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History Taking In Surgery Dr.Ghazi Qasaimeh FRCS History taking ? the key step in surgical diagnosis. Varies according to the complain ? specific histories ? surgical specialty Two types of history in surgical practice: Out-pt or emergency room history ?specific complaint is pinpointed ? diagnosis Clerking of pt admitted for elective surgery object ? to assess that the treatment planned correctly indicated and pt is suitable for that operation. How to take the history ? Personal information : Age, sex, marital status, occupation, etc…… History should be taken in the following order: the present complaint (c/o). History of present complaint. Elaboration on the system involved. Systemic enquiry. History should be taken in the following order: e. Past history ? surgical, medical f. Drug history g. Family history h. Social history Systemic Enquiry GIT: Appetite, Vomiting, Regurgitation, Flatulence, Haematemesis, Abdominal pain, Abdominal Distension, Defecation, Rectal bleeding, Prolapse incontinence, Tenesmsus Respiratory System: Cough, Haemoptysis, Dyspnea, Orthopnea, Praxysmal nocturnal dyspnea, Chest pain. Systemic Enquiry (Cont.) C.V.S: Breathlessness, palpations, chest pain, Orthopnea, Praxysmal nocturnal dyspnea. Peripheral vessels: Intermittent, claudication, rest pain. Urogenital system: micturition, loin pain supropubic pain. Nervous system: Tremor, fainting attacks, fits, weakness… Musculor skeletal: muscle pains, joint swelling Commonest complains in Surgery Pain Lump The history of pain - Site. - Onset. - Severity ? wake him up, need analgesics Rather than: mild, severe. - Nature: Buring, stabing, coliky. - Progression ? - begin ç maximum, then remains steady. - steadily increase till maximum then gradual decline. - Duration. - Aggravating and releaving factors - Radiation. The history OF A LUMP Duration How discovered Symptoms ? pain Changes ? ?in size Other lumps Any cause ? Trauma Physical Examination General Examination: First part ? during taking history ? posture, speech,etc… Vital signs ? pulse, BP, temp Examination of the Head and neck Eyes Pupil reaction to light Sclera jaundice Conjuction paller Movement Exophthalmos Fundoscopy Examination of the Head and neck (cont’d) Ears and Nose Usually forgotten on ex: External auditory canal Eardrum Nostrils Examination of the Head and neck (cont’d) Neck Jugular veins Trachea Lymph nodes Thyroid Examination of A LUMP Position Colour and texture of skin Temperature Tenderness Shape Size Surface Edge Consistency Pulsatile, compressibility (venous malformations) Reducibility Examination of THE ABDOMEN PREPARATION: Warm and private room Good light Comfortable cough or bed Exposure: nipple to knee Get the patient to relax The position of the examiner THE NAMES OF THE REGIONS OF THE ABDOMEN THE STEPS OF Examination Inspection Palpation Percussion Auscultation THE STEPS OF Examination INSPECTION: Shape of abdomen Scars, sinuses & fistulae Distended veins Lumps Pigmentation Movement THE STEPS OF Examination PALPATION: Superficial : Tenderness Rebound Ganding Deep palpation: Masses Organs THE STEPS OF Examination PERCUSSION: All abdomen spec. over masses Fluid thrill Shifting dullness THE STEPS OF Examination AUSCULTATION: Bowl sounds Aorta and iliac anteries - Bruit Succusion splash THANK YOU !!!!!
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