Principle of History Taking in Surgery

History Taking

Tariq AltokhaisAssistant Professor

Consultant, Pediatric Surgery

Department of Surgery

History Taking:Key to diagnosis.Help to tailor the management.

Prepare you self to be a good physician

Your appearance is important:

Proper uniformLab coatsI.D.Etc.

Treat patient as if they are your friend(s) Think of the condition of your patient first

and not yoursSee him walking in and not in the

cubicleAllow his relative to be there if the patient wants.

Be alert and pay him full attention

Introduce yourself

History Taking in Surgery

There is no difference between medical and surgical history.

Components of Patient HistoryDate and time

Identifying data

Source of referral

Source of history

Chief complaint

Present illness

Past medical and surgical history

Family HistorySocial HistoryDrug History

Review of body systems

HistoryPersonal Data

• Date and Time• Name & File number ( Medical record number)• Age• Sex• Religion• Marital status• Occupation• Residency• Who gave the history?

Chief ComplaintMain Complaint

Chief Complaint

Chief complaint may be misleading

Problem may be more serious than the chief complaint

.

History of the presenting Symptom ( Illness)

Elaborate the symptom.Elaborate the system involved.What had been done for the patient?

Past HistoryDm, HypertensionBronchial Asthma Bleeding disorders & Sickle cell disease TB, Syphilis, BilharziasPassage of stonesBlood transfusionOperations, Trauma

Family History

Similar conditionsParents and close relatives cause of

death and serious illnesses.DM, Hypertension Bleeding Disorders& Sickle cell disease Ca Prostate ( others)

Systemic ReviewSystematic Direct Questions

Negative symptoms are as important as positive one.

You have to ask about them all, and keep repeat them in each patient, to memorize them well.

Nervous SystemNervousnessExcitabilityTremorFainting attacksBlackoutFitsLoss of consciousnessMuscle weaknessParalysisSensory disturbancesParaesthesiaeChanges of smell, Vision or hearingHeadachesChange of behavior

Respiratory & CardiovascularCoughSputumHaemoptysisDyspnoeaHoarsenessWheezingTachypnoeaChest painParoxysmal nocturnal dyspnoeaOrthopneaPalpationsDizzinessAnkle swellingPain in limbsWalking distanceTemperature and color of hands and feet

Alimentary & Abdomen Appetite Diet Taste Swallowing Regurgitation Vomiting Indigestion Vomiting Haematemses Abdominal pain Abdominal Distension Bowel habit Stool Jaundice

Urogenital SystemLoin painSymptoms of uremia1. Headache2. Drowsiness3. Fits4. Visual disturbances5. Vomiting6. Oedema of ankles, hands of face Lower urinary tract symptoms ( LUTS) Painful micturirtion Polyuria Color of urine Hematuria Male Infertility history Sexual problems history

Musculoskeletal System

Aches or Pain in muscles, bones and jointsSwelling of joints limitation of joints movementsWeaknessDisturbance of gait

Social History & Habits

Detailed marital status Living accommodation Occupation Travel abroad Leisure activity Smoking Drinking Eating habits

Sensitive TopicsAlcohol or drug use

Physical abuse or violence

Sexual issues

Sensitive Questions GuidelinesRespect patient privacy

Be direct and firm

Avoid confrontation

Be nonjudgmental

Use appropriate language

Document carefullyUse patient’s words when possible

Drug History and allergy

The drugs the patient taking specially: Insulin, Steroids and contraceptive pills

Allergy to any medications

Special ChallengesSilence

Overly talkative patients

Patients with multiple symptoms

Anxious patients

Special ChallengesFalse reassurance

May be tempting Avoid early reassurance or “over reassurance”

Unless it can be provided with confidence

Common symptomsPain1. Site2. Time & mode of onset3. Duration4. Severity5. Nature ( Character)6. Progression of pain7. The end of pain8. Relieving factors9. Exaggerating (Exacerbating) factors10. Radiation11. Cause

History of a lump or an ulcerDuration ( when was the first time noticed)First symptom ( how the patient noticed it)Other symptomsProgression ( change since notice)Persistence ( has it ever disappear or healed)Any other lumps or ulcersCause

Questions ?