---

History Taking, General Examination, Case Sheet Filling & Common Clinical Words

---

PART 1: HISTORY TAKING

Structure of History

---

1. Patient Particulars (Biodata)

Always include the full postal address for future correspondence.

---

2. Chief Complaints

• Record in chronological order of their appearance
• Ask: "What are your complaints?" or "What brings you here?"
• Record duration of each complaint separately
• List simultaneously-occurring complaints in order of severity

1. Swelling in neck - 1 year
2. Evening fever - 10 months
3. Pain in swelling - 6 months
4. Sinus formation - 1 month

---

3. History of Present Illness (HPI)

1. Mode of onset - sudden or gradual; any precipitating cause
2. Progress - exact evolution of symptoms in order
3. Treatment received - type and treating physician

• Record in the patient's own words, not medical jargon
• Let the patient narrate freely; redirect if they wander
• Never ask leading questions (e.g. "Doesn't the pain go to the right shoulder?" - ask instead: "Does the pain move anywhere?")
• Negative history is valuable - e.g. absence of watery discharge at mealtimes rules out parotid fistula in a cheek sinus

---

4. Associated Diseases

• Diabetes mellitus
• Hypertension
• Asthma / COPD
• Bleeding disorders
• Rheumatic fever
• Tropical diseases (malaria, filariasis, amoebiasis)

---

5. Past History

• All previous illnesses in chronological order with dates and duration
• Previous operations - type, date, outcome
• Previous accidents/trauma
• Relevant: peptic ulcer, pancreatitis, tuberculosis, gallbladder disease

---

6. Drug History

• Steroids (adrenal suppression risk)
• Insulin / oral hypoglycaemics
• Antihypertensives, diuretics
• Anticoagulants
• Monoamine oxidase inhibitors (MAOIs)
• Oral contraceptive pill / hormone replacement therapy
• Ergot derivatives

---

7. History of Allergy

• Must not be missed under any circumstances
• Ask about allergies to drugs and foods
• Record in red ink on the cover of the case sheet
• This alone can prevent catastrophic reactions

---

8. Personal History

• Smoking - type (cigarette/cigar/pipe), frequency/pack-years
• Alcohol - type, quantity, duration
• Diet - vegetarian/non-vegetarian; spicy food
• Sleep and micturition habits
• Menstrual history (in females) - cycle regularity, last menstrual period (LMP), menarche, menopause

---

9. Family History

• Similar illness in blood relatives (hereditary conditions)
• Relevant: haemophilia, diabetes, carcinoma, tuberculosis, ischaemic heart disease

---

PART 2: GENERAL EXAMINATION

---

A. General Survey

1. General Assessment of Illness

• Is the patient acutely ill, chronically ill, or comfortable?
• In severely ill patients, limit time on minor findings and move to treatment quickly

2. Mental State and Level of Consciousness

1. Fully conscious, perfectly oriented to time, place, and person
2. Fully conscious, but disoriented to time and place
3. Semi-conscious (drowsy) - can be awakened
4. Unconscious (stupor) - responds to painful stimuli
5. Unconscious (coma) - no response to painful stimuli

3. Build and Nutrition

• Cachectic patient with abdominal lump - suggests GI malignancy
• Endocrine abnormalities may be obvious from body habitus

4. Attitude (Position in Bed)

• Still position - peritonitis (movement worsens pain)
• Restless, tossing - colic (biliary, renal, intestinal)
• Neck retraction and rigidity - meningitis
• Everted leg after fall - fracture neck of femur

5. Gait

• Waddling gait - bilateral CDH, bilateral coxa vara
• Trendelenburg gait - muscle dystrophies, poliomyelitis, hip arthritis
• Abnormal gait may be due to pain, bone/joint disease, neurological disease, or psychiatric causes

6. Facies

7. Decubitus

• Voluntary (chosen for comfort) or involuntary (due to disease)
• Examples: fetal position in peritonitis, orthopnoea (sitting up) in cardiac failure

8. Skin Colour Abnormalities

• Pallor - anaemia; check conjunctiva, nail beds, palms, tongue
• Cyanosis - bluish tinge; check tongue (central) or periphery; normal O₂ tension with methaemoglobinaemia
• Jaundice - check sclera (ask patient to look down), nail beds, ear lobule, tip of nose, undersurface of tongue
  • Faint yellow - viral hepatitis
  • Dark olive-green - obstructive jaundice
  • Scratch marks on skin - obstructive jaundice (bile acid retention causing pruritus)
  • Carotenaemia confusion: yellow pigment in palms/soles/face but not sclera

9. Skin Eruptions

10. Vital Signs

• Rate (fast/slow)
• Rhythm (regular/irregular)
• Tension and force (diastolic and systolic BP)
• Volume (pulse pressure)
• Character: water-hammer pulse (aortic regurgitation, thyrotoxicosis), pulsus paradoxus (pericardial effusion)
• All four limbs should be palpated

• Continuous, remittent, intermittent, hectic/septic

---

B. Regional Systematic Examination (Checklist Format)

• Scalp, skull, hair, eyes (conjunctiva, sclerae, pupils, extra-ocular movements)
• Ears (pinnae, external canals)
• Nose (external, nasal cavity)
• Mouth/pharynx: teeth, gums, tongue, soft palate movement, tonsils, lips (look for pigmentation - Peutz-Jeghers syndrome)
• Neck: movements, jugular venous pressure (JVP), lymph nodes, carotid pulses, thyroid gland

• Vascular supply and nerve supply
• Power, tone, reflexes, sensations
• Axillary lymph nodes
• Joints
• Finger nails: clubbing, koilonychia, leuconychia, splinter haemorrhages

• Chest shape and type
• Breast examination (both sexes)
• Tracheal position
• Apex beat
• Lungs: inspection, palpation, percussion, auscultation
• Heart: inspection, palpation, percussion, auscultation

• Umbilicus position, scars, dilated veins
• Visible peristalsis or pulsation
• Abdominal reflexes
• Palpation, percussion, auscultation
• Hernial orifices
• External genitalia
• Inguinal lymph nodes
• Rectal examination (mandatory in most surgical cases)
• Gynaecological examination if indicated

• Vascular and nerve supply (power, tone, reflexes, sensation)
• Varicose veins
• Oedema (pitting/non-pitting)
• Joints

---

PART 3: FILLING THE CASE SHEET

1. Biodata / Patient particulars
2. Chief complaints (numbered, with duration)
3. History of present illness
4. Associated diseases / comorbidities
5. Past history
6. Drug history
7. Allergy history (mark in red on cover)
8. Personal history
9. Family history
10. General survey findings
11. Local/systemic examination findings
12. Provisional diagnosis
13. Differential diagnoses
14. Investigations ordered
15. Clinical diagnosis (after investigation results)
16. Treatment plan - Pre-operative: surgical prep, anaesthesia notes, consent; Intraoperative: position, incision, technique, closure, drainage; Postoperative care
17. Daily progress notes (investigations, wound status, vitals, dressings)
18. Follow-up
19. Termination/discharge summary - diagnosis, treatment received, postoperative advice, follow-up date

---

PART 4: COMMON CLINICAL WORDS

Symptoms vs. Signs

• Symptom - what the patient feels and reports (subjective) - e.g. pain, nausea, breathlessness
• Sign - what the clinician elicits on examination (objective) - e.g. tenderness, hepatomegaly, crepitus

Pain Terminology

Common Clinical Terms

---

• S. Das - A Manual on Clinical Surgery, 13th Ed. (pp. 1-15)
• Bailey and Love's Short Practice of Surgery, 28th Ed. (pp. 1076-1077)