History taking in general surgery
Transcript of History taking in general surgery
• Surgical History Taking
General
Surgical History Taking
By Hosam M. Hamza, MD
Lecturer of General & Laparo-endoscopic
Surgery
Minia Faculty of Medicine
Why do we take history ?
o DIAGNOSIS:
accurate diagnosis rests firmly upon the foundation of
a thoughtful and inclusive history.
o COMMUNICATION:
to establish a patient – physician relationship.
o DOCUMENTATION:
to pass information to others.
o INDIVIDUALIZATION:
ensuring that care is individualise related to age, social
history …etc
What tools are needed?
The sense of what data are important to take a meaningful history (value of history, of course, will depend on your ability to elicit relevant information), this will grow with time & training.
The ability to listen & ask targeted questions.
Knowing the basics of the pathophysiology in each disease, sophisticated fund of knowledge is not needed to successfully interview a patient.
How to start? Introduce yourself.
Talk & deal in a friendly relaxed way.
Once talk has begun, encourage the patient to continue:
– Mmm Hmm. – Yes?
– And what else? – I am with you
{ Listening body language } or {non-verbal
communication skills}
Try to see things from the patient’s point of view (always
exhibit neutral position….!)
Avoid medical terms.
Respect patient privacy.
Types of History Out-patient or Emergency Room history
?specific complaint is pinpointed ? diagnosis
Elective surgery history
? to assess that the treatment planned is correctly
chosen and that the patient is suitable for that
operation.
Donts’ of History - Don’t interrupt the patient while he/she is telling
you about the story of illness. Listen well but never
allow the patient to guide you away in irrelevant
stories. Specific complaint is pinpointed ? diagnosis
- Don’t be abrupt
- Don’t use medical terms while talking with your
patient
FORMAT
i. Personal History
ii. Chief Complaint
iii. Present History (HPI)
iv. Past History
v. Family History
I- Personal History Ask about:
NAME
AGE
SEX
OCCUPATION
MARIETAL STATE
RESIDENCE
HABITS OF IMPORTANCE You can mention residence & occupation in Arabic if you don’t know in English.
NAME * Identification.
* Registration.
* To elicit doctor – patient
familiarity (patient usually
likes to be called by name)
* To avoid fatal mistakes.
AGE * Certain diseases are
common in certain age groups (e.g. congenital)
* Certain drugs may bbe hazardous in certain age groups (e.g. Quinolones, Tetracycline, NSAIDs…)
Age groups
Neonatal period = up to 1 month old
Infancy = 1 month – 2 years old
Childhood = 2 – 12 years old
Adolescence = 12 – 20 years old
Adulthood = 20 – 40 years old
Middle age = 40 – 60 years old
Elderly = over 60 years old
Cleft lip since birth
Cystic hygroma infancy
Thyroglossal cyst childhood
Appendicitis adolescents & adults
Trauma adolescents & adults
Cancer middle & old age
Goitre child ---------cretinism
puberty ------physiological
adult --------- S.N.G.
elderly ------- malignant thyroid
U. T. adolescents & adults ---------- stones
elderly ----------------------------- cancer or prostatism
Age – disease correlation
CAUTION
Wilm’s Tumour Ewing’s tumour
Neuroblastoma Retinoblastoma
Acute Leukaemia
Juvenile (secretory) breast carcinoma
CANCERS OF CHILDHOOD
SEX
1-Diseases:
Haemophilia
Buerger’s disease
CCC
thyroid diseases
breast diseases…
♀♂ diseases of sexual organs
2- Menstrual history (♀):
Time of Menarche……………………..…....?
Regularity ……………………………….…..?
Related complaints (? pain)………………...?
Post- menopausal………………./………..….?
MARITAL STATUS
Single, married, divorced, widow, widower…
If married:
♂ ask about: fertility, offspring, STD’s
♀ ask about: fertility, offspring, lactation (now),
contraception (now), STD’s
Why to ask about Menstrual
history ?
• For elective operations, don’t operate on a female
during her menses.
• If early menarche & late menopause = risk group of
breast cancer.
• Pain & fullness in the breast during menses draws the
attention to fibroadenosis.
• Whether the patient is pre- or post-menopausal, it is
very important in the ttt of breast cancer.
Why to ask about marital state ?
• Infertility
• STDs
• Psychic troubles…..
OCCUPATION 1 - occupational diseases:
* intellectual
* exposure to carcinogens
1 - occupational diseases:
* porters HERNIAS * Farmers Bilharziasis = SPLENOMEGALLY
* typists, pianists, drill workers RAYNAUD’S PHENOMENON
* teachers, surgeons, nurses VARICOSE VEINS
* intellectual HTN, Peptic Ulcer
* exposure to carcinogens
2 - Standard of living (social class):
* diseases of high social class:
Duodenal ulcer
Irritable Bowel Syndrome * diseases of low social class:
TB
Parasitic infestations
RESIDENSE
1 - endemic diseases:
Delta : Colonic bilharziasis
Upper Egypt: Urinary bilharziasis
Giza & Damietta: Filariasis
Oases: Endemic goitre
Sudan: Malaria
Iraq: Hydatidosis
Europe: Colonic cancer
USA: Breast cancer
Japan: Gastric cancer
2- Follow up: phone No. , postal code
HABITS OF SURGICAL IMPORTANCE
Smoking
Tea & Coffee abuse
Alcohol intake
I.V. drug addiction
Automedications
Diet habits
Swimming in canals
HABITS OF SURGICAL IMPORTANCE
SMOKING .
ASK ABOUT:
- type of smoking…
- duration of smoking …. ex-smoker
- hazards of smoking ( ± ) - smoking index =
NO. of cigarettes × duration (in years)
Index less than 100 = mild smoker
100 – 300 = moderate smoker
more than 300 = heavy smoker
But this index is INACCURATE as it ignores parameters such as age at initiation, passive smoking and other forms of smoking as cigars and pipes.
HAZARDS OF SMOKING
cardiovasc. respiratory GI miscellaneu
s
Tachycardia
Extrasystoles
IHD
Atheromas
Buerger’s
disaese
HTN
Lip cancer
Tongue cancer
Bronchogenic
carcinoma
Glossitis
COPD
Emphysema
↑postoperativ
e respiratory
complications
↑ oesophageal
cancer
↑ gastric
cancer
↓ healing of
peptic ulcers
IBS
↓foetal
growth
Tobacco
amblyopia
EXCESSIVE TEA & COFFEE : ASK ABOUT:
- Amount of intake per day
- Hazards:
* INSOMNIA * DIURESIS
* HYPERACIDITY * CONSTIPATION
ALCOHOL INTAKE
ASK ABOUT:
- type of drink…
- duration of drinking & if stopped
- amount of intake per day
- hazards of alcohol ;
HAZARDS OF ALCOHOL INTAKE
* delerium. *addiction. *peripheral neuritis.
*myopathy. *tremors. *cardiomyopathy.
*gastritis. *alcoholic hepatitis. *alcoholic cirrhosis.
*hyperlipidaemia. *Zieve’s syndrome
I.V. DRUG ADDICTION :
ASK ABOUT:
- type of drug…
- duration of addiction & if stopped
- amount of intake
- hazards of I.V. drug addiction:
AIDS
INFECTIVE HEPATITIS
INFECTIVE ENDOCARDITIS
MALARIA :
DIET HABITS
- excessive fat obesity, fatty
liver, atherosclerosis, cholecystitis,…
- excessive spices gastritis, PU, haemorrhoids,…
SWIMMING IN CANALS :
:
- ask about the MOST DISTRESSING PROBLEM that motivated
patient to seek care + DURATION.
- record & express complaint in one short specific AND NOT
SCIENTIFIC sentence.
IN THE PATIENT’S OWNWORDS (never use medical
terms e.g.
dysphagia = difficult swallowing.
jaundice = yellowish discoloration of the eyes
palpitation = rapid sensible heart beats.
axilla = armpit
inguinal region = groin
ulcer = sore
Rt hypochondrium = Rt upper quadrant of the abdomen.
II- Chief Complaint
For - A patient suffering form jaundice that began 3 weeks ago and is still present.
The complaint is (yellowish discolouration of the skin & sclera OF 3 weeks duration )…
don’t use for, since, ago…
Complaint in surgery my be:
1- pain 2- swelling 3- ulcer 4- disturbed body function
Pain is an annoying unpleasant sensation of varying intensity (= symptom)
Tenderness is pain in relation to a stimulus (=sign)
(patient feels pain & you elicit tenderness)
Never to say “history of tenderness”
this is the chronological story of the patient illness extending from the moment when the patient was quite well till now.
- 3 steps:
1- analysis of patient’s complaint (avoid leading “Yes/No” questions)
2- aetiology, complications and other symptoms related to the patient’s condition and not given by the patient.
3- review for other systems in the body.
4- investigations & TTT received for the presenting condition.
III- History of the present illness
If the main complaint is pain, ask about: OPQRST
• Onset= sudden, rapid or gradual.
• Offset (in pain only) = spontaneously or by drugs.
• Course= progressive, intermittent……
• Duration= of the attack
• Precipitating factors= if pain is related to a stimulus known by the patient
• Quality (character)= dull aching, burning, colicky, throbbing, stitching, squeezing, dragging, heaviness…..etc
• Severity of pain ( tolerable or not? what ↑ pain? what ↓pain ? )
• Site of pain
• Radiation of pain= radiating pain = extension of pain to a distant site while the initial pain persists (e.g. acute appendicitis), referred pain = feeling pain away from its possible source (e.g. acute cholecystitis)
• Time of onset (e.g. at night)
Analysis Of The Complaint ANALYSIS OF PAIN
• Onset= sudden, rapid or gradual.
• Course= progressive, intermittent or in-plateau
• Duration
• Ppt factors= if pain is related to a stimulus known by the patient
• Multiplicity= some swellings tend to be multiple as:
- multiple lymph nodes
- multiple lipomas
- multiple haemangiomas, multiple lymphangiomas
- multiple papillomas (warts)
- multiple naevi
- multiple sebaceous cysts
• Ever disappears (very important in hernias)
• Associated symptoms= 1. pain
2. General manifestations = fever + symptoms of metastases
3. Local manifestations = VAN
Analysis Of The Complaint ANALYSIS OF SWELLING
- Analyze pain also if the swelling is painful !
- Fever: it may be important (not just an association) especially if:
* related to the onset of the swelling.
* recurrent.
- Symptoms of metastases:
• Bone metastases= bone pain, repeated fractures on minor trauma
(= pathological fractures)
• Brain " " = ↑ ICP, fits, sensory or motor affection
• Lung " " = cough, haemoptysis, chest pain
• Liver " " = rt hypochondrial pain, jaundice
Symptoms of metastases are usually negative, say: (No history suggestive of metastases in the form of bony aches, RT hypochondrial pain, headache, vomiting, blurring of vision, cough…etc)
Local manifestations:
VAN= Vein, Artery, Nerve • Swelling in a limb → effect on vein= oedema
on artery= ischaemia
on nerve = numbness & paresis
• Swelling at parotid gland: effect on nerve (facial N.)
• Swelling in breast: effect on vein or lymphatics (causing
lymphoedema of upper limb)
IV- Past history
Ask leading questions about past events having
relationship to presenting complaint:
1. Past history of similar attacks.
2. “ “ “ drug intake.
3. “ “ “ operations.
4. “ “ “ endemic diseases.
5. “ “ “ systemic diseases.
6. “ “ “ childhood diseases.
7. “ “ “ trauma.
8. “ “ “ traveling abroad..
V- Family history
Ask about Family history of similar conditions in:
• Familial diseases: “e.g. T.B., endemic goitre,… etc”
• Herditary diseases: “haemophilia, HA, breast cancer, …etc”
Ask about history of familial diseases.
Ask about history of consanguinity.