HISTORY TAKINGHISTORY TAKING

HISTORY TAKINGHISTORY TAKING

Employ your eyes, ears, nose, Employ your eyes, ears, nose, handshands

Start by telling the patient your Start by telling the patient your name and who you arename and who you are

Guide the conversationGuide the conversation

HISTORY TAKINGHISTORY TAKING

Treat the patients as the rational Treat the patients as the rational human being they arehuman being they are

Explain what and why you are doingExplain what and why you are doing

All questions should leave the patient All questions should leave the patient with a free choice of answers with a free choice of answers

HOW TO TAKE HOW TO TAKE HISTORYHISTORY Always record the pt’s name, age, Always record the pt’s name, age,

sex, ethnic group, marital status, sex, ethnic group, marital status, job, place job, place

Record the date and time of exam.Record the date and time of exam.

Note the way of admission, who Note the way of admission, who referred the pt. to surgeryreferred the pt. to surgery

HOW TO TAKE HOW TO TAKE HISTORYHISTORY

The assessment of the surgical P. The assessment of the surgical P. aims to:aims to:– confirm the diagnosisconfirm the diagnosis– detect associated medical illnessesdetect associated medical illnesses– assess fitness for anesthesiaassess fitness for anesthesia

THE PRESENT THE PRESENT COMPLAINTCOMPLAINT What is the problem ?What is the problem ?

Note the answer in the pt’s own Note the answer in the pt’s own wordswords

Associated complaintsAssociated complaints

HISTORY OF THE HISTORY OF THE PRESENT COMPLAINTPRESENT COMPLAINT

Full details of the history of the Full details of the history of the main complaintmain complaint

Get back to the beginning of the Get back to the beginning of the troubletrouble

Onset: sudden or gradualOnset: sudden or gradual Progression until examinationProgression until examination

HOW TO TAKE HOW TO TAKE HISTORYHISTORY

Remaining questions about of the Remaining questions about of the abnormal systemabnormal system

Systematic direct questionsSystematic direct questions

QUESTIONS OF THE QUESTIONS OF THE DIGESTIVE SYSTEMDIGESTIVE SYSTEM AppetiteAppetite DietDiet WeightWeight SwallowingSwallowing HeartburnHeartburn RegurgitationRegurgitation

QUESTIONS OF THE QUESTIONS OF THE DIGESTIVE SYSTEMDIGESTIVE SYSTEM VomitingVomiting HaematemesisHaematemesis Indigestion or abdominal painIndigestion or abdominal pain Abdominal distensionAbdominal distension DefecationDefecation Change in the skin color Change in the skin color

APPETITEAPPETITE

Has the appetite increased, decreased or Has the appetite increased, decreased or remained unchanged ?remained unchanged ?

If decreased: anorexia or eating causes If decreased: anorexia or eating causes painpain– Anorexia= lack or loss of appetiteAnorexia= lack or loss of appetite– Anorexia nervosa= prolonged refusal to eat, Anorexia nervosa= prolonged refusal to eat,

resulting in emaciation (fear of becoming resulting in emaciation (fear of becoming obese)obese)

What are your new likes and dislikes ?What are your new likes and dislikes ?

DIETDIET

What type of food do you eat ?What type of food do you eat ?

When do you eat your meals ?When do you eat your meals ?

How long do the meals take ?How long do the meals take ?

WEIGHTWEIGHT

Has your weight changed ?Has your weight changed ?

How much ?How much ?

How quickly ?How quickly ?

Clothes have got tighter or looser ?Clothes have got tighter or looser ?

SWALLOWINGSWALLOWING

DysphagiaDysphagia– Difficulty in swallowing, commonly Difficulty in swallowing, commonly

associated with obstructive or motor associated with obstructive or motor disorders of the esophagusdisorders of the esophagus

– What type of food causes difficulty ?What type of food causes difficulty ?– What the level at which the food What the level at which the food

sticks ?sticks ?

Odynophagia= painful swallowingOdynophagia= painful swallowing

REGURGITATIONREGURGITATION

Effortless return of the food into Effortless return of the food into the mouththe mouth

Vomiting- powerful, involuntary Vomiting- powerful, involuntary contraction of the abdominal wallcontraction of the abdominal wall

HEARTBURNHEARTBURN

Burning sensation behind the Burning sensation behind the sternum sternum

Cause- acid reflux from the Cause- acid reflux from the stomach into the esophagusstomach into the esophagus

VOMITINGVOMITING

How often do you vomit ?How often do you vomit ? Is the vomiting preceded by Is the vomiting preceded by

nausea?nausea?

What is the nature and volume of What is the nature and volume of the vomits?the vomits?

What other symptoms are What other symptoms are associated?associated?

HEMATEMESISHEMATEMESIS

Vomiting digested bloodVomiting digested blood Old, altered blood looks like Old, altered blood looks like

“coffee grounds”“coffee grounds” Differentiate hematemesis from Differentiate hematemesis from

hemoptysis and epistaxishemoptysis and epistaxis Hemoptysis- coughing up of bloodHemoptysis- coughing up of blood Epistaxis- nose bleedEpistaxis- nose bleed

ABDOMINAL PAINABDOMINAL PAIN

SiteSite OnsetOnset SeveritySeverity NatureNature Progression and durationProgression and duration Exacerbating and relieving factorsExacerbating and relieving factors

REGARDING REGARDING DEFECATIONDEFECATION

How often do you pass stool ?How often do you pass stool ? Colour, consistence, size, frequency Colour, consistence, size, frequency Have you ever passed any blood?Have you ever passed any blood? Hematochezia- passing fresh blood Hematochezia- passing fresh blood

per anumper anum Is the defecation painful?Is the defecation painful?

QUESTIONS OF THE QUESTIONS OF THE RESPIRATORY SYSTEMRESPIRATORY SYSTEM CoughCough

HemoptysisHemoptysis

DyspneaDyspnea

Chest painChest pain

COUGHCOUGH

Sudden audible expulsion of air Sudden audible expulsion of air from the lungsfrom the lungs

Coughing is preceded by Coughing is preceded by inspiration, glottis partially inspiration, glottis partially closed, accessory EM contract to closed, accessory EM contract to expel the air forcibly from the expel the air forcibly from the resp. passagesresp. passages

COUGHCOUGH

Protective response to clear the Protective response to clear the lungs, bronchi and trachea of lungs, bronchi and trachea of secretionssecretions

Chronic coughing- TBC, lung cancerChronic coughing- TBC, lung cancer

Episodes of chronic coughing- sub Episodes of chronic coughing- sub diaphragmatic irritation, CHF.diaphragmatic irritation, CHF.

HEMOPTYSISHEMOPTYSIS

Coughing up of blood from the Coughing up of blood from the respiratory tractrespiratory tract

Blood-streaked sputumBlood-streaked sputum

More profuse bleeding- lung More profuse bleeding- lung abscess, TBC, lung cancerabscess, TBC, lung cancer

DYSPNEADYSPNEA

Breathlessness- distressful Breathlessness- distressful sensation of uncomfortable sensation of uncomfortable breathingbreathing

Causes- heart conditions, strenuous Causes- heart conditions, strenuous exercise or anxietyexercise or anxiety

Wheeze= a whistling respiratory Wheeze= a whistling respiratory sound- COADsound- COAD

CHEST PAINCHEST PAIN

Site, severity and natureSite, severity and nature

QUESTIONS OF THE QUESTIONS OF THE CARDIOVASCULAR CARDIOVASCULAR SYSTEMSYSTEM Cardiac symptomsCardiac symptoms

– BreathlessnessBreathlessness– Cardiac painCardiac pain– PalpitationsPalpitations– Cough and sputumCough and sputum– Dizziness and headachesDizziness and headaches

Peripheral vascular symptomsPeripheral vascular symptoms

BREATHLESSNESSBREATHLESSNESS

Orthopnea - breathlessness when Orthopnea - breathlessness when lying downlying down

Paroxysmal nocturnal dyspnea - Paroxysmal nocturnal dyspnea - sudden attack in the middle of sudden attack in the middle of the night that waken the pt.the night that waken the pt.

CARDIAC PAINCARDIAC PAIN

Usually retrosternalUsually retrosternal

Its nature- constricting, band-like Its nature- constricting, band-like or squeezingor squeezing

Usually related with exercise or Usually related with exercise or excitementexcitement

QUESTIONSQUESTIONS

Does the pain radiate to the neck Does the pain radiate to the neck or to the left arm?or to the left arm?

Does rest relieve the pain?Does rest relieve the pain?

PALPITATIONSPALPITATIONS

Episodes of tachycardiaEpisodes of tachycardia

Sudden fluttering or thumping of Sudden fluttering or thumping of the heart in the chestthe heart in the chest

DIZZINESS AND DIZZINESS AND HEADACHESHEADACHES Dizziness- hypotensionDizziness- hypotension

Headache- hypertensionHeadache- hypertension

PERIPHERAL PERIPHERAL VASCULAR SYMPTOMSVASCULAR SYMPTOMS Do you get pain in the leg muscles Do you get pain in the leg muscles

on exercise? - intermittent on exercise? - intermittent claudicatingclaudicating

How far can you walk?How far can you walk? How long does the pain take to How long does the pain take to

disappear ?disappear ? Is there any pain in the limb at Is there any pain in the limb at

rest ?rest ?

PERIPHERAL PERIPHERAL VASCULAR SYMPTOMSVASCULAR SYMPTOMS Does the pain interfere with sleep ?Does the pain interfere with sleep ?

What positions relieve the pain ?What positions relieve the pain ?

Are the extremities of the limbs Are the extremities of the limbs cold ?cold ?

Are there color changes in the skin ?Are there color changes in the skin ?

QUESTIONS OF THE QUESTIONS OF THE URO-GENITAL SYSTEMURO-GENITAL SYSTEM

Urinary tract symptomsUrinary tract symptoms– Loin, groin, suprapubic painLoin, groin, suprapubic pain– Ankle swellAnkle swell– Micturition: dysuria, polakyuria, Micturition: dysuria, polakyuria,

polyuriapolyuria– Urine: colour, smell, quantity, Urine: colour, smell, quantity,

hematuria, pneumaturiahematuria, pneumaturia

QUESTIONS OF THE URO-QUESTIONS OF THE URO-GENITAL SYSTEMGENITAL SYSTEM

Genital tract symptomsGenital tract symptoms– Scrotum and urethraScrotum and urethra– MenstruationMenstruation– PregnanciesPregnancies– Breasts: change in size, lumps, Breasts: change in size, lumps,

nipple dischargenipple discharge

QUESTIONS OF THE QUESTIONS OF THE NERVOUS SYSTEMNERVOUS SYSTEM Mental state: calm, nervousMental state: calm, nervous

Brain and cranial nerves: fitsBrain and cranial nerves: fits

Peripheral nerves: paraesthesia, Peripheral nerves: paraesthesia, palsypalsy

QUESTIONS OF THE QUESTIONS OF THE MUSCULOSKELETAL MUSCULOSKELETAL SYSTEMSYSTEM PainPain

SwellingSwelling

Limitation of movementsLimitation of movements

PAST MEDICAL PAST MEDICAL HISTORYHISTORY OTHER ILLNESSESOTHER ILLNESSES

ACCIDENTSACCIDENTS

OPERATIONSOPERATIONS

DRUG HISTORYDRUG HISTORY

DRUGS AND DOSESDRUGS AND DOSES

ALLERGIESALLERGIES

FAMILY HISTORYFAMILY HISTORY

DISEASESDISEASES

CAUSES OF DEATHCAUSES OF DEATH

SOCIAL HISTORYSOCIAL HISTORY

TYPE AND PLACE OF DWELLINGTYPE AND PLACE OF DWELLING OCCUPATIONOCCUPATION CONTACT WITH HAZARDSCONTACT WITH HAZARDS LEISURE ACTIVITIESLEISURE ACTIVITIES TRAVELS ABROADTRAVELS ABROAD

HABITSHABITS

SMOKINGSMOKING

ALCOHOLALCOHOL