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Part 1
Clinical Skills and Investigations
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1
History-taking and Physical Examination
Introduction
Clinical presentation
The history
Physical examination
Examination of specific anatomical areas
Must know Must do
Must know
Symptomatology and signs of common surgical disorders that present electively
Presentation and physical findings of common surgical emergencies
Must do
Take histories of patients with surgical disorders: learn by experience how to establish rapport with patients
Examine patients with surgical disorders: head and neck, chest, abdomen, limbs and genitalia
Perform rectal examinations under supervision
Acquire skill and experience in performing common clinical procedures, e.g. insertion of intravenous lines, insertion of nasogastric tubes, injections, setting up drips, catheterization of the urinary bladder (male and female)
Examine the locomotor system of patients
Attend outpatient general surgical clinics
Attend fracture clinics
Introduction
The mastery of clinical skills is different from knowing how the various clinical tasks are performed. This expertise has several components, including the ability to:
- communicate freely and efficiently with patients and colleagues;
- detect abnormal physical signs, e.g. an enlarged liver, rebound tenderness;
- recognize acute and life-threatening situations;
- perform common clinical procedures with proficiency;
- confirm normality when present.
No amount of encyclopaedic knowledge gained from reading and lectures can ever impart clinical competence. The requirements for proficiency as a doctor are core knowledge of the common medical and surgical disorders and full clinical competence. Rare and obscure illnesses will be encountered by every clinician from time to time. One needs only to be aware of these disorders since the competent doctor will recognize that the patient does not fit any of the common disease patterns and will seek advice or expert opinion.
Clinical presentation
Patients may present in two ways:
- electively, with chronic symptoms of variable duration; or
- acutely, with life-threatening disorders.
The pathways involved in management of the two are quite different.
In the elective (cold) situation, the surgeon proceeds as shown in Table 1.1. If surgical treatment is required, the patient is usually put on the waiting list or is given a date for the operation at the time of the outpatient interview. A priority system based on disease severity is adopted in deciding which patients are operated on soon after the diagnosis is confirmed. Thus a patient with cancer takes precedence over a patient with an uncomplicated inguinal hernia. Cancer patients undergo a process of staging by appropriate investigations based on the TNM (tumour, regional nodes, distant metastases) system before the relevant treatment is selected. This staging process influences management in several ways. In some patients, the disease is found to be inoperable, when non-surgical treatment (chemotherapy, radiotherapy) may be employed. In others, the disease, though operable, is advanced and adjuvant therapy (endocrine, chemotherapy, radiotherapy) before or after surgery is needed in addition to surgical extirpation of the primary tumour. Staging (clinical and pathological) is also the best overall guide to prognosis in the individual patient.
Table 1.1 Management of the elective patient.
| Establish the diagnosis and confirm it, whenever necessary, by the appropriate investigations |
| Decide on the nature of the treatment required: surgical or medical |
| Impart this information to the patient and carry out the treatment if the patient consents to this |
Table 1.2 Management of the acutely ill patient.
| Prompt diagnosis and assessment of the condition |
| Resuscitation (Airway, Breathing, Circulation; see Chapters 11 and 12) |
| Decision on treatment: emergency surgical intervention or conservative management with close clinical observation |
Table 1.3 Priorities in the management of the acutely injured patient.
| A | Airway |
| B | Breathing |
| C | Cardiovascular system |
| D | Neurological Defects |
| E | Exposure to detect all injuries |
Acute patients are admitted as emergencies with lifethreatening disorders or trauma. The pathway of management in these patients is shown in Table 1.2. Frequently, resuscitation and diagnosis go hand in hand in the seriously ill or injured patient. Prompt and efficient resuscitation of seriously ill patients, which necessitates an understanding of the underlying pathophysiological mechanisms (see Chapters 11ā16), is crucial to the survival of these patients. Not all acute conditions need surgical intervention and some are managed conservatively in the first instance, with recourse to surgery if progress is not made or the clinical condition deteriorates. The relief of acute pain by appropriate analgesia (see Chapter 8) is a very important part of the clinical management of acutely ill patients, whether they need emergency surgery or not.
In the management of trauma victims, the priorities in order of precedence are shown in Table 1.3.
The history
Much has been written about the technique of historytaking. For most individuals this is an acquired attribute. Basic to successful history-taking is the ability to establish a rapport with the patient, allowing him or her to relate the story (history) of the illness. In essence, history-taking is the art of conversation and requires a fine balance between listening and interjecting with relevant questions to clarify points and obtain details as the history unfolds(Table 1.4).
In this process there are dos and donāts. The only way a student can verify that an accurate history has been obtained is to summarize the information for the patient to confirm. This provides a valid check of the accuracy of the history-taking process and is highly recommended until full proficiency in history-taking is obtained. The wrong information can be obtained if the technique is poor and the patient is confused by the interviewer. In this respect one should avoid the mistakes outlined in Table 1.5.
Table 1.4 Approach to history-taking.
| Establish a rapport with the patient: introduce yourself, shake hands |
| Initiate the process by asking the patient to tell you what made him or her seek medical advice |
| Listen without interruption to the patient as he or she relates the history of the presenting complaint(s). During this process make a mental note of the key symptoms |
| Wait for the answer before asking another question |
| Obtain further details on specific symptoms, including duration, nature of severity and associations, by specific questions |
| Briefly review the systems by key questions |
| Obtain details of past medical history, including drug medication, surgical conditions, operations and exposure to general anaesthesia. Past medical incidents are important because they may relate to the patientās current illness and may also influence management |
| Obtain details of social history and habits, including alcohol consumption and smoking |
| Obtain a brief family history |
Table 1.5 Donāts of history-taking.
| Do not interrupt the patient |
| Do not use medical terminology |
| Do not ask ambiguous or irrelevant questions |
| Do not use leading questions in the first instance |
| Do not be abrupt or impatient |
Symptoms
Patients can present with specific or non-specific symptoms or a combination of both. Specific symptoms are those that relate to disease in specific organs, e.g. difficulty with swallowing (dysphagia), indicating disorders of deglutition or organic narrowing of the oesophagus. Each system has its own specific symptoms, although there is considerable overlap (Table 1.6).
Patients vary considerably in their clinical presentation. Although a few present with all the characteristic symptoms of a specific illness (classical presentation or āfull-houseā), in the majority of patients the history is not typical and the clinician has to decipher the situation. The ability to identify specific symptoms is one of the reasons for the increasing diagnostic efficiency that comes with clinical experience. Non-specific symptoms do not immediately give a clue to the diagnosis or site of disease. In this situation, a tentative diagnosis is made on the history as a whole. In this group of patients more reliance is placed on investigations in establishing the diagnosis.
Table 1.6 Specific symptoms.
| Nervous system: headache, nausea and vomiting, visual disturbances, motor defects (paralysis), incoordination, sensory loss and disturbances (paraesthesiae), altered levels of consciousness |
| Respiratory system: cough, expectoration, breathlessness, wheezing, chest pain, diminished exercise tolerance |
| Cardiovascular system: loss of consciousness (syncope), breathlessness, diminished exercise tolerance, retrosternal chest pain, intermittent pain in limbs on walking (intermittent claudication), rest pain in the limbs, gangrene (necrosis of tissue) |
| Hepatobiliaryāpancreatic system: nausea and vomiting, pain, jaundice, itching, bleeding tendency, weight gain due to water retention, weight loss |
| Gastrointestinal system: loss of appetite (anorexia), nausea and vomiting, difficulty in swallowing, indigestion, abdominal pain, altered bowel habit (diarrhoea and/or constipation), blood in vomit (haematemesis), passage of slime and fresh or altered blood in the faeces |
| Genitourinary system: loin pain, fever, suprapubic pain, frequency, painful micturition (dysuria), micturition at night (nocturia), poor stream, dribbling and incontinence, blood in urine (haematuria), enlarged or tender testis |
Common important symptoms in general surgery
Pain
Pain is the most common and important symptom in surgical practice. (It used to be said with some truth that pain and blood were the only two events that brought patients quickly to the doctor.) Pain is universal and can be caused by benign or malignant disorders and elective or acute conditions. It is the symptom that is least commonly overlooked by patients, although the threshold for pain varies considerably from one person to another. The information required to establish the clinical significance of pain is shown in Table 1.7.
Table 1.7 Diagnostic clinical information on pain.
| Site |
| Radiation |
| Severity |
| Nature |
| Duration |
| Relieving factors |
| Aggravating factors |
| Associations |
The most reliable way to obtain precise information on the location of pain is to ask the patient to point to the exact site of the pain and where it radiates. Pain may be localized or diffuse and can be referred. Localized pain is either musculoskeletal in origin or is indicative of disease, trauma or inflammation in the affected region. Pain may be referred to the corresponding sensory dermatome. This is exemplified by shoulder tip pain due to a subphrenic abscess causing irritation of the ipsilateral phrenic nerve.
Types of pain
- Colicky pain is indicative of an obstructed hollow organ. It is griping in nature and fluctuates, with peaks of intensity followed by partial or complete relief before a further bout occurs. Colicky pain is always severe and makes the patient restless. The patient rolls about in agony, unable to find a comfortable position. It is usually accompanied by nausea and vomiting.
- Somatic pain, i.e. the severe pain due to inflammation of the parietal peritoneum from localized or general peritonitis, is aggravated by movement. The patient lies still and breathes shallowly to diminish abdominal wall excursion with respiration (e.g. perforated peptic ulcer) or assumes a position that releases tension on the abdominal musculature, i.e. draws the knees up, a posture often observed in patients with acute pancreatitis. The pain of...
