Patient-Doctor relationHistory Taking Dr. Abdelmoniem Eltraifi Consultant Urologist & Clinical Ass. Professor
The patient should be a friend or like a friend Always think of his condition and not yours
See him walking in and not in the cubicleAllow his relative to be there if the patient wants.
History Taking in Surgery There is no difference between medical and surgical history. They are the same.
History • Personal Data ( Patient Demography) • Date and Time • Name & File number ( Medical record number) • Age • Sex • Religion • Marital status • Occupation • Residency • Who gave the history?
History of the presenting Symptom ( Illness) • Elaborate the symptom. • Elaborate the system involved. • What had been done for the patient?
Past History • Dm, Hypertension • Bronchial Asthma • Bleeding disorders & Sickle cell disease • TB, Syphilis, Bilharzias • Passage of stones • Blood transfusion • Operations, Trauma
Family History • Similar conditions • Parents and close relatives cause of death and serious illnesses. • DM, Hypertension • Bleeding Disorders& Sickle cell disease • Ca Prostate ( others)
Systemic ReviewSystematic Direct Questions • Negative symptoms are as important as positive one. • You have to ask about them all, and keep repeat them in each patient, to memorize them well.
Fever weight loss
Nervous System Nervousness Excitability Tremor Fainting attacks Blackout Fits Loss of consciousness Muscle weakness Paralysis Sensory disturbances Paraesthesiae Changes of smell, Vision or hearing Headaches Change of behavior
Respiratory & Cardiovascular Cough Sputum Haemoptysis Dyspnoea Hoarseness Wheezing Tachypnoea Chest pain Paroxysmal nocturnal dyspnoea Orthopnea Palpations Dizziness Ankle swelling Pain in limbs Walking distance Temperature and color of hands and feet
Alimentary & Abdomen Appetite Diet Taste Swallowing Regurgitation Vomiting Indigestion Vomiting Haematemses Abdominal pain Abdominal Distension Bowel habit Stool Jaundice
Urogenital System • Loin pain • Symptoms of uremia • Headache • Drowsiness • Fits • Visual disturbances • Vomiting • Oedema of ankles, hands or face • Lower urinary tract symptoms ( LUTS) • Painful micturirtion • Polyuria • Color of urine • Hematuria • Male Infertility history • Sexual problems history
Musculoskeletal System Aches or Pain in muscles, bones and joints Swelling of joints limitation of joints movements Weakness Disturbance of gait
Social History & Habits • Detailed marital status • Living accommodation • Occupation • Travel abroad • Leisure activity • Smoking • Drinking • Eating habits
Drug History and allergy The drugs the patient taking specially: Insulin, Steroids and contraceptive pills Allergy to any medications
Common symptoms Pain Site Time & mode of onset Duration Severity Nature ( Character) Progression of pain The end of pain Relieving factors Exaggerating (Exacerbating) factors Radiation Cause
History of a lump or an ulcer Duration ( when was the first time noticed) First symptom ( how the patient noticed it) Other symptoms Progression ( change since notice) Persistence ( has it ever disappear or healed) Any other lumps or ulcers Cause
Pre-renal Hematuria Renal Post-renal
Classical history of hematuria • Patient demography • Date and Time= 13/9/2001 at 10 am • Khalid Alotibi File number 12-30-00 • 47 years old • male • Muslim • Married • Teacher • Living Riyadh, before in Hail • History given by the patient him self?
History of present illness He was well tell 5 days ago, when he noticed blood in his urine. The hematuria is episodic, most of the time when ever he is passing urine. The urine color is dark red. He noticed blood clots in the urine, rounded in shape. He had no pain. The hematuria is total through out all his urine. No history of trauma, no ingestion of red colored food or drink. No bleeding from other sites of his body. Finish all urinary tract system symptoms in this part. They inserted for him, 3 ways urethral Folly catheter, and they did continuous bladder irrigation, and he just finished taking X-ray films for him.
Past History No history of similar episode. No history of hematological congenital disease No history of pulmonary Tuberculosis No history of stone disease No history of operations or RTA No history of BA No history STD No History of DM, or Hypertension
Family History No family history of similar episode Parents are dead ( doesn't know the cause of death) No family History of SCD or other hematological disorder No family history of cancer prostate or renal disease No family history of DM or hypertension
Systemic ReviewSystematic Direct Questions No Fever, or loss of weight. Ask here about all the other systems. Exclude urinary tract, as its should be finished with the history of the present illness. Negative symptoms are as important as positive one
Social History & Habits Married to one wife with 3 female and 2 male children Living in his own villa, with good facilities Working as a higher school teacher and had other personal business with good income. Not smoker, but he had other colleague teachers , who are smoking in the office He used to travel in summer with his family to other countries: Egypt, Turkey, Syria and once to Malaysia. Never exposed him self to rivers , ponds or canals water. Never drinks alcohol His leisure are: reading news papers and watching TV only. He used to eat ordinary Saudi food.
Drug History and allergy He is not taking anti-coagulants or any drugs. No know allergy to any medication.
Example of short history taking for the OSCE Exam Ask directly about the patient presenting symptom. Ask related Questions only.
Example: History of Hematuria • Age • Residency. • Duration. • Occupation • Painless or painful • Timing of Hematuria • Amount of bleeding • Clots and shape of clots • Trauma • Bleeding from other sites • Associated Symptoms urinary and Systemic • Bleeding disorders, SC, TB, Bilharzias & stone disease. • Family History of Malignancy or hematological disorders. • Drugs • Colored food or drinks. • Smoking