Principle of History Taken In Surgery Prof Abdulrahman

Principle of History Taken In Surgery Prof. Abdulrahman Albassam. MD Professor and Consultant Pediatric Surgeon. Medical College King Suad University

Approach To Patient’s Problem HISTORY. CLINICAL EXAMINATION. CLINICAL DIAGNOSIS. INVESTIGATIONS. FINAL DIAGNOSIS. TREATMENT.

Principle of History Taken In Surgery • History taking the key step in surgical diagnosis. • Varies according to the complain specific histories surgical specialty

Two types of history in surgical practice: • Out-pt or emergency room history Ø Specific complaint is pinpointed — diagnosis • Clerking of pt admitted for elective surgery Ø To assess that the treatment planned correctly indicated and pt is suitable for that operation.

History Taking • Information gathered during patient interview as part of patient clinical assessment.

Techniques of History Taking • Set the stage: – Provide a safe environment – Your demeanor and appearance – Avoid the patient’s personal space – Inquire about patient’s feelings – Note taking

History Taking • Greeting patient – By name – Shake hands – Avoid unfamiliar or demeaning terms • Patient comfort – Comfort levels – Feelings – Signs of uneasiness

Components of Patient History • Date and time • Identifying (personal) data • Source of referral • Source of history • Chief complaint • History present illness • Past medical and surgicalhistory • Family History • Social History • Drug Hisory • Review of body systems

History Taking Personal information : Age, sex, marital status, occupation, nationality, residence, etc……

Chief Complaint • Symptom/Symptoms that caused patient to seek care • Often: – Pain – Abnormal function – Change in normal state – Unusual observation made by patient (e. g. , heart palpitations).

Chief Complaint • Chief complaint may be misleading • Problem may be more serious than the chief complaint .

History of Present Illness (HPI) • Identifies the chief complaint • Provides full, clear, chronological account of symptoms • A thorough HPI: – Asks questions related to chief complaint – Interprets patient's response to questions

Significant Past Medical History • General state of health – Childhood illnesses – Adult illnesses – Accidents and injuries – Surgeries or hospitalizations • Psychiatric illnesses.

Drug History • Medications taken regularly and why? ( steroids, insulin, oral contraceptive pills, anticoagulants, etc). • Medication compliance. • Herbal remedies.

Family History • Health of immediate family (father, mother, first degree realatives) – High blood pressure, Diabates, heart disease, contagious illnesses • Potential for hereditary diseases

Social History • • • Marital status Occupation Residency The lesiure activities Habits (smoking, alcohol, etc) Travelled abroad.

Womens Reproductive History Age of first period. # Pregnancie. # Abortions. Have you reached menopause? Y / N At what age? Do you have regular periods? Y / N

Systemic Enquiry • GIT: Appetite, Vomiting, Regurgitation, etc. • Respiratory System ? cough, haemoptysis, Dyspnea…. • C. V. S: Breathlessness, palpations, chest pain… Intermittent claudication, rest pain. • Urogenital system: micturition, loin pain supropubic pain • Nervous system: Tremor, fainting attacks, fits, weakness… • Musculor skeletal ? muscle pains, joint swelling

Sensitive Topics • Alcohol or drug use • Physical abuse or violence • Sexual issues

Sensitive Questions Guidelines • Respect patient privacy • Be direct and firm • Avoid confrontation • Be nonjudgmental • Use appropriate language • Document carefully – Use patient’s words when possible

Special Challenges • Silence • Overly talkative patients • Patients with multiple symptoms • Anxious patients

Special Challenges • False reassurance – May be tempting – Avoid early reassurance or “overreassurance” • Unless it can be provided with confidence

Special Challenges • • Anger and hostility Intoxication Crying Depression Confusing behavior or histories Limited intelligence Developmental disabilities.

Barriers to Communication • May result from: – Social or cultural differences – Sight, speech, or hearing impairments • Attempt to find assistance to aid in communication .

Commonest complains in Surgery • Pain • Lump

Commonest complains in Surgery • History of pain -The site -Onset -Duration -Severity -Nature of the pain -Progression of the pain -Relieving and exacerbation factors -Radiation and refering pain

Commonest complains in Surgery • History of a lump -Site. -Duration. -What made the patient notice the lump. -course of the lump. -Associated symptoms. -Other lumps

Different parts of a history �PERSONAL DETAILS �PRESENTING COMPLAINT �HISTORY OF PRESENT ILLNESS �SYSTEMIC INQUIRY �PAST MEDICAL/SURGICAL HISTORY �FAMILY HISTORY �HISTORY OF MEDICATIONS �SOCIAL HISTORY �OTHER HISTORY

Conclusion Obtaining a patient history provides structure to the patient assessment and often is essential to establish priorities in patient care.

Questions?