History taking in surgical patients

Particulars of a patient

• Name of the patient- introduce the patient by three names.

• Age of the patient- in years. For pediatric patients can be in months, weeks or years as well.

• Sex- do not ignore as some patients are trans gender or hermaphrodites. Some disease are more prevalent in certain sex, example breast cancer is common in females.

• Residence – It’s important to know where the patient comes from because it can tell the diagnosis also. Some diseases are common in certain areas, example Schistosomiasis is common in lake zone.

• Religion- this is not so much important but if one asks its best to mention. It could help in some diagnosis. Possibly not to think of pig tape worm among Muslims.

• Hospital registration number is also important and the ward the patient is residing for easy allocation. If possible with the bed number. ( but this is not so important for you as a student in your clinical exams presentation)

A short introduction of a patient/an opening statement-

this includes mentioning the number of days the patient has stayed in the ward, if referred where is he or she referred from and a referral diagnosis if possible. ( In an exam setting you may not be able to see the file or see the referral letter so its best you end up mentioning from where he or she is referred otherwise examiners will poke your eyes). In the introduction remember mentioning if it’s a re-admission at that hospital or it’s the first one. If it’s a re-admission remember to ask for the reason of previous admission and the condition at discharge if possible get a look at the discharge summary at the file. Mention if there is any chronic illness that is known of the patient. Example known patient with HIV on regular/irregular medication for 3years now.

Main complains

this is what brought the patient to hospital. So ask the patient, what made you seek health care today? It could be that the patient has pain for the past six months, but why didn’t he come last month? So did it worsen to necessitate him or her to attend the hospital? Remember to put complains in an order from the one which begun first to the recent one. If all complains started at the same time then arrange them in the order of severity, beginning with the most severe symptom.

History of presenting illness

this is the story of the current illness. How it started, when, anything that gives a relief of the condition, anything that worsens the condition and whether there are accompanying symptoms. This helps you arrive at the diagnosis. Take an example of a patient having a swelling at the forehead. He tells you it has been there for the past two hours, grew up slowly, painful, nothing worsens it but has been massaging it and it is fading away.

It was preceded by a fist from an angry loyal citizen that hit his forehead. There you definitely know the diagnosis. The rule here is DONPARA

• D- DURATION

• O-ONSET

• N-NATURE OF THE CONDITION

• P-PERIODICITY

• A-AGGREVIATING FACTORS

• R-RELIEVING FACTORS

• A-ASSOCIATED SYMPTOMS

In the history of presenting illness we also ask for risk factors regarding the diagnosis you are thinking about, complications of the disease you are suspecting, and ask for symptoms of the disease that may mimic the disease you are suspecting to just be sure it’s not some other disease, and this is what we call ruling out other conditions. Mention if there are any efforts the patient has done regarding his illness along the course and if any interventions were done and lastly ask for the progress in the ward.

Review of other systems

there could be coexistence of other conditions despite the illness the patient has. If you have more than one pathologies, sometimes one is primary the others are secondary. So you might be dealing with renal failure only to forget this patient may have secondarily hyper parathyroidism.

Pre natal history, natal and post natal history

follows incase it’s a pediatric case. Pre natal history involves asking how many times the mother attended clinic while carrying this particular baby in her womb, what was the gestation age at her first visit and ask for any drugs given during the visits and if there was any illness like skin rash during pregnancy to just be sure she never suffered things like rubella. Natal history involves asking for mode of delivery, time of labor, was it at term or not as some conditions are common among pre term such as necrotizing enterocolitis, ask for the birth weight too in the natal history and if the baby cried and sucked immediately. Postnatal events involves the events afterwards, so ask if the baby ever got ill, jaundice or anything. These only appear in pediatric cases and are written under separate headings, don’t include all at once as I did in this paragraph.

Immunization history

this is important in pediatric cases. This can be obtained from the RCH card. Conclude if at all they are appropriate for the child’s age. If the child missed the vaccine we conclude it as “missed opportunity for vaccination”

Developmental milestones

report what the child can do and conclude if appropriate for his or her age. Example for a 9months old baby not be able to sit unsupported is delayed milestones.

Past medical history

this follows review of other systems in an adult male case, otherwise it follows after pre natal, natal, post natal, immunization and milestones history in pediatric case. For a female adult case it follows after past gynecological history and obstetric history and if pregnant history of index pregnancy. Past medical history includes any history of surgery, blood transfusion or any chronic illness. Report any illness of relevance the patient suffered in the past. Example past history of recurrent schistosomiasis could explain the bladder ca the patient has now. Any allergy to drugs or foods should be mentioned.

Family and social history

here we are interested of the conditions that run in families, if there is any social activity that is related to the patient’s illness. Example a long distance driver is at risk of HIV, smokers have a risk of lung cancer. Alcohol is a risk to liver cirrhosis.

Dietary history

mention number of meals, what he eats and amount. And has it changed since he or she became ill.

Summary of the history

remember summary is the mini skirt of the history. It should be short enough and contains important information. It should have important positives and important negatives. If one had a history of bleeding, mentioning in the summary that so and so with history of bleeding and symptoms of anemia not in failure, symptoms of anemia are important positives here. One is interested to hear did this patient bleed so much? And saying not in failure is an important negative, atleast one wants to hear has this patient gone to failure.