Principle of History Taking in Surgery
History Taking
Dr. Khalid Al-ZahraniAssistant Professor of Plastic Surgery
Course Organiser, Surg. 351
Department 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
cubicleAllow 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 System
Aches 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
THANK YOU!!
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