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The technique of history taking, combined with the art (and skill) involved in physical examination, still remains the basis of diagnosis (despite advances in medical technology). This process requires correlation and interpretation of the patient's symptoms and signs. The skill is in placing these factors in proper perspective. To be in a position to do this, good anatomical knowledge is vital.
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After arriving at a provisional diagnosis, a decision is then made regarding the need for investigation or surgical intervention.
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Any surgical condition requires a thorough pre-operative and post-operative assessment, as well as an evaluation of intra-operative progress. The reasons for the decision to operate, and the results expected by all parties (patient, family and treating doctors), depend on assessment, explanation and (informed) consent.
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This program attempts to travel a difficult road - to be applicable in its content to clinical students, surgical trainees, general practitioners and (perhaps) even surgeons in need of revision. The surgical conditions explored are limited to the common conditions encountered by the target audience.
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Clinical assessment leads to a differential diagnosis. The information gained leads to a tissue, site and process 'cross-matching' to help define the specific problem. The approach taken varies in each situation and depends on assessing:
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i) Why the patient is there (defining the presenting complaint)
ii) What is the nature of that reason (assessment of the complaint)
iii) Who the patient is (assessment of the patient)
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The presenting complaint considered alone is of little value - the patient as a whole must be considered. The process of assessment and definition can only be consistently successful by ordered (yet flexible), multifactorial history taking.
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The patient offers a presenting complaint. In order to make the diagnosis, there must be definition of system, region and (pathological) process. The nature of the complaint defines the order of approach. Assessment begins with one or more of four definitions:
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i) Location
ii) System
iii) Process
iv) Undefined
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More specific assessment of this information will direct the clinician in history taking.
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The Surgical Examination
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A general medical examination tends to look at the whole body in a directed pattern. The surgical examination is directed by the history and is dependent on the nature of the presenting complaint.
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i) Direct
ii) Extended
iii) Regional
iv) Systemic
v) General
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With a defined location, (e.g. a lump) the approach is mainly ...