Surgery history taking

1. Patient-Doctor relation
The way to reach the Diagnosis
History Taking
Dr. Abdelmoniem Eltraifi
Consultant Urologist & Clinical Ass. Professor

2.  History taking values about 71.7% in
reaching the correct diagnosis.
 It also directs the usage of other tools

3. Goals of History taking:
 Building a friendly relation with the patient.
 Formulating workup plan
 Reaching a diagnosis.
 Planning of management
 Writing a neat medico-legal document.

4. Be ready; prepare you self to be
a good doctor

5.  The patient should be a friend or like a friend
 Always think of his condition and not yours

6. See him walking in and not in the cubicle
Allow his relative to be there if the patient wants.

7. Introduce your self

8. Be alert and pay him full attention

9. The problem with the formats and the
teachers preferences.

10. History Taking in Surgery
There is no difference between medical and
surgical history. They are almost the same.

11. The classical History

12. History
 Personal Data ( Patient Demography)
• Date and Time
• Name & File number ( Medical record number)
• Age
• Sex
• Religion
• Marital status
• Occupation
• Residency
• Who gave the history?

13. Chief Complaint
Main Complaint
Complain Of ( C/O)

14.  You should write the patient own words.
 If there is more than one complaint, it
should be written according to:
1. Occurrence.
2. Most bothersome.

15. History of the presenting Symptom ( Illness)
 Elaborate the symptom.
 Elaborate the system involved.
 What had been done for the patient?

16. Past History
 Dm, Hypertension
 Bronchial Asthma
 Bleeding disorders & Sickle cell disease
 TB, Syphilis, Bilharzias, STD
 Blood transfusion
 Operations, Trauma

17. Family History
 Similar conditions
 Parents and close relatives cause of
death and serious illnesses.
 DM, Hypertension
 Bleeding Disorders& Sickle cell disease
 Ca Prostate, renal diseases ( others)

18. Systemic Review
Systematic 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.

19.  Fever
 weight loss

20. Nervous System
 Nervousness
 Excitability
 Tremor
 Fainting attacks
 Blackout
 Fits
 Loss of consciousness
 Muscle weakness
 Paralysis
 Sensory disturbances
 Paraesthesiae
 Changes of smell, Vision or hearing
 Headaches
 Change of behavior

21. Respiratory & Cardiovascular
 Cough
 Sputum
 Haemoptysis
 Dyspnoea
 Hoarseness
 Wheezing
 Tachypnoea
 Chest pain
 Paroxysmal nocturnal dyspnoea
 Orthopnea
 Palpations
 Dizziness
 Ankle swelling
 Pain in limbs
 Walking distance
 Temperature and color of hands and feet

22. Alimentary & Abdomen
 Appetite
 Diet
 Taste
 Swallowing
 Regurgitation
 Vomiting
 Indigestion
 Haematemses
 Abdominal pain
 Abdominal Distension
 Bowel habit
 Stool
 Jaundice

23. Urogenital System
 Loin pain
 Symptoms of uremia
1. Headache
2. Drowsiness
3. Fits
4. Visual disturbances
5. Vomiting
6. Oedema of ankles, hands, or face
 Lower urinary tract symptoms ( LUTS)
 Painful micturirtion
 Polyuria
 Color of urine
 Hematuria
 Male Infertility history
 Sexual problems history

24. Musculoskeletal System
 Aches or Pain in muscles, bones and joints
 Swelling of joints
 limitation of joints movements
 Weakness
 Disturbance of gait

25. Social History & Habits
 Detailed marital status
 Living accommodation
 Occupation
 Travel abroad
 Leisure activity
 Smoking
 Drinking
 Eating habits

26. Drug History and allergy
 The drugs the patient taking specially: Insulin, Steroids and
contraceptive pills
 Allergy to any medications

27. Common symptoms
Pain
1. Site
2. Duration
3. Mode of onset
4. Severity
5. Nature ( Character)
6. Progression of pain
7. The end of pain
8. Relieving factors
9. Exaggerating (Exacerbating) factors
10. Radiation
11. Cause

28. History of a lump or an ulcer
 Duration ( when was the first time noticed)
 First symptom ( how the patient noticed it)
 Other symptoms
 Progression ( change since notice)
 Persistence ( has it ever disappear or healed)
 Any other lumps or ulcers
 Cause

29. An Example of classical History
taking

30. Hematuria

31. Classical history of hematuria
 Patient demography
• Date and Time= 13/9/2001 at 10 am
• Khalid Alotibi File number 12-30-00
• 47 years old
• male
• Muslim
• Married
• Teacher
• Living in Riyadh, before in Hail
• History given by the patient himself?

32. c/o blood in urine for 5 days

33. History of present illness
He was well, tell five days ago, when he noticed blood in his urine.
The haematuria is episodic, most of the time when ever he is passing urine.
The urine color is dark red. Also he noticed blood clots in the urine, which are
rounded in shape.
He had no pain. The haematuria is total throughout all his urine stream.
No history of trauma, no ingestion of red colored food, or drink.
No bleeding from other sites of his body.
Finish all urinary tract system symptoms in this part.
They inserted for him, 3 ways urethral Folly catheter, and they did continuous
bladder irrigation by saline, and they just finished doing CT urography for
him.

34. Past History
 No history of similar episode before.
 No history of bleeding disorder.
 No history of pulmonary Tuberculosis
 No history of stone disease
 No history of operations or RTA
 No history STD
 No History of DM, or Hypertension, bronchial asthma, and no known
allergy.

35. Family History
 No family history of similar episode.
 Parents are dead ( unknown cause of death).
 No family History of; SCD, or other hematological disorder.
 No family history of; cancer prostate, or other renal disease
 No family history of DM, or hypertension

36. Systemic Review
Systematic Direct Questions
 No Fever, or loss of weight.
 Ask him- here about all the other systems.
 Exclude urinary tract, as its should be
finished already, in the section of history of
the present illness.
 Negative symptoms: are as important as
positive one

37. Social History & Habits
 Married to one wife, with Three-female and two-male children.
 Living in his own villa, with good facilities.
 Working as a higher school teacher, and had other personal business
with good income.
 Not smoker, but he had other colleague teachers , who are smoking in
the office.
 He used to travel in summer with his family to other countries: Egypt,
Turkey, Syria and once to Malaysia. Never exposed himself to rivers ,
ponds, or canal water.
 Never drank alcohol.
 His leisure are: reading news papers and watching TV only.
 He used to eat ordinary Saudi food.

38. Drug History and allergy
 He is not taking anti-coagulants, or any other drugs.
 No know allergy to any medication.

39. Example of short history
taking for the OSCE Exam
 Ask directly about the patient presenting
symptom.
 Ask related Questions only.

40.  Age
 Residency.
 Duration.
 Occupation
 Painless or painful
 Timing of Haematuria
 Amount of bleeding ( darkness of the color, an presence of clots)
 Shape of clots
 Trauma
 Bleeding from other sites
 Associated urinary, and Systemic Symptoms
 Bleeding disorders, SC, TB, Bilharzias & stone disease.
 Family History of Malignancy, Renal, or hematological
disorders.
 Drugs
 Red colored food or drinks.
 Smoking
Example: History of Hematuria