University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage The History MA MURPHY FRCSI

University of Dublin Trinity College Back to Department of Surgery Homepage

The History

MA MURPHY FRCSI


Lesson Objectives

• To take a history eliciting all of the relevant

facts

• To present a history to an examiner in a

satisfactory manner


Contribution to Diagnoses

HISTORYEXAMINATIONINVESTIGATION


History Taking - Your Objectives

• To elicit the pertinent facts from the patients

symptoms in relation to the illness;

• To derive a differential diagnoses,

• To elicit risk factors and significant co-morbid

pathologies



• To demonstrate compassion to the patient



• To present the history to the examiner in a

clear and sequential fashion


The Presenting Complaint

• The symptom for which the patient first sought

medical advice.

• Elicited by asking;

– “what made you come to hospital / consult

your doctor on this occasion.”


The Presenting Complaint

• When a patient gives a multitude of

complaints;

– which was the worst or most worrying?

– The presenting complaint is often

associated with other symptoms.


History of presenting complaint

• When did you last feel quite well?

• Full description of presenting complaint

• Associated features

• Have you ever suffered from this before?

• Systems review of the relevant system(s)


The presenting complaint

• The most common presenting complaint in

surgical practice is a pain.


Questions to ask about Pain

• Ryle’s 10 questions

• SOCRATES questions



• How, when did it start, how long did it last?

• How bad was it?

• Where was it felt?

• Did it radiate?

• Did it change, move?

• Any associated features?



• Did anything make it better or worse?

• What was the character (dull/sharp)?

• Was it constant or colicky?

• Any associated features?

• How did it end?

• What do you think caused it ?

• Anything else?


A Presenting Complaint• Mrs X presented with a sharp1, severe2 pain in her

right upper quadrant3 of seven hours duration4.

• The pain was constant5 in nature and radiated around into her back6. The pain started suddenly7 1 hour after eating8 and was associated with vomiting9 on three occasions10. The pain was aggravated by movement11 and relieved by lying still12. She had suffered from a similar but less severe pain 3 months ago.13. She had no other gastro-intestinal symptoms.14.


Common Presenting Complaints

– A lump, mole or skin ulcer

– Bleeding

– System specific symptoms

• altered bowel habit, dysphagia

• urinary frequency

– Generalized symptoms

• fever, lassitude, weight loss


Questions to Ask About a Lump

• How long has it been present ?

• What made you first notice it ?

• Has it changed ?

• Is it painful ?

• Any associated features ?

• What do you think caused it ?


Questions to Ask About Bleeding

• Site (PR, PV, PU, Haematemesis, Haemoptysis)

• Duration

• Frequency

• Amount

• Type (Black, Bright red)



Generalized Symptoms

• Duration

• Frequency

• Severity


• Full systems review

• Preceding events (when did you last feel quite well ?)


The Systems Review

• General well-being

• Energy

• Appetite

• Fever

• Sweating

• Mood


Gastrointestinal Review

• Appetite

• Taste

• Swallowing

• Heartburn

• Vomiting


Gastrointestinal Review

• Bloating/ belching

• Abdominal pain/ discomfort

• Post-prandial symptoms

• Bowel habit

• Change in bowel motion smell, colour,

consistency, blood or mucous


Cardio-respiratory review

• Chest pain

• Palpitations

• Breathlessness (dyspnoea)

• Cough - sputum

• Ankle swelling

• Exertional symptoms


Urogenital review

• Loin/ groin pain

• Micturation

– dysuria

– urgency, frequency, nocturia

– hesitancy, stream, dribbling

– haematuria, pneumaturia

– change in colour/ smell of urine


Gynaecological review

• Menses

• Pregnancy

• PV discharge

• Post-menopausal bleeding

• Contraception

• Dyspareunia

• Obstetric history


Neurological review

• Loss of consciousness/ fits

• Loss/ blurring of vision/ speech

• Loss of power

• Loss of balance

• Parasthesia

• Headache

• Tremor

• Behavior/ mood


Orthopaedic review

• Limb pain

• Joint pain

• Limitation of movement

• Weakness

• Disturbance of gait


Vascular review

• Neurological symtoms

• Abdominal back pain swelling

• Claudication

• Limb pain

• Colour change

• Pigmentation

• Limb temperature


Past medical History

• Operations

– when, where for what

• Hospital admissions


• Medications


• Drug allergies


Family history

• Emphasize 1ST Degree relatives

• Cancer history important

• Family illness may have effect on patients

interpretation of their own symptoms and their

psychological response to illness


Social History

• Hygiene ?

• Lives alone ?

• Health of partner ?

• Family support ?

• Community support ?

• Smoking habit ?

• Alcohol/ substance abuse ?


Specific Risk Factors

• Occupation (eg Asbestos exposure)

• Residence (eg hygiene, infection)

• Foreign travel

• Animal exposure


Direct Questions

• Diabetes

• Asthma

• Jaundice

• Rheumatic fever/ TB

• Hypertension

• Epilepsy

• CVA/ MI


The Differential Diagnoses

• Occams razor


William of Oakham (“Occam”)


Occams’ Razor

• one should not increase,

beyond what is necessary, the

number of entities required to

explain anything


The Differential Diagnoses

• List the most likely or most important

differential first

• List at least two possible differentials

• Mention rare diagnoses last

• List non-organic (supratentorial origins) after

organic diagnoses


Interpretation of Abdominal Pain


Summary

• In the summary one should try to piece

together all of the relevant facts along

with significant negatives to present a

concise account of the patients

symptoms and allow formulation of a

differential diagnoses


Special Types of History

• The trauma patient

• The unconscious patient

• The demented patient

• Patients following investigation and treatment


Presenting a History

• Look smart

• Speak clearly

• Present in a logical and sequential manner

• Mention important negatives

• Don’t dwell on irrelevancies

• Try not to use notes



• Presenting complaint

• History of Presenting complaint

• Systems review

• Past history

• Drugs and allergies

• Family history

• Social history

• Summary



• Begin with “I would like to present the case

of…”

• Mention patients age and sex and any

occupation or underlying medical condition

which is of relevance to the case.



• Describe clearly the presenting complaint and

when and how (elective/emergency) the

patient presented

• the presenting complaint may be described in

the patients own words by saying “who

presented with what she described as”


The presenting complaint is the most important part of the surgical history



• The history of the presenting complaint includes;

– a full description of the symptom

– associated symptoms with full description and relation to PC

– previous episodes

– relevant systems review

– when he/she last felt well



• Go through systems reviews emphasizing any

positive findings and relevant negatives



• Past medical history

– mention relevant operations, conditions, investigations first

• List important negatives e.g. diabetes

• List medications

– when and why started

• Allergies



• Family history

– emphasize first degree relatives

– cancer history important

• Social history

– hygiene

– lives alone, health of partner

– family support



• Summarize

– presenting complaint its history

– other relevant findings

• Differential Diagnoses

– most likely and most important

– what to look for examination

– investigations


Get the presenting complaint right

Documents

University of Dublin Trinity College Back to Department of Surgery HomepageBack to Department of Surgery Homepage The History MA MURPHY FRCSI