Tips for Effective Patient Interaction in Surgery Practice
Learn valuable insights on establishing a professional demeanor, treating patients with empathy, and conducting thorough history taking in surgery. From maintaining a proper appearance to understanding the components of patient history, these guidelines will help you build strong patient-physician relationships in a surgical setting.
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Dr. Khalid Al-Zahrani Assistant Professor of Plastic Surgery Course Organiser, Surg. 351 Department of Surgery
Your appearance is important: (wearing proper uniform, ie. Lab coats, I.D., etc.)
Treat patient as if they are your friend(s) Think of the condition of your patient first and not yours See him walking in and not in the cubicle Allow his relative to be there if the patient wants. Be alert and pay him full attention
History Taking in Surgery There is no difference between medical and surgical history. They are the same.
The history compnents Personal data. the present complaint (c/o). History of present complaint. Elaboration on the system involved. Systemic enquiry. Past history ? surgical, medical Drug history Family history Social history
History Personal Data Date and Time Name & File number ( Medical record number) Age Sex Religion Marital status Occupation Residency Who gave the history?
Chief Complaint Main Complaint Complain Of Duration
History of the presenting Symptom ( Illness) Elaborate the symptom. Elaborate the system involved. What had been done for the patient?
Past History Dm, Hypertension Bronchial Asthma Bleeding disorders & Sickle cell disease TB, Syphilis, Bilharzias Passage of stones Blood transfusion Operations, Trauma
Family History Similar conditions Parents and close relatives cause of death and serious illnesses. DM, Hypertension Bleeding Disorders& Sickle cell disease Ca Prostate ( others)
Systemic Review Systematic 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 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 & 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 & Abdomen Appetite Diet Taste Swallowing Regurgitation Vomiting Indigestion Vomiting Haematemses Abdominal pain Abdominal Distension Bowel habit Stool Jaundice
Urogenital System Loin pain Symptoms of uremia Headache Drowsiness Fits Visual disturbances Vomiting Oedema of ankles, hands of face Lower urinary tract symptoms ( LUTS) Painful micturirtion Polyuria Color of urine Hematuria Male Infertility history Sexual problems history 1. 2. 3. 4. 5. 6.
Musculoskeletal 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 symptoms Pain 1. Site 2. Time & mode of onset 3. Duration 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 ulcer Duration ( when was the first time noticed) First symptom ( how the patient noticed it) Other symptoms Progression ( change since notice) Persistence ( has it ever disappear or healed) Any other lumps or ulcers Cause
