Patient-Doctor relation The way to reach the Diagnosis History Taking Dr. Abdelmoniem Eltraifi Consultant Urologist & Clinical Ass. Professor

Be ready; prepare you self to be a good doctor

Your look is important Your dressing Your look is important Your dressing

The patient should be a friend or like a friend Always think of his condition and not yours

See him walking in and not in the cubicle Allow his relative to be there if the patient wants.

Introduce your self

Be alert and pay him full attention

History Taking in Surgery There is no difference between medical and surgical history. They are almost the same.

History Personal Data ( Patient Demography) 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 ( C/O)

You should write the patient own words. If there is more than one complaint, it should be written according to: 1. Occurrence. 2. Most bothersome.

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 Haematemses Abdominal pain Abdominal Distension Bowel habit Stool Jaundice

Urogenital System Loin pain Symptoms of uremia 1. Headache 2. Drowsiness 3. Fits 4. Visual disturbances 5. Vomiting 6. 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. Duration 3. Mode of onset 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

An Example of classical History taking

Hematuria

Classical history of hematuria Patient demography Date and Time= 13/9/2001 at 10 am Khalid Alotibi File number years old male Muslim Married Teacher Living Riyadh, before in Hail History given by the patient himself?

c/o blood in urine for 5 days

History of present illness He was well, tell five days ago, when he noticed blood in his urine. The haematuria is episodic, most of the time when ever he is passing urine. The urine color is dark red. He noticed blood clots in the urine, rounded in shape. He had no pain. The haematuria is total through out all his urine. No history of trauma, no ingestion of red colored food, or drink. No bleeding from other sites of his body. Finish all urinary tract system symptoms in this part. They inserted for him, 3 ways urethral Folly catheter, and they did continuous bladder irrigation, and he just finished taking CT urogrophy for him.

Past History No history of similar episode. No history of hematological congenital disease No history of pulmonary Tuberculosis No history of stone disease No history of operations or RTA No history STD No History of DM, or Hypertension, bronchial asthma, and no known allergy.

Family History No family history of similar episode. Parents are dead ( unknown cause of death). No family History of; SCD, or other hematological disorder. No family history of; cancer prostate, or other renal disease No family history of DM, or hypertension

Systemic Review Systematic Direct Questions No Fever, or loss of weight. Ask him- here about all the other systems. Exclude urinary tract, as its should be finished already, in the section of history of the present illness. Negative symptoms: are as important as positive one

Social History & Habits Married to one wife, with Three-female and two-male children. Living in his own villa, with good facilities. Working as a higher school teacher, and had other personal business with good income. Not smoker, but he had other colleague teachers, who are smoking in the office. He used to travel in summer with his family to other countries: Egypt, Turkey, Syria and once to Malaysia. Never exposed himself to rivers, ponds, or canal water. Never drinks alcohol. His leisure are: reading news papers and watching TV only. He used to eat ordinary Saudi food.

Drug History and allergy He is not taking anti-coagulants, or any other drugs. No know allergy to any medication.

Example of short history taking for the OSCE Exam Ask directly about the patient presenting symptom. Ask directly about the patient presenting symptom. Ask related Questions only. Ask related Questions only.

Age Residency. Duration. Occupation Painless or painful Timing of Haematuria Amount of bleeding ( darkness of the color, an presence of clots) Shape of clots Trauma Bleeding from other sites Associated urinary, and Systemic Symptoms Bleeding disorders, SC, TB, Bilharzias & stone disease. Family History of Malignancy, Renal, or hematological disorders. Drugs Red colored food or drinks. Smoking Example: History of Hematuria