University of Dublin Trinity College Back to Department of Surgery Homepage

The History

MA MURPHY FRCSI

University of Dublin Trinity College Back to Department of Surgery Homepage

Lesson Objectives
To take a history eliciting all of the relevant
facts

To present a history to an examiner in a

satisfactory manner

University of Dublin Trinity College Back to Department of Surgery Homepage

Contribution to Diagnoses

HISTORY
EXAMINATION
INVESTIGATION

University of Dublin Trinity College Back to Department of Surgery Homepage

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

University of Dublin Trinity College Back to Department of Surgery Homepage

History Taking - Your Objectives

To demonstrate compassion to the patient

University of Dublin Trinity College Back to Department of Surgery Homepage

History Taking - Your Objectives

To present the history to the examiner in a

clear and sequential fashion

University of Dublin Trinity College Back to Department of Surgery Homepage

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.

University of Dublin Trinity College Back to Department of Surgery Homepage

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.

University of Dublin Trinity College Back to Department of Surgery Homepage

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)

University of Dublin Trinity College Back to Department of Surgery Homepage

The presenting complaint

The most common presenting complaint in
surgical practice is a pain.

University of Dublin Trinity College Back to Department of Surgery Homepage

Questions to ask about Pain

Ryles 10 questions

SOCRATES questions

University of Dublin Trinity College Back to Department of Surgery Homepage

Questions to ask about Pain

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?

University of Dublin Trinity College Back to Department of Surgery Homepage

Questions to ask about Pain

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?

University of Dublin Trinity College Back to Department of Surgery Homepage

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.

University of Dublin Trinity College Back to Department of Surgery Homepage

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

University of Dublin Trinity College Back to Department of Surgery Homepage

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 ?

University of Dublin Trinity College Back to Department of Surgery Homepage

Questions to Ask About Bleeding

Site (PR, PV, PU, Haematemesis, Haemoptysis)
Duration
Frequency
Amount
Type (Black, Bright red)
Associated features

University of Dublin Trinity College Back to Department of Surgery Homepage

Generalized Symptoms
Duration
Frequency
Severity
Associated features
Full systems review
Preceding events (when did you last feel quite
well ?)

University of Dublin Trinity College Back to Department of Surgery Homepage

The Systems Review

General well-being
Energy
Appetite
Fever
Sweating
Mood

University of Dublin Trinity College Back to Department of Surgery Homepage

Gastrointestinal Review
Appetite
Taste
Swallowing
Heartburn
Vomiting

University of Dublin Trinity College Back to Department of Surgery Homepage

Gastrointestinal Review
Bloating/ belching
Abdominal pain/ discomfort
Post-prandial symptoms
Bowel habit
Change in bowel motion smell, colour,
consistency, blood or mucous

University of Dublin Trinity College Back to Department of Surgery Homepage

Cardio-respiratory review
Chest pain
Palpitations
Breathlessness (dyspnoea)
Cough - sputum
Ankle swelling
Exertional symptoms

University of Dublin Trinity College Back to Department of Surgery Homepage

Urogenital review
Loin/ groin pain
Micturation
dysuria
urgency, frequency, nocturia
hesitancy, stream, dribbling
haematuria, pneumaturia
change in colour/ smell of urine

University of Dublin Trinity College Back to Department of Surgery Homepage

Gynaecological review
Menses
Pregnancy
PV discharge
Post-menopausal bleeding
Contraception
Dyspareunia
Obstetric history

University of Dublin Trinity College Back to Department of Surgery Homepage

Neurological review
Loss of consciousness/ fits
Loss/ blurring of vision/ speech
Loss of power
Loss of balance
Parasthesia
Headache
Tremor
Behavior/ mood

University of Dublin Trinity College Back to Department of Surgery Homepage

Orthopaedic review
Limb pain
Joint pain
Limitation of movement
Weakness
Disturbance of gait

University of Dublin Trinity College Back to Department of Surgery Homepage

Vascular review
Neurological symtoms
Abdominal back pain swelling
Claudication
Limb pain
Colour change
Pigmentation
Limb temperature

University of Dublin Trinity College Back to Department of Surgery Homepage

Past medical History

Operations
when, where for what
Hospital admissions
when, where for what
Medications
when, where for what
Drug allergies

University of Dublin Trinity College Back to Department of Surgery Homepage

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

University of Dublin Trinity College Back to Department of Surgery Homepage

Social History
Hygiene ?
Lives alone ?
Health of partner ?
Family support ?
Community support ?
Smoking habit ?
Alcohol/ substance abuse ?

University of Dublin Trinity College Back to Department of Surgery Homepage

Specific Risk Factors

Occupation (eg Asbestos exposure)
Residence (eg hygiene, infection)
Foreign travel
Animal exposure

University of Dublin Trinity College Back to Department of Surgery Homepage

Direct Questions
Diabetes
Asthma
Jaundice
Rheumatic fever/ TB
Hypertension
Epilepsy
CVA/ MI

University of Dublin Trinity College Back to Department of Surgery Homepage

The Differential Diagnoses

Occams razor

University of Dublin Trinity College Back to Department of Surgery Homepage

William of Oakham (Occam)

University of Dublin Trinity College Back to Department of Surgery Homepage

Occams Razor
one should not increase,
beyond what is necessary, the
number of entities required to
explain anything

University of Dublin Trinity College Back to Department of Surgery Homepage

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

University of Dublin Trinity College Back to Department of Surgery Homepage

Interpretation of Abdominal Pain

University of Dublin Trinity College Back to Department of Surgery Homepage

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

University of Dublin Trinity College Back to Department of Surgery Homepage

Special Types of History

The trauma patient
The unconscious patient
The demented patient
Patients following investigation and treatment

University of Dublin Trinity College Back to Department of Surgery Homepage

Presenting a History
Look smart
Speak clearly
Present in a logical and sequential manner
Mention important negatives
Dont dwell on irrelevancies
Try not to use notes

University of Dublin Trinity College Back to Department of Surgery Homepage

Presenting a History
Presenting complaint
History of Presenting complaint
Systems review
Past history
Drugs and allergies
Family history
Social history
Summary

University of Dublin Trinity College Back to Department of Surgery Homepage

Presenting a History
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.

University of Dublin Trinity College Back to Department of Surgery Homepage

Presenting a History
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

University of Dublin Trinity College Back to Department of Surgery Homepage

The presenting complaint is the most

important part of the surgical history

University of Dublin Trinity College Back to Department of Surgery Homepage

Presenting a 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

University of Dublin Trinity College Back to Department of Surgery Homepage

Presenting a History
Go through systems reviews emphasizing any
positive findings and relevant negatives

University of Dublin Trinity College Back to Department of Surgery Homepage

Presenting a History
Past medical history
mention relevant operations, conditions,
investigations first
List important negatives e.g. diabetes
List medications
when and why started
Allergies

University of Dublin Trinity College Back to Department of Surgery Homepage

Presenting a History
Family history
emphasize first degree relatives
cancer history important
Social history
hygiene
lives alone, health of partner
family support

University of Dublin Trinity College Back to Department of Surgery Homepage

Presenting a History
Summarize
presenting complaint its history
other relevant findings
Differential Diagnoses
most likely and most important
what to look for examination
investigations

University of Dublin Trinity College Back to Department of Surgery Homepage

Get the presenting complaint right