Communication with

surgical patients
(Surgical history taking)

Prof. Galal Abouelnagah, FRCS, PHD, MD

Prof & head of Surgical Oncology unit
Faculty of Medicine
Alexandria University
 Objectives

 Define effective history taking

 Describe components of patient history
 Outline patient interviewing techniques
 Identify strategies in obtaining history
 Techniques facilitating History Taking
 Special challenges
 What is it?
 Patient interview in systematic way to:
 Recording necessary medical information
+ Classical examination signs

 All information must be documented

precisely and accurately
 Importance
 Help for reaching diagnosis
 Help in formulation treatment plan
 Evaluate medical progress
 Medico-Legal record
 Availability of information for:
 Research
 Reportable diseases
 Insurance claims
 ‫‪Example‬‬
‫‪ ‬أنا تعبان جدا يا دكتور‪ .‬والتعب بدأ معايا من مدة‪ .‬رحت لدكاترة‬
‫كثيرة كتبوا لى روشتة‪ .‬عاوزك تشوف لى حل‪ .‬أنا خالص تعبت‬
‫و ما عدتش مستحمل‪ .‬كله بيوجعنى‪ .‬مش عارف أعيش خالص‪.‬‬

‫‪‬‬ ‫?‪What the disease of that patient‬‬

‫?‪ Which body system is affected‬‬
‫?‪ Since when disease started‬‬
‫?‪ What treatment he received & does it help‬‬
 Types of patient interview

 Initial history taking

 Inward daily round: progress of condition,
results of investigations, respond to treatment
 Discharge interview: plain at home
 Follow up visit: New symptoms & signs since
last visit, drug management
 Field research or screening questionnaire
 General rules
 Not just completing a form
 Tell patient your name and explain why
you are seeing him
More important for medical students
 Could be started before patient’s talk
 Give patient whole your attention
 Doctor should be an empathetic listener
 Consent
 Type of consents:
• Oral
• Behavioral
• Written consent

 Why:
• To get adequate information about case
• Avoid medico-legal complains
 Set the stage
 Provide safe environment
 Your behavior and appearance
 Shake hands
 Avoid the patient’s personal space
 Inquire about patient’s feelings
 Avoid unfamiliar or street terms
 Note taking
 Signs of uneasiness
(Body Language )
 ‫‪Significance‬‬ ‫‪Action‬‬
‫االرتياح أو الرضا أو الموافقة‬ ‫‪  ‬اإلبتســــــــــامــــه‬
‫‪.‬‬
‫العصبيةـ أو الغضب أو الضيق ‪.‬‬ ‫قضــــــــــم‬
‫الشفاه ‪.‬‬
 ‫المفاجأة أو عدم‬ ‫رفع الحواجب مع‬
‫التصديق أو الدهشة‬ ‫أو‬
‫الكتف ‪.‬‬
‫التهكم أو السخرية ‪.‬‬ ‫رفع الحواجب مع‬
‫ابتسامه مصطنعة‬
‫عدم الموافقة أو‬ ‫تضييق‬
‫الشعور السلبى‬ ‫العـــــــــــين‬
‫االهتمام أو العناية ‪.‬‬ ‫‪‬االنحناء لإلمام‬

‫القلق أو السأم أو‬ ‫الحركة الكثيرة فى‬

‫التعب‬ ‫الجلسة‬
‫الثقة بالنفس ‪.‬‬ ‫االستقامة واالعتدال‬
‫فى الجلسة ‪.‬‬
‫اإلنصات أو تركيز‬ ‫تركيز العين فى عين‬
‫االنتباه‬ ‫الطرف اآلخر‬
‫تجنب تالقى األعــــين التجنب أو‬
‫الالمبــــاالة أو‬ ‫‪.‬‬
‫العصبية‪.‬‬
‫الملل والضجر ‪.‬‬ ‫التثــاؤب ‪.‬‬
 Guidelines for taking case history
 Questions should be open ended (encourage)
 Guidance of conversation but not restricting
 Avoid leading questions (‘yes’ or ‘no’ answers)
 Clear & specific questions
 Ask one question at a time
 Cover various aspects of diseased organ
 Direct questions may be required sometimes
 Patient symptoms in his own words??
 Special situations
 Infants under 5yrs; parent is interviewed
 Unconscious patients
 Under drugs effect
 Shying patients
 Emergency situation
 In Emergency
 Fast the procedure but do not ignore it
 In case of emergency, obtain information
from patient and/or bystanders
Classical history taking
 Personal data
 Name:
• Full, accurate
• Communicate with patient
• Medico-legal aspects

 Age:
• Date of birth is better
• Growth and development is noted
• Certain diseases correlated with age
• Management techniques according to age
 Personal data
 Sex:
• Some diseases shows sex predilection
• Ethics & religious consideration

 Marital status: Infertility, pregnant…

 Contacts:
• Address: endemic diseases, follow up visits
• Phone
• Nearest kin
 Personal data
 Occupation: Socio economic status

 Race: Some certain diseases

 Religious: Certain considerations

 Date & type of admission

 Hospital number
 Chief Complaint
 First symptoms that caused patient to
seek medical advice

 Often:
 Pain
 Bleeding
 Abnormal function
 Observation of a lump
 Many complaints
 Always record patient’s own words
 In order of severity
 In chronological order

Present History
 Def.: Details of symptoms & their progress
 Should be well organized, clear, detailed
It is important to get right back to
the beginning of the problem
 Present History

 Etiology (predisposing factors)

 Classical course of disease
 Any complications
 Loco-regional effect
 Systemic effect
 Present history
 Negative information should be included if
they contribute to the diagnosis or help
exclude other possibilities
Past & medical history
 Past & medical history
• Allergy & anemia
• Bleeding disorders
• Cardio respiratory disorders
• Drug history
• Endocrine disorders
• Fits & faints
• Gastrointestinal disorders
• Hospital admissions & surgeries
• Infections
• Jaundice & hepatic disease
• Kidney
 Family history

Ask about health or cause of death of patient’s

parents, grandparents, brothers and sisters

Previous similar illnesses in the family

Potential for hereditary diseases

 Reproductive history
 Infertility of both sexes
 Gynecological causes of abdominal pain
 Pregnancy & lactation
 Also ask about:
 Contraceptive use
 Venereal disease
 Habits
 Smoker
 Athletics
 Appetite
 Alcohol
 Coffee
 Sexual
 Sensitive Topics
 Alcohol or drug abuse

 Physical abuse or violence

 Sexual issues

 Psychiatric problems
 Sensitive Questions Guidelines
 Respect patient privacy

 Be direct and firm

 Avoid confrontation

 Be nonjudgmental

 Use appropriate language

 Document carefully
 Use patient’s words as possible
 Special Challenges
 Silence # overly talkative patients
 Patients with multiple symptoms
 Anxious patients
 Anger and hostility
 Crying & depression
 Confusing behavior or histories
 Limited intelligence
 Developmental disabilities
 Barriers to Communication
 May result from:
 Social or cultural differences
 Sight, speech, or hearing impairments

 Attempt to find assistance to aid in

communication
 Patient encourages
Let patient continue talking
 FACILITATION
“Tell me more about it”
“ Please go on”
“I’m interested to hear about it “
 Rocking: “Yes, Uh huh, umm, I see”
 Repeating: ”It usually happens at night?”
 Confirmation
Clarifying
Ex: “What do you mean by fretful?”
“Do you mean this . . . . ?”

"‫" خاطبوا الناس على قــــــدرعقولهم‬

 Finally
 Explain to the patients what is going on
 Encourage patient to ask questions
 Next plain

 Thank the patients

 Date & signature
 Do not
 False quick diagnosis
 Malignancy
 Debilitating disease

 False reassurance
 May be tempting
 Avoid early assurance or “over reassurance”
 Unless it can be provided with confidence
 Any Questions
www.med.alexu.edu.eg/soncology

Thank you….!