surgery - Lec 1

7/29/2019 surgery - Lec 1

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It includes the slides

Today we will take about history and physical examination in general surgery and

anesthesia (because its included in pre-operative procedure).

*General rules in history taking :

1-Welcome the patient - ensure comfort and privacy2-Know and use the patient's name - introduce and identify yourself3-Set the Agenda for the questioning (history taking)4- Use open-ended questions initially

5- Negotiate a list ofall issues - avoid excessive detail initially

Chief complaint(s) and other concerns Specific requests (i.e. medication refills)

Clarify the patient's expectations for this visit - ask the patient "Why now?"

6-Elicit the Patient's StoryIts differ than history of disease which means: the progression of a disease .


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7- Return to open-ended questions directed at the major problem(s)

8- Encourage with silence, nonverbal cues, and verbal cues

9- Focus by paraphrasing and summarizing

*patients: root of administration

Ex: if pt. has been transferred from ICU in basma hospital to ICU in king Abdulla

Hospital >> outer transfer

Ex: if pt. Has been administered to the medical care >surgical care >surgical

Team >> internal transfer.

*You have two types of presentations :

1- Cold present./complain > When pt. comes in out clinic and u begin ur

examination by take history (elective cases ) - in officelong duration ofcomplain


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2- Hot present. / complain > When pt. are in emergencies, so u have 1st to

control his conditions then go u take history when he becomes stableinemergencyshort duration of complain .

Usually vomiting ,sever pain , mass can bring pt. to emergency .

How do I know if my pt. is stable?

Looking to him, body language, language contact, nonverbal language.

if my pt. is obeying my commands so he is at least 50%consiounes >> which

Indicates for normal wake up science.

*Components of the History

1-Chief complaintThis is why the patient is here in the emergency room or the office (out clinic).

U should concern about the duration and onset of it.

Examples: Shortness of breath for 2 days Chest pain of 3 hours Pt. with right upper quadrant colic pain from 2 horse, maybe its

gallbladder stones but it form in 2 h. So we think about other

diseases.

2- History of Present Illness

This is the detailed reason why the patient is here


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We analysis the chief complain to know its effect on effected organ,system of the whole body.

It is the why, when and where, etc

Use the OPQRSTA approach to cover all aspects of information

OPQRSTA

Onset

When did the chief complaint occur Prior occurrences of this problem

Progression

Is this problem getting worse or better Is there anything that the patient does that makes it better or

worse

Using scaling system can help u to draw the line of painpresentation.

Quality

Is there pain, and if so what typehow would the patientdescribe it is words

Chronic pain = discontinuous = such as obstruction of lumen

GIT , biliary tract , urinary track


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Continuous pain = dental caries, Abscess

Radiation

Do the symptoms radiate to anywhere in the body, and if so,where?

To know the side of presentation and from which organ orsystem is come

Scale

On a scale of 1 to 10, how bad are the symptoms Timing

When do the symptoms occur? At night, all the time, in the mornings, etc

Associated symptoms

Ask if there is anything else that the patient has to tell aboutthe chief complaint

To know other symptoms goes parallel with chief complain


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Pain

Location Length of time Severity Qualit

3-Past Medical History These are the medical conditions that the patient has chronically and that

they see a doctor for.

Examples: Hypertension, GERD, Congestive heart failure, Diabetes, Asthma,

Thyroid problems, etc

4- Past Surgical History

These are any previous operations that the patient may have had Make sure to put how old the patient was when they occurred Include even those that occurred in childhood It will guide u to other investigations and help u to rule out others Examples:

Tonsillectomy, Hysterectomy, Appendectomy, Hernias,Cholecystectomy

Pt. with upper and lower right quadrant abdominal pain , his may beabdominal appendicitis , but if he had already appendectomy so I

should rule out this option .


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5- Allergies

Make sure to ask about medication allergies and the reaction that thepatient has to them so u can think in other disease.

Ask about latex, food and seasonal allergies6-Medications

Include all meds the patient is oneven over the counter meds and herbals Try to include the dosages if the patient knows them Include how often the patient takes them

7-Social History

Things to include: Occupation Marriage status Tobacco usehow much and for how long Alcohol use Illicit drug use Immunization status


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8-Family History

Ask if the patients parents, grandparents, siblings or other family membershad any major medical conditions

Examples: Heart disease, heart attacks, hypertension, hyperlipidemia,

diabetes, sickle cell disease, breast and colon cancer.

9- Review of Systems

The review of systems is just that, a series of questions grouped by organsystem including:

General/Constitutional Skin/Breast Eyes/Ears/Nose/Mouth/Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Neurologic/Psychiatric Allergic/Immunologic/Lymphatic/Endocrine

*physical examination :

To improve or rule out the differential diagnosis that we had thought of.

Pt should be in supine position .


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Pt. must feel comfort, privacy while we are diagnosing.U must be smart enough to look around pt. environment and know some of

complains (when u go to pt. home)

ex: if u found basket >> he may complain of vomiting

it includes :GeneralHeartLungsAbdomen (most important)ExtremitiesNeck -

GU if pertinent to the chief complaint

So u had to examine all that first then focused about ur target .

Make sure to include vital signs as part of this Develop a systematic approach for doing the physical exam

How to exam pts. ?

Neck >> expose the upper third of the body from the mid midline and up

Abdomen >> expose the middle line to the mid high line

Lower limbs > expose both of them and keeping in mind we are going to

compare both of them

( sorry , its not clear !! )

*Component of physical examination :

For some disease we have some disease to be performed to reflect something

1- Inspection1st: I check my anatomical layer, we usually start with the skin and focuseson the hidden areas .

Ex: while examining lower limbs, u should check nails and websitesbetween fingers and toes,


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Color Vascularity Lesions Temperature Turgor Texture Wounds

Clubbing of Fingernails

2nd : I go to the subcutaneous layer which composes of fat and veins (no

arteries), I may found dilated vein, or superficial mass.

If pt have a dressing > so for sure he had traumatic injury , I can ask him to

remove it for good diagnosing .


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3rd : to the Abdomen

Contour Size Bowel sounds Tenderness Palpate bladde

the abdominal wall .

All these >> increase the intraperitoneal pressure > then hernia will be shown

>> this is called : visible cough impulse

In Some cases, hernia is not shown such as obstructed or complicated one ,

so pt. in this case is directed to emergency

Ex: we have found a mass >> u should check five (s) :{ shapesites - side

surface } and the overlaying structure of that mass, surrenders and edges .

*the surface could be smooth , nodular , non nodular - charge discharges ,* if the mass is connected to the skin > so there if no overlaying structures

*We should check the symmetry of right side with left side of the abdomen,

contour of abdomen, if it flat or descended or scaphoid


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Another way to check the abdominal wall:

*We should checkPattern of respiration:while respiration, our abdominal wall moves specially in female .

If I have inflammatory process inside my peritoneal cavity, then anymovement of the abdominal wall will irritate the peritoneum > feeling pain

Thats meanpt. with acute abdominal inflammation cant use his ant.

Abdominal wall in respiration, this indicates malignancy (sever not cancer)> so pt. have periodontitis > need surgery in most cases

Peritoneal content ( content of the abdomen ) , u may found intestinal

obstruction .

I can see huge mass in peritoneal cavity by examining symmetry


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Retroperitoneal content , pt with huge liver or spleen .

Then retroperitoneal organs : aorta and pancreas.

Ex : hemorrhagic pancreatitis, and it will give a sign as subcutaneousbleeding

In aorta , we can check epigastric area by pulsation .

2- PalpationThis is the 1

sttime we touch the pt.

We can check his temperature (although checking temp. is a verbal cues

that should be checked before physical examination )

Its divided into:

Light / superficial Deep

Definition To examine the wall to examine the

content

What to check? Tenderness masses

- Muscle tone - Wall

defect

Deep tenderness

masses

ABOUT LIGHT PAPLATION

Ex : pt with subcutaneous lipoma , then when pt. cough the ant. Abdominal

wall will be contracted and the lipoma will pushed upand thats what called

visible cough impulse >> u may think that its hernia, but it is not, why ?? >> if


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u pulped it again and again , there will be no pulpal cough impulse and no

Fascial defect >> so its not hernia

Hernia: its a primary pathology in the fascia of ant . Abdominal wall .

ABOUT DEEP PALPATION

U can divide it into 4 major area or nine sub-ones, but keep in mind u had to

examine clockwise or counter clock wise

In any cases that u found a mass u have to write the five( s ).

3- PercussionIts specific test that is done for the pt. to give him a cue about hidden content

in the peritoneal cavity , we divided the sound result into : tympanic , resonance

,hyperesonance , dullness , flatness

Then u can complete ur examination using telescope until u reach target organ .

(49:5 49 :34) !!!

*When u hear the sound u have to know : Site intensity duration frequency

of it >> these are called general survey

4-Auscultation


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*General Survey

Age, sex, race Body build, height, weight Posture and gait

If pt have acute appendicitis and he his obese , this fat will act as isolator to

the syndrome to appear , so pt. will only feel abdominal pain and loss apatite

, also he will have abnormal gait

Hygiene and grooming Signs of Illness Affect Cognitive Processes

*Head and Neck examination

Inspect scalp and hair Facial Symmetry Ears Inspect Nose Mouth

Checks the skin over the neck and head, u know that the Sternocleiodmastoid

muscles divided the neck into ant. And post. Triangle

Neck ROM


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Lymph Nodes Palpate trachea Palpate carotids Auscultate carotids

Assess for JVD

*This is superficial lymph node enlargement.

*Post. Triangular lymph node or lymphopathy is more serious than ant. Ones

because in most cases the ant. Lymph node are infectious but the post ones

either TP or malignant.

By looking to the external jangler vein and palpate it , we can take a cue about

the hemodynamic static of the pt. how ?

All the body veins are valved veins except the portal and head and neck veins , so

if u lay down and hang ur head below ur heart then u will feel pressure inside ur

head because blood rushed to ur heads .

In most of the times, ur head is above ur heart, in this status, the blood will be

drop dynamically down to ur heart .


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*Chest examination

We should calculate the respiratory rate

Respirations labored unlabored

Chest shape


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Chest symmetry Breath sounds

These are the sites in which we put our telescope in order to hear the

respiratory sounds; it should be symmetrical in right and left

*Extremities

ROM present ( rang of movement ) Strength Capillary refill > it will reflect the perfusion to the target Peripheral pulse > help in knowing if pt. have peripheral vascular disease Edema Nails

*Assessment and Plan

This is what you think is wrong with the patient, and what you plan to doinitially during admission

so u may need to change ur primary deferential diagnosis after physical

examination .


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Example:

-A/P: 1. Chest pain. We will admit the patient to the chest pain protocol. We will

get EKG every 8 hours times three, and cardiac enzymes every eight hours times

three, get a CBC, KFT, Lipid Profile, etc

-I may think of acute appendicitis then when I found a scar and re - ask the pt.

again about it , my diagnosis will change into appendicostomy .

After sitting ur 2nd deferential diagnosis , this will lead u to ask for 59:22 .,

then this will lead u to prepare ur pt to anesthesia

I may need chest x ray as a part of pre-operative assessment for anesthesia ,sometimes I cant ask pt .to have x- ray such in pregnant female .

classify ur pt into :

1- Pt fit for surgery and pre surgical intervention case

2- pt. is not fit for surgery

pt comes to emergency room in top of surgical intervention and have acute

appendicitis , and sometimes if we didnt do surgery then pt may have another

consequences.

**** so this case is divided into : fit for surgery and not fit

If the case is sever and the life life-threating , so we had to make the agreement

of the pt and this called conformed concept,we should tell the pt about his status

and what may happen if we do or not do the surgery .


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we may found pt beyond surgical intervention , And also these either to be fit or

not fit

Example : pt with metastatic breast cancer , and female start to complain fromthis Brest mass , Is she fit for surgery while the malignancy is over her body ?

this is what we called : the beyond surgical intervention

-we can make the surgery for cosmetic fake but this isnt radically

-the mass is in her Brest will not kill the pt. but the malignance spread will do.

*History and Physical

This will all become like second nature after you have done a few. Just stick to the same way you do the H and P each time, and you will do all

right.

>> Present and absent is important , we have 10 marks on attendance

Forgive me for any mistake, I tried my best .

Made by : Farah Salem

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surgery - Lec 1