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