Patient Identification Data and Complaints
The title page of the document contains basic information about the patient. In surgery, the identification section includes eleven mandatory items. These include full name, age, gender, occupation, place of residence, and marital status. The date of hospital admission and a detailed clinical diagnosis (indicating the primary disease, comorbidities, and developed complications) must be recorded. If case management is carried out after a surgical intervention, additional data are entered: the name and date of the surgery, postoperative complications, and the date of discharge.
The key stage of questioning is eliciting complaints. The main rule here is their thorough detailing. Special attention is paid to the pain syndrome, for which it is necessary to establish:
- Precise localization and pathways of pain radiation.
- Time of onset and periodicity.
- Character (aching, sharp, dull) and intensity.
- Relationship with provoking factors (trauma, food intake, physical exertion, physiological excretions).
- Presence of associated manifestations (vomiting, heartburn, loss of consciousness).
- Body temperature dynamics.
- Methods of pain relief (body position, medication intake).
Any other (non-pain) complaints are detailed using a similar algorithm.
Anamnesis collection: development of the disease and patient's life
The Anamnesis morbi section (history of the present illness) reflects the dynamics of the pathological process. It records the time of appearance of the first symptoms, the features of the disease course prior to admission to the clinic, and the time of diagnosis. It is extremely important to describe the preceding treatment, the nature of first aid provided (self-help or mutual aid), and the method of patient transportation, which is of critical importance in trauma. This also includes the subjective status—an assessment of the functioning of body systems from the patient's words.
In the life history (Anamnesis vitae), factors capable of influencing the current condition and treatment outcome are assessed:
- Professional background: presence of occupational diseases and hazardous working conditions.
- Living environment: climate and ecology throughout life.
- Past conditions: previous illnesses, surgeries (their course and complications), allergic history, specifics of treatment (e.g., chemotherapy).
- Heredity and habits: health of parents, use of tobacco, alcohol, or drugs.
Objective examination and Status localis
The Status objectivus section begins with an assessment of the general condition and vital signs (temperature, respiration, pulse). Anthropometry and a sequential examination of all systems are performed: from the skin and lymph nodes to the examination of the heart, lungs, abdominal cavity, urogenital, and nervous systems.
Surgical specifics are clearly manifested in the Status localis section (findings from the examination of the lesion area). It includes:
- Inspection (Inspectio): assessment of the shape and position of the organ, skin color, vascular pattern, tissue transparency, and comparison with healthy symmetrical areas.
- Assessment of movements: checking active and passive movements, measuring the range of joint mobility, identifying pathological mobility and tenderness.
- Percussion (Percussio): determining the character of the sound, localization and boundaries of dullness, as well as their displacement upon posture changes.
Diagnostic search and treatment tactics
The examination plan is structured to confirm hypotheses and includes laboratory, radiological, instrumental, and invasive methods (e.g., puncture or biopsy).
Algorithm for substantiating a preliminary diagnosis:
- Identification of the affected system (digestive, circulatory, musculoskeletal, etc.).
- Grouping of identified symptoms based on the general mechanism of their development.
- Determination of the leading clinical syndrome.
- Synthesis of data and comparison with known nosologies.
After a complete examination, a clinical (final) diagnosis is established. A treatment plan is formed based on it. It must reflect the indications and contraindications for surgery, the degree of its urgency, and the anticipated scope. Treatment itself is divided into conservative (medications, preoperative preparation) and surgical (specific type of intervention). The case history concludes with the determination of the prognosis for the patient's life (Quoad vitam).
Briefly: answers to topical questions
What eleven mandatory items are included in the patient identification section of the case history?
The patient identification section of the case history includes eleven items:
- Full name.
- Age.
- Gender.
- Occupation and place of work.
- Permanent place of residence.
- Marital status.
- Date of hospital admission.
- Clinical diagnosis: primary disease, comorbid conditions, complications of the primary disease.
- Surgery: name and date.
- Postoperative complications.
- Date of discharge.
What classical physical examination methods are used in assessing Status objectivus?
When assessing the patient's objective status, four classical general clinical methods of physical examination are used.
- Inspection (Inspectio) — assessment of the position and shape of the organ, skin color, tissue transparency, and vascular pattern.
- Palpation — identification of tenderness, tumor-like masses, and reflex tension of the abdominal wall muscles.
- Percussion (Percussio) — determination of the character of the sound, boundaries, and localization of dullness.
- Auscultation — a method of listening, which mandatorily complements abdominal palpation.
Class and exam questions
What is the main feature of the patient identification section in a surgical case history?
In surgery, the patient identification section must include information about the surgery (its name and date), the presence of postoperative complications, and the date of discharge.
How to correctly substantiate a provisional diagnosis?
The process consists of four steps: identifying the affected system, grouping symptoms by general development mechanism, isolating the leading syndrome, and final synthesis (comparison with known diseases).
What must be specified when detailing pain syndrome?
It is necessary to indicate the localization and radiation of pain, time of onset, character, periodicity, relationship with provoking factors, associated symptoms, temperature, and methods of relief.
What is included in the concept of Status localis?
This is a detailed examination of the organ or lesion area, which includes visual inspection, assessment of active and passive joint movements, and percussion.
What else to study on this topic
- Algorithm for detailing pain syndrome and other complaints
- Taking the personal and medical history: from occupational hazards to heredity
- Methodology for examining the affected area (Status localis)
- Stages of substantiating provisional and clinical diagnoses
- Determining the indications and urgency of surgical intervention
Master the entire topic in the "General Surgery" course
This is a summary. The course covers everything tested in classes and exams.
- Complete methodical guide on "Case History of a Surgical Patient" and 3,335 more pages on the subject
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 70 video lessons on the subject
Other Topics in «CHAPTER 9. EXAMINATION OF THE SURGICAL PATIENT»
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.