Introduction , History & physical Examination

Introduction, History & Physical Examination

Today , we will talk about history and physical examination in general surgery and anesthesia , the anesthesia wise preparation for surgery . Usually the assessment for surgery has some types from the anesthesiologist .

Those are general rules for history taken , we should almost take them in consideration , we have to : 1. Welcome the patient and it is important to insure privacy and comfort to the patient . 2. Patient's name , usually we call the patient by his name not by other clue . 3. Set our agenda for history taken . 4. We always use open ended questions . Initially , when we take the chief complaint of the patient , and we already guided by the patient what to ask for , then we use specific questions related to the chief complaint . We should always take the chief complaint from the patient in the patient's words . Beside the chief complaint we usually comment in the duration and the onset of that complaint , and we can ask the patient in exact . For example : Why you come now to the hospital ? . If we have patient with gluteal hernia , this patient might have gluteal hernia from many years ago , so why this patient present now to the hospital ? why he did not present in the past by this hernia? Gluteal hernia : Protrusion of intestine through the great sacrosciatic foramen.
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Introduction , History & physical Examination

So, this cause of presentation is the initiative for the patient to contact medical serves . The patient story The patient story is different from the patient history . History of a disease is appropriation of a disease , while the story of the patient it is also important .

I went to the Princess Basma Hospital , then I went contact with the private physician in a private sector => This is the story (The way of the patient to present himself to your clinic). It is important to differentiate between patients , usually we meet patients in out patient's clinic m but sometimes we meet patients in emergency room . So the route of admission to the hospital either from the out patient's clinic or in emergency room .

We have another hidden rule , route for admission to the hospital . For example direct transfer from the ICU from the Princess Basma Hospital to the ICU of King Abdullah University Hospital (KAUH) , this is a hot patient transfer , and we can face inpatient transfer . Another example => patient admitted to the medical care then this patient need a surgical assessment and surgical care , after that the patient should be transferred to the surgical team . This is an internal transfer . What are the difference in elective cases ? We usually (not always ) met the patient in out patient's clinic while the presentation is elective Elective = cold presentation . Then we can approach the patient gradually , slowly obtain these rules , but consider the patient have hot presentation . Example , in the emergency room with a trauma and bleeder , then the history by this is usually short but we have to break these rules and to control the patient's vitals , then go back and take the history .

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Introduction , History & physical Examination

If the patient is stable by inspection how can I know if my patient is stable ? By looking to the patient , body contact and language contact- If the patient obey commands then my patient has Glasgow Coma Scale of fifteen , and if a patient obey commands this means or this at least reflect a normal vital signs . And again , we should retain back to an open ended questions directed to the major problem or problems and beside each problem we should comment on the duration . Sometimes not only verbal clues is important , non-verbal body language is also important .

Component of the history

1. Chief complaint => Take the time and duration of that chief complaint . 2. History of present illness => this is to analyze the Chief complaint and the relation to affected systems and to the body as a whole.

We are approaching the patient with a chief complaint . i.e abdominal pain . Now this in relation to GI tract , so I have to approach my patient in relation to the complaint , then to the system then to the body as a Whole . Not to forget to ask about the effect of that complaint to the vitals or to the body . If I plan this in my mind , then I can approach my patient in a correct way then I will set the differential diagnosis relation to the history in a good minor . After this we should perform physical examination and in physical examination we might rearrange again the differential or confirm already arranged differential diagnosis and both of them will guide me to ask from my colleague , paramedics , or from the radiology department , ultrasonographer , and asking medical history also is very important . This will guide me to ask for annular investigation or to rule out the others comorbidities . Because we are approaching idea and we are approaching patient complaint to the clinic . This complaint is a new one ,

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Introduction , History & physical Examination

this complaint should be composed a previous same complaint or another comorbidities .

Patient present to the emergency with a right upper , right lower quadrants abdominal pain , this may be appendicitis , then I should know if my patient is healthy or my patient might be with diabetes mellitus , or my patient is hypertensive , or with inflammatory bowl disease in steroids . , so this is the past medical history and this is the comorbidities for my patient , this will change my arrangement in the patient to disease process and to other comorbidities and to plan my treatment .
Appendicitis is a medical emergency characterized by inflammation of the appendix
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Past surgical history . It is important if the patient present to emergency room with the right lower abdominal pain , and a past history , and the patient in the route appendectomy . So, appendectomy should not be within the differential diagnosis , if I set the appendectomy with the first differential and I did not toke history of surgical history in the past , then I did a fault . This is a killing mistake. Allergies is important , medications , social history , family history , review of the system, this is the component of the history . I should go throw all these components . Chief complaint , this is why the patient is here in the emergency room or in the office , which is the out patient's clinic , and it is important to set the duration . If the patient have presentation of i.e right upper quadrant colic pain this might be gallbladder stone , but do the gallbladder stone form with 24 hours ? NO . So, why the patient is presented today ? This is the duration of a chief complaint.
Gallbladder stone or gallstone is a crystalline concretion formed within the gallbladder by accretion of bile components. Wikipedia

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Introduction , History & physical Examination

I have right upper colic pain since : 1. 6 hours => (the duration is short) = the complaint is worm and I should approach my patient probably and to take a rapid decision. 2. 2 days => ( the duration is prolong) = the complaint is cold . Here I can feel calm and I can order the investigation as an outpatient orders. In emergency usually the duration is short , while in elective cases in out patient's clinic usually the duration is prolong Now just take a look to this diagram below

The End Done by : Sireen Rabab'ah

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