HISTORY TAKING

HISTORY TAKING.

History is obtained at very initial contact between the anaesthetist and patient. This should be preferably from the patient whenever possible. If the patient is for any reason unable to directly give the required history then the next option is either the relative (s) or attendant(s). In any case an attempt should always be made to obtain at least some relevant history even if the first contact is in the operating room.

DETAILS: -

1. Personal history: -a) Names: for identification purposes.

b) Age: because it directly influences many aspects of anaesthetic management of patients.

c) Ex: this too under special circumstances e.g. in pregnancy does influence anaesthesia.

d) Physical address: geography/ environment significantly influence disease pattern e.g. sickle cells anaemia is most prevalent Kasese of all districts in Uganda.

e) Occupation: this may predispose people to certain specific occupational hazards.

f) Religion: ask for beliefs especially regarding blood transfusion.

2. History of presenting complaint(s): -a) Carefully write down the complaint(s) in chronological order.

b) Duration of complaint(s)

c) Mode of on set: acute or gradual.

d) Severe and aggravating factor(s)

e) Effect(s) on patients physical activity.

3. Past anaesthesia and surgical history: -

a) When?

b) Where?

c) Anaesthesia technique and surgical or any other procedure for which the anaesthetic was given.

d) Final outcome and any significant event(s)

4. Past medical history: -

a) Any past hospital admission(s) and reason(s).

b) Known medical condition(s) and current drug therapy.

5. History of allergy: -

a) Allergic conditions e.g. bronchial asthma.

b) Previous allergy to anaesthetics.

6. Family history: -

a) Both parents alive? If not cause of death?

b) Familial disease e.g. sickle cell disease (SCD).

7. Social history: - especially tobacco smoking and alcohol intake.

PHYSICAL EXAMINATION

GENERAL To any patient examined mention general state of health i.e.

(i) General condition: -

-Good

-Poor

(ii) Hydration

-adequate or dehydrated

(iii) Nutrition

-malnourished or well nourished.

(iv) Anaemia

) these should always follow each other

Jaundice

)

(v) Temperature

(vi) Oedema

-legs

-Face

-Sacrum

(vii) Cyanosis

-a) central tongue and conjunctivae denote hypoxia

-b) peripheral is indicative of impaired blood supply to the affected parts.

Some specific signs.

Depending on the system involved the following are also mentioned.

(i) Finger clubbing in CVS is caused by subacute bacterial endocaditis in respiratory system it is caused by suppurative lung diseases.

(ii) Lympadenopathy reticular endothelial system is involved.

SYSTEMIC EXAMINATION: -

1. Always start with system with significant or positive findings where pathology is detected clinically.

2. CVS: the cardiovascular system.

3. RS: the respiratory system.

4. CNS: the central Nervous System.

5. GIT: the Gastrointestinal System = abd exam

6. Musculoskeltal system.

7. Local examination: for localized lesions.

THE BASIC PRINCIPLES OF MEDICAL PHYSICAL EXAMINATION.These almost entirely apply to all aspects and should be performed in the following order:

1st: inspection or observation.

2nd: palpation.

3rd: percussion.

4th: auscultation.

In all these ensure MINIMUM inconvenience to the patient. Inflicting or aggravating pain is definitely more than sadism and may render the patient unco-operative and hence lose confidence in you.

CARDIOVASCULAR SYSTEM (CVS)

History

Principle symptoms are: -

(i) Dyspnoea (exertional)

(ii) Retrosternal pain.

(iii) Oedema

(iv) Palpitations

(v) Fatigue

(vi) Resting pulse rate and rhythm

(vii) Resting blood pressure

OTHOPNEA dyspoea in supine position that is promptly relieved by sitting.

PAROXYSMAL NOCTURNAL DYSPOEA sudden involuntary need by the patient to sit on the side of the bed or stand up for relief. It commonly occurs at night and is suggestive of mitral valve stenosis.

CHEST PAINOccurs in the following: -

1. Infections: Acute And Chronic.

2. Angina Pectoris

3. Myocardial Infraction

4. Pericardial Effusion Or Tamponade

5. Pulmonary Embolusion Or Infarction

Ask severity, location, radiation; duration and conditions that precipitate, aggravate or relief it.

PALPITATIONS.

This is said to occur when the patient is conscious of his / her heart beat.

Patient may complain of rapid forceful or irregular heart beat.

Causes of palpitation are; -

Anaemia, thyrotoxicosis, fever, anxiety, arrhythmias, and neurosis.

OEDEMAOedema due to right failure appears first on ankles and lower legs in ambulatory patients and over the sacrum in bed-ridden patients. There are numerous causes of oedema, the commonest being; -

Renenal failure.

Liver failure

Malnutrition

Filariasis.

Venous thrombosis

Malnutrition (severe)

Premenstrual fluid retention.

Prolonged sitting or standing

FATIGUE

Easy fatigability relieved by rest is common.

Other causes of fatigue: -

(i) Chronic infection

(ii) Anaemia

(iii) Metabolic disorder

(iv) Endocrine disorder

(v) Malignancy

(vi) Sedative drugs

During examination of CVS like in all other aspects: the 4 golden principled apply VIZ:-

(i) Inspection

(ii) Palpation

(iii) Percussion

(iv) Auscalitation

2. Always stand at RIGHT side of patient.

(a) INSPECTION / OBSERVATION: -

Note position of the patient in bed e.g., [propped up in bed.

(b) PALPATION

I PULSE: radial, pulse note: - Rate

-Volume

-Rhythm

Other peripheral pulse: note their presence or absence

Note: -whenever examining or monitoring patients, think of increased or decreased in the pulse rate.

Pulse rate in an adult ranges from 60 beats to 100 beats < 60 is bradycardia > 100 is tachycardia.

Causes of bradycardia under anaesthesia;

1.Hypoxia

2. Drugs e.g. suxamethonium.

3.para sympathetic stimulation: vaso parasympathetic

4. Increased intracranial pressure (ICP)

5.heart block

6. Hypothyroidism

7.severe liver disease

8. Beta blockers.

II BLOOD PRESSURE: - Ensure use of correct size of cuff.

Whenever measuring blood pressure, always think of cause of hypotension or hypertension whichever is the case.

III CENTRAL VENOUS PRESSURE (CVP). Examine the neck check jugular venous pressure; must distinguish between (JVP)

VIS arterial pulsations: -

Engorgement of neck veins denote raised central venous pressure (CVP)

Look for the HIGHEST point of pulsation of the right jugular vein.

IV EXAMINATION OF THE PRAECORDIUM: - Inspect note if pulsations can be seen. Then feel for the apex beat which in normal

Person is at the 5th intercostals space with the palm of the hand.

The Apex beat is the point of maximum cardiac pulsation.

(i) Palpable thrill-indicates a loud murmur if not felt mention that no thrill felt on palpation.

(ii) Heaving apex beat when examining finger is placed on the apex beat its thrust forwards is sustained finger can easily moves up and stays there for an appreciable.

(iii) Diffuse apex beat:

In very rare instances the apex beat may not be palpable .it is then described as being diffuse.

LOCATION OF APEX BEAT: -

To locate the second inter space feel for angle of Louis. Move a finger from the thyroid notch till when the finger reaches a bump = angle of Louis.

The 2nd inter costal space is just opposite angle of Louis.

Thereafter give the EXACT location of the apex in relation of the MID _ CLAVICULAR line (MCL) i.e. medial or lateral to MCL.

(c ) AUSCALITATION ( TO PRODUCE ILLUSTRATION LATER ON FOR AREAS OF AUSCULTATION)Four areas are auscultated.

Mitral valve at apex

Tricuspid valve just at left ximphi sternum (lower end of sternum)

Aortic valve at the RIGHT 2nd inter costal space, immediately next to the sternum.

Pulmonary valve LEFT 2nd interspace immediately next to the sternum.

1. NORMAL HEART SOUNDS: -

First listen to the heart sound I & II.

1st heart sound is due to closure of mitral & cuspid.

2nd heart sound is due to closure of aortic & pulmonary valves.

Determine if the is any ABNORMAL sound (S) and relate it /them to the cardiac cyde systole or diastole.

2. ABNORMAL OR ADDED HEART SOUNDS

THE MURMURS: -

These are blowing sounds that you may hear in addition to the normal heart sounds as already described.

There are two types of murmurs:-

(i) Functional murmurs

(ii) Pathological murmurs

Functional murmurs

(i) They are soft

(ii) They are audible over all the areas of cardiac auscalitation

(iii) They are always systolic

Pathological murmurs

(i) They are loud (harsh)

(ii) They are transmittable

(iii) Often diastolic

Functional murmurs are due to

(i) Anaemia

(ii) Pregnancy

(iii) Thyrotoxicosis

(iv) Common in children

Pathological murmurs are due to valvular disease.

SUGGESTED CONSTANT PRACTICE:-

Listen to own heart sound to get accustomed to the normal heart sounds which have been de4scribed as LUB (the first /systolic heart sound ) and DUB ( for second /diastolic heart sound)

SITES FOR PALPATION OF PERIPHERAL PULSES:-

1. Radial artery at the wrist

2. Brachial artery-cubital fossa

3. Femoral artery in the groin

4. Poplitial artery knee joint

5. Posterior tibia artery at ankle

6. Dorsalis pedis artery dorsum of foot

RESPIRATORY SYSTEM

1. HISTORY

The principal symptoms of respiratory system disease are cough, chest pain, dyspwheeze and striclor. Also ask for production and colour of sputum, presence of hemoptysis and cyanosis.

COUGH

Is the most common symptom of respiratory system disease a detailed inorrogation must be made. Other causes of cough other respiratory system disease are:

1. Congestive heart failure

2. Mitra valve disease

3. Otitis media

The cough may be dry, irritating, paroxysmal, productive or significantly suppressed by pain.

SPUTUM

May be mucoid, grey white or clear purulent (yellow or green) or mucopurulent

Haemophysis

May range in amount from slight blood stained to massive hemorrhage.

CHEST PAIN

Pain is usually due to involvement of the pleura pariental pleura) characteristically unilateral aggravated by cough, deep breathing or sneezing. Involvement of chest wall pain is usually accompanied by tenderness and pain is more constant and less affected by breathing and coughing.

Dysprosa

Dysprosa is present all the time unlike dysprosa of heart disease which is external and relieved by rest and pasture related.

Wheeze (musical sound)

Is due to obstruction of small airways heard on expiration. It is accompanied by dysprosa.

STRIDOR (crowing sound)

Produced in larynx or trachea during inspiration and is aggravated by coughing. It is due to obstruction of large air way (larynx and trachea)

PHYSICAL EXAMINATION OR RESPIRATORY SYSTEM

Inspection

i) Look features suggestive of difficult laryngoscopy and tracheal inhibited.

ii) Count respiratory rate at foot of bed first

iii) Chest configuration

iv) Movement----( is it uniform? Relate chest to abdominal movement

v) Expansion: compare left to right side of the chest

vi) Ventilation ----( hyperventilation

-----( Hypoventilation

Chest deformities

Kyphosis forward bending of the spine

Scoliosis -. Curved laterally or lateral bending

Peageon chest indicative of chronic obstructive long disease

Movement

Paradoxical on breathing in there is in drawing of a portion of the chest wall it occurs in patients

With fracture of a series of .

Airway obstruction

Paralysis of diaphragm

Palpation

1. Location of trachea place the mid finger at the supras exactly in the mid line the other out either side on the clavicles and move the middle finger up and down. If the other two fingers feel the trachea apart from the mid finger that means it is deviated.

Conditions where it can get displaced are:

Pleural effusion

Several empyema

Tension pneumothrorax

Local conditions e.g. goitrem enlarged lymph node in the neck

Lung collapse and lung fibrosis

Consolidation netral

NOTE; work out conditions in which the trachea is displaced towards VIZ away from the site of the lesion shift of trachea corresponds to shift of the mediastinum.

2.palpation of entire chest

superficial palpation followed by deep palpation.

First palpate lightly and gently may feel .spongy feel as in sub .then deep palpation for any lamps , do not hurt the patient.

Chest expansion Place your hands around the chest at xymphsternum thumbs together and ask the patient to take a deep breath note the movement if it is even or not.

Causes of reduced chest expansion

Pneumonia due to pleurisy

Pneumothorax

Pleural effusion

Emphysema

PERCUSSIONRight handed person places the left hand on the chest wall, palm downwards with the fingers slightly separated so that the second phalanx of the middle finger is over the .to be percussed. Pass the finger firmly against the chest wall preferably along the intercostals space.

The second phantax of muddle finger is struck sharply with the tip of the right middle finger .the right middle finger must be held in partial flexion and the entire movement should come from the wrist joint.

During percussion divide the lungs into zones: upper, middle and lower zones and percuss comparing over exactly corresponding area of both lungs. Note areas of altered resonance.percuss anterior chest and posterior chest.

PERCUSSION NOTE:

Normal- is resonate

Dull note-over heart and liver

Stony dull - due to pleural effusion

Simply

-due to consolidation

-Lung collapse

- Fibrosis

Hypersonanat -due to air i.e. in emphysematous and also over a large air filled spaced such as pneumothorax

Vocal fremitus are transmitted sounds from the larynx to the stethoscope on the chest wall. Ask the patient to say NYAMA NYAMA

A localized reduction in breath in sounds will be associated with decreased conduction of voice sound

Whispering picztrogy sign of consolidation. If consolidation present the pt will be as if whispering loudly in your ear.

Bronchial breathing sounds as in the trachea very high pitched. (Listen to own trachea). The commonest cause of bronchial breathing is consolidation (hardening) of lungs due to pneumonia.

AUSCULATATION

The patient is asked to breath in and out through open mouth. The patient can be either sitting or lying down flat.

Concentrate on the following

1. Breath sound character and intensity

2. Added sounds nature number and position in the respiratory cycle

3. Vocal resonance intensity and quality of the conducted voice.

Place the stethoscope on all lung fields on the chest wall and compare corresponding site both anterior and posterior sides of the chest.

Breath sounds

Normal breath sounds vesicular, clear regular low pitched

Vascular sounds are diminished when:

Breathing is shallow

Thick chest wall

Should listen to own lungs!!

Abnormal breath sounds

TYPEDESCRIPTIONCAUSES

- Ronchi (rates)Wheezy or whistling1. Asthma ) Due to

2. Bronchitis ) bronchilar

3. Broncho spasm ) constriction

4. Anaphylaxis )

- Croptation (crackles)Bubbling (kuto-gota) dry chips feeling1.Pneumonia)means free fluid around

2. Pulmonary oedema) alveoli.

-Bronchia breathingHigh pitched (1st air flow)1. Consolidation in latte stage pneumonia

2. Lung fibrosis

Reduced breath sounds

i) Reduced air entry

ii) No audible sounds1. Upper airway obstruction

2. Muscular chest

3. Pleura thickering

Absent: 1. Emphsema

2. Lung collapse

3. Pleura effusion

History

Principle symptoms are:

Headache.

Vomiting.

Paralysis.

Dizziness.

General weakness (malaria)

Loss of memory (amnesia) Recto grade past loss)

- Anterograde (totally loss of memory

Seizure

Impaired vision

Headache central throbbing headache of long duration denote cerebral tumor it is usually felt in the morning and subsides in the day.

The patient should be asked about the occupance of headache, visual] symptoms, dragness, dizziness abnormalities of sense of small and taste, weakness and altered sensation in his arm] s and legs bladder disfunction and altered consciousness. Should never leave a neuropatient without asking of loss of consciousness, the long the unconsciousness the effect on the condition.

Order of CNS exam

1. Is the patient conscious? Note the level of consciousness if the patient is not fully conscious give glasgaw coma scale.

2. If patient has got uncontroable involuntary movements indicate parts of the body involved if they are absent mention that patient has no observable involuntary movement.

Types of tremors: -

i) Fire tremors

ii) Coarse tumors

3. General examination

4. Physical examination of CNS as follows.

1. Consciousness and signs of increased tracrominal pressure.

2. Kerning

3. Muscle power

4. Muscular tone

5. Tendon reflexes knee kerk

- Ankle jerk

-Babinski

-Bisceps triceps

6. Pupils

7. Sensation

8. Cranal nerves

9. Gait: of course only possible in patients who can walk

1.counciousness

If the patient in not fully conscious give the Glasgow coma scale

Glasgow coma scale (GCS)

FOR ADULT PATIENTS

1. Eye opening

Spontaneous

=4

2. Verbal response(best)

To hand command

=3

full oriented

=5

To pain (gentle pinching)=2

confused

=4

Inappropriate but

Pronunciation clear=3

None (even to pain) =

incompa...=2

NONE

Modified Glasgow coma scale

Eye opening

0= nil

1 = To pain

2 = Spontaneous

Motor response 0 = nil

1 = Extension to pain

2 =Withdraw from pain (flexion)

Verbal response 0

inappropriate

1 Appropriate

Maximum=5

Minimum=0

3. Motor response (best)

Obeys simple command =6

Localizes pain (pinpoints)=5

Avoidance response to pain (withdraws pinched limb)=4

Flexion to pain (decorticate pasture)

=3

Extension to pain (body rigid with limbs extended donates the decerebrated posture

=2

None

=1

Maximum

=15

Minimum

=3

A score of 7 and below is indicative of severe cerebral injury.

MODIFIED GLASGOW COMA SCALE FOR PAEDIATRIC PATIENTS

Note: GCS scoring is mandatory for any patient with a reduced level of consciousness REGARDNESS of cause.

The scoring should be done WHENEVER the patient is reviewed by the anaesthetist.this is because it is probably the most object evaluation of cerebral functein.

Cardial signs of ICP

1.level of consciousness

2.Papilleodema

3.Neurological deficit

4.Bradycardia

5.Pupil dilatation

6.Blood pressure

SIGNS OF MENINGEAL IRRITATION2.kerning~s sign

With both knee and hip joints fully flexed the examiner. the thigh fully against the abdomen then attempt to straighten the knee. If positive resistance of the meninges.

Neck flex and extend the neck or ask the patient to flex and extend if conscious, this should be done first before kerning.

..Kerning is due to

1. Irritation of meninges

2. Meningitis

3. Meningism

4. Subdural hematoma

Patient feels pain due to the pull on the meninges

3.Muscle power

Cooperation of the patient is sought and the power recorded as follows: -

0-no observable movement

1- Visible or palpable contraction without active movement (flicker toe or thumb)

2- Movement with gravity eliminated

3- Movement against gravity

4- Movement against gravity plus resistance

5- Normal power

Relate your findings to myotome of the human body.

4.muscle tone

The examiner asks the patient to relax completely and tone is tested by flexion and extension of the limbs. The tone is noted if normal, decreased or increased.

Spasticity is maximal resistance at beginning of the movement.

Rigidity is continued resistance throughout the range of movement

Hypertonia is in Parkinson disease

Flaccid no tone at all

Compare the musculature of the muscle in all limbs

Tendon reflexes

Tendon reflexes are elicited by applying sudden stretch to the muscle, the muscle stretch produced by a sharp tap from a tendon hammer near the insertion of the tendon.

The biceps)

The triceps)

Knee jerk) are tested

Ankle jerk)

Planater reflex)

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