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    History Taking in Surgery 123

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    tahreem_saeed_1
    This document discusses the process of taking a patient history and performing a physical examination in surgical practice. It notes that history taking is the key first step in surgical diagnosis. There are two main types of histories - for outpatient/emergency visits to pinpoint a specific complaint and diagnosis, and for patients admitted for elective surgery to ensure the planned treatment is correctly indicated. The history should cover personal details, present complaint, history of present illness, elaboration on involved systems, past medical/surgical history, drug use, family history, and social history. A physical exam includes inspection, palpation, percussion, and auscultation of key body systems and areas like the head, neck, eyes, ears, nose,

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    History Taking in Surgery 123

    Uploaded by

    tahreem_saeed_1
    301 views25 pages
    This document discusses the process of taking a patient history and performing a physical examination in surgical practice. It notes that history taking is the key first step in surgical diagnosis. There are two main types of histories - for outpatient/emergency visits to pinpoint a specific complaint and diagnosis, and for patients admitted for elective surgery to ensure the planned treatment is correctly indicated. The history should cover personal details, present complaint, history of present illness, elaboration on involved systems, past medical/surgical history, drug use, family history, and social history. A physical exam includes inspection, palpation, percussion, and auscultation of key body systems and areas like the head, neck, eyes, ears, nose,

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    This document discusses the process of taking a patient history and performing a physical examination in surgical practice. It notes that history taking is the key first step in surgical diagnosis. There are two main types of histories - for outpatient/emergency visits to pinpoint a specific complaint and diagnosis, and for patients admitted for elective surgery to ensure the planned treatment is correctly indicated. The history should cover personal details, present complaint, history of present illness, elaboration on involved systems, past medical/surgical history, drug use, family history, and social history. A physical exam includes inspection, palpation, percussion, and auscultation of key body systems and areas like the head, neck, eyes, ears, nose,

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    301 views25 pages

    History Taking in Surgery 123

    Uploaded by

    tahreem_saeed_1
    This document discusses the process of taking a patient history and performing a physical examination in surgical practice. It notes that history taking is the key first step in surgical diagnosis. There are two main types of histories - for outpatient/emergency visits to pinpoint a specific complaint and diagnosis, and for patients admitted for elective surgery to ensure the planned treatment is correctly indicated. The history should cover personal details, present complaint, history of present illness, elaboration on involved systems, past medical/surgical history, drug use, family history, and social history. A physical exam includes inspection, palpation, percussion, and auscultation of key body systems and areas like the head, neck, eyes, ears, nose,

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 25

    History Taking In Surgery

    Gamal Khairy FRCS,MS


    College of Medicine KKUH

    History taking
    ? the key step in surgical diagnosis.

    Varies according to the complain ? specific histories ? surgical specialty

    Two types of history in surgical practice:

    Out-pt or emergency room history


    ?specific complaint is pinpointed ? diagnosis

    Clerking of pt admitted for elective surgery object


    ? to assess that the treatment planned correctly
    indicated and pt is suitable for that operation.

    How to take the history ?

    Personal information : Age, sex, marital status, occupation, etc

    History should be taken in the following order:


    the present complaint (c/o). History of present complaint. Elaboration on the system involved. Systemic enquiry.

    History should be taken in the following order:


    e. f. g. h. Past history ? surgical, medical Drug history Family history Social history

    Systemic Enquiry
    1.

    GIT: Appetite, Vomiting, Regurgitation, etc. Respiratory System ? cough, haemoptysis, Dyspnea. C.V.S: * Breathlessness, palpations, chest pain
    * Peripheral vessels: Intermittent, claudication, rest pain.

    Urogenital system: micturition, loin pain supropubic pain. Nervous system: Tremor, fainting attacks, fits, weakness Musculor skeletal ? muscle pains, joint swelling

    Commonest complains in Surgery

    Pain Lump

    The history of pain


    Site. - Onset. - Severity ? wake him up, need analgesics Rather than: mild, severe. - Nature: Buring, stabing, coliky. Progression ? - begin maximum, then remains steady. - steadily increase till maximum then gradual decline. Duration. Aggravating and releaving factors Radiation.
    -

    The history OF A LUMP


    Duration How discovered Symptoms ? pain Changes ? ?in size Other lumps Any cause ? Trauma

    Physical Examination

    General Examination: First part ? during taking history ? posture,


    speech,etc vital signs ? pulse, BP, temp

    Examination of the Head and neck


    Eyes

    Pupil reaction to light Sclera jaundice Conjuction paller Movement Exophthalmos Fundoscopy

    Examination of the Head and neck (contd)

    Ears and Nose


    Usually forgotten on ex: External auditory canal Eardrum Nostrils

    Examination of the Head and neck (contd)

    Neck

    Jugular veins Trachea Lymph nodes Thyroid

    Examination of A LUMP

    Position Colour and texture of skin Temperature Tenderness Shape Size Surface Edge Consistency Pulsatile, compressibility (venous malformations) Reducibility

    Examination of THE ABDOMEN

    PREPARATION:
    Warm and private room Good light Comfortable cough or bed Exposure: nipple to knee Get the patient to relax The position of the examiner

    FIG. 16.6
    THE NAMES OF THE REGIONS OF THE ABDOMEN

    THE STEPS OF Examination


    Inspection Palpation Percussion Auscultation

    THE STEPS OF Examination


    INSPECTION:

    Shape of abdomen Scars, sinuses & fistulae Distended veins Lumps Pigmentation Movement

    THE STEPS OF Examination


    PALPATION: Superficial :

    Tenderness Rebound Ganding

    Deep palpation:

    Masses Organs

    THE STEPS OF Examination


    PERCUSSION:
    All abdomen spec. over masses Fluid thrill Shifting dullness

    THE STEPS OF Examination


    AUSCULTATION:
    Bowl sounds Aorta and iliac anteries - Bruit Succusion splash

    THANK YOU !!!!!

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