Patient interview and symptom analysis
The conversation with the patient must be conducted in a clear sequence. It is extremely important for the surgeon to formulate questions correctly and be able to filter the collected data, as patients often misinterpret their sensations. The physician must isolate only the information that helps establish the cause of the disease.
If the patient is experiencing severe pain, establishing contact may be difficult. In such situations, the specialist needs to show sensitivity and patience. First, the patient must be made comfortable. If it is impossible to collect an anamnesis from the patient directly, close relatives or accompanying persons are interviewed.
During the interview, the possible distortion of information by the patient themselves should be taken into account:
- Aggravation — intentional exaggeration of the severity of real pain sensations.
- Simulation — fabricating symptoms that do not actually exist.
- Dissimulation — concealing signs of illness (surgical patients very often hide symptoms due to an intense fear of upcoming surgery).
Any examination begins with identifying complaints. Each of them must be detailed as much as possible. Particular attention is paid to the characteristics of the pain syndrome. A strict algorithm is used for this:
- Exact localization of pain.
- Presence and direction of irradiation (where the pain radiates).
- Exact time of onset of unpleasant sensations.
- Character, intensity, and persistence of the pain syndrome.
- Periodicity of occurrence.
- Association with provoking factors (traumatic impact, physical exertion, physiological functions).
- Combination with other symptoms (body temperature fluctuations, episodes of fainting, dizziness).
Anamnesis collection: from medical history to life history
After recording the complaints, the physician proceeds to collect anamamnestic data, which are divided into two major blocks.
History of present illness (anamnesis morbi) The main goal of this stage is to establish the exact chronology and dynamics of the pathological process development. The physician determines the time of onset of the very first signs of the disease and tracks the development of symptoms up to the present moment. Information about previous treatment (whether it was outpatient, sanatorium-based, or surgical) and its effectiveness must be clarified. An important part of the work is studying medical documentation: certificates, X-rays, test results, and discharge summaries.
Patient's life history (anamnesis vitae) This section includes the collection of biographical data: working and living conditions, diet, and features of growth and development. Past general diseases and hereditary predisposition are taken into account. A gynecological history must be collected for female patients.
The following types of anamnesis are critically important for the surgeon:
- Allergological: presence of past pathological reactions to antibacterial drugs (antibiotics).
- Transfusion: facts of blood or blood substitute transfusions in the past and the presence of reactions to these procedures.
- Risk factors: presence of bad habits and occupational hazards capable of affecting the course of treatment and surgery.
Objective examination and inspection rules
After completing the questioning, the surgeon proceeds to general clinical examination methods. These include inspection, thermometry, palpation, percussion, and auscultation.
Inspection is one of the most important methods for a surgeon. Often, it is a correct visual inspection that allows making a reliable diagnosis immediately. This method requires high observational skills and strict adherence to technique from the physician.
Rules for conducting an inspection:
- Exposure. The body part to be examined must be completely uncovered.
- Lighting. The area being examined must be well lit.
- Comparative analysis (Surgeon's Golden Rule). The physician is obligated to always compare the affected area with the symmetrical healthy one (e.g., in case of a joint injury, the sore knee is compared with the healthy one).
During the visual examination, the surgeon evaluates a number of parameters:
- Forced posture and degree of mobility.
- Changes in the shape and volume of the examined area.
- Condition of skin folds and normal anatomical lines.
- Direction of the organ axis (especially important for limb injuries).
- Coloration and transparency of the integumentary tissues.
Briefly: answers to topical questions
What types of palpation are used in the objective examination of the abdomen in a surgical patient?
Superficial and deep palpation are used during the objective examination of the abdomen.
- Superficial palpation (exploratory) precedes deep palpation and is performed without significant pressure. It includes comparative bimanual palpation and systematic palpation, which is carried out from a healthy area to the affected one.
- Deep palpation is methodical deep sliding palpation according to V.P. Obraztsov for examining deeply located organs. It combines a static phase (sensation from contact with the skin and organ wall) and a dynamic phase (penetration into the depth, pressing, and sliding off the organ).
What characteristics of peripheral lymph nodes does the surgeon evaluate during their palpation?
During the palpation of peripheral lymph nodes, a complex of physical characteristics is evaluated. The physician determines the following parameters:
- Magnitude (size) and number of nodes.
- Consistency (soft or firm).
- Mobility and relationship to surrounding tissues (freely lying or fused).
- Relationship to each other (matted into conglomerates or not).
- Pain sensitivity (intensity of pain, painless).
- Shape (oval, round, nodular).
- Condition of the skin over the palpable nodes.
Palpation is performed with the pads of the fingers using soft sliding circular movements, symmetrically on both sides.
How is limb length measured during a surgical examination of a trauma patient?
Limb length measurement is performed visually and instrumentally using a measuring tape. The patient is laid on their back on a hard couch, the limbs are extended along the longitudinal axis of the body and positioned strictly symmetrically. Measurements with a tape measure are carried out symmetrically on both limbs strictly between identifiable bony prominences. The tape must be taut without sagging. The relative (total) length of the limb and the absolute length of its individual segments are determined. Measurement has diagnostic value only with mandatory comparison of the affected limb with the healthy one.
To remember the pain-assessment algorithm, use the mnemonic LIV SIP + Associated symptoms: Location, Irradiation, Version/time of onset, Steadiness/character, Intensity, Periodicity/Provoking factors, Associated symptoms.
Class and exam questions
What should be done if the patient is experiencing severe pain and communication with them is difficult?
The physician must show sensitivity and patience, placing the patient in the most comfortable position possible. If the patient is unable to answer questions, the anamnesis is gathered from accompanying persons or relatives.
What is the difference between aggravation and malingering?
In aggravation, the patient intentionally exaggerates the intensity of actually existing symptoms. In simulation, the patient completely invents signs of a disease that they do not have.
What is the "golden rule" of surgical inspection?
This is the rule of comparative analysis. It states that a physician must always compare the affected (diseased) area with a symmetrical healthy part of the body.
What else to study on this topic
- Technique and Types of Surgical Palpation
- Application of Percussion and Auscultation in Surgical Practice
- Special Instrumental Examination Methods
- Evaluation of Laboratory Test Results in Surgery
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Other Topics in «CHAPTER 9. EXAMINATION OF THE SURGICAL PATIENT»
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