As explained in the Introduction Clinical Examination rests on two Pillars namely

This includes: Name, Sex, Age, religion, Race, Occupation, Residency, marital sta­tus, Number of Children and their age and Sex, Menstrual History in Females and History of intake of contraceptive Pills, Special habits of Medical importance and right or left handedness.

pathologic diagnosis because it is related to the Epidemiology of the disease.

Age: congenital diseases present mainly in the infancy or childhood but some of

pitched voice.

• Surgery for moderately severe lower limb ischemia may be indicated in a peddler

who needs to walk for long distances to earn living but not in a General Director.

Residency: limb swelling in patients living at Fayoum in Egypt raises the possibil­ity of Filariasis and Neck swelling in patients living at Oasis raises the possibility of Endemic Goiter.

• Benign breast disease and Deep Vein Thrombosis (DVT) is more common in

therapy in the treatment of varicose veins for fear of inducing DVT.

Handedness: A nerve injury in the left hand of a right handed worker is less serious than a nerve injury in his dominant hand while both hands are of equal importance in a pianist.

In the patients’ own words Such as pain in the right side of the abdomen or by Quadrants, “rather than pain in the right iliac fossa”

abdominal pain” (Fig.3.4).

• Also remember in the case of swelling to ask if the swelling is Painful or Painless?

ably benign but some malignant tumors cause pain such as oral cancer, those

causing bowel obstruction, Ulcerating lesions and those inltrating nerves such

as advanced pancreatic cancers and pelvic Malignancies while painless rapidly

growing lesions carries the possibilities of being malignant.

Diagnoses based on which organ is affected “the Anatomical Diagnosis” and

All the three items refer to the pathology putting in mind being categorized into congenital, traumatic, inammatory, neoplastic, autoimmune… etc. as follows:

Onset: (Mode of onset + was it associated with trauma or inammation?)

Mode of onset:

• Instantaneous or sudden i.e. within seconds or minutes refers to trauma (e.g.

hematoma or fracture).

• Acute i.e. within hours or days refer to acute inammations such as cellulitis,

This question is of paramount importance to exclude two of the main pathologies seen in surgical practice and failure to ask such question will lead to missing the diagnosis.

Example: A 50years old lady presenting with a hard mass in the breast with dimpling of the skin and nipple retraction will be considered as being malignant by most clinicians but a good clinician will ask about the history of trauma (direct

violent trauma or repeated minor traumata with an ill-tting bra) or symptoms sug­gestive of inammation (pain, redness, hotness, swelling, fever and rigors) at the onset. Direct violent trauma can lead to hematoma which can become organized and even calcied mimicking cancer breast, similarly minor repeated traumata can lead to fat necrosis and untreated or inadequately treated breast abscess associated with the onset can become calcied over months and years presenting like a breast cancer and the patient has to be asked directly about them.

Course:

Types:

• Rapidly Progressive (minutes, hours, weeks or months).

• Slowly Progressive (over years).

• Stationary.

• Regressive.

• Intermittent (returning to the base line i.e. normal, between attacks). E.g. autoim-

Duration:

A long duration over years usually exclude malignancy.