CASE HISTORY

Dr. Nitin Fating

HOW SHALL I EXAMINE THIS CASE
AND COME TO A DIAGNOSIS ?
 This is a question which confronts each
and every clinicians
 Without doubt methods of history taking
and examination are different in various
types of surgical diseases
 1. HISTORY TAKING
PARTICULARS OF THE PATIENT
2. PHYSICAL EXAMINATION
CHIEF COMPLAINTS
GENERAL EXAMINATION
HISTORY OF PRESENT ILLNESS
EXTRA-ORAL EXAMINATION
PAST MEDICAL AND DENTAL HISTORY
INTRA-ORAL EXAMINATION
PERSONAL HISTORY
FAMILY HISTORE

CASE HISTORY 5. FINAL DIAGNOSIS

3. PROVISIONAL DIAGNOSIS
AND
DIFFERENTIAL DIAGNOSIS

6. TREATMENT

4.INVESTIGATIONS
A MANUAL ON CLINICAL SURGERY
BY S.DAS
 CASE HISTORY INCLUDE HOW TO
FOLLOW A PATIENT FROM HIS
ARRIVAL AT THE HOSPITAL OR
CLINIC UPTO HIS NORMAL
CONDITION
 1. HISTORY TAKING
 1. Particulars of the patient
 2. Chief complaint
 3. History of present illness
 4. Past medical and dental history
 5. Personal history
 6. Family history
PARTICULARS OF THE PATIENT
 Before interrogating about the complaints of
patient, it is a good practice to know the patient
first.
 NAME
 AGE
 SEX
 RELIGION
 SOCIAL STATUS
 OCCUPATION
 RESIDENCE
 NAME
 It is very important to know the patient by
name
 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 are cleft lip and cleft palate
 But a few congenital anomalies may
present later in life such as branchial cyst
and branchial fistulas
 GENDER
 It goes without saying that the diseases, which
affects the sexual organs, will be peculiar to the
sex concerned
 Beside this , certain other diseases are
predominantly seen in a particular sex, such as
disease of thyroid, most of the salivary gland
tumors are comparatively more common in
females
 Haemophilia affects male only, although the
disease is transmitted through the females
 RELIGION
 Carcinoma of genitals in male is hardly
seen in Muslims and Jews due to their
religious custom of compulsory
circumcision in infancy
 SOCIAL STATUS
 Certain diseases are rarely seen in
individuals of high society such as space
infections and oral submucous fibrosis,
probably due to increase awareness
towards oral health
 OCCUPATION
 Some diseases have shown their peculiar
predilection towards certain occupation
 Varicose veins in bus conductors and traffic
policemen due to standing for a long time
 Notching of incisors in tailors
 Erosion seen in people working in chemical industries
 RESIDENCE
 A few surgical diseases have got geographical
distribution
 Fluorosis - north karnataka(raichur, gulbarga), certain
regions of Andhra pradesh(nalgonda) , Tamil nadu and
Punjab

 Filariasis – Orissa
 Leprosy – west Bengal
 Gall bladder diseases – West Bengal
 CHIEF COMPLAINT
 It should always be recorded briefly and in patients
own word
 Patients should be asked ‘ what are your
complaints’
 A few dull patients do not really understand what
we want to know and may start irrelevant talks
 In such cases he should be asked ‘what brings you
here’
 We should also know the duration of complaints
HISTORY OF PRESENT ILLNESS
 This history commences from the beginning of first
symptom and extends to the time of examination
 This includes
 Mode of onset of the symptoms – whether sudden or
gradual, as well as the cause of onset, if at all present
 Progress of the disease – with evolution of symptoms in
exact order of their occurrence
 The treatment – which patient might have received
 PAST MEDICAL AND DENTAL
HISTORY
 All the diseases suffered by the patient, previous
to the present one, should be noted and
recorded in a chronological order
 Particular attention is paid to the diseases like
diabetes, rheumatic fever, bleeding tendencies,
tuberculosis, syphilis, asthma , endocrinal
diseases
 Any previous operation or accidents should also
be noted
 Patient should be asked about all the
drugs he was on
 Special enquiry should be made about
steroids, insulin, antihypertensive,
diuretics and oral contraceptive pills etc
 Patient should be asked whether he or she
is allergic to any medicine or diet
 PERSONAL HISTORY
 Under this heading, patients habit of smoking,
drinking of alcohol, diet are noted
 It is also enquired about the marital status of
the patient
 In women, the menstrual history must be
recorded perfectly
 Number of pregnancies should be noted
 If the patient is pregnant, enquire about the
trimester
 FAMILY HISTORY
 Many diseases do recur in families
 Haemophilia, tuberculosis, diabetes,
essential hypertension, peptic ulcer,
majority of cancers particularly the breast
cancers run in families
 2. PHYSICAL EXAMINATION
 General survey
 Extra-oral examination
 Intra-oral examination
 GENERAL SURVEY
 General assessment of illness
 Mental state and intelligence
 Build and state of nutrition
 Gait
 Facies
 Colour of skin
 Vital signs
 GENERAL ASSESSMENT OF
ILLNESS
 This is very important and should be assessed in
the first opportunity
 In case of severely ill patient or trauma patients
one should cut down the wastage of time to
know other less important findings
 Doctor should hasten the treatment after rapidly
going through the local examination to come to
a probable diagnosis and to find out those signs
which may help him to institute proper
treatment
 MENTAL STATE AND
INTELLIGENCE
 In case of chronically ill patients, the
doctor should always access the mental
state and intelligence of the individual
 An intelligent patient will give a good
history on which doctor can rely
 On the other hand doctor should not rely
wholly on the history from the patient with
very low intelligence
BUILD AND STATE OF NUTRITION

 In case of endocrinal abnormalities or

malnutrition changes can be seen in
patients build and state of nutrition
 GAIT
 This means the way patients walks
 Abnormal gait occurs due to various reasons
 Pain
 Bone and joint abnormalities
 Muscle and neurological disease
 Structural abnormalities
 Psychiatric diseases
 FACIES
 Face is the mirror of the mind
 Just looking at the face good clinician can
assess the depth of the disease and effect
of his treatment
 Mask face – parkinsonism
 Moon face – cushing syndrome
 COLOUR OF THE SKIN
 Colour of skin should be assessed for
pallor, cyanosis or jaundice
 PALLOR
 Pallor of skin is seen in massive
haemorrhage, shock, anaemia and in
intense emotion
 To check for pallor we should examine
 Lower palpebral conjunctiva
 Mucous membrane of lips and cheeks
 Nail beds
 Palmar crease
 CYANOSIS
 It is the bluish or purplish tinge of skin or
mucous membrane which results from the
presence of excessive amount of reduced
haemoglobin in the underlying blood vessels
 For cyanosis to be observed, there must be a
minimum of 5g/dl of reduced haemoglobin in the
blood perfusing the skin
 Peripheral cyanosis
 Central cyanosis
 PERIPHERAL CYANOSIS
 It is due to excessive reduction of
oxyhaemoglobin in the capillaries when the
blood flow is slowed down
 This may happen on exposure to cold
 It is also seen in patients with reduced cardiac
output when differential vasoconstriction diverts
blood flow from the skin to other more
important organs e.g. brain and kidney
 Peripheral cyanosis is looked for in the nail bed,
tip of the nose, skin of palm and toes
 CENTRAL CYANOSIS
 It occurs from inadequate oxygenation of blood
in the lungs
 This may be due to diseases in the lungs or due
to some congenital abnormalities of the heart
where venous blood by-passes the lung and is
shunted into systemic circulation
 For central cyanosis one should look at the tip of
tongue or tip of nose
 JAUNDICE OR ICTERUS
 Jaundice is due to icteric tint of skin,
which varies from faint yellow of viral
hepatitis to dark olive greenish yellow of
obstructive jaundice
 This is due to the presence of excess of
lipid-soluble yellow pigments ( bile
pigments ) in the plasma
 The places where one should look for jaundice are
 Sclera of eyeball – patient is asked to look at his feet
when the surgeon keeps the palpebral fissure wide open
by pulling up the eyelid
 Nail bed
 Lobule of ear
 Tip of nose
 Undersurface of tongue
 When the jaundice is deep and long standing, a distinct
greenish colour becomes evident in the sclera and in the
skin due to development of appreciable quantities of
biliverdin
 CLUBBING
 It is the bulbous swelling around the tip of the finger
and toe
 The angle of the nail to the skin should not exceed
160 deg. This is called as lovibond’s angle and it
determines whether the nail is clubbed or not
 It can reveal indications of systemic diseases but the
changes found are not pathognomonic for specific
diseases
 Causes:
 Respiratory cause
 Bronchitis
 Bronchogenic carcinoma
 Lung abscess
 GIT/Abdominal cause
 Ulcerative colitis
 Malabsortption syndrome
 Biliary cirrhosis
 Chron’s disease
 Cardiovascular cause
 Infective endocarditis
 Cyanotic congenital heart disease
 Endocrinal cause
 Myxoedema
 Thyrotoxicosis
 acromegaly
 VITAL SIGNS
 PULSE
 BLOOD PRESSURE
 RESPIRATORY RATE
 TEMPERATURE
 PULSE
 It gives a good indication of the cardio-vascular condition of the
patient
 Following points should be noted
 1. Rate – fast or slow
 2. Rhythm – regular or irregular
 3. Tension and force – which indicates diastolic and systolic blood
pressure
 4. volume – pulse pressure
 5. Character – water hammer pulse (aortic regurgitation or
thyrotoxicosis)
 Pulse paradoxus – pericardial effusion
 6. Condition of arterial wall – atherosclerotic thickening
 BLOOD PRESSURE
 It is measured using a sphygmomanometer and a
stethoscope
 Measurement of blood pressure is used to detect and
diagnose hypertension as well as to determine whether the
patient may have disease that causes hypertension or
results from hypertension
 If he is being treated for hypertension, a determination
should be made as to whether it is controlled or not
 Ideally the patient should be seated in a chair for several
minutes resting comfortably and the reading should be
obtained with suitable cuff.
 RESPIRATION
 The rate of respiration is the number of
inspirations recorded during one minute
 Respiration is usually rhythmic but not
always regular .
 The rate should be counted by watching the
patients chest rise and fall without making
him or her conscious about it.
 The normal rate is approximately 14 to 18
per minute
 When it is less than 14 it is termed as
bradypnea. It is seen in cases such as
 When it is more than 20 it is termed as
tachypnea and it is seen such as
 TACHYPNOEA
 Fever
 Shock
 Hypoxia
 Cerebral disturbance
 Metabolic acidosis
 Tetany
 Hysteria
 BRADYPNOEA
 Cerebral compression
 TEMPERATURE
 This is normally taken in the mouth or in
the axilla
 Temperature of mouth is about 1 degree F
higher than that of the axilla
 The average oral temperature, 37°C (98.6°F),
fluctuates considerably. In the early morning
hours it may be as low as 35.8°C (96.4°F), and in
the late afternoon or evening it may be as high as
37.3°C(99.1°F).
 HYPERPYREXIA
 Fever or pyrexia refers to an elevated body temperature.
 Hyperpyrexia refers to extreme elevation in temperature,
above 41.1°C (106°F)
 Infection
 Trauma
 Malignancy
 Drug reactions
 Immune disorders
 HYPOTHERMIA
 Hypothermia refers to an abnormally low temperature,
below 35°C (95°F)
 exposure to cold
 reduced movement as in paralysis
 Starvation
 Hypothyroidism
 hypoglycemia
 LOCAL EXAMINATION
 EXTRA-ORAL EXAMINATION
 INTRA-ORAL EXAMINATION
 INSPECTION
 PALPATION
 PERCUSSION
 AUSCULTATION
 MOVEMENTS
 MEASUREMENT
 EXAMINATION OF LYMPHNODES
 INSPECTION
 It should be carried out after complete
exposure
 Diseased site should be compared with
the corresponding normal side
 The importance of proper inspection
cannot be over emphasized, as many of
the surgical conditions can be diagnosed
by looking at it with well trained eyes
 PALPATION
 It includes feeling of the affected part by
the hands of surgeon
 Palpation will not only corroborate the
findings seen in inspection, but also added
information's with trained hands may not
require further examination to come to a
diagnosis
PERCUSSION AND AUSCULTATION

 PERCUSSION- Listening to the tapping

note with a finger on a finger placed on
the affected part
 AUSCULTATION- listening to the sounds
produced within the body with the help of
a stethoscope
MOVEMENTS AND MEASUREMENTS

 Movement of the joint concerned should

be seen, such as TMJ
 Measurement of the part of the body
concerned should be done
 EXAMINATION OF LYMPHNODES

 Lymph nodes of adjoining area should be

examined
 Submental lymph nodes
 Submandibular lymph nodes
 Upper, middle and inferior lymph nodes
around IJV
 EXTRA-ORAL EXAMINATION
 FACE
 UPPER 3RD
 MIDDLE 3RD
 LOWER 3RD

 TEMPOROMANDIBULAR JOINT
 MOUTH OPENING
 LYMPH NODES
 FACE
 Upper 3rd, middle 3rd and lower 3rd of face
should be examined for any abnormality
or facial asymmetry
TEMPOROMANDIBULAR JOINT
 The examiner is positioned either in front or behind the
patient and the path of opening observed with the
deviation noted .
 A stethoscope will reveal abnormal sound which
indicates either dysfunction of the masticatory muscles
or internal derangements within the capsule of the joint
.
 Popping is usually reversible and indicates internal
derangements .
 Crepitus indicates bone to bone contact and is
irreversible and a later stage of an internal
derangement.
 TMJ can be palpated through the anterior valve of the
external auditory meatus . It is palpated using the little
finger. If pain is present one should suspect
inflammation or internal derangement.
 MOUTH OPENING
 The maximum opening between the
incisal edges of the upper and lower
incisor teeth is 40 – 50mm in the adult
and 3 fingers end on end is considered
normal.
 INTRA-ORAL EXAMINATION
 SOFT-TISSUE EXAMINATION
 HARD-TISSUE EXAMINATION
 SOFT TISSUE EXAMINATION
 Oral mucosa
 Tongue
 Floor of the mouth
 Retromolar region
 Palate
 Pharynx
 gingiva
 HARD TISSUE EXAMINATION
 Number of teeth present
 Caries
 Missing tooth/ extracted tooth
 Mobility
 Calculus and plaque deposition
 Status of occlusion
 Impacted tooth
 PROVISIONAL DIAGNOSIS AND
DIFFERENTIAL DIAGNOSIS
 At this stage the clinician should be able
to make a provisional diagnosis
 He should also keep in mind the
differential diagnosis
 While making provisional diagnosis, first
start with common diseases and then go
for the rare diseases
 INVESTIGATION
 RADIOGRAPHS
 BLOOD INVESTIGATION
 BIOPSY
 FINAL DIAGNOSIS
 After getting the reports of special
investigation, the clinician should be able
to give proper clinical diagnosis
 TREATMENT
 On the basis of diagnosis, a proper
surgical treatment plan should be
formulated
THANK YOU