This document provides guidance on taking a thorough surgical history. It emphasizes that history taking is important for accurate diagnosis, communication, documentation, and individualizing patient care. The key components of a surgical history include gathering personal information, chief complaint, present history, past history, family history, and reviewing habits. When analyzing the chief complaint, details about pain, swelling, or other symptoms should be explored thoroughly.

1. • Surgical History Taking

2. General
Surgical History Taking
By
Hosam M. Hamza, MD
Lecturer of General & Laparoendoscopic Surgery

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. 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. How to start?
Greet your patient by his/her name.
Introduce yourself (including your name and role)
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.
Gain consent to proceed with history taking.

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. FORMAT
i. Personal History
ii. Chief Complaint
iii. Present History (HPI)
iv. Past History
v. Family History

8. 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.

9. NAME  * Identification.
* Registration.
* To elicit doctor –
patient familiarity
(patient usually
likes to be called
by name)
* Full name helps to avoid
patient’s misidentification.
AGE 
• age-related diseases:
Certain diseases are
common in certain age
groups (e.g. congenital
diseases)
* Certain drugs may be
hazardous in certain age
groups (e.g. Quinolones,
Tetracycline, NSAIDS…)
* Treatment planning

10. 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

11. 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

12. CAUTION
Wilm’s Tumour Ewing’s tumour
Neuroblastoma Retinoblastoma
Acute Leukaemia
Juvenile (secretory) breast carcinoma
CANCERS OF THE CHILDHOOD

13. SEX 
1- Gender-specific Diseases:
gastric cancer, haemophilia, Buerger’s disease…….
gallstones, thyroid diseases, breast diseases…
2- ♀♂ Diseases of sexual organs
3- Menstrual history (♀):
Time of Menarche……………………..…....?
Regularity ……………………………….…..?
Related complaints (? pain)………………...?
Pre- or Post- menopausal………………..….?

14. 2- Menstrual history (♀):
Time of Menarche……………………..…....?
Regularity ……………………………….…..?
Related complaints (? pain)………………...?
Pre- or Post- menopausal………………..….?

15. Why to ask about Menstrual history ?
• 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.

16. 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

17. Why to ask about marital state ?
• Infertility
• STDs
• Psychic troubles…..

18. OCCUPATION 
1 - occupational diseases:
* intellectual
* exposure to carcinogens

19. 1 - occupational diseases:
* porters  HERNIAS Farmers  Bilharz. SPLENOMEGALLY
* typists, pianists, drill workers  RAYNAUD’S PHENOMENON
* teachers, surgeons, nurses  VARICOSITIES
* intellectual  HTN, Peptic Ulcer
* exposure to carcinogens
2 - Standard of living (social class):
* diseases of high social class:
Duobenal ulcer
Irritable Bowel Syndrome
Inflammatory Bowel Disease
* diseases of low social class:
TB, parasitic infestations, filariasis

20. RESIDENSE 
1 - endemic diseases:
Delta : Colonic bilharziasis
Upper Egypt: Urinary bilharziasis, Amoebiasis
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. HABITS OF SURGICAL IMPORTANCE 
Smoking
Tea & Coffee abuse
Alcohol intake
I.V. drug addiction
Automedications
Diet habits
Swimming in canals

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. HAZARDS OF SMOKING
cardiovasc. respiratory GI miscellaneus
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. EXCESSIVE TEA & COFFEE :
ASK ABOUT:
- Amount of intake per day
- Hazards:
* INSOMNIA * DIURESIS
* HYPERACIDITY * CONSTIPATION

25. ALCOHOL INTAKE
ASK ABOUT:
- type of drink…
- duration of drinking & if stopped
- amount of intake per day
- hazards of alcohol
;

26. HAZARDS OF ALCOHOL INTAKE
*delerium. *addiction. *peripheral neuritis.
*myopathy. *tremors. *cardiomyopathy.
*gastritis. *alcoholic hepatitis. *alcoholic cirrhosis.
*hyperlipidaemia. *Zieve’s syndrome

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. DIET HABITS
- excessive fat  obesity, fatty
liver, atherosclerosis, cholecystitis,…
- excessive spices  gastritis, PU, haemorrhoids,…

29. SWIMMING IN CANALS :
:

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. 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 elicits tenderness)
Never to say “history of tenderness”

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 CO (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. 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
• Ppt 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. • 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 very important in hernias)
• Associated symptoms=
pain
General manifestations = fever + symptoms of metastases=
Local manifestations= VAN
Analysis Of The Complaint
ANALYSIS OF SWELLING

35. - Analyze pain also if the swelling is painful !
- Fever: it may be important & not associated especially
if:
* related to the onset of the swelling.
* if recurrent.
- Symptoms of metastases:
• Bone metastases= bone pain, repeated fractures on
minor trauma (pathological)
• Brain " " = ↑ ICP, fits, sensory or motor affection
• Lung " " = cough, haemoptysis, chest pain
• Liver " " = rt hypochondrial pain, jaundice
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. 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 only (facial N.)
• Swelling in breast: effect on vein and lymph only (causing
lymphoedema of upper limb)

37. IV- Past history
Ask leading questions about past events having relationship to
presenting complaint:
- Past history of similar attacks.
- Past history of drug intake.
- Past history of operations.
- Past history of endemic diseases.
- Past history of systemic diseases.
- Past history of childhood diseases.
- Past history of trauma.
- Past history of traveling abroad..

38. V- Family history
Ask about:
1. history of familial diseases.
2. history of consanguinity.
3. family history of similar conditions in:
• Familial diseases: “e.g. T.B., endemic goitre,… etc”
• Hereditary diseases: “haemophilia, sickle cell disease, certain
forms of breast cancer, …etc”

39. V- Family history
Hereditary disease: A disease running in a family and can be
passed from parents to their offspring (due to inherited
“mutations”).
Familial disease: A disease running in a family either due to gene
mutations or due to other shared factors, such as
environment and lifestyle.