Introduction to History Taking

& Physical Examination in

Surgery
Prof. Ken Agu
Department of Surgery
U.N.E.C.
Preambles
 Patient Evaluation – Tripod
* History
* Physical Examination
* Investigations
 Foundation: History & Physical Findings
 Clinical skills
 Guide to relevant investigations
 Proper interpretation of investigation

results
Surgical Clerkship
 To clerk a patient means to take History and carry
out Physical Examination

 History taking is a directed investigative interview

of a patient and/or informant with the aim of
arriving at a diagnosis of the cause of disease and
determining other relevant factors

 Surgery mostly deals with regional disease with

systemic influence but the reverse holds true in
Internal Medicine
Environment & Attitude
 Adequate space
 Privacy (Need for chaperone)
 Ambient temperature
 Good lighting
 Comfortable sitting arrangement
Environment & Attitude
 Care and Empathy
 A good listener
 Make eye contact
 Use language to communicate

# avoid medical jargons both ways

# may need interpreter
 Your appearance should denote

professionalism
 Be mindful of the prevailing culture
Establishing Rapport
 Greet patient by name and title if you
have it
 Introduce yourself
 History is a semi-formal interview
 Opening small talk if appropriate
 Remain professional
 Know the guiding rules depending on

where you operate

 Document your findings
The History
 Biodata: N-A-S-O-R-E-M-A-P
* Name (identification)
* Age (actual or estimate)
* Sex (Biological)
* Occupation (specific job)
* Religion
* Ethnicity / Race
* Marital status
* Address
* Phone number
 Presenting or Chief Complaint
 The main complaint/s that made the patient decide
to come to hospital that day
 Usually 1 to 3 or 4
 Don’t accept diagnoses or medical jargons

e.g. malaria, pile, dysentery, rheumatism

 Get duration of symptom/s and arrange

chronologically from the earliest to the latest
e.g. PC – Lump in the rt breast……8 months
- Swelling of the rt upper limb …4 weeks
- Breathlessness……..1 week
History of Presenting Complaints
(Main Body of the History)

 Cause
 Course
 Complications
 Care
 Co-morbidities (PMH)
e.g. yellowness of the eyes
NB. You cannot take a good history if
your pathology base is weak!
Past Medical & Surgical History
 Past major illnesses which have been treated
and resolved
 If a past medical/surgical history is linked to
present illness, it should form part of HPC
e.g. Intestinal Obstruction from adhesions
from previous abdominal surgery
 Anaesthetic experience is important here

 On-going chronic illnesses are commonly

listed here e.g. Hypertension, DM, SCD, Asthma
e.t.c.
Drug History
 Is the patient on regular drugs e.g. for
hypertension, DM etc?
 Find out the names and duration of drug use
 Any drug allergies?
 Be mindful of any interactions with the

treatment you are planning to administer

 There may be need to convert oral drugs to

parenteral forms if patient will be on nil per

oris after surgery
 Also note any drugs of abuse
Gynaecological/Obstetric History
 Relevance depends on presenting
complaint
 May be important differentials
 Always find out if a patient is pregnant

or breastfeeding
 Age at menarche
 Last menstrual period
 Vaginal discharge
Gynaecological/Obstetric History
 Coitalexposure
 Number of pregnancies
 Breastfeeding history
 Postmenopausal status
 Use of contraception
Family History
 Parents
 Siblings
 Uncles / Aunties etc
 Familial / Hereditary diseases
 Medical histories
 Cause of death etc
Social History
 Educational attainment
 Marriage/children
 Occupation
 Place and type of residence
 Source of water
 Usual diets
 Faecal disposal
 Tobacco/Alcohol use
Developmental/Immunization
History
 Applicable in infants and young children
 Relevant in Paediatric Surgery
Review of Systems
 Unlike PMH, ROS attempts to capture current
illness that have little association with the
presenting illness
 Depending on education and awareness of

patient, some findings in ROS become major

 The system involved in the presenting

complaint is usually reviewed in the body of

the history (HPC)
 It employs a format of standardized

questions for each system

ROS: CNS
 Special senses: changes in sight, smell,
hearing, taste
 Numbness, paraesthesia
 Limb weakness
 Headache
 Seizures. faints
 Speech problems
 Poor balance
 Sphincter problems
 Psychiatric symptoms
ROS: CVS
 Chest pain
 Shortness of breath
 Exercise intolerance
 PND
 Orthopnoea
 Dependent oedema
 Palpitations
 Claudication
 Faintness
 Loss of consciousness
ROS: Digestive System
 Abdominal pain  Diarrhoea
 Dysphagia  Constipation
 Odynophagia  Haematemesis

 Indigestion  Haematochezia

 Bloating  Melaena

 Anorexia  Tenesmus
 Weight loss
 Nausea
 Abdominal swelling
 Vomiting
 Groin swelling
 Polyphagia
ROS: Respiratory System
 Chest pain
 Cough
 Sputum production
 Haemoptysis
 Shortness of breath
 Wheezing
 Exercise intolerance
ROS: Genitourinary System
 Frequency of micturition
 Nocturia
 Dysuria
 Polyuria
 Hesitancy
 Poor stream
 Terminal dribbling
 Urethral/vaginal discharge
 Scrotal swelling/pain
 Sexual function
 LMP etc (if not covered in gynae history)
ROS: Musculoskeletal System
 Joint/muscle pain
 Joint swelling
 Joint stiffness
 Decreased range of movement
 Deformity
 Gait
 Paralysis
 Weakness
ROS: Integumentary/Breast
 Rashes
 Pruritus
 Sweating
 Hair loss
 Wounds/incisions
 Nodules/tumours
 Hyper-/hypopigmentation
 Breast pain
 Breast lump
 Nipple discharge
ROS: Endocrine
Usually covered in other systems
Diagnosis
 Diagnosis is based on deductive reasoning
from the information obtained
 Beware of multiple pathologies
 Adopt a divergent view
 Avoid preconceived diagnosis
 Common things are common
 Be mindful of the peculiar characteristics of

the patient like age and sex

 If in doubt, go for the worst case scenario
Differential Diagnoses
 Listof other likely alternative
diagnoses
 Arranged in order of probability
 Confirming the authentic diagnosis

forms the focus of the other 2 legs of

the tripod – physical examination and
investigations
ANY QUESTIONS
Physical Examination of the Surgical
Patient
In Surgery we mostly deal with
 Lumps
 Swellings
 Masses [inside or outside]
 Collections
 Deformities
 Pain
 Egress of effluents from natural

orifices: serous, bloody, bilious,

purulent, mucoid etc
Physical Examination of the Surgical
Patient
 General Examination

 Lumps

 Abdomen

 The rest to be taken in other

lectures
Physical Examination of the Surgical
Patient
 Obtain informed consent
 A quiet environment
 Tape, thermometer, sphyg. Tendon

hammer, torchlight, pin, cotton wool,

gloves, spatula, etc
 Privacy (chaperon)
 Natural light
 Couch with patient at about 45 deg.
 Stand at the right of patient
 Expose only the part under examination
General Examination
 Identify sex and estimate age
 Appearance: well-nourished, emaciated,

cachectic, obese, ill-looking, in distress etc

 Level of concsiousness
 Pallor, icterus, pyrexia, dehydration,
 Hands for finger clubbing
 On tubes e.g. i.v. line, NGT, urethral catheter,

feeding gastrostomy tube etc.

 Vital signs pulse, resp. rate, temperature, b.p.
 Peripheral lymphadenopathy
 Dependemt oedema
 Any striking feature
Lumps
 Site  Temperature
 Size  Borders/margins

 Shape  Consistency
 Fluctuancy
 Surface
 Attachments:
 Colourchanges
 Tenderness
skin/underlying
structures

. .
Lumps
Special signs  Slipping

 Reducibility  Punctum

 Emptying  Cough impulse

 Pitting/indentibility  Regional
 Pulsation lymphadenopathy
 Thrill/bruit
 Lobulation
 Trans-illumination
Lumps: localization to anatomic
plane of origin
 Skin
e.g. sebaceous cyst,
papilloma, keloid
 Subcutis
e.g. subcutaneous lipoma
 Muscle/fascia/tendon/nerve
e.g. ganglion,
rhabdomyosarcoma
 Bone
e.g. osteoma, osteosarcoma,
metastatic spread
Abdominal Examination
Generally in physical Examination,
we use 4 modalities
Inspection
Palpation
Percussion &
Auscultation
Abdominal Examination
 Exposure
from nipple line to midthighs
 Inspection

# level of fullness or distension

# movement with respiration
# symmetry
# position of the umbilicus
# scars/scarification marks
# striae, visible veins, pigmentation
# visible peristalsis
# hair distribution
# the groin
The 9 regions of the Abdomen
Abdominal Examination
 Palpation

# superficial palpation (tenderness)

# hernial orifices
# deep palpation
* liver
* spleen
* kidneys
* bladder
* others
Abdominal Examination
 Percussion

# general
# over masses
# liver span
# shifting dullness
Abdominal Examination
 Auscultation

# bowel sounds
# bruit
# succusion splash
Abdominal Examination
 Digital
rectal examination (chaperone)
# position
# inspection (stops here in painful
anorectal conditions)
# palpation
Abdominal Examination
 Finally for the men

 Posterior abdominal wall

 Lumbar hernia
Hope to meet you

in the clinics and wards for

practical demonstrations
Thank You
 Any
Questions?