Download History taking in surgery

Patient-Doctor relation
The way to reach the Diagnosis
History Taking
Dr. Abdelmoniem Eltraifi
Consultant Urologist & Clinical Ass. Professor
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History taking values about 71.7% in
reaching the correct diagnosis.
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It also directs the usage of other tools
Goals of History taking:
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Building a friendly relation with the patient.
Formulating workup plan
Reaching a diagnosis.
Planning of management
Writing a neat medico-legal document.
Be ready; prepare you self to be
a good doctor
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The patient should be a friend or like a friend
 Always think of his condition and not yours
See him walking in and not in the cubicle
Allow his relative to be there if the patient wants.
Introduce your self
Be alert and pay him full attention
The problem with the formats and the
teachers preferences.
History Taking in Surgery
There is no difference between medical and
surgical history. They are almost the same.
The classical History
History
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Personal Data ( Patient Demography)
• Date and Time
• Name & File number ( Medical record number)
• Age
• Sex
• Religion
• Marital status
• Occupation
• Residency
• Who gave the history?
Chief Complaint
Main Complaint
Complain Of ( C/O)
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You should write the patient own words.
If there is more than one complaint, it
should be written according to:
1. Occurrence.
2. Most bothersome.
History of the presenting Symptom ( Illness)
Elaborate the symptom.
 Elaborate the system involved.
 What had been done for the patient?
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Past History
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Dm, Hypertension
Bronchial Asthma
Bleeding disorders & Sickle cell disease
TB, Syphilis, Bilharzias, STD
Blood transfusion
Operations, Trauma
Family History
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Similar conditions
 Parents and close relatives cause of
death and serious illnesses.
 DM, Hypertension
 Bleeding Disorders& Sickle cell disease
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Ca Prostate, renal diseases ( others)
Systemic Review
Systematic 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.
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Fever
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weight loss
Nervous System
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Nervousness
Excitability
Tremor
Fainting attacks
Blackout
Fits
Loss of consciousness
Muscle weakness
Paralysis
Sensory disturbances
Paraesthesiae
Changes of smell, Vision or hearing
Headaches
Change of behavior
Respiratory & Cardiovascular
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Cough
Sputum
Haemoptysis
Dyspnoea
Hoarseness
Wheezing
Tachypnoea
Chest pain
Paroxysmal nocturnal dyspnoea
Orthopnea
Palpations
Dizziness
Ankle swelling
Pain in limbs
Walking distance
Temperature and color of hands and feet
Alimentary & Abdomen
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Appetite
Diet
Taste
Swallowing
Regurgitation
Vomiting
Indigestion
Haematemses
Abdominal pain
Abdominal Distension
Bowel habit
Stool
Jaundice
Urogenital System
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Loin pain
Symptoms of uremia
Headache
Drowsiness
Fits
Visual disturbances
Vomiting
Oedema of ankles, hands, or face
Lower urinary tract symptoms ( LUTS)
Painful micturirtion
Polyuria
Color of urine
Hematuria
Male Infertility history
Sexual problems history
Musculoskeletal System
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Aches or Pain in muscles, bones and joints
Swelling of joints
limitation of joints movements
Weakness
Disturbance of gait
Social History & Habits
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Detailed marital status
Living accommodation
Occupation
Travel abroad
Leisure activity
Smoking
Drinking
Eating habits
Drug History and allergy
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The drugs the patient taking specially: Insulin, Steroids and
contraceptive pills
Allergy to any medications
Common symptoms
 Pain
Site
2. Duration
3. Mode of onset
4. Severity
5. Nature ( Character)
6. Progression of pain
7. The end of pain
8. Relieving factors
9. Exaggerating (Exacerbating) factors
10. Radiation
11. Cause
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History of a lump or an ulcer
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Duration ( when was the first time noticed)
 First symptom ( how the patient noticed it)
 Other symptoms
 Progression ( change since notice)
 Persistence ( has it ever disappear or healed)
 Any other lumps or ulcers
 Cause
An Example of classical History
taking
Hematuria
Classical history of hematuria
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Patient demography
• Date and Time= 13/9/2001 at 10 am
• Khalid Alotibi File number 12-30-00
• 47 years old
• male
• Muslim
• Married
• Teacher
• Living in Riyadh, before in Hail
• History given by the patient himself?
c/o blood in urine for 5 days
History of present illness
He was well, tell five days ago, when he noticed blood in his urine.
The haematuria is episodic, most of the time when ever he is passing urine.
The urine color is dark red. Also he noticed blood clots in the urine, which are
rounded in shape.
He had no pain. The haematuria is total throughout all his urine stream.
No history of trauma, no ingestion of red colored food, or drink.
No bleeding from other sites of his body.
Finish all urinary tract system symptoms in this part.
They inserted for him, 3 ways urethral Folly catheter, and they did continuous
bladder irrigation by saline, and they just finished doing CT urography for
him.
Past History
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No history of similar episode before.
No history of bleeding disorder.
No history of pulmonary Tuberculosis
No history of stone disease
No history of operations or RTA
No history STD
No History of DM, or Hypertension, bronchial asthma, and no known
allergy.
Family History
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No family history of similar episode.
Parents are dead ( unknown cause of death).
No family History of; SCD, or other hematological disorder.
No family history of; cancer prostate, or other renal disease
No family history of DM, or hypertension
Systemic Review
Systematic Direct Questions
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No Fever, or loss of weight.
 Ask him- here about all the other systems.
 Exclude urinary tract, as its should be
finished already, in the section of history of
the present illness.
 Negative symptoms: are as important as
positive one
Social History & Habits
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Married to one wife, with Three-female and two-male children.
Living in his own villa, with good facilities.
Working as a higher school teacher, and had other personal business
with good income.
Not smoker, but he had other colleague teachers , who are smoking in
the office.
He used to travel in summer with his family to other countries: Egypt,
Turkey, Syria and once to Malaysia. Never exposed himself to rivers ,
ponds, or canal water.
Never drank alcohol.
His leisure are: reading news papers and watching TV only.
He used to eat ordinary Saudi food.
Drug History and allergy
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He is not taking anti-coagulants, or any other drugs.
No know allergy to any medication.
Example of short history
taking for the OSCE Exam
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Ask directly about the patient presenting
symptom.
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Ask related Questions only.
Example: History of Hematuria
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Age
Residency.
Duration.
Occupation
Painless or painful
Timing of Haematuria
Amount of bleeding ( darkness of the color, an presence of clots)
Shape of clots
Trauma
Bleeding from other sites
Associated urinary, and Systemic Symptoms
Bleeding disorders, SC, TB, Bilharzias & stone disease.
Family History of Malignancy, Renal, or hematological
disorders.
Drugs
Red colored food or drinks.
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Smoking
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