SURGERY 1 2nd Shifting 

History Taking and Physical Examination A.Y. ‘19 - ‘20 

Dr. Peterson M. Paner Section ​A / B 
January 24, 2020 

   
OUTLINE  2. ​Chief Complaint 
● It is usually the ​reason for patient’s visit 
I. Overview of History Taking in Surgery  ● It  is  stated  in  the  patient's  own  words  (no  medical 
A. Synopsis of a history  terms)  
B. Pain  
C. Lump/Mass/Ulcer   ● Ask  the  patient  about:  What?  Why?  Where?  When? 
D. Constitutional Symptoms   How? 
II. Head, Neck, and Regional Lymphatics  ● Common:  pain,  swelling,  ulcers,  vomiting,  bleeding, 
A. Health Assessment  
B. Health History   discharge, deformity 
C. Evaluating Chief Complaint    
D. Past Health History   3.​ History of Present Illness  
E. Family Health History   
F. General Approach to Head and Neck Assessment  
● Elaborate on the chief complaint in detail 
G. Assessment of the Head   ● Describes how each symptom developed: 
H. Inspection and Palpation of the Scalp   [SOCRATES] 
I. Assessment of the Face  
○ S​ite 
J. Mandible  
K. Neck   ○ O​nset (gradual, sudden) 
L. Thyroid Gland   ○ C​haracter 
M. Lymph Nodes   ○ R​adiation 
N. Pathology  
III. Physical Examination of the Chest  ○ A​ssociation (ie nausea, sweating) 
A. Chest Topography   ○ T​iming (pain, duration) 
B. Observation   ○ E​xacerbating and Relieving Factors 
C. Palpation   
D. Percussion   ○ S​everity (scale of 1 - 10) 
IV. Breast Examination  ● Pulls in relevant portions of the Review of Systems, 
A. History   “pertinent positives and negatives” 
B. Examination  
C. Lymphadenopathy  
 
V. Abdomen  4, ​Past Medical History  
A. History Taking in Abdominal DIseases    
B. Abdominal Pain 
C. Radiation Pain   ● Do you have any other/chronic medical problems? 
D. Substernal Pain   ● Do you have diabetes, high cholesterol, high blood 
E. Dysphagia  
F. Odynophagia   pressure, asthma? 
G. Weight Loss   ● Is it controlled? 
H. Nausea and Vomiting   ● Have you been hospitalized for this problem? 
I. Abdominal Gas   
J. Bowel Movement   ● What medications are you on? 
K. Gastrointestinal Bleeding  
L. Jaundice  
 
M. Physical Examination   ● Immunizations:  ​BCG.  Diphtheria.  Tetanus.  Typhoid. 
N. Digital Rectal Examination   Whooping cough. Measles. 
   
● Previous  illnesses​,  ​operations  or  accidents. 
I. OVERVIEW OF HISTORY TAKING IN SURGERY  Allergies​. 
“A proper history and physical exam will get you to your   
diagnosis almost 70% of the time” 
For Surgical History:  
 
● Have you had any operations in the past?  
SYNOPSIS OF A HISTORY  ● What? When? Where was it done?  
1. ​Identifying Data.   ● Any  complications?  (infection,  wound  healing, 
● Such as age, gender, occupation, marital status.   recurrences) 
   
   
 
 
1 ​of ​17 | ​HISTORY TAKING AND PE ​Abellar, Ali, Arana, Cruz, Esguerra, Leal, Oraya, Pocot, Silang, Villarey
 SURGERY 1 2nd Shifting 
History Taking and Physical Examination A.Y. ‘19 - ‘20 
Dr. Peterson M. Paner Section ​A / B 
January 24, 2020 

● Medications:  Especially  insulin,  steroids,  monoamine  Urgency.  Precipitancy.  Painful  micturition.  Polyuria. 
oxidase  inhibitors,  and  the  contraceptive  pill.  Drug  Thirst.  Fluid  intake.  Color  of  urine.  Hematuria. 
abuse.  Inhalers.  Blood  thinners  (ie  warfarin  and  Problems  with  sexual  intercourse:  dyspareunia  or 
aspirin)  impotence.  Date  of  menarche  or  menopause. 
  Frequency,  quantity,  and  duration  of  menstruation. 
5. ​Family History  Dysmenorrhea.  Previous  pregnancies  and  their 
● Cause  of  death of close relatives and presence of any  complications. Breast symptoms. 
serious familial illnesses.   
  f. Musculoskeletal System 
6. ​Personal and Social History  ● Aches  or  pains  in  muscles,  bones,  or  joints.  Swelling 
● Social  History:  ​Marital  status.  Sexual  habits.  Living  of  joints.  Limitation  of  joint  movements.  Weakness. 
accommodation.  Occupation.  Exposure  to  industrial  Disturbances of gait. 
hazards. Travel abroad. Leisure activities.   
● Habits: ​Smoking, drinking, and eating habits.  g. Nervous System 
  ● Nervousness.  Excitability.  Tremor.  Fainting  attacks. 
Blackouts.  Fits.  Loss  of  consciousness.  Muscle 
For Smoking History:  
weakness.  Paralysis.  Sensory  disturbances. 
● Do you smoke? 
Paresthesia.  Changes  of  smell,  vision,  or  hearing. 
● What do you smoke? 
Headaches. Changes of behavior or psyche. 
● How much/day? 
 
● When did you start? 
PAIN 
 
7. Review of Systems (ROS)  ● Site 
a. General Survey  ● Time and mode of onset, duration 
● Change  of  weight.  Appetite.  General  body  build  and  ● Nature of pain 
appearance.  Presence  and  time  of  development  of  ○ Sharp, dull, stabbing, aching, burning 
secondary sex characteristics.  ● Pattern of Pain  
  ○ Continuous, intermittent 
b. Respiratory System   ● Radiation 
● Cough.  Sputum.  Hemoptysis.  Dyspnea.  Hoarseness.  ○ Where did the pain pain start? 
Wheezing. Tachypnea. Chest pain. Exercise tolerance.  ○ Where does the pain travel to? 
  ● Severity 
c. Cardiovascular System   ○ How bad is the pain? 
● Dyspnea.  Paroxysmal  Nocturnal  Dyspnea. Orthopnea.  ○ Scale from 1–10 (0 = no pain, 10 = worst pain) 
Chest  pain.  Cough.  Sputum.  Dizziness.  Headaches.  ● Aggravating and relieving factors 
Ankle  swelling.  Pain  in  limbs.  Walking  distance.  ○ What causes the pain? 
Temperature and color of hands and feet.  ○ What relieves the pain? 
   
d. Abdomen and Alimentary system  LUMP/MASS/ ULCER 
● Appetite.  Diet.  Weight.  Taste.  Nausea.  Swallowing.  ● Location 
Regurgitation.  Flatulence.  Heartburn.  Vomiting.  ● How / when did you notice it? 
Haematemesis.  Indigestion.  Abdominal  pain.  ● Change in size / color of skin 
Abdominal  distension.  Bowel  habit.  Nature  of  stool.  ● Pain 
Rectal bleeding. Jaundice.  ● Discharge or bleeding 
  ● Affecting function or daily activities 
e. Urogenital system   ● Any other ones? 
● Loin  pain.  Symptoms  of  uremia:  headache,   
drowsiness,  fits,  visual  disturbances,  vomiting,  edema   
of  ankles,  hands,  or  face.  Frequency  of  micturition. 

 
2 ​of ​17 | ​HISTORY TAKING AND PE ​Abellar, Ali, Arana, Cruz, Esguerra, Leal, Oraya, Pocot, Silang, Villarey
 SURGERY 1 2nd Shifting 
History Taking and Physical Examination A.Y. ‘19 - ‘20 
Dr. Peterson M. Paner Section ​A / B 
January 24, 2020 

CONSTITUTIONAL SYMPTOMS  PAST HEALTH HISTORY 

● Weight loss or weight gain  ● Medical Conditions 
● Fever  ● Surgeries 
● Night sweats  ● Medications 
● Loss of appetite  ● Injuries or accidents 
● Any similar symptoms in other areas of the body or in the   
past 
FAMILY HEALTH HISTORY 
 
Determine if family history of: 
II. HEAD, NECK, AND REGIONAL LYMPHATICS  ● Thyroid disease 
  ● Headache 
● Cause of death of close relatives 
HEALTH ASSESSMENT 
● Presence of any serious familial illnesses. 
● The  integration  of  body  systems  and  regions  begins with   
the head and neck. 
● The  head  provides  a  means  of  identifying  individuals  GENERAL APPROACH TO HEAD AND NECK 
ASSESSMENT 
through  the  uniqueness  of  hair,  eyes,  and  facial 
characteristics.  ● Greet the patient, explain assessment techniques 
● With  assessment  of  the  head  and  neck,  clues  to  the  ● Environment should be: 
client’s  nutritional  status,  airway  clearance,  tissue  ○ Quiet 
perfusion,  metabolism,  level  of  activity,  sleep, rest, stress,  ○ Warm 
and self-care abilities will be identified.  ○ Private 
● As  a  physician,  you  always  have  to be safe. There should  ○ Adequate lighting 
always  be  someone  with  you,  preferably  a  female  ○ Upright sitting position 
assistant  if  the  patient  is  a  female.  This  is  to  protect  ● Compare right and left sides 
yourself  from  accusations  of  sexual  advancements  /  ● Systematic approach 
lawsuits.   ● Equipment 
● Always  observe  proper  decorum  and  explain every step /  ○ Tape measure 
procedure that you will do to the patient.  ○ Stethoscope 
  ○ Cup of water (for evaluation of thyroid gland) 
 
HEALTH HISTORY 
ASSESSMENT OF THE HEAD 
● Determine  the  presence  or  absence  of  age-  and 
gender-specific diseases of the head and neck   ● Inspection 
● Common chief complaints:   ○ Shape 
○ Neck pain or stiff neck   ○ Symmetry 
○ Hoarseness   ● Palpation 
○ Neck mass   ○ Contour 
○ Headache   ○ Masses 
○ Head injury  ○ Depression 
  ○ Tenderness 
 
EVALUATING CHIEF COMPLAINT 
INSPECTION AND PALPATION OF THE SCALP 
● Determine the following characteristics: 
○ Quality  ● Inspect 
○ Associated manifestations   Lesions or masses 
○
○ Aggravating factors  ● Normal findings 
○ Alleviating factors  ○ Scalp is intact, without lesions or masses 
○ Setting  ● Abnormal findings 
○ Timing  ○ Bleeding, lesions, masses, hematomas 

 
3 ​of ​17 | ​HISTORY TAKING AND PE ​Abellar, Ali, Arana, Cruz, Esguerra, Leal, Oraya, Pocot, Silang, Villarey
 SURGERY 1 2nd Shifting 
History Taking and Physical Examination A.Y. ‘19 - ‘20 
Dr. Peterson M. Paner Section ​A / B 
January 24, 2020 

ASSESSMENT OF THE FACE 

● Inspection 
o Shape 
o Symmetry 
 
● Normal findings 
o Symmetrical features 
o Palpebral fissures equal 
o Shape can be oval, round, or slightly square 
 
● Abnormal findings 
o Deformed or absent structures   
o Asymmetry  Figure 1.​ Structures of Neck region 
o More or less pronounced facial features 
 
Diseases which may alter facial features: 
● Bell’s  palsy​:  a  temporary  disorder  affecting  cranial 
nerve VII and producing a unilateral facial paralysis. 
 
●   ​Acromegaly:  ​an  enlargement  of  the  skull  and  cranial 
bones due to increased growth hormone. 
 
● Hydrocephalus:  ​enlargement  of  the  head  caused  by 
inadequate  drainage  of  CSF  leading  to  increased 
intracranial pressure.   
  Figure 2​. Anterior and Posterior Triangle 
 
MANDIBLE 
THYROID GLAND 
● Palpate  and  auscultate  the  temporomandibular  joint when 
the client opens and closes the mouth.  ● Inspection  
  ● Palpation  
● Normal findings.  ● Auscultation  
○ No  discomfort,  joint  articulates  smoothly  without  ● Normal findings  
clicking or crepitus  ○ Symmetrical movement with swallowing  
  ○ Adam’s apple more pronounced in males  
● Abnormal findings.  ○ No masses, tenderness, or enlargement  
○ Pain, tenderness, crepitus  ○ Absent bruit  
  ● Abnormal findings  
○ Mass  
NECK 
○ Enlarged gland  
● Inspection   ○ Goiter  
● Palpation  ○ Asymmetrical enlargement  
● Normal findings   ○ Presence of a nodule or bruit  
○ Full ROM, pain free, symmetrical muscles, no masses  ● Normal:​ patient swallows and thyroid moves upward.   
● Abnormal findings   ● Tumor:  patient  swallows  and  the  thyroid  does  not  move; 
○ Limited ROM, pain, asymmetrical muscles, masses   this is because the tumor holds on to the organ. 
 
 

 
4 ​of ​17 | ​HISTORY TAKING AND PE ​Abellar, Ali, Arana, Cruz, Esguerra, Leal, Oraya, Pocot, Silang, Villarey
 SURGERY 1 2nd Shifting 
History Taking and Physical Examination A.Y. ‘19 - ‘20 
Dr. Peterson M. Paner Section ​A / B 
January 24, 2020 

● Hyperthyroidism:  the  excessive  production  of  thyroid 

hormones,  resulting  in  enlargement  of  the  gland, 
exophthalmos  (bulging  eyes),  fine  hair,  weight  loss, 
diarrhea, and other alterations. 
● Hypothyroidism:  metabolic  disorder  causing  enlarged 
thyroid due to iodine deficiency. 
 
LYMPH NODES 
● Inspection  
● Palpation  
● Location 
○ Preauricular 
○ Postauricular 
○ Occipital 
○ Submental 
 
○ Submandibular 
Figure 4​. Levels of Cervical Lymph Nodes 
○ Anterior and posterior cervical chains  
 
○ Tonsillar  SURGICAL LEVELS OF CERVICAL LYMPH NODES 
○ Supraclavicular  ● 1 ​→ Submental and Submandibular 
● 2, 3, 4 ​→ Upper, Middle, and Lower Jugular 
● 5​ → Posterior Cervical 
● 6​ → Central Compartment 
 
● Normal findings 
○ Unable to palpate or see nodes 
 
● Abnormal findings 
○ Enlarged nodes 
○ Able to palpate or see nodes  
○ Tenderness 
○ Firm, hard nodes 
   
Figure 3​. Neck Lymphatics 

 
Figure 5​. Position of the thumbs to evaluate the midline 
position of the trachea 
 

 
5 ​of ​17 | ​HISTORY TAKING AND PE ​Abellar, Ali, Arana, Cruz, Esguerra, Leal, Oraya, Pocot, Silang, Villarey
 SURGERY 1 2nd Shifting 
History Taking and Physical Examination A.Y. ‘19 - ‘20 
Dr. Peterson M. Paner Section ​A / B 
January 24, 2020 

   
HYDROCEPHALUS 
PATHOLOGY 
CUSHING SYNDROME 

 
Figure 9​. Hydrocephalus 
● Characteristic  enlarged  head,  bulging  fontanel,  dilated 
  scalp veins. 
Figure 6​. Moon-shaped face   
● Facies  include  a  rounded  or  “moon-shaped”  face  with  EARLY ACROMEGALY 
thin, erythematous skin. 
● Hirsutism  may  also  be  present,  especially  if  the condition 
is caused by adrenal cancer. 
 
HYPERTHYROID FACIES 

 
Figure 10​. Acromegaly features 
● Note  the  coarsening  of  features  with  broadening  of  the 
nasal alae and prominence of the zygomatic arches 
 
III. PHYSICAL EXAMINATION OF THE CHEST 
 
  CHEST TOPOGRAPHY 
Figure 7​. Hyperthyroid facies 
ANTERIOR CHEST 
● Note  fine,  moist skin with fine hair, prominent eyes and lid 
retraction, and staring or startled expressions. 
 
DOWN SYNDROME 

 
Figure 8​. Down Syndrome 
 
● Note  depressed nasal bridge, epicanthal folds, mongoloid 
Figure 11​. Anterior Chest 
slant of eyes, low-set ears, and large tongue. 
 
 
 
6 ​of ​17 | ​HISTORY TAKING AND PE ​Abellar, Ali, Arana, Cruz, Esguerra, Leal, Oraya, Pocot, Silang, Villarey
 SURGERY 1 2nd Shifting 
History Taking and Physical Examination A.Y. ‘19 - ‘20 
Dr. Peterson M. Paner Section ​A / B 
January 24, 2020 

   
 

   
Figure 12. ​Topographic position of lung fissures on anterior chest.  ​Figure 14. ​Topographic position of lung fissures on posterior chest. 
   
LATERAL CHEST 
 

 
Figure 15. ​Location of Lobes 
 
OBSERVATION/ INSPECTION 
PATIENT SURROUNDINGS 
● Refers to the view from the door 
● Equipment present 
● Posted signs 
 
BREATHING PATTERN 
 
Figure 13. ​Lateral Chest  ● Eupnea  (Normal)  -  normal respiratory rate is about 14 - 20 
  bpm in adults and up to 44 bpm in infants. 
POSTERIOR CHEST 

 
Figure 16​. Eupnea 
● Tachypnea  (Rapid  Shallow  Breathing)  -    rapid  shallow 
breathing  has  numerous  causes,  including  salicylate 
intoxication,  restrictive  lung  disease,  pleuritic  chest  pain, 
and an elevated diaphragm. 

 
 
Figure 17​. Tachypnea 
Figure 14​. Posterior Chest 
 
7 ​of ​17 | ​HISTORY TAKING AND PE ​Abellar, Ali, Arana, Cruz, Esguerra, Leal, Oraya, Pocot, Silang, Villarey
 SURGERY 1 2nd Shifting 
History Taking and Physical Examination A.Y. ‘19 - ‘20 
Dr. Peterson M. Paner Section ​A / B 
January 24, 2020 

● Bradypnea  (Slow  Breathing)  -  ​slow  breathing  with  or  THORACIC CONTOURS 

without  an  increase in tidal volume that maintains alveolar  ● Pectus  Excavatum  (Funnel  Chest)  -  ​depression  in  the 
ventilation.  Abnormal  alveolar  hypoventilation  without  lower portion of the sternum.   
increased  tidal  volume  can  arise  from  uremia, 
drug-induced  respiratory  depression,  and  increased 
intracranial pressure.  

   
Figure 18. ​ Bradypnea  Figure 21​. Pectus Excavatum 
   
● Biot  Breathing  (Ataxic  Breathing)  - ​breathing is irregular -  ● Pectus  Carinatum  (Pigeon  Chest)  -  ​the  sternum  is 
periods  of  apnea  alternate  with  regular  deep  breaths  displaced  anteriorly,  increasing  the  AP  diameter.  The 
which  stop  suddenly  for  short  intervals.  Causes  include  costal  cartilages  adjacent  to  the  protruding  sternum  are 
meningitis,  respiratory  depression,  and  brain  injury,  depressed.  
typically at the medullary level. 

 
Figure 19​. Biot Breathing 
 
● Cheyne  -  Stokes  Breathing  -  ​periods  of  deep  breathing 
alternate  with  periods  of  apnea  (no  breathing).  This 
pattern  is  normal  in children and older adults during sleep.   
Causes  include  heart  failure,  uremia,  drug  -  induced  Figure 22​. Pectus Carinatum 
respiratory  depression,  and  brain  injury  (typically   
bihemispheric)  ● Kyphosis  (Roundback/  Hunchback)  -  abnormal  spinal 
curvature that occurs in the thoracic and sacral regions.  
 
● Scoliosis -​ an abnormal sideways curvature of the spine.  
 
● Kyphoscoliosis  -  abnormal  spinal  curvatures and vertebral 
  rotation deform the chest.  
Figure 20​. Cheyne - Stokes Breathing 
 
● Kussmaul  breathing  -  ​a  compensatory  overbreathing  due 
to  systemic  acidosis.  The  breathing  rate  may  be  fast, 
normal, or slow. 
 
 
   
  Figure 23​. Thoracic Kyphoscoliosis 
   
  ● Symmetry of chest movement 
   
   
   
 
8 ​of ​17 | ​HISTORY TAKING AND PE ​Abellar, Ali, Arana, Cruz, Esguerra, Leal, Oraya, Pocot, Silang, Villarey
 SURGERY 1 2nd Shifting 
History Taking and Physical Examination A.Y. ‘19 - ‘20 
Dr. Peterson M. Paner Section ​A / B 
January 24, 2020 

CLUBBING  CHEST EXCURSION 

● Is the bulbous enlargement of the fingertips   ● Level of T10 Vertebrae 
● Pathogenesis:  Vasodilation  and  proliferation  of  ● Feel  the  range  and  symmetry as it expands and contracts 
subcutaneous  tissue  of  the  nail  bed  and  there  is  an  (lung excursion) 
increase  in  the  capillary  permeability  leading  to  interstitial 
edema 

 
 

   
Figure  24​.  ​(A)  ​Normal  Digital  Configuration;  ​(B)  ​Mild  digital  Figure 26.​ Chest Excursion 
clubbing  with  increased  hyponychial  angle;  ​(C)  Severe  digital   
clubbing:  depth  of finger at the base of the nail (DPD) is greater  VOCAL FREMITUS 
than the depth of interphalangeal joint (IPD) with clubbing.   ● Bilateral comparison of vocal vibrations 
  ● Increased with alveolar consolidation 
● Decreased  with  increased  distance  between  lung  and 
PALPATION  chest wall 
TRACHEAL ALIGNMENT  ○ Pneumothorax 
● Certain  diseases  or  conditions  causes  the  trachea  to  shift  ○ Pleural effusion 
from the midline 
● Abnormalities 
○ Pneumothorax ​→ shifts to unaffected side 
○ Pleural Effusion​ → shifts to unaffected side  
○ Fibrosis/Atelectasis​ → shifts towards affected side  
○ Pulmonary consolidation​ → no shift 

 
Figure 27​. Vocal Fremitus 
 
PERCUSSION 
● Assess density of underlying tissue 
● Resonance​ – normal 
● ​Dullness​ – increased density   
  ○ Atelectasis 
○ Alveolar filling/consolidation 
Figure 25. ​ PE for Tracheal Alignment  ○ Pleural effusion 
  ○ Fibrosis 
  ● Hyperresonance​ – decreased density Hyperinflation 
  (COPD), Pneumothorax 
 
   
   
   
   
   
   

 
9 ​of ​17 | ​HISTORY TAKING AND PE ​Abellar, Ali, Arana, Cruz, Esguerra, Leal, Oraya, Pocot, Silang, Villarey
 SURGERY 1 2nd Shifting 
History Taking and Physical Examination A.Y. ‘19 - ‘20 
Dr. Peterson M. Paner Section ​A / B 
January 24, 2020 

OBSTETRIC/GYNECOLOGY HISTORY 
IV. BREAST EXAMINATION 
• Menarche, menses 
  • Parity? When? After 30 increases risk 
HISTORY  • Breastfed? 
 
 
● Presenting complaint is very important  EXAMINATION 
● Regular  risk:  ​Just  being  female  poses  one  to  get  breast  ● Introduce yourself to the patient 
cancer  o  This  is  why  every  female  should  know  how  to  ● Undress to waist, sit on the couch at 45 degrees 
examine herself  ● Maintain patient dignity (e.g. bed sheet) 
● The  best  time  to  do  so  is  7  days  after  the  first  day  of  ● Asess in the following position: 
regular menses.  a.  ​Patient’s  hands  behind  their  head  to  accentuate  lumps, 
● The  mere  presence of just one breast cancer risk factor in  asymmetry, tethering 
a  patient  already  puts  her  in  “high  risk”  status.  On  the  b.  ​Pushing  against  their  hips  to accentuate lumps attached to 
other  hand,  patients  with  no  risk  factor  is  already  the pectoralis 
considered to be on a “normal risk” status.  c.  ​Patient  leaning  over  the  side  of  the  bed  to  accentuate 
  abnormalities in large breast 
LUMP  ● Exam good breast first, then the “diseased” breast 
• Always ask how long been present   
• Relation to menstrual cycle  INSPECTION 
• Does its size vary? Is it getting larger?  ● 6 S’s 
  ○ S​ite 
PAIN  ○ S​ize 
• Is it cyclical? Is the lump painful?  ○ S​hape 
• Nipple discharge: ascertain  ○ S​ymmetry 
• Color, quality, pattern, frequency  ○ Overlying ​S​kin 
  ○ Associated ​S​cars 
AGE OF PATIENT  ● Fungation:  comment  on  fungating  presence  of  carcinoma 
•  ​Cancers  are uncommon if the patient is less than 30 years old  (check inframammary fold) 
but ​fibroadenomas are common  ● Asymmetry: carcinoma may be present in higher breast 
  ● Tethering: due to infiltration of ligaments of Astley-Cooper 
  ● Peau d’orange: micro-edema 
ASK THE PATIENT HAS NOTICED ANY  ● Lymphedema:  may  indicate  lymphatic  infiltration  by 
• Nipple retraction  carcinoma or previous surgery with LN removal 
• Breast distortion  ● Erythema 
• Metastatic related symptoms  ● Nipple Signs: 6 D’s 
  ○ Paget’s ​D​isease 
PREVIOUS BREAST DISEASE HISTORY  ○ D​ischarge 
• ​Was it investigated or treated?  ○ D​epression 
  ○ D​isplacement 
FAMILY HISTORY  ○ D​eviation 
• Genetics; 5-10% are inherited dominantly  ○ D​estruction 
• They have early onset and associated with other tumors    
(e.g. bowel, ovarian)  PALPATION 
• BRCA1 (chromosome 17q21)  ● Ask about pain and if patient has a lump 
• BRCA2 (chromosome 13q24)  ● Assess the patient in three positions 
• PS3 gene chromosome 17  ● Examine good breast first then diseased breast 
  ● Patient puts hand behind head on exam side 
MEDICATIONS  ● Check for temperature change 
• HRT, Pill   
 
10 ​of ​17 | ​HISTORY TAKING AND PE ​Abellar, Ali, Arana, Cruz, Esguerra, Leal, Oraya, Pocot, Silang, Villarey
 SURGERY 1 2nd Shifting 
History Taking and Physical Examination A.Y. ‘19 - ‘20 
Dr. Peterson M. Paner Section ​A / B 
January 24, 2020 

● Use following with lumps: 

LYMPHADENOPATHY 
○ Surface 
○ Edge  AXILLARY LYMPHADENOPATHY 
○ Consistency (hard, firm, soft)  ● Support their arm with their corresponding arm (e.g. 
○ Fixation to skin and underlying structures  patient’s right arm with your right arm and palpate with 
○ Fluctuance  your left hand)  
○ Pulsatility and expansility  ● Examine  the  anterior,  posterior,  medial,  and  lateral  walls 
○ Transilluminability  in addition to the apex. 
○ Reducibility  ○ Medial wall​ (serratus anterior)  
  ○ Lateral wall​ (body of humerus)  
● Palpate  using  ​palmar  surfaces  of  index,  middle,  and ring  ○ Anterior wall​ (pectoralis major)  
fingers​ of both hands, sweeping down clock face positions  ○ Posterior wall​ (latissimus dorsi)  
○ Most  carcinomas present in the ​upper outer quadrant  ○ Apices  (arch  of  armpit  –  high  in  the  head  of  the 
because majority of the breast tissue is in that area.  humerus) 
 
CERVICAL & SUPRACLAVICULAR LYMPHADENOPATHY 
● Cervical  
○ Anterior superficial and deep nodes  
■ Submental  and  Submaxillary  / 
Tonsillar  
○ Anterior cervical lymph nodes  
■ Prelaryngeal,  Thyroid,  Pretracheal, 
Paratracheal 
○ Posterior lymph nodes  
 
● Supraclavicular  
○ drain  lymph  from the back of the scalp, neck, 
  and from upper deep cervical, axillary nodes. 
Figure 29​. Breast quadrants and its respective prevalence   
  ● Always  cover  the  patient  once  the  examination  has 
already been completed and then thank the patient. 
 
● For completion: 
○ Respiratory exam: metastasis? 
○ Abdomen  exam:  (+)  hepatomegaly  - 
Metastasis? 
○ Spinal exam: (+) tenderness - metastasis? 
 
● Encourage  self  exam​:  encourage  the  patient  to 
monitor  their  breasts  regularly  using  simple 
  examination in front of the mirror. 
Figure 30​. Pattern of Palpation   
   

📣 REMEMBER 
● Inframammary fold 
 
 
● Axillary Tail of Spence   
● Nipple  Discharge  -  explain  important  to  check   
discharge but first gain permission/consent   
   

 
11 ​of ​17 | ​HISTORY TAKING AND PE ​Abellar, Ali, Arana, Cruz, Esguerra, Leal, Oraya, Pocot, Silang, Villarey
 SURGERY 1 2nd Shifting 
History Taking and Physical Examination A.Y. ‘19 - ‘20 
Dr. Peterson M. Paner Section ​A / B 
January 24, 2020 

● Vasculitis 
V. ABDOMEN 
● Pneumonia 
  ● Sickle Cell Crisis 
HISTORY TAKING IN ABDOMINAL DISEASES  ● Herpes zoster 
 
FAMILY HISTORY 
● Colon cancer   RADIATION PAIN 
● Gallstones   ● Ulcer Disease: ​To the back  
  ● Biliary Pain: ​To the back, right scapula, right shoulder  
FACTORS, HABITS, AND PREVIOUS DISEASES 
● Pancreatic:​ Band-like, to the back 
● Diet  
● Kidney, Ureter: ​To the genitalia, groin 
● Drugs  
● Splenic:​ Left shoulder 
● Alcohol  
 
● Smoking  
● Transfusion   SUBSTERNAL PAIN 
● IV Drug Abuse   CARDIAC PAIN 
● Lifestyle  ● Radiation:​ Left 
  ● Type: ​Pressing, constricting 
ABDOMINAL PAIN  ● Aggravating Factors:​ Physical Activity, Stress 
● Relieving Factors:​ Nitrates 
● Localization  ● Associated Symptoms:​ Dyspnea, Sweating 
● Type   
● Severity  ESOPHAGEAL PAIN 
● Chronology  ● Radiation:​ Back 
● Aggravating or relieving factors  ● Type:​ Burning, Spasmodic 
● Associated symptoms  ● Aggravating Factors:​ Body  
● Radiation of pain  ● Relieving Factors: ​Antacid 
  ● Associated symptoms:​ Dysphagia, Regurgitation 
DIFFUSE ABDOMINAL PAIN 
 
● Peritonitis 
● Intestinal Obstruction  DYSPHAGIA 
● Irritable Bowel Syndrome  ● Difficulty in swallowing 
● Tense Ascites  ● Where does the food “hang up”? Oropharyngeal or 
  esophageal? 
ACUTE ABDOMEN  ● Any difficulty to swallow liquids? 
● Peritonitis   
● Appendicitis 
● Bowel or Gastric Perforation  ODYNOPHAGIA 
● Gallbladder Perforation  ● Painful swallowing 
● Intestinal Obstruction (Ileus)   
● Mesenteric ischemia  WEIGHT LOSS 
● Extrauterine Pregnancy (Ectopic Pregnancy) 
● Is it associated with anorexia? 
● Acute Necrotising Pancreatitis 
● Chronology 
● Biliary Colic 
● Severity (Significance: >5% of body weight) 
● Renal Colic 
● Underlying diseases  
 
● Causes: 
OTHER CAUSES OF ABDOMINAL PAIN 
○ General Disorders 
● Diabetic Ketoacidosis 
■  Diabetes,  Hyperthyroidism,  Chronic  infections, 
● Hypothyroidism 
Malignancy, Medications 
● Acute Intermittent Porphyria 
 
● Hypercalcemia, Hyperkalemia 
 
12 ​of ​17 | ​HISTORY TAKING AND PE ​Abellar, Ali, Arana, Cruz, Esguerra, Leal, Oraya, Pocot, Silang, Villarey
 SURGERY 1 2nd Shifting 
History Taking and Physical Examination A.Y. ‘19 - ‘20 
Dr. Peterson M. Paner Section ​A / B 
January 24, 2020 

○ Behavioral Disorders  ■ Obstipation – cannot poop and cannot fart 

■ Anorexia nervosa, Depression  ○ Two or less stools/week  
  ○ Chronic or recent onset  
○ GI Disorders   
■  Malignancy,  Malabsorption,  Hepatic,  Biliary,  ● Causes ​(of constipation) 
Pancreatic Diseases  ○ Decreased fluid and/or fluid intake 
  ○ Functional (Irritable Bowel Syndrome) 
○ Medications  
NAUSEA AND VOMITING 
○ Hypothyroidism  
● Organic, functional or psychogenic?  ○ Fecal impaction  
● Connection with meals  ○ Rectal or colon cancer  
● Accompanied by weight loss  ○ Chronic debilitating disease 
● Content of the vomit   
● Factors: Taste, smell, color, pH  ● Stool alterations 
  ○ Color 
● Subtypes:  ■ Hypocholic, acholic  
○ Acid: Reflux disease, Duodenal Ulcer  ■ Pleiochromic  
○ Bile: Bilio-pancreatic Diseases  ■ Bloody 
○ Undigested food: Obstruction of Upper GI   
○ Feces (Miserere): Bowel Obstruction (Ileus)  ○ Content 
○ Blood: ie. Ulcer, Tumor, Esophageal Varix  ■ Mucus  
  ■ Blood  
ABDOMINAL GAS  ■ Fat: Steatorrhea  
● Belching, Bloating (meteorism), Flatulence   ■ Undigested proteins: Creatorrhea 
● Causes:    
○ Aerophagia  (habitual,  poor  dentition,  GASTROINTESTINAL BLEEDING 
inadequate chewing, rapid chewing)   ● Classifications 
○ GI motor dysfunction or obstruction  ○ Hematemesis ​- fresh blood 
○ Malabsorption, Maldigestion   ○ Melena​ - coffee ground 
○ Bacterial overgrowth  ○ Hematochezia​ - blood on the stool or blood mixed 
  with the stool 
BOWEL MOVEMENT   ○ Occult bleeding 
● Factors    
○ Frequency  
○ Volume  
📣 Most common cause of LGIB: ​Hemorrhoids 
 
○ Fluidity  
○ Color   JAUNDICE 
○ Associated sensations   ● Observe it in bright, natural light 
○ Change in bowel habits Stool calibre  ●   If  you  are examining the patient for the first time, you can 
  observe on the sclerae  
● Diarrhea  ● Important factors 
○ More than 3 loose watery stools/day  ○ Color of the Skin 
■ > 300g of stool/day  ■ Overproduction: Lemon 
  ■ Obstructive: Dark-yellow/Greenish 
● Constipation   
○ Constipation vs. Obstipation  ○ Color of the Stool 
■ Constipation  –  absence  of  bowel  movement but  ■ Overproduction: Dark, Greenish (Pleiochromic) 
can still fart  ■ Obstructive: Hypocholic or Acholic 

 
13 ​of ​17 | ​HISTORY TAKING AND PE ​Abellar, Ali, Arana, Cruz, Esguerra, Leal, Oraya, Pocot, Silang, Villarey
 SURGERY 1 2nd Shifting 
History Taking and Physical Examination A.Y. ‘19 - ‘20 
Dr. Peterson M. Paner Section ​A / B 
January 24, 2020 

  ○ Altered: 
○ Color of Urine  ■ Absent – Paralytic ileus 
■ Overproduction: Cherry Red  ■ Hyperperistalsis  –  Diarrhea,  Mechanical  bowel 
■ Obstructive: Dark, Brown  obstruction 
  ● Detect ​bruits​ → arterial: aortic, renal, iliac arteries 
○ Associated Symptoms  ● Friction rubs​ → spleen, liver or peritonitis 
■ anemia,  pain,  fever,  hepatomegaly,  ● Succussion splash 
splenomegaly, ascites  ○ Normal: Above stomach 
  ○ Pathologic: Gastric or bowel obstruction 

📣 Reliable landmark for observation: ​Frenulum 

 
 
PHYSICAL EXAMINATION OF THE ABDOMEN 
INSPECTION 
● Configuration of the abdomen 
● In the level, above or below the chest 
○ Apple type:​ Visceral obesity → CVD Risk 
○ Pear type​: Gluteal obesity 
● Abdominal skin 
● Striae: white, livid pink 
● Hernias   
● Veins: Caput medusae  Figure 31​. Area for auscultation 
● Visible Peristalsis   PERCUSSION 
● Visible Pulsations  ● Liver Span 
● Scars  ○ Midclavicular line: 6-12cm 
● Abdominal Distention  ○ Midsternal line: 4-8cm 
○ Generalised   
■ Obesity  ● Splenic Dullness 
■ Pregnancy  ○ Normal: in the ​midaxillary line 
■ Ascites  ○ Pathologic:  dullness  in  the  anterior  axillary  line during 
■ Bowel Obstruction - Ileus  inspiration 
■ Ovarian cyst   
■ Peritonitis  ● Absent Liver or/and Splenic dullness: Perforation 
○ Localised   
■ Hepatomegaly 
■ Splenomegaly 
■ Polycystic kidney 
■ Gastric distention 
■ Inflammatory mass 
■ Tumor 
■ Obstructed bladder 
■ Hernia 
 
AUSCULTATION 
● Observe the bowel sounds 
○ Location: Above the umbilicus or at the RUQ   
○ Normal:  5  -  35/mins,  characterized  as  clicks  and  Figure 32​. Percussion 
gurgles   

 
14 ​of ​17 | ​HISTORY TAKING AND PE ​Abellar, Ali, Arana, Cruz, Esguerra, Leal, Oraya, Pocot, Silang, Villarey
 SURGERY 1 2nd Shifting 
History Taking and Physical Examination A.Y. ‘19 - ‘20 
Dr. Peterson M. Paner Section ​A / B 
January 24, 2020 

 
Figure 35.​ Light palpation 

 
Figure 33​. Liver dullness and Liver edge 
 

 
​Figure 36.​ Deep Palpation  
 
Characteristics of an Abdominal Mass 
● Location 
● Size 
  ● Shape 
​Figure 34​. Shifting dullness (Ascites)  ● Consistency 
  ● Surface 
PALPATION  ● Tenderness 
● Position  ● Movable or fixed 
● Warm hands, short fingernails  ● Shifting by respiration 
● Approach slowly and avoid quick movements 
● Examine tender areas last 
● Watch  the  patient’s  facial  expression  for  any  sign  of 
discomfort or pain 
● Techniques: 
○ Light palpation​ to observe and look for: 
■ Muscular  resistance  /  guarding  -  defense 
mechanism 
■ Alterations in the abdominal wall 
 
○ Deep palpation​ to assess 
■ Abdominal masses 
■ Abdominal tenderness 
 
​Figure 37. ​Palpation findings  
 
15 ​of ​17 | ​HISTORY TAKING AND PE ​Abellar, Ali, Arana, Cruz, Esguerra, Leal, Oraya, Pocot, Silang, Villarey
 SURGERY 1 2nd Shifting 
History Taking and Physical Examination A.Y. ‘19 - ‘20 
Dr. Peterson M. Paner Section ​A / B 
January 24, 2020 

Palpation of the Liver and Spleen 

ANAL FISTULA 
Characteristics 
- an inflammatory tract between the anal canal and the skin.   
● Size   
● Surface  General  Types  (based  on  the  relationship  of  fistula  to 
● Edge  sphincter muscles) 
● Consistency   
1. Intersphincteric  -   through  the  dentate  line  to the anal 
● Tenderness 
verge,  tracking  along  the  interspinceric  plane,  ending 
● Liver pulsation  in the perianal skin 
   
2. Transsphincteric  -  ​through  the  external  sphincter  into 
the  ischiorectal  fossa,  encompassing  a  portion  of  the 
internal  and  external  sphincter,  ending  in  the  skin 
overlying buttocks 
  
3. Suprasphincteric  -  through  the  anal  crypts  and 
encircling  the  entire  sphincter,  ending  in  the 
ischiorectal fossa 
 
  
4. Extrasphincteric  -  starting  high  in  the  anal  canal, 
Figure 38. ​ Palpation of the Liver    encompassing  the  entire  sphincter  and  ending  in  the 
skin overlying the buttocks 
 
Goodsall Rule ​(help anticipate the anatomy of anal fistula) 
 
1.  Fistula  with  an  external  opening  anterior  to  a  plane 
passing  ​transversely  through  the  center  of  the  anus  will 
follow a ​straight radial course​ to the dentate line. 
 
  2. Fistulas with their openings ​posterior to this line will follow 
Figure 39​. Palpation of the spleen    a ​curved course​ to the posterior midline. 
 
  3.  Exception:  External  openings  lying  more  than  3  cm  from 
Palpation of the gallbladder  the anal verge. 
● Curvoisier’s Sign   
○ Painless  enlargement  of  the  gallbladder  due  to 
cancer of the head of the pancreas. 
 
● Murphy’s Sign 
○ RUQ  pain  aggravated  by  inspiration  →  acute 
cholecystitis  (“Respiratory  arrest  upon  palpation  of 
the RUQ”) 
 
DIGITAL RECTAL EXAMINATION (DRE) 
 
● Perianal diseases fistulas, masses  Figure 40.​ Illustration of Goodsall’s Rule 
● Anal alterations hemorrhoids, fissures, masses   
● Rectal alterations polyp, neoplasm, ulcer   
● Prostate Gland 
 
● Stool on the Glove 
   
   
   
   

 
16 ​of ​17 | ​HISTORY TAKING AND PE ​Abellar, Ali, Arana, Cruz, Esguerra, Leal, Oraya, Pocot, Silang, Villarey
 SURGERY 1 2nd Shifting 
History Taking and Physical Examination A.Y. ‘19 - ‘20 
Dr. Peterson M. Paner Section ​A / B 
January 24, 2020 

REFERENCES 
● Main Reference. ​Dr. Peterson Paner’s Powerpoint 
● Transcribers’ notes 
● Dr.  Murali’s  Powerpoint.  History  Taking  in  Surgery. 
Retrieved.​https://www.slideshare.net/UthamalingamMurali
/history-taking-for-surgical-patients-drum 
● Dr.  Abdullah  Kattan’s  Prezi  Powerpoint.  Principles  of 
History  Taking  in  Surgery.  Retrieved  from 
https://prezi.com/z8spfetftd2y/principles-of-history-taking-
in-surgery/ 
● Anal  FIstula  and  Fissures.  Retrieved  from 
https://emedicine.medscape.com/article/776150-overview 
● Book.  ​Bickley  et  al.  Bates’  Guide  to  Physical  Examination 
and  History  Taking,  12th  ed. Philadelphia: Wolters Kluwer. 
2017 
 
 
APPENDIX A 
 

 
17 ​of ​17 | ​HISTORY TAKING AND PE ​Abellar, Ali, Arana, Cruz, Esguerra, Leal, Oraya, Pocot, Silang, Villarey