Structure of an Educational Surgical Case History
Sections in the order expected by most academic departments. The generator uses this exact structure; if your department requires a specific format, upload it as a template.
- 1General patient data
Age (not date of birth), gender, occupation/profession (omit organization name), date and time of admission, department, referral source/delivery method, referring facility diagnosis, admission diagnosis. Do not include full name, address, or document numbers: use "Patient N."
- 2Complaints
Chief complaints with details (localization, character, intensity, radiation, duration, triggers, and relieving factors) along with general symptoms; complaints upon admission and at the time of examination.
- 3History of the present illness (Anamnesis morbi)
Onset and progression, initial symptoms, clinical course, previous medical consultations, prior diagnostic tests and treatments before admission along with their efficacy, as well as the reason and circumstances of hospitalization.
- 4Past Medical History (Anamnesis vitae)
- Brief biographical data, living conditions, and dietary habits
Birthplace and upbringing, education, housing and living conditions, dietary habits, physical activity.
- Occupational history
Profession, length of service, working conditions, occupational hazards (without naming the organization).
- Past medical history, surgeries, injuries
Childhood infections, chronic diseases, surgeries, trauma, tuberculosis, viral hepatitis, STIs, blood transfusions (with reactions).
- Bad habits
Smoking (duration, pack-years), alcohol (frequency, quantity), illicit drug use.
- Medication history
Regular medications taken by the patient (name, dose, frequency).
- Allergic history
Drug, food, and household allergen intolerance; type of reaction.
- Epidemiological history
Contact with infectious patients, travel outside the region/country over the past 6 months, parenteral interventions, bites, dietary history, contact with animals.
- Family history
First-degree relatives' medical history (CVD, diabetes mellitus, oncology, tuberculosis, psychiatric conditions).
- Obstetric and gynecological history
For women: menarche, menstrual cycle characteristics, menopause, pregnancies/childbirth/abortions.
- Insurance history
Certificate of incapacity for work (duration), disability group.
- 5Objective examination (Status praesens objectivus)
- General physical examination
General condition, level of consciousness, body position, physique, body type, height, body weight, BMI, body temperature; skin and visible mucous membranes, subcutaneous adipose tissue, edema, lymph nodes, muscles, bones, joints.
- Respiratory system
Chest inspection, respiratory rate, palpation (resistance, vocal fremitus), comparative and topographical percussion, auscultation (breath sounds, rales, crepitation, pleural friction rub), bronchophony, SpO2.
- Cardiovascular system
Inspection of the heart and neck vessels, apex beat, boundaries of relative cardiac dullness, auscultation (heart sounds, murmurs), pulse (rate, rhythm, volume, tension), blood pressure on both arms, peripheral arterial pulsation.
- Digestive system
Oral cavity, tongue, abdomen (inspection, superficial and deep palpation according to Obraztsov-Strazhesko, percussion, auscultation), liver dimensions according to Kurlov, gallbladder (symptoms), spleen, stool.
- Urinary system
Lumbar region inspection, kidney palpation, tapping sign (Pasternatsky's sign), urination, diuresis.
- Endocrine system
Thyroid gland (palpation, eye signs), subcutaneous fat distribution, secondary sexual characteristics.
- Nervous system and sense organs
Consciousness, orientation, sleep, memory, meningeal signs, focal symptoms, reflexes, vision, hearing.
- 6Local status (Status localis)
Detailed description of the lesion area: inspection, palpation, percussion, auscultation; dimensions, borders, tenderness, peritoneal irritation signs and special tests (Shchetkin–Blumberg, Rovsing, Sitkovskiy, Ortner, Murphy, etc.).
- 7Preliminary diagnosis and its rationale
Identify syndromes based on complaints, history, and objective data, justify each; formulate a preliminary diagnosis.
- 8Examination plan
Laboratory and instrumental studies and consultations with the purpose of each: according to clinical guidelines of the Russian Ministry of Health (mandatory and as indicated).
- 9Results of laboratory and instrumental studies
All available results with dates (in a table where appropriate) and interpretation: what is normal, what is abnormal, and what it means. Unperformed/missing studies should be listed as "no data".
- 10Differential diagnosis
At least 2–3 diseases with a similar presentation: for each, common features and differences used to rule it out (based on this patient's data).
- 11Clinical diagnosis and its rationale
Formulation according to the classification from clinical guidelines and ICD-10 (code): underlying disease, complications of the underlying disease, comorbid conditions; rationale for each component.
- 12Etiology and pathogenesis
Etiology and pathogenesis of the disease in general and applied to this patient (risk factors, mechanisms of syndrome development).
- 13Preoperative epicrisis
Rationale for the diagnosis, indications for surgery (absolute/relative), choice of surgical technique and anesthesia, operative-anesthetic risk (ASA), patient consent, preoperative preparation.
- 14Operative report
- 15Treatment and its rationale
Regimen, diet, non-pharmacological treatment, pharmacotherapy: drug (INN), dose, route, frequency, duration, and rationale with reference to clinical guidelines; At the end: prescriptions in Latin (Rp.: … D. S. …) for 2–3 main medications. Separately: surgical treatment (type, approach, rationale) and postoperative management.
- 16Curation logs (postoperative period)
- 17Stage (discharge) epicrisis
Briefly: patient, age, date of admission, reason for admission, main examination results, clinical diagnosis, treatment performed and its effect, condition at the end of curation, recommendations.
- 18Prognosis and recommendations
Prognosis for life, for recovery, for working capacity (with justification); discharge recommendations and follow-up care according to clinical guidelines.
- 19References
formatted according to GOST R 7.0.100-2018.
How a surgical case history differs from a therapeutic one
The department of surgery checks whether you can describe a pathological focus so that the text visualizes the picture, and whether you can justify the indications for surgery and its urgency. In general surgery, patients with wounds and purulent soft tissue infections are more often curated, and status localis becomes paramount. In faculty surgery, typical acute and elective abdominal diseases are analyzed, while in hospital surgery, the focus is on differential diagnosis and complicated forms.
Status localis
Described in a separate section after the general status. For the abdomen: shape, involvement in respiration, tension of the anterior abdominal wall muscles, area of tenderness, peritoneal signs and symptoms of the suspected disease with the authors' names (Rovsing, Sitkovskiy, Voskresenskiy, Shchetkin-Blumberg, Ortner, Murphy), abdominal percussion and auscultation. In acute abdomen, digital rectal examination is mandatory. For hernia: dimensions of the protrusion, reducibility, cough impulse test, size of the hernia ring. For wounds, ulcers, and fistulas: location, dimensions in centimeters, edges, base, discharge, state of surrounding tissues.
Which sections are checked more strictly
- Preoperative epicrisis: diagnosis, indications for surgery and their urgency (emergency, urgent, elective), planned scope and approach, type of anesthesia, ASA physical status classification, Caprini score VTE risk and prevention measures, antibiotic prophylaxis, informed consent of the patient.
- Operation report: date, start and end time, surgical team, anesthesia, approach, findings on exploration, stages of the operation, drainage, specimens sent for histological examination.
- Classifications in the diagnosis: severity of acute pancreatitis (mild, moderate, severe), severity of acute cholecystitis according to the Tokyo Guidelines, type of hernia by location and reducibility, CEAP clinical class for chronic venous diseases.
- Postoperative logs: condition of the wound and dressing, drains and their output, temperature, bowel motility, stool, diuresis, mobilization.
Alvarado and Caprini scores are conveniently calculated in the clinical scales section, and the scope of examination and treatment can be checked against clinical guidelines.
Example of a surgical case history: acute appendicitis
Model example, the patient is fictional. Patient N., 27 years old, delivered 14 hours after the onset of the disease.
Status localis
Tongue is dryish, coated with white fur. Abdomen is of normal shape, right half lags behind in respiration. On superficial palpation, muscular defense and marked tenderness in the right iliac region. Rovsing, Sitkovskiy, Voskresenskiy, and Shchetkin-Blumberg signs are positive. Ortner and Murphy signs are negative, costovertebral angle tenderness sign is negative on both sides. Bowel sounds are audible, weakened. On digital rectal examination, there is no bulging or tenderness of the walls.
Justification of the diagnosis
The diagnosis of "acute appendicitis" was made based on:
- complaints of pain that started in the epigastrium and shifted to the right iliac region after 4 hours (Kocher-Volkovich sign), nausea, and single episode of vomiting;
- local tenderness and muscular defense in the right iliac region, positive Rovsing, Sitkovskiy, Voskresenskiy, and Shchetkin-Blumberg signs;
- temperature of 37.6 °C, leukocytosis of 13.2 × 10⁹/L with a left shift of the leukocyte formula;
- ultrasound data: appendix with a diameter of 9 mm, non-compressible with the transducer, wall thickened.
Alvarado score is 9 points: pain migration, nausea and vomiting, tenderness in the right iliac region, Shchetkin-Blumberg sign, temperature, leukocytosis, and left shift of the formula. Negative Ortner, Murphy, and costovertebral angle tenderness signs help rule out acute cholecystitis and renal colic.
Clinical diagnosis and preoperative epicrisis
Main disease: Acute appendicitis.
ICD-10 code: K35.8 (acute appendicitis, other and unspecified).
Indications for emergency surgery: acute appendicitis. Laparoscopic appendectomy under endotracheal anesthesia is planned. ASA physical status classification I. VTE risk assessed using the Caprini scale, early mobilization prescribed. Antibiotic prophylaxis 30–60 minutes before the incision (verify the drug and dose with clinical guidelines and department protocol). Informed consent for surgery and anesthesia was obtained.
After surgery, the diagnosis is refined based on intraoperative findings and histology, for example, "Acute phlegmonous appendicitis". If local (limited) peritonitis is found, the code changes to K35.3; in case of generalized peritonitis, to K35.2.
Common mistakes in a surgical case history
- Status localis is mixed with the general status or reduced to a single phrase "abdomen is tender in the right iliac region".
- Only positive signs are listed; negative signs for differential diagnosis are not specified.
- In acute abdomen, digital rectal examination is missing.
- Time from disease onset to admission and to surgery is not indicated.
- Preoperative epicrisis lacks indications and their urgency, type of anesthesia, risk assessment, and patient consent.
- Operation report lacks findings on exploration, stages, drainage, and sending material for histology.
- Morphological form ("phlegmonous", "gangrenous") is specified in the diagnosis even before surgery.
- Postoperative logs lack description of the wound, drains, bowel motility, stool, and temperature.
- Real patient data used in the identification section instead of anonymized data.
Compile your own surgical case history
The patient can be simulated for a specific condition, or you can upload your own clinical notes (text, handwritten photos, audio). Cross-checked with clinical guidelines, ICD-10 coding, and export to Word and PDF. 2 case histories per month for free.
Frequently asked questions
What is the scheme of a surgical patient's case history?
Identification section (anonymized), complaints, history of present illness and life history, general status, status localis, provisional diagnosis and examination plan, differential diagnosis, clinical diagnosis, preoperative epicrisis, operation report, postoperative logs, epicrisis, and references. The order and set of sections may vary between departments, so check with your methodical guidelines.
How to describe status localis in a surgical case history?
Describe the focus according to the scheme: inspection, palpation, percussion, auscultation: shape and dimensions, tenderness, tissue tension, specific signs with authors' names and their results. Indicate negative signs required for differential diagnosis. Dimensions of wounds, hernias, and infiltrates are written in centimeters.
What to write in the preoperative epicrisis?
Diagnosis, indications for surgery and their urgency, planned surgery and approach, type of anesthesia, assessment of surgical and anesthetic risk, VTE prevention and antibiotic prophylaxis, note on the patient's informed consent. The epicrisis must logically follow from the justification of the diagnosis.
How does a case history in general, faculty, and hospital surgery differ?
General surgery usually describes wounds and purulent soft tissue infections, and the main section there is status localis. Faculty surgery analyzes typical abdominal diseases, while hospital surgery pays more attention to differential diagnosis, complicated forms, and choice of tactics.
What to do if the curated patient did not undergo surgery?
The operation report is not written in this case; instead, the chosen tactics are justified: conservative treatment, observation, or elective surgery later. Some departments ask to describe the planned intervention, so clarify this with your instructor.
Can a surgical case history be written using a neural network?
You can use a neural network to understand the topic and compile a draft, and you will defend the work yourself. The generator compiles a study case history following the surgical scheme or your department's uploaded template based on curation notes (text, file, photo of handwriting, audio), checks the diagnosis and treatment against the Russian Ministry of Health clinical guidelines, assigns the ICD-10 code, and marks missing data as "not specified". Do not insert real full name, date of birth, address, and insurance policy of the patient into the prompt: this is medical confidentiality (Article 13 of Federal Law No. 323-FZ) and personal data (Federal Law No. 152-FZ), the identification section is written anonymously. 2 case histories per month are available for free on any account, and another 5 on the "Maximum" plan.
Case histories for other subjects
How the generator works and how to check its output: case history with AI. All tools: AI for medical professionals.