Patient-Doctor relationPatient-Doctor relationThe way to reach the Diagnosis The way to reach the Diagnosis

History Taking History Taking

Dr. Abdelmoniem EltraifiConsultant Urologist & Clinical Ass. Professor

Be ready; prepare you self to be Be ready; prepare you self to be a good doctora good doctor

Your look is importantYour look is importantYour dressing Your dressing

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 cubicleSee him walking in and not in the cubicleAllow his relative to be there if the patient wantsAllow his relative to be there if the patient wants..

Introduce your self Introduce your self

Be alert and pay him full attentionBe alert and pay him full attention

History Taking in SurgeryHistory Taking in Surgery

There is no difference between medical and surgical history. They are almost the same.

HistoryHistoryPersonal Data ( Patient Demography)

• Date and Time• Name & File number ( Medical record number)• Age• Sex• Religion• Marital status• Occupation• Residency• Who gave the history?

Chief ComplaintChief ComplaintMain Complaint Main Complaint

Complain Of ( C/O) Complain Of ( C/O)

You should write the patient own words.

If there is more than one complaint, it should be written according to:

1. Occurrence.

2. Most bothersome.

History of the presenting Symptom ( Illness)History of the presenting Symptom ( Illness)

Elaborate the symptom.Elaborate the system involved.What had been done for the patient?

Past HistoryPast History

Dm, Hypertension Bronchial Asthma Bleeding disorders & Sickle cell disease TB, Syphilis, Bilharzias Passage of stones Blood transfusion Operations, Trauma

Family HistoryFamily History

Similar conditions Parents and close relatives cause of

death and serious illnesses. DM, Hypertension Bleeding Disorders& Sickle cell disease Ca Prostate ( others)

Systemic ReviewSystemic ReviewSystematic Direct QuestionsSystematic 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 SystemNervous 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 & CardiovascularRespiratory & 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 & AbdomenAlimentary & Abdomen Appetite Diet Taste Swallowing Regurgitation Vomiting Indigestion Haematemses Abdominal pain Abdominal Distension Bowel habit Stool Jaundice

Urogenital SystemUrogenital System Loin pain Symptoms of uremia

1. Headache

2. Drowsiness

3. Fits

4. Visual disturbances

5. Vomiting

6. Oedema of ankles, hands of face Lower urinary tract symptoms ( LUTS) Painful micturirtion Polyuria Color of urine Hematuria Male Infertility history Sexual problems history

Musculoskeletal SystemMusculoskeletal 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 symptomsCommon symptomsPain1. Site

2. Duration

3. Mode of onset

4. Severity

5. Nature ( Character)

6. Progression of pain

7. The end of pain

8. Relieving factors

9. Exaggerating (Exacerbating) factors

10.Radiation

11.Cause

History of a lump or an ulcerHistory of a lump or an ulcer

Duration ( when was the first time noticed)First symptom ( how the patient noticed it)Other symptomsProgression ( change since notice)Persistence ( has it ever disappear or healed)Any other lumps or ulcersCause

An Example of classical History An Example of classical History takingtaking

HematuriaHematuria

Classical history of hematuriaClassical 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 himself?

c/o blood in urine for 5 daysc/o blood in urine for 5 days

History of present illnessHistory of present illness

He was well, tell five days ago, when he noticed blood in his urine.

The haematuria 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 haematuria 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 CT urogrophy for him.

Past HistoryPast 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 STD No History of DM, or Hypertension, bronchial asthma, and no known

allergy.

Family HistoryFamily History

No family history of similar episode. Parents are dead ( unknown cause of death). No family History of; SCD, or other hematological disorder. No family history of; cancer prostate, or other renal disease No family history of DM, or hypertension

Systemic ReviewSystemic ReviewSystematic Direct QuestionsSystematic Direct Questions

No Fever, or loss of weight.Ask him- here about all the other systems.Exclude urinary tract, as its should be

finished already, in the section of history of the present illness.

Negative symptoms: are as important as positive one

Social History & HabitsSocial History & Habits

Married to one wife, with Three-female and two-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 himself to rivers , ponds, or canal 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 Drug History and allergy

He is not taking anti-coagulants, or any other drugs. No know allergy to any medication.

Example of short history Example of short history taking for the OSCE Examtaking for the OSCE Exam

Ask directly about the patient presenting Ask directly about the patient presenting symptom.symptom.

Ask related Questions only.Ask related Questions only.

Age Residency. Duration. Occupation Painless or painful Timing of Haematuria Amount of bleeding ( darkness of the color, an presence of clots) Shape of clots Trauma Bleeding from other sites Associated urinary, and Systemic Symptoms Bleeding disorders, SC, TB, Bilharzias & stone disease. Family History of Malignancy, Renal, or hematological disorders. Drugs Red colored food or drinks.

Smoking

Example: History of HematuriaExample: History of Hematuria