What are the key steps in taking a long case history in a surgery department?

Key Steps in Taking a Long Case History in a Surgery Department

A comprehensive surgical case history should follow a structured approach that includes patient information, clinical findings, diagnostic assessment, therapeutic interventions, and follow-up outcomes as recommended by the International Journal of Surgery. 1

Essential Components

Initial Presentation

• Begin with demographic details (age, sex, ethnicity, occupation, BMI if relevant) and the presenting complaint 1
• Document the mode of presentation (ambulance, walk-in, referral) and chief concerns 1
• Include relevant past medical/surgical history and outcomes from previous interventions 1, 2
• Record medication history, allergies, psychosocial history, and family history including genetic information when relevant 1

Clinical Assessment

• Present relevant physical examination findings in a systematic manner 1, 3
• Document all diagnostic methods used (physical exam, laboratory testing, imaging, histopathology) 1, 2
• Explain diagnostic reasoning and differential diagnoses considered 1
• Include prognostic characteristics when applicable (e.g., tumor staging) 1

Timeline and Interventions

• Present the sequence of events in chronological order to avoid confusion 1, 2
• Use tables or figures to clarify complex timelines 1
• Document any delays between presentation and intervention 1
• Describe pre-intervention considerations and patient optimization measures 1, 3
• Detail the interventions performed (pharmacologic, surgical, etc.) and reasoning behind treatment choices 1, 2
• For surgical cases, include specific details on anesthesia, positioning, equipment, and techniques used 1
• Document the operator's experience level and any modifications to standard approaches 1

Outcomes and Follow-up

• Report clinician-assessed and patient-reported outcomes with specific time periods 1, 3, 2
• Document complications or adverse events in detail, including how they were managed 1, 3, 2
• Include future surveillance requirements when applicable 1, 2
• Incorporate the patient's perspective on the treatments received when appropriate 3, 2

Effective Interviewing Techniques

• Establish rapport with the patient to facilitate open communication and accurate information gathering 4
• Use attentive listening techniques to ensure comprehensive data collection 5
• Allocate sufficient time for patient interaction as this may help avoid unnecessary testing, procedures, and referrals 4
• Structure questions to systematically gather information while allowing the patient to express concerns 4

Common Pitfalls to Avoid

• Presenting information in a non-chronological order, which can confuse listeners 1, 2
• Rushing through the interview process due to time pressures, which may lead to missing critical information 4
• Over-reliance on technology at the expense of thorough patient interaction 4
• Failing to document informed consent from the patient 3, 2
• Neglecting to analyze strengths, weaknesses, and limitations in your approach to the case 3

Documentation Requirements

• State that informed consent was obtained from the patient 3, 2
• Include conflicts of interest, sources of funding, and ethics committee approval when required 3
• For surgical cases, submit a completed SCARE checklist with the manuscript 2
• Explicitly state compliance with the SCARE guideline in the report 2