CASE TAKING FROM S DAS
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
HISTORY TAKING:
1)
for identification purpose, to build rapport with the patient,
psychological benefit to the patient just before operation and in
postoperative period.
congenital anomalies are present at birth; cystic hygroma, cleft lip,
cleft palate, phimosis, sacrococcygeal teratoma
Acute arthritis, acute osteomyelitis, Wilms tumour in infants
Sarcoma affects teenagers, appendicitis in girls of 14 to 25 years of age
Osteoarthritis and benign hypertrophy of prostate are disease of old age.
diseases that affect sexual organs are peculiar to the sex concerned
Females: thyroid, visceroptosis, movable kidney, cystitis
Males: carcinoma of stomach , lungs and kidney.
Haemophilia affects males.
carcinoma of penis is hardly seen in Jews and Muslims because
of compulsory circumcision infancy. Phimosis , subprepucial infection is
also not seen in them.
Intussusception is seen after month long fast( Ramzan) Muslim
high social status: acutely appendicitis
Low social status: tuberculosis
varicose veins: bus conductors, surgeons
Urinary bladder cancer : workers in aniline dye industries
Scrotum carcinoma: chimney sweepers
Medial semilunar cartilage injury: footballers, miners
Students elbow, housemaid knee, tennis elbow.
filariasis in Orissa, leprosy in Bankura district of West Bengal.
Peptic ulcer in northwestern part and southern parts of India as they take
more spicy foods .
Sleeping sickness: Africa
Hydatid disease in sheep rearing countries( Greece, turkey, Iran, Iraq,)
Kangri cancer in Kashmir due to their habit of carrying Kangri
( earthenware filled with burning charcoal to keep themselves warm)
2)CHIEF COMPLAINT
In chronological order
Duration
For eg:
1) swelling in the neck- 1year
2) Fever- 10 mo the
3) Slight pain in swelling- 6 months
4) Sinus in the neck- 1 month
IF FEW COMPLAINTS START SIMULTANEOUSLY THEN LIST IN ORDER OF SEVERITY.
Make clear that the patient was free from any complaint before the period mentioned by the
patient ( so that patient tell each and every complaint even if he consider them insigni cant)
3) HISTORY OF PRESENT ILLNESS:
Begin with first symptom
1) mode of onset of the symptoms: sudden or gradual
2) Progress of disease with evolution of symptom
3) Treatment: mode and doctor who treated
Information should be recorded in patient ‘s own language
Leading questions should not be asked .
4) PAST HISTORY:
Chronological order
diabetes, tuberculosis, asthma,rheumatic fever , syphilis, gonorrhea, bleeding tendencies,
hypertension.
Any past operations or accidents.
Dates and type of operation should be mentioned in chronological order.
5) Drug History:
Patient should be asked all the drugs he was before.
Important from anaesthetist point of view
6) History of allergy:
Very important and should not be missed
IT should be noted with Red on cover of history sheet.
Allergies to food or medicine
7) Personal History:
Diet( regular or irregular, vegetarian or non vegetarian, spicy food or not)
Addiction :smoking (cigarettes and frequency), alcohol drinking (quality and quantity)
Sleep
Appetite
In women Menstrual history
(Regular menstruation, pain , last date of menstruation.)
Number of pregnancies and miscarriages with dates
Whether deliveries are normal or not if not so reason
White discharge per vaginum is also asked
fi
8) Family history
Haemophilia, tuberculosis, diabetes , essential hypertension, peptic ulcer, Breast cancer, piles, ssure in
ano
Members of family ; any disease, if dead reason
9) History of immunisation
diphtheria, tetanus,whooping cough tuberculosis
fi
