General scheme of case taking (Medical study)

General scheme of case taking :

In this chapter it will be narrated in brief, how to follow a patient from his arrival at the hospital or clinic unto his normal condition, i.e. after he has come round, It is a general scheme and applied to all patients whoever come to the surgeon . The student should learn this scheme and make it a reflex, so that he can apply to all his patients, ultimately, this will become a habit in his professional career.

Doctor's case investigation

This general scheme includes – (1) History taking (2)Physical examination; (3)Special investigation; (4)Clinical diagnosis;(5) Treatment-both medical and surgical; (6)Progress during postoperative period ;(7) Follow –Up; (8) Termination.

In the clinic, It is a good practice to start examining the patient since he walks into the room rather than to meet him undressed on a coach in a cubicle. It is helpful if the person, who accompanied the patient, remains by the side of the patient in the early part of the history –taking and examination.

He can provide valuable information about the type of injury the patient might have sustained some details of the complaints or about changes in health or behavior of the patient is the recent past.

                                   

                                         HISTORY-TAKING

1.Partuculars of the patient –Before investigation about the complaints of the patient ,it is a good practice to know the first .That means the following headings should be noted in the history-sheet:

NAME  -  It is very important to know the patient by name .The patients like it be asked by name, as for example ,’Mr.Sirkar, how long are you having this problem? This will not only help to elicit the history properly, but also it will be of psychological benefit to the patient just before the operation and in postoperative period .

AGE  -  Congenital anomalies mostly present since birth ,e.g cystic hygroma, cleft lip, cleft such as persistent urachus ,branchial cyst ,branchial fistula ctc.Certain diseases are peculiar to a particular age . Acute arthritis ,acute osteomyelitis,wilms tumor of the kidney are found mostly in infants. Sarcomas affect teenagers. Appendicitis is commonly seen is girls between 14 to 25 Years of age. Though carcinomas affect mostly those who  have passed  40 Years of age , yet it must be remembered that they should not be excluded by age alone. Osteoarthritis and benign hypertrophy of  the prostate are diseases of old age

SEX -  It goes without saying that the diseases ,which affect the sexual organs, will be peculiar to the s4ex concerned , Besides these ,certain other diseases are predominantly seen in particular sex, such as diseases of the thyroid ,visceroptosis ,movable kidney ,cystitis are commoner in females ,whereas carcinomas of the stomach, lungs kidneys are commoner in males. Hemophilia affects males only ,although the disease is transmitted through the females .

RELIGION -  Carcinoma of penis is hardly seen in Jews and Muslims owing to their religious custom of compulsory circumcision in infancy ,For the same reason ,phimosis ,subprepucial infection etc .are not al all seen in them .On the other hand , intussusceptions is sometimes seen after the month-long fast(Ramjan) in Muslims.

OCCUPATION – Some diseases have shown their peculiar predilection towards certain occupations. As for example, varicose veins are commonly seen among bus conductors.

As for example ,varicose veins are commonly seen among bus conductors .Workers in aniline dye factories are more prone to urinary bladder neoplasms than others .carcinoma of the scrotum is more  commonly seen among chimney sweepers and in those ,who work in tar and shale oil . Injury to the medial semi-lunar cartilage of the knee is common among footballers and miners . Enlargement of certain bursae may occur from repeated friction of the skin over the burse, e.g. student’s elbow ,house-maid’s knee etc. Strain to the ex-tensor origin from the lateral epicondyle of the humorous is commonly seen among tennis players and is known as tennis “elbow”

RESIDENCE  - A few surgical diseases have got geographical distribution. Filariasis is common in Orissa , whereas leprosy in Bankura district of West Bengal. Gall-Bladder diseases are commoner in West Bengal and Bangladesh. Peptic ulcer is more commonly seen in north-western part and southern parts of India as they are habituated to take more spicy food .Bilharxiasis is common in Egypt, sleeping sickness in Africa and hydatid disease in sheep-rearing districts of Australia, Greece, Turkey, Iran, Iraq, U. K etc. Tropical diseases, such as amoebas ,are obviously common in tropical countries. Khangri cancer ( )is peculiar among the Kashmiri on their abdomen due to their habit of carrying the Khangri (an earthenware filled with burning charcoal to keep themselves warm).

In this column, the students must not forget to write the full postal address of the patient for future correspondence.

A khangri cancer on the abdomen

2.Chief Complaints – The complaints of the patient are recorded under tis heading in a chronological order to their appearance. The patient is asked ,”What brings you here ?”You should also know the duration of these complaints. For this ,ask the patient ,”How long have you been suffering from each of these complaints?” These should be recorded in a chronological order .As for example ,in case of a sinus in the neck ,The complaints may be put down in the following way:

(a) Swelling in the neck – 1Year

(b)Fever (mostly in the evening) - 10  

(c) slight pain in the swelling – 6 month .

(d) Sinus in the4 neck  - 1 month.

The students should make it very clear that the patient was free from any complaint before the period mentioned by the patient .For this ,the students should ask the patient with sinus in the neck,” Were you perfectly well before the appearance of swelling in the neck?” This is very important ,as very often the patients may not mention some of his previous complaints as he considers them insignificant or unrelated to his present trouble. But ,on the contrary, this may give a very important clue to arrive at a diagnosis.

As for example ,a patient with rigidity and tenderness in right hypochondriac region of the abdomen may not have told you of his “hunger pain’s few months back. But this simple hint at once tells you that this is a case of peptic perforation.

3.History of Present illness – This history commences from the beginnings of the first symptom and extends to the time of examination. This includes (i)The mode of onset of the symptoms – whether sudden or gradual ,as well as the cause of onset, if at all present; (ii)The progress of the disease with evolution of symptoms in the    exact order of their occurrence ;and lastly  (iii) The treatment which the patient might have received – the mode of treatment and the doctor. who has treated. To know the mode of onset ,the patient is asked ,”What in the next thing that happened ?” Or any such relevant question as the type of case may necessitate .This should be recorded in the patient’s own language and not in scientific terms. The patient should be allowed to describe his own story of symptoms .They know more about their  complaints than the doctors. But if they wander too far from the point ,they should be put such question – ‘What is the matter?” The patient will obviously tell  you his or another doctor’s diagnosis ,which you do not want to know . ‘Leading questions’ should not be put to the patients. By this ,it is meant that questions, which yield only one answer ,should not be asked .As for example, if the patient is asked like this – “Doesn’t the pain move to the inferior angle of the right scapula?”

Obviously a well – behaved patient will answer “Yes “to please you. So the question should be such that it leaves the patient with a free choice of answer .As for example ,the question should be. “Does should not necessarily be ‘LEADING”, but to help  the patient to narrate the different aspects of his symptoms to arrive at a definite diagnosis.

Sometimes negative answers are more valuable in arriving at a diagnosis and should never be disregarded. As for example in case of a sinus on the cheek ,absence of the history of watery discharge at the time of meals at once excludes the possibility of a parotid fistula.

Fistula

symptom of fistula                             

4. Past History – All the diseases suffered by the patient, previous to the present one, should be noted and recorded in a chorological order. There should be mention of dates of their occurrence and the duration. These diseases may  to have any relation with the present disease .Particular attention is paid to the diseases like diabetes ,diphtheria ,rheumatic fever, bleeding tendencies, tuberculosis ,syphilis , gonorrhea ,tropical ,diseases ,asthma etc. Under this heading, the students should not forget to mention any of the previous operation or accidents, which the patient might have sustained. The dates and the types of operation should be mentioned in a chronological order.

5. Drug History – The patient should be asked about all the drugs he was on. Besides the fact that this will help to give a clue to the present illness or in the subsequent treatment,

It has tremendous importance from anesthetic point of view. Special enquiry should be made about steroids, insulin, antihypertensive, diuretics, ergot derivatives, monoamine oxides inhibitors, hormone replacement therapy, contraceptive pills etc.

6. History of allergy - this is very important and should not be missed under any circumstances ,while taking history of a patient . The patient should not be asked whether he or she is allergic to any medicine or diet. It should be noted with red type on the cover of the history sheet. The students should make it a practice and they will definitely find that this valuable practice will save many catastrophes.

7. Personal History – Under this heading , the patient’s habit of smoking (cigarettes ,cigar or pine and the frequency), dirking of alcohol (quality and quantity),diet(regular or irregular, vegetarian or non-vegetarian ,takes spicy food or not etc.) are noted. It is also enquired about the marital status of the individual – whether married or single ,a widow or a widower. In woman ,the menstrual history must be recorded perfectly – whether the patient is having regular menstruation or not , the days of menstruation, whether any pain is associated with menstruation or not and last date of menstruation, The number of pregnancies and miscarriages ate noted with their dates,- whether the deliveries were normal or not, whether the patient had Caesarean section or not and if so, for what reason, The patient is also asked whether there is any white discharge per vaginam or not.

8. Family history – This part of the history is very important .May diseases do recur in families .Hemophilia, tuberculosis, diabetes, essential hypertension ,peptic ulcer, majority of the cancers particularly the breast cancer and certain other diseases like fissure–in-ano, piles etc. run in families. So the students must not forget to en-quire about other members of the family ,such as about parents if they are still alive. How are they maintaining their health’s ? Did they suffer from any major ailments? If they are dead, what were the causes of their deaths? You should also en-quire about the brothers and sisters and children of the patient .

9. History of immunization – Children should be asked whether they have been immunized again diphtheria, tetanus, whooping caught, poliomyelitis ,small pox, tuberculosis etc.