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Surgical History Taking Essentials

This document outlines the process of taking a history in surgery. It discusses that history taking is the key step in surgical diagnosis and varies according to the patient's complaint and surgical specialty. There are two main types of histories - those taken for outpatient/emergency visits to pinpoint a specific complaint and diagnosis, and those taken when admitting a patient for elective surgery to ensure the planned treatment is correctly indicated. The history should cover personal information, present complaint, history of present illness, review of systems, past medical/surgical history, drug history, family history, and social history. Common complaints in surgery are pain and lumps. Physical examination involves inspection, palpation, percussion, and auscultation of lumps

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484 views25 pages

Surgical History Taking Essentials

This document outlines the process of taking a history in surgery. It discusses that history taking is the key step in surgical diagnosis and varies according to the patient's complaint and surgical specialty. There are two main types of histories - those taken for outpatient/emergency visits to pinpoint a specific complaint and diagnosis, and those taken when admitting a patient for elective surgery to ensure the planned treatment is correctly indicated. The history should cover personal information, present complaint, history of present illness, review of systems, past medical/surgical history, drug history, family history, and social history. Common complaints in surgery are pain and lumps. Physical examination involves inspection, palpation, percussion, and auscultation of lumps

Uploaded by

Asem Al-domaini
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPT, PDF, TXT or read online on Scribd
  • History Taking in Surgery
  • Physical Examination

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 !!!!!

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 ?
Two types of history in surgical practice:  Out-pt or emergency room history ?specific complaint is pinpointed ?
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.  Elabora
History should be taken in the following order: e. Past history ? surgical, medical f. Drug history g. Family history h.
Systemic Enquiry 1. GIT: Appetite, Vomiting, Regurgitation, etc.  Respiratory System ? cough, haemoptysis, Dyspnea….  C
Commonest complains in Surgery Pain Lump
The history of pain - Site. - Onset. - Severity ? wake him up, need analgesics Rather than: mild, severe. - Nature: Burin
The history OF A LUMP Duration How discovered Symptoms ? pain Changes ? ?in size Other lumps Any cause ? Trauma

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