History Taking Surgical Case Sheet Writing Notes

History Taking Case Sheet Writing

• When I was a student, clinical examination was the only method available to detect disease and to guide its management in the majority of patients. Radiological investigations were minimal and hence it was very important to do a complete clinical examination with judicial use of clinical methods.

Read And Learn More: Clinical Medicine And Surgery Notes

• It was not uncommon to find a large crowd of faculty members accepting the so-called ‘final diagnosis’ from a senior professor even though it was proved ‘wrong’ later by laparotomy or by investigations. Gone are those days of the so-called ‘final word’. We now believe in evidence-based science.
• Today after 30 years, because of the availability of radiological investigations such as CT scans and endoscopies, diagnosis of many conditions has become easy. Consequent to this, students may cut short the history-taking and clinical methods. In India, clinical methods are still relevant in the clinical examination. It should be remembered that clinical medicine is the most
• The important and most challenging event in medicine. Students must develop communication skills, interpretation skills, and analytical skills. Above all, this communication gives them an opportunity to know what suffering is and teaches them how to conduct themselves with the patients.

The very fact that a person has come to the hospital means that he has some complaints

• Complaints can be major or minor. The first thing students need to do before commencing history-taking and examination is to make the patient comfortable.
• A comfortable patient is more likely to cooperate with eliciting history and permitting clinical examination. This is also the first lesson in the importance of doctor-patient rapport.
• Enough time should be spent in the history-taking, taking the patient into confidence. It is always better to talk to the patient in his own language. Patients can explain the events better in their own language than in a language known to the students but not to them.
• Often, when you ask one question you may get a lengthy answer. In such situations, it is better to listen to the patient than tell him that it is irrelevant or not required, etc. Allow the patient to express himself. It helps in the building of rapport.

Secrets of successful student and patient interaction

1. Treat the patient as your own relative
2. Communicate in his own language
3. Be sensitive to his feelings/Suffering
4. Be gentle while examining the patient
5. Read and be prepared so that you will not waste your time, at the bedside clinics.
6. Do not read the book in front of the patient and ask questions
7. Even though you are a student, please see them even after you finish your clinics means following one or 2 days, and find out what has been done to him, what treatment he has received, and how he has responded. Show interest in the overall management of the patient.

The students should conduct themselves with dignity and be sensitive to the feelings of the patients. Dress well, wear proper shoes, and look neat. This inspires confidence in them. Students are required to carry the following equipment—stethoscope, knee hammer, pen torch, skin marking pencil, etc.

Let Us Start Now…

Patient Data

Name: What is the patient’s name?

You get familiarised with the patient by calling him by his name. Don’t you feel happy when a teacher calls you by your name?

Age: How old is the patient?

A few diseases are common in certain age groups. The following are a few examples.

• Tuberculous lymphadenitis in young patients.
• Cystic hygroma (lymphatic cyst) and haemangioma are common in children.
• Oral cancer is common in elderly patients.
• Secondaries in the neck (metastasis) are common in elderly patients.
• Thromboangiitis obliterans (TAO) is common in male smokers between 20 and 40 years of age and atherosclerotic disease is common after 50 years.
• Appendicitis is common in young patients.
• Branchial cyst, though congenital, appears in the second or third decade.

Gender: What is the patient’s gender?

For reasons less known, certain diseases are more common in women than in men.

The following are a few examples:

• Tuberculous lymphadenitis is more common in women
• Postcricoid carcinoma is more common in women
• Bronchogenic carcinoma present as neck swelling in the posterior triangle is common in male smokers.
• Haemophilia is seen exclusively in male children even though it is transmitted by females.

Occupation: What is the patient’s occupation?

Some diseases are related to occupation

• Varicose veins occur in patients who require to stand for a prolonged period of time such as agriculturists, hotel workers, barbers, etc.
• Truck drivers and sailors in India have an increased incidence of HIV.
• Carcinoma lip is common in those with outdoor occupations such as agriculturists. Hence, it is called a countryman’s lip.
• Gardeners are susceptible to thorn prick injuries which can give rise to implantation dermoid cysts.
• Trumpet blowers may have a laryngoscope.
• If a patient is a teacher or a singer, who may present with thyroid swelling — utmost care should be taken during surgery to avoid injuries to laryngeal nerves. Possible complications should be clearly explained to the patients.
• Farmers and butchers can get anthrax.

Place: Where is he/she from?

Certain regions of the state or country have increased the incidence of some diseases.

• Thyroid swellings are more common in low-lying areas where the iodine content of the water is less. They are called endemic goiters.
• Chronic pancreatitis is more common in Kerala state.
• Gallstones are more common in North Indian states.
• Peptic ulcer is common in South India.

Socio-Economic Status: What is his socio-economic status?

• Poor socio-economic status—Thrombo-angiitis obliterans, carcinoma penis.
• Higher socio-economic status—Atherosclerotic disease in the form of ischemia of the limbs.

Date Of Admission: When did he get admitted to the hospital?

This is for record purposes.

• Did he get admitted from the patient department (OPD) which means it is an elective case
• Did he get admitted through casualty which means it must have been an emergency situation?
• Does he have any records from the referred hospital—If so, please make a note of it.

Summary: After getting all this information, please summarise and present the case. One example is given as follows.

Mr. Gangadhar, a 35-year-old male patient, a teacher by occupation, coming from Manipal presented to the outpatient department with the following complaints.

Complaints

Every complaint is an important complaint. Hence, there is nothing like chief complaints. All are chief complaints. They have to be listed in chronological order, i.e. every disease starts with certain complaints. Hence, whichever complaint has appeared first has to be mentioned first. A few examples are given below.

Example 1: Thyroid swelling

1. Swelling in front of the neck—5 years
2. Palpitation for 3 months

Analysis of the complaints: Swelling is of 5-year duration—it means it is a benign lesion. It is in front of the neck – so, most probably it is a thyroid swelling.

The patient has developed palpitation for 3 months which means the thyroid gland is producing more hormones. Hence, toxic features have developed in this swelling – hence the case is mostly toxic goiter.

Example 2: Complaints: Ulcer leg

1. Ulceration in the sole of the foot—6 months
2. Swelling in the groin2—30 days

Analysis of the complaints: Ulcer in the leg started first. This may be malignant as in squamous cell carcinoma or malignant melanoma and the groin swelling could be metastasis in lymph nodes. In case the ulcer is benign as in callous ulcers or diabetic foot, the groin swelling may be due to lymph node enlargement or secondary infection.

Example 3: Case of dysphagia

1. Difficulty in swallowing—3 months
2. Swelling neck—15 days
3. Fever for 10 days.

You will understand better after you complete reading and seeing patients.

The groin is an area lateral to the pubic tubercle, in the inguinal region close to the junction of the trunk to the thigh.

Analysis of the complaints: Difficulty in swallowing is dysphagia. This started first and could be due to some lesion in the posterior third of the tongue or oropharynx. This was followed by swelling in the neck, most likely due to metastasis. He has developed a fever for 10 days suggesting some inflammatory process. The most likely possibility is a respiratory tract infection common in patients with oral cavity malignancies.

Note: You should not jump to conclusions in the beginning but you should analyze the case right from the beginning. Ask yourself, is this the diagnosis or is it something else?

The chronological order of presentation is a must

History Of Present Illness Or Complaints

From the time the complaint started till the time you are presenting the case comes under a history of present illness.

• Narrate the sequence of events in detail. However, any irrelevant history need not be mentioned. In the beginning, you will not be in a position to conclude what is relevant and what is not. Hence, better to present all that the patient tells you.
• Take any case and start asking questions about the complaints, how it started, when it started, how is the growth, whether has it grown big within a short period, whether has it been growing slowly or has it become smaller in size?
• How and when: Many thyroid swellings start insidiously or they are noticed by relatives or friends. In such cases, it is better to say that the swelling is insidious in onset. On the other hand, hemorrhage in multinodular goiter appears suddenly.
• A patient may tell you that he had a small swelling in his back for 3 years and never gave him any problems but suddenly since the previous night, he is getting pain. It could be an infection in a sebaceous cyst. This is described as a sudden onset of pain.
• Progress of the disease

1. 1. Rapid progress is a feature of malignancies, for example. soft tissue sarcoma, poorly differentiated carcinoma, carcinoma oral cavity.
   2. Slow progress is a feature of benign diseases —cystic swellings, goiters, etc. The size of the swelling may decrease as in inflammatory diseases or resolving hematoma, The patient says he had a fall and then noticed swelling in his thigh. It is becoming smaller in size over the last few days.

• Pain

1. 1. Any ulcer or swelling that starts with pain and fever indicates an inflammatory condition. Examples Boil, thyroiditis, carbuncle (abscess in diabetic patients usually seen in the nape of the neck). Low-grade fever may be a part of inflammation but high-degree fever indicates the presence of pus.
      Painful benign swelling can arise from nerve fibers such as neurofibroma or neurilemmoma, etc.
   2. However, a swelling which was painless initially but later became painful can be due to various reasons:
      • Secondary infection, for example. sebaceous cyst.
      • Malignant tumor infiltrating bone, for example. carcinoma cheek infiltrating mandible. In this situation, pain is constant, dull aching, and well localized.
      • Malignancy infiltrates nerve fibers, for example. carcinoma tongue involving the lingual nerve, sarcoma thigh infiltrating sciatic nerve, etc. In this situation, the pain radiates along the nerve fibers. Some patients describe this as a shooting type of pain.

Thus I have given a few complaints and analysis. With each disease, you will find many such complaints and you should try to get more details about each one of them. Then, develop the history.

Past History

Once again all relevant complaints and the treatment received by the patient have to be recorded in chronological order. Students may feel some of them may not be relevant but you have to record them. What you feel is not relevant at this stage may be an important relevant history and later may clinch the diagnosis. I shall give a few examples.

1. A patient has presented to the hospital with a sinus (blind track with opening) in the chin discharging pus. His past history is that he has been getting recurrent pain in his tooth. Students may feel it is irrelevant but the fact is that the Caries teeth are responsible for this sinus formation.
2. A patient has presented to the hospital with a huge swelling in the groin. He had a lesion in the sole of the foot which was cauterized 3 years back. What is the relevance of this history? The lesion cauterized may be a malignant melanoma and groin swelling is due to enlarged lymph nodes.

Personal History

This mainly refers to some of the habits such as smoking, consumption of alcohol, tobacco betel nut chewing, etc. A detailed history should include the number of beedis or cigarettes smoked, the amount of alcohol consumed or pan chewing, etc.

• Heavy smoking, alcohol, and a non-vegetarian diet predispose to carcinoma of the upper aerodigestive tract such as oral cancer or carcinoma stomach, etc.
• Smoking also causes bronchogenic carcinoma and Buerger’s disease (thromboangitis obliterans).
• Pan chewing causes oral cancer.
• Is the patient married or single, a widow or widower? How is the family—number of children and their health?
• Single bachelors and frequent travelers have increased chances of sexual exposure and related diseases including HIV infections (syphilis is almost rare nowadays).
• Frequent traveling and consumption of water and food can also precipitate hepatitis, amoebiasis, etc.
• Tuberculous infection of the lungs can easily spread from one person to another if precautions are not taken properly.
• Undoubtedly, cardiac diseases (myocardial infarction) have a strong genetic predisposition.

Family History

Enquire whether any member of the family has suffered from similar diseases.

• Carcinoma colon runs in families.
• Carcinoma breast can be familial
• Medullary carcinoma thyroid also can be familial First-degree relatives also can be affected by following genetic diseases.
• Haemophilia
• Polycystic disease of the kidney
• Diabetes
• Piles.

Treatment History

1. Drugs for chronic diseases such as antidiabetic agents oral hypoglycaemic agents and injection insulin), antitubercular agents, antihypertensive drugs, etc.
2. Anticoagulants: Many elderly patients are receiving these for treatment of stroke or cardiac illness.
3. Any surgical procedures that are known for recurrences—inadequate excision if done for malignant tumors, the lesion will recur, e.g. sarcoma.
4. Any hospitalization for a major illness such as for a surgical procedure or for a medical illness.
5. History of allergic reactions.

General Physical Examination

A general survey of the patient from head to toe must be done now. The important points and their relevance are given below.

General appearance: A quiet, cooperative patient indicates that he is not in agony. Patients who are in pain will not cooperate with students and will never be quiet.

• An emaciated, cachectic patient is typically seen in carcinoma esophagus or tuberculosis, etc.
• Prominent eyes associated with thyroid swelling suggest primary thyrotoxicosis.

Attitude: Occasionally, the diagnosis can be arrived at by looking at the attitude of the patients in the bed. A few examples are given below.

• An elderly male sitting in the outpatient department with a handkerchief spitting saliva frequently is almost diagnostic of carcinoma of the posterior third of the tongue.
• A restless patient who is sweating even in cold climatic conditions may be having thyrotoxicosis.
• A child sitting with hands pressing the chin-up may be having tuberculosis of the cervical spine with the collapse of vertebrae.
• A chronic smoker, who is unable to sleep in the night sitting on the bed with his legs hanging down is probably having severe ischaemic rest pain (TAO).

Build: Average build indicates adequate nutrition. Poor nutrition indicates malnutrition or chronic diseases such as tuberculosis, uncontrolled diabetes, or carcinoma.

• A patient with a tall build and marfanoid features may have medullary carcinoma of the thyroid.
• Interestingly varicose veins of the leg are also common in tall patients.
• Short build-dwarfs —can be due to various causes especially endocrinal as in hypopituitarism.

Anaemia: Anaemia refers to decreased hemoglobin or circulating red blood cells and manifests as pallor. Look at the conjunctiva and look for anemia. Anemia may be because of nutritional causes, blood loss from the gastrointestinal tract, or chronic diseases including tuberculosis or carcinomas. Pallor refers to pale skin and conjunctival coloration.

• The mucous membrane is the ideal site to look for pallor (oral mucosa and tongue).
• The lower eyelid is turned down to look for conjunctival pallor.

Icterus: Yellowish discoloration of sclera, skin, and mucous membranes indicates jaundice. In obstructive jaundice, sclera can occasionally have a deep yellow or even greenish hue due to oxidation of bilirubin to biliverdin. The generalized yellow color may be present not only in jaundice hut but also in pernicious anemia and carotenemia. However, the sclera will not be yellow in carotenemia. Depending upon the depth of the jaundice it can be of the following types.

• Pale yellow color: Haemolytic jaundice
• Orange yellow: Hepatocellular jaundice
• Greenish yellow: Obstructive jaundice

Cyanosis: Bluish discoloration of the conjunctiva occurs due to many causes including respiratory and cardiac causes

Sites To Look For Jaundice

• Sclera
• Sublingual mucosa
• Oral cavity
• Palms and soles
• Skin

Nails:

Pink nails indicate good circulation and pale ridged nails indicate poor circulation (leukonychia).

Koilonychia: It means ‘spoon-shaped nails’ as seen in anemia

Clubbing: It refers to bulbous enlargement of terminal phalanges. It occurs due to arteriovenous shunt resulting in increased vascularity of the local part. Clubbing is seen in many conditions, the important ones being—chronic pulmonary diseases such as bronchiectasis, lung abscess, emphysema, bronchogenic carcinoma, and cardiovascular causes such as congenital and cyanotic heart diseases, subacute bacterial endocarditis, etc.

Onycholysis: Destruction of nails is seen in local fungal infections and psoriasis.

Oral cavity:

• A bad odor of the oral cavity reflects malignancy very often. It is due to putrefying bacterial infection in a malignant lesion.
• Hygiene can be poor.
• Teeth—Nicotine stains are characteristic which can suggest diseases related to tobacco, e.g. thromboangitis obliterans. Teeth may fall off by themselves if there is the expansion of the mandible, destruction of the mandible as in osteomyelitis, or malignancies infiltrating the mandible. A dentigerous cyst arises from the nonerupted permanent tooth.
• Examine the tongue, buccal mucosa, and lips, especially for any nonhealing ulcers that suggest malignancy.

Lymphadenopathy: The neck, axilla, and groin are the common sites of lymph node enlargement. There are many causes of lymphadenopathy which will be discussed later.

• When a lymph node is palpable more than 1 cm in size in the neck or 2 cm in the groin, when the node is hard, or when the node is fixed, it is called a ‘clinically significant lymph node’.
• However, the supraclavicular lymph node when it is just palpable is significant as it very often signifies underlying malignancy.

• It should be remembered that the inguinal vertical chain of lymph nodes can be more than 2 cm but may not be significant especially in Indian patients due to barefoot walking.
• When 2 or more anatomical sites of the lymph nodes are palpable, it is called generalized lymphadenopathy.
• Tender lymph nodes suggest enlargement following acute infections.
• For a quick recall

Multiple, matted, mobile nodes—TB
Multiple discrete. Rubbery—Hodgkin’s
Lymphoma (HL)
Multiple fixed hard—Metastasis.

Pedal edema: It can occur due to many reasons, the common ones being—hypoproteinaemia, nephrotic syndrome, cardiac failure, etc. Pitting refers to depression created by the pressure of the finger over the oedematous part. It is checked in the lower third of the leg on the medial side
of the leg.

Spinal tenderness: This is especially highlighted in Indian cases because the patient’s spine or TB spine was once a common problem. Tenderness over the spine was one of the common manifestations of the TB spine.

It is elicited by exerting firm pressure over the lateral aspect of the spinous process of the vertebrae and rotation of the vertebral body results in pain. Kyphotic deformity of the 2 or 3 vertebrae together is called gibbous. A deformity of one vertebra is called a knuckle.

Pulse:

More details on the pulse are given in the medicine books. However, relevant points for students of surgery have been given here.

• Pulse volume is weak in peripheral vascular diseases such as TAO or atherosclerotic vascular diseases.
• High volume pulse is seen in thyrotoxicosis
• Low volume pulse is seen in hypotension typically in hemorrhagic shock.
• Tachycardia is a feature of thyrotoxicosis and many other medical conditions
• Bradycardia is seen in athletes.
• Arterial wall thickening is seen in atherosclerotic vascular diseases.
• Dancing brachials—thickened prominent pulsations of the brachial artery is suggestive of atherosclerotic disease.

Blood pressure:

It should be made a common practice to measure the blood pressure in all patients. More details are given in medicine books.

• Hypertension should be controlled well before surgery to avoid complications such as cerebral hemorrhage or cardiac failure following the surgical procedure.
• A bilateral renal mass with hypertension should suggest the possibility of polycystic kidneys.
• Renal conditions are very important causes of hypertension—acute glomerulonephritis can result in microscopic haematuria which is a clue to the renal cause of hypertension.
• Malignant hypertension with papilloedema in a young patient can be due to phaeochromocytoma—a functioning tumor of the adrenals.

Temperature:

Is the patient normothermic, hypothermic, or hyperthermic? The patient looks sick, not interested in what is happening around or he may be covering himself when he has a high temperature— diagnosis of fever can be done even from a distance when you see him. Fever indicates a certain degree of infection —may be bacterial, viral, or fungal. There are numerous causes of fever which are of interest to physicians.

A few important aspects of surgical fever are given below:

• High-grade fever with or without chills and rigors suggests the following conditions
  1. Abscess—may be intra-abdominal or in the soft tissues; boil or carbuncle in diabetic patients.
  2. Urinary tract infection—quite common in female patients
  3. Biliary tract infections—cholangitis
  4. Malaria, filaria, and pneumonia.
• Low-grade fever suggests a low-grade continuing inflammation or infection as in diabetic cellulitis being treated or postoperative low-grade fever due to infection.
• Evening rise in temperature with some chills may be due to tuberculous infections (not necessarily seen in all patients).
• Hyperpyrexia is a complication of surgery following thyroidectomy for primary thyrotoxicosis. It occurs in unprepared patients who are undergoing thyroidectomy. However, it is rarely seen nowadays.

Respiration:

• Normal breathing is abdominothoracic. In cases of peritonitis, there will be minimal movement of the abdomen. Hence, breathing is mainly thoracic.
• Tachypnoea refers to an increased respiratory rate and referred to as number of breaths per minute. More details are given in medicine books. It may be an early sign of sepsis.

Local Examination

This refers to the examination of the diseased area. Adequate light should be present. Daylight is preferred. Mild jaundice can be missed in artificial lighting conditions.

• Position of the patient:
  1. Supine and lateral positions for abdominal examination
  2. Prone position for examination of the back
  3. Sitting position for examination of head, neck, and oral cavity
  4. Standing position for varicosity of veins, varicocele, and inguinoscrotal swelling (hernia).
• The local examination must be done in the following order: Inspection, palpation, percussion, and auscultation.
• Please do not start palpating as soon as you see a lesion such as swelling or ulcer. Spend some time in inspection which can reveal so much information and clue to the diagnosis in many cases. The importance of each of these examinations has been given below with examples.

Local Examination Inspection

• This must be done in good daylight with adequate exposure of the patient. Explain to the patient what you are doing.
• Specific examination of swelling or ulcer is given under the respective chapters. A few general principles of each of these methods are given here.
• Some books mention that examination of the neck requires exposure from the chin to the nipple. Just imagine a young lady with a small 2 cm nodule in her thyroid being examined for swelling in the neck and is also asked to expose her chest. Is it required? Not really but if you suspect follicular carcinoma thyroid which can spread by blood spread and can metastasize to ribs… This will manifest as swelling.
  • What is the best solution? Just after examination of the neck, ask the patient whether she has any swelling or pain in her rib cage or chest wall. If it is present, then examine the area.
  • Otherwise, it is not required. We should also be aware that participation of the patient, cooperation, and support of the patient during clinical examination differs from a government college hospital to a private medical college hospital.
• Please be careful while examining a female patient in cases of breast or neck examination. Request a nurse to be present always. Spend some time carefully inspecting the local area or the part. Vital clues can be obtained which can clinch the diagnosis without even touching the patient.

1. 1. A -A patient with, a swelling in the posterior triangle of the neck has minimal ptosis of the upper eyelid: It is called as pseudoptosis and the diagnosis is Horner’s syndrome.
   2. Patient with thyroid swelling: The lower border of the swelling is not seen—A case of retrosternal goiter.
   3. Prominent veins are present over the swelling: This suggests increased vascularity and maybe a soft tissue sarcoma.
   4. Swelling is pulsatile—may be an aneurysm
   5. Mild deviation of the angle of the mouth can be due to injury or paralysis of the marginal mandibular nerve.

Palpation

• Palpation is done with a palmar aspect of the fingers.
• Palpation should be gentle, reassure the patient that you will not hurt them.
• More details about what points are to be noted under palpation are given in the respective chapters.
• The local rise in temperature and tenderness has to be mentioned first under palpation for swellings.
• Different methods of palpation are available, for example. Dipping method while examining the abdomen in cases of ascites. Please also check in chapters on neck and thyroid.

Percussion

Organs that are solid, hollow, or those containing air or liquid give different sounds on percussion like percussion instruments— this forms the basis of percussion. A few examples are given below.

1. Percussion over the chest is resonant because of the underlying lung which contains air.
2. Normally percussion over the sternum is resonant but if there is a retrosternal extension of the thyroid swelling it may be dull.
3. Resonant notes all over the abdomen may indicate distended loops of the intestine in cases of intestinal obstruction or paralytic ileus.

• It should be remembered that the clinical method of examination like percussion should be used if you feel it is useful. There is no point in percussing over the thyroid swelling, causing inconvenience to the patient, and saying it is dull.
• A rare case of laryngocele in the neck may give a tympanitic note. Otherwise, percussion is not of much use for BDS students in surgery.

Auscultation

This is an important method of clinical examination in medicine for the respiratory system and cardiovascular system which will be dealt with in detail in medicine. However, a few relevant things to be remembered in surgery are given below.

• A swelling with a bruit suggests increased vascularity typically seen in arteriovenous malformations.
• Logically speaking in a case of swelling in the neck, if on palpation you find a thrill, then auscultate for a bruit, e.g. carotid artery aneurysm, dilatation of subclavian artery in cases of cervical rib.
• In primary thyrotoxicosis, you may find a bruit at the upper pole of the thyroid gland.
• Auscultation of the trachea can be done to check air entry.

Systemic Examination

Respiratory system examination for normal or abnormal sounds such as rhonchi or crepitations must be done. They reflect the status of the lungs. It is necessary to assess the lungs before surgery. Chronic smokers will have restricted pulmonary disease called COPD.

Cardiovascular system: It is examined for heart sounds, any abnormal sounds, etc. The cardiovascular system can give a clue in some cases, for example. a patient with upper limb acute ischemia of the fingers is found to have mid-diastolic murmur on auscultation of the heart. It is a case of mitral stenosis with emboli causing ischemia.

Skeletal system: Skeletal system is examined thoroughly. Firstly, ask the patient about bony pains and ask him to point out at which site. Accordingly, look for any tenderness. Ask the patient for any bony swelling of recent origin, for example. follicular carcinoma thyroid can have metastasis in skull bones, ribs, and other flat bones. Malignant lesions such as sarcoma and carcinoma can infiltrate the bone and give rise to pathological fractures. This may result in abnormal mobility of the bones. This also should be tested in appropriate cases.

Abdominal examination: It is not very relevant for dental students. Those of you who are interested can refer to standard textbooks for learning. However, the minimum you need to know is to examine the enlarged liver and spleen1.

Clinical Diagnosis

At the end of the clinical examination, students should quickly summarise. Think of possibilities through an elimination process and come to a clinical diagnosis. This diagnosis may or may not be right but we start working from there and hence it is also called the ‘working diagnosis’.

• While giving the clinical diagnosis, a common diagnosis has to be kept in mind. As the old saying goes, ‘Common things are common’.
• It is important to realize that while giving a diagnosis you not only use your five senses properly but also use the most important 6th sense—common sense.

Clinical Diagnosis

• Working diagnosis—Provisional diagnosis
• Use common sense
• Give a common diagnosis
• Give one diagnosis (preferably)
• Give a complete diagnosis
• While giving a diagnosis, first think of the anatomical diagnosis, meaning which anatomical structure this is arising from, for example. is it from lymph nodes, thyroid gland submandibular salivary gland, etc……. Then consider what pathological condition is affecting this structure.
• Both combined together form the clinical diagnosis, for example. tuberculous lymphadenitis, carcinoma parotid, carcinoma tongue, metastasis in cervical lymph nodes, etc.
• As far as possible try to give one etiological diagnosis It may not explain all physical signs and symptoms which is difficult in many situations. To give a few examples A patient may have lymph nodes in the neck that are matted suggesting tuberculosis.
• He may also have a nonhealing lesion in the tongue which is indurated (hard). The diagnosis will be carcinoma tongue with metastasis in the lymph nodes rather than tuberculosis of the tongue with neck nodes (carcinoma tongue is more common than tuberculosis of the tongue).
• When there are multiple swellings or masses in the neck, lymph node swellings should be offered as the first diagnosis.
• A lady has a thyroid swelling with another swelling in the scalp bone. The complete diagnosis is not just carcinoma thyroid but also secondary in the skull bone.
• As you study and present different cases, you will find the appropriate adjectives in the diagnosis. The whole purpose is to highlight the important aspects while giving the clinical diagnosis.

Differential Diagnosis

In a given case, all findings may not fit with one diagnosis which prompts a differential diagnosis.

• Sometimes the physical findings are so typical there is only one clinical diagnosis and no differential diagnosis as in the typical case of carcinoma breast or carcinoma cheek.
• The differential diagnosis should be the nearest possible diagnosis: One example is given here. A nonhealing lesion in the oral cavity can be malignant if there is induration. However, nonhealing can also be due to constant irritation caused by dentures.
• If signs are equivocal, carcinoma of the tongue should be the first diagnosis followed by dental ulcer as the second diagnosis. In the case of jaw tumors or salivary gland tumors, it is difficult to give a firm diagnosis. First mention it is a jaw tumor, followed by a few differential diagnoses such as adamantinoma or dental cyst, etc.
• Take another example of a sebaceous cyst. If it has a sebaceous punctum, it is diagnostic, no other differential diagnosis needs to be offered. However, if the punctum is absent, you have to consider other swellings such as dermoid cysts or lipomas, etc.

The clinical discussion ends here. However, it is good practice to now think of relevant investigations in a given case, their interpretation, and the planning of treatment. You will be able to understand further only when you have studied the subject well. For now, I will stop the case sheet documentation and clinical diagnosis.

Please note: There is always anxiety and apprehension in the clinical examination for dental MBBS and MS students. In an attempt to reduce this tension and anxiety, I have given the possible list of cases with their page numbers, which can be allowed to you as long or short cases. This list may differ from place to place. I am confident that you will benefit from this list and clinical methods.

Short Cases (Most Probable Cases) And Clinical Methods

1. Examination of swellings, for example. Lymph nodes, branchial cyst, cold abscess, salivary gland enlargement, haemangioma, lymphangioma.
2. Sebaceous cyst, dermoid cyst, neurofibroma, lipoma,
3. Skin tumours
4. Jaw tumors: Adamantinoma, dental cyst, Dentigerous.
5. Sinus —Median mental, osteomyelitis
6. TB lymphadenitis
7. Soft tissue
8. Secondaries in the.

• • Some cases can be also given as short cases depending upon the physical findings.
  • Please note there is no end to the list of clinical cases. 1 has given commonly asked cases and their clinical methods.