INTRODUCTION TO SURGICAL CASE SHEET
History Taking
- Personal data (particulars of the patient, personal history or basic data): Full name, sex, age, residence, occupation, marital status (and menstrual history).
- Date of admission: Exact date of admission to hospital.
- Complaints and duration: Arranged according to chronological order or importance.
- Present history:
- Analysis of the complaints (onset, course, duration, etc.)
- Treatment received so far by the patient and its effect
- Negative data (regarding the same abnormal system or other systems).
- Past history: Previous diseases related to the present condition, similar diseases or attacks, trauma, infections and fever, operations, hospitalization, and other diseases (systemic, allergic, endemic, venereal).
- Drug history and immunizations (in children).
- Family history: Similar condition (genetic, familial, environmental, endemic).
- Personal habits: Smoking, alcohol, addiction, diet, bowel habits, sleeping rhythm, and recreations.
Clinical Examination
General Examination
- General survey of the patient: Mental state, distress, built, facial expression, attitude, skin and mucous membranes (lips, tongue, conjunctiva)
- Vital signs: Temperature, pulse rate, blood pressure, respiratory rate
Local Examination
- Inspection
- Palpation
- Percussion
- Auscultation
- Movements (of different joints)
- Measurements.
Investigations (Workup of the Patient)
- General investigations: Blood and urine analysis, chest X-ray, electrocardiography (if >50 year)
- Specific investigations: Laboratory, radiological, endoscopic, biopsy, others.
Diagnosis
- Provisional diagnosis (clinical diagnosis using symptoms and signs).
- Differential diagnosis.
- Definite diagnosis (following investigations, including biopsy and exploration).
Therapeutic Plan
- Preoperative preparation of the patient.
- Operative plan (and adjuvant therapy if indicated).
- Postoperative care.
- Follow-up (for short- and long-term results, including both morbidity and mortality).
HISTORY TAKING
Personal History (Personal Data)
- It includes full name, sex (gender), age, occupation, residence, marital status (single, married, divorced, widow or widower—number of pregnancies and abortions, number of children or sterility—menstrual history if relevant)
- It must be written as a sentence, e.g. a 50-year, old gentleman, named ….., working as a farmer, married since 12 years and has four children, admitted to hospital on the 4th of July 2008, complaining of ………
What is the Importance of Personal History?
Name
- For identification and registration of the patient
- To be familiar with the patient (patient–doctor relationship)
- For follow-up of the patient (medical records).
Apart from diseases involving sex organs (e.g. cancer cervix in women and cancer penis in men), there is special predilection of certain diseases to a certain gender such as:
- Thyroid, breast and gallbladder diseases are more common in women.
- Gastric, Buerger’s, and cardiopulmonary diseases are more common in men.
Age
- Predilection of certain diseases to certain age groups:
- Since birth ________________ Meningocele, cleft lip/palate
- Infancy (up to 2 years) ________Cystic hygroma, Wilm’s tumor
- Childhood (2–12 years) _______ Osteomyelitis, rickets, tuberculosis, thyroglossal cyst
- Adolescence (12–20 years) ____ Appendicitis
- Adulthood (20–40 years) ______Sarcoma, peptic ulcer, thyrotoxicosis
- Middle age (40–60 years) _____ Chronic cholecystitis, carcinoma (no age is immune)
- Old age (> 60 years) __________Osteoarthritis, carcinoma
- Congenital anomalies may present
- Since birth, e.g. cleft lip
- In infancy, e.g. cystic hygroma
- In childhood, e.g. thyroglossal cyst.
- Inflammatory lesions, in general, are more common in adolescents and adults
- Malignancy, in general, is more common in middle and old age, but no age is immune
- Predilection of certain pathologic types to certain age groups:
- Breast lumps: Fibroadenoma occurs more in young women and cancer in the elderly.
- In goiters: Cretinism occurs in children, physiological goiter at puberty, simple nodular goiter (SNG) in adults and malignancy in the elderly.
- In chronic ischemia: Buerger’s disease occurs more among adults, while atherosclerosis in the elderly.
- In urinary troubles: Stones are more common in young age, while prostatic lesions or malignancy are more common in the elderly.
Occupation
The job of the patient could be a predisposing factor to certain diseases (occupational):
|
Teachers, surgeons, dentists (prolonged standing) |
| Porters (heavy weight lifting) |
| Drillers, typists, pianists (exposure to vibrations) |
| Farmers (working in infected water of canals) |
| Housemaids (prepatellar) or students (olecranon) |
Residence
- It is the place where the patient resides now, i.e. his postal address (for registration and follow-up), but you have to pay attention to the place where he was born or raised and ask about travelling abroad.
- Endemic diseases in Egypt include bilharziasis (colonic in the Delta and urinary in upper Egypt), filariasis (Giza, Sharkeya, Damietta), malaria, amebiasis, ascariasis, ankylostoma, goiter [in oasis away from the sea with iodine (I2)], tuberculosis (TB) (in poor localities).
Date of Admission
The exact date of admission to hospital should be mentioned, i.e. the patient was admitted to hospital on …….. (mention the day, month and year).
Complaints and their Duration
What are your complaints? How long have you been suffering?
- Complaints should be arranged either
- Chronologically (e.g. pain in the left hypochondrium for 3 months, general weakness for one month, etc.)
- According to their importance (the most important complaint is the most dangerous or threatening to the life of the patient), e.g. hematemesis for 2 months, pain in the left hypochondrium for 6 months, etc.).
Present History (History of Present Illness)
Present history includes the following items:
- Analysis of the complaints of the patient (onset, course or progression, etc.).
- Questions about other symptoms involving the abnormal body system.
- Systemic direct questions about other systems of the body:
- Negative answers should be mentioned because they are as important as positive ones. They aid in exclusion of certain diseases.
- Positive answers (complaints) should be added to the complaints of the patient mentioning their duration and analyzing them in the present history.
Analysis of Complaints
Type of onset
- Sudden ____________________ Trauma
- Acute ______________________ Acute inflammation
- Gradual (insidious) ___________ Chronic inflammation or tumors
Course (progress) of the illness
| Rapidly (acute inflammation), slowly (chronic inflammation) |
| Acute inflammation (after a rapid progressive course) |
| Some benign lesions (i.e. reach a plateau). |
Analyses of certain complaints in details (pain, bleeding, swelling, ulcer)… look later.
Treatment Received by the Patient
The modality of treatment received so far by the patient and its effect on the course of the disease should be mentioned. Did therapy improve the patient’s condition or not ? Was the therapy given adequate or appropriate or not ? For example, inadequate antibiotic course for mastitis may lead to a chronic breast abscess that may be misdiagnosed as a tumor.
Questions about Other Symptoms Involving the Abnormal System
For example, when a patient complains of constipation, you have to ask about other gastrointestinal tract (GIT) symptoms, such as vomiting, dyspepsia, etc.
Systemic Direct Questions
- All patients should be asked about:
- Other systems of the body.
- These are useful in determination of:
- Etiology of a local disease, e.g. DM in a patient with lower limb ischemia.
- Effect of a local disease, e.g. metastatic effects of a malignant tumor.
- Fitness of the patient for anesthesia and surgery.
- Examples include the following.
- Alimentary tract
- Appetite, diet, and weight.
- Teeth, taste, and swallowing.
- Regurgitation, vomiting, hematemesis/melena.
- Bowel habits (diarrhea, constipation), distention, and flatulence.
- Heart burn and abdominal pain.
- Skin color (e.g. yellowish in jaundice) and itching (biliary obstruction).
- Respiratory system
- Cough: Is it dry or wet? How often? When? Precipitating and relieving factors?
- Sputum: Quantity? Color? Taste? Smell? Tinged with blood?
- Hemoptysis: Color? Quantity? Frequency?
- Dyspnea: At rest? When lying down (orthopnea)? Waking the patient up at night [paroxysmal nocturnal dyspnea (PND)]?
- Chest pain: Site? Severity? Nature? Continuous? Increased by inspiration (pleuritic pain)?
- Cardiovascular system (CVS)Cardiac symptomsPeripheral vascular symptoms
- Breathlessness?
- Pain in the limbs (claudication)
- Orthopnea? Paroxysmal nocturnal dyspnea (PND)?
- What group of muscles?
- Cardiac pain: Nature, duration, radiation?
- Walking distance?
- Palpitations?
- Temperature and color of hands and feet?
- Cough and sputum?
- Is there any paresthesia in the limbs, e.g. tingling and numbness?
- Dizziness and headache (hypertension)?
- Ankle swelling? When? Extent? Effect of rest or leg elevation?
-
Urinary tractGenital tract
- Pain: Site, radiation, nature, severity, etc.
- Edema: Site, severity, extent, etc.
- Thirst: Quantity or volume of water?
- Micturition: Volume? Frequency? Painful? Difficult? Dribbling?
- Urine changes: Quantity? Color? Smell? Bloody (hematuria)? Gas bubbles (pneumaturia)?
- Uremia: Headache, drowsiness, visual disturbances, fits, vomiting?
- Both Sexes:
- Secondary sex characters.
- Breasts (pain, lump, discharge)
- Male (scrotum and urethra):
- Pain, discharge, swelling?
- Erection, ejaculation?
- Female:
- Menstruation: Menarche, menopause, dysmenorrhea, bleeding?
- Pregnancy: No. complications.
- Dyspareunia?
- Nervous systemMental statusBrain and cranial nervesPeripheral nerves
- Nervous?
- Unconscious or stupor?
- Limbs (weak, paralyzed)?
- Easily excitable?
- Does he get fits?
- Loss of sensation (pain, temperature and touch)?
- Change in behavior?
- Changes of his senses?
- Paresthesias (tingling in the limbs)?
- Depression?
- Changes in motor power (face paralysis or paresis)?
- Musculoskeletal system
- Aches (pains) in the muscles? Bones? Or joints?
- Swelling of joints?
- Limitation of movements?
- Weakness? Which groups of muscles?
- Disturbance of gait?
- Congenital musculoskeletal deformities?
- Metabolism
- Change in weight?
- General body built and appearance?
- Presence and time of development of secondary sex characters?
- Normal growth?
Past History
The patient should be asked about past history of the following:
Diseases which might be related to the present condition
- Bilharziasis and melena in a patient presenting with an enlarged spleen
- Mastitis before chronic breast abscess
- Jaundice in liver disease
- Acute appendicitis (not operated) is significant in diagnosis of a mass in the right iliac fossa.
Similar conditions of attacks
- Hernia (elsewhere)
- Biliary colic before calcular obstructive jaundice.
Trauma, even if Mild
- Chronic subdural hematoma
- Arteriovenous fistula
- Scrotal lesions (hematocele).
Infections (acute or chronic) with emphasis on fever
- Fever of viral hepatitis before hepatocellular jaundice
- Fever of DVT before secondary varicose veins
- Fever of acute lymphangitis before lymphedema.
Operations
- Appendectomy before a right-sided inguinal hernia
- Mastectomy before arm lymphedema
- To exclude bleeding diasthesis or to exclude the operation as a cause of the presenting condition.
Hospitalization
- Jaundiced patient (viral hepatitis?).
- Severe cardiopulmonary problems? risk of anesthesia?
Other diseases
- Systemic diseases:
- Diabetes mellitus and hypertension (atherosclerosis) before chronic ischemia.
- Bleeding tendency in patients with bleeding from various parts of the body.
- Pulmonary TB before cervical lymphadenopathy.
- Allergic diseases:
- Bilaharziasis (before lower limb edema due to hepatic insufficiency).
- Filariasis before lower limb edema (lymphedema).
- Amebiasis (of the colon) before amebic abscess (in the liver).
- Venereal diseases: For example, lymphogranuloma inguinale before inguinal lymphadenopathy.
Drug History and Immunization
Drugs
- Contraceptive pills may cause DVT, vulvar vestibulitis (VV), and some breast changes
- Aspirin or antirheumatic drugs in a patient with hematemesis or melena
- Insulin, corticosteroids and anticoagulant R/ should be asked about before operation
- Any drug sensitivity?
- Immunization: In children, ask about immunization against diphtheria, whooping cough, tetanus, poliomyelitis, smallpox, typhoid, and TB.
Family History
History of similar disease affecting parents, siblings, children, or wife?
- Some conditions are often hereditary (genetic factor) such as hemophilia, dyshormogenesis causing goiter in more than one member of the family.
- Some diseases are endemic, e.g. simple goiter, bilharziasis [schistosomal hepatic fibrosis (SHF)], etc.
- Other diseases occur in families because of exposure to the same environment (environmental factor), such as infections, e.g. TB (causing lymphadenopathy) iodine deficiency or exposure to goiterogenic substances causing goiter
- Some surgical conditions show a familial tendency, such as cancer, familial polyposis, endocrinal disorders, varicose veins, etc.
Personal Habits
You have to analyze carefully the habits of the patient
Smoking: Type? Quantity? Frequency? Duration?
- It predisposes to cancer of lips, cheeks, tongue, lungs
- It is a very important factors for Buerger’s disease and cardiac problems.
Alcohol: Type? Quantity? Frequency? Duration?
- It may cause liver cirrhosis (portal hypertension) and pancreatitis.
Diet: Unusual eating habits?
- Spices: Excess spices may cause peptic ulcer, piles, etc.
- Excess fat: It may cause atherosclerotic phenomenon to occur earlier.
- Excess tea or coffee: Can cause epigastric pain and constipation.
Bowel habits: Usual number of motions/day? This is useful in patients complains of constipation.
Addiction and drug abuse
- Can cause serum hepatitis (B and C) (VHB and VHC).
- It can also cause acquired immunodeficiency syndrome (AIDS).
Sleeping rhythm and recreations.
SPECIAL PRESENT HISTORY (PAIN, BLEEDING, SWELLING, AND ULCER)
How can you analyze these conditions in the present history?
What are the questions to be asked and what is their relevance?
Pain
Site
- Record the exact site (the area affected and the point of maximum intensity)
- Ask about depth of pain (i.e. near the skin or deep inside).
Time and Mode of Onset?
- Record the time and date of onset
- Ask if pain began insidiously or suddenly. Ask about why pain started?
Severity (Intensity)
Assess the severity of pain by its effect on the patient’s life, work, sleep, etc.
Character (Nature or Type) of Pain
- Burning: Similar to contact of skin with intense heat
- Throbbing: It denotes suppurative or purulent infection (presence of pus)
- Stabbing: It denotes ischemic pain. Pain is sudden, sharp, severe and short-lived
- Constricting: It suggests pain that encircles a part (chest, abdomen, head or limb) and compresses it from all directions, e.g. angina, which also reflects ischemic pain
- Distention: It occurs in an organ which has an encircling and restricting wall, such as bowel, urinary bladder (UB), encapsulated tumor, or fascial compartment (bursting pain)
- Colicky: It occurs in a hollow organ (it comes and goes and tends to force the contents of a tube forward)
- Sawing: It reflects pain that occurs in bones
- Stitching: It denotes inflammation in or around a serous membrane (e.g. pleuritis) or capsule of an organ (e.g. splenitis or perisplenitis)
- Dragging: It results from dragging of an organ by its weight, e.g. splenomegaly
- Dull aching: Pain which is difficult to describe, i.e. just a pain!
Progression
- It may steadily, reach a peak or the opposite, begin at a peak, and slowly
- Severity of pain may fluctuate.
End of Pain
- It may end spontaneously or by the doctor
- Sudden or gradual
- End of pain does not necessarily mean cure, it may mean that the condition became worse!
Duration
Duration of pain episode must be recorded from the time of onset till the end.
Relieving Factors
- Position or movement
- Warm compresses
- Drugs (aspirin, antacids).
Aggravating Factors
- Food (quantity and type)
- Movements, posture, etc. (according to the organ affected).
Radiation
- Radiation of pain means extension of pain to another site whilst the initial pain persists. For example, pain of duodenal ulcer is felt in the epigastrium (site of pathology) and may radiate to the back (site where pain is radiated to). The distance in-between is also painful
- Referred pain is different. In such cases, pain is felt at a distance from its source. For example, pain from acute appendicitis (site of pathology at the right iliac fossa) is felt around the umbilicus (site of referred pain). The distance in-between is free of pain. Referred pain is due to inability of the central nervous system (CNS) to differentiate between visceral and somatic sensory impulses.
Cause
Make a note of the patient’s opinion on what he thinks the cause of pain!
Bleeding
- Bleeding from other sites: Bleeding diasthesis—melena + hematemesis in portal hypertension
- Number of attacks?
- Duration of each attack?
- Time interval between attacks?
- Precipitating factors (e.g. drug intake such as aspirin).
- Amount of bleeding?
- Color of blood: Fresh red, brown, coffee ground
- Special characters: Frothy as in hemoptysis or contains food particles as in hematemesis
- The condition preceding bleeding: Severe epigastric pain as in bleeding from peptic ulcer, sleeping or heavy meals as in bleeding from esophageal varices
- Associated symptoms?
Swelling
Duration (When was the Lump First Noticed?)
Bear in mind that many lumps exist for months or years before being noticed (e.g. breast cancer).
What Made the Patient Notice the Lump?
- While washing?
- Due to pain?
- Told by another person (e.g. goiter).
Mode of Onset (How did the Selling Start?)
- After trauma, e.g. hematoma
- Spontaneously and grew rapidly (e.g. inflammation) steadily (e.g. malignancy) or very slowly (e.g. benign tumor).
- A swelling may arise on a preexisting condition, e.g. malignant melanoma on a birth mark or breast duct carcinoma on top of a duct papilloma.
Exact Site and Shape
The exact site and shape of the swelling when first noticed by the patient should be recorded.
What are the Symptoms Caused by the Lump?
A patient suffering from a lump anywhere in the body may complains any of the following (which should be described carefully in detail):
- Disfigurement: As in swellings of the face, neck (goiter) or legs (varicose veins).
- Interference with function of the involved part according to its site, e.g. interference with movement, respiration, swallowing, etc.
- Pressure effects: Local effects of the swelling such as pressure effects of an enlarged thyroid gland causing dyspnea.
- Systemic effects: Some swellings may cause systemic manifestations, such as:
- Acute inflammation—general constitutional manifestations (fever, headache, malaise, etc.)
- Tuberculosis [lymph nodes(LNs)]—loss of appetite, loss of weight, night fever and night sweating
- Functional swellings (endocrinal), such as toxic manifestations of thyrotoxicosis or symptoms of hypertension (e.g. headache) resulting from pheochromocytoma.
- Lymphoma—fever, pruritus, etc.
- Malignant tumors—paraneoplastic syndrome (e.g. bronchogenic carcinoma) or metastatic manifestations according to their location (secondaries).
Metastatic manifestationsSite of metastasesSymptomsSignsLung metastases- Cough
- Hemoptysis
- Chest pain
- Crepitations
- Wheezes
- Pleural effusion
Liver metastases- Jaundice
- Right hypochondrial pain
- Abdominal distention
- Hepatomegaly (hard, tender, nodular, with a sharp border)
- Ascites
Bone metastases- Bone aches
- Pathological fractures
- Tender, firm masses of bones
- Egg-shell crackling sensation of flat bones
Brain metastases- Fits and convulsions
- Behavioral changes
- Brain deficits according to the affected area
- Sensory and motor changes
- Electroencephalography changes
- Progress of the swelling:
- Stationary or slowly growing____
- Stationary then rapidly growing__
- Rapidly growing______________
- Diminishing or regressing_______
Benign tumorMalignant transformationMT or inflammationInflammation.
Secondary Changes has the Lump Changed Since it was First Noticed?
- Ulceration, infection bleeding, pigmentation, fixation, fungation, etc.
Does the Lump Ever Disappear?
- Reducible? Spontaneously on lying down (hernia, varicocele) or by manual reduction (hernia, piles).
- Compressible, such as hemangioma.
Mutiplicity
Is the swelling single (solitary) when first noticed (e.g. hernia, tumor, or solitary lymph node) or multiple (e.g. multiple LNs or multiple lipomatosis)?
Similar or Other Swellings
Does the patient have or ever had any other lump anywhere in his or her body?
Loss of Body Weight Since the Appearance of the Swelling?
- Associated with anorexia (loss of appetite), e.g. malignancy or TB.
- Despite good or increased appetite, e.g. thyrotoxicosis.
Recurrence
Is the swelling primary or recurrent after operation (e.g. hernia), radiotherapy (no scar), e.g. malignancy or recurrence of a cyst after aspiration (e.g. breast cyst).
What does the Patient Think Caused the Lump-precipitating Factor?
Injury or trauma (e.g. hematoma), lifting a heavy object (e.g. hernia or disc prolapsed) or systemic illness.
Ulcer
Duration
- When the ulcer was first noticed?
- Short (acute ulcer, e.g. acute inflammatory)
- Long (chronic ulcer, e.g. venous or neuropathic ulcer).
First Symptom
What drew the attention of the patient? Is it pain? Bleeding? Discharge?
Mode of Onset
- Did it appear as an ulcer from the start? For example, epithelioma or rodent ulcer
- Has the ulcer been preceded by a nodule or lump? (e.g. tuberculous LN, syphilitic gumma or malignant melanoma)
- Has the ulcer started on an irritable patch of dermatitis? (e.g. venous ulcer)
- Has the ulcer developed on a scar or burn? (e.g. Marjolin’s ulcer)
- Has the ulcer been preceded by a corn (callosity)? (e.g. neuropathic ulcer).
Associated Symptoms
Pain (describe in detail): For example, syphilitic and trophic ulcers are painless, malignant ulcers are painless in the early stages, while TB ulcers are usually painful (N.B. secondary infection of any ulcer results in pain).
Discharge: Type (pus, blood, serum, etc.), smell, amount.
General symptoms: Pyrexia, loss of weight and debility.
Progression
- How has the ulcer changed since it was first noticed? Changes in shape, edge, base, depth, discharge, etc.
- Progressive (malignant ulcer)......... Regressive (inflammatory ulcer).
Persistence
Has the ulcer ever disappeared, e.g. dyspeptic ulcers? Or healed, e.g. venous ulcer?
Multiplicity
Has or had the patient any other lumps or ulcers? The same site or elsewhere?
Cause
What does the patient think caused the ulcer? Trauma? Itching? ......., etc.
CLINICAL EXAMINATION AND DIAGNOSIS
General Examination
Survey of the Patient (General Look or Appearance)
- Mental state: Conscious (well oriented to persons, time and place), drowsy or comatose.
- Distress: Patient in agony or having severe colic, anxious, depressed, etc.
- Built (e.g. dwarfism, gigantism) and nutrition: Body weight (normal, underweight, overweight), wasting or obesity (soft tissues), dehydration or edema (body fluids).
-
- Risus sardonicus in tetanus
- Facies hippocraticus in generalized peritonitis (eyes are sunken but bright, nose is pinched, lips show crusts, tongue is dry and shriveled and the forehead is cold and clammy)
- Facies of cretinism (face is pale, puffy and wrinkled. Skin is dry and cold. Protruding tongue is characteristic. The anterior fontanely remains open)
- Adenoid facies (the triad of high vaulted palate, narrow dental arch and protruding incisor teeth has been abandoned. This triad of defects is familial (Hamilton Bailey).
- Attitude
- On standing (stance) kyphosis, scoliosis, lordosis, etc.
- On walking (gait) limping or waddling gait
- On sitting (attitude)
- On lying down (Decubitus), such as frog-leg position in patients with deep vein thrombosis (DVT).
- Skin: For color (cyanosis, anemia, jaundice, pigmentation, rash), petechiae, spider nevi.
- Mucous membranes (conjunctiva, lips, tongue): For pallor, cyanosis, jaundice, etc. For example, a normally developed, well nourished, fully conscious and well oriented, young (or old) man, not in distress and with normal facies, gait and decubitus.
Vital Signs
Temperature
- Normal: 36.7–37.7°C
- It in acute inflammation and in some malignant tumors and in hypovolemic shock.
Pulse (HR)
- Normal: 60–80 beats/minuteFigs 1.1A to L: Characteristic facies. (A) Facies of a cretin. The large protruding tongue is characteristic; (B) Facies of tetanus risus sardonicus; (C) Micrognathia. The profile should enable prompt diagnosis; (D) Adenoid facies (the triad of defects is familial); (E) Facies of congenital syphilis saddle-nose and scar of interstitial keratitis; (F) Hippocratic facies, advanced peritonitis (G) Carcinoid facies, facial flushing; (H) Spider nevi. Hepatic cirrhosis (liver failure); (I) Exophthalmos (bilateral). Typical of Graves’ disease; (J) Virile facies (a woman, 25 years, with adrenocortical hyperplasia; (K) Moon facies (a woman, 19 years, with Cushing’s syndrome); (L) Myasthenia gravis facies (ptosis and drooping jaw are intermittent)
- If the radial pulse can not be felt, try the other wrist; occasionally the radial artery is absent. If unsuccessful at either wrist, try the femoral arteriesNote: Rhythm, rate, volume, character, condition of arterial wall and equality on both sides.
- Condition of vessel wall, such as atherosclerosis (vessel wall is felt and is rigid).
Age (year) fetus | Normal pulse rate/min (140–160) |
---|---|
0–1 | 135 |
1–2 | 120 |
3–4 | 110 |
5–9 | 90 |
9–11 | 85 |
12–17 | 80 |
Adults | 72 |
Blood pressure (BP)
- Normal: 90–140/60–90 mm Hg
- Hypertension means persistent diastolic pressure over 95 mm Hg, e.g. in atherosclerosis and thyrotoxicosis
- Hypotension, such as shock.
Respiratory rate (RR)
- Normal: 12–20 cycles/minute, thoracoabdominal in women and abdominothoracic in menNote: Rhythm, rate, depth and character (e.g. respiration could be thoracic only as in abdominal diseases, such as peritonitis. On the other hand, it could be abdominal only as in chest diseases, such as pneumonia).
Systematic Examination
Examination of the patient from ‘top-to-tip’, i.e. from top of hairs to tip of toes.
Head
- Skull: For example, exostosis.
- Scalp: For example, hair distribution, hematoma, etc.
- Face: observe the follows:
- Eyes: Eyebrows, eyelids (edema, ptosis), sclera (jaundice), cornea (ulcer), pupil (size, equality, regularity, reaction to light, accommodation) and conjunctiva (pallor, subconjunctival hemorrhage, inflammation), exophthalmos or enophthalmos
- Lips (pallor, cyanosis, etc.)
- Tongue (central cyanosis, ulcers, vitamin deficiency, etc.)
- Teeth and gums (sepsis, swellings, etc.)
- Oral mucosa (sepsis, swellings, etc.) and tonsils (tonsillitis)
- Ears (deformity, discharge, etc.).
Neck
- Mobility of the neck in the different directions.
- Thyroid swellings or other cervical swellings.
- Lymph nodes (cervical lymphadenopathy alone or part of generalized disease).
- Neck veins (dilated, pulsating) and carotid pulse (on both sides).
- Scars.
Chest and breast
- Lungs: Dullness or hyper-resonance, adventitious sounds, etc.
- Breasts: Good examination of both breasts and axillary lymph nodes.
Heart and big vessels
- Heart: Size, thrills, murmurs, etc.
- Blood vessels: Examine and compare, on both sides, the radial pulse, brachial pulse, carotid pulse, femoral pulse, popliteal pulse, posterior tibial and dorsalis pedis pulses.Note: No heart examination is complete without blood vessel examination).
Abdomen and pelvis
- Shape and contour.
- Organomegaly (palpable colon).
- Ascites.
- Abdominal wall musculature.
- Hernial orifices.
- Hairs, scars, dilated veins, etc.
- External genitalia and rectal (PR) examination and pelvic (PV) examination (if appropriate).
Back and spine:
Examine the following:
- Spine.
- Chest.
- Renal angles.
- Skin lesions.
Extremities (musculoskeletal system)
- Upper limbs and hands (palms, skin, fingers and nails): For deformities, nerve lesions, joints, major blood vessels, hand ‘temperature; hot or cold?; dry or wet?; clubbing?; tremors?; palmar erythema?’ (Figures 1.2A to L).
- Lower limbs: For gait, joints, edema, varicose veins, peripheral pulses, ischemic manifestations (e.g. ulcers, gangrene), arteriovenous (AV) fistula, aneurysm, temperature of feet, etc.
Skin
- Color (pale, yellow, etc.).
- Marks of itching (e.g. obstructive jaundice, Hodgkin’s disease, etc.).
- Spider nevi.
- Tumors, ulcers, scars, dilated veins, etc.
Figs 1.2A to L: Characteristic hand lesions. (A) Tetany; (B) Gout; (C) Syndactyly; (D) Enchondroma; (E) Paronychia infection through a hanging nail; (F) Implantation dermoid following human bite; (G) TB dactylitis (painful) bone is enlarged and spindle-shaped; (H) Verruca necrogenica (Butcher’s wart) TB inoculation via a breach in the skin; (I) Pannus of rheumatoid arthritis (hypertrophy of synovial membrane of joints, mostly MCP and proximal IP joints); (J) Heberden’s nodes bony nodules at the base of terminal phalanges (occurs in osteoarthritis); (K) Koilonychia (In iron deficiency anemia). Nails are soft, thin, brittle and normal convexity is lost and replaced by a concavity; (L) Clubbing tissues at base of nail are thickened and the angle between the nail base and adjacent skin of finger is obliterated
Importance of examination of all these systems or regions |
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Local Examination
- The complaints and history taking will direct you to the part of the body to be examined.
- C/E of each part will be discussed in a separate sheet, e.g. thyroid, breast, etc.
- In general, local examination comprises the following items:
- Inspection: Never use your hands before your eyes; but always remember that ‘the eyes do not see what the brain does not know’. Always compare with the normal contralateral side.
- Palpation: Confirms what is found by inspection and adds information by feeling the various parts with the hands and fingers.
- Percussion: Tapping with the fingers and listening to the sound produced can yield ‘resonance’ (denotes gas, e.g. lung or bowel), or ‘dullness’ (denotes solid or fluid).
- Auscultation: Hearing of normal or abnormal sounds (e.g. heart sounds, peristalsis).
- Special tests, such as movements of different joints, measurement, etc.
Investigations: Workup of the Patient
The aim of the investigations or workup of the patient is double-fold:
- To aid in reaching the final or definite diagnosis (specific investigations).
- To assess the general condition of the patient, so that we can optimize condition and prepare the adequately before operation (general or routine investigations).
General (Routine) Studies
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- Complete blood count (CBC), hemoglobin (Hb), bleeding time and coagulation time, erythrocyte sedimentation rate (ESR)
- Serum urea and creatinine (to assess the kidney function)
- Fasting blood sugar.
- Urine analysis: Sugar, proteins, casts, parasitic ova.
- Chest X-ray (CXR).
- Electrocardiography (ECG) (for patients above 50 years of age).
Specific or Special Studies
- Special studies will differ according to the condition, e.g. portal hypertension, peptic ulcer, breast lesion, thyroid disease or occlusive peripheral disease
- Each disease has special investigation to help in reaching diagnosis and evaluating extent of the disease
- It is advisable to choose the easier and most illustrative study, e.g. estimation of blood levels of T3 and T4 in hyperthyroidism.
- These investigations usually fall into one of the following categories:
- Laboratory investigations: For example, liver function tests (LFTs) (bilirubin, albumin, enzymes, and prothrombin time) for patients with suspected liver disease or portal hypertension.
- Radiological studies: Plain X-rays, or contrast studies [e.g. barium studies for gastrointestinal tract (GIT), intravenous urography (IVU) for the urinary tract, and angiography for blood vessels].
- Endoscopic studies: For example, fiberoptic upper GI endoscopy for diagnosis of esophageal varices or peptic ulcer or lower GI endoscopy for diagnosis of colonic mass or polyp.
- Biopsy: For example, needle biopsy or fine needle aspiration cytology (FNAC).
- Others: For example, hemodynamic studies in cases of portal hypertension, manometric studies of the esophagus in motility disorders, or gastric acidity in peptic ulcer.
Diagnosis
Provisional Diagnosis
- After completing the thorough history taking and complete physical examination, you can identify the important findings in the patient (which may include symptoms and signs) and list them according to importance, what we call: ‘Problem List’, for example:
- Hematemesis.
- Ascites.
- Anemia.
- Left hypochondrial pain.
- Now you can reach what we call ‘provisional diagnosis’ (differential diagnosis?).
Final Diagnosis
After surgery, exploration and histopathological study, you will definitely reach at the final diagnosis.
Therapeutic Plan
The plan of therapy will be based upon diagnosis and should include (in case of surgery):
- Preoperative preparation: Preparation of the patient for the operation with correction of any disturbance discovered.
- Operative plan: Type and timing of the operation, as well as the aim of surgery (e.g. cure or palliation in case of malignancy?).
- Postoperative care: Stress should be laid on:
- Assessment of the level of consciousness of the patient.
- Patients general mood.
- Vital signs.
- Chest and heart condition.
- Abdominal condition (e.g. distention and peristalsis).
- Extremities (e.g. DVT).
- Follow-up: For short- and long-term results, including mortality and morbidity (complications).
In case of malignancy, adjuvant therapy may be required such as hormonal therapy, radiotherapy, and/or chemotherapy.