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HISTORY TAKING IN SURGERY

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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. f. g. h. Past history ? surgical, medical Drug history Family history 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 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 (contd)

Ears and Nose


Usually forgotten on ex: External auditory canal Eardrum Nostrils

Examination of the Head and neck (contd)

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

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