Principle of History Taking in Surgery History Taking

1. Principle of History Taking in Surgery History Taking Dr. Khalid Al-Zahrani Assistant Professor of Plastic Surgery Course Organiser, Surg. 351 Department of Surgery

2. Prepare you self to be a good physician

3. Your appearance is important:(wearing proper uniform, ie. Lab coats, I.D., etc.)

4. Treat patient as if they are your friend(s) • Think of the condition of your patient first and not yours • See him walking in and not in the cubicleAllow his relative to be there if the patient wants. • Be alert and pay him full attention

5. Introduce your self

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

7. 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

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

9. Chief Complaint Main Complaint  Complain Of Duration

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

11. Past History • Dm, Hypertension • Bronchial Asthma • Bleeding disorders & Sickle cell disease • TB, Syphilis, Bilharzias • Passage of stones • Blood transfusion • Operations, Trauma

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

13. 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.

14. Fever • weight loss

15. 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

16. 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

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

18. Urogenital System • Loin pain • Symptoms of uremia • Headache • Drowsiness • Fits • Visual disturbances • Vomiting • Oedema of ankles, hands of face • Lower urinary tract symptoms ( LUTS) • Painful micturirtion • Polyuria • Color of urine • Hematuria • Male Infertility history • Sexual problems history

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

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

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

22. Common symptoms • Pain • Site • Time & mode of onset • Duration • Severity • Nature ( Character) • Progression of pain • The end of pain • Relieving factors • Exaggerating (Exacerbating) factors • Radiation • Cause

23. 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

24. THANK YOU!!