history taking in general surgery
TRANSCRIPT
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• Surgical History Taking
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General
Surgical History Taking
By Hosam M. Hamza, MD
Lecturer of General & Laparo-endoscopic
Surgery
Minia Faculty of Medicine
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Why do we take history ?
o DIAGNOSIS:
accurate diagnosis rests firmly upon the foundation of
a thoughtful and inclusive history.
o COMMUNICATION:
to establish a patient – physician relationship.
o DOCUMENTATION:
to pass information to others.
o INDIVIDUALIZATION:
ensuring that care is individualise related to age, social
history …etc
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What tools are needed?
The sense of what data are important to take a meaningful history (value of history, of course, will depend on your ability to elicit relevant information), this will grow with time & training.
The ability to listen & ask targeted questions.
Knowing the basics of the pathophysiology in each disease, sophisticated fund of knowledge is not needed to successfully interview a patient.
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How to start? Introduce yourself.
Talk & deal in a friendly relaxed way.
Once talk has begun, encourage the patient to continue:
– Mmm Hmm. – Yes?
– And what else? – I am with you
{ Listening body language } or {non-verbal
communication skills}
Try to see things from the patient’s point of view (always
exhibit neutral position….!)
Avoid medical terms.
Respect patient privacy.
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Types of History Out-patient or Emergency Room history
?specific complaint is pinpointed ? diagnosis
Elective surgery history
? to assess that the treatment planned is correctly
chosen and that the patient is suitable for that
operation.
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Donts’ of History - Don’t interrupt the patient while he/she is telling
you about the story of illness. Listen well but never
allow the patient to guide you away in irrelevant
stories. Specific complaint is pinpointed ? diagnosis
- Don’t be abrupt
- Don’t use medical terms while talking with your
patient
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FORMAT
i. Personal History
ii. Chief Complaint
iii. Present History (HPI)
iv. Past History
v. Family History
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I- Personal History Ask about:
NAME
AGE
SEX
OCCUPATION
MARIETAL STATE
RESIDENCE
HABITS OF IMPORTANCE You can mention residence & occupation in Arabic if you don’t know in English.
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NAME * Identification.
* Registration.
* To elicit doctor – patient
familiarity (patient usually
likes to be called by name)
* To avoid fatal mistakes.
AGE * Certain diseases are
common in certain age groups (e.g. congenital)
* Certain drugs may bbe hazardous in certain age groups (e.g. Quinolones, Tetracycline, NSAIDs…)
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Age groups
Neonatal period = up to 1 month old
Infancy = 1 month – 2 years old
Childhood = 2 – 12 years old
Adolescence = 12 – 20 years old
Adulthood = 20 – 40 years old
Middle age = 40 – 60 years old
Elderly = over 60 years old
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Cleft lip since birth
Cystic hygroma infancy
Thyroglossal cyst childhood
Appendicitis adolescents & adults
Trauma adolescents & adults
Cancer middle & old age
Goitre child ---------cretinism
puberty ------physiological
adult --------- S.N.G.
elderly ------- malignant thyroid
U. T. adolescents & adults ---------- stones
elderly ----------------------------- cancer or prostatism
Age – disease correlation
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CAUTION
Wilm’s Tumour Ewing’s tumour
Neuroblastoma Retinoblastoma
Acute Leukaemia
Juvenile (secretory) breast carcinoma
CANCERS OF CHILDHOOD
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SEX
1-Diseases:
Haemophilia
Buerger’s disease
CCC
thyroid diseases
breast diseases…
♀♂ diseases of sexual organs
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2- Menstrual history (♀):
Time of Menarche……………………..…....?
Regularity ……………………………….…..?
Related complaints (? pain)………………...?
Post- menopausal………………./………..….?
MARITAL STATUS
Single, married, divorced, widow, widower…
If married:
♂ ask about: fertility, offspring, STD’s
♀ ask about: fertility, offspring, lactation (now),
contraception (now), STD’s
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Why to ask about Menstrual
history ?
• For elective operations, don’t operate on a female
during her menses.
• If early menarche & late menopause = risk group of
breast cancer.
• Pain & fullness in the breast during menses draws the
attention to fibroadenosis.
• Whether the patient is pre- or post-menopausal, it is
very important in the ttt of breast cancer.
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Why to ask about marital state ?
• Infertility
• STDs
• Psychic troubles…..
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OCCUPATION 1 - occupational diseases:
* intellectual
* exposure to carcinogens
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1 - occupational diseases:
* porters HERNIAS * Farmers Bilharziasis = SPLENOMEGALLY
* typists, pianists, drill workers RAYNAUD’S PHENOMENON
* teachers, surgeons, nurses VARICOSE VEINS
* intellectual HTN, Peptic Ulcer
* exposure to carcinogens
2 - Standard of living (social class):
* diseases of high social class:
Duodenal ulcer
Irritable Bowel Syndrome * diseases of low social class:
TB
Parasitic infestations
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RESIDENSE
1 - endemic diseases:
Delta : Colonic bilharziasis
Upper Egypt: Urinary bilharziasis
Giza & Damietta: Filariasis
Oases: Endemic goitre
Sudan: Malaria
Iraq: Hydatidosis
Europe: Colonic cancer
USA: Breast cancer
Japan: Gastric cancer
2- Follow up: phone No. , postal code
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HABITS OF SURGICAL IMPORTANCE
Smoking
Tea & Coffee abuse
Alcohol intake
I.V. drug addiction
Automedications
Diet habits
Swimming in canals
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HABITS OF SURGICAL IMPORTANCE
SMOKING .
ASK ABOUT:
- type of smoking…
- duration of smoking …. ex-smoker
- hazards of smoking ( ± ) - smoking index =
NO. of cigarettes × duration (in years)
Index less than 100 = mild smoker
100 – 300 = moderate smoker
more than 300 = heavy smoker
But this index is INACCURATE as it ignores parameters such as age at initiation, passive smoking and other forms of smoking as cigars and pipes.
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HAZARDS OF SMOKING
cardiovasc. respiratory GI miscellaneu
s
Tachycardia
Extrasystoles
IHD
Atheromas
Buerger’s
disaese
HTN
Lip cancer
Tongue cancer
Bronchogenic
carcinoma
Glossitis
COPD
Emphysema
↑postoperativ
e respiratory
complications
↑ oesophageal
cancer
↑ gastric
cancer
↓ healing of
peptic ulcers
IBS
↓foetal
growth
Tobacco
amblyopia
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EXCESSIVE TEA & COFFEE : ASK ABOUT:
- Amount of intake per day
- Hazards:
* INSOMNIA * DIURESIS
* HYPERACIDITY * CONSTIPATION
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ALCOHOL INTAKE
ASK ABOUT:
- type of drink…
- duration of drinking & if stopped
- amount of intake per day
- hazards of alcohol ;
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HAZARDS OF ALCOHOL INTAKE
* delerium. *addiction. *peripheral neuritis.
*myopathy. *tremors. *cardiomyopathy.
*gastritis. *alcoholic hepatitis. *alcoholic cirrhosis.
*hyperlipidaemia. *Zieve’s syndrome
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I.V. DRUG ADDICTION :
ASK ABOUT:
- type of drug…
- duration of addiction & if stopped
- amount of intake
- hazards of I.V. drug addiction:
AIDS
INFECTIVE HEPATITIS
INFECTIVE ENDOCARDITIS
MALARIA :
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DIET HABITS
- excessive fat obesity, fatty
liver, atherosclerosis, cholecystitis,…
- excessive spices gastritis, PU, haemorrhoids,…
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SWIMMING IN CANALS :
:
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- ask about the MOST DISTRESSING PROBLEM that motivated
patient to seek care + DURATION.
- record & express complaint in one short specific AND NOT
SCIENTIFIC sentence.
IN THE PATIENT’S OWNWORDS (never use medical
terms e.g.
dysphagia = difficult swallowing.
jaundice = yellowish discoloration of the eyes
palpitation = rapid sensible heart beats.
axilla = armpit
inguinal region = groin
ulcer = sore
Rt hypochondrium = Rt upper quadrant of the abdomen.
II- Chief Complaint
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For - A patient suffering form jaundice that began 3 weeks ago and is still present.
The complaint is (yellowish discolouration of the skin & sclera OF 3 weeks duration )…
don’t use for, since, ago…
Complaint in surgery my be:
1- pain 2- swelling 3- ulcer 4- disturbed body function
Pain is an annoying unpleasant sensation of varying intensity (= symptom)
Tenderness is pain in relation to a stimulus (=sign)
(patient feels pain & you elicit tenderness)
Never to say “history of tenderness”
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this is the chronological story of the patient illness extending from the moment when the patient was quite well till now.
- 3 steps:
1- analysis of patient’s complaint (avoid leading “Yes/No” questions)
2- aetiology, complications and other symptoms related to the patient’s condition and not given by the patient.
3- review for other systems in the body.
4- investigations & TTT received for the presenting condition.
III- History of the present illness
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If the main complaint is pain, ask about: OPQRST
• Onset= sudden, rapid or gradual.
• Offset (in pain only) = spontaneously or by drugs.
• Course= progressive, intermittent……
• Duration= of the attack
• Precipitating factors= if pain is related to a stimulus known by the patient
• Quality (character)= dull aching, burning, colicky, throbbing, stitching, squeezing, dragging, heaviness…..etc
• Severity of pain ( tolerable or not? what ↑ pain? what ↓pain ? )
• Site of pain
• Radiation of pain= radiating pain = extension of pain to a distant site while the initial pain persists (e.g. acute appendicitis), referred pain = feeling pain away from its possible source (e.g. acute cholecystitis)
• Time of onset (e.g. at night)
Analysis Of The Complaint ANALYSIS OF PAIN
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• Onset= sudden, rapid or gradual.
• Course= progressive, intermittent or in-plateau
• Duration
• Ppt factors= if pain is related to a stimulus known by the patient
• Multiplicity= some swellings tend to be multiple as:
- multiple lymph nodes
- multiple lipomas
- multiple haemangiomas, multiple lymphangiomas
- multiple papillomas (warts)
- multiple naevi
- multiple sebaceous cysts
• Ever disappears (very important in hernias)
• Associated symptoms= 1. pain
2. General manifestations = fever + symptoms of metastases
3. Local manifestations = VAN
Analysis Of The Complaint ANALYSIS OF SWELLING
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- Analyze pain also if the swelling is painful !
- Fever: it may be important (not just an association) especially if:
* related to the onset of the swelling.
* recurrent.
- Symptoms of metastases:
• Bone metastases= bone pain, repeated fractures on minor trauma
(= pathological fractures)
• Brain " " = ↑ ICP, fits, sensory or motor affection
• Lung " " = cough, haemoptysis, chest pain
• Liver " " = rt hypochondrial pain, jaundice
Symptoms of metastases are usually negative, say: (No history suggestive of metastases in the form of bony aches, RT hypochondrial pain, headache, vomiting, blurring of vision, cough…etc)
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Local manifestations:
VAN= Vein, Artery, Nerve • Swelling in a limb → effect on vein= oedema
on artery= ischaemia
on nerve = numbness & paresis
• Swelling at parotid gland: effect on nerve (facial N.)
• Swelling in breast: effect on vein or lymphatics (causing
lymphoedema of upper limb)
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IV- Past history
Ask leading questions about past events having
relationship to presenting complaint:
1. Past history of similar attacks.
2. “ “ “ drug intake.
3. “ “ “ operations.
4. “ “ “ endemic diseases.
5. “ “ “ systemic diseases.
6. “ “ “ childhood diseases.
7. “ “ “ trauma.
8. “ “ “ traveling abroad..
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V- Family history
Ask about Family history of similar conditions in:
• Familial diseases: “e.g. T.B., endemic goitre,… etc”
• Herditary diseases: “haemophilia, HA, breast cancer, …etc”
Ask about history of familial diseases.
Ask about history of consanguinity.