen in patients with acidosis.
 
Temperature
Core temperature of the patient is recorded from the mouth, rectum, nose or esophagus. The peripheral temperature is recorded in axilla or groin and is about 1°C less than the core temperature. Cutaneous temperature may be recorded from the skin of forehead or ears.
Pyrexia or fever is the elevated body temperature above 38°C seen in both medical and surgical conditions and often following complications of operations (Table 1.3). The following types of fever are noted:
Continuous fever: When the fever does not fluctuate for more than 1°C during 24 hours but at no time touches the normal, it is described as continuous.
Remittent fever: When the daily fluctuations exceed 2°C, it is remittent.
Table 1.3   Classification of temperature
Core temperature (rectal, esophageal, etc.)
  • Hypothermia
<35.0°C (95.0°F)
  • Normal
36.5–37.5°C (97.7–99.5°F)
  • Fever
>37.5–38.3°C (99.5–100.9°F)
  • Hyperthermia
>37.5–38.3°C (99.5–100.9°F)
  • Hyperpyrexia
>40.0–41.5°C (104–106.7°F)
Note: The difference between fever and hyperthermia is the mechanism
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Fig. 1.10: Types of fever
Intermittent fever: The fever is present for only a few hours during the day. The types of intermittent fevers are—quotidian, when fever occurs daily, tertian, when fever occurs on alternate days and quartan, when fever occurs on every third day (Fig. 1.10). As mercury is carcinogenic, such thermometers are banned. Hence, use a digital thermometer.
 
SYSTEMIC EXAMINATION
The systemic examination should be conducted in the manner as described below:
 
Head and Neck
Eyes: Visual fields, conjunctiva and pupils, movements of the eye and fundus (Figs 1.11 A and B).
Mouth and pharynx: Teeth and gum, movement of soft palate, the tongue and its undersurface, tonsils. Lips for color, pigmentation and eruptions (Fig. 1.12). Lymph nodes of the neck, neck veins, and carotid pulses and thyroid gland, movements of the neck.
Cranial nerves: Particularly the III, IV, V, VI, VII, IX, X, XI and XII cranial nerves.
 
Chest
  • Type of chest
  • Presence of any dilated vessels and pulsations
  • Position of the trachea
  • Apex beat, lungs, breasts, the heart.
 
Abdomen
  • Abdominal wall—umbilicus, presence of scars, dilated veins.
  • Abdominal reflexes
  • Visible peristalsis or pulsation
  • Hernial orifices
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    Figs 1.11A and B: Bilateral senile cataracts
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    Fig. 1.12: Scar due to insertion of nasogastric tube in patientwith upper gastrointestinal bleeding
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  • Genitalia
  • Inguinal lymph nodes
  • Palpation, percussion and auscultation.
 
Upper Limbs
  • Arms and hand
    – Pulses
  • Power, tone, reflexes, and sensations
  • Axillae and lymph nodes
  • Fingers and nails.
 
Lower Limbs
  • Legs and feet—edema and varicose veins
    • Peripheral pulses
    • Power, tone, reflexes and sensation
    • Joints.
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Figs 1.13A and B: Childhood burns due to boiling water
 
External Genitalia and Hernial Orifices
  • Size of scrotum
    • Position of the testis
  • Testicular sensation
  • Epididymis, spermatic cord, phimosis, meatus and body of penis.
 
Spine
  • Midline position
  • Deformity—scoliosis on kyphosis
  • Weakness—paraplegia
  • Straight leg raising test.
 
Pelvic Examination
  • Per-rectal examination
    • Sentinel pile, hemorrhoids
    • Sphincter tone
    • Prostate
    • Finger tall
  • Per-vaginal examination
    • Lump at introitus
    • Speculum examination
    • Vagina and cervix
    • Bimanual examination.
 
LOCAL EXAMINATION
Local examination implies the examination of the region involved in disease or the affected region. This should be carried out in the following manner:
 
Inspection
This involves looking at the involved part or affected part of the body. Inspection should be carried out only after complete exposure in good light. The affected part should be compared with the corresponding normal side. Several of the surgical conditions can be diagnosed only by inspection, e.g. piles and early stage of an inguinal or umbilical hernia.
 
Palpation
This involves feeling of the involved part by the examiner's fingers or hand. Palpation will corroborate the findings of inspection and provide additional information.
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Percussion
This involves listening to the tapping note of the fingers over the normal as well as the involved area and finally
 
Auscultation
This involves listening to the sounds produced within the body with the help of a stethoscope. Auscultation is important in several surgical conditions, which will be discussed later.
 
Movements and Measurements
Movements of the concerned joints and measurement of the part of the body are important, particularly in fractures, and injuries of different nerves.
 
Regional Lymph Nodes
The draining lymph nodes are examined at the end of the local examination.
 
PROVISIONAL DIAGNOSIS
When the complete examination has been performed, one can reach a provisional or working diagnosis. It is wise to entertain several possibilities or differential diagnoses.
 
INVESTIGATIONS
To arrive at the correct diagnosis, the examiner will need to perform several investigations. Besides several routine examinations of the blood, urine and stool, a few special investigations will be required to arrive at a complete diagnosis. These are discussed in details in appropriate chapters and at the end of the text. A few are discussed below:
 
Ultrasonography
In the last twenty years, the ultrasound as an investigative tool has invaded all aspects of medicine—from the antenatal examination of the head in a neonate for hydrocephalus to the examination of superficial lesions like melanomas. No discussion is complete in surgical practice without a discussion on the ultrasound findings. Almost all institutions have a (wo) man and machine to assist in this. Hence, there is no doubt that it must become a regular part of the processes of examination of the patient (see Fig. 1.4).
 
Fine Needle Aspiration
Insertion of a fine needle (23 gauges) and aspiration of the contents of a swelling allows for gross, microscopic and microbiological examination of its contents. It also provides tactile information of the texture of swelling—soft, firm, gritty or hard, as the needle traverses the tissues.
In many hospitals, this procedure of fine needle aspiration (FNAC) is employed as an extension of palpation.
 
COMPLETE DIAGNOSIS
When the results of all the investigations are available, one can make the complete diagnosis, for example,
  • Carcinoma of right breast T2, N2, M1 in upper outer quadrant with multiple metastases to the lungs and liver (Stage IV)
  • Indirect inguinal hernia on the right side, complete, reducible and enterocele.
 
MANAGEMENT
This is beyond the scope of this text and the reader is referred to other texts of surgery.
 
TREATMENT
The prescribed treatment should be recorded on a separate sheet of the case-records of the patient. The details of all the drugs, including their dosages and the duration for which prescribed, should be recorded, e.g. antihypertensives, oral hypoglycemic, analgesics and antibiotics.
The schedule of drugs prior to an operation should be recorded on a separate page. When planning a surgical procedure, one should note the type of anesthesia given and type of operation performed.
The operative records of the operation should be made in the operation theater itself and should include the following:
  • Name of the procedure
  • Type of anesthesia and names of anesthetists
  • Name of the surgeons/surgical team
  • Position of the patient on the operation table
  • The type of incision
  • Technique of operation
  • Closure
  • Drains
  • Packs (if any)/sponge count
  • Operative findings (including any diagrams).
 
Progress Notes
When the patient is admitted in the wards, daily progress of the patient should be recorded both in the mornings and in the evenings. If the patient is admitted and nothing active is done after discussions (masterly inactivity), even this should be recorded. If, following operation, any investigations are performed, wound inspected or dressing or drains removed, all these should be recorded with date and time.
 
DISCHARGE OF THE PATIENT
At the time of discharge, the patient should be provided a legible discharge summary, preferably typed. This should 14include the brief history and examination, the complete diagnosis, the operation performed, the postoperative course and the treatment that the patient has to take and lastly, the date and time of the follow-up visit.
In case, the patient has expired while undergoing treatment, a death discharge summary should be made and a copy attached to the case records of the patient.
 
FOLLOW-UP VISIT
Once discharged, the patient is required to visit on the appointed date and time for a follow-up visit. At this visit, one should examine the patient to find out if he is making expected recovery. The postoperative wound should be inspected to ensure proper healing. If taking any drugs, their dose should be adjusted or stopped if not required. One should also look for any complications that may have set in or perform investigations as required.
 
Termination of Follow-up
Most patients will report for follow-up after treatment as advised by the doctor. However, there will come a time when the patient has recovered and the process of follow-up must be terminated. This decision must be exercised by the physician with due care, while at the same time providing him some means of access if required in an emergency.
 
LAST POINT
Many students feel uncomfortable with the history-taking and physical examination, the whole process being highly intrusive. Hence, student should proceed in a manner that maintains respect for the patient's dignity and privacy.
However, the student must have a sequential order in the conduct of history taking and physical examination. He must frame the questions beforehand and not reflexly go about the interview. An example of my own ill-organized history taking is this—
What is your name?
………………………….
How old are you?
………………………….
Are you married?
No, divorced.
Why?
…………… Is that your business?
It was indeed not my business and I* should have been alert while framing questions to her.
Lastly, it is said that eyes do not see what the mind does not know. The students should know how to diagnose common disease first and only then think of rare diseases. If you diagnose a rare disease, you will be rarely correct!**
Now, let us start learning the first steps of clinical surgery.
BIBLIOGRAPHY
  1. Allan Chain (Ed). In: Hamilton Bailey's Demonstration of Physical Signs in Clinical Surgery, 16th edn, Bristol John Wright and Sons Ltd. and the English Language Book Society, 1980.
  1. Chumber Sunil, Deo SVS, Bal S, Saxena Ravi. Response of the Body to Injury. In: Sunil Chumber (ed), Essentials of Surgery; New Delhi, Jaypee Brothers;  2005. pp. 17–27.
  1. Das S. A Manual of Clinical Surgery, 6th edn, S Das Publishers,  Calcutta;  2004.
  1. David C Sabiston, Jr H Kim Lyerly. The biological basis of modern surgical practice. Textbook of Surgery, 15th edn. WB Saunders Company. 
  1. Dhawan IK, Khanduri P, Anantakrishnan N. Textbook of Surgery for Undergraduates. BI Churchill Livingstone,  New Delhi;  1994.
  1. Epstein O, Perkin DG, Cookson J, Watt SI, Rakhit R, Robins A, Hornett GAW (Eds). In: Clinical Examination, 4th edn, Edingurg, London, Mosby-Elsevier,  2008.
  1. Kasper DL, Braunwald E, Hauser S, Longo D, Jameson JL, Fauci AS (Eds). In: Harrison's Principles of Internal Medicine, 16th edn; New York, McGraw-Hill Inc,  2005.
  1. Rewari Vimi, Chumber Sunil. Shock. In: Sunil Chumber (ed), Essentials of Surgery; New Delhi, Jaypee Brothers;  2005. pp. 28–41.
  1. Sriram M Bhat. In: SRB's Clinical Methods in Surgery, New Delhi, Jaypee Brothers Medical Publishers,  2010.
  1. Srivastava Anurag, Kumar Subodh, Chumber Sunil. History of Surgery: An enlightening story. In: Sunil Chumber (Ed), Essentials of Surgery; New Delhi, Jaypee Brothers;  2005. pp. 3–16.