Patient Examination: History, Diagnosis, Patient Records

Abstract

It may seem perhaps redundant to say so, but before a surgeon or his assistant does recommend surgery to a patient, there first should be a secure diagnosis. Elemental to the procuring of an adequate diagnosis is the taking of a careful history from the patient concerning his illness or his problem. This statement may even seem to resemble those recipes for cooking elephant pie: those which begin with the admonition that first you catch an elephant. A patient’s history may very well indicate and then even dictate to a great extent, the goals of an approach which will terminate in a surgical procedure. Should the history reflect professional needs of a particular type, in many instances, this may very well result in the choice of a different surgical procedure or in some instances, the abandonment of the recommendation for surgery. More specifically, a person who has chronic hoarseness may well find that the symptom is indeed affecting the proper performance of his job. It may be an indication of an underlying vocal fold pathology such as vocal fold nodules. This same speaker may also have a very high pitched voice which it may be important to correct surgically — a factor of less importance for persons in more isolated occupation such as bookkeeper or as housewife, where quality of voice or tambour of voice may not be of as much relevance as it is in a minister, or a public school teacher.