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Principle of History Taking in Surgery
History Taking
Tariq AltokhaisAssistant Professor
Consultant, Pediatric Surgery
Department of Surgery
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History Taking:Key to diagnosis.Help to tailor the management.
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Prepare you self to be a good physician
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Your appearance is important:
Proper uniformLab coatsI.D.Etc.
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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
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Introduce yourself
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History Taking in Surgery
There is no difference between medical and surgical history.
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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
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HistoryPersonal Data
• Date and Time• Name & File number ( Medical record number)• Age• Sex• Religion• Marital status• Occupation• Residency• Who gave the history?
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Chief ComplaintMain Complaint
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Chief Complaint
Chief complaint may be misleading
Problem may be more serious than the chief complaint
.
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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 HistoryDm, HypertensionBronchial Asthma Bleeding disorders & Sickle cell disease TB, Syphilis, BilharziasPassage of stonesBlood transfusionOperations, Trauma
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Family History
Similar conditionsParents and close relatives cause of
death and serious illnesses.DM, Hypertension Bleeding Disorders& Sickle cell disease Ca Prostate ( others)
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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.
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Nervous SystemNervousnessExcitabilityTremorFainting attacksBlackoutFitsLoss of consciousnessMuscle weaknessParalysisSensory disturbancesParaesthesiaeChanges of smell, Vision or hearingHeadachesChange of behavior
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Respiratory & CardiovascularCoughSputumHaemoptysisDyspnoeaHoarsenessWheezingTachypnoeaChest painParoxysmal nocturnal dyspnoeaOrthopneaPalpationsDizzinessAnkle swellingPain in limbsWalking distanceTemperature and color of hands and feet
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Alimentary & Abdomen Appetite Diet Taste Swallowing Regurgitation Vomiting Indigestion Vomiting Haematemses Abdominal pain Abdominal Distension Bowel habit Stool Jaundice
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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
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Musculoskeletal System
Aches or Pain in muscles, bones and jointsSwelling of joints limitation of joints movementsWeaknessDisturbance of gait
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Social History & Habits
Detailed marital status Living accommodation Occupation Travel abroad Leisure activity Smoking Drinking Eating habits
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Sensitive TopicsAlcohol or drug use
Physical abuse or violence
Sexual issues
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Sensitive Questions GuidelinesRespect patient privacy
Be direct and firm
Avoid confrontation
Be nonjudgmental
Use appropriate language
Document carefullyUse patient’s words when possible
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Drug History and allergy
The drugs the patient taking specially: Insulin, Steroids and contraceptive pills
Allergy to any medications
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Special ChallengesSilence
Overly talkative patients
Patients with multiple symptoms
Anxious patients
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Special ChallengesFalse reassurance
May be tempting Avoid early reassurance or “over reassurance”
Unless it can be provided with confidence
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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
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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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Questions ?