History Taking In Medicine And Surgery - Pastest

h Past me dical histor yIs there history of previous GI disease? (Indigestion, abdominal pain)Do you suffer from gallstones?Have you had an AAA, peptic ulcer, diverticular disease or pancreatitisbefore?Have you had abdominal surgery previously (adhesions)?Have you had previous gynaecological problems?Have you had a previous appendicectomy?Consider the patient’s fitness for general anaesthesia – Have you had anyreactions to general anaesthetics in the past?h Drug histor yAre you taking any medications, especially:y Anti-inflammatories? (Cause PUD)y Steroids? (Mask abdominal signs)y The pill or HRT? (Need to be stopped prior to surgery due toincreased thromboembolic risk)Compliance, side-effect(s) of medication, OTC/herbal remedies, allergies.(What happens?)h Social histor yDo you smoke? (Important to stop pre-operatively because ofincreased risk of thrombosis)Do you drink alcohol? (Gastritis, acute/chronic pancreatitis)Acute abdominal painDo you use recreational drugs?ggSexual history – I need to ask you some important though ratherpersonal questions, if I may, which may or may not relate to thesymptoms you’ve been having. Have you had recent unprotectedintercourse with a new partner? (PID/salpingitis)How would you manage at home after a possible operation? Who isat home to look after you on discharge? (The situation at home is veryimportant if considering surgery.)26hh

h Family histor yIs there a family history of any GI conditions, eg IBD (UC/Crohn’s disease)?Is there a family history of rare metabolic causes of abdominal pain, egporphyria, familial Mediterranean fever?Do any anaesthetic reactions run in the family? (Malignant hyperpyrexiasyndrome)Acute abdominal paingg27hh

h Dif ferential diagnosisRight hypochondriumEpigastricBasal pneumoniaHepatitisGallbladder pathology(biliary colic, acute/chronic sophagitis/gastritisPeptic ulcer diseaseGallbladder pathologyAcute pancreatitisMyocardial infarctPerforated oesophagus(Boerhaave’s)Abdominal aorticaneurysmRight /ureteric colicRenal infarctRight iliac fossaAcute abdominal painAppendicitisMeckel’s diverticulitisMesenteric adenitisPerforated caecalcarcinomaCrohn’s diseaseTerminal ileitisRenal/ureteric colicOvarian cyst accident(rupture, haemorrhage,torsion)Ectopic pregnancySalpingitisTesticular torsiongg28hhLeft hypochondriumBasal pneumoniaRuptured spleenSplenomegalySplenic infarctionSubphrenic abscessLeft loin/flankAbdominal aorticaneurysmAcute pancreatitisGastroenteritisBowel obstructionEarly appendicitisIschaemic bowel(mesentericthrombosis)Testicular torsionPyelonephritisRenal/ureteric colicRenal infarctSuprapubicLeft iliac fossaCystitis/UTIUrinary retentionUterine fibroid reteric colicSigmoid volvulusColitis (ischaemic,infective, ulcerative)Ovarian cyst accident(rupture, haemorrhage,torsion)Ectopic pregnancySalpingitisTesticular torsion

Medical causes of abdominal painCardiovasculary Myocardial infarctiony Aortic dissectiony Bornholm’s disease (Coxsackie B)Respirator yy Basal pneumoniaM etabolicyyyyyyyyDiabetic ketoacidosisAddisonian crisisSickle cell crisisHypercalcaemiaUraemiaPhaeochromocytomaAcute intermittent porphyriaLead poisoningInfe c tionsyyyyyyyGastroenteritisTuberculosisTyphoid feverMalariaCholeraYersinia enterocoliticaUrinary tract infectionN eurologicalAcute abdominal painy Herpes zoster/shingles (NB: dermatomal)y Tabes dorsalisgg29hh

Inf lammator yy Vasculitisy HSPy PANy Familial Mediterranean feverPs ychogenicy Narcotic addictiony Irritable bowel syndromeh InvestigationsBlood test sAcute abdominal painy Haematology – FBC, ESR, clotting, cross-match/G Sy Anaemia (bleeding, anaemia of chronic disease)y Raised WCC (infection, inflammation)y ESR (infection, inflammation, malignancy)y Clotting (pre-op prep)y Cross-match/G S (AAA, ectopic, pre-op prep)y Biochemistryy U Es (vomiting and diarrhoea, renal lesions)y CRP (infection)y Glucose (DKA, pancreatitis)y LFTs (hepatitis, gallstones)y Ca2 (pancreatitis, renal colic, hypercalcaemia as a primarycause)y Amylase (pancreatitis, ischaemic bowel)y Lipids (pancreatitis)y β-hCG (ectopic)y Microbiologyy Blood cultures (Gram-negative sepsis)y Arterial blood gases (pancreatitis, metabolic acidosis)gg30hh

Urinalysis (M ,C S)yyyyPus cells, nitrites, protein, organisms (pyelonephritis, UTI)Blood (renal colic)β-hCG (ectopic)Glucose, ketones (DKA)ECGy Exclude MIy Pre-op preparation for anaestheticy Arrhythmias (eg AF) leading to emboli (acutely ischaemic bowel)RadiologyAcute abdominal painy Erect CXRy Perforated viscusy Basal pneumoniay Pneumomediastinum (Boerhaave’s syndrome)y AXR ( lateral decubitus)y Bowel obstructiony Constipationy AAAy Renal calculiy Thumbprinting of bowel wall (bowel ischaemia)y Transabdominal/transvaginal USSy Exclude gynaecological pathologyy Collection/cysty Free fluid (peritonitis, ascites)y AAAy Gallstonesy Renal stonesy CT abdomen/pelvisy Collectionsy Anastomotic leaky Diverticulitisy Renal colic (CTU)y Tumoursgg31hh

Fur t he r inve st ig at ionsAcute abdominal painy OGD biopsy and Helicobacter pylori testing (peptic ulcer,malignancy)y Large-bowel enema/Gastrografin (‘instant’) enema (cause forlarge-bowel obstruction)y Small-bowel enema/follow-through (Crohn’s disease)y Duplex Doppler/angiography (mesenteric thrombosis)y Diagnostic laparoscopyy Vaginal/endocervical swabs (PID)y Blood film/Hb electrophoresis (sickle cell crisis)y VDRL (tabes dorsalis)y Urinary porphobilinogens (acute intermittent porphyria)y Short synacthen test (Addison’s disease)gg32hh

Alcohol -related problemsh Histor y of presenting complaintHow much do you drink? How much do you drink on each occasion?How often do you drink?What do you drink?How many units do you drink in a week? (1 unit 1 small (125-ml) glasswine, 1 shot (25 ml) whisky, 0.5 pint beer (standard 3.5%))How long does it take you to finish a bottle of whisky/vodka?h C AGE questionnaireHave you ever thought that you ought to cut down on your drinking?Have people annoyed you by criticising your drinking?Have you ever felt guilty about your drinking?Have you ever had a drink first thing in the morning to overcome ahangover? (An eye opener)Two or more positive replies identifies problem drinkers; one is anindication for further enquiry about the person’s drinking.Do you find that you tend to drink more than your friends around youwhen you are out socialising? Do they ever comment on how much youdrink, or ask you to reduce your intake?Alcohol-related problemsHow often during the past year have you been unable to rememberwhat happened the night before because you had been drinking?Histor yIf intake is low risk, ask about any previous history of heavy drinking ordependence.Age of onset of regular drinking/alcohol misuse/harmful drinking.gg33hh

AmountAre you a binge drinker, or do you drink consistently? (If the former istrue, ask for how long, how much consumed, how long in betweenbinges and precipitating factors for binges)How much money do you spend on alcohol?Place of drink ingDo you drink alone or with other people?O therWhat is the purpose of your drinking?What is your attitude towards alcohol?Do you take any drugs as well?Conditions associate d with drink ingy CNS:Wernicke–Korsakoff syndrome, polyneuropathyy Gastrointestinal: gastritis, pancreatitis, liver disease, carcinoma ofoesophagusy Endocrine: cushingoid facey Cardiovascular: hypertension, cardiac arrhythmias,cardiomyopathyy Metabolism: gouty Musculoskeletal: myopathiesD ep endenc yAlcohol-related problemsWhat happens when you go without alcohol for long periods of time?(Manifestations of dependency)ggAre you aware of your compulsion to drink?ToleranceIs your tolerance increasing? Are you able to drink more now than youused to before getting drunk?34hh

Withdrawal s ymptomsDo you get withdrawal symptoms if you go without a drink for a longperiod of time?When – first thing in the morning?Do you get shaking, agitation, nausea, retching, sweating?Are your symptoms relieved by drinking alcohol?Do you get hallucinations, or altered perceptions?Counselling/advice/treatment sAsk about previous advice, counselling and treatments received foralcohol problems.h Past me dical histor yHave you ever had to detoxify?Were you admitted to hospital or managed at home?Establish the history and current situation with regard to the followingsystems:G astrointestinalLiver diseaseJaundicePancreatitisAbdominal painGastritisGI haemorrhageCarcinoma of mouth, oesophagus, liverAlcohol-related problemsyyyyyyyCardiovasculary Hypertensiony Cardiomyopathyy Arrhythmiasgg35hh

N eurologicalyyyyyyyyyNeuropathyPsychosisMemory difficultiesHallucinationsCognitive impairmentBlackoutsFitsAccidentsAnxietyRespirator yy Chest infectionsM etabolicy GoutReproduc tivey Sexual dysfunctiony Fetal alcohol syndrome (in women of reproductive age)h Drug histor yDo you take any medications?Alcohol-related problemsDo you take any drugs that may interact with alcohol, eg warfarin,anticonvulsants, disulfiram, metronidazole?ggh Social histor yDo you smoke? (Reinforces drinking behaviour and vice versa)Do you use recreational drugs?Have there been any requests for medical certificates?Has there been any absenteeism at work?Do you have any marital or family problems and has there been anydomestic violence?36hh

Has alcohol ever led you to neglect yourself, your family or work?Do you have any financial difficulties?Have you had any prosecutions for violent behaviour or drivingoffences? Have you ever been done for drink/drunk driving? Have youor someone else been injured as a result of your drinking?Have you ever had your driving licence taken away or penalty pointsawarded relating to alcohol misuse?Family, housing, social and employment situations and the effect ofalcohol misuse on these.Do you receive any state benefits – unemployment, incapacity,disability?Have you made any attempts to stop drinking? What? When was thelast time? How? Why did you fail?Do you presently attend or have you ever been to AlcoholicsAnonymous? Have you heard of it? Have you thought before aboutgoing?h Complications of alcohol misuseG astrointestinalAlcohol-related problemsy Oesophagusy Gastro-oesophageal refluxy Oesophageal carcinomay Oesophageal varicesy Mallory–Weiss syndromey Stomachy Gastritisy Peptic ulcer diseasey Small intestiney Malabsorption and malnutritiony Altered motor activity (diarrhoea)gg37hh

y Livery Fatty liver (steatosis)y Alcoholic hepatitisy Liver cirrhosis and its complicationsh Ascitesh Spontaneous bacterial peritonitish Portal hypertensionh Hepatocellular carcinomay Spleeny Splenomegaly (portal hypertension)y Pancreasy Pancreatitis (acute and chronic)y Pancreatic carcinomaCardiovascularyyyyCoronary heart diseaseDilated cardiomyopathyHypertensionCardiac arrhythmiasRespirator yy Aspiration pneumoniaN eurologicalAlcohol-related problemsyyyyyyyyyyyyygg38hhSeizures/uncontrolled epilepsyCerebrovascular accidentsCerebellar degeneration (ataxia)Wernicke–Korsakoff syndrome (thiamine deficiency)Peripheral polyneuropathy (mainly sensory)Hypoglycaemic comaHepatic encephalopathyAlcoholic dementiaMarchiafava–Bignami syndrome (corpus callosum atrophy)Central pontine myelinolysisMyopathy (acute/chronic)RhabdomyolysisNeuropraxia

HaematologicalyyyyyyyyyHaemolysis (Zieve’s syndrome)Impaired erythropoiesisMacrocytosisAlcoholism-associated folate deficiencySideroblastic anaemiaNeutropeniaThrombocytopeniaClotting factor deficiency (liver failure)Warfarin and other drug interactions (liver c trogenaemia/gynaecomastiaPseudo-Cushing’s acturesD ermatologicalFacial flushingPalmar erythemaSpider naeviLinear telangiectasiaDupuytren’s contractureCaput medusae (portal hypertension)Parotid enlargementAlcohol-related problemsyyyyyyyPre gnanc yyyyyInfertilityFetal alcohol syndromeIntrauterine growth retardationIncreased risk of abortion/stillbirthgg39hh

Ps ychiatricyyyyyyyyyAlcohol dependency/addiction/misuseAlcohol withdrawalAcute confusional stateAlcohol intoxication (falls/blackouts/accidents/injuries,dangerous driving, violence, criminal behaviour)Alcoholic hallucinosisDelirium tremensDepression and anxietySuicideAlcoholic dementiaSocialyyyyyJob lossMarital/relationship difficultiesCriminal activityViolenceDriving offences and RTAsh InvestigationsBlood test sAlcohol-related problemsy Haematology – FBC, clotting, haematinicsy Anaemia (multifactorial)y Thrombocytopenia (multifactorial)y MCV (macrocytosis)y Clotting (liver disease)y Haematinics (vitamin B12, red cell folate)y Biochemistryy LFTs including GGT (cirrhosis)y U Es (hepatorenal syndrome)y Glucose (liver disease, pancreatic failure)y Albumin (liver failure)y Lipids (secondary hyperlipidaemia)y Blood ethanol levels (intoxication)gg40hh

Radiologyy CXRy Large heart (dilated cardiomyopathy)y Aspirationy USSy Fatty livery Hepatitisy Cirrhosisy Evidence of portal hypertensionFur t he r inve st ig at ionsyyyyyyyCarbohydrate-deficient transferrin (alcoholism)Red cell transketolase (Wernicke’s)Echocardiography (dilated cardiomyopathy)OGD (varices, PUD)Liver biopsy (liver disease)EEG (hepatic encephalopathy)Nerve conduction studies (neuropathy)Alcohol-related problemsgg41hh

Ano -rec tal painh Histor y of presenting complaintSiteWhere do you feel the pain? (in the skin or deep inside?)O nsetSudden vs gradualIs it there the whole time or precipitated by something, eg passingstool?Duration?Charac terIs the pain spasmodic? (proctalgia)Is it worse during or after defecation (anal fissure)?Does it persist after defecation?A ssociate d s ymptomsyyyyyAno-rectal painyyyggy42hhAre there any other pains, such as abdominal pain?Is there any bleeding from the back passage?Are there any changes in bowel habit? Is there tenesmus?Is there passage of mucus/pus/blood?Are there any lumps, or the sensation of something coming downwhen you pass stools?Are you still able to reduce your piles?Is there a history of trauma?Are you able to pass urine, or is there any back pain or weakness ofyour legs? (rarely cauda equina lesions present this way).Are there any systemic features – weight loss, fever, malaise,anorexia, rigors?

Case scenariosh Case 1You are the surgical SHO on call. It is midnight. You have accepted areferral from a GP for a 35-year-old woman who has pain in the rightiliac fossa.Please take a detailed history from her to determine the cause of herproblem.What questions would you like to ask the patient?PCWhen you ask the patient what is wrong, she explains that she hashad right iliac fossa pain since lunchtime that day. She was out at arestaurant with her best friend and just as she got up from her chair atlunch the pain came on. But she tells you nothing much else until directquestions are asked.HPCODQ the pain came on suddenly.ODQ the pain has been constant and severe.ODQ about radiation – The location of the pain is vague and she isunsure whether the pain initially started around the umbilicus butshe thinks it may well have. There is no radiation down to the groin.However, ODQ about shoulder-tip pain she agrees that there isradiation to the right shoulder, although she puts this down to a recentshoulder injury that she sustained while playing netball.ODQ there is no history of trauma to the abdomen.Associated symptoms:Bit of nausea, no vomitingNo feverNo distensionLoss of appetiteNo urinary symptoms (dysuria, urgency, frequency)Case scenariosyyyyygg407 hh

y ODQ she has noticed she has passed some vaginal dischargewhich is dark red and possibly blood but she suspects this is awithdrawal bleed/breakthrough bleeding from the OCP.Exacerbating factors – Walking around makes the pain worse.Relieving factors – Lying/sitting still relieves it.She took ibuprofen earlier but that has not helped.Severity – The worst pain she has ever had, 9/10. She could never sleepwith this pain.ODQ about her LMP, her last withdrawal bleed (from being on the OCP)was 6 weeks ago.PMHxNil. Has not had her appendix out. No past operations.No gynaecological history apart from suffering from painful heavyperiods as a teenager.DHxOCP – No allergies.ODQ about compliance, she admits that a few weeks ago while onholiday and because of the excitement of being away from home sheforgot to take her pill for two consecutive days.SHxFunctionally independent. Has no children. Shares a flat with a womanfriend.ODQ about travel she recently went on holiday to Ibiza with six otherfriends, including her boyfriend.ODQ – Nothing significant about her holiday but she did have a D Villness from sampling the local delicacies.Case scenariosSmokes 10 a day and has done since the age of 15.ggDrinks about 10 units alcohol a week (ODQ five large glasses of wine aweek on average).ODQ sexual history – She has been going out with her boyfriend for3 years now. No other sexual partners. ODQ no ‘one night stands’ onholiday in Ibiza.408 hh

FHxGrandmother diagnosed with bowel cancer at age of 80. Grandfatherdied of MI at age of 72.Mother diabetic (insulin-controlled). Father alive and well.One brother and one sister, alive and well.SENil. No weight loss.What is your differential diagnosis?What investigations would you like to carry out?Case discussionThis case illustrates well the importance of taking a structured andaccurate history in any patient presenting with acute abdominal pain. Inthis case it would be easy to assume, early on, that the diagnosis is acuteappendicitis.However, further questioning revealed that the patient forgot to takeher pill while on holiday in Ibiza with her friends (who included herboyfriend). This, together with the fact that she has also noticed somedark-red vaginal discharge and her last withdrawal bleed is late, puts aruptured ectopic pregnancy at the top of the differential diagnosis. Theinefficacy of the OCP due to patient non-compliance was compoundedfurther by a D V illness while on holiday, which reduces absorption of thedrug.Other diagnoses that would also feature in the differential diagnosis arePID, an ovarian accident (rupture, torsion, haemorrhage), appendicitis,miscarriage, Crohn’s disease, etc. However, these are all less like

h Family history Are there any diseases or illnesses that ‘run in the family’? Is there a FHx of malignancy, especially bowel carcinoma? Has there been any contact with TB or other infections? Is there a FHx of polycystic kidney disease? Is there any consanguinity? Draw a family tree. h D