Case Files Surgery, (LANGE Case Files) 4th Ed.

SECTION I. How to Approach Clinical Problems

Part 1. Approach to the Patient

The transition from textbook or journal article learning to an application of the information in a specific clinical situation is one of the most challenging tasks in medicine. It requires retention of information, organization of the facts, and recall of myriad data with precise application to the patient. The purpose of this text is to facilitate this process. The first step is gathering information, also known as establishing the database. This includes recording the patient’s history; performing the physical examination; and obtaining selective laboratory examinations, special evaluations such as breast ductograms, and/or imaging tests. Of these, the historical examination is the most important and most useful. Sensitivity and respect should always be exercised during the interview of patients.

CLINICAL PEARL

Images The history is usually the single most important tool in reaching a diagnosis. The art of obtaining this information in a nonjudgmental, sensitive, and thorough manner cannot be overemphasized.

HISTORY

1. Basic information:

a. Age: Must be recorded because some conditions are more common at certain ages; for instance, age is one of the most important risk factors for the development of breast cancer.

b. Gender: Some disorders are more common in or found exclusively in men such as prostatic hypertrophy and cancer. In contrast, women more commonly have autoimmune problems such as immune thrombocytopenia purpura and thyroid nodules. Also, the possibility of pregnancy must be considered in any woman of childbearing age.

c. Ethnicity: Some disease processes are more common in certain ethnic groups (such as diabetes mellitus in the Hispanic population).

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Images The possibility of pregnancy must be entertained in any woman of child-bearing age.

2. Chief complaint: What is it that brought the patient into the hospital or office? Is it a scheduled appointment or an unexpected symptom such as abdominal pain or hematemesis? The duration and character of the complaint, associated symptoms, and exacerbating and/or relieving factors should be recorded. The chief complaint engenders a differential diagnosis, and the possible etiologies should be explored by further inquiry.

CLINICAL PEARL

Images The first line of any surgical presentation should include age, ethnicity, gender, and chief complaint. Example: A 32-year-old Caucasian man complains of lower abdominal pain over an 8-hour duration.

3. Past medical history:

a. Major illnesses such as hypertension, diabetes, reactive airway disease, congestive heart failure, and angina should be detailed.

i. Age of onset, severity, end-organ involvement.

ii. Medications taken for a particular illness, including any recent change in medications and the reason for the change.

iii. Last evaluation of the condition. (eg, When was the last echocardiogram performed in a patient with congestive heart failure?)

iv. Which physician or clinic is following the patient for the disorder?

b. Minor illnesses such as a recent upper respiratory tract infection may impact on the scheduling of elective surgery.

c. Hospitalizations no matter how trivial should be detailed.

4. Past surgical history: Date and type of procedure performed, indication, and outcome. Laparoscopy versus laparotomy should be distinguished. Surgeon, hospital name, and location should be listed. This information should be correlated with the surgical scars on the patient’s body. Any complications should be delineated, including anesthetic complications, difficult intubations, and so on.

5. Allergies: Reactions to medications should be recorded, including severity and temporal relationship to administration of medication. Immediate hypersensitivity should be distinguished from an adverse reaction.

6. Medications: A list of medications, including dosage, route of administration and frequency, and duration of use should be developed. Prescription, over-the-counter, and herbal remedies are all relevant.

7. Social history: Marital status; family support; alcohol use, use or abuse of illicit drugs, and tobacco use; and tendencies toward depression or anxiety are important.

8. Family history: Major medical problems, genetically transmitted disorders such as breast cancer, and important reactions to anesthetic medications, such as malignant hyperthermia (an autosomal dominant transmitted disorder) should be explored.

9. Review of systems: A system review should be performed focusing on the more common diseases. For example, in a young man with a testicular mass, trauma to the area, weight loss, neck masses, and lymphadenopathy are important. In an elderly woman, symptoms suggestive of cardiac disease should be elicited, such as chest pain, shortness of breath, fatigue, weaknesses, and palpitations.

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Images Malignant hyperthermia is a rare condition inherited in an autosomal dominant fashion. It is associated with a rapid rise in temperature up to 40.6°C (105°F), usually on induction by general anesthetic agents such as succinylcholine and halogenated inhalant gases. Prevention is the best treatment.

PHYSICAL EXAMINATION

1. General appearance: Note whether the patient is cachectic versus well nourished, anxious versus calm, alert versus obtunded.

2. Vital signs: Record the temperature, blood pressure, heart rate, and respiratory rate. Height and weight are often included here. For trauma patients, the Glasgow Coma Scale (GCS) is important.

3. Head and neck examination: Evidence of trauma, tumors, facial edema, goiter and thyroid nodules, and carotid bruits should be sought. With a closed-head injury, pupillary reflexes and unequal pupil sizes are important. Cervical and supraclavicular nodes should be palpated.

4. Breast examination: Perform an inspection for symmetry and for skin or nipple retraction with the patient’s hands on her hips (to accentuate the pectoral muscles) and with her arms raised. With the patient supine, the breasts should be palpated systematically to assess for masses. The nipples should be assessed for discharge, and the axillary and supraclavicular regions should be examined for adenopathy.

5. Cardiac examination: The point of maximal impulse should be ascertained, and the heart auscultated at the apex as well as at the base. Heart sounds, murmurs, and clicks should be characterized. Systolic flow murmurs are fairly common in pregnant women because of the increased cardiac output, but significant diastolic murmurs are unusual.

6. Pulmonary examination: The lung fields should be examined systematically and thoroughly. Wheezes, rales, rhonchi, and bronchial breath sounds should be recorded.

7. Abdominal examination: The abdomen should be inspected for scars, distension, masses or organomegaly (ie, spleen or liver), and discoloration. For instance, the Grey Turner sign of discoloration on the flank areas may indicate an intra-abdominal or retroperitoneal hemorrhage. Auscultation should be performed to identify normal versus high-pitched, and hyperactive versus hypoactive, bowel sounds. The abdomen should be percussed for the presence of shifting dullness (indicating ascites). Careful palpation should begin initially away from the area of pain, involving one hand on top of the other, to assess for masses, tenderness, and peritoneal signs. Tenderness should be recorded on a scale (eg, 1 to 4, where 4 is the most severe pain). Guarding and whether it is voluntary or involuntary should be noted.

8. Back and spine examination: The back should be assessed for symmetry, tenderness, or masses. The flank regions are particularly important in assessing for pain on percussion that may indicate renal disease.

9. Genital examination:

a. Female: The external genitalia should be inspected, and the speculum then used to visualize the cervix and vagina. A bimanual examination should attempt to elicit cervical motion tenderness, uterine size, and ovarian masses or tenderness.

b. Male: The penis should be examined for hypospadias, lesions, and infection. The scrotum should be palpated for masses and, if present, transillumination should be used to distinguish between solid and cystic masses. The groin region should be carefully palpated for bulging (hernias) on rest and on provocation (coughing). This procedure should optimally be repeated with the patient in different positions.

c. Rectal examination: A rectal examination can reveal masses in the posterior pelvis and may identify occult blood in the stool. In females, nodularity and tenderness in the uterosacral ligament may be signs of endometriosis. The posterior uterus and palpable masses in the cul-de-sac may be identified by rectal examination. In the male, the prostate gland should be palpated for tenderness, nodularity, and enlargement.

10. Extremities and skin: The presence of joint effusions, tenderness, skin edema, and cyanosis should be recorded.

11. Neurologic examination: Patients who present with neurologic complaints usually require thorough assessments, including evaluation of the cranial nerves, strength, sensation, and reflexes.

CLINICAL PEARL

Images A thorough understanding of anatomy is important to optimally interpret the physical examination findings.

12. Laboratory assessment depends on the circumstances.

a. A complete blood count: To assess for anemia, leukocytosis (infection), and thrombocytopenia.

b. Urine culture or urinalysis: To assess for hematuria when ureteral stones, renal carcinoma, or trauma is suspected.

c. Tumor markers: For example, in testicular cancer, β-human chorionic gonadotropin, α-fetoprotein, and lactate dehydrogenase values are often assessed.

d. Serum creatinine and serum urea nitrogen levels: To assess renal function, and aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values to assess liver function.

13. Imaging procedures:

a. An ultrasound examination is the most commonly used imaging procedure to distinguish a pelvic process in female patients, such as pelvic inflammatory disease. It is also very useful in diagnosing gallstones and measuring the caliber of the common bile duct. It can also help discern solid versus cystic masses.

b. Computed tomography (CT) is extremely useful in assessing fluid and abscess collections in the abdomen and pelvis. It can also help determine the size of lymph nodes in the retroperitoneal space.

c. Magnetic resonance imaging identifies soft tissue planes and may assist in assessing prolapsed lumbar nucleus pulposus and various orthopedic injuries.

d. Intravenous pyelography uses dye to assess the concentrating ability of the kidneys, the patency of the ureters, and the integrity of the bladder. It is also useful in detecting hydronephrosis, ureteral stones, and ureteral obstructions.