Heritage Case in Surgery - Complete MBBS Guide

Structure of the Heritage / Surgical Long Case

A. HISTORY

1. Patient Particulars (Bio-Data)

• Name, Age, Sex, Religion, Occupation
• Address, Socioeconomic status
• Date of Admission, Date of Examination
• Bed No. / MR No.

2. Chief Complaints (CC)

• Written in chronological order with duration
• Each symptom on a separate line - never club two symptoms together
• Example:
  • Swelling in the right groin - 2 years
  • Pain over the swelling - 3 days

3. History of Present Illness (HPI)

• Onset (sudden/gradual), duration, progression
• Character and severity of each complaint
• Aggravating and relieving factors
• Associated symptoms
• Negative history (pertinent negatives that help rule out differentials)

4. Past Medical History (PMH)

• Previous similar illness
• Hospitalizations, surgeries, blood transfusions
• Known comorbidities: Diabetes, Hypertension, Tuberculosis, Asthma, Jaundice, Cardiac disease

5. Drug History

• Current medications, drug allergies, reaction type

6. Personal History

• Diet (vegetarian/mixed), appetite, bowel habits, bladder habits
• Sleep, addiction history (tobacco, alcohol)

7. Family History

• Relevant hereditary diseases (e.g., cancer in first-degree relatives for breast/colorectal cases)

8. Menstrual & Reproductive History (for female patients)

• Age of menarche, LMP, regularity, menopause
• Parity (G_P_ notation), breastfeeding history
• OCP/HRT use

9. Socioeconomic History

• Living conditions, occupation-related risk factors

B. PHYSICAL EXAMINATION

1. General Examination

2. Local Examination (Most important in surgical case)

3. Systemic Examination

• Cardiovascular system (CVS)
• Respiratory system (RS)
• Central nervous system (CNS) - only if relevant
• Abdomen - always relevant in GI/GU surgery

C. SUMMARY OF THE CASE

• Para 1: Brief history (age, sex, presenting complaint, duration, important positive and negative history)
• Para 2: Brief examination findings (general + local + relevant systemic)

"Mr. Ramesh Kumar, a 52-year-old male laborer, presented with a gradually increasing, non-painful swelling in the right inguinal region for 2 years, which increases on standing and straining and reduces on lying down. No history of fever, vomiting, or change in bowel habits."

"On examination, patient is conscious and cooperative. General examination is unremarkable with no pallor/icterus/cyanosis/clubbing/edema. Local examination reveals a 10x2 cm pyriform swelling in the right inguinoscrotal region, lying above the inguinal ligament, reducible with positive cough impulse. Cannot get above the swelling. Testis palpable separately. Bowel sounds heard over swelling."

D. PROVISIONAL DIAGNOSIS

• Type of condition
• Site (right/left)
• Nature (reducible/irreducible/strangulated)
• Any staging (for malignancies - TNM staging)

• "Right-sided indirect complete reducible inguinal hernia with bowel as content"
• "Carcinoma of the left breast T2N1M0 (Stage IIA) in a postmenopausal woman"
• "Obstructive jaundice probably due to carcinoma of head of pancreas"
• "Solitary toxic adenoma of right lobe of thyroid (hyperthyroid)"

E. INVESTIGATIONS SUGGESTED

1. To confirm diagnosis - FNAC, biopsy, USG, CECT, endoscopy, hormone levels
2. To determine extent/staging - CT chest/abdomen, PET scan, bone scan, LFTs
3. Routine preoperative workup:
   • CBC, Blood group & Rh typing
   • RBS, Blood urea, Serum creatinine
   • LFT, Coagulation profile (PT/INR)
   • Urine R/E and C&S
   • Chest X-ray (PA view)
   • ECG (especially >40 years)
   • Anesthesia fitness

F. DIFFERENTIAL DIAGNOSIS

• List in order of probability - most likely first
• Use the rule: "If you hear hoofbeats, suspect a horse, not a zebra"

G. TREATMENT PLAN

• Medical / Conservative management first if applicable
• Surgical management - procedure, approach, anesthesia type
• Operative details - briefly outline the surgery
• Post-operative care
• Complications - the examiner will ask about these

Common Heritage Case Topics in MBBS Surgery

Tips for Heritage Case in Surgery Exams

1. Write in past tense for history, present tense for examination findings
2. Pertinent negatives matter - always mention relevant negative history (e.g., in hernia - no h/o chronic cough, no h/o straining at micturition/defecation, no h/o abdominal distension)
3. Complete provisional diagnosis - examiner often asks "What is your case?" - give a one-line complete diagnosis with side, type, and character
4. Local examination before systemic - in surgery, local examination is the most important
5. Know your operative details - for any diagnosis you give, be prepared to discuss the surgery, its steps, and complications
6. TNM staging - for any malignancy case, staging is mandatory and will be asked
7. Swelling description - use all standard parameters (site, size, shape, surface, margin, consistency, reducibility, transillumination, pulsation, bruit, regional lymph nodes)
8. Time yourself - in a long case exam, you typically get 45-60 minutes with the patient before presenting

Heritage Case Format at a Glance

HERITAGE / SURGICAL LONG CASE
│
├── A. HISTORY
│   ├── Bio-data
│   ├── Chief Complaints (chronological, with duration)
│   ├── History of Present Illness
│   ├── Past Medical History
│   ├── Drug History
│   ├── Personal History
│   ├── Family History
│   └── Menstrual/Reproductive History (females)
│
├── B. PHYSICAL EXAMINATION
│   ├── General Examination (Pallor, Icterus, Cyanosis, Clubbing, Edema, Vitals)
│   ├── Local Examination (Inspection → Palpation → Percussion → Auscultation)
│   └── Systemic Examination (CVS, RS, CNS, Abdomen)
│
├── C. CASE SUMMARY (2 paragraphs)
│
├── D. PROVISIONAL DIAGNOSIS (Complete)
│
├── E. INVESTIGATIONS SUGGESTED
│   ├── Diagnostic
│   ├── Staging
│   └── Preoperative routine
│
├── F. DIFFERENTIAL DIAGNOSIS (most likely first)
│
└── G. TREATMENT PLAN
    ├── Preoperative preparation
    ├── Operative procedure
    └── Post-operative care & complications