Principle of History Taking in Surgery

History Taking

Dr. Khalid Al-ZahraniAssistant Professor of Plastic Surgery

Course Organiser, Surg. 351Department of Surgery

Prepare you self to be a good physician

Your appearance is important:(wearing proper uniform, ie. Lab coats, I.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 cubicle

Allow his relative to be there if the patient wants.

Be alert and pay him full attention

Introduce your self

History Taking in Surgery

There is no difference between medical and surgical history. They are the same.

The history compnents Personal data. the present complaint (c/o). History of present complaint. Elaboration on the system involved. Systemic enquiry. Past history ? surgical, medical Drug history Family history Social history

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

Complain Of

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.

Fever

weight loss

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 SystemAches 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

Drug History and allergy

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

Allergy to any medications

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

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