"History taking in surgery" - PowerPoint Presentation

Slide1

"History taking in surgery"Management = diagnosis + treatment + follow upDiagnosis = History + examination + investigation.

Case

sheet

Name : Age :

Sex : Religion :

Marital status : Occupation :

Residence :

Date of admission : Date of operation :

Chief complaint & duration :

History of the present illness :

Review of systems :

Gastrointestinal tract

Respiratory system

Cardiovascular system

Urogenital system

Central nervous system

Musculoskeletal system

Past medical history :

Past surgical history :

Drug (treatment) history :

Family history :

Social history :

Slide2

History is the key step in the surgical diagnosis.Seeing the patient walking into the room gives some information.Always introduce yourself so that the patient knows to whom he is talking, shake his hand, ask him whether comfortable or not, be social with him.Sometimes the relatives or the accompanying persons (witness) give better history than the patient himself.Do not ask leading questions.

 

Slide3

Name (should be triple) :-For social reasons & to differentiate him.Age :-e.g. vomiting have different diagnosis in different ages e.g. :- Neonate may be pyloric stenosis

Infant may be Intussusceptions

Preschoolers may be Mesenteric lymphadenitis

Adult may be Peptic ulcer

Old age may be CA colon

E.g. volvulus of

midgut

occurs mostly in early age while volvulus of sigmoid colon occurs mostly in elderly.

E.g. multiple myeloma occurs in elderly while diphtheria & poliomyelitis occur in children.

Slide4

Sex : -Disease occurs only in male e.g. benign prostatic hyperplasia,haemophilia. Disease occurs only in female e.g. uterine fibroid, ovarian disease. Disease occurs more common in male : inguinal hernia, CA lung, CA esophagus, Hirschsprung's disease.

Disease occurs more common in female : femoral hernia, thyroid disease, gall bladder disease,

paraumbilical

hernia, urinary tract infection.

 

Religion :-

Muslim : circumcision

Christian :

taenia

solium

Jewish : in born error of metabolism, inflammatory bowel disease.

Slide5

Occupation :-Wool sorter(Anthrax) ,farmers (bird flu), butchers (brucellosis, ),(ofr or pustular dermatitis), job with prolong standing (deep venous thrombosis), hair dresser (pilonidal sinus). Residence :-Rural : infectious disease, hook worm infestation

Urban : rickets, pneumoconiosis (functional lung disease)

Whether there is endemic area or if there is communicable disease.

 

Marital status :-

Varicose vein in male

Hysterectomy in female

Gonorrhea & other sexually transmitted disease.

Slide6

Date of admission:-e.g. 1st of oct.2010 2ed of Dec. 2011 3rd of April 2012 & so on.To see whether the problem acute or chronicDate of operation :-

The same day of surgery is called day 0

The next day is called day 1 post operation & so on.

To see the course of hospitalization.

 

Chief complaint & duration :-

It is better not to know the diagnosis.

It is the thing which brings the patient to the doctor.

If more than one; which is more concerned about?

By the patient words not medical term.

For how long this complain & if recurrent attacks; the last episode.

Slide7

History of the present illness :-Details of the story from the beginning of the problem until reaching the hospital & taking the proper management.Do not ask leading question.Do not interrupt the patient.Mention the related symptoms of the same system which is abnormal.

 

 

Review of systems :-

To reveal other disorder unaware by the patient.

Starting with the involved system unless you mentioned in the present illness.

Here you allowed asking direct question.

-

ve

answered are as important as +

ve

one.

These symptoms you have to know by heart.

Slide8

"History taking in surgery"Part 2Gastrointestinal tract:-

Appetite : increased, decreased, changed

Diet : type of food; solid, liquid, salty, sweaty, spicy.

Weight : increase or decrease, clothes get looser or tighter.

Relatives or friends notice the change in his weight better than

himself.

Swallowing : dysphagia = difficulty in swallowing.

Odynophagia = pain with the swallowing.

Nausea :

Regurgitation : effortless return of food into the mouth.

Vomiting : powerful with involuntary contraction of abdominal wall.

Mention the frequency, associated with pain or not, type of the

vomited materials, amount, color, coffee ground, and the taste.

Slide9

Heart burn : burning sensation behind the sternum due to reflux of gastric acid into the esophagus.Flatulence : wind escape upward (frequent belching) or downward (flatus) & dose it relief the symptoms.Haematemesis : vomited blood.(Haemoptysis) : coughed up blood.Indigestion : discomfort after eating.

Abdominal pain :

Abdominal distention :

Jaundice : yellowish appearance of the skin, mucous membrane, sclera.

Any change in the color of the stool & urine.

Is there any jaundice in the family or friends.

Any injection or blood transfusion.

Slide10

Defecation : constipation, diarrhea. Never use these words without recording the frequency of bowel motion & the consistency of the stool (watery, formed, and solid). Is the patient taking any purgative drugs or drug causing constipation. If he passed mucous , pus in the stool.

If he passed blood in the stool :-

Mixed with the stool (infection)

On the surface of the stool (fissure)

After passing stool (hemorrhoid)

Malaena

(black tarry stool)

Slide11

Respiratory system :-Cough : dry or productive, time of occurrence, aggravating &relieving factors, like cold, pollens , dust. Associated with pain or not. Sputum : quantity time of expectoration, color, odor, consistency, blood(streaks, clot, or massive).Wheezing : constant or intermittent, provoking factors.Haemoptysis : coughed up blood.

Dyspnea : feeling of difficulty in breathing (breathlessness).

Tachpnea

: increase respiratory rate (shortness of breath).

Orthopnea : dyspnea on lying flat

Chest pain :

Slide12

Cardiovascular system :-Chest pain :Dyspnea, orthopnea, paroxysmal nocturnal dyspnea :Palpitation : awareness of heart beats.Cough :

Haemoptysis

:

Sputum :

Dizziness, headache :

leg swelling :

Peripheral vascular system :-

Intermittent claudication :

Pain in limb on rest :

Cold extremities :

Change in color :

Parasthesia

(tingling sensation or numbness).

Slide13

Genitourinary system :-Urinary :- 1-Pain :loin, groin, suprapubic 2-Edema : swelling 3-Urine :-Color : faint yellow(normal), bloody (hematuria), cloudy (urinary tract infection or could be normal), tea color (obstructive jaundice), dark yellow(concentrated of dehydration), transparent (diluted of polyuria).

Quantity :

Smell :

Hematuria : microscopic & macroscopic

Pneumaturia

: air bubbles in urine.

Slide14

4-Micturition problems :-Frequency : frequent timesPolyuria : increase amount (volume more than 3000ml/24 hr.)Oliguria : decrease amount(less than 300 ml / 24 hr.)Anuria : less than 50 ml /24 hr.Dysuria : difficult & painful urination

Nocturia

: desire to urinate at night

Hesitancy : hesitate in initiation of urination

Latency : delay in starting urination

Intermittency : intermittent stream of urine

Stream of urine : narrow caliber or good

Drippling at the end of micturition.

Slide15

 Genital system :-Pain in the scrotumSwelling in the scrotumUrethral dischargeMenstruation in female :-

Menarche : date of 1

st

menstrual cycle

Menopause : date of cessation of cycle

Dysmenorrhea : painful menstruation.

Quantity & duration

Amenorrhea : no menstrual cycle

Mid cycle pain : (

mittelschmerz

syn.): loin pain at the mid cycle due to ovulation.

Slide16

 Central nervous system :-Mental state : nervous, calmConsciousness: coma, blackoutTremor:Fit (convulsion):

Headache :

Any change in smell, vision. Hearing

Paralysis or weakness in the face

Paralysis or weakness in the limbs(

hemipalgia

, hemiparesis).

Loss of cutaneous sensation (

parasthesia

).

Musculoskeletal :-

Pain

Swelling in joint

Limitation of joint movement

Congenital deformities

Slide17

 Past medical history :-Common infectious disease, serious illnesses, previous hospitalization, ischemic heart disease, hypertension, diabetes mellitus, T.B, asthma, jaundice, epilepsy, stroke, renal disease.Past surgical disease :-Previous surgery : cause & if any complication

Anesthetic problems : malignant hyperthermia,

scoline

apnea.

Blood transfusion

Renal colic

Peptic ulcer

Urinary tract infection

Slide18

 Treatment history :-Current treatment oral drug or injectableChronic usageSelf taken drugCompliance

Allergies

Steroid & NSAID.

Radiotherapy

Chemotherapy

Slide19

 Family history :-No. of family memberPatient position in the familyAge of childrenParent dead or alive

Cause of death in the 1

st

degree relatives

Hereditary disease in the family : atopy, hypertension, diabetes, epilepsy, T.B.

Social history :-

Smoking :type (cigar, pipe, cigarette), amount & for how long

Alcohol : amount & for how long

Tattoo

Overseas travelled abroad

Animals at home

Sanitary condition : (water supply, overcrowding)

Slide20

“special History in surgery" History of pain :-

The pain is warning us that are something is going wrong in our body.

Pain : subjective feeling by itself.

Tenderness : feeling of pain in response to stimulus (by the examiner).

Site : described in the proper anatomical areas.

Time of onset: morning, night, suddenly, insidiously.

Severity : effect of pain on the patient activities.

Slide21

 Nature : burning like esophagitis, throbbing like headache, stabbing like dissecting aneurysm, constricting like myocardial infarction, distending like ascites,

colicky like intestinal colic = (comes & goes, occur in hollow tubular

structure, ask him with example)

just a pain with no character.

Progression : steady, gradual worsening, gradual decline, fluctuating.

End : suddenly or gradual.

Duration.

Slide22

Relieving factors.Aggravating factors.Radiation : extensions of pain to another site while the initial pain persist E.G. (perforated DU or pancreatitis in the epigastrium radiate to the back). Referred pain : pain felt at a distance from its source (cholecystitis pain

referred to right shoulder).

Shifted pain : pain disappears from one site & appear at another site.

(acute appendicitis appears in epigastric region then shifted to the right

iliac fossa region).

Slide23

History of mass (lump) : -When it was first be noticed.(the lump was firstly appeared = wrong) (the lump was firstly be noticed = right).What made the patient notice the mass (accidentally, pain, by someone else).Symptoms of the mass (pain, disfiguring, interfere with the movement, with respiration, with swallowing).Change in the mass (in size, in shape, in surface, in the pain).

Disappearance.

Other masses.

Slide24

History of ulcer :-Ulcer : break in the continuity of an epithelium.When it was first be noticed.What made the patient notice it (pain, discharge, bleeding).Symptoms (pain, interfere with eating, with walking, with defecation) .Change.

Other ulcers.