Uruk University/College of Dentistry

Fourth Year/General Surgery Assist. Prof. Khaleel A. Hassoon

Lecture 11

Principles of History Taking in Surgical Patients

Introduction

History taking is an ART, and this art to be mastered, need long time experience & scientific background,
which are gained by continuous learning. The ability to evaluate important comments or any abnormalities
which can lead to the correct diagnosis developed from the continuous and frequent practice of the routines
of our work (Repetition is the secret of learning). Always give the patient your whole attention and never
take shortcut.

When you take a history try to see the patients walk into the room better than finding them lying,
undressed on a couch, because general malaise and debility, breathlessness, cyanosis and difficulty with
particular movement are much more obvious during exercise.

All questions should leave the patient with a free choice of answer, avoid asking a leading question that
have one answer, for example: " the pain moves to the right-hand side, doesn't it? " This is a "leading
question", because it means that it should have moved in that direction, the best question to be asked is "If
the pain ever moves? “, if the answer is "yes”, you must then ask the supplementary question, where does it
go? The patient should provide the correct answer providing you asked the correct question.

How to take the history

The history should be taken in the order described in this form:(case sheet). Make sure that you record the
patient's name, age, sex, religion, marital status, occupation, address; and always record the date of
examination.

The chief complaint and duration:

(Why the patient came to hospital?) It is customary to ask the patient “what are you complaining of” and
to record the answer in the patient's words. If you ask "what is the matter" the patient will probably tell
you their diagnosis. It is better not to know the diagnosis made by the patient or other doctors, because
none may be correct.

The Duration usually is when the patient asked for medical advice (i.e. from the start of the problem to the
time of asking for medical advice).

If the patient has many complaints, it is favorable to list them according to their sequence of severity or
their date of occurrence.

Case Sheet

 Name, age, sex, marital status, occupation, religion.

 Chief complaint and its duration

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  History of present illness (details of the complaint of the patient from its beginning till now)
 Systemic Review: as shown below:

1-Alimentary system and abdomen: Pain, appetite, diet, weight, anorexia, nausea, vomiting, dysphagia,
regurgitation, flatulence, heart burn, hematemesis, bowel habits, rectal bleeding,

2- Respiratory system: cough, sputum, dyspnea, orthopnea, hemoptysis, hoarseness wheezing, chest pain
(pleurisy)

3- Cardiovascular system: Chest pain, palpitation, paroxysmal nocturnal dyspnea, orthopnea, ankle
swelling, limb pain, color changes in hands and feet

4- Urogenital system: Loin pain, micturition (frequency, urgency, hesitancy, poor stream, dribbling)
painful micturition, polyurea, thirst, hematuria.

5- Musculoskeletal system: pain in (muscles, bones, joints), swelling of joint, limitation of joints movement

6- Nervous system: change of behavior, depression, memory loss, anxiety, tremor, fits, paralysis, and
sensory disturbances.

7- Medical & surgical History: any illnesses (Diabetes mellitus - Hypertension), previous operations or
accidents &their dates.

8- Drug history: insulin, steroid, anti-allergic, anti-depressant, (for female contraceptive pills).

9- Family history: Familial diseases in parents and siblings, cause of death of close relatives.

10- Social history: Smoking, drinking, living conditions, travel history.

History of present illness: The full history of the main complaint or complaints must be recorded in detail
with precise dates. It is important to get right back to the beginning of the problem, for example, a patient
may complain of a recent sudden attack of indigestion. If further questioning reveals that similar
symptoms occurred some years previously, their description should be included in this section.

Remaining questions about the affected system

When the patient is complaining of indigestion, for example, it is sensible to ask other questions about the
alimentary system because many answers may aid in diagnosing the cause of the indigestion.

Systematic direct questions

These are direct questions that every patient should be asked, because the answers may increase your
knowledge about the main complaint and will often reveal the presence of other disorders of which the
patient was unaware or thought not important. Negative answers are just as important as positive answers.

The Alimentary System

Pain: concentrate on the features of pain, site, time of onset, severity, nature, progression, duration,
radiation, (precipitating, exacerbating, & relieving) factors.

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Appetite: has the appetite increased, decreases, or remained unchanged?
Diet: what type of food do patients eat? When do they eat their meals?
Weight: has the patient's weight changed? By how much? Over how long of a time?
Anorexia, nausea, vomiting: these are three stages of the same symptom. What is the nature & volume of
the vomitus? How often do they vomit?
Dysphagia: does the patient complain of difficulty in swallowing? Ask about the type of food that causes
difficulty, the level at which the food sticks.
Regurgitation: this is the effortless return of food into the mouth. This differ from vomiting, does the
patient regurgitate? What comes up?
Flatulence: does the patient belch frequently? Does flatulence have any relation with any type of food?
Heartburn: it is a burning sensation behind the sternum caused by the reflux of acid into the esophagus.
How often does it occur &what makes it happen, e.g., Lying flat or bending over?
Hematemesis: this is vomiting of blood. It is either fresh blood or old, altered blood looks like "coffee
ground"
Bowel habit: how often does the patient defecate? What are the characteristics of the stool (color,
consistency, amount, smell) beware of the terms "diarrhea" &" constipation" because they mean different
things to different people?
Rectal bleeding: has the patient ever passed any blood in the stool? Was it bright or dark? Was it before
defecation or after it? Was it mixed with stool?

The Respiratory System:

Cough: how often does the patient cough? Does the coughing come in bouts? What factors precipitate or
relieve the attack of coughing? Is it a dry or a productive cough?
Sputum: what is the quantity and color of sputum?
Dyspnea: does the patient wheeze? Does he get breathless? (Dyspnea on lying flat is called orthopnea). Does
the breathlessness wake them up at night? (This is called paroxysmal nocturnal dyspnea).
Hemoptysis: (coughing of blood) has the patient ever coughed up blood? What quantity was produced?
How often does hemoptysis occur? Was it frothy?
Hoarseness of voice: does the patient noticed any change in his/her voice? if yes, for how long?
Chest pain: the site, severity, & nature of the pain. Chest pain which is continuous made worse by
respiration (pleurisy).

The cardiovascular system:

Cardiac symptoms:
Pain: cardiac pain begins in the mid-line and is usually retrosternal but may be epigastric. It is often
described as constricting or band-like. It is usually brought by exercise or excitement. The patient should
be asked if the pain radiates to the neck or to the left arm and if it is relieved by rest.
Palpitation: these are episodes of tachycardia which the patient notices as a sudden fluttering in the chest.
Ankle swelling: do the ankles or legs swell? Is there any effect of elevation of the legs on swelling?
Dizziness, headache, &blurred vision: these are some of the symptoms of hypertension or hypotension.

Peripheral vascular symptoms: does the patient get pain in the leg muscle on exercise (intermittent
claudication)? How far does the patient walk before the pain begins? is there any pain in the limb at rest?
Does the pain interfere with sleep? Are the extremities of the limbs cold? Are there color changes in the
skin of the limbs? Does the patient experience any paresthesia in the limb such as tingling or numbness?

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The Urogenital System: Pain: has there been any pain in the loin, groin, or suprapubic region? What is its
nature? Does it radiate to the groin or scrotum?

Micturition: how often does the patient pass urine? How much urine is passed? Is micturition painful? Is
there any difficulty with micturition, such as a need to strain or to wait? Is the stream good? Is there any
dribbling at the end of micturition?
Urine: has the patient ever passed blood in the urine (this is called hematuria)? Has the patient passed gas
bubbles with the urine (pneumaturia).
Symptoms of uremia: these include headache, drowsiness, visual disturbance, fits and vomiting.

Genital tract symptoms:

Male: scrotum, penis, and urethra: has the patient any pain in the penis or urethra during micturition or
intercourse? Is there any urethral discharge? Is there any swelling in the scrotum?

Female: menstruation: when did menstruation begin (menarche)? When did it end (menopause)? What is
the quantity & duration of menses? Is menstruation associated with pain (dysmenorrhea)? is there any
vaginal discharge? Is there urinary incontinence on straining or coughing (stress incontinence)?

Musculoskeletal system: any pain in the muscles or bones, any swelling in the joints, is there limitation of
joints movement?

The nervous system: Has the patient noticed any change in his behavior or reaction to others? Is there any
memory loss? Is the patient anxious about something?

Medical & surgical history: Has the patient any chronic medical diseases e.g. diabetes mellitus,
hypertension? Any previous operations and their dates or had the patient any accident previously?

Drug history: Is the patient taking any drugs e.g. insulin, antiallergic drugs, steroids, antihypertensive?

Family history: Ask about some diseases that run-in families,

Social history: Smoking, drinking, life style & living conditions.

History of Pain:

Pain is a very common symptom and it is shared by many diseases, so it is a good example to be taken as a
model for detailed history taking.

What is pain? It is an unpleasant sensation of varying intensity. Pain can come from any of the body's
systems. It is important to differentiate between pain& tenderness.

Tenderness is pain which occurs in response to a stimulus, such as a pressure from the doctor's hand, or
forced movement. The patient feels pain, the doctor elicits tenderness.

Although patients usually complain of pain, they may also, have observed & complain of tenderness if they
happen to have pressed their fingers on a painful area, so tenderness can be both a symptom & a physical
sign.

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The features of pain that must be recorded

Site, time& mode of onset, duration, severity, nature/ character, radiation, referral, progression, relieving
& exacerbating factors, cause of pain in patient's opinion.

Site: the location by the patients of the site of pain is very important, it is not enough to describe a pain as
abdominal pain, you must be more specific. The patients must point to the site of maximum intensity,
which can be converting into an exact description.

Time & mode of onset: it may be possible to pinpoint the onset of pain to the minute, but if this cannot be
done, the part of the day or the night when the pain began should be recorded. Remember that you should
record the date of your examination. Whenever you write a note about a patient, make certain that you
start your note by writing down the date. Ask if the pain began suddenly or gradually.

Severity: individuals react differently to pain. What is a severe pain to one person might be described as a
dull ache by another? To evaluate the severity of pain, you have to ask the following questions: did the pain
stop the patient going to work? Did it wake the patient up at night or stop him going to sleep?

Nature or character of pain: some of the adjectives which are commonly used mentioned below, having a
similar meaning to majority of people:

Burning: a sensation following contact with intense heat.

Throbbing: it is like pulsation; the patient feels the area affected as if it pulsates.

Stabbing: sudden, severe, sharp, and short-lived.

Constricting: pain that encircles the relevant part (chest, abdomen, head, or a limb) & compresses it from
all directions.

Colic: a colicky pain has two features: it comes & goes in a sinusoidal way; it feels like a migrating
constriction in the wall of a hollow tube which attempting to force the contents of the tube forwards.

Exacerbating factors (aggravating factors): the type of stimulus that exacerbates a pain, will depend on the
organ from which it arises & its cause. For example, alimentary tract pains may be made worse by eating
particular types of food.

Relieving factors: patients will know whether there is anything, such as position, movement, food and
certain drugs, which relieve the pain.

Clinical types of pain: from the patient's viewpoint, the pain is where they feel it. The fact that the source is
some distant organ does not concern them.

 Radiation (Radiated pain): it is the extension of the pain to another site whilst the initial pain
persists. e.g., patients with a posterior penetrating duodenal ulcer usually have a persistent pain in
the epigastrium, but sometimes the pain spreads through the abdomen to the back.
 Referral (Referred pain): this is a pain which is felt at a distance from its source. e.g., inflammation
of the diaphragm will cause a pain which is felt at the tip of the shoulder. This is because they share
the same dermatomes (C345 keep the diaphragm alive& the cutaneous dermatome for the shoulder
tip)., this is because the inability of the CNS to distinguish between visceral& somatic sensory
impulses.

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