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Surgery -medical history and case presentation
Fundamentals
Begin with the individual's name, age, occupation, and the mode of presentation, such as Accident and Emergency (A&E), general practitioner referral, or admission from a clinic.
• Address all key aspects of the comprehensive medical history, as outlined below. Chief complaint This is a concise statement of the patient's primary symptoms, such as "right iliac fossa (RIF) pain," "abdominal pain and vomiting," or "bleeding per rectum (PR)."
• Do not record a diagnosis here in emergency admissions (e.g. ischemia leg). The referral diagnosis may prove to be incorrect. In elective admissions, it is appropriate to state, for example, 'elective admission for anterior resection for rectal cancer.' Chronology of presenting complaint This is a comprehensive delineation or examination of the primary symptom(s) and must encompass the pertinent systems inquiry
. • Begin with pertinent historical context to provide the framework for the presenting issue.
• Prioritize significant positives, such as "right-sided lower abdominal pain, exacerbated by movement and coughing, accompanied by anorexia."
• Include pertinent negatives, such as "no vomiting, no rectal bleeding." Clearly delineate the sequence of events. In a complex history or with numerous symptoms, utilize titles such as 'Previous Episodes/Operations for This Issue,' 'Current Episode,' and 'Results of Investigations.' Systematically summarize the findings of prior investigations: hematological analyses, microbiological assessments, histopathological examinations, radiological evaluations, and specialist diagnostic procedures. Previous medical history
• Enumerate particular medical diagnoses. • Include pertinent negatives, as it is prudent to inquire about cardiorespiratory and renal conditions that influence the patient's operative and anesthetic risk, such as ischemic heart disease (IHD), heart failure, chronic obstructive pulmonary disease (COPD), and renal impairment, in addition to those specific to the presenting complaint, such as neurological diagnoses in neurosurgery or ear, nose, and throat (ENT) conditions, as well as risk factors for atherosclerosis in vascular surgery. •
• Enumerate and date all prior operations. Inquire whether any prior complications associated with anaesthesia. Methodical investigation This is crucial, however frequently overlooked—it is essential to exclude alternative diagnoses (e.g., gynaecological etiology for lower abdomen pain) and to evaluate the patient's surgical and anaesthetic risk
. • Cardiovascular. Chest pain, exertional dyspnoea, orthopnoea, nocturnal dyspnoea, palpitations, edema of the ankles, strokes, transient ischemic attacks (TIAs), claudication.
• Respiratory. Dyspnea, cough, sputum production, wheezing, hemoptysis.
• Gastrointestinal. Anorexia, alteration in appetite, weight reduction (specify the amount and duration).
• Genitourinary (GU). Sexual activity, dyspareunia (intercourse-related pain), abnormal discharge, and last menstrual cycle (all female patients). Neurological. Three Fs: fits; fainting; humorous episodes. Nil by mouth (NBM) duration: what was the last time they consumed food or beverages? for urgent admissions Societal history Inquire regarding the individual responsible for the patient's care. Do they require assistance with mobility and/or activities of daily living?
• History of smoking and alcohol consumption. •
profession.
Two Recommendations for Case Presentation
• Engage in practice. Each instance represents a potential presentation to an individual. Consistently establish the context appropriately. Commence with the individual's name, age, occupation (if elderly, include general fitness and independence), pertinent medical history, mode of referral, and presenting complaint, e.g., ‘78-year-old male, typically fit and well, with a previous history of open anterior resection for rectal adenocarcinoma, presents with a 3-day history of abdominal pain and vomiting.’ • Adhere to a chronological order. Commence with the onset of any pertinent prodrome or accompanying symptoms, as they are likely to constitute a significant aspect of the presenting history, e.g., 'He was in good health until... when he began suffering... the current symptoms commenced...
• Summarize the past medical history succinctly. Only elaborate on aspects that you genuinely believe may be pertinent to the diagnosis or management. •
• Initially, summarize the overall look and vital signs. Present the most critical findings initially, adhering to a methodical approach, such as 'upon examination . . . , during palpation . . . , upon percussion . . . , and by auscultation.'
• Concisely outline further systemic observations. Elaborate on them if they are directly pertinent to the diagnosis or treatment.
• Ultimately, condense and integrate. Attempt to categorize symptoms and indications into clinical patterns that inform the proposed diagnoses or differential diagnosis list.
• Be prepared to discuss which diagnostic or additional evaluation tests may be required.
Fundamentals
Begin with the individual's name, age, occupation, and the mode of presentation, such as Accident and Emergency (A&E), general practitioner referral, or admission from a clinic.
• Address all key aspects of the comprehensive medical history, as outlined below. Chief complaint This is a concise statement of the patient's primary symptoms, such as "right iliac fossa (RIF) pain," "abdominal pain and vomiting," or "bleeding per rectum (PR)."
• Do not record a diagnosis here in emergency admissions (e.g. ischemia leg). The referral diagnosis may prove to be incorrect. In elective admissions, it is appropriate to state, for example, 'elective admission for anterior resection for rectal cancer.' Chronology of presenting complaint This is a comprehensive delineation or examination of the primary symptom(s) and must encompass the pertinent systems inquiry
. • Begin with pertinent historical context to provide the framework for the presenting issue.
• Prioritize significant positives, such as "right-sided lower abdominal pain, exacerbated by movement and coughing, accompanied by anorexia."
• Include pertinent negatives, such as "no vomiting, no rectal bleeding." Clearly delineate the sequence of events. In a complex history or with numerous symptoms, utilize titles such as 'Previous Episodes/Operations for This Issue,' 'Current Episode,' and 'Results of Investigations.' Systematically summarize the findings of prior investigations: hematological analyses, microbiological assessments, histopathological examinations, radiological evaluations, and specialist diagnostic procedures. Previous medical history
• Enumerate particular medical diagnoses. • Include pertinent negatives, as it is prudent to inquire about cardiorespiratory and renal conditions that influence the patient's operative and anesthetic risk, such as ischemic heart disease (IHD), heart failure, chronic obstructive pulmonary disease (COPD), and renal impairment, in addition to those specific to the presenting complaint, such as neurological diagnoses in neurosurgery or ear, nose, and throat (ENT) conditions, as well as risk factors for atherosclerosis in vascular surgery. •
• Enumerate and date all prior operations. Inquire whether any prior complications associated with anaesthesia. Methodical investigation This is crucial, however frequently overlooked—it is essential to exclude alternative diagnoses (e.g., gynaecological etiology for lower abdomen pain) and to evaluate the patient's surgical and anaesthetic risk
. • Cardiovascular. Chest pain, exertional dyspnoea, orthopnoea, nocturnal dyspnoea, palpitations, edema of the ankles, strokes, transient ischemic attacks (TIAs), claudication.
• Respiratory. Dyspnea, cough, sputum production, wheezing, hemoptysis.
• Gastrointestinal. Anorexia, alteration in appetite, weight reduction (specify the amount and duration).
• Genitourinary (GU). Sexual activity, dyspareunia (intercourse-related pain), abnormal discharge, and last menstrual cycle (all female patients). Neurological. Three Fs: fits; fainting; humorous episodes. Nil by mouth (NBM) duration: what was the last time they consumed food or beverages? for urgent admissions Societal history Inquire regarding the individual responsible for the patient's care. Do they require assistance with mobility and/or activities of daily living?
• History of smoking and alcohol consumption. •
profession.
Two Recommendations for Case Presentation
• Engage in practice. Each instance represents a potential presentation to an individual. Consistently establish the context appropriately. Commence with the individual's name, age, occupation (if elderly, include general fitness and independence), pertinent medical history, mode of referral, and presenting complaint, e.g., ‘78-year-old male, typically fit and well, with a previous history of open anterior resection for rectal adenocarcinoma, presents with a 3-day history of abdominal pain and vomiting.’ • Adhere to a chronological order. Commence with the onset of any pertinent prodrome or accompanying symptoms, as they are likely to constitute a significant aspect of the presenting history, e.g., 'He was in good health until... when he began suffering... the current symptoms commenced...
• Summarize the past medical history succinctly. Only elaborate on aspects that you genuinely believe may be pertinent to the diagnosis or management. •
• Initially, summarize the overall look and vital signs. Present the most critical findings initially, adhering to a methodical approach, such as 'upon examination . . . , during palpation . . . , upon percussion . . . , and by auscultation.'
• Concisely outline further systemic observations. Elaborate on them if they are directly pertinent to the diagnosis or treatment.
• Ultimately, condense and integrate. Attempt to categorize symptoms and indications into clinical patterns that inform the proposed diagnoses or differential diagnosis list.
• Be prepared to discuss which diagnostic or additional evaluation tests may be required.
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