History taking and case presentation

Question 1

What to inquire about in past medical history in general surgery?

Answer 1

• List specific medical diagnoses.
• Relevant negatives (it is good practice to ask about cardiorespiratory and renal conditions, which impact on the patient’s
  operative/ anaesthetic risk, e.g. ischaemic heart disease (IHD), heart
  failure, COPD, renal impairment, as well as those specific to the presenting complaint, e.g. neurological diagnoses in neurosurgery/
  ear, nose, and throat (ENT), risk factors for atherosclerosis in vascular surgery.
• List and date all previous operations.
• Ask about previous problems with an anaesthetic.

Question 2

Social history in general surgery

Answer 2

• Ask about who will look after the patient. Do they need help to
  mobilize and/ or with activities of daily living?
• Smoking and alcohol history.
• Occupation.

Question 3

How to present a general surgery case?

Answer 3

• Always ‘set the scene’ properly. Start with name, age, occupation (if elderly,
  general fitness/ independence), relevant background history, mode of referral,
  and presenting complaint, e.g. ‘78- year- old man, normally fit and well, with a prior history of open anterior resection for rectal adenocarcinoma, presents with a 3- day history of abdominal pain and vomiting’.
  Be chronological. Start at the beginning of any relevant prodrome
  or associated symptoms; they are likely to be an important part
  of the presenting history, e.g. ‘He was well until . . . when he started
  experiencing . . . the current symptoms started . . . ’
• Be concise with the past medical history. Only expand on things that you really feel may be relevant either to the diagnosis or to the management.
• Always summarize the general appearance and vital signs first.
• Describe the most significant findings first, but be systematic, e.g. ‘on
  inspection . . . , palpation . . . , percussion . . . , auscultation’.
• Briefly summarize other systemic findings. Expand on them if they are
  directly relevant to the diagnosis or management.
• Finally, summarize and synthesize. Try to group symptoms and signs into
  clinical patterns that lead to the proposed diagnoses or differential list.
• Be prepared to discuss what diagnostic or further evaluation tests might
  be necessary.

Question 4

History of presenting complaint in gen surg patients

Answer 4

This is a detailed description or exploration of the main symptom(s) and should include the relevant systems enquiry.
- Start with any relevant background history to set the context for the
presenting complaint.
- Try to put the important positives first, e.g. “right- sided lower abdominal pain, worse with moving and coughing, anorexia.
- Include the relevant negatives, e.g. “no vomiting, no PR bleeding.
- Be very clear about the chronology of events.
- In a complicated history or with multiple symptoms, use headings, e.g.
‘Previous episodes/ operations for this problem’, ‘Current episode’,
‘Results of investigations’.
- Summarize the results of previous investigations systematically: blood tests,
microbiology, histopathology, radiology, and specialized tests.

Question 5

How to write presenting complaint in gen surg patients?

Answer 5

• This is a one- or two- word summary of the patient’s main symptoms, e.g. “right iliac fossa (RIF) pain”, “abdominal pain and vomiting”, “bleeding per
  rectum (PR)”.
• In emergency admissions, do not write a diagnosis here (e.g. ischaemic
  leg). The diagnosis of referral may well turn out to be wrong.
• In elective admissions, it is reasonable to write e.g. ‘elective admission for anterior resection for rectal adenocarcinoma’.

Question 6

What acronym can be used to know more about pain?

Answer 6

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 breathing, moving, or
coughing suggests peritoneal/ pleural irritation; relief with hot water
bottles suggests deep inflammatory or infiltrative pain.
* Surgical history. Does the pain relate to surgical interventions?

Question 7

Obstructive bowel sounds characteristics

Answer 7

Absent or high- pitched, frequent sounds, often with crescendos of activity, e.g. ‘tinkling’, ‘bouncing marbles