An Introduction for History Taking

Dr. Abdelmonem Gado, MS Surgery, FRCSIConsultant Paediatric Surgeon, Division of

Paediatric Surgery, Department of Surgery

•Your professional obligations, the expectation placed upon you by the public, the law and your colleagues, start on your first day as a student and continue throughout your working life.

• The qualities that patients look for in a doctor:•Humaneness•Competence•Accuracy•Honesty•Openness•Responsiveness•Trusthworthiness•Involving the patient in the decision making process •Time and listen

Guidelines and Certain Rules

-Language:- Learn to speed read- A good clinician is someone who interested in

people-Put yourself in situation of the patient or their

relatives-The best doctor are invariably the most humble and -good observer-Dress, Demeanour and confidentiality to establish

successful patient – doctor relationship

Set-up:-Where will you see your patient?-Keep always quite and private space-How long this interview?-How will you sit?

Hand washing and Cleanliness:- Is the single most effective way to prevent the spread of infection

Infections that can be transmitted on the hands of healthcare workers”-Healthcare – acquired infections:

-MRSA - Clostridium difficile-Diarrheal infection:

-Salmonella - Shigella - E.coli - Noro virus- Respiratory Infection:

- Influenza - Common cold - Resp. Syncytial virus (RSV)

- Other Infections: Hepatitis A

Communication Skills, How?-Maintain good eye contact-Active listening, then write-Encourage verbal or non verbal communication-Avoiding jargon-Ability to discuss difficult issues-Going at a place that is comfortable for the patient-Diligent and frequent practice

Introduce yourself:-I am Mr…., I am 3rd year medical student-I have been asked to talk to you and examine you with some of my colleagues-It might take 30 minutes-Privacy -Notes (it does not mean I’m not listening to you-Are you happy with all that?

Things to remember:-Never write while talking-See the patient walking-See the accompanying person (mother, wife, friend)

-Can often provide valuable information -However, many patients are inhibited from discussing their problems by the presence of third person

Guide the conversation:-Explain what you are doing, and why you are doing it, at all stages- patients know more about their complaints than you, but cannot interpret their significance:- Interpreter – short and simple questions- Leading questions - one answer- open questions- Example : Does the pain ever move?- Always ask the questions in the right way.

Principle of History taking in Surgery:

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.

History Taking• Information gathered during patient interview

Components of Patient History

- Date and Time - Chief Complaint

- Identifying data - Present illness

- Source of referral - Past medical and surgical history

- Source of history - Family History- Social History- Drug History

History TakingI. Personal Information

- Age, Sex, marital status, occupation nationality, residence, etc..

HISTORY cont..:2) Present complain:

- open question- closed question- write in patients words

Chief Complaint

• Symptoms that caused patient to seek care• Often:

• Pain• Abnormal function• Change in normal state• Unusual observation made by patient (e.g., heart palpitations)

History:3) History of present illness (Complaint)

- Provide full, clear, chronological account of symptoms

- In scientific term- Similar attacks- Determine the abnormal system

HISTORY cont..:

4) Remaining question of abnormal system

HISTORY cont.:

5) Systemic direct question:◦ it reveals the presence of other disorders

of which the patient was unaware, or thought irrelevant

◦ -ve answers are as important as +ve answers

The Alimentary System

• Appetite - Heartburn• Diet - Vomiting• Weight - Haematemesis• Teeth and Taste - Indigestion• Swallowing - Abdominal pain• Regurgitation - Defecation• Flatulence - Change of skin

Color

Respiratory System-Cough- Sputum- Haemoptysis- Dyspnea- Orthopnea- Chest pain

Cardio Vascular System- Breathlessness- Orthopnea- Paroxy swal noctural dyspnea- Pain- Palpitations- Cough and sputum- Dizziness and headaches- Ankle swelling

Urogenital system- Pain - Scrotum & urethra- Oedema - Menstruation- Thirst - Dyspareunia- Micturation - Breast- Urine –haematuria - Secondary sex character

Nervous system and musculoskeletal system

General state of health:◦ Childhood illnesses◦ Adult illnesses◦ Accident and injuries◦ Surgeries or hospitalizations

Significant Past History

Health of immediate family◦ High blood pressure, heart disease, contagious

illnesses

Potential for hereditary diseases

Family History

Marital status Occupation Residency The lesiure activities Habits (smoking, alcohol,etc) Travelled abroad.

Social History

Alcohol or drug use

Physical abuse or violence

Sexual issues

Sensitive Topics

Respect patient privacy

Be direct and firm

Avoid confrontation

Be nonjudgmental

Use appropriate language

Document carefully◦ Use patient’s words when possible

Sensitive Questions Guidelines

Silence

Overly talkative patients

Patients with multiple symptoms

Anxious patients

Special Challenges

Anger and hostility Intoxication Crying Depression Sexually attractive or seductive patients Confusing behavior or histories Limited intelligence Developmental disabilities

Special Challenges

May result from:◦ Social or cultural differences◦ Sight, speech, or hearing impairments

Attempt to find assistance to aid in communication

Barriers to Communication

Pain Lump

Commonest complains in Surgery

History of pain-The site-Onset-Duration -Severity-Nature of the pain-Progression of the pain-Relieving and exacerbation factors-Radiation and refering pain

Commonest complains in Surgery

History of a lump-Site.-Duration.-What made the patient notice the lump.-course of the lump.-Associated symptoms.-Other lumps

Commonest complains in Surgery

- QUIZ

QUESTIONS?

- THANK YOU!