Patient examination

1. Examination of a surgical
patient
Lecturer: dr. Suiundukova Begaiym
Sharypbekovna

2. • The surgical patient undergoes operative
procedures to remove or replace diseased
organs/tissue. Specific aspects of the surgical
patient’s care are different to those of a
medical patient’s care; these include the
treatment and prevention of post-operative
complications.

3. • A medical history form is a questionnaire used
by health care providers to collect information
about the patient’s medical history during a
medical or physical examination.
PATIENT HISTORY FORM
Date: _______/_________/________
NAME: Birthdate: _____/______/_____
Last First M. I.
Age:___________ Sex:  F  M
How did you hear about this clinic?
Describe briefly your present symptoms:
Please list the names of other practitioners you have seen for this problem:
Psychiatric Hospitalizations (include where, when, & for what reason):
Have you ever had ECT? Have you had psychotherapy?

4. CURRENT MEDICATIONS
Drug allergies:  No  Yes To what?
Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements:
Name of drug Dose (include strength & number of pills per day) How long have you been taking this?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
PAST MEDICAL HISTORY
Do you now or have you ever had:
 Diabetes  Heart murmur  Crohn’s disease
 High blood pressure  Pneumonia  Colitis
 High cholesterol  Pulmonary embolism  Anemia
 Hypothyroidism  Asthma  Jaundice
 Goiter  Emphysema  Hepatitis
 Cancer (type) _________________  Stroke  Stomach or peptic ulcer
 Leukemia  Epilepsy (seizures)  Rheumatic fever
 Psoriasis  Cataracts  Tuberculosis
 Angina  Kidney disease  HIV/AIDS
 Heart problems  Kidney stones
Other medical conditions (please list):

5. PERSONAL HISTORY
Were there problems with your
birth? (specify)
Where were your born & raised?
What is your highest education? High school Some college College graduate Advanced degree
Marital status:  Never married  Married  Divorced  Separated  Widowed  Partnered/significant other
What is your current or past occupation?
Are you currently working? :  Yes  No Hours/week ______ If not, are you  retired  disabled  sick leave?
Do you receive disability or SSI?  Yes  No If yes, for what disability & how long?___________________________
Have you ever had legal problems? (specify)
Religion:
FAMILY HISTORY
IF LIVING IF DECEASED
Age (s) Health & Psychiatric Age(s) at death Cause
Father
Mother
Siblings
Children
EXTENDED FAMILY PSYCHIATRIC PROBLEMS PAST & PRESENT:
Maternal Relatives:
Paternal Relatives:

6. SYSTEMS REVIEW
In the past month, have you had any of the following problems?
GENERAL NERVOUS SYSTEM PSYCHIATRIC
 Recent weight gain; how much____  Headaches  Depression
 Recent weight loss: how much____  Dizziness  Excessive worries
 Fatigue  Fainting or loss of consciousness  Difficulty falling asleep
 Weakness  Numbness or tingling  Difficulty staying asleep
 Fever  Memory loss  Difficulties with sexual arousal
 Night sweats  Poor appetite
 Food cravings
MUSCLE/JOINTS/BONES STOMACH AND INTESTINES  Frequent crying
 Numbness  Nausea  Sensitivity
 Joint pain  Heartburn  Thoughts of suicide / attempts
 Muscle weakness  Stomach pain  Stress
 Joint swelling  Vomiting  Irritability
Where?  Yellow jaundice  Poor concentration
 Increasing constipation  Racing thoughts
EARS  Persistent diarrhea  Hallucinations
 Ringing in ears  Blood in stools  Rapid speech
 Loss of hearing  Black stools  Guilty thoughts
 Paranoia
EYES SKIN  Mood swings
 Pain  Redness  Anxiety
 Redness  Rash  Risky behavior
 Loss of vision  Nodules/bumps
 Double or blurred vision  Hair loss
 Dryness  Color changes of hands or feet OTHER PROBLEMS:
THROAT BLOOD
 Frequent sore throats  Anemia
 Hoarseness  Clots
 Difficulty in swallowing
 Pain in jaw KIDNEY/URINE/BLADDER
 Frequent or painful urination
HEART AND LUNGS  Blood in urine
 Chest pain
 Palpitations Women Only:
 Shortness of breath  Abnormal Pap smear
 Fainting  Irregular periods
 Swollen legs or feet  Bleeding between periods
 Cough  PMS
WOMENS REPRODUCTIVE HISTORY:
Age of first period:
# Pregnancies:
# Miscarriages:
# Abortions:
Have you reached menopause? Y / N At what age?
Do you have regular periods? Y / N

7. SUBSTANCE USE
DRUG CATEGORY
(circle each substance used)
Age when
you first
used this:
How much &
how often did
you use this?
How many
years did you
use this?
When did
you last
use this?
Do you currently
use this?
ALCOHOL Yes □ No □
CANNABIS:
Marijuana, hashish, hash oil
Yes □ No □
STIMULANTS:
Cocaine, crack
Yes □ No □
STIMULANTS:
Methamphetamine—speed, ice, crank
Yes □ No □
AMPHETAMINES/OTHER STIMULANTS:
Ritalin, Benzedrine, Dexedrine
Yes □ No □
BENZODIAZEPINES/TRANQUILIZERS:
Valium, Librium, Halcion, Xanax, Diazepam,
“Roofies”
Yes □ No □
SEDATIVES/HYPNOTICS/BARBITURATES:
Amytal, Seconal, Dalmane, Quaalude,
Phenobarbital
Yes □ No □
HEROIN
Yes □ No □
STREET OR ILLICIT METHADONE Yes □ No □
OTHER OPIOIDS:
Tylenol #2 & #3, 282’S, 292’S, Percodan,
Percocet, Opium, Morphine, Demerol,
Dilaudid
Yes □ No □
HALLUCINOGENS:
LSD, PCP, STP, MDA, DAT, mescaline,
peyote, mushrooms, ecstasy (MDMA),
nitrous oxide
Yes □ No □
INHALANTS:
Glue, gasoline, aerosols, paint thinner,
poppers, rush, locker room
Yes □ No □
OTHER:
specify)_______________________________
_____________________________________
_____________________________________
Yes □ No □

8. • Physical assessment is a systematic data
collection method that uses the senses of sight,
hearing, smell and touch to detect health
problems. There are four techniques used in
physical assessment and these are:- Inspection,
palpation, percussion and auscultation. Usually
history taking is completed before physical
examination
Inspection
It’s the use of vision to distinguish the normal from
the abnormal findings. Body parts are inspected to
identify color, shape, symmetry, movement,
pulsation and texture.

9. • General Examination :(ABC²DE)(stand in front of the patient)
• 1. Appearance: The patient is (young, middle aged or old) and looks
well.
• 2. Body built: He looks (normal, thin or obese.)
• 3. Connections: Around bed I can't see any medications or any
equipment connecting to the patient.
• 4. Color: He doesn't look pale or jaundiced.
• 5. Distress: The patient look comfortable and he doesn't appear
short of breath and he doesn't use accessory muscles
• 6. ELSE: He is conscious - I can't see any pigmentation or thickening
of the skin. Be confident!
• **DON’T MISS THE ROOM LIGHTING**
• Example: The patient looks well, he is lying comfortably on the bed,
not distressed, the patient is having good body shape, and he is
obviously not jaundiced , not connected to I.V lines nor oxygen
mask.

10. Palpation
It involves use of hands to touch body parts for
data collection. The EMT uses fingertips and
palms to determine the size, shape, and
configuration of underlying body structure and
pulsation of blood vessels. It help to detect the
outline of organs such as thyroid, spleen or liver
and mobility of masses. It detects body
temperature, moisture, turgor, texture,
tenderness, thickness, and distention.

11. • Principles of palpation
Help client to relax and be comfortable
because muscle tension impairs effective
assessment. Advise patient to take slow deep
breaths during palpation.
• Palpate tender areas last and note nonverbal
signs of discomfort.Rub hands to warm them,
have short fingernails and use gentle touch

17. Quadrants of Abdomen
Topographically,
the abdomen can be
divided into right and
left upper and right and
left lower quadrants by
vertical and horizontal
lines through the
umbilicus. The quadrants
are often abreviated on
the request form to
RUQ, RLQ, LUQ and LLQ.

18. Nine Regions of Abdomen
The abdomen
may also be divided into
nine regions by two
longitudinal lines (right
and left midclavicular
lines) and two transverse
planes (subcostal and
interspinous planes). The
regions are: right and left
hypochondriac, right and
left lumbar, right and left
inguinal (or iliac),
epigastric, umbilical and
hypogastric.

20. Bony Landmarks of the Lower
Abdomen
When imaging the
abdomen the
common bony
landmarks used by
radiographers are
the Iliac crest, ASIS,
and the Pubic
Symphysis.

23. • Laboratory Examination
• Laboratory examinations in surgical patients have
the following objectives:
• Screening for asymptomatic disease that may
affect the surgical result (eg, unsuspected anemia
or diabetes)
• Appraisal of diseases that may contraindicate
elective surgery or require treatment before
surgery (eg, diabetes, heart failure)
• Diagnosis of disorders that require surgery (eg,
hyperparathyroidism, pheochromocytoma)
• Evaluation of the nature and extent of metabolic
or septic complications

24. • Complete Blood Count
This test, also known as a CBC, is the most common blood test
performed. It measures the types and numbers of cells in the
blood, including red and white blood cells and platelets. This test is
used to determine general health status, screen for disorders and
evaluate nutritional status. It can help evaluate symptoms such as
weakness, fatigue and bruising, and can help diagnose conditions
such as anemia, leukemia, malaria and infection.
• Prothrombin Time
Also known as PT and Pro Time, this test measures how long it
takes blood to clot. This coagulation test measures the presence
and activity of five different blood clotting factors. This test can
screen for bleeding abnormalities, and may also be used to monitor
medication treatments that prevent the formation of blood clots.
• Basic Metabolic Panel
This test measures glucose, sodium, potassium, calcium, chloride,
carbon dioxide, blood urea nitrogen and creatinine which can help
determine blood sugar level, electrolyte and fluid balance as well as
kidney function.

25. • Lipid Panel
The lipid panel is a group of tests used to evaluate cardiac risk. It
includes cholesterol and triglyceride levels.
• Liver Panel
The liver panel is a combination of tests used to assess liver
function and establish the possible presence of liver tumors.
• Thyroid Stimulating Hormone
This test screens and monitors the function of the thyroid.
• Urinalysis
Often the first lab test performed, this is a general screening test
used to check for early signs of disease. It may also be used to
monitor diabetes or kidney disease.
• Cultures
Cultures are used to test for diagnosis and treatment of infections.
Illnesses such as urinary tract infections, pneumonia, strep throat,
MRSA and meningitis can be detected and tested for appropriate
antibiotic treatment.