Surgical history taking and examination

Apr 15th, 2015
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HISTORY AND PHYSICALEXAMINATION OF ASURGICAL PATIENTDR. GEORGE MUGENYAMBCHB, M.MED, FCS (ECSA)SurgeryDefinition:Branch of medicine specializing in makingdiagnosis and treating diseases, deformities andinjuries, wholly or in part, by manual or operativeprocedures.Surgical DiagnosisMaking a surgical diagnosis involves: History taking Physical examination Relevant investigation Imaging Biochemical Microbiological Histological Endoscopic/ Laparoscopic Exploratory laparotomy PostmortemImportant Tips In History TakingTry to see the patient walk into theexamination room/area rather than meethim/her undressed on the couch/bed in acubical: Generalmalaise and debility, breathlessness,cyanosis and difficulty with particular movementsare more obvious when the patient is exercisingthan when he/she is at rest. Always give the patient your whole attention andnever take short-cuts.Taking Surgical HistorySteps involved include:1.2.3.4.5.6.7.8.9.Identifying DataChief ComplaintHistory of Present Illness (HPI)Review of Systems (ROS or SE)Past Medical History (PMH)MedicationsAllergiesFamily HistorySocial HistoryIdentifying DataPatients nameAgeSex/genderMarital statusOccupationReligionRegistration numberMay add other relevant personal information;eg: Ethnicgroup or race, etc.Chief ComplaintReason given by the patient for see

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