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) !ge because it directly influences many aspects of anaesthetic
management of patients.
c) "x this too under special circumstances e.g. in pregnancy does influence
anaesthesia.
d) #hysical address geography$ environment significantly influence disease
pattern e.g. sic%le cells anaemia is most prevalent &asese of all districts in
'ganda.
e) (ccupation this may predispose people to certain specific occupational
ha)ards.
f) *eligion as% for beliefs especially regarding blood transfusion.
. History o! "resentin# $o%"laint&s': -
a) +arefully write down the complaint(s) in chronological order.
b) ,uration of complaint(s)
c) -ode of on set acute or gradual.
d) .evere and aggravating factor(s)
e) "ffect(s) on patient/s physical activity.
(. Past anaesthesia an) s*r#i$al history: -
a) 0hen1
b) 0here1
c) !naesthesia technique and surgical or any other procedure for which the
anaesthetic was given.
d) 2inal outcome and any significant event(s)
+. Past %e)i$al history: -
a) !ny past hospital admission(s) and reason(s).
b) &nown medical condition(s) and current drug therapy.
,. History o! aller#y: -
a) !llergic conditions e.g. bronchial asthma.
b) #revious allergy to anaesthetics.
3
-. .a%ily history: -
a) 4oth parents alive1 If not cause of death1
b) 2amilial disease e.g. sic%le cell disease (.+,).
5. So$ial history: 6 especially tobacco smo%ing and alcohol inta%e.
PHYSI/AL E0A1INATION
GENERAL 7To any patient examined mention general state of health i.e.
(i) 8eneral condition 6
68ood
6#oor
(ii) Hydration 6adequate or dehydrated
(iii) Nutrition 6malnourished or well nourished.
(iv) !naemia ) these should always follow each other
9aundice )
(v) Temperature
(vi) (edema 6legs
62ace
6.acrum
(vii) +yanosis 6a) central 7tongue and con:unctivae 7denote hypoxia
6b) peripheral is indicative of impaired blood supply to the
affected parts.
.ome specific signs.
,epending on the system involved the following are also mentioned.
(i) 2inger clubbing in +;. is caused by subacute bacterial endocaditis in
respiratory system it is caused by suppurative lung diseases.
(ii) <ympadenopathy 7 reticular endothelial system is involved.
SYSTE1I/ E0A1INATION: -
3. !lways start with system with significant or positive findings where
pathology is detected clinically.
=. +;. the cardiovascular system.
>. *. the respiratory system.
?. +N. the central Nervous .ystem.
@. 8IT the 8astrointestinal .ystem A abd exam
B. -usculos%eltal system.
5. <ocal examination for locali)ed lesions.
=
THE 2ASI/ PRIN/IPLES O. 1EDI/AL PHYSI/AL E0A1INATION.
These almost entirely apply to all aspects and should be performed in the following order
3
st
inspection or observation.
=
nd
palpation.
>
rd
percussion.
?
th
auscultation.
In all these ensure -INI-'- inconvenience to the patient. Inflicting or aggravating
pain is definitely more than sadism and may render the patient unco6operative and hence
lose confidence in you.
/ARDIO3AS/4LAR SYSTE1 &/3S'

History
#rinciple symptoms are 6
(i) ,yspnoea 7 (exertional)
(ii) *etrosternal pain.
(iii) (edema
(iv) #alpitations
(v) 2atigue
(vi) *esting pulse rate and rhythm
(vii) *esting blood pressure
OTHOPNEA 7 dyspoea in supine position that is promptly relieved by sitting.
PARO0YS1AL NO/T4RNAL DYSPOEA 7 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.
/HEST PAIN
(ccurs in the following 6
3. Infections !cute !nd +hronic.
=. !ngina #ectoris
>. -yocardial Infraction
?. #ericardial "ffusion (r Tamponade
@. #ulmonary "mbolusion (r Infarction
!s% severityC locationC radiationD duration and conditions that precipitateC aggravate or
relief it.
>
PALPITATIONS.
This is said to occur when the patient is conscious of his $ her heart beat.
#atient may complain of rapid forceful or irregular heart beat.
+auses of palpitation areD 6
!naemiaC thyrotoxicosisC feverC anxietyC arrhythmiasC and neurosis.
OEDE1A
(edema due to right failure appears first on an%les and lower legs in ambulatory patients
and over the sacrum in bed6ridden patients. There are numerous causes of oedemaC the
commonest beingD 6
6 *enenal failure.
6 <iver failure
6 -alnutrition
6 2ilariasis.
6 ;enous thrombosis
6 -alnutrition (severe)
6 #remenstrual fluid retention.
6 #rolonged sitting or standing
.ATIG4E
"asy fatigability relieved by rest is common.
(ther causes of fatigue 6
(i) +hronic infection
(ii) !naemia
(iii) -etabolic disorder
(iv) "ndocrine disorder
(v) -alignancy
(vi) .edative drugs
,uring examination of +;. li%e in all other aspects the ?// golden E/ principled apply
;IF6
(i) Inspection
(ii) #alpation
(iii) #ercussion
(iv) !uscalitation
?
=. !lways stand at *I8HT side of patient.
&a' INSPE/TION 5 O2SER3ATION: -
Note position of the patient in bed e.g.C Gpropped up in bed.
&6' PALPATION
I 7 P4LSE radialC pulse 7 note 6 *ate
6;olume
6*hythm
6 (ther peripheral pulse note their presence or absence
Note 6whenever examining or monitoring patientsC thin% of increased or decreased in the
pulse rate.
#ulse rate in an adult ranges from BH beats to 3HH beats I BH is bradycardia J 3HH is
tachycardia.
+auses of bradycardia under anaesthesiaD
3.Hypoxia
=. ,rugs 7 e.g. suxamethonium.
>.para sympathetic stimulation vaso 7 parasympathetic
?. Increased intracranial pressure (I+#)
@.heart bloc%
B. Hypothyroidism
5.severe liver disease
K. 4eta bloc%ers.
II 2LOOD PRESS4RE: -
"nsure use of correct si)e of cuff.
0henever measuring blood pressureC always thin% of cause of hypotension or
hypertension whichever is the case.
III /ENTRAL 3ENO4S PRESS4RE &/3P'.
"xamine the nec% 7 chec% :ugular venous pressureD must distinguish between (9;#)
;I. arterial pulsations 6
6 "ngorgement of nec% veins denote raised central venous pressure (+;#)
<oo% for the HI8H".T point of pulsation of the right :ugular vein.
@
I3 E0A1INATION O. THE PRAE/ORDI41: -
Inspect note if pulsations can be seen. Then feel for the apex beat which in normal
#erson is at the @
th
intercostals space with the palm of the hand.
The !pex beat 7 is the point of maximum cardiac pulsation.
(i) #alpable thrill6indicates a loud murmur if not felt mention that no thrill felt on
palpation.
(ii) Heaving apex beat 7 when examining finger is placed on the apex beat its
thrust forwards is sustained 7 finger can easily moves up and stays there for an
appreciable.
(iii) ,iffuse apex beat
In very rare instances the apex beat may not be palpable .it is then described
as being diffuse.
LO/ATION O. APE0 2EAT: 6
To locate the second inter space 7feel for angle of <ouis. -ove a finger from the thyroid
notch till when the finger reaches a bump A angle of <ouis.
The =
nd
inter costal space is :ust opposite angle of <ouis.
Thereafter give the "L!+T location of the apex in relation of the -I, M +<!;I+'<!*
line (-+<) i.e. medial or lateral to -+<.
(c ) A4S/ALITATION & TO PROD4/E ILL4STRATION LATER ON .OR
AREAS O. A4S/4LTATION'
2our areas are auscultated.
-itral valve at apex
Tricuspid valve :ust at left ximphi 7 sternum (lower end of sternum)
!ortic valve at the *I8HT =
nd
inter costal spaceC immediately next to the sternum.
#ulmonary valve <"2T =
nd
interspace immediately next to the sternum.
1. NOR1AL HEART SO4NDS: -
2irst listen to the heart sound I N II.
3
st
heart sound is due to closure of mitral N cuspid.
=
nd
heart sound is due to closure of aortic N pulmonary valves.
,etermine if the is any !4N(*-!< sound (.) and relate it $them to the cardiac cyde 7
systole or diastole.
B
. A2NOR1AL OR ADDED HEART SO4NDS
TH" -'*-'*. 6
These are E blowing E sounds that you may hear in addition to the normal
heart sounds as already described.
There are two types of murmurs6
(i) 2unctional murmurs
(ii) #athological murmurs
2unctional murmurs
(i) They are soft
(ii) They are audible over all the areas of cardiac auscalitation
(iii) They are always systolic
#athological murmurs
(i) They are loud (harsh)
(ii) They are transmittable
(iii) (ften diastolic
2unctional murmurs are due to
(i) !naemia
(ii) #regnancy
(iii) Thyrotoxicosis
(iv) +ommon in children
#athological murmurs are due to valvular disease.
S4GGESTED /ONSTANT PRA/TI/E:-
<isten to own heart sound to get accustomed to the normal heart sounds
which have been de?scribed as O<'4P (the first $systolic heart sound ) and
O,'4P ( for second $diastolic heart sound)
SITES .OR PALPATION O. PERIPHERAL P4LSES:-
3. *adial artery at the wrist
=. 4rachial artery6cubital fossa
>. 2emoral artery 7 in the groin
?. #oplitial artery 7 %nee :oint
@. #osterior tibia artery 7 at an%le
B. ,orsalis pedis artery 7 dorsum of foot
5
RESPIRATORY SYSTE1
1. HISTORY
The principal symptoms of respiratory system disease are coughC chest painC dyspQ
whee)e and striclor. !lso as% for production and colour of sputumC presence of
hemoptysis and cyanosis.
/O4GH
Is the most common symptom of respiratory system disease a detailed inorrogation must
be made. (ther causes of cough other respiratory system disease are
3. +ongestive heart failure
=. -itra valve disease
>. (titis media
The cough may be dryC irritatingC paroxysmalC productive or significantly suppressed by
pain.
SP4T41
-ay be mucoidC grey white or clear purulent (yellow or green) or mucopurulent
Hae%o"hysis
-ay range in amount from slight blood stained to massive hemorrhage.
/HEST PAIN
#ain is usually due to involvement of the pleura pariental pleura) characteristically
unilateral aggravated by coughC deep breathing or snee)ing. Involvement of chest wall
pain is usually accompanied by tenderness and pain is more constant and less affected by
breathing and coughing.
Dys"rosa
,ysprosa is present all the time unli%e dysprosa of heart disease which is external and
relieved by rest and pasture related.
8hee9e (musical sound)
Is due to obstruction of small airways heard on expiration. It is accompanied by dysprosa.
K
STRIDOR (crowing sound)
#roduced in larynx or trachea during inspiration and is aggravated by coughing. It is due
to obstruction of large air way (larynx and trachea)
PHYSI/AL E0A1INATION OR RESPIRATORY SYSTE1
Ins"e$tion
i) <oo% features suggestive of difficult laryngoscopy and
tracheal inhibited.
ii) +ount respiratory rate at foot of bed first
iii) +hest configuration
iv) -ovement6666 is it uniform1 *elate chest to abdominal
movement
v) "xpansion compare left to right side of the chest
vi) ;entilation 6666 hyperventilation
66666 Hypoventilation
+hest deformities
&yphosis 7 forward bending of the spine
.coliosis 6QQ. +urved laterally or lateral bending
#eageon chest 7 indicative of chronic obstructive long disease
1o:e%ent
#aradoxical 7 on breathing in there is in drawing of a portion of the chest wall it occurs in
patients
6 0ith fracture of a series of QQ.
6 !irway obstruction
6 #aralysis of diaphragm
Pal"ation
3. <ocation of trachea place the mid finger at the suprasQQ 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.
+onditions where it can get displaced are
6 #leural effusion
6 .everal empyema
6 Tension pneumothrorax
6 <ocal conditions e.g. goitrem enlarged lymph node in the nec%
6 <ung collapse and lung fibrosis
6 +onsolidation netral
R
N(T"D wor% out conditions in which the trachea is displaced towards ;IF away from the
site of the lesion shift of trachea corresponds to shift of the mediastinum.
=.palpation of entire chest
superficial palpation followed by deep palpation.
2irst palpate lightly and gently may feel QQQ.spongy feel as in sub
QQQQQQ.then deep palpation for any lamps C do not hurt the patient.
/hest e;"ansion
#lace your hands around the chest at xymphsternum thumbs together and as% the patient
to ta%e a deep breath note the movement if it is even or not.
+auses of reduced chest expansion
6 #neumonia 7 due to pleurisy
6 #neumothorax
6 #leural effusion
6 "mphysema
PER/4SSION
*ight handed person places the left hand on the chest wallC palm downwards with the
fingers slightly separated so that the second phalanx of the middle finger is over the
QQ.to be percussed. #ass the finger firmly against the chest wall preferably along the
intercostals space.
The second phantax of muddle finger is struc% 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 :oint.
,uring percussion divide the lungs into )ones upperC middle and lower )ones and
percuss comparing over exactly corresponding area of both lungs. Note areas of altered
resonance.percuss anterior chest and posterior chest.
PER/4SSION NOTE:
Normal 6 is resonate
,ull note 6over heart and liver
.tony dull 6 due to pleural effusion
.imply 6due to consolidation
6<ung collapse
6 2ibrosis
Hypersonanat 6due to air i.e. in emphysematous and also over a large air filled spaced
such as pneumothorax
3H
;ocal fremitus 7 are transmitted sounds from the larynx to the stethoscope on the chest
wall. !s% the patient to say < NYA1A NYA1A=
6 ! locali)ed reduction in breath in sounds will be associated with decreased
conduction of voice sound
6 0hispering pic)trogy 7 sign of consolidation. If consolidation present the pt will
be as if whispering loudly in your ear.
6 4ronchial breathing 7 sounds as in the trachea very high pitched. (<isten to own
trachea). The commonest cause of bronchial breathing is consolidation
(hardening) of lungs due to pneumonia.
A4S/4LATATION
The patient is as%ed to breath in and out through open mouth. The patient can be either
sitting or lying down flat.
+oncentrate on the following
3. 4reath sound 7 character and intensity
=. !dded sounds 7 nature number and position in the respiratory
cycle
>. ;ocal resonance 7 intensity and quality of the conducted voice.
#lace the stethoscope on all lung fields on the chest wall and compare corresponding site
both anterior and posterior sides of the chest.
4reath sounds
Normal breath sounds 7 vesicularC clear regular low pitched
;ascular sounds are diminished when
6 4reathing is shallow
6 Thic% chest wall
6 .hould listen to own lungsSS
33
A6nor%al 6reath so*n)s
TYPE DES/RIPTION /A4SES
6 *onchi (rates) 0hee)y or whistling 3. !sthma ) ,ue to
=. 4ronchitis ) bronchilar
>. 4roncho spasm )
constriction
?. !naphylaxis )
6 +roptation (crac%les) 4ubbling (O%uto6
gotaP) dry chips
feeling
3.#neumonia)means free fluid
around
=. #ulmonary oedema) alveoli.
64ronchia breathing High pitched (3
st
air
flow)
3. +onsolidation in latte stage
pneumonia
=. <ung fibrosis
6 *educed breath
sounds
i) *educed
air entry
ii) No
audible
sounds
3. 'pper airway obstruction
=. -uscular chest
>. #leura thic%ering
!bsent 3. "mphsema
=. <ung collapse
>. #leura effusion
History
#rinciple symptoms are
6 Headache.
6 ;omiting.
6 #aralysis.
6 ,i))iness.
6 8eneral wea%ness (malaria)
6 <oss of memory (amnesia) 7 *ecto grade past loss)
6 !nterograde (totally loss of memory
6 .ei)ure
6 Impaired vision
Headache 7 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 as%ed about the occupance of headacheC visualT symptomsC
dragnessC di))iness abnormalities of sense of small and tasteC wea%ness and altered
sensation in his armT s and legs bladder disfunction and altered consciousness. .hould
never leave a neuropatient without as%ing of loss of consciousnessC the long the
unconsciousness the effect on the condition.
3=
Or)er o! /NS e;a%
3. Is the patient conscious1 Note the level of consciousness if the patient is not fully
conscious give glasgaw coma scale.
=. 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 6
i) 2ire tremors
ii) +oarse tumors
>. 8eneral examination
?. #hysical examination of +N. as follows.
3. +onsciousness and signs of increased tracrominal pressure.
=. &erning
>. -uscle power
?. -uscular tone
@. Tendon reflexes 7%nee %er%
6 !n%le :er%
64abins%i
64isceps triceps
B. #upils
5. .ensation
K. +ranal nerves
R. 8ait of course only possible in patients who can wal%
3.counciousness
If the patient in not fully conscious give the 8lasgow coma scale
Glas#o> $o%a s$ale &G/S'
2(* !,'<T #!TI"NT.
3. "ye opening
.pontaneous A? =. ;erbal response (best)
To hand command A> full oriented A@
To pain (gentle pinching) A= confused A?
Inappropriate but
#ronunciation clear A>
None (even to pain) A incompaQQQQQ...A=
N(N"
-odified 8lasgow coma scale
"ye opening H A nil
3 A To pain
3>
= A .pontaneous
-otor response H A nil
3 A "xtension to pain
= A0ithdraw from pain (flexion)
;erbal response H inappropriate
3 !ppropriate
-aximum A@
-inimum AH
>. -otor response (best)
(beys simple command AB
<ocali)es pain (pinpoints) A@
!voidance response to pain (withdraws pinched limb) A?
2lexion to pain (decorticate pasture) A>
"xtension to pain (body rigid with limbs extended donates the decerebrated
posture A=
None A3
-aximum A3@
-inimum A>
! score of 5 and below is indicative of severe cerebral in:ury.
1ODI.IED GLASGO8 /O1A S/ALE .OR PAEDIATRI/ PATIENTS
Note 8+. scoring is mandatory for any patient with a reduced level of consciousness
*"8!*,N".. of cause.
The scoring should be done 0H"N";"* the patient is reviewed by the anaesthetist.this
is because it is probably the most ob:ect evaluation of cerebral functein.
/ar)ial si#ns o! I/P
3.level of consciousness
=.#apilleodema
>.Neurological deficit
?.4radycardia
@.#upil dilatation
B.4lood pressure
SIGNS O. 1ENINGEAL IRRITATION
=.%erningUs sign
0ith both %nee and hip :oints fully flexed the examinerQQ. the thigh fully against the
abdomen then attempt to straighten the %nee. If positive resistance of the meninges.
Nec% 7 flex and extend the nec% or as% the patient to flex and extend if consciousC this
should be done first before %erning.
3?
QQQQQQ..&erning is due to
3. Irritation of meninges
=. -eningitis
>. -eningism
?. .ubdural hematoma
#atient feels pain due to the pull on the meninges
>.-uscle power
+ooperation of the patient is sought and the power recorded as follows 6
H6no observable movement
36 ;isible or palpable contraction without active movement
(flic%er toe or thumb)
=6 -ovement with gravity eliminated
>6 -ovement against gravity
?6 -ovement against gravity plus resistance
@6 Normal power
*elate your findings to myotome of the human body.
?.muscle tone
The examiner as%s the patient to relax completely and tone is tested by flexion and
extension of the limbs. The tone is noted if normalC decreased or increased.
.pasticity 7is maximal resistance at beginning of the movement.
*igidity 7 is continued resistance throughout the range of movement
Hypertonia is in #ar%inson disease
2laccid 7 no tone at all
+ompare the musculature of the muscle in all limbs
Tendon reflexes
Tendon reflexes are elicited by applying sudden stretch to the muscleC the muscle stretch
produced by a sharp tap from a tendon hammer near the insertion of the tendon.
The biceps )
The triceps )
&nee :er% ) are tested
!n%le :er% )
#lanater reflex)
3@