Case History: Introduction To The Patient

Lec 1 ‫احمد فاضل ابراهيم‬.‫د‬.‫م‬.
‫ا‬
Case History
Introduction to the Patient
History taking is a most important process and must be rehearsed well. No matter
how efficient and skilled the surgeon is, he or she must make the patient feel
confident.
hand-shake, a smile, a pleasant introduction and a caring gesture will make the
remainder of contact with the patient much easier and more pleasant.
Introduction to the patient is a most important moment, this allows a rapport to
develop with the patient that will facilitate the rest of the interview and enhance the
possibility of achieving an appropriate diagnosis and treatment plan.
Premature physical examination of a lesion may not only reduce the patient's
confidence but also unnerve the surgeon if the diagnosis is not immediately apparent
with visual examination.
History of the presenting Complaint
This is the patient's opportunity to tell the surgeon about the problem and it is
important to avoid leading questions.
many will also have difficulty in remembering the timescale of the illness. A good
initial beginning with history taking is to ask the patient to think back to the start of
the problem to ensure that he or she gives an account in chronological order. It is
also important, while the patient is giving the history, to ensure that he or she gives
a clear account of what has happened, and does not discuss what he or she thinks is
the cause of the problem.
Patients wishing to avail themselves of the best medical attention will usually wish
to please and will therefore tend to agree, using a positive response, to any direct
question asked.
This problem can be overcome by providing the patient with alternatives: 'Is the pain
constant?' is more likely to be answered accurately if the patient is asked 'Is the pain
constant or not?'.
Several features of the presenting problem should then be elicited:
• When was the problem first noted?
• What is the location?
• Are the symptoms continuous or intermittent?
• Does anything make the problem' better or worse?
• Is the problem getting better or worse?
Relevant medical history
This is the surgeon's chance to take a history from the patient. This part has two
aspects: first, the opportunity to elaborate on any points in the history that the
surgeon felt were unclear; second, to enquire from the patient any aspect of his or
her health that might otherwise influence the treatment plan.
Family history
Two main items are worth enquiring regarding family history:
(1) is there a genetic family problem, especially any blood-related problem such as
haemophilia?
(2) has any member of the family had any problem with anaesthetics,
Drug therapy
As outlined above, it is critical to know about certain drugs prior to performing any
surgery. Dosage of corticosteroids and anticoagulants need to be controlled and
monitored carefully.
Social history
Knowledge of tobacco smoking and alcohol consumption will not only inform the
surgeon of the potential risks for general anesthesia and surgery but also the patient's
likelihood of smoking- and alcohol-related diseases
Allergies
A history of asthma and anaphylaxis is important. The surgeon must know about
drug allergies
Common surgical symptoms
Pain
Pain anywhere should have the same features elicited. These can be summarized by
the acronym SOCRATES.
• Site. Where is the pain, is it localized, in a region, or generalized?
• Onset. Gradual, rapid, or sudden? Intermittent or constant?
• Character. Sharp, stabbing, dull, aching, tight, sore?
• Radiation. Does it spread to other areas? (From loin to groin in ureteric pain, to
shoulder tip in diaphragmatic irritation, to back in retroperitoneal pain, to jaw and
neck in myocardial pain.)
• Associated symptoms. Nausea, vomiting, dysuria, jaundice?
• Timing. Does it occur at any particular time?
• Exacerbating or relieving factors. Worse with deep breathing, moving, or coughing
suggests irritation of somatic nerves either in the pleura or peritoneum; relief with
hot water bottles suggests deep inflammatory or infiltrative pain.
• Surgical history. Does the pain relate to surgical interventions?
Terms used in General Surgery and History Taking
Dyspepsia (epigastric discomfort or pain, usually after eating) What is the

frequency? Is it always precipitated by food or is it spontaneous in onset? Is there
any relief, especially with milky drinks or food? Is it positional?
Dysphagia (difficulty during swallowing) Is the symptom new or longstanding?

Is it rapidly worsening or relatively constant? Is it worse with solid food or fluids?
(Worse with fluids suggests a motility problem, rather than a stenosis.)
Oesophageal reflux (bitter or acidic tasting fluid in the pharynx or mouth) How
frequently? What colour is it? (Green suggests bile whereas white suggests only
stomach contents). When does it occur (lying only, on bending, spontaneously when
standing)? Is it associated with coughing?
Haematemesis (the presence of blood in vomit) What colour is the blood (dark red-
brown ‘coffee grounds’ is old or small-volume stomach bleeding; dark red may be
venous from the oesophagus; bright red is arterial and often from major gastric or
duodenal arterial bleeding)?
Bleeding per rectum What colour is the blood? Is it pink-red and only on the paper
when wiping? Does it splash in the pan? (Both suggest a case from the anal canal.)
Is it bright red on the surface of the stool (suggests a lower rectal cause)? Is the blood
darker with clots or marbled into the stools (suggests a colonic cause)? Is the blood
fully mixed with the stool or altered (suggests a proximal colonic cause)?
Haematuria (blood in the urine) Does the blood occur at the start (suggests bladder
origin), during, or end (suggests prostatic or penile origin) of the stream? Is there
associated pain (suggests infection or stone disease)?
Dyspnoea (difficulty in or increased awareness of breathing) When does the

dyspnoea occur—quantify the amount of effort. Is it positional?
• Orthopnoea. Difficulty in breathing that occurs on lying flat; quantify it by asking

how many pillows the patient needs at night to remain symptom-free.
• Paroxysmal nocturnal dyspnoea. Intermittent breathlessness at night. Both

orthopnoea and paroxysmal nocturnal dyspnoea suggest cardiac failure.

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Lec 1 ‫احمد فاضل ابراهيم‬.‫د‬.‫م‬.

Terms used in General Surgery and History Taking

Dyspepsia (epigastric discomfort or pain, usually after eating) What is the

Dysphagia (difficulty during swallowing) Is the symptom new or longstanding?

Dyspnoea (difficulty in or increased awareness of breathing) When does the

• Orthopnoea. Difficulty in breathing that occurs on lying flat; quantify it by asking

• Paroxysmal nocturnal dyspnoea. Intermittent breathlessness at night. Both

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