1. This document provides guidance on performing a patient examination, including taking a medical history and conducting a physical examination of a swelling. 2. It details the key components of a patient's medical history to cover, such as their personal history, present complaint, past medical history, and family history. 3. The document also describes how to physically examine a swelling, including inspecting it, palpating it, performing percussion and auscultation, and discussing different types of sutures used in surgery.

1. GENERAL
SURGERY
- 302 -
SUMMARY PREPARED
BY
SABRI KHALIL SHAMALI
College of medicine
2011
2nd version
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2. Start by putting the patient at ease: ( )
• Greet the patient by name: "Good morning, Mrs Jones"
• Introduce yourself and explain that you are a medical student.
• Shake the patient's hand, or if they are unwell rest your hand on theirs.
• Ensure that the patient is comfortable.
You should always begin the physician-centered phase of the interview with "WH"
questions (where? what? when?) directed at the chief complaint(s). Build on the
information the patient has already given you. Flesh out areas of the story you don't
fully understand. Try to quantify whenever possible (pain on a scale of 1 to 10,
number of days instead of "a while," etc.). Be as specific as possible and try to record
what the patient says accurately, without interpretation
A.Personal history:
1- Name:
Medical registration
To be familiar with patient
2-Age: Why we ask about age: "age related diseases as:
"
Infant (0-2 yrs) --- congenital diseases
Childhood (2-12 yrs) --- Parasitic infection mumps
Adolescence (12-20 yrs) --- Trauma, TB
Adulthood (20-40yrs)--- Hernia )
Middle age (40-60yrs) --- Gall bladder diseases, Atherosclerosis
Old age (above 60rs --) --- Malignancy, vascular disease)
3. Sex: Why sex: "sex related diseases"
emale
Breast cancer
Gall bladder stones
Femoral Hernia
Goiter
SLE "Systemic Lupus Erythematosis"
ale
Hypertension
Inguinal hernia
Peptic ulcer
Gastric and bladder carcinoma
4- Residence: íÚ^Î÷]<á^ÓÚ
Farmer ---- Malnutrition and parasitic infection "bilharziasis"
Endemic diseases: Oases ---goitre
Bilharziasis---Egypt
stomach cancer Japan
Burkett's lymphoma central Africa, esophageal cancer china
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3. 5. occupation :‫ﺍﻟﻤﻬﻨﺔ‬
Porter ‫ --- ﺍﻟﻌﺘﺎﻝ‬hernia
teachersurgeon ‫ﺟﺮﺍﺡ‬barber ‫ --- ﺣﻼﻕ‬Varicose vein
Vibration --- vascular diseases
Radiation --- Bone marrow depression
6. Marital status:
Single, married, divorced or widow, offspring. the age of the youngest
7. Menstrual History:
regularity of menstruation, age of menarchemenopause
8. Special Habits:
Smoking:"number of cigarette and period of smoking"
Lung cancer, Lip cancer , Urinary bladder cancer
Atherosclerosis
Respiratory tract infection
Emphysema, chronic bronchitis
Alcohol Abuse:
Peptic ulcer
Liver cirrhosis
Drug Abuse and addiction.--- injection lead to hepatitis and AIDS
B. Complaint:
1-Written in patient words "only translation without medical terms"
2- only one complaint the most sever and recent"(distressing one)
3- in brief
4-Duration of complaint
5-Complaint may be swelling , pain or disturbed function
6- one complain one system
C. present History:
1-history of pain:
If the history of the presenting complaint includes pain, ask about it using the
mnemonic SOCRATES
Site - where exactly is this pain?
Onset - when did the pain start, did it start suddenly or gradually?
• sudden "trauma > hematoma" ( MCQ )
• gradual "neoplasia"
• acute "inflammation , infection"
• Accidental "discovered by patient"
2

4. Character – describe the pain - sharp? knife-like? gripping? burning?
crushing?
• Colic pain
• Throbbing pain - infection with pus
• dragging "heaviness" – varicose vein
• Radiation - "Referred pain " extension-of pain to another site"
does the pain spread anywhere? To the arm, jaw, groin etc?
Renal pain back pain ,radiate to inguinal region and testicular
o Gall bladder pain mid-epigastrium and tip of right scapula
o appendicitis pain around the umbilicus
• Associated symptoms - is the pain accompanied by any other features?
o like oedema, hemoptysis , vomiting
• Timing duration - does the pain vary in intensity during the day?
( )
o Short "inflammation"
o Long "benign lesion"
• Exacerbating
srotcaf gniveiler dna - does anything make the pain better or worse?
• Severity - does the pain interfere with daily activities or with sleep?
o Mild
o Moderate
o Sever " life stopping"
2-History of swelling :
( ‫) ﺍﻭﻝ٦ ﻧﻘﺎﻁ ﻟﻠﺘﻮﺿﻴﺢ-ﺗﺘﺤﺪﺙ ﻋﻦ ﻃﺮﻳﻘﺔ ﺳﺆﺍﻝ ﺍﻟﻤﺮﻳﺾ‬
Some key questions to be asked regarding a swelling (generally)
1. When do you first notice the lump?
REMEMBER, first noticed the lump 3 months ago is not the same as first appeared 3
months ago.
2. How do you notice it?
Below are the 3 commonest answers :
a) It's painful b) I noticed it accidentally c) Others told me about it
Generally, if the lump is painful, the commonest aetiology is inflammation.
Most of the patients thought that only painful lumps are cancerous.
3. How does the lump disturbs you?
Basically, the question is asking about the associated symptoms.
It can be pain, discharge, dysphagia, dyspnoea, cosmetically disfiguring, fear of
malignancy, etc.
4. Any changes to the lump since you first notice it?
The commonest change is the size.
Whether the lump has increased or decreased in size, or it's size fluctuates.
5. Has the lump ever dissapears before?
Does the lump dissapears when the patient is lying down supine?
or any other activities
6. Do you ever had any other lumps before this?
Asking for multiplicity
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5. 1. Onset:
o Sudden "trauma hematoma" _MCQ_
o Gradual "neoplasia"
o Acute "inflammation, infection"
o Accidental "discovered by patient or others"
2. Course:
o Progressive rapid "malignant lesion" or slow
"Benign lesion"
o Regressive acute infection
o Stationary cysts or benign lesion
o Intermittent jaundice due to obstruction
3. Duration:
o Short "inflammation
o Long "benign lesion"
4. Relation to pain:
o Swelling then pain --malignancy
o Pain then swelling- inflammation
5. Relation of onset to constitutional manifestation:
o Fever , redness, headache, malaise
6. effect on body function and nearby structures
7. possible cause (aetiology):
o Carrying Heavy object -- hernia
o Trauma -› hematoma
8. Special character:
o Move up and down with deglutition thyroid swelling
o increase size with food pharyngeal diverticulum
o Pulsations aneurysms or vascular swelling
o Impulse on cough and reduce on laying down hernia
D.past history:
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The past medical history is essentially background information related to the
patient's health and well being. A brief past medical (and social) history often
includes these elements
General question:
• Have you suffered from any previous illness?
1. Allergies and Reactions to Drugs (What happened?)
2. Current Medications (Including "Over-the-Counter")
3. Medical/Psychiatric Illnesses (Diabetes, Hypertension, Depression, etc.)
4. Surgeries/Injuries/Hospitalizations (Appendectomy, Car Accident, etc.)
5. Immunizations
6. smocking/Alcohol
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6. 7. Reproductive Status for Females
o Last Menstrual Period
o Last Pelvic Exam/Pap Smear
o Pregnancies/Births/Contraception
8. Birth History/Developmental Milestones for Children
9. Exposures
:lufpleh DAERHT cinomenm eht dnif yam uoY
• Tuberculosis
• Hypertension (myocardial infarction and strokes)
• Rheumatic fever
• Epilepsy
• Asthma, anxiety and arthritis
• Diabetes and depression
E. Family History:
• Are your father, mother, brothers, sisters alive? - If they have died, at what
age did he/she/they die? What did he/she/they die of?
• Do they have any current illnesses?
• Do any illnesses run in your family?
Similar cases in family "hereditary disease
Consanguinity ‫ا رب‬
relevant - cancer breast and hemolytic anemia
goiter , varicose veins
irrelevant-hernia
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7. Local examination of
swelling
a- inspection: <ì‚â^Ž¹^e<
o 1- solitary or multiple
o 2- site (anatomical)
o 3- Size ( in cm)
o 4- Shape (rounded, oval, etc.)
o 5. Surface:
• - Smooth
• - Irregular :
granular (<0.5 cm), nodular (1-2 cm), lobulated (>2 cm)
o 6. Surrounding structures:
( relation & effect of swelling in the surrounding structures ):
Relation to muscle:
(ask the patient to contract the muscle and see if the swellings):
- decrease in size --> deep to muscle
- Increase in size - superficial to muscle
-No change- muscular swelling
Relation to surrounding structures as arteries and veins
o 7-Other Swelling: draining lymph nodes
o 8-Special sings:
• Move up and down with deglutition > thyroid swelling
• increase size with food > pharyngeal diverticulum
• Pulsations > aneurysms or vascular swelling
• Impulse on cough and reduce on laying down > hernia
o 9.skin overlying:
• Normal
• Sings of inflammation (redness, dilated veins)
• Sings of malignancy (skin retraction , dilated veins)
• Scars
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8. B) palpation ‚éÖ^e<Œ^Šu÷]<
1-tenderness ‫اﻻﻟﻢ ﻋﻨﺪ اﻟﻠﻤﺲ‬
2-Temperature- by dorsum of hand which is more dry
3-consistency :
solid :
• Hard like bone
• Firm like tip of nose
• Soft like lobule of ear
Systic : fluctuant "presences of fluid" (MCQ )
Can be detected by:
• fluctuation test : -
- cross fluctuation test
- Bipolar fluctuation test- for swelling have 2 place
NB . fluctuation test uses > 2 cm
Pagets test uses < 2 cm
4-Edge:
well defined edges or ill defined edges
remember . comment on edge by palpation ( MCQ )
C) Percussion:
• Resonant: gaseous swellings
• Dull: cyst and solid swellings
D) Auscultation:
• Systolic murmurs in aneurysm
• Contentious murmurs in A/V fistula
• Venous hum in portal hypertention
• Intestinal sounds in hernias
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9. - Sutures -
Def: Surgical suture is a medical device used to hold body tissues
together after an injury or surgery.
Uses: wound closure (Wound healing) :
1ry intention
2ry intention – granulation tissue/leave scar and doesn't look nice
3ry intention – infection wound sutured after wound healing
Type of sutures:
1-absorbable:
o Not for skin
o For abdominal layer
o Intestine , stab knife
(NB. We can use non-absorbable but prone to infection)
2- non-absorbable:
For skin suture : / multifilament
fix drain (natural)
prolene (polyprolene) suture/ (synthetic) ( mcQ)
BN . Prolene {inert} the body doesn't react against it
Uses:
1- for suture tough structure, we suture linea alba , rectus sheath at midline
with prolene
2- repair of hernia: protrusion of a sac
Sac = -omentum – intestine
Prolene mesh non absorbable for treatment of hernia
:erutus elbabrosba fo epyT
(every thread has tensile strength)
A) chromic catgut (natural)
• induce very severe immune reaction
• has tensile strength remain 90 days (loss of tensile strength after 3
weeks)
B) synthetic vicryl :
• not much severe immune reaction at natural
• monofilament (monocryl) mcq
• multifilament (vicryl) : mcq
o More tensile
o More liability to infection
o Absorbed after 70 days
8

10. :Chromic Catgut suture:
is an absorbable, sterile, surgical suture composed of highly purified connective
tissue (mostly collagen) derived from either beef or sheep intestines
Application: General Closure , Urology , Plastic Surgery
: Silk Suture
Natural Non-absorbable Suture (braided)
Indications: Eye and lip skin surgery , Intraoral surgery
Advantages: Best handling and tying of any Suture Material
Disadvantages: - Least tensile strength of any Suture Material
- High tissue reactivity (similar to CatgutSuture)
- Increases risk of infection due to high capillarity
:esoohc ot woH
‫ﻛﻞ ﻣﺎ ﺍﺯﺩﺍﺩ ﺭﻗﻢ ﺍﻟﺨﻴﻂ ﻛﻠﻤﺎ ﻗﻠﺖ ﺳﻤﺎﻛﺘﻪ‬
Example :
Face : 0.4 and late
Scalp : 1
Vascular non absorbable – prolene : 6.0
BN . Cartilage (not sutured) lead to ISCHEMIA
Precaution to ensure increase intention healing :
A) approximate not strangulate
cut of blood supply of edges no wound healing
B) don t increase number of sutures more than needed
(wound 5 cm need 4 sutures)
Every needle in for out lead to trauma
Every suture will contain foreign body / bacteria
BN . If there is skin loss ; leave to heal natural –skin graft
C) no tension on wound
D) suture memory
♦ ability of suture material to regain its normal shape
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11. complication of suturing a wound
1- infection :
♦ tools not clean
♦ disease transmission (as AIDS)
♦ inflammation ( auto immune Reaction)
2- scar
♦ wound healing but leave mark
♦ not raised / not elevated
♦ respect edges of wound
3- , keloid (occur more with natural)
♦ spread out of wound edges
♦ itching
♦ raised
4- improper healing (opened the wound)
BN .(radiotherapy) : ( endarteitis obliteranis )
i.e small vessels are blocked lead to impair healing
BN . Human glue ( skin stripsskin dips)
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