The management of surgical disorders requires not only the application of technical skills and training in the basic sciences to the problems of diagnosis and treatment, but also a genuine sympathy, and indeed love, for the patient. The surgeon must be a doctor in the old-fashioned sense: an applied scientist, an engineer, an artist, and a minister to his or her fellow human beings. Because life or death often depends upon the validity of surgical decisions, the surgeon’s judgment must be matched by courage in action and by a high degree of technical proficiency.
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 ...