University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage The History MA MURPHY FRCSI

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Lesson Objectives To take a history eliciting all of the relevant facts To present a history to an examiner in a satisfactory manner

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Contribution to Diagnoses

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage History Taking - Your Objectives To elicit the pertinent facts from the patients symptoms in relation to the illness; To derive a differential diagnoses, To elicit risk factors and significant co-morbid pathologies

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage History Taking - Your Objectives To demonstrate compassion to the patient

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage History Taking - Your Objectives To present the history to the examiner in a clear and sequential fashion

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage The Presenting Complaint The symptom for which the patient first sought medical advice. Elicited by asking; –“what made you come to hospital / consult your doctor on this occasion.”

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage The Presenting Complaint When a patient gives a multitude of complaints; –which was the worst or most worrying? –The presenting complaint is often associated with other symptoms.

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage History of presenting complaint When did you last feel quite well? Full description of presenting complaint Associated features Have you ever suffered from this before? Systems review of the relevant system(s)

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage The presenting complaint The most common presenting complaint in surgical practice is a pain.

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Questions to ask about Pain Ryle’s 10 questions SOCRATES questions

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Questions to ask about Pain How, when did it start, how long did it last? How bad was it? Where was it felt? Did it radiate? Did it change, move? Any associated features?

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Questions to ask about Pain Did anything make it better or worse? What was the character (dull/sharp)? Was it constant or colicky? Any associated features? How did it end? What do you think caused it ? Anything else?

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage A Presenting Complaint Mrs X presented with a sharp 1, severe 2 pain in her right upper quadrant 3 of seven hours duration 4. The pain was constant 5 in nature and radiated around into her back 6. The pain started suddenly 7 1 hour after eating 8 and was associated with vomiting 9 on three occasions 10. The pain was aggravated by movement 11 and relieved by lying still 12. She had suffered from a similar but less severe pain 3 months ago. 13. She had no other gastro-intestinal symptoms. 14.

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Common Presenting Complaints –A lump, mole or skin ulcer –Bleeding –System specific symptoms altered bowel habit, dysphagia urinary frequency –Generalized symptoms fever, lassitude, weight loss

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Questions to Ask About a Lump How long has it been present ? What made you first notice it ? Has it changed ? Is it painful ? Any associated features ? What do you think caused it ?

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Questions to Ask About Bleeding Site (PR, PV, PU, Haematemesis, Haemoptysis) Duration Frequency Amount Type (Black, Bright red) Associated features

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Generalized Symptoms Duration Frequency Severity Associated features Full systems review Preceding events (when did you last feel quite well ?)

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage The Systems Review General well-being Energy Appetite Fever Sweating Mood

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Gastrointestinal Review Appetite Taste Swallowing Heartburn Vomiting

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Gastrointestinal Review Bloating/ belching Abdominal pain/ discomfort Post-prandial symptoms Bowel habit Change in bowel motion smell, colour, consistency, blood or mucous

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Cardio-respiratory review Chest pain Palpitations Breathlessness (dyspnoea) Cough - sputum Ankle swelling Exertional symptoms

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Urogenital review Loin/ groin pain Micturation –dysuria –urgency, frequency, nocturia –hesitancy, stream, dribbling –haematuria, pneumaturia –change in colour/ smell of urine

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Gynaecological review Menses Pregnancy PV discharge Post-menopausal bleeding Contraception Dyspareunia Obstetric history

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Neurological review Loss of consciousness/ fits Loss/ blurring of vision/ speech Loss of power Loss of balance Parasthesia Headache Tremor Behavior/ mood

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Orthopaedic review Limb pain Joint pain Limitation of movement Weakness Disturbance of gait

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Vascular review Neurological symtoms Abdominal back pain swelling Claudication Limb pain Colour change Pigmentation Limb temperature

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Past medical History Operations –when, where for what Hospital admissions –when, where for what Medications –when, where for what Drug allergies

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Family history Emphasize 1 ST Degree relatives Cancer history important Family illness may have effect on patients interpretation of their own symptoms and their psychological response to illness

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Social History Hygiene ? Lives alone ? Health of partner ? Family support ? Community support ? Smoking habit ? Alcohol/ substance abuse ?

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Specific Risk Factors Occupation (eg Asbestos exposure) Residence (eg hygiene, infection) Foreign travel Animal exposure

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Direct Questions Diabetes Asthma Jaundice Rheumatic fever/ TB Hypertension Epilepsy CVA/ MI

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage The Differential Diagnoses Occams razor

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage William of Oakham (“Occam”)

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Occams’ Razor one should not increase, beyond what is necessary, the number of entities required to explain anything

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage The Differential Diagnoses List the most likely or most important differential first List at least two possible differentials Mention rare diagnoses last List non-organic (supratentorial origins) after organic diagnoses

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Interpretation of Abdominal Pain

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Summary In the summary one should try to piece together all of the relevant facts along with significant negatives to present a concise account of the patients symptoms and allow formulation of a differential diagnoses

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Special Types of History The trauma patient The unconscious patient The demented patient Patients following investigation and treatment

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Presenting a History Look smart Speak clearly Present in a logical and sequential manner Mention important negatives Don’t dwell on irrelevancies Try not to use notes

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Presenting a History Presenting complaint History of Presenting complaint Systems review Past history Drugs and allergies Family history Social history Summary

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Presenting a History Begin with “I would like to present the case of…” Mention patients age and sex and any occupation or underlying medical condition which is of relevance to the case.

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Presenting a History Describe clearly the presenting complaint and when and how (elective/emergency) the patient presented the presenting complaint may be described in the patients own words by saying “who presented with what she described as”

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage The presenting complaint is the most important part of the surgical history

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Presenting a History The history of the presenting complaint includes; –a full description of the symptom –associated symptoms with full description and relation to PC –previous episodes –relevant systems review –when he/she last felt well

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Presenting a History Go through systems reviews emphasizing any positive findings and relevant negatives

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Presenting a History Past medical history –mention relevant operations, conditions, investigations first List important negatives e.g. diabetes List medications –when and why started Allergies

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Presenting a History Family history –emphasize first degree relatives –cancer history important Social history –hygiene –lives alone, health of partner –family support

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Presenting a History Summarize –presenting complaint its history –other relevant findings Differential Diagnoses –most likely and most important –what to look for examination –investigations

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage Get the presenting complaint right