Anamnesis and Physical Examination in General Surgery PDF

Anamnesis and Physical Examination in General Surgery Prof. Dr. M. Levhi AKIN İstinye University Medical School Department of General Surgery  Anamnesis Obtaining information to make a diag...

Anamnesis and Physical Examination in General Surgery Prof. Dr. M. Levhi AKIN İstinye University Medical School Department of General Surgery  Anamnesis Obtaining information to make a diagnosis or determine the status of an existing disease A specific order and sequence of questions A good anamnesis may give more clues than physical examination for diagnosis Asking questions according to the order in the anamnesis form Medical jargon Taking anamnesis in a way that solves the problem and makes a diagnosis (a preliminary diagnosis from complaints, testing this with further questions)  Anamnesis / environment and communication Chair Noise and privacy Friendly approach, accessibility, smile Sociocultural appeal Introducing yourself Explaining the reason for the interview (information gathering practice) Obtaining the patient's consent Respect, attention, physical comfort and privacy  Anamnesis / expecting dressing and behavior The clothes are plain and clean (no denim fabric, belly should not be seen, low collar cut should not be worn) Hospital uniforms are designed according to the rules determined by each hospital. Name badges or name tags must be always worn Hair should be kept clean and tidy, long hair should be gathered at the back Jewelry should not be worn, except for the following Ring (in the form of a metal ring, stone rings should not be worn) Earrings (with screws only) Necklace (simple chains only, kept under clothing) No bracelets or wrist bands should be worn Nails are short and clean. False nails should not be used. Comfortable shoes (no sneakers, heeled shoes, open-toed shoes)  Anamnesis / ID information Name and surname Age Incidence of diseases Decreased organ functions Co-morbidities Occurrence of symptoms (signs of appendicitis and peritonitis, delirium and loss of consciousness, babies under 1 year old) Gender Cancer types specific to men and women Non-cancer diseases and conditions specific to men and women (sex-related) Differential diagnosis of abdominal pain and acute abdomen in men and women Frequency and prognosis of diseases (autoimmune diseases, Crohn's and ulcerative colitis, ankylosing spondylitis)  Anamnesis / ID information Marital status Height and weight (BMI) HT, DM, coronary disease, gallbladder disease, osteoarthritis, sleep and respiratory problems, some cancers (endometrium, breast, colon) in obese people Address Endemic goiter, FMF (Familial Mediterranean Fever), radioactivity Job Doctors (hepatitis, HIV) Veterinary or livestock (tetanus, anthrax, rabies) Chemists (pesticide, lead) Silicosis, asbestosis, metal dust, cotton dust, aluminum dust Carpal tunnel syndrome and tenosynovitis Post-traumatic stress disorder (military, police) Telephone Follow-up, examination or biopsy result  Anamnesis / disease information Disease Information Diagnosis (preliminary diagnosis, definitive diagnosis) Treatment (at discharge, treatment and surgery) Pathology (result, stage) Archive Information Hospital File Number (a single file number, also on subsequent applications) Service Number (separate for each service) Specialist Dr (lecturer or specialist doctor following the patient) Assistant Dr (assistant doctor following the patient)  Anamnesis Complaint Asked and listened without interruption Confirmation of understanding (verbal or body language) Whether there are other complaints (weight loss, abdominal pain, nausea, vomiting in a patient who complains of not being able to eat) List of complaints Story Complaints will be examined one by one, and the reasons why If it goes off topic, politely redirect Taking notes Not ignoring their distress (pain, not being able to lie down comfortably) Not ignoring when asked about diagnosis and treatment  Anamnesis / examination of the complaints All complaints, especially pain complaints Location (localization) Qualification (blunt - peptic ulcer, biliary colic, appendicitis), (sharp - intestinal and renal colic) Severity (ischemic, pancreatitis, generalized peritonitis) Chronology When did it started How was it start How did it end Duration Frequency Periodicity Causes that increase or decrease the complaint (including treatment) Accompanying symptoms (dysphagia, loss of appetite, nausea, vomiting, weight loss, constipation, diarrhea, fever, GI bleeding, jaundice)  Anamnesis Resume Diseases (diabetes, hypertension, ischemic heart disease, heart failure, asthma, COPD, chronic kidney failure) Operations (previous surgeries, with dates) Cigarette-Alcohol (if used, amount, duration) Medicines used (if can not remember the name drug boxes, doses, why used it, ordering these medicines when hospitalized) Bleeding diathesis (ecchymosis due to mild trauma or spontaneous, bleeding history after minor procedures, hypermenorrhea) Allergy (history of allergy, especially to the medicines intended to be used, possibility of cross-reaction) Family history Mother, father, siblings, second-degree relatives Diseases in the family If the mother and father are not alive, the causes of death and their ages  Anamnesis / query of systems System inquery via a written form so that symptoms are not missed The patient may forget to tell you all his complaints Trying to apply the whole list tires both the patient and the physician (selective, systems related to the patient's problem) Head-Neck Headache - Photophobia Dizziness - Double vision Hearing loss - Eye discharge, stinging, watering Tinnitus - Runny nose, congestion Ear discharge - Postnasal drip Earache - Hoarseness Visual impairment - Sore on gums, mouth and throat Cold, Flu - Lymphadenopathy Goitre  Anamnesis / query of systems Cardiovascular system Chest pain (angina) - Paroxysmal nocturnal dyspnea Shortness of breath (with or without exercise) - Palpitations Orthopnea - Swelling in the legs Respiratory system Chest pain Shortness of breath and wheezing Cough, sputum, hemoptysis Gastrointestinal system Loss of appetite and weight loss - Jaundice Dysphagia - Abdominal pain Nausea, vomiting, hematemesis - Constipation, diarrhea Indigestion, pyrosis - Mucus discharge, flatulence Hematochezia, melena  Anamnesis / query of systems Genito - Urinary System Frequency, dysuria, nocturia, polyuria, oliguria - Age at menarche Duration of bleeding and menstrual pattern - Hematuria Urinary incontinence, urgency - Monoragia (blood loss) Prostatic symptoms - Dysmenorrhea Impotence - Menopause Menstruation - Infertility Central Nervous System Headache - Muscle weakness Fainting, unconsciousness - Drowsiness, burning, tingling Dizziness - Memory loss, personality change Vision, double vision - Anxiety, depression Hearing  Anamnesis / query of systems Endocrine system Skin Menstrual disorders Rash Hirsutism, alopecia Pruritis (itching) Abnormal secondary sex characteristics Acne Polyuria, polydipsia Sweating amount Hair quality Musculoskeletal system Pain, swelling, muscle stiffness Limitation in movements Muscle strength Ability to wash by oneself Ability to climb stairs  Anamnesis / Physical examination Washing hands, wearing gloves Hello and introducing yourself Inspection permit General condition and environment of the patient Undressing the area to be examined Classical order of inspection Inspection - Observation Auscultation - Listening examination with a stethoscope Palpation - Tactile examination Percussion – Finger tap The patient is asked to tell if he/she has pain without hurting him/her. The patient's face should also be looked at while palpating.  Anamnesis / abdominal examination Should be opened from xiphoid to pubis A pillow under head Examination from the right of the patient Knees slightly flexed  Anamnesis / abdominal examination Peripheral Inspection General condition (pain, respiratory distress, etc.) Signs of weight loss (templates collapsed), hydration, ecchymosis (bleeding diathesis) Drain, catheter, stoma bag Surroundings (kidney tub at bedside, enteral nutrition solutions, bile on patient or on the bed, bloodstains or other stains) Palmar erythema or flapping tremor of the hands (cirrhosis) Jaundice in the sclera (obstructive jaundice), pallor in the conjunctiva (anemia), xanthelasma (chronic cholestasis), swelling in the parotid gland (alcoholic) Sore lips (iron deficiency), aphthous ulcers (Crohn's disease), red steak-like tongue (folate/B12 deficiency), atrophic and flattened tongue surface (atrophic glossitis, iron deficiency) More than 5 spider angiomas and gynecomastia (liver cirrhosis) on the trunk Loss of body hair (liver disease)  Anamnesis / abdominal examination Abdominal inspection Findings of weight loss in the abdomen (collapsed abdomen, thin skin, visible bowel movements from the outside) Shape and symmetry of the abdomen (asymmetrical distention of the abdomen in sigmoid volvulus, large masses) 5F causing abdominal distention Flatus (gas) Feces (stool) Fetus (pregnancy) Fat (obesity) Fluid (ascid) Surgical incisions Prominent veins Hernia (distortion of the shape of the navel in umbilical hernia) Participation of the abdomen in breathing (in peritonitis or other acute abdominal conditions)  Anamnesis / abdominal examination Auscultation Bowel sound every 5-10 seconds (at least 5 breaths) Grave silence in ischemic conditions (mesenteric ischemia) Decreased bowel sounds in peritonitis and other paralytic ileus conditions In intestinal obstruction, bowel sounds increase and metallic sound Murmur  Anamnesis / abdominal examination Abdominal palpation To the right of the patient, banding over or sitting (hands should be warm) First, superficial palpation of all quadrants (presence of tenderness and defense) Starts from the farthest area to the pain, the last painful area Looking at the patient's face should not be neglected Then deep palpation (presence of mass, characteristics of the mass) Looking for rebound in the sensitive area (peritoneal irritation) (defense, etc.) Clepotage (when pressing the epigastric area (on the stomach) quickly, churning sound - pyloric stenosis)  Anamnesis / abdominal examination Palpation of organs Liver Between the fifth intercostal space and the costal arch Hand to right iliac fossa, impingement of the liver when breathing, normally (rarely) 1-2 cm the liver may pass into the costal arc Spleen Palpable when doubled in size Traube area closes first, then becomes palpable Palpation like liver Kidneys Retroperitoneal Not palpable except in very slim patients One hand is placed on the lumbar region, the other hand is pressed from the lateral rectus, it is told to breathe, and if palpable, slides up and down between our hands  Anamnesis / abdominal examination Percussion Liver Both in the intercostal spaces and in the abdomen (their borders) Spleen If the Traube field is closed, its downward boundaries is found Ascit Radial percussion from xiphoid to pubis and right - left iliac fossas (points where tympanic sound turns to dull/mat sound are marked with a pen) Matte facing upward ascites, matte facing downward mass, hydropic bladder or pregnancy Matte displaced by position (if tympanic sound is heard from the matted areas when turning to the right or left) Sensation des flots (fluctuation sensation) (assistant presses vertically on the middle of the abdomen with the side of the hand, the examiner makes a flick from one side, feels the ripple sensation on the other side) Ballotman (ice finding) (to press quickly without raising hand, as if hitting the hand while the hand is in contact with the abdomen. Floating masses, enlarged liver or spleen in the ascit hit your hand)  Anamnesis / abdominal examination Anorectal Examination Diagnosis of anorectal diseases (hemorrhoids, fissures, abscesses, fistulas, cancer) Neighboring organs (deepest part of the peritoneum, prostate, tenderness in cases of pelvic appendicitis, rectocele, Blummer’s shelf) Left side position (Sims position). Patient lies on his left, left leg (bottom) straight, right leg (top) flexed Knee-chest position. Prostate examination is easier in this position Dorsal recumbent position. Bimanual palpation is possible Lithotomy position. Suitable for rectal, vaginal and bimanual examinations Examination positions  Breast, thyroid and hernia examination Breast examination sitting and lying down Pizillo’s method Thyroid examination from the back of the patient while sitting Lying down Hernia examination is best while the patient is Straining standing. Coughing Incarceration Strangulation  Special findings and nomenclature detected in abdominal examination Cullen Sign Edema and ecchymosis around the umbilicus (ruptured ectopic pregnancy, mostly acute hemorrhagic pancreatitis), symptoms take 24-28 hours to appear, Gray Turner sign may accompany Grey Turner Sign Ecchymosis in the lumbar region. Retroperitoneal hemorrhage, 24-48 hours to appear. Usually acute pancreatitis, as well as ruptured ectopic pregnancy and ruptured aortic aneurysm.  Special findings and nomenclature detected in abdominal examination Diastasis Recti (Abdominal Seperation) It is the separation of the rectus abdominus muscles of the anterior abdominal wall. Like a longitudinal hernia in the midline. Mostly seen in pregnants and newborns Frog-shaped belly If there is ascit in the abdomen and the skin is loose, the abdomen spreads to the sides while lying down and the middle is flat.  Special findings and nomenclature detected in abdominal examination Traube’s space On the left side, 6th rib (or horizontal line drawn at the level of the xiphoid), anterior axillary line and costal arc (projection of the spleen). Tympanic sound on percussion due to gastric fundus, submatite-matite (Castelli’s sign) when spleen enlarges, spleen palpable if enlarged Caput Medusae Enlarged and elongated superficial epigastric veins emerge from the umbilicus (recanalized umbilical vein). Portal hypertension, head of Medusa.  Special findings and nomenclature detected in abdominal examination Murphy’s sign When the liver is palpated, the patient stops breathing (acute cholecystitis) as a result of the sensitive gallbladder hitting the hand. Right upper quadrant pain and tenderness. McBurney’s point The point one-third from the anterior superior iliac spine to the umblicus. The point where the appendix emerges from the cecum (appendicitis), pain, tenderness and defense. McBurney’s incision Oblique incision passing through McBurney point. 1/3 of the incision is above the McBurney point and 2/3 below.  Special findings and nomenclature detected in abdominal examination Sensation des flots (ripple sensation, fluctuation sensation) While the assistant presses vertically on the middle of the abdomen with the side of her/his hand, the examiner makes a flick from one side, feeling the ripple sensation on the other side. Ballottement (ice’s sign) To press quickly without raising hand, as if hitting the hand while the hand is in contact with the abdomen. Floating masses, enlarged liver or spleen in the ascit hit your hand. Charcot Triad A sign of cholangitis. Right upper quadrant pain, jaundice and fever.  Special findings and nomenclature detected in abdominal examination Courvoisier-terrier sign Non-sensitive hydropic gallbladder (meaning that the swelling is not caused by gallstones and is accompanied by jaundice) (pancreas, biliary tract and gallbladder cancers) Sandblom triad It is seen in hemobilia (melena, obstructive jaundice, biliary colic) Saint triad Gallstones, diverticulosis, hiatal hernia. Virchow triad Hypercoagulability, stasis, endothelial injury. Clapotage When the epigastric region (on the stomach) is pressed rapidly, a churning sound (pyloric stenosis)  Special findings and nomenclature detected in abdominal examination Borborygmi Loudness (hearing bowel sounds with bare ears) Virchow node Left supraclavicular lymph node (metastatic in advanced gastric cancer because it receives lymphatic flow from the abdomen) Sister Mary Joseph node Palpable nodule in the umblicus (mostly gastric cancer metastases, also pancreatic, colon, ovarian and uterus cancers)  Special findings and nomenclature detected in abdominal examination Irish node Metastatic lymph node in the left axilla in gastric cancer. Blummer’s shelf Metastasis of gastric cancer to the rectouterine (Douglas) or rectovesical fossa. On rectal examination, the metastasis is felt as an anterior shelf.  Special findings and nomenclature detected in abdominal examination Fetor hepaticus Stool-like malodor (thiols, ammonia and ketones) in the patient's breath in the last stage of liver failure. It is often accompanied by hepatic encephalopathy.. Xanthoma - xanthelesma Xanthoma for yellow, subcutaneous cholesterol deposits in any part of the body, xantholesma for those on the eyelids (hyperlipidemia, chronic bile duct obstructions and primary biliary cirrhosis) Kayser–Fleischer ring Dark brown ring around the iris (copper deposition in the cornea) seen in Wilson's disease  Special findings and nomenclature detected in abdominal examination Palmar erythema Redness of the palms (portal hypertension, chronic liver disease, pregnancy, polycythemia, thyrotoxicosis) Flapping tremor (asterixis) Coarse tremor when the hands are extended from the wrist (chronic liver disease, all metabolic encephalopathies (CRF, CHF, respiratory failure))  Laboratory examinations Hemogram Urogram Routine laboratory tests Tumor markers Ultrasonography Mammography Computed tomography (CT) MR (magnetic resonance) Medicated X-rays Scintigraphy Gastroenterological examinations Anamnesis form Anamnesis form Anamnesis form Anamnesis form Anamnesis form Anamnesis form Anamnesis form Anamnesis form Ultrasonography Abdominal (Abdominal) Ultrasound (.../.../...): Breast Ultrasound (.../.../...): Thyroid Ultrasound (.../.../...): Neck Ultrasound (.../.../...): Superficial Tissue Ultrasound (.../.../...): Breast Mammography and Breast Ultrasound (.../.../...): Computed Tomography (CT) Upper Abdomen CT (.../.../...): Lower Abdomen (Pelvis) CT (.../.../...): Dynamic CT (liver, pancreas, kidney etc.) (.../.../...): Neck CT (.../.../...): Thorax CT (.../.../...): Abdominal Aorta BR Angiography (.../.../...): MRI (Magnetic Resonance) Upper Abdomen MRI (.../.../...): Lower Abdomen MR (.../.../...): MR Cholangiopancreatography (.../.../...): Neck MRI (.../.../...): Breast MRI (.../.../...): Contrast Radiographs Esophagus-Stomach-Duodenum X-ray (.../.../...): Double Contrast Column Graph (.../.../...): Percutaneous Cholangiography (.../.../...): T-tube Cholangiography (.../.../...): Small bowel Passage Graph (.../.../...): Enteroclysis (.../.../...): IVP (intravenous pyelography) (.../.../...): Fistulography (.../.../...): Pouch Graph (Pochography) (.../.../...): Scintigraphy Thyroid Scintigraphy (.../.../...): Parathyroid Scintigraphy (.../.../...): Whole Body Bone Scintigraphy (.../.../...): Marked Erythrocyte Scintigraphy (.../.../...): Gastroenterological Examinations Upper GI Endoscopy (Esophague, Stomach, Duodenum) (.../.../...): Anoscopy (.../.../...): Rectoscopy (.../.../...): Rectosigmoidoscopy (.../.../...): Colonoscopy (.../.../...): ERCP (Endoscopic Retrograde Cholangio Panreaticography) (.../.../...): Anamnesis and Physical Examination in General Surgery Prof. Dr. M. Levhi AKIN İstinye University Medical School Department of General Surgery