HISTORY TAKING

HISTORY TAKING
 Employ your eyes, ears, nose,
hands

 Start by telling the patient your

name and who you are

 Guide the conversation

HISTORY TAKING
 Treat the patients as the rational
human being they are

 Explain what and why you are

doing

 All questions should leave the

patient with a free choice of
answers
HOW TO TAKE
HISTORY
 Always record the pt’s name, age,
sex, ethnic group, marital status,
job, place

 Record the date and time of

exam.

 Note the way of admission, who

referred the pt. to surgery
HOW TO TAKE
HISTORY

 The assessment of the surgical P.

aims to:
– confirm the diagnosis
– detect associated medical illnesses
– assess fitness for anesthesia
THE PRESENT
COMPLAINT
 What is the problem ?

 Note the answer in the pt’s own

words

 Associated complaints
HISTORY OF THE
PRESENT COMPLAINT

 Full details of the history of the

main complaint
 Get back to the beginning of the
trouble
 Onset: sudden or gradual
 Progression until examination
HOW TO TAKE
HISTORY

 Remaining questions about of the

abnormal system

 Systematic direct questions

QUESTIONS OF THE
DIGESTIVE SYSTEM
 Appetite
 Diet
 Weight
 Swallowing
 Heartburn
 Regurgitation
QUESTIONS OF THE
DIGESTIVE SYSTEM
 Vomiting
 Haematemesis
 Indigestion or abdominal pain
 Abdominal distension
 Defecation
 Change in the skin color
APPETITE

 Has the appetite increased, decreased

or remained unchanged ?
 If decreased: anorexia or eating
causes pain
– Anorexia= lack or loss of appetite
– Anorexia nervosa= prolonged refusal to
eat, resulting in emaciation (fear of
becoming obese)
 What are your new likes and dislikes ?
DIET

 What type of food do you eat ?

 When do you eat your meals ?

 How long do the meals take ?

WEIGHT
 Has your weight changed ?

 How much ?

 How quickly ?

 Clothes have got tighter or

looser ?
SWALLOWING
 Dysphagia
– Difficulty in swallowing, commonly
associated with obstructive or motor
disorders of the esophagus
– What type of food causes difficulty ?
– What the level at which the food
sticks ?

 Odynophagia= painful swallowing

REGURGITATION
 Effortless return of the food into
the mouth

 Vomiting- powerful, involuntary

contraction of the abdominal wall
HEARTBURN
 Burning sensation behind the
sternum

 Cause- acid reflux from the

stomach into the esophagus
VOMITING
 How often do you vomit ?
 Is the vomiting preceded by
nausea?

 What is the nature and volume of

the vomits?
 What other symptoms are
associated?
HEMATEMESIS
 Vomiting digested blood
 Old, altered blood looks like
“coffee grounds”
 Differentiate hematemesis from
hemoptysis and epistaxis
 Hemoptysis- coughing up of blood
 Epistaxis- nose bleed
ABDOMINAL PAIN
 Site
 Onset
 Severity
 Nature
 Progression and duration
 Exacerbating and relieving factors
REGARDING
DEFECATION

 How often do you pass stool ?

 Colour, consistence, size,
frequency
 Have you ever passed any blood?
 Hematochezia- passing fresh
blood per anum
 Is the defecation painful?
QUESTIONS OF THE
RESPIRATORY SYSTEM
 Cough

 Hemoptysis

 Dyspnea

 Chest pain
COUGH
 Sudden audible expulsion of air
from the lungs

 Coughing is preceded by
inspiration, glottis partially
closed, accessory EM contract to
expel the air forcibly from the
resp. passages
COUGH
 Protective response to clear the
lungs, bronchi and trachea of
secretions

 Chronic coughing- TBC, lung

cancer

 Episodes of chronic coughing- sub

diaphragmatic irritation, CHF.
HEMOPTYSIS
 Coughing up of blood from the
respiratory tract

 Blood-streaked sputum

 More profuse bleeding- lung

abscess, TBC, lung cancer
DYSPNEA
 Breathlessness- distressful
sensation of uncomfortable
breathing

 Causes- heart conditions,

strenuous exercise or anxiety

 Wheeze= a whistling respiratory

sound- COAD
CHEST PAIN

 Site, severity and nature

QUESTIONS OF THE
CARDIOVASCULAR
SYSTEM
 Cardiac symptoms
– Breathlessness
– Cardiac pain
– Palpitations
– Cough and sputum
– Dizziness and headaches
 Peripheral vascular symptoms
BREATHLESSNESS
 Orthopnea - breathlessness when
lying down

 Paroxysmal nocturnal dyspnea -

sudden attack in the middle of
the night that waken the pt.
CARDIAC PAIN
 Usually retrosternal

 Its nature- constricting, band-like

or squeezing

 Usually related with exercise or

excitement
QUESTIONS
 Does the pain radiate to the neck
or to the left arm?

 Does rest relieve the pain?

PALPITATIONS
 Episodes of tachycardia

 Sudden fluttering or thumping of

the heart in the chest
DIZZINESS AND
HEADACHES
 Dizziness- hypotension

 Headache- hypertension
PERIPHERAL
VASCULAR SYMPTOMS
 Do you get pain in the leg
muscles on exercise? -
intermittent claudicating
 How far can you walk?
 How long does the pain take to
disappear ?
 Is there any pain in the limb at
rest ?
PERIPHERAL
VASCULAR SYMPTOMS
 Does the pain interfere with sleep
?

 What positions relieve the pain ?

 Are the extremities of the limbs

cold ?
QUESTIONS OF THE
URO-GENITAL SYSTEM

 Urinary tract symptoms

– Loin, groin, suprapubic pain
– Ankle swell
– Micturition: dysuria, polakyuria,
polyuria
– Urine: colour, smell, quantity,
hematuria, pneumaturia
QUESTIONS OF THE URO-
GENITAL SYSTEM

 Genital tract symptoms

– Scrotum and urethra
– Menstruation
– Pregnancies
– Breasts: change in size, lumps,
nipple discharge
QUESTIONS OF THE
NERVOUS SYSTEM
 Mental state: calm, nervous

 Brain and cranial nerves: fits

 Peripheral nerves: paraesthesia,

palsy
QUESTIONS OF THE
MUSCULOSKELETAL
SYSTEM
 Pain

 Swelling

 Limitation of movements
PAST MEDICAL
HISTORY
 OTHER ILLNESSES

 ACCIDENTS

 OPERATIONS
DRUG HISTORY
 DRUGS AND DOSES

 ALLERGIES
FAMILY HISTORY
 DISEASES

 CAUSES OF DEATH
SOCIAL HISTORY

 TYPE AND PLACE OF DWELLING

 OCCUPATION
 CONTACT WITH HAZARDS
 LEISURE ACTIVITIES
 TRAVELS ABROAD
HABITS

 SMOKING

 ALCOHOL