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• Surgical History Taking
General
Surgical History Taking
By Hosam M. Hamza, MD
Lecturer of General & Laparo-endoscopic
Surgery
Minia Faculty of Med...
Why do we take history ?
o DIAGNOSIS:
accurate diagnosis rests firmly upon the foundation of
a thoughtful and inclusive hi...
What tools are needed?
The sense of what data are important to take
a meaningful history (value of history, of
course, wil...
How to start?
Introduce yourself.
Talk & deal in a friendly relaxed way.
Once talk has begun, encourage the patient to con...
Types of History
Out-patient or Emergency Room history
?specific complaint is pinpointed ? diagnosis
Elective surgery hist...
Donts’ of History
- Don’t interrupt the patient while he/she is telling
you about the story of illness. Listen well but ne...
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 resid...
NAME 
* Identification.
* Registration.
* To elicit doctor – patient
familiarity (patient usually
likes to be called by n...
Age groups
Neonatal period = up to 1 month old
Infancy = 1 month – 2 years old
Childhood = 2 – 12 years old
Adolescence = ...
Cleft lip  since birth
Cystic hygroma  infancy
Thyroglossal cyst  childhood
Appendicitis  adolescents & adults
Trauma ...
CAUTION
Wilm’s Tumour Ewing’s tumour
Neuroblastoma Retinoblastoma
Acute Leukaemia
Juvenile (secretory) breast carcinoma
CA...
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)………………....
Why to ask about Menstrual
history ?
• For elective operations, don’t operate on a female
during her menses.
• If early me...
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...
RESIDENSE 
1 - endemic diseases:
Delta : Colonic bilharziasis
Upper Egypt: Urinary bilharziasis
Giza & Damietta: Filarias...
HABITS OF SURGICAL IMPORTANCE 
Smoking
Tea & Coffee abuse
Alcohol intake
I.V. drug addiction
Automedications
Diet habits
...
HABITS OF SURGICAL IMPORTANCE 
SMOKING .
ASK ABOUT:
- type of smoking…
- duration of smoking …. ex-smoker
- hazards of sm...
HAZARDS OF SMOKING
cardiovasc. respiratory GI miscellaneu
s
Tachycardia
Extrasystoles
IHD
Atheromas
Buerger’s
disaese...
EXCESSIVE TEA & COFFEE :
ASK ABOUT:
- Amount of intake per day
- Hazards:
* INSOMNIA * DIURESIS
* HYPERACIDITY * CONSTIPAT...
ALCOHOL INTAKE
ASK ABOUT:
- type of drink…
- duration of drinking & if stopped
- amount of intake per day
- hazards of alc...
HAZARDS OF ALCOHOL INTAKE
*delerium. *addiction. *peripheral neuritis.
*myopathy. *tremors. *cardiomyopathy.
*gastritis. *...
I.V. DRUG ADDICTION :
ASK ABOUT:
- type of drug…
- duration of addiction & if stopped
- amount of intake
- hazards of I.V....
DIET HABITS
- excessive fat  obesity, fatty
liver, atherosclerosis, cholecystitis,…
- excessive spices  gastritis, PU, h...
SWIMMING IN CANALS :
:
- ask about the MOST DISTRESSING PROBLEM that motivated
patient to seek care + DURATION.
- record & express complaint in o...
For - A patient suffering form jaundice that began 3 weeks
ago and is still present.
The complaint is (yellowish discolour...
this is the chronological story of the patient illness extending
from the moment when the patient was quite well till
now....
If the main complaint is pain, ask about: OPQRST
• Onset= sudden, rapid or gradual.
• Offset (in pain only) = spontaneousl...
• Onset= sudden, rapid or gradual.
• Course= progressive, intermittent or in-plateau
• Duration
• Ppt factors= if pain is ...
- Analyze pain also if the swelling is painful !
- Fever: it may be important (not just an association)
especially if:
* r...
Local manifestations:
VAN= Vein, Artery, Nerve
• Swelling in a limb → effect on vein= oedema
on artery= ischaemia
on nerve...
IV- Past history
Ask leading questions about past events having
relationship to presenting complaint:
1. Past history of s...
V- Family history
Ask about Family history of similar conditions in:
• Familial diseases: “e.g. T.B., endemic goitre,… etc...
Thank You
hosam_hamza@ymail.com
History taking in general surgery
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History taking in general surgery

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introduction to clinical surgery for medical students

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History taking in general surgery

  1. 1. • Surgical History Taking
  2. 2. General Surgical History Taking By Hosam M. Hamza, MD Lecturer of General & Laparo-endoscopic Surgery Minia Faculty of Medicine
  3. 3. 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
  4. 4. 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.
  5. 5. 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.
  6. 6. 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.
  7. 7. 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
  8. 8. FORMAT i. Personal History ii. Chief Complaint iii. Present History (HPI) iv. Past History v. Family History
  9. 9. 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.
  10. 10. 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…)
  11. 11. 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
  12. 12. 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
  13. 13. CAUTION Wilm’s Tumour Ewing’s tumour Neuroblastoma Retinoblastoma Acute Leukaemia Juvenile (secretory) breast carcinoma CANCERS OF CHILDHOOD
  14. 14. SEX  1-Diseases: Haemophilia Buerger’s disease CCC thyroid diseases breast diseases… ♀♂ diseases of sexual organs
  15. 15. 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
  16. 16. 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.
  17. 17. Why to ask about marital state ? • Infertility • STDs • Psychic troubles…..
  18. 18. OCCUPATION  1 - occupational diseases: * intellectual * exposure to carcinogens
  19. 19. 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
  20. 20. 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
  21. 21. HABITS OF SURGICAL IMPORTANCE  Smoking Tea & Coffee abuse Alcohol intake I.V. drug addiction Automedications Diet habits Swimming in canals
  22. 22. 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.
  23. 23. 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
  24. 24. EXCESSIVE TEA & COFFEE : ASK ABOUT: - Amount of intake per day - Hazards: * INSOMNIA * DIURESIS * HYPERACIDITY * CONSTIPATION
  25. 25. ALCOHOL INTAKE ASK ABOUT: - type of drink… - duration of drinking & if stopped - amount of intake per day - hazards of alcohol;
  26. 26. HAZARDS OF ALCOHOL INTAKE *delerium. *addiction. *peripheral neuritis. *myopathy. *tremors. *cardiomyopathy. *gastritis. *alcoholic hepatitis. *alcoholic cirrhosis. *hyperlipidaemia. *Zieve’s syndrome
  27. 27. 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:
  28. 28. DIET HABITS - excessive fat  obesity, fatty liver, atherosclerosis, cholecystitis,… - excessive spices  gastritis, PU, haemorrhoids,…
  29. 29. SWIMMING IN CANALS : :
  30. 30. - 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
  31. 31. 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”
  32. 32. 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
  33. 33. 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
  34. 34. • 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
  35. 35. - 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)
  36. 36. 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)
  37. 37. 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..
  38. 38. 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.
  39. 39. Thank You hosam_hamza@ymail.com

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