History taking in Surgery

Dr. CS Yongolo
 References
 A manual of Clinical Surgery by S.
Das.
 Clinical Methods by Hanchinsons
 Introduction
 Involves getting information from the
patient regarding his/her illness
 The most important part in clinical
medical training
 A systematic way of recording
history, physical findings and
investigations
 Aimed at arriving at the diagnosis
 Introduction
 Requirements:
• Clinical coat
• Stethoscope
• Tape measure
• Pencil-torch
• Tendon-hammer
• Blood-pressure machine
• Others depending on the area of
specialty eg ENT, Opthamology.
 The History
 Involves:
• Identification of the patient
• Chief Complaint
• Amplification
• Review of other systems
• Past medical history
• Personal History
• Family history
• Drugs (including blood transfusion) and
allergies
 Patient particulars

 Name
 Age/sex
 Congenital, pediatrics, teenage elderly
 Males vs females
 Occupation
 Residence/place of domicile
 Social status
 Religion
 Chief complaints

• Ask what the patient’s complaints are

and arrange them in chronological order
according to duration :e.g.
 Cough I month
 Fever 3 weeks
 Chest pain 2 days.
• Was the patient free of any complaint
before the period?
 Amplification or History of
present illness

• Elaborate at length each of the patients’

chief complaints
• Use patients own words as far as
possible
• Avoid “leading” questions; i.e. questions
suggesting answers.
• Does the pain move to the inferior angle of right
scapular? X
• Does the pain ever move? Where does it go?
• Important negative points should also
be noted and recorded.
Amplification or History of
present illness

•Mode of onset/ cause

 Sudden vs insidious

•The progression (evolution)

 Hrs, days, weeks, months
or years.
•The treatment if any and
outcome.
 Applied your knowledge !!

 Relate what you learnt in Anatomy,

Physiology, Pathology, Pharmacology.
 A disease can be localized in a system
but causing other symptoms else
where.
 Natural history of a disease is
important.
 Local examination relates to the
system affected
 Review of other systems
 Ask specific questions about other
systems not complained about by the
patient:
• CNS,
• respiratory;
• cardiovascular;
• GIT;
• genitourinary;
• musculoskeletal
 Past medical history

• Note illnesses prior to the current one

• Note on dates and duration
• Any hospital admissions and events
• Any surgical operations and
outcomes/complications
• Again some information may have to be
recorded even if negative.
 Drug history.
 History of allergies (diet or medicines).
 Immunization history.
 Personal History:

• Note on personal habits e.g.

• smoking,
• Alcohol
• Diet
• Marital history, sexual habits
• Number of children and their health
status
 Family History
 Enquire if other members have
suffered from similar illness
 Ask history of
• peptic ulcer,
• diabetes mellitus,
• tuberculosis,
• carcinoma of the breast
• Hypertension
• Allergies
 General examination
 Observe general appearance of the
patient
• Ill looking
• Not ill-looking
• Facies; toxic
• Attitude of the patient
• Pulse
• Respiration
• Temperature
 Local examination
 This may mean examination of the
affected system or a region.
 Whichever the case the plan is the
same:
• Inspection (look)
• Palpation (feel)
• Percussion
• auscultation
 Local examination
 Expose the affected part adequately
 Where possible compare
 Observe closely
 Feel for tenderness, consistency, guarding,
crepitus, thrills etc
 Listen to sound produced by percussion:
resonant, dull, tympanitic
 Listen by use of the stethoscope
 Examine the regional lymph nodes
 Systemic examination
 Examine the other systems in an orderly
manner under the same headings of
inspection, palpation, percussion and
auscultation.
 Purpose:
• For diagnosis/differential diagnosis
• For knowing extent of disease
• For selecting type of anaesthesia/surgery
• Sometimes can lead to finding a pathology in
another system.
 Conclusion

 Analyze information from history and

physical examination
 Make a provisional diagnosis
 Use the law of probability: common
things occur more commonly.
 Plan investigations
• to augment your diagnosis
• to plan management