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CASE HISTORY 
 Dr. Murali. U. M.S ; M.B.A. 
Prof. of Surgery 
D Y Patil Medical College 
Mauritius.
Definition 
 A case history is defined as a planned 
professional conversation that enables the 
patient to communicate his/her symptoms, 
feelings and fears to the clinician so as to 
obtain an insight into the nature of patient’s 
illness & his/her attitude towards them.
Objectives 
 To establish a positive professional relationship. 
 To provide the clinician with information 
concerning the patient’s past medical / surgical & 
personal history. 
 To provide the clinician with the information that 
may be necessary for making a diagnosis. 
 To provide information that aids the clinician in 
making decisions concerning the treatment of the 
patient.
Steps - Involved 
 Assemble all the available facts gathered from 
statistics, chief complaints, history of presenting 
complaints and relevant history. 
 Analyze and interpret the Examination details to 
reach the provisional diagnosis. 
 Make a differential diagnosis of all possible 
complications. 
 Select a closest possible choice-final diagnosis. 
 Plan a effective treatment accordingly.
Components 
 Particulars - Patient 
 Chief complaint 
 History of present illness 
 Past history 
 Personal history 
 Family history 
 Treatment history 
 General examination 
 Local examination 
 Other Systems exam. 
 Provisional diagnosis 
 Investigations 
 Final diagnosis 
 Treatment plan
Self Introduction 
 Greet the patient by name: "Good morning, 
Mr. X / Mrs. Y ." 
 Introduce yourself and explain that you are a 
medical student. 
 Shake the patient's hand, or if they are 
unwell rest your hand on theirs. 
 Ensure that the patient is comfortable.
Particulars 
 Patient registration number 
 Date 
 Name 
 Age 
 Sex 
 Address 
 Occupation 
 Religion
Pt. Reg. No. Date 
 Maintaining a record 
 Billing purposes 
 Medico legal aspects 
 Time of admission 
 Ref.- follow up visits 
 Record maintenance
Name Age 
 To communicate with 
the patient 
 To establish a rapport 
with the patient 
 Record maintenance 
 Psychological benefits 
 Age related diseases 
 For diagnosis 
 Treatment planning
Sex Residence / Address 
 Certain diseases – 
gender specific 
 Record maintenance 
 Psychological benefits 
 For future 
correspondence 
 View of socio-economic 
status 
 Prevalence & 
geographical 
distribution
Occupation Religion 
 To assess socio-economic 
status 
 Predilection of diseases 
in different occupations 
 Predilection of diseases 
in certain Religion 
 To identify festive 
periods when religious 
people are reluctant to 
undergo treatment
Chief Complaints 
 The chief complaint is usually the reason for the 
patient’s visit. 
 It is stated in patient’s own words [No medical terms] 
in chronological order of their appearance & their 
severity. { Brief & Duration } 
 Make clear – patient was free from any complaint 
before the period mentioned. 
 The chief complaint aids in diagnosis & treatment 
therefore should be given utmost priority.
History of Present Illness 
 Elaborate on the chief complaint in detail 
 The symptoms can be elaborated in terms of:- 
- Mode & cause of onset 
- Course & Duration of disease 
- Symptom related & Relation to constitutional factors 
- Special character & Effects – nearby structures 
 Treatment taken 
 Leading questions – to help the patient 
 Negative answers – more valuable to exclude the disease
Common Chief Complaints 
 Pain 
 Swelling 
 Ulcer 
 Vomiting 
 Bleeding 
 Discharge 
 Deformity
Past History 
Note the past history in chronological order 
 All diseases – previous to present – noted 
{ Attention to diseases like – Diabetes, 
Bleeding disorders, Tuberculosis, SHT, 
Asthma etc. } 
 Previous operations or Accidents – noted 
Mneumonic – T H R E A D
Personal History 
 Diet 
 Habit of smoking & drinking of alcohol 
 Bowel & micturition habits 
 Sleep 
 Allergy to any drug [or] diet 
 Marital status 
 Females – Menstrual history 
[ regularity / menarche ,menopause / no. of 
pregnancy – normal or LSCS / any discharge PV ]
Family History 
 Family members share their genes, as well as 
their environment, lifestyles and habits. 
Certain diseases run in families - Diabetes, 
cancers – breast, thyroid, SHT, piles, peptic 
ulcer etc. should be noted 
 Enquire about family members – alive or 
dead / current illnesses / consanguinity 
among family
Treatment or Drug History 
 Ask about the drugs the patient was on. 
 Special enquiry on – Steroids / 
Antihypertensives, HRT, contraceptivs pills, 
Antidiabetic drugs etc. 
Treatment for the current illness & doctor 
treated
General Survey or Examination 
 Analyze the patient entering the clinic for 
gait, built & nutrition, attitude and mental 
status. 
 Check for any pallor, cyanosis, jaundice, 
clubbing, any skin eruptions and edema. 
Record vital signs like 
T U R P
Local Examination 
 Most important part – definite clue to arrive at a 
diagnosis. 
 Examination of affected region. 
 Inspection – looking at affected part 
 Palpation – feeling of affected part 
 Percussion – listening to the effects of affected part 
 Auscultation – listening to the sounds produced 
 Movements & Measurements 
 Lymph node examination
Inspection 
 Visual assessment of the patient. 
 Make sure good lighting is available. 
 Position and expose body parts so that all surface can 
be viewed. 
 Inspect each area of size, shape, colour, symmetry, 
position and abnormalities. 
 If possible, compare each area inspected with the same 
area on the opposite side of the body. 
 Varies to the presentation of the complaints.
Palpation 
 A technique in which the hands and fingers are used to 
gather information by touch. 
 Palmar surface of fingers and finger pads are used to 
palpate for 
– Texture 
– Masses 
– Fluid 
 For assessing skin temperature – dorsal surface 
 Client should be relax and positioned comfortably 
because muscle tension during palpation impair its 
effectiveness.
Palpation - Types 
 Light palpation 
 Deep palpation 
 Bimanual palpation 
 Bidigital palpation
Percussion 
 Percussion involve tapping the body with the 
fingertips to evaluate the size, border and nature of 
body organs. 
 Used to evaluate for presence of 
air or fluid in body tissues 
 Sound waves heard as percussion tones.
Percussion - Types 
 Direct Percussion 
- It is by tapping the affected area directly using flexed 
finger. 
 Indirect Percussion 
- It can be performed by using two fingers. Lt middle 
finger [pleximeter finger] is placed over the area and its 
middle phalanx is tapped with the tip of Rt middle finger 
or index finger [percussing finger]. 
 Fist Percussion 
- It involves placing one hand flat against the body 
surface and striking the back of the hand with a clenched 
fist of the other hand.
Auscultation 
 Auscultation is listening 
to sound produce by the 
body. 
 Following characteristics 
of sound are noted:- 
- Pitch 
- Loud or soft 
- Duration 
- Quality 
 Done by stethoscope.
Other systems – Examination
Head & Neck 
 Cranial nerves –3,4,5,6,7,9,11&12 - examined 
 Eyes – visual field, pupils, movements 
Mouth & pharynx – teeth & gum, tongue & 
tonsil 
Movements of neck, neck veins & lymph 
glands, carotid pulse & thyroid gland
Upper Limbs 
 Arms & hand – Power, tone, reflexes & 
sensations 
 Axillae & Lymph nodes 
 Joints 
 Finger nails
Lower Limbs 
 Legs & feet – Power, tone, reflexes & 
sensations 
Varicose vein 
 Joints 
 Oedema
Thorax 
Type of chest 
 Breasts 
 Dilated vessels & pulsations 
 Position of trachea 
Apex beat 
 Lungs – whole 
Heart – whole
Abdomen 
 Abdominal wall – umbilicus, scars, dilated veins 
 Visible peristalsis or pulsations 
 Hernial orifices 
 Generalised examination 
 Inguinal glands 
 Rectal examination 
 Gynaecological examination – if required
Spine 
Curvature of spine observe for:- 
 Lordosis / Scoliosis / Kyphosis 
 Pain & Tenderness 
 Swellings
Provisional Diagnosis 
 It is also called tentative diagnosis or 
working diagnosis. 
 It is formed after evaluating the case history 
& performing the physical examination.
Investigations 
Routine Special 
 Blood 
- CBP/TC/DC/ESR 
- BT/CT 
- Sr. Electrolytes / RFT 
 Urine complete 
 Pus – C/S 
 X-ray 
 FNAC 
 Doppler 
 U/S 
 CT 
 MRI 
 Invasive procedures
Differential Diagnosis 
 The process of listing out of 2 or more 
diseases having similar signs and symptoms 
of which only one could be attributed to the 
patient’s disease.
Final Diagnosis 
 The final diagnosis can usually be reached following 
chronologic organization and critical evaluation of the 
information obtained from the : 
- patient history 
- physical examination and 
- the result of radiological and laboratory examination. 
 The diagnosis usually identifies the diagnosis for the 
patient primary complaint first, with subsidiary 
diagnosis of concurrent problems.
Treatment Plan 
 The formulation of treatment plan will depend on both 
knowledge & experience of a competent clinician and 
nature and extent of treatment facilities available. 
 Evaluation of any special risks posed by the 
compromised medical status in the circumstance of the 
planned anesthetic diagnostic or surgical procedure. 
 Medical assessment is also needed to identify the need 
of medical consultation and to recognize significant 
deviation from normal health status that may affect 
management.
Prognosis 
 It is defined as act of foretelling the course of 
disease that is the prospect of survival & recovery 
from a disease as anticipated from the usual course 
of that disease or indicated by special features of 
the case.
 Clinical diagnosis is an art, 
and the mastery of an art has no end; 
you can always be a better diagnostician. 
- Logan Clendening
T

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History taking - For Surgical patients

  • 1. CASE HISTORY  Dr. Murali. U. M.S ; M.B.A. Prof. of Surgery D Y Patil Medical College Mauritius.
  • 2. Definition  A case history is defined as a planned professional conversation that enables the patient to communicate his/her symptoms, feelings and fears to the clinician so as to obtain an insight into the nature of patient’s illness & his/her attitude towards them.
  • 3. Objectives  To establish a positive professional relationship.  To provide the clinician with information concerning the patient’s past medical / surgical & personal history.  To provide the clinician with the information that may be necessary for making a diagnosis.  To provide information that aids the clinician in making decisions concerning the treatment of the patient.
  • 4. Steps - Involved  Assemble all the available facts gathered from statistics, chief complaints, history of presenting complaints and relevant history.  Analyze and interpret the Examination details to reach the provisional diagnosis.  Make a differential diagnosis of all possible complications.  Select a closest possible choice-final diagnosis.  Plan a effective treatment accordingly.
  • 5. Components  Particulars - Patient  Chief complaint  History of present illness  Past history  Personal history  Family history  Treatment history  General examination  Local examination  Other Systems exam.  Provisional diagnosis  Investigations  Final diagnosis  Treatment plan
  • 6. Self Introduction  Greet the patient by name: "Good morning, Mr. X / Mrs. Y ."  Introduce yourself and explain that you are a medical student.  Shake the patient's hand, or if they are unwell rest your hand on theirs.  Ensure that the patient is comfortable.
  • 7. Particulars  Patient registration number  Date  Name  Age  Sex  Address  Occupation  Religion
  • 8. Pt. Reg. No. Date  Maintaining a record  Billing purposes  Medico legal aspects  Time of admission  Ref.- follow up visits  Record maintenance
  • 9. Name Age  To communicate with the patient  To establish a rapport with the patient  Record maintenance  Psychological benefits  Age related diseases  For diagnosis  Treatment planning
  • 10. Sex Residence / Address  Certain diseases – gender specific  Record maintenance  Psychological benefits  For future correspondence  View of socio-economic status  Prevalence & geographical distribution
  • 11. Occupation Religion  To assess socio-economic status  Predilection of diseases in different occupations  Predilection of diseases in certain Religion  To identify festive periods when religious people are reluctant to undergo treatment
  • 12. Chief Complaints  The chief complaint is usually the reason for the patient’s visit.  It is stated in patient’s own words [No medical terms] in chronological order of their appearance & their severity. { Brief & Duration }  Make clear – patient was free from any complaint before the period mentioned.  The chief complaint aids in diagnosis & treatment therefore should be given utmost priority.
  • 13. History of Present Illness  Elaborate on the chief complaint in detail  The symptoms can be elaborated in terms of:- - Mode & cause of onset - Course & Duration of disease - Symptom related & Relation to constitutional factors - Special character & Effects – nearby structures  Treatment taken  Leading questions – to help the patient  Negative answers – more valuable to exclude the disease
  • 14. Common Chief Complaints  Pain  Swelling  Ulcer  Vomiting  Bleeding  Discharge  Deformity
  • 15. Past History Note the past history in chronological order  All diseases – previous to present – noted { Attention to diseases like – Diabetes, Bleeding disorders, Tuberculosis, SHT, Asthma etc. }  Previous operations or Accidents – noted Mneumonic – T H R E A D
  • 16. Personal History  Diet  Habit of smoking & drinking of alcohol  Bowel & micturition habits  Sleep  Allergy to any drug [or] diet  Marital status  Females – Menstrual history [ regularity / menarche ,menopause / no. of pregnancy – normal or LSCS / any discharge PV ]
  • 17. Family History  Family members share their genes, as well as their environment, lifestyles and habits. Certain diseases run in families - Diabetes, cancers – breast, thyroid, SHT, piles, peptic ulcer etc. should be noted  Enquire about family members – alive or dead / current illnesses / consanguinity among family
  • 18. Treatment or Drug History  Ask about the drugs the patient was on.  Special enquiry on – Steroids / Antihypertensives, HRT, contraceptivs pills, Antidiabetic drugs etc. Treatment for the current illness & doctor treated
  • 19. General Survey or Examination  Analyze the patient entering the clinic for gait, built & nutrition, attitude and mental status.  Check for any pallor, cyanosis, jaundice, clubbing, any skin eruptions and edema. Record vital signs like T U R P
  • 20. Local Examination  Most important part – definite clue to arrive at a diagnosis.  Examination of affected region.  Inspection – looking at affected part  Palpation – feeling of affected part  Percussion – listening to the effects of affected part  Auscultation – listening to the sounds produced  Movements & Measurements  Lymph node examination
  • 21. Inspection  Visual assessment of the patient.  Make sure good lighting is available.  Position and expose body parts so that all surface can be viewed.  Inspect each area of size, shape, colour, symmetry, position and abnormalities.  If possible, compare each area inspected with the same area on the opposite side of the body.  Varies to the presentation of the complaints.
  • 22. Palpation  A technique in which the hands and fingers are used to gather information by touch.  Palmar surface of fingers and finger pads are used to palpate for – Texture – Masses – Fluid  For assessing skin temperature – dorsal surface  Client should be relax and positioned comfortably because muscle tension during palpation impair its effectiveness.
  • 23. Palpation - Types  Light palpation  Deep palpation  Bimanual palpation  Bidigital palpation
  • 24. Percussion  Percussion involve tapping the body with the fingertips to evaluate the size, border and nature of body organs.  Used to evaluate for presence of air or fluid in body tissues  Sound waves heard as percussion tones.
  • 25. Percussion - Types  Direct Percussion - It is by tapping the affected area directly using flexed finger.  Indirect Percussion - It can be performed by using two fingers. Lt middle finger [pleximeter finger] is placed over the area and its middle phalanx is tapped with the tip of Rt middle finger or index finger [percussing finger].  Fist Percussion - It involves placing one hand flat against the body surface and striking the back of the hand with a clenched fist of the other hand.
  • 26. Auscultation  Auscultation is listening to sound produce by the body.  Following characteristics of sound are noted:- - Pitch - Loud or soft - Duration - Quality  Done by stethoscope.
  • 27. Other systems – Examination
  • 28. Head & Neck  Cranial nerves –3,4,5,6,7,9,11&12 - examined  Eyes – visual field, pupils, movements Mouth & pharynx – teeth & gum, tongue & tonsil Movements of neck, neck veins & lymph glands, carotid pulse & thyroid gland
  • 29. Upper Limbs  Arms & hand – Power, tone, reflexes & sensations  Axillae & Lymph nodes  Joints  Finger nails
  • 30. Lower Limbs  Legs & feet – Power, tone, reflexes & sensations Varicose vein  Joints  Oedema
  • 31. Thorax Type of chest  Breasts  Dilated vessels & pulsations  Position of trachea Apex beat  Lungs – whole Heart – whole
  • 32. Abdomen  Abdominal wall – umbilicus, scars, dilated veins  Visible peristalsis or pulsations  Hernial orifices  Generalised examination  Inguinal glands  Rectal examination  Gynaecological examination – if required
  • 33. Spine Curvature of spine observe for:-  Lordosis / Scoliosis / Kyphosis  Pain & Tenderness  Swellings
  • 34. Provisional Diagnosis  It is also called tentative diagnosis or working diagnosis.  It is formed after evaluating the case history & performing the physical examination.
  • 35. Investigations Routine Special  Blood - CBP/TC/DC/ESR - BT/CT - Sr. Electrolytes / RFT  Urine complete  Pus – C/S  X-ray  FNAC  Doppler  U/S  CT  MRI  Invasive procedures
  • 36. Differential Diagnosis  The process of listing out of 2 or more diseases having similar signs and symptoms of which only one could be attributed to the patient’s disease.
  • 37. Final Diagnosis  The final diagnosis can usually be reached following chronologic organization and critical evaluation of the information obtained from the : - patient history - physical examination and - the result of radiological and laboratory examination.  The diagnosis usually identifies the diagnosis for the patient primary complaint first, with subsidiary diagnosis of concurrent problems.
  • 38. Treatment Plan  The formulation of treatment plan will depend on both knowledge & experience of a competent clinician and nature and extent of treatment facilities available.  Evaluation of any special risks posed by the compromised medical status in the circumstance of the planned anesthetic diagnostic or surgical procedure.  Medical assessment is also needed to identify the need of medical consultation and to recognize significant deviation from normal health status that may affect management.
  • 39. Prognosis  It is defined as act of foretelling the course of disease that is the prospect of survival & recovery from a disease as anticipated from the usual course of that disease or indicated by special features of the case.
  • 40.  Clinical diagnosis is an art, and the mastery of an art has no end; you can always be a better diagnostician. - Logan Clendening
  • 41. T