At their first contact, the surgeon must gain the patient’s confidence and convey the assurance that help is available and will be provided. The surgeon must demonstrate concern for the patient as a person who needs help and not just as a “case” to be processed. This is not always easy to do, and there are no rules of conduct except to be gentle and considerate. Most patients are eager to like and trust their doctors and respond gratefully to a sympathetic and understanding person. Some surgeons are able to establish a confident relationship with the first few words of greeting; others can only do so by means of a stylized and carefully acquired bedside manner. It does not matter how it is done, so long as an atmosphere of sympathy, personal interest, and understanding is created. Even under emergency circumstances, this subtle message of sympathetic concern must be conveyed.
Eventually, all histories must be formally structured, but much can be learned by letting the patient ramble a little. Discrepancies and omissions in the history are often due as much to overstructuring and leading questions as to the unreliability of the patient. The enthusiastic novice asks leading questions; the cooperative patient gives the answer that seems to be wanted; and the interview concludes on a note of mutual satisfaction with the wrong answer thus developed.
History taking is detective work. Preconceived ideas, snap judgments, and hasty conclusions have no place in this process. The diagnosis must be established by inductive reasoning. The interviewer must first determine the facts and then search for essential clues, realizing that the patient may conceal the most important symptom—for example, the passage of blood by rectum—in the hope (born of fear) that if it is not specifically inquired about or if nothing is found to account for it in the physical examination, it cannot be very serious.
Common symptoms of surgical conditions that require special emphasis in the history taking are discussed in the following paragraphs.
A careful analysis of the nature of pain is one of the most important features of a surgical history. The examiner must first ascertain how the pain began. Was it explosive in onset, rapid, or gradual? What is the precise character of the pain? Is it so severe that it cannot be relieved by medication? Is it constant or intermittent? Are there classic associations, such as the rhythmic pattern of small bowel obstruction or the onset of pain preceding the limp of intermittent claudication?
One of the most important aspects of pain is the patient’s reaction to it. The overreactor’s description of pain is often obviously inappropriate, and so is a description of “excruciating” pain offered in a casual or jovial manner. A patient who shrieks and thrashes about is either grossly overreacting or suffering from renal or biliary colic. Very severe pain—due to infection, inflammation, or vascular disease—usually forces the patient to restrict all movement as much as possible.
Moderate pain is made agonizing by fear and anxiety. Reassurance of a sort calculated to restore the patient’s confidence in the care being given is often a more effective analgesic than an injection of morphine.
What did the patient vomit? How much? How often? What did the vomitus look like? Was vomiting projectile? It is especially helpful for the examiner to see the vomitus.
A change in bowel habits is a common complaint that is often of no significance. However, when a person who has always had regular evacuations notices a distinct change, particularly toward intermittent alternations of constipation and diarrhea; colon cancer must be suspected. Too much emphasis is placed upon the size and shape of the stool—for example, many patients who normally have well-formed stools may complain of irregular small stools when their routine is disturbed by travel or a change in diet.
Hematemesis or Hematochezia
Bleeding from any orifice demands the most critical analysis and can never be dismissed as due to some immediately obvious cause. The most common error is to assume that bleeding from the rectum is attributable to hemorrhoids. The character of the blood can be of great significance. Does it clot? Is it bright or dark red? Is it changed in any way, as in the coffee-ground vomitus of slow gastric bleeding or the dark, tarry stool of upper gastrointestinal bleeding? The full details and variations cannot be included here but will be emphasized under separate headings elsewhere.
Trauma occurs so commonly that it is often difficult to establish a relationship between the chief complaint and an episode of trauma. Children in particular are subject to all kinds of minor trauma, and the family may attribute the onset of an illness to a specific recent injury. On the other hand, children may be subjected to severe trauma though their parents are unaware of it. The possibility of trauma having been inflicted by a parent must not be overlooked.
When there is a history of trauma, the details must be established as precisely as possible. What was the patient’s position when the accident occurred? Was consciousness lost? Retrograde amnesia (inability to remember events just preceding the accident) always indicates some degree of cerebral damage. If a patient can remember every detail of an accident, has not lost consciousness, and has no evidence of external injury to the head, brain damage can be excluded.
In the case of gunshot wounds and stab wounds, knowing the nature of the weapon, its size and shape, the probable trajectory, and the position of the patient when hit may be very helpful in evaluating the nature of the resultant injury.
The possibility that an accident might have been caused by preexisting disease such as epilepsy, diabetes, coronary artery disease, or hypoglycemia must be explored.
When all of the facts and essential clues have been gathered, the examiner is in a position to complete the study of the present illness. By this time, it may be possible to rule out (by inductive reasoning) all but a few diagnoses. A novice diagnostician asked to evaluate the causes of shoulder pain in a given patient might include ruptured ectopic pregnancy in the list of possibilities. The experienced physician will automatically exclude that possibility on the basis of gender or age.
The family history is of great significance in a number of surgical conditions. Polyposis of the colon is a classic example, but diabetes, Peutz-Jeghers syndrome, chronic pancreatitis, multiglandular syndromes, other endocrine abnormalities, and cancer are often better understood and better evaluated in the light of a careful family history.
The details of the past history may illuminate obscure areas of the present illness. It has been said that people who are well are almost never sick, and people who are sick are almost never well. It is true that a patient with a long and complicated history of diseases and injuries is likely to be a much poorer risk than even a very old patient experiencing a major surgical illness for the first time.
In order to make certain that important details of the past history will not be overlooked, the system review must be formalized and thorough. By always reviewing the past history in the same way, the experienced examiner never omits significant details. Many skilled examiners find it easy to review the past history by inquiring about each system as they perform the physical examination on that part of the body.
In reviewing the past history, it is important to consider the nutritional background of the patient. There is a clear awareness throughout the world that the underprivileged malnourished patient responds poorly to disease, injury, and operation. Malnourishment may not be obvious on physical examination and must be elicited by questioning.
Acute nutritional deficiencies, particularly fluid and electrolyte losses, can be understood only in the light of the total (including nutritional) history. For example, low serum sodium may be due to the use of diuretics or a sodium-restricted diet rather than to acute loss. In this connection, the use of any medications must be carefully recorded and interpreted.
A detailed history of acute losses by vomiting and diarrhea—and the nature of the losses—is helpful in estimating the probable trends in serum electrolytes. Thus, the patient who has been vomiting persistently with no evidence of bile in the vomitus is likely to have acute pyloric stenosis associated with benign ulcer, and hypochloremic alkalosis must be anticipated. Chronic vomiting without bile—and particularly with evidence of changed and previously digested food—is suggestive of chronic obstruction, and the possibility of carcinoma should be considered.
It is essential for the surgeon to think in terms of nutritional balance. It is often possible to begin therapy before the results of laboratory tests have been obtained, because the specific nature and probable extent of fluid and electrolyte losses can often be estimated on the basis of the history and the physician’s clinical experience. Laboratory data should be obtained as soon as possible, but knowledge of the probable level of the obstruction and of the concentration of the electrolytes in the gastrointestinal fluids will provide sufficient grounds for the institution of appropriate immediate therapy.
The Patient’s Emotional Background
Psychiatric consultation is seldom required in the management of surgical patients, but there are times when it is of great help. Emotionally and mentally disturbed patients require surgical operations as often as others, and full cooperation between psychiatrist and surgeon is essential. Furthermore, either before or after an operation, a patient may develop a major psychotic disturbance that is beyond the ability of the surgeon to appraise or manage. Prognosis, drug therapy, and overall management require the participation of a psychiatrist.
On the other hand, there are many situations in which the surgeon can and should deal with the emotional aspects of the patient’s illness rather than resorting to psychiatric assistance. Most psychiatrists prefer not to be brought in to deal with minor anxiety states. As long as the surgeon accepts the responsibility for the care of the whole patient, such services are superfluous.
This is particularly true in the care of patients with malignant disease or those who must undergo mutilating operations such as amputation of an extremity, ileostomy, or colostomy. In these situations, the patient can be supported far more effectively by the surgeon and the surgical team than by a consulting psychiatrist.
Surgeons are increasingly aware of the importance of psychosocial factors in surgical convalescence. Recovery from a major operation is greatly enhanced if the patient is not worn down with worry about emotional, social, and economic problems that have nothing to do with the illness itself. Incorporation of these factors into the record contributes to better total care of the surgical patient.