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History and Physical Examination (H&P)

Today we are going to talk about history and physical examination in general surgery and anesthesia.
Anesthesia: it is a preparation for surgery, usually preoperative of assessment for surgery has some parts for the anesthesiologist .

The following are general rules for history taking; we should almost always take them in consideration.
Patients profile Chief complaint History of present illness Review of systems Past history Social history Family history

Components of the history

Dont forget to welcome the patient and its important to insure privacy and comfort to the patient .

#Patients profile
1-Name: usually we call the patient by his name not by other clue. 2-Age or DOB 3-Gender 4-Occupation 5-Marital status 6-Address 7-Source of information

After knowing the patients name and profile we set our agenda for the history taking .
We always use open ended questions initially, then when we take the chief complaints of the patient and we are already guided by the patient what to ask about, we use specific questions in relation to the chief complaint.

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#Chief complaint: The first component of the history, and illustrate why
the patient is here in the emergency room or in the office which is the outpatient clinic. Information related to the chief complaint: We should always take the chief complaints from the history of the patient in his own words. We usually comment on the time, duration and the onset of that complaint. Example : if the patient have right upper quadrant colic pain , this might be gallbladder stone but do the gallbladder bladder stone form in 24 hours ...no so we have to focus on the duration of the chief complaint. We can ask the patient in exact about his complaint, for example: why you come now to the hospital.

Example : have a patient with a hiatal hernia , this patient might having hernia for twenty years ago , then why this patient present now to our hospital why he didnt present in the past for the hernia, so this cause of presentation is the initiative for the patient to contact care-giver or medical service.

*Patient story
The patient story is different from the patient history of a disease. Patient history of a disease : is the progression of the disease. The story of the patient : it is also important ,and here is an example : I went to Basma hospital then , I went to a private physicianetc this is the story of the patient to present himself in your clinic. Its important to differentiate between patients, usually we meet patient in out-patients clinics but sometimes we meet patients in emergency room, so the root of admission to the hospital is either from the out-patient clinic or the emergency room.

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We have another hidden rules for admission to the hospital related to transfer: 1- Out-patient transfer: example : directly transfer from the ICU from Prince Basme hospital to the ICU of king Abdulla university hospital.

2- In patient transfer ( internal transfer) : example: : patient admitted to the medical care then the patient need a surgical assessment and surgical care after that the patient should be transferred to the surgical team.

Conclusion: the out transfer will transfer the patient from hospital to another,
while the internal will transfer the patient from one department to another in the same hospital

What is the difference between out-patient clinic and emergency room related to history taking?!
In elective cases we usually not always meet the patient in the out-patient clinic while the presentation is elective ,elective means cold presentation, then we can approach our patient gradually , slowly obeying these rules of history taking. But consider the patient has hot presentation example: in the emergency room with a trauma and bleeder in the face for example, then the history by this is usually short so we have to break these rules and to conform the patient vitals then go back and take the history . If my patient is stable by his fiction, how can I judge that my patient is stable: 1- Looking to the patient body and language contact. 2- If the patient is obeying commands. If the above conditions were confirmed then my patient has Glasgow Coma Scale or conscious scale of fifteen or fully conscious and these reflect a normal vital signs.
The Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person. (Wikipedia)

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Again.. We should return back to open ended questions directed to the major problems and beside each one we should comment on the duration and the onset.

Note:

sometimes not only verbal clues are important, non verbal body language is also important from the patient.

#history of present illness

* The description of the patient illness as told by the patient or his family or a combination of the two. * To analyze the chief complaint and to review the effect of the chief complaint in relation to affected system and to the body as a hole. We are approaching a patient with a chief complaint for example : abdominal pain now this in relation to the GI tract then I have to approach my patient in relation to the complaint then to the system then to the body as a hole.
The human gastrointestinal tract (GI tract) : is the stomach and intestine, sometimes including all the structures from the mouth to the anus.

** You shouldnt forget to ask about the effect of that complaint to the vitals or to the body.

Result : if I planned this in my mind then I can approach my patient in the

correct way leading to sitting the deferential diagnoses in relation to the history in a good manner. After history we should perform physical examination and we might again rearrange the differential diagnoses or confirm them and both of them will guide me to ask from my colleague the paramedics for example or a lab , radiology and ultrasonography or ultrasound departments.

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#Past medical history

It is also important, it will guide me to ask for another investigation, because we are approaching a patient complaint to the clinic this complaint is a new one, this complaint might be super composed a previous same complain. Example: patient present to the emergency with right upper and right lower quadrant abdominal pain, then I should know if my patient is healthy or my patient might be with diabetes mellitus or my patient is hypertensive or my patient with inflammatory bowel disease in steroids or with anti collagenase or. or .or ....., so this is the past medical history and this the comorbidity for my patient.

This will change the arrangement in relation to the disease process, to other comorbidities and plan treatments.

#Past surgical history

Were past surgeries are listed, along with the rough date when they occurred and of course it is important . Example : if the patient present to the emergency room with right lower abdominal pain and the past history that the patient underwent Appendectomy, so Appendectomy will not be with the differential diagnoses , if I set the Appendectomy as a diagnose and i didnt take the surgical history of the past then what I did is a killing mistake

Extra : An appendectomy is the surgical removal of the vermiform appendix.

(Wikipedia)

Allergies, medication and family and social history are also important.

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Review for this script 1- The general rules for taking the history 2-The first component of history which is the chief complaint 3- In and out patient transfer 4-We talked about past history in general

These are some questions .. 1- What is the different between patient history and patient story?! 2- Give three components of the history 3- What are the benefits of past medical history?! 4-What is the history of present illness?! Note: all of the answers are written in the script

I hope you enjoyed this script good luck .