Common surgical symptoms

Pain

Pain anywhere should have the same features elicited. These can be summarized by the acronym SOCRATES.

• Site. Where is the pain, is it localized, in a region. or generalized?
• Onset. Gradual, rapid, or sudden? Intermittent or constant?
• Character. Sharp, stabbing, dull, aching, tight, sore?
• Radiation. Does it spread to other areas? (From loin to groin in ureteric pain, to shoulder tip in diaphragmatic irritation, to back in retroperitoneal pain, to jaw and neck in myocardial pain.)
• Associated symptoms. Nausea, vomiting, dysuria, jaundice?
• Timing. Does it occur at any particular time?
• Exacerbating or relieving factors. Worse with deep breathing, moving, or coughing suggests irritation of somatic nerves either in the pleura or peritoneum; relief with hot water bottles suggests deep inflammatory or infiltrative pain.
• Surgical history. Does the pain relate to surgical interventions?

Dyspepsia

(epigastric discomfort or pain, usually after eating).
What is the frequency?
Is it always precipitated by food or is it spontaneous in onset?
Is there relief from anything, especially milky drinks or food?
Is it positional?

Dysphagia

(pain or difficulty during swallowing).
Is the symptom new or longstanding?
Is it rapidly worsening or relatively constant?
Is it worse with solid food or fluids? (Worse with fluids suggests a motility problem rather than a stenosis.)
Can it be relieved by anything, e.g. warm drinks?
Can the patient point to a level of hold-up on the surface (usually related to the sternum)? This often accurately relates to the level of an obstructing lesion.
Is it associated with spluttering? (suggests tracheo-oesophageal fistula).

Acid reflux

(bitter or acidic tasting fluid in the pharynx or mouth).
How frequently?
What colour is it? (Green suggests bile, whereas white suggests only stomach contents).
When does it occur (lying only, on bending, spontaneously when standing)?
Is it associated with coughing?

Haematemesis

(the presence of blood in vomit).
What colour is the blood (dark red-brown coffee grounds is old or small-volume stomach bleeding; dark red may be venous from the oesophagus; bright red is arterial and often from major gastric or duodenal arterial bleeding).
What volume has occurred over what period?
Did the blood appear with the initial vomits or only after a period of prolonged vomiting (suggests a traumatic oesophageal cause).

Abdominal distension

Symmetrical distension suggests one of the cause (fluid ascites, flatus due to ileus or obstruction, fetus of pregnancy, fat, or a flipping big mass).
Asymmetrical distension suggests a localized mass.
What is the time course?
Does it vary?
It is changed by vomiting, passing stool/flatus?

Change in bowel habit

May be change in frequency, or looser or more constipated stools. Increased frequency and looser stools suggests a pathological cause.
Is it a persistent or transient?
Are there associated symptoms?
Is it variable?

Frequency and urgency of defecation

New urgency of defecation is almost always pathological.
What is the degree of urgency?
how long can the patient delay?
Is there associated discomfort?
What is passed?
Is the stool normal?

Bleeding per rectum

What colour is the blood?
Is it pink-red and only on the paper when wiping?
Does it splash in the pan? (Both suggest a case from the anal canal.)
Is it bright red on the surface of the stool? (Suggests a lower rectal cause.)
Is the blood darker, with clots or marbled into the stools? (Suggests a colonic cause.)
Is the blood fully mixed with the stool or altered? (Suggests a proximal colonic cause.)

Tenesmus

(desire to pass stools with either no result or incomplete satisfaction of defecation). Suggests rectal pathology.

Jaundice

(yellow discoloration due to hyperbilirubinaemia; ).
How quickly did the jaundice develop?
Is there associated pruritus?
Are there any symptoms of pain, fever, or malaise? (Suggests infection.)

Haemoptysis

(the presence of blood in expectorate).
What colour is the blood? (Light pink froth suggests pulmonary oedema.)
Are there clots or dark blood? (Infection or endobronchial lesion.)
How much blood? Moderate bleeds quickly threaten airways: get help quickly.

Dyspnoea

(difficulty in or increased awareness of breathing).
When does the dyspnoea occur?
quantify the amount of effort. Is it positional?

• Orthopnoea is difficulty in breathing that occurs on lying flat: quantify it by asking how many pillows the patient needs at night to remain symptom-free.
• Paroxysmal nocturnal dyspnoea is intermittent breathless at night. Both orthopnoea and paroxysmal nocturnal dyspnoea suggest cardiac failure.

Claudication

(the presence of pain in the muscles of the calf, thigh, or buttock precipitated by exercise and relieved by rest).
After what degree of exercise does the pain occur (both distance on the flat and gradients)?
How quickly is the pain relieved by rest?

Rest pain

(pain in a limb at rest without significant exercise)
How long has the pain been present?
Is it intermittent?
Does it occur mainly at night?
Is it relieved by dependency of the limb involved?