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14
A. Farag and E. A. Mansour
Analysis oftheComplaint
Common complaints should be analyzed systemically as will be presented in each
sheet. Analysis of the complaint is useful in either anatomical diagnosis or
pathologic diagnosis e.g.
Pain: Type, site, referral, what brings, what relieves and associated symptom.
Examples:
Type of pain helps in anatomical diagnosis (Colicky pain occurs in hollow organs
such as GI, biliary or urinary systems and non-colicky pain is in solid organs).
Site of pain helps in anatomical diagnosis putting in mind that it may be related
to an organ at the site of pain or referred from another site e.g. Epigastric pain may
originate from Anterior abdominal wall, stomach, Transverse colon, Pancreas,
Aorta or posterior abdominal wall mainly vertebrae or may be referred from inferior
infarction or Myocardial ischemia.
Referral of pain: helps in anatomical diagnosis but may be helpful in pathologic
diagnosis. E.g. A pain in the epigastrium which refers to the back suggests the pancreas or aorta as a source of pain. In cases diagnosed as gastric pain or known gastric ulcer, pain referred to back suggests a posterior penetration of the ulcer or
gastric cancer invading the pancreas.
What brings pain: helps in anatomical diagnosis e.g. fatty dyspepsia suggests a
biliary pathology, while acid dyspepsia suggests a gastric pathology?
What relieves pain: suggests anatomical diagnosis. E.g. pain which is relieved by
vomiting and alkalis suggests stomach as a source of pain and pain which is relieved
by defecation of passage of gas suggest the colon as an anatomical diagnosis.
Associated symptoms: Suggests Anatomical diagnosis where nausea and vomiting suggest Stomach and small bowel. Bloating refers to the colon and jaundice
suggests Hepato-bilio-pancreatic system or blood “in hemolytic crises as a source
of pain, while simple regurgitation of undigested food suggests esophagus as an
anatomic diagnosis….etc.
Similarly analysis of complaints like vomiting may suggest pathologic diagnosis. E.g. forceful vomiting suggests mechanical obstruction while regurgitated vomiting suggests adynamic obstruction.
Screening Questions fortheBody Systems (Fig.3.6)
This helps in assessment of:
1. The general condition of the patient which is important to tailor treatment for
each patient “we are treating the patient not the disease”. E.g. the decision to
treat a hernia in a normal patient is different from the decision to treat hernia in
a child grade C liver failure or will have an impact on choosing the type of
Anesthesia if surgery is a must.
3 General Examination Sheet
Fig. 3.6 Correlation
between screening of the
body systems and the
categories of anatomy,
pathology and general
condition
15
2. The clue for the diagnosis may be only uncovered by systematic General
examination
• Can help in the anatomical diagnosis of the disease such as in metastases of
unknown Primary and in Fever of unknown Origin.
• Can Help in diagnosis the pathologic diagnosis, (e.g. xanthomas and xanthelasmas refers to atherosclerosis as a cause of arterial obstruction or aneurysms, while rheumatoid arthritis may refer to the cause of
splenomegaly ….etc.). In addition presence of generalized lymphadenopathy
may refer to the cause of abdominal complaints such as abdominal masses or
Jaundice e.g. Lymphoma).
3. Helps to stage the disease such as in cancer or in Organ failure (pathologic diagnosis). The clue for the diagnosis may be only uncovered by systematic General
examination
Screening Questions of the body Systems:
• GIT:
• General such as appetite and recent change in body weight.
• Upper GI Symptoms: Dysphagia, regurgitation, Heart-burn, hyperacidity,
Dyspepsia, nausea, Vomiting, satiety, Colics, Hematemesis and or Melena.
• Lower GI: Colonic distension, Colonic pain, Diarrhea, Constipation, Bleeding
or Mucous per rectum.
• Anal and rectum: Tenismus, bleeding, mucous or discharge peranus, swelling,
prolapse or pain and its relation to defecation.
• Hepato-Biliary: Pain and/or swelling in the upper right quadrant of the abdo-
men. Jaundice.
• Spleen: Pain and/or swelling in the Left upper quadrant of the abdomen. +/−
Manifestations of hypersplenism.
• Urinary Symptoms:
• Upper Urinary: Loin pain, Renal Colics, Mass or Symptoms suggestive
of Uremia.
16
Fig. 3.7 Correlation
between associated
disease/s and both
pathology and general
condition
A. Farag and E. A. Mansour
• Lower Urinary which includes:
• Urine Color: Amber or normal, red due to blood jaundice or dye, white due
to phosphaturia or Chyluria or Prune Colored due to vitamin A or B12”, abnormal contents “Air or Pneumaturia, crystals or Crystaluria, Stones or Necrotic
tissue or Necroturia” and act of micturition: Frequency, urgency, precipitancy,
urge incontinence, Start of the act, stream of urine, Termination of the act, postoperative dripping, and double micturition.
• Chest symptoms: Cough, wheezes, Expectoration and hemoptysis.
• Cardiac Symptoms: Palpitation, chest pain during exercise or during rest may
present as pain in the upper abdomen, Left shoulder, inside the left arm or left
sided neck or signs of heart failure such as Dyspnea, orthopnea or Paroxysmal
nocturnal Dyspnea.
• Neurologic Symptoms:
• Central: Such as Insomnia, change in mood, change in behavior. Or periph-
eral: Such as Tremors, Anesthesia, and Paresthesia.
• Musculoskeletal: Such as Weakness, Spasm, abnormal movement.
History of associated Diseases (Fig. 3.7): e.g. Diabetes Mellitus, Hypertension,
Tuberculosis …etc. They help in the pathology of the current disease and in General
condition of the patient which may affect the decision for the management of the
patient including investigations and treatment.
Past Medical History (Fig.3.8)
Like T.B, Cancer, Infectious mononucleosis etc. They can help in the current pathologic diagnosis or in the General condition of the patient. An abdominal pain and or
masses in the abdomen in a patient with past history of proved TB is tuberculous
peritonitis till prove otherwise.
3 General Examination Sheet
Fig. 3.8 Correlation
between medical history
and both pathology and
general condition
Fig. 3.9 Correlation
between surgical history
and both anatomy and
pathology
Past History ofSurgeries (Fig.3.9)
17
It can help in Anatomical diagnosis e.g. to exclude appendicitis in Acute abdomen
or to suggest ectopic pregnancy in a female in the childbearing period who had an
operation for an ectopic pregnancy on one side before.
It can help in pathologic diagnosis in a patient with pain and swelling in the right
hypochondrium who had a surgery for G.IL cancer before, “? Metastases” or adhesive etiology of Intestinal obstruction or vague abdominal pain after abdominal
exploration.
History ofAllergies toMedications or General Allergies
(Fig.3.10)
This is a vital part of any sheet in the General condition of the patients and failure
to record this in the patient sheet may lead to Medico-legal issues to the doctor if
this patient is given the medication he is allergic to it. It is also important to suggest
the pathology of some complaints like joint pains in a patient known to be allergic
in General to food or pollutants,
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Fig. 3.10 Correlation
between history of
allergies and both
pathology and general
condition
Fig. 3.11 Correlation
between family history and
both anatomy and
pathology
Family History
A. Farag and E. A. Mansour
Family History ofSimilar Disease (Fig.3.11)
It helps in the Pathologic diagnosis. Family history of Colorectal Cancer or breast
Cancer are Common example.
Family History ofMedical Diseases (Fig.3.12)
It helps in Anatomical diagnosis such as Thyroid disease “Goiter” which will be veried by examination and may suggest the pathology of the current disease with familial
predilection such as cancer, DM and/or Hyperlipidemia. The last two may accelerate
the incidence of vascular disease at a younger age such as Ischemia or aneurysm.
Family History ofCancer (Fig.3.13)
Mentioned separately due to its importance not only for specic organ cancers but
for the familial types of cancers such as HNPCC or “Hereditary Non-Polyposis
Colorectal cancers”.
Second Time-Out: Provisional diagnosis at the end of History taking.
3 General Examination Sheet
Fig. 3.12 Correlation
between family history of
medical disease and both
anatomy and general
condition +/− pathology
Fig. 3.13 Correlation
between family history of
cancer and both anatomy
and pathology
General Examination (Fig.3.14)
19
General Principles in General Examination:
1. Areas to be examined:
• The body areas can be divided as areas above the diaphragm and areas below
the diaphragm.
• Areas above the diaphragm include General Look, head and Neck, both upper
limbs, Chest front and back (Heart, Lungs and both breasts in males and
females).
• Areas Below the diaphragm include both lower limbs, abdomen front and
back including buttocks and the Perineum.
• In short case with a complaint in any area above the diaphragm all the areas
above the diaphragm should be examined + a minimum of one area below the
diaphragm namely the liver. (e.g. in thyroid swelling the local examination is
the head and neck together with general look, both upper limbs, chest specially both breasts and the liver reserving the local examination (H & N) to
the end. While in short cases with unilateral edema, both lower limbs should
be examined together with the Abdomen front and back, the perineum and at
least the Virchow and the left supraclavicular lymph nodes. The cause of the
unilateral edema may be due to compression of the ipsilateral iliac vein by a
metastatic lymph nodes from a squamous cell carcinoma in the buttocks or
carcinoma of the anal Canal for example.
20
Fig. 3.14 Correlation
between general
examination and all
categories “Anatomy,
Pathology and General
condition”
A. Farag and E. A. Mansour
2. In Long Cases a recommended sequence of examination (March of Examination)
is recommended to achieve the 3 goals of General examination:
N.B. The items mentioned in general examination are for screening of the
patient in general examination but never enough for local examination.
• General look: Normal or Abnormal “e.g. Toxic, earthy, anxious, Apathetic
look …etc.”
• Decubitus in Bed: Elevated leg in DVT, hanging limb beside the bed near a
fan in critical ischemia, folded on himself in pancreatic pains and aortic
aneurysm.
• Upper Limb in the following sequence: Fine tremors, Flapping tremors,
Nails (Clubbing, vertical ridging, spooning …etc.), Palm of the hand (warmth,
color, sweating), Pulse on both sides for equality in volume and arrival)
delayed pulse in one side compared to the other is pathognomonic of a proximal aneurysm. Then sampling of pulse on one of them for rate and rhythm if
they are equal on both sides. Water Hummer Pulse and Blood pressure.
• Then we complete the Vital Signs namely Temperature and Respiratory rate.
• Head and Neck: Jaundice, Pallor, Central cyanosis, Supraclavicular and
Virchow Lymph node +/− thyroid gland and the main group of the deep cervical lymph nodes deep to the sternomastoid on both sides.
• Chest: front and back including the heart and lungs and both breasts in males
and females.
• Both Lower Limbs: for pedal pulse, edema “Unilateral or bilateral, Pitting
or Non-pitting” and tender calf muscles.
• Abdominal examination:
• Examination includes examination of the Liver and spleen in lesions in the
upper half of the body and full abdominal examination specially both inguinal and iliac lymph nodes in lesions of the lower limbs and perineum.
3 General Examination Sheet
Fig. 3.15 Correlation
between local examination
and both anatomy and
pathology
Local Examination (Box 3.4 andFig. 3.15)
Will be addressed in the relevant section it includes
Box 3.4 Important Points to Remember
• Always remember in Local examination the Head, Neck and Mouth rather
than the traditional Head and Neck.
• Also remember the Examination of the Chest is “Chest Front, Back and
Breast” rather that chest and breast separately.
• Remember Examination of the Abdomen is Examination of the Abdomen
Front and Back, Perineum, Gluteal region and Upper thighs.
21
• Inspection: “No touch to the patient with few exceptions”
• Palpation: e.g. “Supercial and deep” in the abdomen or by tips of the ngers
and Flat of the hand in the breast.
• Percussion: For resonance or dullness.
• Auscultation: for sounds using the stethoscope.
It helps in Anatomical and pathologic diagnosis.
Investigations
Should be guides by the sound Clinical history taking and Clinical examination
“both General and Local” they are directed to achieve:
1. Conrmation of the diagnosis If not already conrmed by Clinical sheet “i.e. No
investigation is needed for a conrmed Lipoma, Haemangioma or Ingrowing
toe nail.
2. To determine the disease not only in cancer but also for suspected organ dysfunc-
tion “Liver, Kidney, lung, heart or Brain dysfunctions’ as a part of complete
22
A. Farag and E. A. Mansour
assessment of the patient condition and tailoring the treatment for each individual patient.
3. To discover a suspected more serious disease discovered by the complete though
swift general examination such as hidden thyrotoxicosis or arrhythmias in a cardiac patient presenting with a simple hernia or other common surgical complaints.
4. As a routine preoperative Investigations as suggested by the hospital or national
Guidelines.
Investigations can be categorized into 4 main categories for the purpose of memorization for the undergraduate and postgraduate students during examination in that
order of invasiveness.
1. Lab tests:
2. Radiology:
3. Instrumental: like endoscopy “+/− biopsies” or manometry.
4. Pathologic diagnosis: which may be
• Needle biopsies:
• Fine needle for cytology “or aspiration of uids for cytology, to study the
characters of the cells including the mitotic gures and the nuclearcytoplasmic ratio suggestive of malignancy.
• Tru-Cut needle biopsy for Histopathology
• Endoscopic biopsies.
• Surgical Biopsies:
• Incisional: a Small wedge of the lesion.
• Excisional: the lesion is removed totally and sent for pathology.
The Histopathology can be examined as:
• Frozen section “Immediate”
• Parafn blocks.
Sections from Parafn blocks are examined with Haematoxyline and Eosin or specic stains.
Chapter 4
Examination ofSwellings
MohamedYehiaElbarmelgi andMahmoudMostafa
Abstract Examination of a swelling related to an organ such as Thyroid or parotid
swelling and not related to an anatomical area such as Groin, Popliteal fossa, femoral triangle, axilla for example is discussed in their relevant chapters in this book.
By Examination of a swelling in this Chapter we mean a swelling in the Skin,
Subcutaneous tissue related to deep Fascia, Muscle or bone. Over a cavity or in a
limb. By a Cavity we mean, the Cranium, spinal Cord.
Keywords Swelling · Examination · Organ · Skin · Subcutaneous · Fascia ·
Muscle · Cavity
Examination of a swelling related to an organ such as Thyroid or parotid swelling
and not related to an anatomical area such as Groin, Popliteal fossa, femoral triangle, axilla for example is discussed in their relevant chapters in this book. By
Examination of a swelling in this Chapter we mean a swelling in the Skin,
Subcutaneous tissue related to deep Fascia, Muscle or bone. Over a cavity or in a
limb. By a Cavity we mean, the Cranium, spinal Cord “e.g. Meningocele and its
variant”, Chest Cavity which extends into the Lowe Neck “e.g. Empyema necessitans (EN) and Pneumatocele in the Posterior triangle of the Neck”, Abdominal
Cavity which extends to the front, back, Perineum and femoral triangle “e.g.
Hernia”.
The same principles apply to the swellings in other sheets except the Abdominal
Cavity, Thyroid and Lymph nodes and in the Anatomical areas of surgical importance mentioned above.
Components of the sheet includes (Tables 4.1 and 4.2):
M. Y. Elbarmelgi (*)
Cairo University, Cairo, Egypt
M. Mostafa
Arab Contractors Medical Centre ACMC, Cairo, Egypt
Switzerland AG 2024
A. Farag et al. (eds.), Clinical Surgical Skills Made Easy,
https://doi.org/10.1007/978-3-031-69158-4_4
23© The Author(s), under exclusive license to Springer Nature