• 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.

Thank You

hosam_hamza@ymail.com