Surgery

Dr. Ebtisam Lec: -1-

1-Oct-06

Introduction

 Alertness
 Never take a short –cut
 Try to see the patient walking
 Patient companion
 Identify yourself to the patient
 Guide the conversation but never dictate
 Language
 Avoid leading questions

Taking the history

Patient name Sex marital status Address

Age Religion occupation
Date of examination

1. History of present complaints

2. Present complaint
3. Qs about abnormal systems
4. Systematic direct Qs
Negative answers

The Alimentary System

Appetite…Diet…Weight…Teeth and taste
Swallowing…Regurgitation…Flatulence…
Heart burn….Vomiting…Hematamesis…
Abd. Pain…. Abd. Distention… Defecation
N.B Blood in stool
Mucous or pus
Changes of skin color

Respiratory System
Cough…sputum…haemoptysis…Dyspnoea
Chest pain

1
Cardiovascular System
A. Cardiac symptoms
Breathlessness…Orthopnoea…Paroxysmal nocturnal dysponea…Pain…palpitations…Cough
and sputum…Dizziness and headache…ankle edema

B. Peripheral vascular Symptoms

 Intermittent claudication

 Cold extremities

 Skin changes

 Parasthesia

The urogenital system

. Urinary tract symptoms
Pain…Edema…thirst…micturation…urine..
Other Symptoms
B. Genital tract symptoms
Scrotum and urethra
Menstruation
Pregnancies
Dyspareunia
Breast
Secondary sex characters

The Nervous System

 Mental status

 Brain and Cranial nerves

 Peripheral Nerves ( Paralysis, Cutenous sensation, Parasthesia )

Musculo- Skeletal System

 Pain, swelling or limitation of joint movement
 Weak or painful muscles

2
Metabolism

 Rate of growth
 Weight and appetite

5. Previous history of other illnesses or accidents

6. Drug history
7. Immunization
8. Family history
9. Social history
10. Habits

History of pain

 Definition

1. Site
2. Time and mode of onset
Sudden at a maximum severity
Sudden with gradual decline
Gradual
3. Severity
4. Nature ( Burning, throbbing, stabbing, constricting, distention, colicky )
5. Progression ( Steady, gradual decline, Gradual worsening, fluctuating )
6. Cessation of pain ( sudden, Gradual, crescendo and sudden end )
7. Duration of the pain
8. Relieving factors
9. Exacerbating factors
10. Radiation…refereed pain
11. causes

3
History of a lump

 When was the lump first noticed?

 What made the patient notice the lump?
 What are the symptoms of the lump?
Painful, disfiguring, infection and interfering with activities
 has the lump changed in size?
 Does the Lump ever disappear?
 Has the patient ever had any other lumps?
 The cause

History of an ulcer
 Definition
1. When was the ulcer noticed?
2. What draw the attention to the ulcer?
3. What are the symptoms of the ulcer?
4. How has the ulcer changed since it first appeared?
5. Similar ulcers?
6. The Cause

N.B Big ulcer following minor injury suggest abnormal skin.

Written By:
Rand Aras Najeeb