Surgical History and Examination
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Direct answer
The case sheet is diagnostic instrument number one — the sequence of its headings is the sequence of clinical reasoning, and every BDS viva is marked against it. History runs demographic details, presenting complaint in the patient's own words, history of present illness (onset, duration, progression, aggravating and relieving factors, associated symptoms), past history including diabetes, tuberculosis, jaundice and previous anaesthesia, treatment history, personal history — in Indian practice this must name tobacco in all its forms with years of habit, alcohol, and occupation — and family history. Examination proceeds general survey and vitals, systemic examination, then local examination by the swelling routine — inspection (site, size, shape, skin, surface, edge, surrounding), palpation (temperature, tenderness, consistency, fluctuation, translucency, reducibility, pulsatility, mobility, relations to sternomastoid, swallowing and tongue protrusion), percussion and auscultation — and for ulcers the site, size, floor, edge, discharge, base and regional nodes. The diagnosis is then written as the triad: anatomical, pathological, clinical.
What you must remember
- History headings in order: biodata, chief complaint, history of present illness, past history (diabetes, hypertension, cardiac disease, tuberculosis, jaundice, seizures, transfusions, drug allergies, previous surgery and anaesthesia), family history, personal and occupational history — writing them in this order is pass-mark material in every Indian surgical and oral-surgery practical.
- Pain interrogation: site, onset, character, radiation, associations, timing, exacerbating and relieving factors, severity — the SOCRATES string applied to surgical pain from pulpitis to perforated ulcer.
- The habits question, verbatim for India: tobacco — smoked (bidi, cigarette, years, packs) and smokeless (gutka, khaini, paan with tobacco, years kept in which sulcus), plus alcohol and areca nut — this single history line assigns oral cancer risk and drives the examination.
- Swelling examination routine: inspection then palpation — site, size, shape, surface, edge, skin over it, temperature, tenderness, consistency (soft, cystic, firm, hard, rubbery, variegated), fluctuation, transillumination, reducibility and compressibility, pulsatility (transmitted versus expansile), mobility and relation to planes and muscles, regional lymph nodes.
- Ulcer examination routine: site, size and shape, edge (sloping, punched out, undermined, everted, rolled — the diagnostic edge), floor (granulation, slough, membrane), discharge (serous, purulent, bloody), base (fixity to deep structures), surrounding skin, and regional nodes with a search for the primary.
- Diagnostic triad to write at the end: anatomical diagnosis (which structure), pathological diagnosis (what lesion — inflammatory, neoplastic benign or malignant), and clinical diagnosis (complications and stage) — the three-line conclusion examiners read first.
- Red flags that restructure the whole examination: weight loss, night pain, age over 40 with a new swelling, previous malignancy, and non-healing beyond three weeks — each pushes the differential toward malignancy.
A lump examined the way examiners watch
A 45-year-old presents with a swelling below the angle of the jaw, three months, slowly enlarging, painless, a 15-year khaini habit. Watch the routine earn its marks. Inspection first, from in front and profile: side, exactly where in the submandibular triangle, roughly 4 × 3 cm, oval, smooth surface, overlying skin free, no ulceration or pulsation. Palpation from behind the seated patient: warm? not; tender? not; consistency firm; no fluctuation; does not transilluminate; mobile in the skin plane but bimanual palpation clarifies its relation to the submandibular gland and the mandible; moves with swallowing? not. Then the two bimanal manoeuvres of this triangle — the swelling ballotting between internal and external fingers, and the tongue pushed aside to view the floor of mouth and duct orifice, milking the gland for a stone at the submandibular duct. Then the nodes: levels I to VI on both sides. Then the habits line, already taken, converts a dry anatomy recital into a case: this is either submandibular sialadenitis with a calculus, or a node bearing metastasis from an occult oral primary — and the next steps (ultrasound, FNAC, and a full oral examination) write themselves. Structure, then suspicion: the routine finds the lump, the history indicts it.
How the exam frames it
University practicals award the case presentation on exactly this skeleton — a complete, ordered history; a rehearsed swelling or ulcer routine; and the triad diagnosis with investigations listed in a logical sequence (bloods, imaging, then cytology or biopsy). Viva examiners interrupt deliberately: What does an everted edge mean? What does mobility on swallowing tell you? Which swelling transilluminates brilliantly? The Indian twist is the habits history — a candidate who forgets to quantify tobacco in pack-years and gutka-years loses marks that no amount of examination recovers, because in this country the habit is the aetiology section of half the surgical short cases.
Frequently asked questions
In what order is a surgical swelling examined?
Inspection (site, size, shape, surface, edge, overlying skin), then palpation (temperature, tenderness, consistency, fluctuation, transluminancy, reducibility, pulsatility, mobility and plane), then percussion and auscultation, finishing with regional lymph nodes.
Why is the edge of an ulcer examined so carefully?
The edge is diagnostic shorthand — sloping for healing, punched out for gummatous, undermined for tuberculous, everted for squamous carcinoma, rolled for basal cell carcinoma.
What three lines complete a surgical diagnosis?
The anatomical diagnosis (structure involved), the pathological diagnosis (nature of the lesion) and the clinical diagnosis (stage and complications) — the concluding triad of every case sheet.
Which personal-history details are mandatory in Indian surgical practice?
Tobacco in all forms with duration and amount (bidi, cigarette, gutka, khaini, paan), alcohol, areca nut use and occupation — the aetiological core of oral and upper-aerodigestive presentations.
What is the significance of a swelling that moves on swallowing?
Attachment to the larynx by pretracheal fascia — thyroid swellings and thyroglossal cysts move on swallowing, and the thyroglossal cyst additionally ascends on tongue protrusion, localising the lesion before any imaging.