History

Acute Appendicitis
History taking:

Chief complaint: abdominal pain or right lower abdominal pain for ## days
or hours
History of present illness:
1) Analysis of pain:
- Duration of pain: when did the pain start?
- Mode of onset of the pain: gradual or sudden.
- Site & radiation or shifting: for example; "started as central abdominal pain
then shifted to right lower aspect of abdomen". Avoid using right iliac fossa
. because it's a medical term.
- Character: dull, colicky.
- Severity: whether the pain interferes with daily activity or sleep.
- Aggravating or relieving factors.
- Associated symptoms: complete GIT and GUT review (arranged from the
more important to less important) nausea, vomiting, loss of appetite,
fever, change in bowel habits, change in color of stool, dysphagia,
odynophagia, abdominal distention, yellowish discoloration of skin or
sclera (jaundice), loin pain, burning on urination, change in color of urine,
change in amount of urine, frequency of urination, nocturia, hesitancy,
intermittency.
2) Patient reaction: what did the patient do about the pain and where did
he/she go (e.g. private doctor, hospital)?
3) Hospital reaction:
- What investigations were done and what are the results?
- What treatment did the patient receive?
4) Condition of the patient now: improved, same or worse.

Example:
Chief complaint: abdominal pain for 2 days duration.
History of present illness:
Pre-op Hx: Patient's condition started 2 days ago in the evening as
abdominal pain of gradual onset, central in location, dull in nature, moderate
in severity, no aggravating or relieving factors. After 10 hours the pain shifted
to right lower abdomen & became more severe. The pain is associated with 2
episodes of vomiting, loss of appetite and low grade fever. There is no change
in bowel habits or color of stool, no dysphagia, no odynophagia, no abdominal
distention, no yellowish discoloration of skin or sclera, no loin pain, no burning
on micturition, no change in urine color, no change in amount of urine or
frequency of urination, no nocturia, no hesitancy or intermittency.
Yesterday at 7:00 PM, the patient went to the emergency department, He was
examined, investigations were done in the form of blood & urine tests and he
was diagnosed with appendicitis. He received IV fluids & IV medications, then
he was referred to operating theater.

Op Hx: The patient was admitted to operating theater at 11:00 PM for

appendicectomy. The operation was done under general anesthesia. There
were no known complications & no blood transfusion. The patient was
discharged from the operating theater at 12:30 AM. He regained partial
consciousness at 12:30 AM and full consciousness at 2:00 AM.

Post-op Hx: Day 0: the patient had cough, sputum, mild pain at the site of
operation. But there was no fever, no nausea or vomiting, no oral intake, no
chest pain, no shortness of breath. He passed urine but hasn't passed flatus
or stool. No leg pain & hasn't started mobilizing yet. He received IV fluids & IV
medications.

Acute Cholecystitis
History taking:

Chief complaint: right upper abdominal pain for ## days or hours

History of present illness:
1) Analysis of pain:
- Duration of pain: when did the pain start?
- Mode of onset of pain: gradual or sudden.
- Site & radiation or shifting: for example; "Right upper abdominal pain
radiating to the right shoulder". Avoid using right hypochondrial pain
because it's a medical term.
- Character: dull, colicky, sharp.
- Severity: whether the pain interferes with daily activity or sleep.
- Aggravating or relieving factors: usually aggravated by food especially
fatty food.
- Associated symptoms: complete GIT and GUT review (arranged from the
more important to less important) nausea, vomiting, yellowish
discoloration of skin or sclera (jaundice), loss of appetite, change in color
of stool • •
(pale 'clay-colored' stool), change in urine color (dark 'tea-colored
urine), itching.* fever, change in bowel habits, dysphagia, odynophagia,
abdominal distention, loin pain, burning on urination, change in amount of
urine, frequency of urination, nocturia, hesitancy, intermittency.
2) Patient reaction: what did the patient do about the pain and where did
he/she go (e.g. private doctor, hospital)?
3) Hospital reaction:
- What investigations were done and what are the results?
- What treatment did the patient receive?
4) Condition of the patient now: improved, same or worse.

* Note: jaundice, pale stool, dark urine & itching occur in obstructive jaundice
when a stone moves from gallbladder into the biliary tree and obstructs the
common bile duct.

Example:

Chief complaint: right upper abdominal pain for 3 days duration.

History of present illness:
Patient's condition started 3 days ago as right upper abdominal pain of
sudden onset, radiating to right shoulder, the pain is continuous, moderate in
severity, aggravated after eating & no relieving factors. The pain is associated
with 4 episodes of nausea & vomiting, the vomiting contains undigested food
from previous meal but no blood or bile & no specific taste or odour. The pain
is also associated with mild fever which is continuous but no sweating or rigor.
There's no yellowish discoloration of skin or sclera, no change in color of
stool, no change in color of urine, no itching, no loss of appetite, no
dysphagia, no odynophagia, no abdominal distention, no loin pain, no burning
on urination, no change in amount of urine or frequency of urination, no
nocturia, no hesitancy, no intermittency.
 On the next day (2 days ago), the patient went to a private doctor which
examined her and send her for blood tests, urine tests and ultrasound and he
diagnosed her as acute cholecystitis and then referred her to the hospital for
admission. The patient was admitted to the hospital yesterday at 9:00 AM. In
the hospital, blood and urine tests were done & she received IV fluids, IV and
oral medications.
Regarding her condition now, the pain, fever and nausea and vomiting are
subsided and she is waiting for further evaluation and management.

Breast Mass
History taking:

Chief complaint: breast mass for ## duration.

History of present illness:
1) Analysis of mass:
- Time and mode of discovery: when and how did the patient discover the -

·-
IN# -4£
mass?

-.
← - Site.
&- Size: approximate size.
HEE - Painful or painless.
- Aggravating or relieving factors.
- Associated symptoms: ask about local symptoms such as nipple
discharge, skin changes. Systemic symptoms such as fever, fatigue,
headache, back pain, shortness of breath,• jaundice (suggests metastatic
-
breast cancer).
sina.IE#- - Changes in the mass from discovery until now (e.g. increased in the size,
-

~
became painful).
- Risk factors of breast cancer (some doctors may not agree on this): ask
about age menarche, age of menopause, number of children, breast
feeding, use of oral contraceptive pills (OCP), and family history of breast
cancer.
2) Reaction: where did the patient go, and what investigations were done?
(e.g. fine needle aspiration biopsy, excisional biopsy).
3) Condition of the patient now.
 Example 1: Painless breast mass (possibly
tumor):

Chief complaint: breast mass •

-
(swelling) for 2 weeks duration.
HPI:
a mass in her breast while she was taking shower. The mass is located in the
Location size

upper outer aspect of the right breast and is small in size. The mass is

-
panful Associated
painless. There are no associated symptoms such as nipple discharge, skin
symptom
changes of the mass, fever, fatigue, headache, shortness, jaundice, bone
pain. The mass gradually increased in size over the last 2 weeks but
remained painless.
change in mass
children breastfeeding
The age of menarche was at 12 years, the patient has 2 children, no breast
contraceptive
feeding were done, she uses oral contraceptive pills since 5 years and she
has no family history of breast cancer.· family history
2 days ago the patient went to a private doctor which examined her and
referred her to the hospital for surgical biopsy.
The patient was admitted to the hospital yesterday, blood investigation were
done and she is currently waiting for biopsy.

Example 2: Breast abscess:

Chief Complaint: breast swelling (mass) for 5 days duration.

HPI:
Pre-Op: on started 5 days ago as sudden onset of breast
swelling, the swelling is located in the left breast, moderate in size associated
with pain throbbing in nature, severe and continuous, aggravated by touching
s also fever, high grade and
continuous. The swelling gradually increased in size and pain increased in
severity.
The patient took some oral medications and antipyretics but did not relieve the
condition.
Yesterday, the patient went to a private doctor which examined her,
diagnosed her with breast abscess and referred her to hospital for admission.
In the hospital, blood investigations were done.

&
time
Op Hx: The patient was admitted to the operating room yesterday at 8:00 PM

* surgery for abscess drainage. The procedure was done under general anesthesia. No Anesthesat
of
type
known complications. The patient was discharged from operation room at Complication
8:30 PM and she regained partial consciousness at 8:30 PM and full ↳
consciousness at 9:30 PM. I discharge
return their
consciousness
 Post-op Hx:

Hernia
History taking:

Chief complaint: e.g. swelling in the right groin.

iron
History of present illness:
1) Analysis of mass:
ñg - Time and mode of discovery: when and how did the patient discover the
5. Cds
mass?
s.GG - Site.
5. & - Size: approximate size.
5. * ⇐E
- Painful or painless.

discus
↳↳
- Aggravating or relieving factors (coughing, laughing, standing, lying down).
- Associated symptoms: ask about the GIT symptoms.
.IM - Changes in the mass from discovery until now (e.g. increased in the size,
-

became painful).
2) Reaction: where did the patient go, and what investigations were done?
3) Condition of the patient now.

Example:

Chief complaint: right groin swelling for 1 year duration.

HPI:

swelling in the right groin while he was showering. The swelling is painless.
Increases in size by coughing or laughing and decreases in size while lying
down. There are no associated symptoms such nausea, vomiting, anorexia,
fever, abdominal pain, abdominal distension, changes in bowel habit or color
of stool, jaundice.
The swelling gradually increased in size over the last year.
The patient visited a private doctor which examined him and referred him to
the hospital for admission.
In the hospital, blood investigations were done and the patient is waiting for
surgery.

Thyroid Swelling
History taking:

Chief complaint: e.g. neck swelling for ## duration.

History of present illness:
1) Analysis of mass:
- Time and mode of discovery: when and how did the patient discover the
swelling?
- Site.
- Size: approximate size.
- Painful or painless.
- Aggravating or relieving factors.
- Associated symptoms: ask about:
- Local symptoms: shortness of breath (pressure on trachea), difficulty
swallowing (pressure on esophagus), and hoarseness of voices (pressure
or invasion of recurrent laryngeal nerve).
- Symptoms of hyperthyroidism: palpitation, weight loss, increased appetite,
change in bowel motion toward diarrhea, heat intolerance, sweating,
nervousness, anxiety, insomnia, menstrual changes (oligomenorrhea or
amenorrhea), proximal muscle weakness (some consider it a sign rather
than a symptom; ask about ability to comb the hair and stand from sitting
position), tremor (also a sign).
- Symptoms of hypothyroidism: fatigue, cold intolerance, change in bowel
motion toward constipation, apathy, excessive sleeping, weight gain,
decreased appetite, menstrual changes (heavy period: menorrhagia)
- Changes in the mass from discovery until now (e.g. increased in the size,
became painful).

2) Reaction: where did the patient go, and what investigations were done?
3) Condition of the patient now.

Example:
Chief complaint: neck swelling for 1 month duration
HPI:

small swelling in the frontal aspect of the neck on the right side while she was
looking at herself in the mirror. The swelling is painless. No specific factors
that increase or decrease the swelling. There are no associated symptoms
such as shortness of breath, difficulty swallowing, hoarseness of voice,
palpitation, changes in the weight, changes in the appetite, changes in bowel
motion, changes in the menstruation, heat or cold intolerance, fatigue, sleep
disturbances, nervousness.
The swelling gradually increased in size over the last month.
The patient visited a private doctor which examined her and referred to the
hospital for admission for surgical biopsy.
In the hospital, blood investigations were done and the patient is waiting for
surgery.

Operative Hx
History taking:

Ask about the following:

- Name & reason of the operation.
- Time of admission to operating theater.
- Type of anesthesia.
- Blood transfusion.
- Known complications (note some doctors would not agree on asking
this question because the patient is unconscious and unaware of the
complications).
- Time of discharge from operating theater.
- Time of regaining consciousness.

Example:
Op Hx: The patient was admitted to the operating theater at 9:00 AM for
elective cholecystectomy. The operation was done under general anesthesia.
There were no known complications & no blood transfusion. The patient was
discharged from the operating theater at 10:30 AM. She regained partial
consciousness at 10:30 AM and full consciousness at 11:30 AM.
Post-op Hx
History taking:

Ask about the following points and repeat them every day starting from
day 0 (day of operation):
- Fever (review the causes of post-op fever, below).
- Nausea and vomiting (causes: pain, opioids analgesics, paralytic ileus,
and anesthesia).
- Oral intake: solid and liquid.
- Cough/sputum (causes: anesthesia, chest infection).
- Dyspnea.
- Chest pain.
- Pain at site of operation: excessive pain maybe caused by wound
infection.
- Wound discharge or bleeding.
- Passage of flatus or stool (indicates the return of GIT function).
- Passage of urine.
- Mobility (i.e. does the patient get up and start walking? prolonged
immobility is bad DVT).
- Pain in the legs (may indicate DVT).
- Tubes & Drains: e.g. Foley catheter, nasogastric tube (NG tube), surgical
drain.
- Treatment received: Drugs & IV fluids.

Example:
Post-op Hx:
- Day 0: the patient had cough, sputum, mild pain at the the site of
operation. But there was no fever, no nausea or vomiting, no oral intake,
no chest pain, no shortness of breath. She passed urine but hasn't passed
flatus or stool. No leg pain & hasn't started mobilizing yet. She received IV
fluids & IV medications.

- Day 1: No fever, no nausea or vomiting, no cough, no chest pain or

dyspnea, she passed flatus and stool & oral intake was resumed in the
form of liquid & soft food (e.g. orange juice & biscuit). The pain is
 decreased at the site of operation. The patient started walking in the ward
and going to bathroom. She received IV fluids & IV medications.

- Day 2: no fever, no nausea or vomiting, no cough, no chest pain or

shortness of breath, mild pain at operation wound, normal oral intake,
normal passage of stool and urine, no leg pain and normal mobility.

Notes
Criteria of colicky pain:
- Intermittent.
- Hollow viscus
- Smooth muscles
- Peristalsis.
- Distal obstruction.

Seen in the following organs: bowel, ureters, fallopian tubes, biliary tree, &
salivary glands ducts.

Causes of post-op vomiting:

- Pain: stimulation of chemoreceptor trigger zone.
- Drugs: narcotics; morphine. Prescribe an antiemetic with the narcotics.
- Effect of anesthesia.
- Paralytic ileus.

Note The term acute abdominal pain generally refers to previously

undiagnosed pain that arises suddenly and is of less than 7 days' (usually less
than 48 hours') duration.

Ballotable organs:
- Kidney.
- Gravid uterus.
- Ovarian cyst.

Note Auscultation for bowel sounds: 5 cm below & right to umbilicus &
wait for 2 minutes. Normal bowel sounds 8\minutes.
Note Renal angle tenderness examination by thumb & fist.
Note Shifting dullness: wait 30-60 seconds before turning the patient.

Post-op return of GI function:

- Small bowel: 12-24h.
- Stomach: 24-48h.
- Large bowel: 48-72h.

Causes of post-op fever:

Days 0, 1 & 2:
- Reactionary fever: anesthesia, tissue damage & absorption of blood &
inflammatory mediators.
- Atelectasis.
- Infection: clostridial infection.

Days 3, 4 & 5:
- Cellulitis & wound infection.
- UTI.
- Pneumonia.
- Thrombophlebitis.

Days 6, 7 & 8:
- DVT.
- Abscess.

Note Drug fever & transfusion reaction can occur at any time.

Physical Exam

General Examination
- Introduce yourself.