Transcript 01_PRINCIPLE OF HISTORY TAKINGx

Dr. Khalid Al-Zahrani
Assistant Professor of Plastic Surgery
Course Organiser, Surg. 351
Department of Surgery
Prepare you self to be a good physician
Your appearance is important:
(wearing proper uniform, ie.
Lab coats, I.D., etc.)
 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 cubicle
Allow his relative to be there if the patient
wants.
 Be alert and pay him full attention
Introduce your self
History Taking in Surgery
There is no difference between medical and surgical
history. They are the same.
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
History
 Personal Data
• Date and Time
• Name & File number ( Medical record number)
• Age
• Sex
• Religion
• Marital status
• Occupation
• Residency
• Who gave the history?
Chief Complaint
Main Complaint
Complain Of

History of the presenting Symptom ( Illness)
 Elaborate the symptom.
 Elaborate the system involved.
 What had been done for the patient?
Past History
 Dm, Hypertension
 Bronchial Asthma
 Bleeding disorders & Sickle cell disease
 TB, Syphilis, Bilharzias
 Passage of stones
 Blood transfusion
 Operations, Trauma
Family History
 Similar conditions
 Parents and close relatives cause of
death and serious illnesses.
 DM, Hypertension
 Bleeding Disorders& Sickle cell disease
 Ca Prostate ( others)
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.
 Fever
 weight loss
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
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
Alimentary
&
Abdomen
 Appetite













Diet
Taste
Swallowing
Regurgitation
Vomiting
Indigestion
Vomiting
Haematemses
Abdominal pain
Abdominal Distension
Bowel habit
Stool
Jaundice
Urogenital System
 Loin pain
 Symptoms of uremia
1.
2.
3.
4.
5.
6.







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
Musculoskeletal System
 Aches or Pain in muscles, bones and joints
 Swelling of joints
 limitation of joints movements
 Weakness
 Disturbance of gait
Social History & Habits








Detailed marital status
Living accommodation
Occupation
Travel abroad
Leisure activity
Smoking
Drinking
Eating habits
Drug History and allergy
 The drugs the patient taking specially: Insulin, Steroids and
contraceptive pills
 Allergy to any medications
Common symptoms
Pain
1. Site
2. Time & mode of onset
3. Duration
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
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
THANK YOU!!