In this chapter it will be narrated in brief, how to follow a patient from his arrival at the hospital or clinic up to his normal condition, i.e., after he has come round. It is a general scheme and applied to all patients whoever come to the surgeon. The student should learn this scheme and make it a reflex, so that he can apply this scheme to all his patients. Ultimately, this will become a habit in his professional career.
This general scheme includes—(1) History taking; (2) Physical examination; (3) Special investigation; (4) Clinical diagnosis; (5) Treatment—both medical and surgical; (6) Progress during postoperative period; (7) Follow-up; (8) Termination.
In the clinic, it is a good practice to start examining the patient when he walks into the room rather than to meet him undressed on a coach in a cubicle. It is helpful if the person, who accompanied the patient, remains by the side of the patient in the early part of the history- taking. He can provide valuable information about the type of injury the patient might have sustained, some details of the complaints or about changes in health or behavior of the patient in the recent past.
HISTORY-TAKING
1. Particulars of the patient: Before interrogating about the complaints of the patient, it is a good practice to know the patient first. That means the following headings should be noted in the history sheet:
Name: It is very important to know the patient by name. The patients like to be asked by name, as for example, ‘Mr. Sirkar, how long are you having this problem?’ 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. The patient is assured that you know him by name.
Age: Congenital anomalies mostly present since birth, e.g., cystic hygroma, cleft lip, cleft palate, sacrococcygeal teratoma, phimosis, etc. But a few congenital anomalies present later in life, such as persistent urachus, branchial cyst, branchial fistula, etc. Certain diseases are peculiar to a particular age. Acute arthritis, acute osteomyelitis, Wilms’ tumor of the kidney are found mostly in infants. Sarcomas affect teenagers. Appendicitis is commonly seen in girls between 14 to 25 years of age. Though carcinomas affect mostly those who have passed 40 years of age, yet it must be remembered that they should not be excluded by age alone. Osteoarthritis and benign hypertrophy of the prostate are diseases of old age.
Sex: It goes without saying that the diseases, which affect the sexual organs, will be peculiar to the sex concerned. Besides these, certain other diseases are predominantly seen in a particular sex, such as diseases of the thyroid, visceroptosis, movable kidney, cystitis are common in females, 2whereas carcinomas of the stomach, lungs, kidneys are common in males. Hemophilia affects males only, although the disease is transmitted through the females.
Religion: Carcinoma of penis is hardly seen in Jews and Muslims owing to their religious custom of compulsory circumcision in infancy. For the same reason, phimosis, subprepucial infection, etc., are not at all seen in them. On the other hand, intussusception is sometimes seen after the month-long fast (Ramjan) in Muslims.
Social status: Certain diseases are more often seen in individuals of high social status, e.g., acute appendicitis; whereas a few diseases are more often seen in individuals of low social status, e.g., tuberculosis due to malnourishment and poor living conditions.
Occupation: Some diseases have shown their peculiar predilection towards certain occupations. As for example, varicose veins are commonly seen among bus conductors. Workers in aniline dye factories are more prone to urinary bladder neoplasms than others. Carcinoma of the scrotum is more commonly seen among chimney sweepers and in those, who work in tar and shale oil. Injury to the medial semilunar cartilage of the knee is common among footballers and miners. Enlargement of certain bursae may occur from repeated friction of the skin over the bursae, e.g., student's elbow, housemaid's knee, etc. Strain to the extensor origin from the lateral epicondyle of the humerus is commonly seen among tennis players and is known as ‘tennis elbow’.
Residence: A few surgical diseases have got geographical distribution. Filariasis is common in Odisha, whereas leprosy in Bankura district of West Bengal. Gallbladder diseases are common in West Bengal and Bangladesh. Peptic ulcer is more commonly seen in northwestern part and southern parts of India as they are habituated to take more spicy foods. Bilharziasis is common in Egypt, sleeping sickness in Africa and hydatid disease in sheep-rearing districts of Australia, Greece, Turkey, Iran, Iraq, UK, etc. Tropical diseases, such as amoebiasis, are obviously common in tropical countries. ‘Kangri’ cancer (Fig. 1.1) is peculiar among the Kashmiri on their abdomen due to their habit of carrying the ‘Kangri’ (an earthenware filled with burning charcoal to keep themselves warm).
In this column, the students must not forget to write the full postal address of the patient for future correspondence.
2. Chief complaints: The complaints of the patient are recorded under this heading in a chronological order of their appearance. The patient is asked, ‘What are your complaints?’ A few dull patients do not really understand what do you want to know and may start irrelevant talks. In that case, he should be asked, ‘What brings you here?’. You should also know the duration of these complaints. For this, ask the patient, “How long have you been suffering from each of these complaints?” These should be recorded in a chronological order. As for example, in case of a sinus in the neck, the complaints may be put down in the following way:
(a) Swelling in the neck—1 year.
(b) Fever (mostly in the evening)—10 months.
(c) Slight pain in the swelling—6 months.
(d) Sinus in the neck—1 month.
The students should make it very clear that the patient was free from any complaint before the period mentioned by the patient. For this, the student should ask the patient with sinus in the neck, “Were you perfectly well before the appearance of swelling in the neck?” This is very important, as very often the patients may not mention some of his previous complaints as he considers them insignificant or unrelated to his present trouble. But, on the contrary, this may give a very important clue to arrive at a diagnosis. As for example, a patient with rigidity and tenderness in right hypochondriac region of the abdomen may not have told you of his ‘hunger pains’ a few months back. But this simple hint at once tells you that this is a case of peptic perforation.
3. History of present illness: This history commences from the beginning of the first symptom and extends to the time of examination. This includes: (i) the mode of onset of the symptoms—whether sudden or gradual, as well as the cause of onset, if at all present; (ii) the progress of the disease with evolution of symptoms in the exact order of their occurrence; and lastly (iii) the treatment which the patient might have received—the mode of treatment and the doctor, who has treated. To know the mode of onset, the patient is asked, “How did the trouble start?” To know the progress of the disease, the patient is asked, “What is the next thing that happened?” or any such relevant question as the type of case may necessitate. This should be recorded in the patient's own language and not in scientific terms. The patient should be allowed to describe his own story of symptoms. They know more about their complaints than the doctors. But if they wander too far from the point, they should be put such questions as to bring them back into the matter. Never ask the question—“What are you suffering from?” The patient will obviously tell you his or another doctor's diagnosis, which you do not want to know. ‘Leading questions’ should not be put to the patients. By this, it is meant that questions, which yield only one answer, should not be asked. As for example, if the patient is asked like this—“Doesn't the pain move to the inferior angle of the right scapula?” Obviously a well-behaved patient will answer “Yes” to please you. So the question should be such that it leaves the patient with a free choice of answer. As for example, the question should be, “Does the pain ever move?” If the patient says, “Yes”, you should ask, “Where does it go?” So the questions should not necessarily be ‘leading’, but to help the patient to narrate the different aspects of his symptoms to arrive at a definite diagnosis.
Sometimes negative answers are more valuable in arriving at a diagnosis and should never be disregarded. As for example, in case of a sinus on the cheek, absence of the history of watery discharge at the time of meals at once excludes the possibility of a parotid fistula.
4. Associated diseases: Patients may be suffering from associated medical diseases apart from the one which he/she is complaining of: diabetes, high blood pressure, asthma, tropical diseases, bleeding disorders, rheumatic fever or even rarely syphilis or gonorrhea. This history is highly important as these may require additional treatment.
5. Past history: All the diseases suffered by the patient, previous to the present one, should be noted and recorded in a chronological order. There should be mention of dates of their occurrence and the duration. This may have influence on the present condition. Peptic ulcer, acute pancreatitis, tuberculosis, gallbladder disease, appendicitis, etc., are important. Students should not forget to mention any of the previous operations or accidents which the patient might have undergone or sustained. The dates and the types of the operations should be mentioned in a chronological order.
6. Drug history: The patient should be asked about all the drugs he was on. Besides the fact that this will help to give a clue to the present illness or in the subsequent treatment, it has 4tremendous importance from anesthetic point of view. Special enquiry should be made about steroids, insulin, antihypertensives, diuretics, ergot derivatives, monoamine oxidase inhibitors, hormone replacement therapy, contraceptive pills, etc.
7. History of allergy: This is very important and should not be missed under any circumstances, while taking history of a patient. The patient should be asked whether he or she is allergic to any medicine or diet. It should be noted with red type on the cover of the history sheet. The students should make it a practice and they will definitely find that this valuable practice will save many catastrophies.
8. Personal history: Under this heading, the patient's habit of smoking (cigarettes, cigar or pipe and the frequency), drinking of alcohol (quality and quantity), diet (regular or irregular, vegetarian or nonvegetarian, takes spicy food or not, etc.) are noted. It is also enquired about the marital status of the individual—whether married or single, a widow or a widower.
In women, the menstrual history must be recorded perfectly—whether the patient is having regular menstruation or not, the days of menstruation, whether any pain is associated with menstruation or not and last date of menstruation. The number of pregnancies and miscarriages are noted with their dates—whether the deliveries were normal or not, whether the patient had cesarean section or not and if so, for what reason. The patient is also asked whether there is any white discharge per vaginum or not.
9. Family history: This is also important. Many diseases do recur in families. Hemophilia, tuberculosis, diabetes, essential hypertension, peptic ulcer, majority of the cancers particularly the breast cancer and certain other diseases like fissure-in-ano, piles, etc., run in families. So the students must not forget to enquire about other members of the family, such as about the parents if they are still alive. How are they maintaining their health? Did they suffer from any major ailments? If they are dead, what were the causes of their deaths? You should also enquire about the brothers, sisters and children of the patient.
10. History of immunization: Children should be asked whether they have been immunized against diphtheria, tetanus, whooping cough, poliomyelitis, smallpox, tuberculosis, etc.
PHYSICAL EXAMINATION
This includes General survey, Local examination and General examination.
A. GENERAL SURVEY: Under this heading comes general assessment of illness, mental state, intelligence, build, state of nutrition, the attitude, the decubitus (position in bed), color of the skin, skin eruptions if present and pulse, respiration and temperature.
Physical examination starts when the patient enters the clinic. It requires daylight and of course a cooperative patient. In artificial light, one may miss the faint yellow tinge of slight jaundice. For complete examination, the patient should be asked to take off all his clothes and covered by only a dressing gown. For examining a female patient there must be an attendant nurse.
General assessment of illness: This is very important and should be assessed in the first opportunity. In case of severely ill patients, one should cut down the wastage of time to know other less important findings. The doctor should hasten into 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.
5Mental state and intelligence: In case of chronically ill patients, the doctor should always assess the mental state and intelligence of the individual. An intelligent patient will give a very good history on which the doctor can rely. On the other hand the doctor should not rely wholly on the history from the patient with very low intelligence.
Mental state (level of consciousness) is of particular importance in a head injury patient. There are five stages of level of consciousness—(1) Fully conscious with perfect orientation of time, space and person. (2) Fully conscious with lack of orientation of time and space. (3) Semiconsciousness (drowsy) but can be awakened. (4) Unconscious (stupor), but responding to painful stimuli. (5) Unconscious (coma) and not responding to painful stimuli. In all cases clinician must be well aware of the mental state of his patient.
Build and state of nutrition: Besides the fact that a few endocrine abnormalities become obvious from the build of the patient, a hint to clinical diagnosis may be achieved from a look on the build of the patient. As for example, a cachectic patient suffering from an abdominal discomfort with a lump, is probably suffering from carcinoma of some part of the gastrointestinal (GI) tract.
Attitude: This is very important and gives valuable information to arrive at a diagnosis. Patients with pain due to peritonitis lie still, whereas patients with colicky pain become restless and toss on the bed. Meningitis of the neck will show neck retraction and rigidity. An old patient after a fall, when lies helplessly with an everted leg, possibility of fracture of the neck of the femur becomes obvious.
Gait: This means the way the patient walks. Abnormal gait occurs due to various reasons—(a) Pain; (b) Bone and joint abnormalities; (c) Muscle and neurological diseases; (d) Structural abnormalities and (e) Psychiatric diseases. ‘Waddling gait’ is typical in bilateral congenital dislocation of hip and bilateral coxa vara. ‘Trendelenburg gait’ is typically seen in muscle dystrophies, poliomyelitis, unilateral coxa vara, Perthes’ disease and different arthritis of the hip.
Facies: The face is the ‘mirror of the mind’ and the eyes are the ‘windows of the mind’. Just looking at the face good clinician can assess the depth of the disease and effect of his treatment. The general diagnostic importance of the facies is enormous. Typical ‘Facies hippocratica’ in generalized peritonitis, ‘Risus Sardonicus’ in tetanus, ‘Mask face’ in Parkinsonism, ‘Moon Face’ in Cushing's syndrome and ‘Adenoid facies’ in hypertrophied adenoids are very characteristic and once seen is difficult to forget.
Decubitus: This means the position of the patient in bed. This is sometime informatory, e.g., in cerebral irritation the patient lies curled upon his side away from light.
Color of the skin: So far as the color of the skin is concerned, broadly the students should try to find out the presence of pallor, cyanosis or jaundice.
Pallor of the skin is seen in massive hemorrhage, shock and intense emotion. Anemic patients are also pale. One should look at the lower palpebral conjunctiva, mucous membrane of the lips and cheeks, nail beds and palmar creases for pallor.
Cyanosis, i.e., bluish or purplish tinge of the skin or mucous membrane which results from the presence of excessive amount of reduced hemoglobin in the underlying blood vessels. It may be either due to poor perfusion of these vessels (peripheral cyanosis) or due to reduction in the oxygen saturation of arterial blood (central cyanosis). For cyanosis to be observed, there must be a minimum of 5 g/dL of reduced hemoglobin in the blood perfusing the skin. So cyanosis is not detectable in presence with severe anemia. Peripheral cyanosis is due to excessive 6reduction of oxyhemoglobin in the capillaries when the blood flow is slowed down. This may happen on exposure to cold (cold-induced vasoconstriction). 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., the brain, the kidney, etc. Peripheral cyanosis is looked for in the nail bed, tip of the nose, skin of the palm and toes.
Central cyanosis 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 the systemic circulation. For central cyanosis one should look at the tongue and other places as mentioned above. The tongue remains unaffected in peripheral cyanosis. Very occasionally cyanosis may be due to the presence of abnormal pigments, e.g., methemoglobin or sulfhemoglobin in the bloodstream. In these cases arterial oxygen tension is normal. This may occur due to taking of drugs such as phenacetin. Carbon monoxide poisoning produces a generalized cherry-red discoloration.
Jaundice is due to icteric tint of the 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 (mostly the bile pigments) in the plasma. The places where one should look for jaundice are—(i) sclera of the eyeball—for this the patient is asked to look at his feet when the surgeon keeps the palpebral fissure wide open by pulling up the eyelid, (ii) nail bed, (iii) lobule of the ear, (iv) tip of the nose, (v) undersurface of the tongue, etc. When the jaundice is deep and long standing, a distinct greenish color becomes evident in the sclerae and in the skin due to the development of appreciable quantities of biliverdin. Scratch marks may be prominent in the skin in obstructive jaundice as a result of pruritus which is believed to be due to retention of bile acids.
Jaundice may be confused with hypercarotenemia in which yellow pigment of carotene is inequally distributed and is particularly seen in the face, palms and soles but not in the sclerae. Such hypercarotenemia may occur occasionally in vegetarians and in those who eat excessive quantities of raw carrot.
Skin eruption: Under this heading comes macules, papules, vesicles, pustules, wheals, etc.
Macules—are alterations in the color of the skin, which are seen but not felt. They may be due to capillary naevi or erythemas which disappear on pressure, whereas purpuric macules do not blanch when pressed. Papules—are solid projections from the surface of the skin. It may be epidermal papule, e.g., a wart or a dermal papule, which will become less prominent if the skin is stretched, e.g., a granuloma of tuberculosis, reticulosis or sarcoidosis. Vesicles—are elevations of horny layer of the epidermis by collection of transparent or milky fluid within them. Pustules—are similar elevations of the skin as vesicles, but these contain pus instead of fluid within them. Wheal—is a flat edematous elevation of the skin frequently accompanied by itching. It is the typical lesion of urticaria and may be seen in sensitive persons provoked by irritation of the skin.
Pulse: This is an important index of severity of illness. Pulse gives a good indication as to the severity of acute appendicitis and thyrotoxicosis. Generally, it gives a good indication of the cardiovascular condition of the patient. Abnormalities of the heart and the vascular system, e.g., hypertension and hypotension are also revealed in pulse. Shock, fever and thyrotoxicosis are a few conditions, which are well reflected in pulse. Following points are particularly noted in pulse: (a) Rate—fast or slow, (b) Rhythm—regular or irregular, (c) Tension and force which indicate diastolic and systolic blood pressure respectively, (d) Volume which indicates pulse pressure, (e) Character, e.g., Water-hammer pulse of aortic regurgitation or 7thyrotoxicosis, pulsus paradoxus of pericardial effusion, etc., and (f) condition of arterial wall, e.g., atherosclerotic thickening, etc.
Respiration: The students will gradually learn the importance of respiration as a finding not only for diagnosis, but also to assess the condition of the patient under anesthesia and in early postoperative days. Tachypnea (fast breathing) is seen in fever, shock, hypoxia, cerebral disturbances, metabolic acidosis, tetany, hysteria, etc. Slow and deep respiration is an ominous sign in cerebral compression. Also note if there is any irregular breathing, e.g., Cheyne-Stokes respiration. In Cheyne-Stokes respiration there is gradual deepening of respiration or overventilation alternating with short periods of apnea.
Temperature: This is normally taken in the mouth or in the axilla of the patient. The temperature of the mouth is about 1°F higher than that of the axilla. Fever or high temperature is come across in various conditions, which the students will be more conversant in medical ward. But broadly, the students should know that there are three types of fever—the continued, the remittent and the intermittent. When the fever does not fluctuate for more than 1°C during 24 hours, but at no time touches the normal, it is described as continued. When the daily fluctuations exceed 2°C it is remittent and when the fever is present only for a few hours during the day, it is called intermittent. When a paroxysm of intermittent fever occurs daily, it is called quotidian, when on alternate days it is called tertian and when two days intervene between the consecutive attacks, it is called quartan.
B. LOCAL EXAMINATION: This is the most important part in the physical examination, as a careful local examination will give a definite clue to arrive at a diagnosis. By ‘Local examination’ we mean examination of the affected region. This should be done by inspection (looking at the affected part of the body), palpation (feeling of the affected part by the hands of the surgeon), 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 (of the joints concerned), measurement (of the part of the body concerned) and examination of the lymph nodes draining the affected area. Detailed description of these examinations are discussed in subsequent chapters.
Inspection of the part should be carried out after complete exposure. It should be compared with the corresponding normal side, whenever possible. The importance of proper inspection cannot be overemphasized, as many of the surgical conditions can be diagnosed by looking at it with well-trained eyes. It is said that eyes do not see what mind does not know. So a thorough knowledge of the whole subject is essential before one can train one's eyes for such good inspection.
Palpation will not only corroborate the findings seen in inspection, but also added informations with trained hands may not require any further examination to come to a diagnosis.
Percussion and auscultation are not so important as in the medical side for clinical diagnosis of surgical diseases. These are only important in a few surgical conditions, which will be discussed later in appropriate chapters.
Movements and measurements are important particularly in orthopedic cases, in fractures and in injuries of different nerves.
Local examination is never complete without the examination of the draining lymph nodes. More often than not the students forget to do this valuable examination and fail to diagnose many important cases.
8C. GENERAL EXAMINATION: In chronic cases, one should always examine the patient as a whole, after completing the local examination. In acute cases, this examination may be omitted to save the valuable time. But even in acute cases, certain general examinations should be carried out either for anesthetic sake or for treatment point of view. General examination is required mainly for the following purposes:
1. For the diagnosis and differential diagnosis: For example, in case of retention of urine, one should examine the knee and ankle jerks and pupillary reflexes (Argyll Robertson pupil) to come to a diagnosis of Tabes dorsalis. Similarly examination of the chest or spine should be carried out in an otherwise obscure abdominal pain to find out basal pleurisy or caries spine as the cause of pain. Sometimes the patient complains of pain in the knee when the pathology lies in the hip joint. Cases are on record when teen-aged boy with the complain of pain in the right iliac fossa was referred to the hospital by the general physician as a case of acute appendicitis. Only after examination of the scrotum, the surgeon found torsion of the testis as the cause of pain and not appendicitis.
2. For selecting the type of anesthetic: The anesthetist should always examine the patient generally, particularly the heart and lungs to select the proper anesthetic. Sometimes the operation should be performed under local anesthesia in old and cardiac patients.
3. To determine the nature of the operation: In case of an inguinal hernia, one should examine the chest to exclude a cause of chronic cough, for enlarged prostate or for stricture of urethra as an organic cause of an obstruction to the outflow of urine and to exclude constipation as cause for increased abdominal pressure to initiate hernia. So patients with these conditions, if operated on, will definitely come back with recurrence of hernia. At the same time, the surgeon should look for the tone of the abdominal muscles to determine whether herniorrhaphy or hernioplasty will give the best result.
4. To determine the prognosis: In a case of gastric cancer, if general examination reveals involvement of the supraclavicular glands, the prognosis is obviously grave. Similarly cancer of the breast, if shows secondary metastases in bones and lungs, is considered to be in the last stage.
A list is given below to remember the points to be examined under the heading of ‘general examination’:
Head and neck
1. Cranial nerves—particularly the 3rd, 4th, 5th, 6th, 7th, 9th, 11th and 12th cranial nerves should be examined.
2. Eyes: Tests are done to know the visual field, condition of the conjunctiva and pupils (equality, reaction to light and accommodation reflex), movements of the eye and ophthalmic examination of the fundi.
3. Mouth and pharynx: Teeth and gum, movement of soft palate, the tongue and its undersurface, tonsils and lips for color, pigmentation (seen in Peutz-Jeghers syndrome) and eruptions.
4. Movements of the neck, neck veins and lymph nodes of the neck, carotid pulses and the thyroid gland.
Upper limbs
(1) General examination of the arms and hand with particular reference to their vascular supply and nerve supply (power, tone, reflexes and sensations). (2) Axillae and lymph nodes. (3) Joints. (4) Finger nails—clubbing or koilonychia.
Thorax
(1) Type of chest. (2) Breasts. (3) Presence of any dilated vessels and pulsations. (4) Position of the trachea. (5) Apex beat. (6) Lungs—as a whole, i.e., inspection, palpation, percussion 9and auscultation. (7) The heart should be examined as a whole, i.e., palpation, percussion and auscultation.
Abdomen
(1) Abdominal wall—position of the umbilicus, presence of scars, dilated vessels, etc. (2) Abdominal reflexes. (3) Visible peristalsis or pulsation. (4) Generalized palpation, percussion and auscultation. (5) Hernial orifices. (6) Genitalia. (7) Inguinal glands. (8) Rectal examination. (9) Gynecological examination, if required.
Lower limbs
(1) General examination of legs and feet—with particular reference to the vascular supply and nerve supply (power, tone, reflexes and sensation). (2) Varicose vein. (3) Edema. (4) Joints.
Examination of the external genitalia
Sputum, vomit, urine, stool should be examined by naked eye and under microscope, if required.
PROVISIONAL DIAGNOSIS
At this stage the clinician should be able to make a provisional diagnosis. He should also keep in mind the differential diagnosis. He will now require a few investigations to come to the proper clinical diagnosis. The students should know how to diagnose common diseases first and then he should think for possibility of rare diseases. A word of the caution will not be irrelevant here that ‘if you diagnose a rare disease, you will be rarely correct’.
SPECIAL INVESTIGATIONS
Besides the routine examination of the blood, urine and stool, a few special investigations depending upon the provisional diagnosis will be required to arrive at a proper diagnosis. These are discussed in details in appropriate chapters.
CLINICAL DIAGNOSIS
After getting the reports of special investigations, the clinician should be able to give proper clinical diagnosis. By this we mean that not only the ailing organ is identified, but the type of pathological process at work and its extent in different directions is also understood. As for example, in carcinoma of the breast, one should mention under this heading the clinical stage of the disease and the various structures involved in metastasis. Similarly in case of inguinal hernia, the clinician should not only mention that whether it is direct or indirect, reducible or irreducible, but also should mention its content—either the intestine or omentum or a portion of urinary bladder.
TREATMENT
The students should record under this heading the details of medical treatment and the surgical treatment which the patient has received. While writing medical treatment the students should clearly mention the drugs given to the patient, their doses and duration of the treatment. In surgical treatment they should clearly mention the type of anesthesia given and type of operation performed.
(i) Type of anesthesia and anesthetics used; (ii) Name of the anesthetist; (iii) Name of the surgeons; (iv) Position of the patient on the operation table; (v) The type of incision made; (vi) Technique of operation; (vii) Closure; (viii) Drainage—given or not.
PROGRESS
Daily progress of the patient starting from the time the patient came out of the operation theater should be clearly noted. Students should also mention if any investigation performed during the postoperative period, the dressings done during the period, condition of the wound, etc.
FOLLOW-UP
This resumes when the patient is discharged from the hospital and extends till he starts his normal active life. The students should learn how to make a discharge certificate mentioning in nutshell the diagnosis, special investigations performed, the treatment received and the postoperative advice. He should also mention the date when the patient should report to the outpatient clinic to let the surgeon know his progress and his complaints. Now the students should make a record of the days the patient came for follow-up and the advice given by the surgeon.
TERMINATION
To terminate the history sheet of the patient, the students should mention whether the patient was completely cured when his follow-up period ended or the patient was relieved of his symptoms but not cured or whether the patient died during his stay in hospital or in follow-up period. In case of death, the student should mention the cause of death and also make a note of the result of the postmortem examination, if carried out.