Tariq Altokhais Assistant Professor Consultant, Pediatric Surgery Department of Surgery

History Taking: Key to diagnosis. Help to tailor the management.

Prepare you self to be a good physician

Your appearance is important: Proper uniform 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 yourself

History Taking in Surgery There is no difference between medical and surgical history.

Components of Patient History Date and time Identifying data Source of referral Source of history Chief complaint Present illness Past medical and surgical history Family History Social History Drug History Review of body systems

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 

Chief Complaint Chief complaint may be misleading Problem may be more serious than the chief complaint.

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.

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. 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

Sensitive Topics Alcohol or drug use Physical abuse or violence Sexual issues

Sensitive Questions Guidelines Respect patient privacy Be direct and firm Avoid confrontation Be nonjudgmental Use appropriate language Document carefully Use patient’s words when possible

Drug History and allergy The drugs the patient taking specially: Insulin, Steroids and contraceptive pills Allergy to any medications

Special Challenges Silence Overly talkative patients Patients with multiple symptoms Anxious patients

Special Challenges False reassurance May be tempting Avoid early reassurance or “over reassurance” Unless it can be provided with confidence

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

Questions ?