Sign and symptom in general surgery history taking

Sign and symptom Sign and symptom in general surgery in general surgery

history takinghistory taking

Dr mahendra lodhaDr mahendra lodhaAiims jodhpur Aiims jodhpur

Pain Pain

This is very common symptom This is very common symptom Latin word –poena –penalty or punishment Latin word –poena –penalty or punishment Superficial –iritation of peripheral n.Superficial –iritation of peripheral n. Segmental –iritation of sensory trunk or Segmental –iritation of sensory trunk or

root,located to a dermatomeroot,located to a dermatome Deep –iritation of deep structuresDeep –iritation of deep structures Psychogenic –pain arises from brain,which Psychogenic –pain arises from brain,which

may be functional pain ,either may be functional pain ,either emotional ,hysterical or lesion in thalamus emotional ,hysterical or lesion in thalamus or STTor causalgiaor STTor causalgia

History takingHistory taking Original site of pain-askOriginal site of pain-ask to locate pain by to locate pain by

finger ,where did pain start? ,ex- finger ,where did pain start? ,ex- appendicitis appendicitis

Origin and mode of onset-Origin and mode of onset- long continued pain with incidious onset –long continued pain with incidious onset –

chronic disease like chr peptic ulcer ,chr chronic disease like chr peptic ulcer ,chr pancreatitis ,sub acute appendicitis pancreatitis ,sub acute appendicitis

recent onset of pain with sudden arrival –recent onset of pain with sudden arrival –acute pancreatitis ,acute appendicitisacute pancreatitis ,acute appendicitis

Enquire –how did pain started? –traumatic Enquire –how did pain started? –traumatic or non traumaticor non traumatic

Severiety-varies from person to person Severiety-varies from person to person

Nature of pain Nature of pain

Vague aching pain –mild continous pain Vague aching pain –mild continous pain

Burning pain –peptic ulcer , GERDBurning pain –peptic ulcer , GERD

Throbbing pain-PYOGENIC ABSCESS Throbbing pain-PYOGENIC ABSCESS Pins and needles sensation-injury to peripheral sensory nerve Pins and needles sensation-injury to peripheral sensory nerve

Scalding pain –burning sensation –Scalding pain –burning sensation –cystitis ,urethritis,pyelonephritiscystitis ,urethritis,pyelonephritis

Shooting pain –sciatica,along cource of nerve Shooting pain –sciatica,along cource of nerve

Stabbing pain –sudden , severe ,sharp and short lived pain-Stabbing pain –sudden , severe ,sharp and short lived pain-perforated peptic ulcer perforated peptic ulcer

Constricting pain –angina pain (tightness in chest )Constricting pain –angina pain (tightness in chest ) Distension –ex- distesion of holo viscusDistension –ex- distesion of holo viscus Colic –uretric ,billiary,appendicular,intestinal –comes suddenly and Colic –uretric ,billiary,appendicular,intestinal –comes suddenly and

goes off suddenlygoes off suddenly Twisting pain –volvulus of intestine ,torsion of testes or ovarian Twisting pain –volvulus of intestine ,torsion of testes or ovarian

cyst cyst Just a pain –cant describe the pain Just a pain –cant describe the pain

Progression of the pain Progression of the pain How is pain progressing?How is pain progressing?

1.1. weak-severe (peak)-platue-declines weak-severe (peak)-platue-declines

2.2. Maximum sevierity –constant –Maximum sevierity –constant –disappear disappear

3.3. Severiety may fluctuate Severiety may fluctuate

Duration of pain Duration of pain

Griping pain of intestine colic is felt Griping pain of intestine colic is felt for less then a minute.for less then a minute.

Pain of angina of afforts ceases Pain of angina of afforts ceases within 5 min of resting within 5 min of resting

Pain of M I lasts for hourPain of M I lasts for hour

Movement of pain Movement of pain

Radiation of pain –penetrating duodenal Radiation of pain –penetrating duodenal ulcer ulcer

Reffered pain –pain is felt at distance Reffered pain –pain is felt at distance from its source , no pain at site of from its source , no pain at site of disease disease

shifting or migration of pain – pain is felt shifting or migration of pain – pain is felt at one site in the beginning and pain is at one site in the beginning and pain is shifted to another site and original pain shifted to another site and original pain disappear-acute appendicitisdisappear-acute appendicitis

Special times of occurrence Special times of occurrence

AppendicitisAppendicitis pain in early pain in early morning ,pain awaken patientmorning ,pain awaken patient

DuodenalDuodenal ulcer pain at 4 pm afternoon ulcer pain at 4 pm afternoon and 2-3 am in morning (hunger pain )and 2-3 am in morning (hunger pain )

MigrainMigrain –morning ,either every –morning ,either every weekend or durning mensesweekend or durning menses

Headache of Headache of frontal sinusitisfrontal sinusitis is its is its peak after few hours of rising peak after few hours of rising

Periodicity of pain Periodicity of pain

Pt will be pain free between attackPt will be pain free between attack Varies from days to month Varies from days to month Peptic ulcer –one week to several Peptic ulcer –one week to several

weeksweeks Trigeminal neuralgia Trigeminal neuralgia

Precipitating or aggravating Precipitating or aggravating factor factor

G.I.pain worse by eating particular type G.I.pain worse by eating particular type of foods, peptic ulcer by spicy foodsof foods, peptic ulcer by spicy foods

Musculoskeletal pain worse by joint Musculoskeletal pain worse by joint movement movement

Pain of appendicitis and uretric colic Pain of appendicitis and uretric colic worse by jolting , coughing ,running ,by worse by jolting , coughing ,running ,by moving up the stairs.moving up the stairs.

Reflux oesophagitis by stoopingReflux oesophagitis by stooping Acute pancreatitis -lies down Acute pancreatitis -lies down Disc prolapse by lifting heavy wt from Disc prolapse by lifting heavy wt from

stooping position stooping position

Relieving factor Relieving factor

Pain of peptic ulcer relieved within by Pain of peptic ulcer relieved within by alkalies and antacids in 5 to 15 minutes alkalies and antacids in 5 to 15 minutes

Acute pancreatitis by sitting in leaning Acute pancreatitis by sitting in leaning forward position on forward position on

GERD and reflux oesophagitis –by proped GERD and reflux oesophagitis –by proped up position up position

Colicy pain of intestinal colic by passing Colicy pain of intestinal colic by passing flatus flatus

Perforated peritonitisPerforated peritonitis pt wants to pt wants to remain remain still.still.

Associated symptom Associated symptom Severe pain may be associated with Severe pain may be associated with

pallor,vomiting ,sweating ,tachycardia .pallor,vomiting ,sweating ,tachycardia . Colicy pain is associated with Colicy pain is associated with

sweating,vomiting and calmmy extremities sweating,vomiting and calmmy extremities Migrain symptom are preceded by visual Migrain symptom are preceded by visual

disturbance and accompanied vomiting disturbance and accompanied vomiting Uretric colic - hematuria Uretric colic - hematuria Biliary colic –jaundice ,pale stool Biliary colic –jaundice ,pale stool Excessive sweating and cold extremities Excessive sweating and cold extremities

very common associated with complicaed very common associated with complicaed aneurysm and haemorrhagic pancreatitis aneurysm and haemorrhagic pancreatitis

VomitingVomitingcauses are wide causes are wide

Gastric iritation Gastric iritation Severe intestinal colic Severe intestinal colic CNS disorder like .-fear ,motion CNS disorder like .-fear ,motion

sickness ,migrain,inner ear sickness ,migrain,inner ear disorder ,meningitis ,intracranial tumour. disorder ,meningitis ,intracranial tumour.

Systemic condition –pregnancy ,renal Systemic condition –pregnancy ,renal failure ,diabetic ketoacidosisfailure ,diabetic ketoacidosis

Surgical –pyloric Surgical –pyloric stenosis,cholecystitis,pancreatitis,intestinal stenosis,cholecystitis,pancreatitis,intestinal obstructionobstruction

Ask for frequency ,time of Ask for frequency ,time of day ,taste,quantity,colour,smellday ,taste,quantity,colour,smell

Type of vomitusType of vomitus

Recent food,in case of GOO-acidicRecent food,in case of GOO-acidic Alkali –achalasia of oesophagus ,gerd and Alkali –achalasia of oesophagus ,gerd and

stricturestricture Bile will give yellow colourBile will give yellow colour Green colour-upper small bowel Green colour-upper small bowel Faeculant –brown and faecal odourFaeculant –brown and faecal odour Faeces-gastrocolic fistula, large bowel Faeces-gastrocolic fistula, large bowel

obstruction .obstruction . Blood-due to ulcer , varices ,Blood-due to ulcer , varices , Ingestion of red wine,iron also give red Ingestion of red wine,iron also give red

colour to vomitus colour to vomitus

Itching or pruritisItching or pruritis

Skin disease –scabes , urticaria ,eczema Skin disease –scabes , urticaria ,eczema Generalised disease –thyrotoxicosis,obst. Generalised disease –thyrotoxicosis,obst.

jaundice ,uremia ,hepatic failure, jaundice ,uremia ,hepatic failure, lymphoma ,other malignancies,lymphoma ,other malignancies,

DM- pruritis ani ,pruritus vulvaeDM- pruritis ani ,pruritus vulvae Local irritation-threadworm,fleas,mosquitoesLocal irritation-threadworm,fleas,mosquitoes Excessive discharge from anorectum , Excessive discharge from anorectum ,

veginalveginal Poor hygienePoor hygiene Drug induced -Drug induced -

HiccupHiccup

Spasmodic contraction of diaphragmSpasmodic contraction of diaphragm Majority are not significant.Majority are not significant. Postoperative ileus Postoperative ileus Peritonitis leading to diaphragmic Peritonitis leading to diaphragmic

iritation iritation Advanced renal failure Advanced renal failure

Abnormal superficial veins Abnormal superficial veins visible veinsvisible veins

External jugular vein External jugular vein Engorged vein –due to increased fluids and Engorged vein –due to increased fluids and

myocardial failure(B/L raised)myocardial failure(B/L raised) Unilateral engorgement- retrosternal Unilateral engorgement- retrosternal

goitor,lymph node ,tumour,subclavian goitor,lymph node ,tumour,subclavian aneurysmaneurysm

Caput madusae- portal HTCaput madusae- portal HTB/L Engorged vein of flank-(inguino-axillary B/L Engorged vein of flank-(inguino-axillary

vein) due ot obst of IVCvein) due ot obst of IVCU/L engorged I-A VEINU/L engorged I-A VEIN due to blockage of due to blockage of

common illiac or external illiac common illiac or external illiac

TongueTongue

Wide medical condition Wide medical condition Surgical condition Surgical condition Ankyloglossia,tongue-tie,ca tongue,Ankyloglossia,tongue-tie,ca tongue,Deviation- hemiplegia of tongue-motor Deviation- hemiplegia of tongue-motor

nerve paralysisnerve paralysisMacroglossia –Macroglossia –

acromegly,cretinism(children),myxoedemaacromegly,cretinism(children),myxoedema,lymphangioma ,amyloidosis,lymphangioma ,amyloidosis

Tremor of tongue-Tremor of tongue-thyrotoxicosis,delirium ,parkinsonismthyrotoxicosis,delirium ,parkinsonism

Furring on dorsum Furring on dorsum heavy smoker heavy smoker

Black hairy Black hairy tongue(brown fur)-tongue(brown fur)-fungus infection fungus infection

StomatitisStomatitis TonsillitisTonsillitis Bronchitis Bronchitis pneumoniapneumonia

Smooth tongueSmooth tongue –b12, –b12,

iron deficiency, G I iron deficiency, G I disorderdisorder

LeukoplakiaLeukoplakia

Congenital fissuring-papilla Congenital fissuring-papilla normal ,irregular fold normal ,irregular fold presentpresent

Medina rhomboid glossitis-Medina rhomboid glossitis-loss of papilla and loss of papilla and fissuring present in fissuring present in midline midline

Lingual thyroid ,Lingual thyroid ,

NailsNails

Transverse groove-systemic Transverse groove-systemic disturbance,previous illnessdisturbance,previous illness

Splinter haemorrhage under nail-Splinter haemorrhage under nail-systemic vasculitis, infective systemic vasculitis, infective endocarditisendocarditis

Brittle nail-flat nail-koilochynia –Brittle nail-flat nail-koilochynia –IDA,PLUMMER VINSON SYNDROMEIDA,PLUMMER VINSON SYNDROME

Whitening of nail bed (terry”s nail)-Whitening of nail bed (terry”s nail)-hypoalbumenemia hypoalbumenemia

ClubbingClubbing

Tissue at base of nail bed become thickened Tissue at base of nail bed become thickened and angle between nail base and adjcent skin and angle between nail base and adjcent skin become obliterated,terminal phalynx become become obliterated,terminal phalynx become swollen.swollen.

Losses longitudinal ridges,and become Losses longitudinal ridges,and become convex from above downward and side to convex from above downward and side to side.side.

Chr. Cyanosis,CHD,Suppuration in chest ,ca Chr. Cyanosis,CHD,Suppuration in chest ,ca lung,pulmonary TB,polyposis of colon,crohn”s lung,pulmonary TB,polyposis of colon,crohn”s disease ,U.C., SABE,disease ,U.C., SABE,

NAIL BED INFARCTS-occur in vasculitis-NAIL BED INFARCTS-occur in vasculitis-SLE,PANSLE,PAN

PITTING ON PRESSURE PITTING ON PRESSURE

Sign of subcutaneous edema Sign of subcutaneous edema Local edema -lymphatic and Local edema -lymphatic and

venous,inflamation or allergy, venous,inflamation or allergy, myxoedemamyxoedema

Generalised -oedema due to disorder Generalised -oedema due to disorder of kidney , heart ,liver,gut,or diet,of kidney , heart ,liver,gut,or diet,

CrepitusCrepitus

Grating sensation-#of bone ,OA,Grating sensation-#of bone ,OA, Crackling sensation-presence of air in sc Crackling sensation-presence of air in sc

area,area, Crepitus of subcutaneous emphysema Crepitus of subcutaneous emphysema Traumatic-#ribs,nasal air sinuses,tooth Traumatic-#ribs,nasal air sinuses,tooth

extraction,extraction, tracheostomy tracheostomy Gas gangreneGas gangrene Operative woundOperative wound Rupture of oesophagusRupture of oesophagus

FacesFaces

Naked eye inspectionNaked eye inspection Amount –copious OR scanty,Amount –copious OR scanty, liquid,semisolid, formed or hardliquid,semisolid, formed or hard Colour-black-due to int. haemorrhageColour-black-due to int. haemorrhage Pale colour-obst. Pale colour-obst.

Jaundice ,diarrohea,malabsorption Jaundice ,diarrohea,malabsorption syndrome,chr. Pancreatitissyndrome,chr. Pancreatitis

Odour-jaundice stool very Odour-jaundice stool very offensive,bacillary dysentry-offensive,bacillary dysentry-odourless,amoebic dysentry-semen like odourless,amoebic dysentry-semen like smellsmell

Abnormal stoolAbnormal stool Slimy stool-disorder of large gut(excess Slimy stool-disorder of large gut(excess

mucus)mucus) Blood in stool Blood in stool Melaena -stomachMelaena -stomach Clot mix stool –small intestineClot mix stool –small intestine Jelly like –large gutJelly like –large gut Frank bleeding- ,rectum , anus ,Frank bleeding- ,rectum , anus , Steatorrohea-malabsorption syn Steatorrohea-malabsorption syn Pipe stem stool-carcinomatous stricturePipe stem stool-carcinomatous stricture Tooth paste stool-hirschprung”s disease Tooth paste stool-hirschprung”s disease Meconium-stool of new born for first three Meconium-stool of new born for first three

days days