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Principles of History Taking in Surgery

351 Surg
by

abdullah kattan

on 10 September 2012

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Transcript of Principles of History Taking in Surgery

Principles of History Taking in Surgery
351 Surgery
Dr. Abdulalh Kattan

A proper history and physical exam
will get you to your diagnosis
almost 70% of the time Name, age,occupation
History of chief complaint
Past Medical History
Past Surgical History
Medications/tetanus
Allergies
Smoking
Review of systems Pain:
Site
Time and mode of onsent, duration
Nature of pain (sharp, dull, stabbing, aching, burning)
Pattern of pain attack (continuous, intermittent)
Radiation
Severity ( scale from 1 - 10 )
Aggravating and releaving factors Chief Complaint (Reason for Referral RFR):
What?
Why?
Where?
When?
How? Lump/mass/ulcer:
Location
How/when did you notice it
Change in size/color of skin
Pain
Discharge or bleeding
Affecting function or daily activities
Any other ones? Constitutional symptoms:
Weight loss/gain
Fever/night sweats
Loss of appetite
Any similar symptoms in other
areas of the body or in the past Past Medical History:
Do you have any other/chronic medical problems?
Do you have diabetes, high cholesterol, high blood pressure, asthma?
Is it controlled?
Have you been hospitalized for this problem?
What medicatinos are you on? Past Surgical History:
Have you had any operations in the past?
what? when? where was it done?
any complications?
(infection, wound healing,recurrences) Pregnancy:
Are you/Could you be pregnant? What medications are you taking?
inhalers (for asthma)
oral contraceptives
blood thinners (aspirin or warfarin)
When was your last tetanus vaccine?
usually given every 10 years
important question in trauma Allergies:
Do you know if you are allergic to any medications?
How did you find out?
What happens if you take that
medication?
What do you do if you get a allergic reaction? Smoking:
Do you smoke?
What do you smoke?
How much/day?
When did you start? Review of Systems:
GI
Resp
Cardiovascular
Urogenital
Nervous
Musckuloskelital ID (name, age, gender, occupation)
RFR (chief complaint with date of admission or date of complaint-in the patient's words)
HPI (history of presenting illness)
PMH,PSH,Meds,Allergies
Review of systems Putting it all together (Presenting) Review of system involved Summary:

3-4 lines
ID, chief complaint + HPI
Relevant information from review of systems (positive or negative) Questions? www.prezi.com
Full transcript