This document provides guidance on taking a surgical history. It emphasizes the importance of history for diagnosis, communication and documentation. The key components of a surgical history include personal history, chief complaint, present history, past history, and family history. Personal history involves gathering information on name, age, sex, occupation, habits, etc. The chief complaint is the patient's main problem in their own words. The present history analyzes the chief complaint and reviews other body systems. Past history looks at prior relevant events. Family history identifies familial or hereditary conditions. Proper history taking establishes trust and aids in individualizing patient care.

1. • Surgical History Taking

2. General
Surgical History Taking
By Hosam M. Hamza, MD
Lecturer of General & Laparo-endoscopic
Surgery
Minia Faculty of Medicine

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

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

14. SEX 
1-Diseases:
Haemophilia
Buerger’s disease
CCC
thyroid diseases
breast diseases…
♀♂ diseases of sexual organs

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. 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. 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  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. 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. 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 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

25. EXCESSIVE TEA & COFFEE :
ASK ABOUT:
- Amount of intake per day
- Hazards:
* INSOMNIA * DIURESIS
* HYPERACIDITY * CONSTIPATION

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

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

28. 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:

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

30. SWIMMING IN CANALS :
:

31. - 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

32. 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”

33. 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

34. 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

35. • 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

36. - 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)

37. 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)

38. 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..

39. 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.

40. Thank You
hosam_hamza@ymail.com