Dr. Md.

Abdul Alim Shaikh

Assistant Professor, Dept. of Surgery
HISTORY-TAKING:
1. Particulars of the patient
NAME:
 The patients likes and assured by name.
 It helps to elicit the history properly
AGE:
 Congenital anomalies mostly present-
 Since birth- Cystic hygroma, Cleft lip, Cleft
palate, Phimosis etc.
 Later in life- Thyroglossal cyst, Persistent urachus,
Branchial cyst, Branchial fistula.
 Child hood tumours- Neuroblastoma,
Retinoblastoma, Hepatoblastoma,
Nephroblastoma.
 Teen age- Sarcomas, Appendicitis.
 After 40 years- Carcinoma.
 Old age- Osteoarthritis and Benign hypertrophy of
the prostate.
SEX:
 Common in female- Cystitis, Gall stone diseases,
Carcinoma of Breast, Thyroid diseases.
 In male- Carcinomas of Stomach, Lungs, Kidneys.

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  Haemophilia affects males only, and transmitted
through the females.
RELIGION:
 Carcinoma of penis is hardly seen in Jews and
Muslims due to circumcision in infancy.
OCCUPATION:
 Varicose veins- common among bus conductors.
 Urinary bladder neoplasms- Workers in aniline
dye factories.
 Carcinoma of the scrotum- Chimney sweepers.
 Footballers- Medial meniscus injury.
 Enlargement of bursa- by repeated friction e.g.
student's elbow.
RESIDENCE:
 Goitre common in North Bengal.
 Carcinoma of stomach common in Japan.
DATE OF ADMISSION:
DATE OF EXAMINATION:
2. Presenting Complaints:
 What are your complaints?
 Record in a chronological order with durations e.g.
(a) Swelling in the neck — 1 year.
(b) Fever (mostly in the evening) — 10 months.
(c) Slight pain in the swelling — 6 months.
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 (d) Sinus in the neck — 1 month.
 Or list them in order of severity
3. History of Present Illness:
 Elaborate each presenting complaints,
 Patient’s own wards,
 Avoid medical terms.
 Positive history for diagnosis,
 Negative history to exclude other diagnosis.
 Any features of Metastasis, features of Tuberculosis
(Particularly in swellings)
 Bowel and Bladder habits
 Suffering from DM, HTN, Bronchial Asthma, other
chronic diseases.
4. Past History:
 Previous diseases e.g. TB, Malignancy
 Any of the previous operations or accidents
 Recorded in a chronological order.
5. Treatment history:
 For Present illness or Previous illness
 Enquiry about Steroids, Insulin, Anti-hypertensive,
Diuretics, Anti platelet drug, Monoamine oxidase
inhibitors, Hormone replacement therapy,
Contraceptive pills etc.
 With Dose & Duration of drug.
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6. Family history:
 None of family member (Father, Mother, Brothers,
Sisters and children) suffered such kind of disease.
 Most Malignancy-Breast cancer, Colon cancer,
Haemophilia, Tuberculosis, Diabetes, Essential
hypertension etc. run in families.
7. History of allergy:
 He or she is allergic to any medicine or diet.
8. Personal history:
 Habit of smoking (cigarettes, cigar or pipe and the
frequency)
 Drinking of alcohol (quality and quantity)
 Diet-
 Socio-economic status.
(High social status e.g. acute appendicitis, Low social
status e.g. tuberculosis due to malnourishment)
 Menstrual & Obstetric history ( In Female)
 Age of menarche
 Menstrual period
 Menstrual cycle-Regular or not
 Last date of menstruation
 Menopause- for 5 years
 Obstetric history
 Number of pregnancy

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  Any abortion
 Mode of Delivery-Vaginal or Caesarean section
 Age of last child.
9. History of immunization:
 Immunized against Tuberculosis, Tetanus, Hepatitis-B
etc. or as per EPI schedule.

10. Examinations:
General:
 Appearance: Normal/ill looking/Toxic-Perforation.
 Decubitus (Position in bed):
 Supine-Perforation, Leaning forward-Pancreatitis.
 Co-operation: Cooperative/Non cooperative
 Body Built: Average/Tall stature/Short stature
 Nutrition: Normal/average/Poor or Cachectic
 Cachectic found in Malignancy, Mal absorption
syndrome.
 Anemia: Absent/Mild/Moderate/Severe.
 Found in Malignancy or chronic disease
 Site- Lower palpebral conjunctiva, Dorsum of
tongue, Mucous membrane, Palmar creases, Nail
beds, Sole of foot & Generalized skin.
 Jaundice: Absent/Mild/Moderate/Severe
 Site- Upper sclera, Under-surface of the tongue
between frenulum & lingual veins, nail bed, Palms
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 & sole of foot, Mucous membrane, Generalized
skin.
 Cyanosis: Present/Absent
 Peripheral cyanosis-Nail bed, Tip of the nose, Skin
of the palm and toes.
 Central cyanosis- Tip of the tongue
 Clubbing:
 Oedema:
 Pitting
 Non-pitting- Myxoedema, Filariasis.
 Site-Over medial malleolus of tibia, over the sacrum,
Malar prominence of face.
 Pigmentation:
 Engorged neck veins:
 Lymph node:
 Pulse: Increased in shock, Infection, Abscess, pain.
 Blood pressure: Fall in shock.
 Respiration:
 Temperature: Increased in Infection, Abscess.
11. EXAMINATION OF ABDOMEN
A. Inspection:
 Shape of abdomen: normal/scaphoid/distended
 Position of umbilicus: central/not
 Flanks –Full in Ascites, Obesity.
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  Movements of abdomen: (Examiner’s eye must be at
the level of patient’s abdomen)
Respiratory-
 In Male: Abdomino-thoracic
 In Female-Thoraco-abdominal
 In child-purely abdominal
 No movement-Perforation, Generalized
peritonitis
Visible peristalsis-From left to right-Gastric outlet
obstruction, Right to left-Left colonic obstruction,
Step ladder pattern-Small intestinal obstruction.
Visible pulsation-Expansile-Abdominal Aortic
Aneurysm, Transmitted-Growth over Aorta.
 Skin over the abdomen: Any scar/pigmentation/venous
engorgements
 Any obvious swelling: Brief description of the
swelling
 Hernial orifices: Intact/Any expansile impulse on
cough
 External genitalia
B. Palpation:
 Superficial palpation
 Temperature
 Tenderness
 Any muscle guard/Rigidity
 Any swelling
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  Deep palpation
 Any tenderness
 Palpation of liver/spleen/kidneys (Kidneys-
Bimanually palpable or Ballotable)
 Palpation of any swelling
 Fluid thrill
C. Percussion:
 General-Tympanitic
 Shifting dullness
 Upper border of liver dullness-Right 5th intercostal
space
 Percuss over the lump
D. Auscultation:
 Bowel sounds-Absent in Intestinal obstruction,
Paralytic ileus.
 Any added sound
E. Per-rectal examination
 Pelvic deposit-In pelvic metastasis of malignancy

12. EXAMINATION OF RESPIRATORY SYSTEM

13. EXAMINATION OF CARDIOVASCULAR SYSTEM
14. EXAMINATION OF NERVOUS SYSTEM

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15. Salient feature
 Summary of history & clinical finding in favour of
diagnosis and some negative points to exclude
differential diagnosis.
16. Clinical/Provisional Diagnosis
 Most likely diagnosis
17. Differential Diagnosis
 Points in favour
 Points against favour
18. Investigations
 For diagnosis & exclude differential diagnosis
 For staging-In malignant case
 For fitness of anaesthesia
19. Confirm diagnosis
20. Treatment
21. Follow up

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History of pain:
 Pain is an unpleasant sensory and emotional
experience associated with actual or potential tissue
damage
 The word 'pain' is derived from Latin word 'poena'
which means penalty or punishment
 Pain is an indicator of disease
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  It is due to inflammatory, infective or obstructive
pathology
 Most common & important symptom for every body
system
 Responses to pain vary with age, sex, ethnic origin,
education and personality
 The patient feels pain – the doctor elicits tenderness.
 Pain is a symptom and tenderness is a sign.

When patient complaints pain, please ask (Formula-

SOCRATES)
S: Site – where is the pain?
O: Onset- is it sudden or gradual?
C: Character-What is the nature/character of pain?
R: Radiation-Does the Pain move to anywhere?
(Radiation, Referred, Shifting)
A: Associations-Associated symptoms like Nausea,
Vomiting, Fever, sweating.
T: Timing/Duration-How long are you suffering from
pain?
E: Exacerbating/relieving factors
S: Severity-How severe is it?
Site of pain:
 The site of pain is a good indicator of its origin
 GIT Pain Foregut origin- in Epigastrium
 GIT pain Midgut origin-Umbilical region
 GIT pain Hindgut-Hypogastrium
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  Epigastrium – Gastric ulcer, Duodenal ulcer,
Cholecystitis, Pancreatitis.
 Retrosternal chest pain-Acute MI, GERD (Gastro
oesophageal reflux disease
 Right hypochondriac –Cholecystitis, Viral hepatitis,
Liver abscess, Subphrenic abscess
 Left hypochondriac- Splenic abscess
 Loin-Renal colic, Acute pyelonephritis
 Right iliac fossa-Acute Appendicitis, Acute
Salpingitis
 Left iliac fossa-Volvulus
 Generalized/whole abdominal pain-Peritonitis,
Gastroenteritis.

The abdomen is divided into nine areas for ease of

description:
 These regions are demarcated by the midclavicular
lines in the vertical axis and by the transpyloric and
transtubercular lines in the horizontal axis.
 It also indicates some of the common organs and
pathological processes that commonly cause pain
experienced in these regions

Onset of pain:
 Sudden: Acute case-Acute cholecystitis, Acute
appendicitis
 Gradual: Chronic case-Chronic duodenal ulcer,
Chronic cholecystitis

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Severity:
 Severe-Acute pancreatitis, Perforation of PUD,
Ureteric colic
 Less severe-Renal colic-Dull ache

Nature/character of pain
 Colic/colicky pain:
Intermittent spasmodic or griping pain found in
tubular structures (GIT, Biliary tree, Ureter, Fallopian
tube) which have peristalsis due to obstruction e.g.
Intestinal colic in intestinal obstruction, biliary colic in
Stone in CBD, Acute cholangitis, Ureteric colic in
stone in ureter, Renal colic is misnomer.
 Continuous pain: It is due to ischaemia e.g.
strangulation of gut in volvulus, or in strangulated
hernia
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  Constricting pain:Something is encircling and
compressing from all directions e.g. angina pectoris,
Acute MI
 Burning pain: PUD, Cystitis, Urethritis
 Throbbing pain: Tense pain, increase in tension with
each heart beat e.g. Pyegenic abscess, Aneurysm
 Dull ache pain: This is a mild continuous pain e.g.
Renal colic
 Stabbing pain: Pleuritic pain
 Shooting pain: In sciatica when pain shoots along the
course of the sciatic nerve
 Pin & needle sensation/Numbness: Injury to the
peripheral sensory nerve, Peripheral neuropathy

Movements of pain:
 Pain may move from one place to the other place
3 types
 Radiation
 Referred
 Shifting or migration of pain.
Radiation of pain:
 Pain is felt at one site in the beginning then it goes to
another site and the pain persists at original site & the
area between both sites
 The pain in the epigastrium which radiates to the
back e.g.
 Duodenal ulcer
 Acute cholecystitis
 Acute pancreatitis
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Referred pain:
 Pain is at one site in the beginning and patient felt at a
distance site but there is no pain the area between both
sites
 In Acute cholecystitis, Pain right upper abdomen
which referred to the tip of right shoulder or inferior
angle of scapula or between shoulder blades.
 (It is due to Irritation or inflammation of the
diaphragm, here diaphragm is supplied by phrenic
nerve (C3, 4 and 5) and the cutaneous supply of the
shoulder is also C4 and C5causes)
Shifting or migration of pain:
 Pain is felt at one site in the beginning then it goes to
another site and the pain at original site disappears
 In Acute appendicitis pain is first felt at the umbilical
region, then it shifted to right iliac fossa
 (In acute appendicitis pain is first felt at the umbilical
region which is supplied by the T9 and 10 spinal
segment, but later on pain is felt in the right iliac fossa
when the parietal peritoneum becomes inflamed)
Duration of the pain:
 The period from the time of onset to the time of
disappearance e.g. Intestinal colic is felt for less than a
minute
Periodicity of pain:
 Pain recurs in episodes lasting for one to several
weeks, then pain free intervals of weeks or months e.g.
Duodenal ulcer, Trigeminal neuralgia

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Precipitating or aggravating factors:
 Peptic ulcer disease –Smoking, alcohol, NSAIDs,
Steroid
 Duodenal ulcer-Empty stomach
 Gastric ulcer-After meal
 Cholecystitis-Fatty meal
 Acute pancreatitis-Alcohol
 Peritonitis/Perforation/Ureteric colic-Movement
 Musculoskeletal pains- Joint movements

Relieving factors:
 Peptic ulcer disease-Antacids or PPI
 Duodenal ulcer- After meal
 Gastric ulcer-Antacid or PPI
 Acute pancreatitis-Leaning forward
 Gastric outlet obstruction-Vomiting

Associated symptoms:
 Acute appendicitis-Shifting pain in right iliac fossa
associated with nausea, vomiting, low grade fever.
 Acute pyelonephritis/ureteric colic-Loin pain may be
associated with high fever with chills & rigor, Burning
micturition, haematuria.
 Acute cholangitis-Right upper abdominal pain may be
associated with jaundice, high colour urine, pale stool
and high fever with chills & rigor

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Acute appendicitis
 Sudden, Severe, Colicky pain, first felt at the umbilical
region, then it shifted to right iliac fossa associated
with nausea, vomiting, low grade fever

Acute cholecystitis
 Sudden, severe, colicky or constant pain in Right upper
abdomen
 may radiate to the back and may
 referred to the tip of right shoulder or inferior angle of
scapula or between shoulder blades,
 Associated with nausea and vomiting, fatty food
intolerance & Jaundice, aggravated by fatty meal &
relieved by antispasmodic drugs or spontaneously
Chronic cholecystitis
 Gradual in onset, mild discomfort to severe, colicky or
constant pain in Right upper abdomen which may
radiate to the back and
 which may referred to the tip of right shoulder or
inferior angle of scapula or between shoulder blades,
 associated with nausea and vomiting, fatty food
intolerance & Jaundice, aggravated by fatty meal &
relieved by antispasmodic drugs or spontaneously
Acute pancreatitis
 Pain in the epigastrium or diffusely throughout the
abdomen,
 Develops quickly, reaching maximum intensity and
persists for hours or even days.

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  Pain is sudden in onset, severe, constant and refractory
to the usual doses of analgesics.
 It radiates to the back or chest and may gain relief by
sitting or leaning forwards.
 Nausea, repeated vomiting and retching
Duodenal ulcer:
 Pain in epigastrium, sudden in onset, severe, burning in
nature, aggravated in empty stomach, anxiety,
smoking, alcohol & relieved by taking meal & H2
blocker or antacid.
 Pain is radiates to back
 Pain was periodic & associated with good appetite

Gastric ulcer:
 Pain in epigastrium, sudden in onset, severe, burning in
nature, aggravated after taking food, anxiety, smoking,
alcohol & relieved by vomiting which is often induced,
taking H2 blocker or antacid.
 Pain is radiates to back
 Periodicity of pain was not well marked & associated
with afraid taking food, weight loss, haematomesis &
melaena.

Renal colic:
 Dull aching pain in Loin, No radiation, pain may be
associated with Burning micturition, haematuria, high
fever with chills & rigor,.
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Upper Ureteric colic:
 Sudden, severe, colicky pain in Loin which radiates to
groin, pain may be associated with Burning
micturition, haematuria, high fever with chills & rigor.

Lower Ureteric colic:

 Sudden, severe, colicky pain in Groin which radiates to
upper part of inner aspect of thigh, Tip of penis, Labia
majora, pain may be associated with Burning
micturition, haematuria, high fever with chills & rigor.

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