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?
