History Taking

In Surgery
Gamal Khairy FRCS,MS
College of Medicine KKUH
 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

1. GIT: Appetite, Vomiting, Regurgitation, etc.

 Respiratory System ? cough, haemoptysis, Dyspnea….
 C.V.S: * Breathlessness, palpations, chest pain…
* 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

 FIG. 16.6
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 !!!!!