History Taking in Surgery 123

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History Taking

In SurgeryGamal Khairy FRCS,MS

College of Medicine KKUH


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History taking

? the key step in surgical diagnosis.

Varies according to the complain

? specific histories

? surgical specialty


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Two types of history in surgical practice:

Out-pt or emergency room history

?specific complaint is pinpointed ? diagnosis

Clerking of pt admitted for electivesurgery object

?to assess that the treatment planned correctlyindicated and pt is suitable for that operation.


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How to take the history ?

Personal information : Age, sex, maritalstatus, occupation, etc


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History should be taken

in the following order: the present complaint (c/o).

History of present complaint.

Elaboration on the system involved.

Systemic enquiry.


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History should be takenin the following order:

e. Past history ? surgical, medical

f. Drug history

g. Family history

h. Social history


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Systemic Enquiry

1. GIT: Appetite, Vomiting, Regurgitation, etc.

Respiratory System ? cough, haemoptysis, Dyspnea.

C.V.S: * Breathlessness, palpations, chest pain

* Peripheral vessels: Intermittent, claudication, rest pain.

Urogenital system: micturition, loin pain supropubicpain.

Nervous system: Tremor, fainting attacks, fits,

weakness Musculor skeletal ? muscle pains, joint swelling


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Commonest complains in

Surgery

Pain

Lump


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The history of pain-

Site.- Onset.

- Severity ? wake him up, need analgesics

Rather than: mild, severe.

- Nature: Buring, stabing, coliky.- Progression ? - begin maximum, then remains steady.

- steadily increase till maximum then gradualdecline.

-

Duration.- Aggravating and releaving factors

- Radiation.


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The history OF A LUMP

Duration

How discovered

Symptoms ? pain

Changes ? ?in size

Other lumps Any cause ? Trauma


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Physical Examination

General Examination:

- First part ? during taking history ? posture,speech,etc

- vital signs ? pulse, BP, temp


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Examination of the Head and

neck

Eyes

Pupil reaction to light

Sclera jaundice

Conjuction paller

Movement

Exophthalmos Fundoscopy


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Examination of the Head and neck (contd)

Ears and Nose

Usually forgotten on ex:

External auditory canal

Eardrum

Nostrils


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Examination of the Head and neck (contd)

Neck

Jugular veins

Trachea

Lymph nodes

Thyroid


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Examination of A LUMP

Position Colour and texture of skin Temperature Tenderness

Shape Size Surface Edge Consistency Pulsatile, compressibility (venous malformations) Reducibility


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Examination of THE ABDOMEN

PREPARATION: Warm and private room

Good light Comfortable cough or bed Exposure: nipple to knee

Get the patient to relax The position of the examiner


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FIG. 16.6THE NAMES OF THE REGIONS OF THE

ABDOMEN


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THE STEPS OF Examination

Inspection Palpation

Percussion Auscultation


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INSPECTION: Shape of abdomen Scars, sinuses & fistulae

Distended veins Lumps Pigmentation

Movement


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PALPATION:Superficial :

Tenderness Rebound Ganding

Deep palpation: Masses Organs


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PERCUSSION:All abdomen spec. over masses

Fluid thrill

Shifting dullness


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AUSCULTATION:Bowl sounds

Aorta and iliac anteries - Bruit

Succusion splash


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THANK

YOU !!!!!

History Taking in Surgery 123

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