EXAMINATION OF A SURGICAL PATIENT

The problem of doctor-patient relationship is as old as disease itself. It concerns both medical
professionals and those turning for medical help. The relationship begins at the first meeting with the
patient, the stage of examining the patient. The success of diagnosing and treating the disease depends very
much on whether the doctor can dispose the patient to himself.
The famous Syrian author and doctor Abu-al-Faraj who lived in the 12 th century wrote that an ancient
doctor used to say to the patient: there are three of us - you, the disease and I. If you side with the disease
then the two of you will defeat me. If you side with me, there will the two of us and we will defeat the
disease.
For the doctor the diagnostic process begins with the moment the patient comes in, his appearance,
walk, speech and so on. You should not forget, however, that the patient, too, estimates the doctor from the
first moment. The difference is that while for the doctor the patient is one of many, the patient views the
doctor as a unique person to whom he entrusts his welfare and life. So the patient studies him curiously. The
impression that he forms lays the foundation for the future psychotherapeutic action. Let us remember the
well-known quotation: "If the patient does not feel better after the first appointment, the doctor is not a
good one".
The doctor is like an actor on stage: his appearance, gestures and words are closely studied by the
patient.
Now some words about the average patient of nowadays. The general features apart from his individual
disease are:
- multiple diseases. Gerontologists think that persons over 60 have no less than three health
problems. This multiplicity is typical of younger people, too. The reason is simple: only 100 years ago
people could not survive serious diseases, many people did not reach the age when chronic diseases
develop. They died without chronic problems, nowadays people live with them.
- Another specific feature of today's patients is the presence of more or less pronounced
disorders of central nervous system. In most countries every fifth person has some emotional problems.
You should not ask the modern patient if he has neurosis. You had better ask what neurotic
manifestations he has.
- The third feature is the propensity for overweight and obesity. It is considered that
obesity reduces the life span twice as often as malignant tumours.
- The fourth feature is widespread allergy. Most authors agree that 10-15% of population
suffer from various allergic manifestations. Among those seeking medical help this value is even higher.
- The fifth feature is the presence of chronic seats of infection, often in the teeth, tonsils
and urogenital tract (chlamydiosis, mycoplasmosis).
- All the features above lead to another one: the combination of these factors, interrelated
complaints, sensations and symptoms often efface distinctive signs of a disease which makes diagnosis
more difficult.

The talk with the patient

While talking with the patient you should not inform him of your preliminary diagnostic conclusions,
however evident they may be. The doctor gives his advice, recommendations and conclusions when the
complete examination is over, sometimes it may be several days after the patient was admitted to hospital.
Irrespective of the patient's age, some of his traits or situations can cause the doctor's annoyance or
embarrass him. Let us dwell on some of these difficult situations.
Keeping silent - the patient may keep silent because of the doctor's mistakes. Perhaps you are asking
too many direct questions? Then the patient gives up the initiative to you and plays a passive role in the talk.
Can you have hurt his feelings in some way (for instance, showing your disapproval or censure?)
Anger and hostility. Patients can have different reasons for anger: they are suffering from ill health,
habitual lifestyle has changed, they feel helpless. They can vent their anger on you. Face their feelings with
calm assurance. Do not share the patient’s hostility to another doctor or hospital. You should know that a
rational resolution of a conflict is not always possible and it takes time for people to overcome their anger.
Alcoholic intoxication. Intoxicated people can disrupt the work of clinic in a bad way. They are usually
disgruntled, aggressive and unruly. Before talking with such people you should first inform hospital security.
 It is important that you keep a friendly, non-provoking attitude. Avoid eye contact with a drunken man,
do not try to stop his shouting and cursing. Remember, no matter how he behaves you will have to give him
medical help.
Unusual behaviour and incoherent life history. Sometimes you may feel dissatisfied and disappointed
by your contact with the patient. You have written down accurately all his answers but the case history
remains vague and ambiguous, with incoherent ideas. Even if you clearly formulate your questions, you do not
get precise answers. The description of symptoms can be flowery: “My nails feel heavy”, “My stomach wriggles
like a snake”. Such descriptions should alert you to the possibility of a mental disease (schizophrenia).
Many psychotics can more or less adapt in the society. They are often candid about their diagnosis,
symptoms, hospital stays and drugs. You can ask the patient direct questions about that.
Patients with low intelligence. Patients with moderately low intelligence are often capable of giving you
correct information for case history. You may even overlook his deficiency and give him instructions which he
is unable to even understand. If the patient is seriously retarded, fill out his case history with the help of his
family and friends. Like in dealing with children, do not show your superiority, avoid being condescending.
Talking with family and friends. It is sometimes useful to talk with family members to clear up some
details. If you are going to talk with a third person, you should have the patient’s agreement. Sometimes
family members or friends insist on being present at the talk or even examination. Try to find out why they
want it and the patient’s reaction. If he is not able to give the necessary information, then you will need the
help of a knowledgeable person. If the patient is able to communicate, you had better observe confidentiality.
You can divide the talk into two stages: alone with the patient and then in the presence of that other person.
All the information you obtain from the patient should be classified to be entered into the case
history.
First comes introductory information.
State the date and time of your talk.
The information about the patient’s age, sex, nationality, occupation enables you to form an idea of his
personality and the type of problem he has.
If the patient did not come to you of his own accord, find out how it happened (patients who were
referred by their employer, teacher or insurance company are usually different from those who come
themselves).
The main part of the case history begins with the patient’s complaints.
In the section History of the present complain emphasize the order n which the symptoms developed
and what they are related to.
Describing the symptoms state the following:
1. localisation
2. quality
3. severity
4. time of onset, duration, frequency
5. circumstances of their development
6. factors aggravating or alleviating them
7. accompanying manifestations.
You should also note symptoms which the patient denies having (the absence of certain symptoms can
help in differential diagnosis).
You should also note what the patient himself thinks of his problem, what exactly made him seek help,
how this problem influenced his lifestyle.
In the section Life history list all the diseases and traumas experienced earlier. Find out if the
patient has allergy, harmful habits, drug or alcohol addiction.
Diet. Describe the habitual diet, any restrictions or additions to diet.
Immunization. List all vaccinations (for instance, against tetanus, diphtheria, poliomyelitis).
Family history helps you to estimate the risk of developing certain diseases and to assume the nature
of the current problem. State the age, health condition or cause of death of other family members.
You should always note if there is diabetes, cardiac disease, arterial hypertension, insult, kidney
disease, tuberculosis, cancer, arthritis, allergy, asthma, mental disease, alcoholic or drug addiction, or
symptoms like those of the patient in family history.

Physical examination.
 It is desirable to observe a certain consistency while performing a physical examination. You should
first note the patient’s general condition, motion activity, facial expression and odour. Then examine the vital
functions: pulse rate, BP, respiratory rate, body temperature.
After that you will examine
- the skin
- scalp, eyes, ears, nose, mouth and pharynx
- neck
- chest and lungs with percussion and auscultation
- mammary glands
- cardiovascular system
- abdomen
- rectal or vaginal examination
- lower extremities.
The extent of the examination depends on the time the doctor has and urgency of the situation.
Although patients often complain of specific organs or systems, you should look at the whole body. Even if
physical examination does not produce anything new, the fact itself of a thorough examination allows the
doctor to arrive at a conclusion and may protect him from conflict or complaint in future.
After a complete clinical examination additional investigations are administered that can specify the
tentative diagnosis.
Bacteriological investigations can take place in two ways:
bacterioscopy when the smear is stained and examined under a microscope. This is a fast but rather
inaccurate method because for a bacterial colony to be seen the concentration of microbes should be high
enough.
The other way is culture for nutrient medium. The results are obtained in 2-3 days and sensitivity to
antibiotics is usually determined, too.
Samples for bacterial investigation (blood, sputum, urine, pus, excretions) should be always collected
into sterile glass observing the rules of aseptics.
Before collecting sputum the patient is asked to brush his teeth and to rinse the mouth with a weak
baking soda solution. The sputum is collected in the morning in the amount of 3-5 ml in a sterile glass. It is
important to deliver the sample to the lab as soon as possible.
It is advisable to do the investigations of stools in the morning, too. The day before you should cancel
all drugs that can change the stool. You should remember that after radiography of gastrointestinal tract
with barium it is difficult to do microscopic examination for 2-3 days. The stools are collected into a clean
dry glass or paper cup.
When examining emetic masses their amount should be noted. The presence of food remnants or blood
is determined macroscopically. If there is suspicion of poisoning or intoxication the emetic masses are sent
for chemical or bacterial investigation.
Radiographic examination is an important part of diagnostics in surgery.
The most common occasion for radiography is diagnosis of pneumonia (in surgery it is a possible
postoperative complication).
Instrumental methods of examination are a great range of investigatory techniques. The quickly
developing methods of endoscopic examination are of great importance.
Esophagoscopy is required when a foreign body in the esophagus is suspected; it can help to determine
the spot of bleeding, to diagnose varicose veins of the esophagus, scarry constriction or tumour.
Bronchoscopy is used in practically all bronchial diseases.
Gastroduodenoscopy is used to diagnose disorders of the esophagus and stomach, some hepatic,
pancreatic, biliary diseases (endoscopic retrograde pancreatocholangiography).
Colonoscopy is a method of visual examination of the mucous membrane of the large intestine.
Laparoscopy and thoracoscopy have been more used for treatment rather than diagnosis.
In some cases when all else fails surgery can be resorted to for diagnostic purposes – diagnostic
laparotomy and diagnostic thoracotomy.