The Complete Guide to Clinical History and Exam in Surgery

Introduction: What is a Clinical History, Why is it Important, and How is it Done?

Clinical history is the story of a patient’s illness from their perspective. It is important because it provides information about the patient’s health and medical history which will help the surgeon diagnose and treat them.

Clinical history can be made in different ways. Still, most commonly a health care provider will ask questions about the patient’s medical history and symptoms, perform a physical examination, take a blood sample to test for diseases, and order laboratory tests to find out more.

How to Conduct a Surgical Examination

A surgical examination is a physical examination of the abdomen, pelvis, and/or rectum. It can be used to diagnose diseases such as appendicitis or cancer.

A surgical examination is performed by a doctor and is typically the first step in diagnosing abdominal pain or discomfort. The doctor will feel the abdomen for areas of tenderness, masses, or abnormal lumps that may indicate an underlying problem. They will also perform a rectal exam and pelvic exam to check for abnormalities in those areas.

The doctor will usually do a surgical examination after taking your medical history and performing a physical exam to rule out other possible causes of abdominal pain or discomfort.

In the following sections, we will see various history and various examinations

History taking you can learn here.

Neck examination

The neck examination is a surgical examination that is used to check the lymph nodes and other structures in the neck. This examination can be done as an outpatient procedure or it can be performed as part of a surgical procedure.

The neck examination is performed by checking for swelling, redness, or any visible masses in the lymph nodes. You will also look for enlarged lymph nodes, which may indicate a problem with the immune system. You will also examine the thyroid gland, which is located in front of the larynx and trachea. You will also feel for enlarged blood vessels and then use a stethoscope to listen to the heart and lungs.

Here are a few videos you can use to excel in Neck examination in clinics

Breast Examination

breast examination is a surgical examination of the breasts. It is usually done to check for abnormalities such as lumps, discharge, or nipple discharge. This examination can also be done to check whether the lymph nodes are enlarged in case of cancer.

A breast examination can be done by a physician or a nurse practitioner and takes about 10 minutes.

The following video is helpful to understand the examination –

Abdominal Examination

The abdominal examination is a physical examination of the abdomen. It is usually done by a physician, nurse practitioner, or other qualified healthcare professional.

The abdominal examination may be done as part of a routine check-up, to screen for signs of disease, or to diagnose specific problems. The physician will ask the patient about any pain or discomfort in the abdomen and will then do an exam to check for signs of disease. This can include palpating (touching) and pressing on areas to feel for lumps or tenderness as well as listening with a stethoscope for bowel sounds and bowel movements.

Digital Rectal Examination

A digital rectal examination is an examination of the rectum and lower colon using one or more fingers introduced into the anus. It is usually done to check for signs of colorectal cancer, but may also be done to check for signs of other diseases.

The examination is performed by inserting a lubricated finger into the anus and carefully examining the anal canal and rectum. The examiner may feel the prostate gland with the fingers. They may also examine lymph nodes in the area around the anus and rectum by pressing gently on them with their finger.

Peripheral Vascular Examination

A peripheral vascular examination is a surgical examination of the veins and arteries in the arms, legs, and feet. This type of examination is used to detect any abnormalities.

The procedure is done by a surgeon, but can also be done by a physician or podiatrist. A patient may have this examination if they are having symptoms that suggest there may be an abnormality or if they are at risk for developing an abnormal condition.

Diabetic Foot Examination

Diabetic foot examination is a surgical procedure that is used to examine the lymph nodes and the anatomy of the feet.

A diabetic foot examination involves looking for any ulcers or sores on the feet and checking for any abnormalities in the skin. After examining the feet, doctors will also check for any abnormalities in the lymph nodes.

A diabetic foot examination is usually done by a podiatrist or a surgeon. It should be done every six months in order to identify any changes in your condition.