Chapter 1

(1) What is a Surgical crescendo? Briefly discuss in chronological order.

A surgical patient coming to the hospital can be:

The stages through which a surgical patient passes

is described as a Surgical crescendo. These are:
1. History taking
2. Clinical examination Elective Case Emergency Case
3. Making a clinical diagnosis and keeping the possibilities
of various differential diagnoses.
Elective case reports in the surgical outdoors during Emergency case reports in the casualty at any time and
4. Investigations routine hours where diagnosis of disease is made. is managed in a different way. After quick history and
5. Making final diagnosis Then examination, resuscitation is started.
6. Surgery he is admitted in indoor and operation is performed.
7. Even after investigation, a diagnosis may not always be
reached. In such a case, either the disease is naturally cured
and no diagnosis is ever made, or the patient passes away
and a postmortem reveals the specific pathology.

1. History Taking

Objectives a. To reach the clinical diagnosis

b. To look for fitness of patient for surgery.

- ‘Symptoms’ are the complaints told by the patient.

- ‘Signs’ are the features seen by the clinician on
clinical examination.

1.2 History of Present Illness

Duration of illness Asking condition before the present illness

Mode of onset How the illness started?
Progress Better or Worse
Aggravating and relieving factors Pain during movements
Constitutional symptoms Occur secondary to illness, e.g. pain

Past history Any illness suffered in the past is recorded

in chronological order. It may or may not be related to
present illness.
Personal history Alcohol, Smoking, Beetle Chewing, Lifestyle
Menstrual history any menstrual irregularity, vaginal
discharge, age at menopause, postmenopausal bleeding
Family history Cancer, Diabetes Mellitus
Treatment history Any treatment taken before(for the taken drugs)

2. EXAMINATION

General Physical Examination Local Examination Systemic Examination

Make the patient sit or lie in the bed comfortably. • Side of the lesion To know the patient as a whole.
Examine with warm hands. • A few simple instruments: Various systems to be examined
Look at * Pocket torch are:
• General appearance, viz. * Black paper • CVS
* Tongue depressor • CNS
□ Level of consciousness * Metal scale • Respiratory system (chest)
□ Patient cooperative/uncooperative. * Measuring tape • GIT (Abdomen)
• Build (assessed by skeletal frame work). * Hammer • Genitourinary system
• Nourishment (fat, skin texture, muscle mass). * Stethoscope
• Pulse rate (normal 72/min.), regularity, volume. * Disposable gloves
• Blood pressure (normal 120/80 mm Hg). * Thermometer
* Skin marking pen
• Temperature (normal 37°C).
• Noting its site, external appearance, possible anatomical organ of
• Respiratory rate (normal 12-16/min.), regularity, type origin.
• Look for various clinical signs from head to toe: • The lesion may present as swelling, ulcer, sinus or
* Anemia in palpebral conjunctiva, nailbeds, tongue. fistula and are described in
* Jaundice in upper sclera, undersurface of tongue, the relevant sections.
palmar creases. • Examine the lymph nodes

3. INVESTIGATIONS Various investigations

Aims of doing investigations are:

i. To reach final diagnosis
ii. To look for fitness for anesthesia and surgery.
iii. In case of malignancy, staging of disease so as to Hematological Investigations Pathological Examination
plan treatment and assess prognosis.
• Hemoglobin—for anemia. • Fine needle aspiration cytology
• Bleeding time, clotting time—for bleeding • Tissue biopsy
disorders. • USG/CT guided biopsy—helpful in localizing the site
• Total and differential leucocyte count—raised in of lesion especially if it is deep seated.
infections.
• ESR—raised in chronic infections.
• Blood Sugar—raised in diabetes.
• Blood urea and serum creatinine—raised in Other Investigations
renal • Urine examination: For albumin, sugar and micro-
failure. scopy.
• Thyroid function tests—in case of thyroid • Stool examination: For ova, cyst, pus cells, occult
pathology. blood.

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