Introduction to History Taking PDF

Introduction to history Presented by taking Assistant professor Dr. Ali Al-najjar...

Introduction to history Presented by taking Assistant professor Dr. Ali Al-najjar General Surgeon The First & The Only Franchise in the Iraq 1  OBJECTIVES At the end of the lecture the students should be able to: Know the importance of history taking. Ask the systematic direct questions Identify the features of a pain that must be elicited and recorded. Know how to write the history of a lump or an ulcer. Why we are teaching you general surgery and you are dentists? The First & The Only Franchise in the Iraq You want to do tooth extraction to this patient but you saw his eyes were yellow What to Do???? Loading… The First & The Only Franchise in the Iraq Another patient still bleeding after tooth extraction What to Do???? The First & The Only Franchise in the Iraq Another patient still bleeding after tooth extraction What to Do???? You change the cotton piece but still bleeding You put adrenaline but still bleeding Loading… Now what to Do????? The First & The Only Franchise in the Iraq SO You must ask the patient some questions before you do any thing to him Like are you hypertensive, Diabetic, any blood diseases or bleeding tendency Do you infected by viral hepatitis, are you alcoholic These questions we call them History taking The First & The Only Franchise in the Iraq  History Names; taking:- date of birth; sex; marital status; occupation. Present complaints or problems (PC, CO) Preferably in the patient’s own words. History of present complaint (HPC) Include the answers to the direct questions concerning the system of the presenting complaint. The First & The Only Franchise in the Iraq  Systematic direct questions (a) Alimentary system and abdomen (AS) Appetite. Diet. Weight. Nausea. Dysphagia. Regurgitation. Flatulence. Heartburn. Vomiting. Hematemesis. Indigestion pain. Abdominal pain. Abdominal distension. Bowel habit. Nature of stool. Rectal bleeding. Mucus. Slime. Prolapse. Incontinence. Tenesmus. Jaundice. The First & The Only Franchise in the Iraq  (b) Respiratory system (RS) Cough. Sputum. Haemoptysis. Dyspnoea. Hoarseness. Wheezing. Chest pain. Exercise tolerance. (c) Cardiovascular system (CVS) Dyspnoea. Paroxysmal nocturnal dyspnoea. Orthopnoea. Chest pain. Palpitations. Dizziness. Ankle swelling. Limb pain. Walking distance. Colour changes in hands and feet. The First & The Only Franchise in the Iraq  (d) Urogenital system (UGS) Loin pain. Frequency of micturition including nocturnal frequency. Poor stream. Dribbling. Hesitancy. Dysuria. Urgency. Precipitancy. Painful micturition. Polyuria. Thirst. Hematuria. Iincontinence. In men Problems with sexual intercourse and impotence. In women Date of menarche or menopause. Frequency. Quantity and duration of menstruation. Vaginal discharge. Dysmenorrhoea. Dyspareunia. Previous pregnancies and their complications. Prolapse. Urinary incontinence. Breast pain. Nipple discharge. Lumps. Skin changes. The First & The Only Franchise in the Iraq  (e) Nervous system (NS, CNS) Changes of behaviour or psyche Depression. Memory loss. Delusions. Anxiety. Tremor. Syncopal attacks. Loss of consciousness. Fits. Muscle weakness. Paralysis. Sensory disturbances. Loading… Paraesthesiae. Dizziness. Changes of smell, vision or hearing. Tinnitus. Headaches. The First & The Only Franchise in the Iraq  (f) Musculoskeletal system (MSkS) Aches or pains in muscles, bones or joints. Swelling joints. Limitation of joint movements. Locking. Weakness. Disturbances of gait. The First & The Only Franchise in the Iraq  Previous history (PH) Previous illnesses. Operations or accidents. Diabetes. Rheumatic fever. Diphtheria. Bleeding tendencies. Asthma. Hay fever. Allergies. Tuberculosis. Syphilis. Gonorrhoea. Tropical diseases. The First & The Only Franchise in the Iraq  Drug history Insulin. Steroids. Anti-depressants and the contraceptive pill. Drug abuse. Immunizations BCG. Diphtheria. Tetanus. Typhoid. Whooping cough. Measles. Family history (FH) Causes of death of close relatives. Familial illnesses in siblings and offspring. Social history (SH) Marital status. Sexual habits. Living accommodation. Occupation. Exposure to industrial hazards. Travel abroad. Leisure activities. Habits Smoking. Drinking. Number of cigarettes smoked per day. Units of alcohol drunk per week. The First & The Only Franchise in the Iraq  The features of a pain that must be elicited Site,and recorded Time and mode of onset Record the time and date of onset and the way the pain began – suddenly or gradually. Duration:-Record the duration of the pain. Severity:-Assess severity by its effect on the patient. Nature/character Aching, burning, stabbing, constricting, throbbing, distending, colic. Radiation Record the time and direction of any radiation of the pain; remember to ask if the The First & The Only Franchise in the Iraq nature of the pain changed at the time it moved.  Referral Was the pain experienced anywhere else? Progression Describe the progression of the pain. Did it change or alter? The end of the pain Describe how the pain ended. Was the end spontaneous or brought about by some action by the patient or doctor? Relieving and exacerbating factors Cause Note the patient’s opinion of the cause of the pain. The First & The Only Franchise in the Iraq  The history of a lump Duration :-When was it first noticed? or an ulcer First symptom :-What brought it to the patient’s notice? Other symptoms:-What symptoms does it cause? Progression:-How has it changed since it was first noticed? Persistence:-Has it ever disappeared or healed? Multiplicity:-Has (or had) the patient any other lumps or ulcers? Cause:-What does the patient think caused it? Remember the four basic techniques Inspection Palpation The First & The Only Franchise in the Iraq  The examination of a lump or ulcer Local examination fluid thrill } Solid, fluid, gas Site, Size translucence, resonance pulsatility Shape, Surface compressibility } Vascular Depth bruit, Reducibility Relations to surrounding structures Colour, Temperature ,mobility/fixity Tenderness Regional lymph glands State of local tissues: Edge arteries, nerves Composition: bones and joints The First & The Only Franchise in the Iraq  consistence Why we are teaching you general surgery and you are dentists? The First & The Only Franchise in the Iraq  Because:- The First & The Only Franchise in the Iraq  1-The principles of surgery are the same in oral surgery & general surgery 2-The preoperative assessments and preparations for surgery are the same 3-Oral manifestations may indicates systemic diseases like Peutz-Jeghers syndrome 4-Systemic diseases may affects oral cavity like GERD, malnutrition, diabetes, HIV/ AIDS. Dental professionals can be the first to identify these oral manifestations and make early referrals to the appropriate health professionals 5-Dentists must know surgical systemic diseases like DU, Goiter, lymphadenopathy…..etc 6-Dentists are doctors but specialized in oral cavity. The First & The Only Franchise in the Iraq  In general surgery the first step must be Taking history Like name, age, sex…..etc. then ask about the chief complaint (means why patient coming to see the doctor) After that must do general examination Start with:- General appearance (inspection) of the patient, look to the hands, eyes, face, mouth Then neck ,chest, abdomen …etc. The First & The Only Franchise in the Iraq The First & The Only Franchise in the Iraq HANDS Nails Nail clubbing, is a deformity of the finger or toe nails associated with a number of diseases, mostly of the heart and lungs Koilonychia is indented nails. Instead of growing straight, your nails look concave, like spoons. is a sign of iron deficiency The First & The Only Franchise in the Iraq  Leuconychia or white nails HANDS Palmar erythema Dupuytren’s contractures Red hand because of alcoholic liver Congenital or liver disease cirrhosis or pregnancy The First & The Only Franchise in the Iraq  Sclera: FACE, EYES … jaundice, Conjunctival pallor Jaundice a condition in which the skin and the whites of the eyes become yellow due to (anaemia) a increase bilirubin level in the blood sign of iron deficiency The First & The Only Franchise in the Iraq  MOUTH Breath (fetor hepaticus) signs of liver disease, Acetone smell sign of ketosis Lips Peutz-Jeghers syndrome Gums Gingivitis, bleeding due to inflammation and vitamin deficiency Tongue Leukoplakia premalignant The First & The Only Franchise in the Iraq  Causes of dry, cracked lip corners that can trigger angular cheilitis include: Atopic dermatitis or eczema. Dentures that don't fit. Drooling during sleep. Fungal or yeast infections in the mouth, such as thrush. Misaligned teeth. MOUTH Skin allergies. Sucking on a thumb Wearing a face mask The First & The Only Franchise in the Iraq  Atrophic glossitis Loading… is an inflammatory disorder of the tongue mucosa that shows a smooth, glossy appearance with a red or pink background a well-known oral feature of B12 Thrush ,candidiasis deficiency The First & The Only Franchise in the Iraq Thyrotoxocosis Goiter, The First & The Only Franchise in the Iraq NECK AND CHEST Gynaecomastia The First & The Only Franchise in the Iraq  Shape and movements, Scars ,Distension Prominent veins (caput medusae), Striae, Bruises ,Pigmentation ,Visible peristalsis The First & The Only Franchise in the Iraq  Distended abdomen due to fluid Ascitic abdomen The First & The Only Franchise in the Iraq  Polydactaly Acongenital anomaly The First & The Only Franchise in the Iraq Thank you