If the patient has been seen before for complete examination, it is very important to review the findings noted on the history and the physical and laboratory examinations during prior visits. Such a review is bound to raise certain questions:

1. What is the present status of symptoms complained of or physical findings noted at the time of the previous examination?

2. Has there been any change in the patient's habits, occupation, etc. since the previous examination?

New Patient

If examining a new patient, then the record must be assembled from the beginning.

Family History

This should contain the usual data, particularly the following:

1. Have any blood relatives

(a) Developed or died of cancer?

(b) Had any premalignant conditions?

(c) Had any illnesses which in modern times might be diagnosed as cancer?

2. List details on any of these (especially age, site, and outcome).

Knowing the size of the family is of some assistance in evaluating the importance of the cancer history. The significance of these points in the history as they relate to the individual site are expanded upon in subsequent chapters.

Past Medical History

This is the customary review, with emphasis on the following:

1. Any hospitalization, operation, or medical treatment for cancer or precancerous conditions.

2. Any vague or suspicious illnesses. Patients are often not aware of the specific diagnosis or reason for operation especially if cancer is involved. These facts may have to be ascertained by deduction or inquiry from the family, or it may be necessary to write to other physicians or hospitals for details.

Environmental History

This deals with extrinsic factors which may increase the risk of cancer, usually of specific sites. These factors have already been mentioned in the discussion of the selection of patients for examination and will be dealt with in subsequent chapters as they relate to the individual sites.

1. Tobacco. Has the patient ever smoked?

(a) Type?

(b) Amount?

(c) Duration?

(d) Inhalation practiced?

2. Alcohol. Has the patient ever consumed alcoholic beverages regularly?

(a) Type?

(b) Amount?

(c) Duration?

3. Occupation-hobbies. What sort of work has the patient done or what hobbies has he had during his adult life?

(a) Type?

(b) Duration?

(c) Any known hazards?

Particular attention should be given to those jobs which have an inhalation hazard or in which there is exposure to skin carcinogens, radiation, or other noxious agents.

4. Radiation exposure

(a) Has the patient ever had x-ray therapy for any medical conditions? For example:

(1) Acne?

(2) Hirsutism?

(3) Enlargement of the thymus gland?

(4) Arthritis or bursitis?

(5) Pruritus ani or pruritus vulvae?

(6) Other benign conditions?

(b) Has the patient ever had unusual exposure to x-ray as a result of intensive, extensive, or repeated diagnostic procedures?

5. Hormone therapy

(a) Has the patient ever taken hormones?

(1) Type?

(2) Amount?

(3) Duration?

(4) Reason?

Review Of Systems

This part of the history is usually best accomplished during the actual physical examination of the patient.

Not only is this economical of time, but it also allows the doctor to inspect the area or part under discussion immediately.

Once again, opportunity is presented for inquiry into possible exposure to factors known to predispose to cancer as well as previous diagnosis of or treatment for cancer or precancerous conditions in the specific areas of the body.

Most important in the system review is a detailed questioning in regard to symptoms of malignant or premalignant conditions. Areas and complaints of high cancer potential are emphasized, but there is nothing else to distinguish the cancer detection survey from a systematic and thorough system review conducted on any presumably well adult.

In the following outline only those items of most significance in terms of cancer are listed.

The significance of positive answers to these questions is dealt with in the individual chapters.

General

1. Impaired sense of well-being; loss of physical and mental vigor

2. Weight loss

3. Loss of appetite

4. Pallor

1. Appearance of any sores, lumps, or moles

2. Change in character of any of above (e.g., failure to heal, increase in size, bleeding, color change, etc.)

Head And Neck

1. Lesions on skin or lips which are growing or do not heal

2. Sores, lumps, or bleeding inside the mouth

3. Hoarseness or change in voice

4. Difficulty in swallowing

5. Persistent sore throat

6. Lumps in the neck

7. Thyroid disease, especially nodules

Chest

1. Appearance of or change in character of cough

2. Sputum production

3. Hemoptysis

4. Chest pain, discomfort, or awareness

5. Audible wheeze

6. Dyspnea

7. Repeated attacks of "pneumonia"

Breast

1. Breast mass, pain, tenderness, or asymmetry

2. Axillary or supraclavicular masses

3. Nipple retraction, ulceration, or discharge (especially bloody)

4. Nursing history

Upper Gastrointestinal Tract

1. Loss of appetite

2. Difficulty in swallowing

3. Repeated episodes of indigestion

4. "Ulcer" symptoms

5. Hematemesis or melena

6. Weight loss

7. Pallor, history of "anemia"

Lower Gastrointestinal Tract

1. Any change in bowel habits

2. Constipation

3. Diarrhea

4. Melena

5. Rectal bleeding or appearance of mucus

6. Episodes of lower abdominal distress, cramping, flatulence

7. History of polyps, ulcerative colitis, etc.

8. Pallor or anemia

Genitourinary Tract

1. Hematuria

2. Flank pain

3. Urinary frequency, urgency, burning

4. Renal colic

5. Unexplained fever

6. Pallor or history of "anemia"

7. Symptoms of prostatism

Female Genital Tract

1. Menorrhagia or change in the character or amount of flow

2. Metrorrhagia or intermenstrual bleeding

3. Vaginal discharge

4. Persistent lesion in vulvar area

5. Obstetrical history

6. Date of last menstrual period or menopause

7. Use of contraceptives, especially ill-fitting diaphragms

8. Treatment with hormones, radiation, or cauterization

Lymphoma-Leukemia

1. Enlargement of glands

2. Easy bruising or bleeding tendency

3. Pallor, easy fatiguability

4. History of "anemia"