Hamilton Bailey's Physical Signs

Demonstrations of Physical Signs in Clinical Surgery, 19th Edition

John S. P. Lumley, Anil K. D'Cruz, Jamal K. Hoballah, Carol E. H. Scott-Connor

• Publisher: CRC Press
• Year: 2016
• ISBN:
  9781482261134
• Edition: 19
• Topic: Medicine
• Subtopic: Surgery & Surgical Medicine

It is approaching a century since the first edition of Demonstrations of Physical Signs in Clinical Surgery was first published, authored by the pioneering surgical teacher Hamilton Bailey. That it has survived is testimony to the continuing need for those learning surgery to be able to elicit physical signs in the patient and to understanding thei

PART

1

Principles

1 History-taking and general examination

2 Distinctive clinical syndromes

3 Lumps, ulcers, sinuses and fistulas

4 Inflammation

5 HIV and AIDS

CHAPTER 1

History-taking and General Examination John S. P. Lumley and Natalie Anne Hirst

LEARNING OBJECTIVES

• To be able to take a concise, structured patient history

• To understand the basis for a systematic general examination of the patient

• To know the methods for taking a manual blood pressure reading

• To be able to undertake a focused examination of systems and a formulation of initial working diagnoses

• To be aware of the specific requirements of the neonate and child in the surgical examination

HISTORY-TAKING

A patient usually comes to see a doctor with a specific problem (a symptom) and the doctor’s aim is to make the patient better. To do this, the doctor tries to work out what is causing the problem (the diagnosis), determine its severity (assessment) and then institute appropriate treatment. The total process of assessment and treatment is termed ‘management’.

Disease may be due to social and psychological as well as physical abnormalities – the surgeon must be aware of, and sensitive to, all of these factors. To diagnose and assess a patient’s problems, the doctor can obtain information from three sources:

• taking a history;

• carrying out a physical examination;

• requesting appropriate investigations.

The history is the single most important factor in making a diagnosis. Although this textbook is primarily concerned with eliciting abnormal physical signs, these are not always present at the time a patient presents. The history directs the clinician to search for the physical abnormalities and find them at the earliest possible stage of the disease, thus facilitating further management.

The skilled clinician becomes an expert on the pattern of diseases, but their greatest skill is to listen to what the patient volunteers. This is the key to the diagnosis and the clinician must not shape, elaborate, flavour or direct a history into a particular category just so that it fits a classical package. Such prompting may result in misdiagnosis.

Sometimes it is not possible to make a diagnosis. However, the process of assessment serves to exclude serious abnormalities, allowing the clinician to reassure the patient and advise symptomatic treatment. This strategy is based on the nature and duration of the symptoms. It allays the patient’s fears and avoids an overinvestigation of trivial and self-limiting disease.

A decision must be made, however, on whether the patient needs to be seen again for further assessment. Continual explanation to the patient and good patient rapport are of vital importance and will translate into a more accurate diagnosis and increased patient knowledge. Management occasionally has to be initiated before a definitive diagnosis has been made, such as in the control of severe pain or haemorrhage.

The following scheme for history-taking is intended as an introduction to the subject and outlines the prime headings that need to be considered when interviewing each patient.

SCHEME FOR HISTORY-TAKING

First record the date and time of the examination. Note the patient’s name, age, sex, occupation (past and present) and who they live with at home (including any dependants). The history emerges from the patient’s description of the problem, directed by your planned questioning. It is conveniently recorded under the following six headings.

Present Illness

Presenting Complaint(s)

‘Can you tell me why you’ve attended the hospital today?’ This must be put in a short statement, preferably using the patient’s own words, for example ‘c/o [complaining of] abdominal pain and vomiting for the last 24 hours’ or ‘increasing breathlessness for 2 weeks’. If there is more than one complaint, these are listed and then taken in turn through the following two sections.

History of Presenting Complaint(s)

This should record the details of each problem, using mainly the patient’s own words. Record as accurately as possible how long the complaint has been present and include the sequence of events in chronological order with dates (e.g. 1 year ago, 1 month ago, yesterday). Let the patient begin by telling the story in their own words without interruption. Afterwards, ask specific questions using terms readily understood by the patient, either enlarging upon or clarifying their symptoms.

The presenting disorder is usually related to one system, and questions referable to this – and any other system involved in the presenting complaint – are delivered at this stage. Pain is one of the most common symptoms; appropriate questions are given below. Many of these questions can also be applied to other symptoms.

If the patient is a poor historian or is unable to give a history, or you suspect them of giving unreliable information, it may be helpful to talk to relatives or witnesses. Record the source of this and all aspects of the history that are not obtained directly from the patient.

Previous History of Presenting Complaint(s)

If the patient has had similar symptoms in the past, obtain detailed information in chronological order, including any treatment received and the results of any investigations (if known). Report any past event with a clear bearing on the present condition, such as operations, trauma, weight loss, medication, contact with others with disease or any recent travel abroad.

Past Medical History

Note all other previous non-trivial illnesses, operations, accidents and periods of admission to hospital for non-related illnesses, together with their dates. For children, note illnesses, investigations and immunizations. In adults, note relevant childhood problems, for example chronic respiratory disease, cardiac problems and rheumatic fever.

Drugs and Allergies

Note all drugs being taken, their doses and for how long they have been taken. Ask what drugs have been taken in the past and for what conditions. Ensure that non-prescription medications, for example St John’s Wort, and any other drugs the patient may not consider as medication, such as the oral contraceptive pill, are also documented. Record drug allergies and any allergic symptoms. Ask what is meant by any admitted allergy or sens...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Biography of Hamilton Bailey
• List of contributors
• Preface
• Part One: Principles
• Part Two: Trauma and (elective) orthopaedics
• Part Three: Skin
• Part Four: Head and neck
• Part Five: Breast and endocrine
• Part Six: Cardiothoracic
• Part Seven: Vascular
• Part Eight: Abdominal
• Part Nine: Genitourinary
• Index