SURGERY

Define as the” branch of medical practice that treats injuries, diseases, and deformities by the
physical removal, repair, or readjustment of organs and tissues often involving cutting into the
body”

BRIEF BACKGROUND OF SURGERY

Evidence of trepanation, the first surgical procedure was done in 6500 b. c. trepanation was the
practice of drilling or cutting a hole through the skull to expose brain. This was though to cure
mental illness, migraine headache, epileptic seizures and was used as emergency surgery after a
head wound

Sushruta is one of the Indian surgeons who contributed in the first surgical procedure and he was
call the father of surgery. successful surgery was done with aneasthesia in October 16th 1846 by
Dr. Morton and that time it now calls modern surgery

HISTORY TAKING AND PHYSICAL EXAMINATION

The history is a patient’s account of their illness together with other relevant information that
you have gleaned from them. Like all things in medicine, there is a tried and tested standard
sequence which you should stick to and is used by all practitioners. It is good practice to make
quick notes whilst talking to the patient that you can use to write a thorough history afterwards—
don’t document every word they say as this breaks your interaction! By the end of the history
taking, you should have a good idea as to a diagnosis or have several differential diagnoses in
mind. The examination is your chance to confirm or refute these by gaining more information.
History taking is not a passive process. You need to keep your wits about you and gently guide
the patient into giving you relevant information using all the communication skills

RULES OF HISTORY TAKING

 Write in blue or black ink; other colours do not photocopy well.

 Date, time, and sign all entries; always identify retrospective entries.
 Be accurate.
 Make it clear which diagnoses are provisional.

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  Abbreviations are lazy and open to misinterpretation; avoid them.
 Clearly document information given to patients and relatives.
 Avoid non-medical judgements of patients or relatives.

1. DEMOGRAPHIC DATA

The demographic information includes; name, age, occupation, religion, residential, sex, etc

2. PRESENTING COMPLAINT (PC)/CHIEF COMPLAIN (C/C)

This is the patient’s chief symptom(s) in their own words and should be no more than a single
sentence.

Remember, this is the problem in the patient’s words. ‘Haemoptysis’ is rarely a presenting
complaint but ‘coughing up blood’ may well be.

If the patient has several symptoms, present them as a list which you can expand on later in the
history.

Ask the patient an open question such as ‘What’s the problem?’ or ‘What made you come to the
doctor?’ Each practitioner will have their own style. You should choose a phrase that suits you
and your manner (one of the authors favours ‘tell me the story’ after a brief introduction).

The question ‘what brought you here?’ usually brings the response ‘an ambulance’ or ‘the
taxi’—each patient under the impression that they are the first to crack this show-stopper of a
joke.

3. HISTORY OF THE PRESENTING COMPLAINT (HPC)

Here, you ask about and document the details of the presenting complaint. By the end of this,
you should have a clear idea about the nature of the problem along with exactly how and when it
started, how the problem has progressed over time, and what impact it has had on the patient in
terms of their general physical health, psychology, social, and working lives. This is best tackled
in two phases:

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First, ask an open question and allow the patient to talk through what has happened for about 2
minutes. Don’t interrupt! Encourage the patient with non-verbal responses and make discreet
notes. This also allows you to make an initial assessment of the patient in terms of education
level, personality, and anxiety. Using this information, you can adjust your responses and
interaction. It should also become clear to you exactly what symptom the patient is most
concerned about.

In the second phase, you should revisit the whole story asking more detailed questions. It may
be useful to say ‘I’d just like to go through the story again, clarifying some details. This is your
chance to verify time-lines and the relationship of one symptom to another. You should also be
careful to clarify pseudo-medical terms (exactly what does the patient mean by ‘vertigo’, ‘flu’, or
‘rheumatism’?). Remember, this should feel like a conversation, not an interrogation!

At the end of the history of presenting complaint, you should have established a problem list.
You should run through this with the patient, summarizing what you have been told and ask
them if you have the information correct and if there is anything further that they would like to
share with you.

In history of presenting illness use “SOCRATES” The questions to ask about the characteristics
of pain can be remembered with the mnemonic ‘SOCRATES’:

 S: Site (where is the pain worse? Ask the patient to point to the site with one finger)
 O: Onset (how did it come on? Over how long?)
 C: Character (i.e., ‘dull’, ‘aching’, ‘stabbing’, ‘burning’, etc.)
 R: Radiation (does the pain move or spread to elsewhere?)
 A: Associated symptoms (e.g., nausea, dyspepsia, shortness of breath)
 T: Timing (duration, course, pattern)
 E: Exacerbating and relieving factors
 S: Severity (scored out of 10, with ‘10’ as the worst pain imaginable).

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 4. PAST MEDICAL & SURGICAL HISTORY (PM & SHX)

Some aspects of the patient’s past illnesses or diagnoses may have already been covered. Here,
you should obtain detailed information about past illness and surgical procedures. Ask if they’re
‘under the doctor for anything else’ or have ever been to hospital before. Ensure you get dates
and location for each event. There are some conditions which you should specifically ask
patients about nd these are shown in Box 2.7; see also the notes in Box 2.8. For each
condition, ask:

 What was diagnosed?

 How was it diagnosed?
 How has it been treated?

The common condition that you may ask about

o Diabetes, Rheumatic fever, Jaundice, Hypercholesterolaemia, Hypertension, Angina,

Myocardial infarction, Stroke, Asthma, TB, Epilepsy, Anaesthetic problems, Blood
transfusions, Aneamia & previous surgery.

5. DRUG HISTORY (DHX)

Here, you should list all the medications the patient is taking, including the dose, duration, and
frequency of each prescription along with any significant side effects. If the patient is unsure,
you should confirm with the GP or pharmacy/ notes or medical form. You should make a special
note of any drugs that have been started or stopped recently. You should also ask about
compliance/adherence—does the patient know what dose they take? Do they ever miss doses? If
they are not taking the medication—what’s the reason? Do they have any compliance/adherence
aids such as a pre-packaged weekly supply? The patient may not consider some medications to
be ‘drugs’ so specific questioning is required. Don’t forget to ask about:

 Eye drops.
 Inhalers.
 Sleeping pills.
 Oral contraception.

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  Over-the-counter drugs (bought at a pharmacy), vitamin supplements.
 Herbal remedies.
 ‘Illicit’ or ‘recreational’ drug use (record exactly what type of drug, route of
administration, site, frequency of use, shared needles).

6. ALLERGIES AND REACTIONS (A & RHX)

This should be documented separately from the ‘drug history’ due to its importance. Ask if the
patient has any allergies or ‘is allergic to anything’ if they are unfamiliar with the term. Be sure
to probe carefully as people will often tell you about their hay fever and forget about the rash
they had when they took penicillin. Ask specifically if they have had any ‘reactions’ to drugs or
medication. If an allergy is reported, you should obtain the exact nature of the event and decide if
the patient is describing a true allergy, an intolerance, or simply an unpleasant side effect. All
true allergies should be clearly recorded in the patient’s case notes and drug chart.

7. FAMILY HISTORY (FHX)

The FHx details:

The make-up of the current family, including the age and gender of parents, siblings, children,
and extended family as relevant.

The health of the family, you should ask about any diagnosed conditions in other living family
members. You should also document the age of death and cause of death for all deceased first-
degree relatives and other family members if you feel it is appropriate. It is worth noting that
whilst many conditions run in families, some are due to a single gene disorder. If this is the case
(such as Huntington’s disease and cystic fibrosis) you should go back several generations for
details of consanguinity and racial origins. These are particularly useful in paediatric
assessments.

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 8. SOCIAL HISTORY (SHX)

This is your chance to document the details of the patient’s personal life which are relevant to
the working diagnosis, the patient’s general well-being, and recovery/convalescence. It will help
to understand the impact of the illness on the patient’s functional status. This is a vital part of the
history but sadly, perhaps because it comes at the end, it is often given only brief attention. The
disease, and indeed the patient, do not exist in a vacuum but are part of a community which they
interact with and contribute to. Without these details, it is impossible to take an holistic approach
to the patient’s well-being. Some of the social history are as follow;

o Marital status, sexual orientation.

o Occupation (or previous occupations if retired).
o You should establish the exact nature of the job if it is unclear— does it involve sitting at
a desk, carrying heavy loads, travelling?
o Other people who live at the same address.
o The type of accommodation (e.g., house, flat—and on what floor).
o Does the patient own their accommodation or rent it?
o Are there any stairs? How many?
o Does the patient have any aids or adaptations in their house (e.g., rails near the bath,
stairlift)?
o Does the patient use any walking aids (e.g., stick, frame, scooter)?
o Does the patient receive any help day-to-day?
o Who from (e.g., family, friends, social services)?
o Who does the laundry, cleaning, cooking, and shopping?
o Does the patient have relatives living nearby?
o What hobbies does the patient have?
o Does the patient own any pets?
o Has the patient been abroad recently or spent any time abroad in the past (countries
visited, travel vaccination, malaria prophylaxis)?
o Does the patient drive?

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 9. SYSTEMATIC ENQUIRY (SE)/SYSTEMIC REVIEW (SR)

After talking about the presenting complaint, you should perform a brief screen of the other
bodily systems. This often proves to be more important than you expect, finding symptoms that
the patient had forgotten about or identifying secondary, unrelated, problems that can be
addressed. The questions asked will depend on the discussion that has gone before. If you have
discussed chest pain in the history of presenting complaint, there is no need to ask about it again.

A. General symptoms
 Change in appetite (loss or gain).
 Fever.
 Lethargy.
 Malaise.
B. Respiratory symptoms
 Cough.
 Sputum.
 Haemoptysis.
 Shortness of breath.
 Wheeze.
 Chest pain.
C. Cardiovascular symptoms
o Shortness of breath on exertion.
o Paroxysmal nocturnal dyspnoea.
o Chest pain.
o Palpitations.
o Ankle swelling.
o Orthopnoea.
o Claudication.
D. Gastrointestinal symptoms
 Weight loss or gain.
 Abdominal pain.
 Indigestion.

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  Dysphagia.
 Odynophagia.
 Nausea.
 Vomiting.
 Change in bowel habit, diarrhoea, constipation.
 PR blood loss
E. Genitourinary symptoms
o Urinary frequency.
o Polyuria.
o Dysuria.
o Haematuria.
o Nocturia.
o Urine incontance
o Urine retention

F. The history Systematic enquiry (SE) Neurological symptoms

 Headaches.
 Dizziness.
 Tingling.
 Weakness.
 Tremor.
 Fits, faints, ‘funny turns’.
 Black-outs.
 Sphincter disturbance.
G. Endocrine symptoms
o Heat or cold intolerance.
o Neck swelling (thyroid).
o Menstrual disturbance.
o Erectile dysfunction.

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 o Increased thirst.
o Sweating, flushing.
o Hirsutism.
o Muscle weakness.
H. Locomotor symptoms
 Aches, pains.
 Stiffness.
 Swelling. Skin symptoms
 Lumps/bumps.
 Ulcers.
 Rashes.
 Other lesions (e.g. skin colour or texture change).
 Itch

10. SEXUAL HISTORY (SHX)

A detailed sexual history does not form part of the standard routine. However, if the patient
complains of genitourinary symptoms, a full and thorough sexual history should be obtained.
This can be awkward for both the patient and the history taker. It should be undertaken in a
sensitive, confident, and confidential manner. Before the discussion takes place, the patient
should be reassured about the levels of privacy and confidentiality and that they are free to
openly discuss their sexual life and habits.

Make no assumptions, remain professional, and try to use the patient’s own words and language.
Beware of cultural and religious differences surrounding both sex and talking about it. You
should approach a sexual history in a structured way.

Sexual activity This should include an assessment of the risk of acquiring a sexually transmitted
disease (STD). You need to determine the number and gender of the patient’s sexual partners,
what their risk of having an STD is and what precautions (if any) were taken.

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Try asking the following questions:

o Do you have sex with men, women, or both?

o In the past 2 months, how many people have you had sex with?
o When did you last have sexual intercourse?
o Was it with a man or a woman?
o Were they a casual or regular partner?
o Where were they from?
o Do they use injected drugs?
o Do they have any history of STDs?
o How many other partners do you think they’ve had recently?
o In what country did you have sex?
o What kind of sex did you take part in (e.g. vaginal, anal, oral)?
o For each type of sex . . .did you use a condom?
o Does your partner have any symptoms?
o Have you had any other partners in the last 6 weeks?
o If so, repeat the questions for each partner

11. SUMARY OF HISTORY

In this context you would need to summarize the history of the patient in very
informative ways for easy understand the case of the patient by other physician on duty
EXAMPLE: Maria 19years old female who presents with complain of periumbilical pain
which migrates to right iliac fossa, nausea and fever for 2 days. O/E patient sick looking,
positive rebound tenderness, BP; 110/65 mmHg PR;101 bpm.
Impression, probably acute appendicitis

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 TERMINOLOGY USED IN SURGERY/OPERATION
How to describe an operation The terminology used to describe all operations is a
composite of basic Latin or Greek terms.
 First describe the organ to be operated on Examples:
 lapar-, abdomen (laparus = flank)
 nephro-, kidney
 pyelo-, renal pelvis
 cysto-, bladder
 chole-, bile/the biliary system
 ileo-, small bowel (distal)
 col(on)-, large bowel
 hystero-, uterus
 thoraco-, chest
 rhino-, nose
 masto/mammo-, breast.
 Second describe any other organs or things involved in the procedure Examples:
o docho-, duct
o angio-, vessel (blood- or bile-carrying)
o litho-, stone.
 Third describe what is to be done Examples:
 -otomy, to cut (open)
 -ectomy, to remove
 -plasty, to change shape or size;
 -pexy, to change position
 -raphy, to sew together
 -oscopy, to look into
 -ostomy, to create an opening in (stoma = mouth)
 -paxy, to crush
 -graphy/gram, image (of).
 Lastly add any terms to qualify how or where the procedure is done Examples:

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 percutaneous, via the skin
 trans-, across
 antegrade, forward
 retrograde, backward
 ventral, anterior surface of. Examples of terms Choledochoduodenostomy. An
opening between the bile duct and the duodenum.
 Rhinoplasty. Nose reshaping.
 Pyelolithopaxy. Destruction of pelvicalyceal stones

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